When gatekeepers meet the sentinel: the impact of a prior authorization requirement for cefuroxime on the prescribing behaviour of community‐based physicians

Abstract

AimsPrior authorization (PA), the requirement of physicians to obtain pre-approval as a prerequisite for coverage, may decrease drug utilization via a 'sentinel effect', a decrease in utilization caused by external review of prescribing. The purpose of this study was to assess the affect a PA restriction had on the utilization patterns of cefuroxime tablets in a managed care organization (MCO) in Israel. MethodsPhysician prescribing patterns were evaluated by conducting a retrospective drug utilization analysis. Data were derived from the electronic patient records of the MCO studied. All prescriptions for solid state antibiotics for patients diagnosed with an infectious disease written during three parallel 3-month segments, before, during and after a PA restriction for cefuroxime was enforced, were included. Frequency and proportion of antibiotic prescriptions for cefuroxime tablets, distribution of infectious diseases treated with cefuroxime, and the request rejection rate when PA was required were calculated. ResultsPrescriptions for cefuroxime declined from 5538 prescriptions (8.0% of eligible antibiotic prescriptions, 95% CI 7.8, 8.2) in the initial period to 1036 (1.2%, 95% CI 1.1, 1.3) during the PA period, rising to 3961 (4.3%, 95% CI 4.2, 4.4) in the post-PA period. Changes in the distribution of diseases treated with cefuroxime during the PA stage tended to regress after revocation to those observed in the pre-PA period. The rejection rate was found to be 8.5% (95% CI = 6.9, 10.1). ConclusionsThe implementation of a prior authorization requirement for cefuroxime tablets markedly reduced the use of this drug, probably due to a 'sentinel effect'.

Variability in Outpatient Antimicrobial Consumption in Israel

“…Infectious disease specialists conducted lectures on the importance of restricting outpatient antibiotic use to family practitioners, ''Clalit Health Services'' implemented the supervision of specific antibiotic preparations, such as azithromycin, used by each doctor in the outpatient clinics of the northern district, and formal guidelines for the use of antibiotics for common infections encountered in outpatient clinics were issued by ''Clalit Health Services'' in 2005. The effects of these measures can be seen in terms of the prescription of cefuroxime in a number of outpatient clinics in Israel: when restrictions in the prescription of this antibiotic were applied for 3 months, cefuroxime prescriptions dropped from 8 to 1.2% during the restriction period and stabilized at 4.3% after the restriction period [6]. Another study conducted in military outpatient clinics in Israel showed a decline in the prescription of azithromycin following an educational intervention that consisted of issuing guidelines on indications for use [7].…”

Trends in celecoxib and etoricoxib prescribing following removal of prior authorization requirement in Spain

“…One Spanish study found that removal of prior authorization for some topical immunosuppressive medicines (tacrolimus and pimecrolimus) was followed by a sharp increase in the number of prescriptions for such medicines . One study in Israel observed a sharp increase in the number of prescriptions of cefuroxime after removal of cefuroxime prior authorization . And one study in Canada found a sharp increase in the number of prescriptions of glitazones after removal of prior authorization …”

Practice characteristics and prior authorization costs: secondary analysis of data collected by SALT-Net in 9 central New York primary care practices

“…Thus, these findings complement the estimates from previous studies by providing the granularity that is needed to inform both the practice and legislative communities about the burden of prior authorization activities on primary care practices [ 19 ]. It is also important to consider that prior authorization requirements may yield benefits, such as cost savings to the system [ 20 ] or the promotion of rational prescribing trends [ 21 ], although to date, the literature on this point appears to be equivocal [ 2 , 22 - 27 ]. In light of the pivotal role of primary care now and in the future [ 28 - 30 ], the benefits and costs of prior authorization activities in primary care deserves further understanding and action, and primary care offices should be appropriately compensated for this work.…”