Course 2: Improving Value at the Bedside (Modules 6-7) > 4.High-Value Prescribing

4.High-Value Prescribing

MODULE 6 | Section 4 of 10

High-Value Prescribing

WHAT IS HIGH-VALUE PRESCRIBING?

High-value prescribing entails providing the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome.1

VALUE IN PRESCRIBING CAN BE IMPROVED BY

DECREASING

COSTS

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DECREASING

COMPLEXITY

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DECREASING

RISK OF MEDICATIONS

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Decreasing either cost, complexity, or risk of medications can improve value. Ideally we should aim to decrease all simultaneously.

LET’S LOOK AT COMPLEXITY...

Imagine you have diabetes and are prescribed atorvastatin at night, colesevelam (once daily) and glipizide-metformin (twice daily). You should not take colesevelam within four hours of glipizide-metformin, and both glipizide-metformin and colesevelam should be taken with meals. All medications should be taken at the same time each day to get the full effect. If you are a woman and on oral birth control, make sure you take your birth control at least 4 hours before colesevelam. Also, be aware that colesevelam may reduce effectiveness of some birth control types, so you may need to find a new one. With this sort of regimen, how likely is it that you will be able to follow it perfectly?

LET’S TEST THIS

You are the prescriber in this scenario, and your patient, Margaret, is having trouble with her regimen. Create a schedule for her that ensures she can follow her regimen sustainably.

Drag and drop Margaret’s pills and meals to create a daily schedule. You may have up to two events per hour. Ensure all parameters described in the below scenario are followed. For pills that need to be taken with a meal, place the meal first.

Margaret has diabetes and is prescribed atorvastatin and colesevelam (each once daily) and glipizide-metformin (twice daily). Atorvastatin needs to be taken at night. She should not take colesevelam within four hours of glipizide-metformin, and both glipizide-metformin and colesevelam should be taken with meals. All medications should be taken at the same time each day to get the full effect. Margaret is on birth control and needs to be sure to take her birth control at least 4 hours before colesevelam.

INCORRECT

Colesevelam and Glipizide are not taken with meals.

ARTOVASTATIN
COLESEVELAM
GLIPIZIDE-METFORMIN (X2)
BIRTH CONTROL
MEAL (X3)

8:00
AM 		9:00
AM 		10:00
AM 		11:00
AM 		12:00
PM 		1:00
PM 		2:00
PM
             
             
3:00
PM 		4:00
PM 		5:00
PM 		6:00
PM 		7:00
PM 		8:00
PM 		9:00
PM
             
             

CORRECT!

This Schedule works. Did you find that easy? Difficult? Reducing complexity reduces the risk of non-compliance, generally lowers cost, and increases outcomes that matter to prescribers and their patients.

INCORRECT

Colesevelam and Glipizide need to be taken with meals

Birth control needs to be taken at least 4 hours before Colesevelam

Colesevelam and Glipizide cannot be taken within 4 hours of one another

Glipizide-metformin needs to be taken twice, each time with meals

Artovastatin needs to be taken at night (past 6:00 pm)

Patients have trouble with complex medication regimens due to multiple dosage forms, frequency of dosing, and additional usage directions. In patients with poorly controlled diabetes, taking diabetic medications more than twice daily led to decreased adherence and worsened blood sugar control (as measured by hemoglobin A1c).2 In another study, adherence improved from 59% on a three-time daily regimen to 84% on a once-daily regimen, leading the authors to declare, “Probably the single most important action that prescribers can take to improve compliance is to select medications that permit the lowest daily prescribed dose frequency.”3

 

Medication complexity is a modifiable risk factor to adherence; therefore, efforts should be made to provide patients with the simplest appropriate regimen.

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“It is imperative that prescribers take into account their patients’ ability to pay for, understand, and adhere with their medication regimen, lest their efforts to provide thoughtful and effective medical care be easily undermined.”

Chris Moriates MD
Assistant Dean for Healthcare Value, and Associate Professor of Internal Medicine
Dell Medical School at the University of Texas, Austin

Once again, team-based care can make this work easier for all. For example, having a clinical pharmacist located with the team could allow for the pharmacist to lead these conversations.

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“As a pharmacist working directly with the medicine team, I am able to help assist clinicians with identifying medications that could be de-escalated, discontinued or interchanged to provide high-value care and communicate the signifcance of these changes directly to the patient.”

Molly Curran, PharmD, BCPS, BCCCP
Department of Pharmacy Practice
The University of Texas College of Pharmacy

Learn More

ARTICLE

Overcoming Barriers to Discussing Out-of-Pocket Costs with PatientsConversing with Patients About the Cost of Care

Increased cost sharing, in the forms of higher co-payments, deductibles, and yearly maximums, has been advocated to encourage patients to become smarter consumers and thus to reduce the overall cost of medical care.

Riggs KR, Ubel PA. JAMA Int Med. 2014;174(6):849-850.

ARTICLE

What Strategies do Physicians and Patients Discuss to Reduce Out-of-Pocket Costs? Analysis of Cost-Saving Strategies in 1,755 Outpatient Clinic Visits

More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized.

Hunter WG et al. Med Decis Making. 201636(7):90-100

REFERENCES

  1. 1- Moriates C, Arora V. High value medication prescribing. In Moriates C and Arora V, eds. Understanding Value Based Healthcare. Pennsylvania, PA: McGraw-Hill; 2015. 257-278.

 

  1. 2- Odegard PS, Gray SL. Barriers to medication adherence in poorly controlled diabetes mellitus. Diabetes Educ. 2008;34(4):692-697.

 

  1. 3- Eisen SA, Miller DK, Woodward RS, Spitznagel E, Przybeck TR. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med. 1990;150(9):1881-1884.

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