title: Shifting physician prescribing to a preferred histamine-2-receptor antagonist. Effects of a multifactorial intervention in a mixed-model health maintenance organization.
abstract: OBJECTIVE
  This study was undertaken to determine whether a program of education, therapeutic reevaluation of eligible patients, and performance feedback could shift prescribing to cimetidine from other histamine-2 receptor antagonists, which commonly are used in the management of ulcers and reflux, and reduce costs without increasing rates of ulcer-related hospital admissions.
  
  
  METHODS
  This study used an interrupted monthly time series with comparison series in a large mixed-model health maintenance organization. Physicians employed in health centers (staff model) and physicians in independent medical groups contracting to provide health maintenance organization services (group model) participated. The comparative percentage prescribed of specific histamine-2 receptor antagonists (market share), total histamine-2 receptor antagonist prescribing, cost per histamine-2 receptor antagonist prescription, and the rate of hospitalization for gastrointestinal illness were assessed.
  
  
  RESULTS
  In the staff model, therapeutic reevaluation resulted in a sudden increase in market share of the preferred histamine-2 receptor antagonist cimetidine (+53.8%) and a sudden decrease in ranitidine (-44.7%) and famotidine (-4.8%); subsequently, cimetidine market share grew by 1.1% per month. In the group model, therapeutic reevaluation resulted in increased cimetidine market share (+9.7%) and decreased prescribing of other histamine-2 receptor antagonists (ranitidine -11.6%; famotidine -1.2%). Performance feedback did not result in further changes in prescribing in either setting. Use of omeprazole, an expensive alternative, essentially was unchanged by the interventions, as were overall histamine-2 receptor antagonist prescribing and hospital admissions for gastrointestinal illnesses. This intervention, which cost approximately $60,000 to implement, resulted in estimated annual savings in histamine-2 receptor antagonist expenditures of $1.06 million.
  
  
  CONCLUSIONS
  Annual savings in histamine-2 receptor antagonist expenditures after this multifaceted intervention were more than implementation costs, with no discernible effects on numbers of hospitalizations. The magnitude of effect and cost savings were much greater in the staff model; organizational factors and economic incentives may have contributed to these differences. More research is needed to determine the generalizability of this approach to other technologies and managed care settings.
authors.affiliation: Harvard Pilgrim Health Care, Boston, MA, USA.
authors.forename: J W
authors.initials: JW
authors.lastname: Brufsky
authors.forename: D
authors.initials: D
authors.lastname: Ross-Degnan
authors.forename: D
authors.initials: D
authors.lastname: Calabrese
authors.forename: X
authors.initials: X
authors.lastname: Gao
authors.forename: S B
authors.initials: SB
authors.lastname: Soumerai
mesh_terms: D001900:Boston; D017046:Cost Savings / Q000191:economics / Q000706:statistics & numerical data; D016527:Drug Costs / Q000706:statistics & numerical data; D004363:Drug Utilization / Q000191:economics / Q000706:statistics & numerical data*; D005764:Gastroesophageal Reflux / Q000188:drug therapy / Q000191:economics; D006279:Health Maintenance Organizations / Q000191:economics* / Q000706:statistics & numerical data; D006635:Histamine H2 Antagonists / Q000191:economics / Q000627:therapeutic use*; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D010437:Peptic Ulcer / Q000188:drug therapy / Q000191:economics; D010818:Practice Patterns, Physicians' / Q000191:economics* / Q000706:statistics & numerical data
chemical_list: D006635:Histamine H2 Antagonists