Exploring cost awareness as an influence on prescribing behaviours in secondary care: a mixed methods study

Introduction: Making clinicians aware of diagnostic test cost at the point of ordering can reduce expenditure[1]. Application of this principle to medicines at the point of prescribing, therefore, has the potential to change prescribing behaviour but evidence for this is minimal.

Aim: This study aims to explore healthcare professional (HCP) opinion on the introduction of a medication cost display onto an electronic prescribing system (EPS) at the point of prescription.

Method: Questionnaires were developed after review of published literature, subjected to academic scrutiny and piloted on 10 HCPs. Final questionnaires were distributed manually and by e‐mail to a purposive and convenience sample of HCPs based at an acute hospital site in the West Midlands. Audio‐recorded, semi‐structured, face‐to‐face interviews were conducted with 12 prescribing HCPs, transcribed and analysed thematically using the framework method. The study was ethically approved.

Results: 101 questionnaires were completed by a range of HCPs, 82% of whom were prescribers. Approximately half (49%) had been qualified for 6 or more years. Half (50%) rated their cost awareness of medicines as poor and, whilst all of them knew where to find cost information, just over half (55%) felt that they were given insufficient information about it. Two‐thirds (66%) considered cost to have little or no impact on their decision to prescribe, dispense or administer a medicine. Almost all (93%) anticipated that displaying medicine costs on the EPS would change hospital drug expenditure.

All 12 interviewees were prescribers with almost half (46%) having prior exposure to a primary care EPS with readily accessible cost information. The majority (n = 10) considered their awareness of medicines’ cost as poor. Reasons for this fell into three main themes, (a) availability of information, (b) evidence‐based and patient‐centred prescribing approaches and (c) lack of training and education. Only two interviewees felt their cost awareness was good. All participants wanted more cost information but most (n = 7) suggested time constraints prohibited further investigation at the point of prescribing. Most (n = 7) interviewees wanted easily accessible cost information via the EPS and 10 felt that implementing such a system would reduce medication expenditure.

Conclusion: HCPs felt unaware and inadequately informed about the cost of medicines. Counterintuitively, whilst many felt knowledge of medicine cost would not change their practice, most determined that cost information at the point of prescribing would change hospital drug expenditure. In particular, prescribers anticipated a reduction in spend. Good rational prescribing considers efficacy, safety, suitability and cost. Cost‐effectiveness is usually accounted for by local formularies which may explain why most prescribers believed it would not influence their choices. However, this does not account for the anticipated reduction in spend If a cost display was added to the EPS. All HCPs welcomed the proposal to provide more readily available cost information. In this regard, a cost display has the potential to address the perceived lack of cost awareness. This study is limited by the range of questionnaire respondents. Although the majority were prescribers a small minority without prescribing experience may have introduced bias. Previous studies in primary care have shown the introduction of medication costs information within an EPS does not to reduce drug expenditure [2]. This preliminary study which explores perceptions and anticipated behaviours will inform further research into the implementation and impact of an EPS cost display.