The effects of educational or regulatory policies targeting medicine prescribers

The aim of this Cochrane Review was to assess the effects of policies targeting people prescribing medicines. The review authors collected and analysed all relevant studies to answer this question and found two studies.

This review is one of a series of planned or completed reviews that look at the effects of different types of pharmaceutical policies on rational medicine use.

Key messages

We do not know what the effects of educational or regulatory policies are on the prescribing of medicine because the evidence is of very low certainty.

What are educational and regulatory policies?

Large amounts of health care funds are spent on medicines, and these amounts are increasing. And healthcare providers do not always prescribe the right medicines. Policy makers are therefore looking for ways to control the costs of medicines but still making sure that patients get the medicines they need. Governments, non-governmental organisations and health insurers sometimes try to do this through targeting the people who prescribe the medicines.

One way of doing this is to introduce educational policies. This can include laws, rules and regulations that require medicine prescribers to get certain types of information, education or feedback about their prescribing behaviour.

Another approach is to introduce regulatory policies. This can include laws, rules and regulations regarding who can prescribe medicines, what type of medicines they can prescribe and how much they can prescribe. Usually, prescribers are monitored to make sure they follow these policies.

What are the main results of the review?

The review authors found two relevant studies. Both of these studies were from the USA and both assessed policies that were introduced in the late 1990s.

The first study assessed a policy that aimed to get doctors to prescribe antihistamines that were cheaper but considered to be just as good as other antihistamines. In one part of the study, letters were sent to doctors and to their patients telling them about the new policy, and giving them information about the antihistamine. In another part of the study, letters were only sent to doctors.

The second study assessed a policy that aimed to get doctors to prescribe fewer benzodiazepines to certain types of patients. This policy required doctors in the State of New York to fill in three copies of the same form each time they prescribed benzodiazepines. Pharmacies then sent one of these copies to a state surveillance unit that monitored what doctors were prescribing. The study compared these doctors to doctors in the State of New Jersey, who were not monitored in the same way.

Because the evidence from both of these studies was of very low certainty, we do not know what effects these policies had on people’s medicine use. We also do not know whether these policies had any effect on people’s health or their use of healthcare services or on costs because the studies did not measure this.

How up to date is this review?

The review authors searched for studies that had been published up to March 2018.

Authors' conclusions: 

We are uncertain of the effects of educational or regulatory policies targeting prescribers due to very limited evidence of very low certainty. The impacts of these policies therefore need to be evaluated rigorously using appropriate study designs. Evaluations are needed across a range of settings, including low- and middle-income countries, and across different types of prescribers and medicines.

Read the full abstract...
Background: 

Pharmaceuticals make an important contribution to people's health. Medicines, however, are frequently not used appropriately. Improving the use of medicines can improve health outcomes and save resources. On the other hand, regulatory and educational policies may have unintended effects on health and costs.

Objectives: 

To assess the effects of pharmaceutical educational and regulatory policies targeting prescribers on medicine use, healthcare utilisation, health outcomes and costs (expenditures).

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, and two trial registries in March 2018 and several other databases between 2014 and 2018. We reviewed the reference lists of included studies and other relevant reviews, contacted authors of relevant reviews and studies to identify additional studies, and did a citation search for all included studies using ISI Web of Science (searched 05 January 2016).

Selection criteria: 

Randomised trials, non-randomised trials, interrupted time series studies, repeated measures studies and controlled before‒after studies of policies regulating who can prescribe medicines and other policies targeted at prescribers. We included in this category monitoring and enforcement of restrictions, generic prescribing, programmes to implement treatment guidelines, system-wide policies regarding monitoring medicine safety, and legislated or mandatory continuing education or quality improvement specifically targeted at prescribing. We defined 'policies' in this review as laws, rules, financial and administrative orders made by governments, non-governmental organisations or private insurers. We excluded interventions applied at the level of a single facility. For us to include a study, it had to include an objective measure of at least one of the following outcomes: medicine use, healthcare utilization, health outcomes, or costs.

Data collection and analysis: 

Two review authors independently reviewed abstracts and reference lists of relevant reports, assessed full-text studies for inclusion, extracted data, and assessed risk of bias and certainty of the evidence (GRADE). For all the steps in the above process we resolved disagreements by discussion.

Main results: 

We identified two studies that met our selection criteria: a controlled interrupted time series study evaluating a regulatory policy involving the monitoring of prescribing of benzodiazepines; and a controlled before‒after study of an educational policing involving mailed educational materials on prescribing for physicians and Health Maintenance Organization (HMO) members as well as an intervention to regulate drug reimbursement.

We are uncertain about the effects on medicine use of a regulatory policy involving the monitoring of prescribing with triplicate prescriptions, compared with no regulatory intervention (very low certainty evidence).

We are also uncertain about the effects on medicine use, assessed through doctors' prescribing, and costs of an educational policy involving mailed educational materials on prescribing for physicians and HMO members, compared to no educational intervention or an intervention to regulate drug reimbursement (very low certainty evidence).

Neither of the included studies measured healthcare utilization, health outcomes, or additional costs, if any, to patients.

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