Alerts about high medication costs did not affect inpatient prescribing

The retrospective analysis found that orders declined only for the two expensive medications that were restricted by the pharmacy or removed from order sets.


Displaying the costs of medications to inpatient prescribers did not significantly change their ordering patterns, a recent study found.

The retrospective analysis looked at inpatient orders for nine expensive medications before and after Johns Hopkins Hospital in Baltimore implemented a cost-transparency initiative. From April 10 to Oct. 5, 2015, the hospital's computerized provider order entry system displayed the cost of the medications. For seven of the medications, there were also alerts such as “Levothyroxine injection cost: $55 per 100 mcg dose vs $0.80 per 200 mcg oral dose. Consider enteral therapy at a 50% dose conversion unless clinically contraindicated.” Medication orders during the intervention period were compared to a baseline period from Jan. 1, 2013, to April 9, 2015.

No significant changes were seen in orders for seven of the medications: IV eculizumab, calcitonin, levetiracetam, linezolid, mycophenolate, ribavirin, and levothyroxine. There were immediate and sustained reductions in use of two drugs. However, both of those drugs were affected by policy changes during the study. IV pantoprazole was restricted due to a national shortage and required approval from the pharmacy (−985 orders per 10,000 patient-days; 73% decrease), and oral voriconazole was replaced by another drug in several oncology order sets (−110 orders per 10,000 patient-days; 46% decrease). The study was published in the August Journal of Hospital Medicine.

The findings “suggest that the passive strategy of displaying cost alone was not effective in altering prescriber ordering patterns for the selected medications,” the authors said. The significant reduction in prescriptions for the two medications affected by policy changes suggests that more active strategies might be more successful at changing prescribing patterns, they added.

Previous research at the same hospital has shown that notifying clinicians about the costs of tests did affect their ordering of lab tests, but not imaging. “One might speculate that ordering fewer laboratory tests is viewed by providers as eliminating waste rather than choosing a less expensive option to accomplish the same diagnostic task at hand,” the authors wrote. They noted that the effects of cost transparency might also differ in situations where the clinician entering the orders has more autonomy (e.g., lab vs. medication orders or community vs. academic hospitals). The intervention might also be more effective in institutions that offer incentives to clinicians for practicing cost-conscious care, the authors said.