The best way to ensure costs are not higher than they need to be and complexity is decreased is to not prescribe unnecessary medications in the first place.
Dr. Gordon Schiff, Quality and Safety Director for the Harvard Medical School Center for Primary Care, has led the charge on an approach he calls “conservative prescribing.”
This approach broadly includes:
Polypharmacy, the state of being on multiple drugs for a single condition, is commonly seen in elderly populations where the prescription of medication is often the first response to any medical concern. This makes conservative prescribing particularly important for this population. Many elderly patients and those in nursing homes have poor prognoses and chronic conditions that will limit their life expectancies, and it is these patients that are often taking a list of medications without regard to whether they will live long enough to benefit from them.
Think beyond drugs
Seek non-drug alternatives first
Prescribe exercise, physical therapy, diet changes, smoking cessation, orthotics, or surgery when appropriate.
Use the test of time as a diagnostic and therapeutic trial whenever possible
Evidence supports delayed strategy of diagnosis for rhinosinusitis, otitis media, back pain and many other conditions.
Practice more strategic prescribing
Use only a few drugs and learn to use them well
Studies have shown that having a more limited personal formulary is associated with higher-quality prescribing and less risk for errors.
Avoid frequent switching to new drugs without clear compelling evidence-based reasons
Avoid the common but often irrational practice of switching inpatient antibiotics frequently without clear indications.
Studies have shown that having a more limited personal formulary is associated with higher-quality prescribing and less risk for errors.
Temper the urge to start treatment with medications for a new patient’s hypertension, urinary tract infection, dyspepsia, headaches, and toenail infection—all on one visit.
Maintain heightened vigilance regarding adverse effects
Have a high index of suspicion for adverse drug effects
Consider whether “fibromyalgia” pain could actually be statin-induced myopathy or whether worsening heart failure could be due to an NSAID or rosiglitazone.
Educate patient about possible adverse effects to ensure that they are recognized as early as possible
Better-informed patients are more likely to recognize adverse effects early.
Be alert to clues that you may be treating or risking withdrawal symptoms
Caffeine or other analgesics are used to treat headaches but ultimately can cause daily headaches.
Approach new drugs and new indications cautiously and skeptically
Learn about new drugs and new indications from trustworthy unbiased sources
Avoid education from pharmaceutical representatives or “experts” with conflicts of interest. Instead turn to independent drug bulletins (eg, Medical Letter) or specialists with reputations for integrity and conservative approaches.
Do not rush to use newly marketed drugs
In pre-marketing trials, only carefully selected patients are exposed, who are often younger and not already taking multiple medications. There are many examples of medications that were found to have serious side effects following their widespread release, such as COX-2 inhibitors and thiazolidinediones.
Be certain that the drugs improve actual patient-centered clinical outcomes rather than just treating or masking a surrogate marker
Many randomized trials show statistically significant improvements in surrogate markers such as laboratory or radiologic findings, but may lack proof of meaningful clinical benefit.
Do not hastily or uncritically succumb to patient requests for drugs, especially drugs that they have heard advertised
With the growth of direct-to-consumer advertising, clinicians are under greater pressure from their patients to prescribe advertised drugs, but taking the path of least resistance and prescribing without an appropriate discussion and indication is dangerous.
Avoid mistakenly prescribing additional drugs for refractory problems, failing to appreciate the potential for patient nonadherence
Studies have shown that in most instances of poorly controlled hypertension, patients are not taking their prescribed medications.
Work with patients’ desires to be conservative with medications
Some patients actually prefer to avoid medications. Leading meaningful discussions with these patients and providing honest education can earn the patients’ trust in your judicious approach to limiting drug therapy and may convince them to more readily accept treatment recommendations when medications are truly essential.
Think beyond short-term beneficial drug effects to consider longer-term benefits and risks
Dopamine antagonists such as chlorpromazine and haloperidol, which caused tardive dyskinesia, continue to haunt us as examples of drugs that were dramatically effective but were later found to cause irreversible structural brain damage.
Look for opportunities to improve prescribing systems, changes that can make prescribing and medication use safer
Implementing well-designed computerized provider order entry or improved patient or laboratory monitoring systems have been shown to improve drug treatment, often more than the marginal impact of many new “breakthrough” drugs.
“Although others have used labels such as healthy skepticism, more judicious, rational, careful, or cautious prescribing, we believe that the term conservative prescribing conveys an approach that goes beyond the oft-repeated physician’s mantra, ‘first, do no harm.’”
1- Schiff GD, Galanter WL, Duhig J, et al. Principles of conservative prescribing. Arch Intern Med. 2011;171(16):1433-1440.