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Pharmacists and prescribing

Clinical bottom line

There is some evidence that certain actions can change prescribing behaviour, but no evidence that doing so is useful. We don't know that it benefits patients, or reduces costs at the same level of benefit. The authors also comment on the lack of evidence on the benefits of limited formularies.

Reference

KA Grindrod et al. What interventions should pharmacists employ to impact health practitioners' prescribing practices? Annals of Pharmacotherapy 2006 40: 1546-1557.

Background

It is now common, especially in primary care, for pharmacists to help clinicians employ more evidence-based, or effective, or cost effective prescribing. There exist a host of different methods, from proscriptive limited formularies, guidelines, or even, in some parts of the UK, pharmacists making changes to doctors prescriptions without reference to the doctor.

There are a number of issues, mainly about the goals of all this activity. Is it to improve patient outcomes, to provide the same outcomes at least cost, or is it just about reducing spending on drugs at all costs. The most prevalent view is that it is the latter - an exercise in cost cutting.

So we need evidence in two forms, first about what works to influence prescribing practice, and whether that impacts positively or negatively on patient outcomes. A systematic review of systematic reviews tells us how little we know.

Searching

The systematic search was for English-language systematic reviews using a number of electronic databases, up to July 2005.

Results

Thirty-four systematic reviews were identified. Much of the evidence in them was of relatively poor quality.

Consistently effective interventions to change prescribing behaviour were:

Inconsistently effective were:

There was no consistent evidence to say whether any of the effects were sustainable, were cost effective, or improved patient outcomes.

Comment

What this shows is that while there is evidence that doing something can change prescribing behaviour, there is zero evidence that it is worth it. We don't know that it benefits patients, or reduces costs at the same level of benefit. The authors also comment on the lack of evidence on the benefits of limiting formularies.

Given that so much effort is expended in this area, it might be useful to know whether it is anything but a complete waste of time.