When Is It Cost-effective to Change the Behavior of Health Professionals?
Largely because of direct-to-consumer and other marketing efforts that influence physicians to use one product over another, the most widely used medical products are not always the most cost-effective nor highest value option. Policymakers could implement methods to correct for these inefficiencies, but such efforts may be costly, both fiscally and politically. The authors, Mason and colleagues, of this JAMA article call this "policy cost-effectiveness" and they provide a method for calculating it to determine when policy interventions are worthwhile in changing physicians' practice behavior.

Naturally, policymakers are more likely to invest in changing physician behavior for those treatments where the benefit or savings is most substantial. Changes will require:
1. A clear, evidence-based message that current care is suboptimal
2. A forceful estimate of the cost and impact of behavioral change
3. An understanding of local health care organizations

2 suboptimal practices were identified in this article in England: underuse of angiotensin-converting enzyme (ACE) inhibitors for patients with heart failure, and overuse of new antidepressants without demonstrable added value. An economic analysis found that each prescription of the newer antidepressant cost an additional $75 per episode, without added benefit. Patients who did not receive an ACE inhibitor were denied a treatment valued at $2156 per life-year gained. Pharmacists were enlisted to make educational visits to community physicians to attempt to change the behavior in these 2 areas of practice.

After adjusting for the cost of this intervention, the authors conclude that the cost-effectiveness message (regarding ACE inhibitors) was worth implementing, but the cost-saving message (regarding antidepressant selection) was not. The large health benefit achieved by ACE inhibitors was more persuasive than the cost savings achieved by changing the choice of antidepressants.

Thus, interventions to reduce mortality or major morbidity are more likely to be attractive -- both to physicians and to policymakers -- than those aimed at saving costs by switching to a less expensive drug. Other intervention strategies than the one analyzed here could be similarly assessed to determine whether they are worthwhile in achieving physician behavior change.

Mason J, Freemantle N, Nazareth I, Eccles M, Haines A, Drummond M JAMA. 2001;286(23):2988-2992