Strategic opportunities for effective optimal prescribing and medication management.

BACKGROUND Canadians receive over 422 million prescriptions and spend over $26 billion annually on drugs. Yet, we do not systematically capture information on whether the right drugs reach the right people with the intended benefits, while avoiding unintended harm. It is important to identify and understand the effectiveness of approaches used to improve prescribing and medication use. OBJECTIVE To discuss the medication-use system, identify factors affecting prescribing, and assess effectiveness of interventions. METHODS A literature review was conducted using electronic databases, federal agencies', provincial health departments', health service delivery organizations' and Canadian health research organizations' websites, the Internet, and some hand searching. Interventions identified were categorized according to the Effective Practice and Organization of Care Group (EPOC) classification, with effectiveness based on the literature. RESULTS Factors affecting prescribing relate to the patient and society, medication, prescriber, practice environment and organization, available information and other external factors. Interventions reported as generally effective are multi-faceted interventions, academic detailing, and reminders. Interventions reported as sometimes effective are audit and feedback or physician profiling, local opinion leaders, drug utilization review, and local consensus guidelines. Passive dissemination of educational materials is deemed generally ineffective. CONCLUSIONS No single approach is appropriate for every prescribing problem, health professional prescriber practice or health care setting. Interventions to improve prescribing in community and institutional settings have variable effect sizes. Effectiveness is related to content, delivery mechanisms, intensity, intervention's context, and implementation environment. Even an intervention with a small effect size (< 10%) may yield important changes in drug use when applied on a population basis. Further research and evaluation is needed to determine how or why the interventions work and identify barriers to effective implementation.