A review of studies conducted in managed care settings that used a variety of strategies to reduce prescription drug cost and improve the quality of medication use finds that the dissemination of education materials to physicians by itself has little or no effect on cost or quality. Researchers at Harvard Medical School and Harvard Pilgrim Health Care found that one-to-one academic detailing, computerized alerts and reminders, pharmacist-led collaborative care, and multifaceted disease management were effective. The review, in BMC Health Services Research, covered studies published from 2001 through 2007.

“One-to-one educational intervention has the potential to achieve the broad goal of increasing rational use of medicines and could deliver cost-effectiveness over the long term,” says Christine Lu, PhD, a research fellow at Harvard Medical School and co-author of the study.

She cautions that formulary interventions may be a quick fix for high drug spending but it could have negative outcomes because a member may avoid filling a prescription due to increased patient out-of-pocket expenses or formulary tier change.

The studies were classified according to predominant strategy. The most common strategies were formulary-related interventions (40 percent), disease management (25 percent), monitoring and feedback (13 percent), educational interventions (12 percent), and collaborative care involving pharmacists (10 percent).

Interventions targeting drug use
Type of intervention	All studies	Methodologically acceptable studies	Randomized clinical trial	Interrupted time series	Pre/post studies with comparison	Comments
Education	20	7	5	0	2	Dissemination of educational material is ineffective and one-to-one educational outreach visits are effective in increasing adherence to prescribing guidelines.
Monitoring and feedback	22	16	10	5	1	Computerized alerts showed promise in improving short-term outcomes including changing prescribing and test ordering.
Formulary	66	15	2	5	8	Tiered formulary, patient copayment interventions, and prior authorizations decrease non-preferred drug use, reduce overall insurer costs, and increase patient out-pocket- expenses.
Collaborative care involving pharmacists	15	5	3	0	2	Collaborative care led by pharmacists improves quality of care, including medication adherence
Disease management	41	8	7	0	1	Disease management interventions are associated with improvements in the process and quality of care, for both the short and long term.
Total	164	51	27	10	14
Source: Lu CY, Ross-Degnan D, Soumerai S, Pearson SA. Interventions designed to improve the quality and efficiency of medication use in managed care: A critical review of the literature — 2001–2007. BMC Health Serv Res. 2008;8:75–89.

“Formulary interventions can lead to discontinued use of all drugs in the affected class in some patients,” says Christine Lu, PhD, Harvard Medical School.