Now, researchers at Stanford University Medical Center have confirmed that a less-common strategy - pill-splitting - could yield significant cost savings without compromising drug efficacy or safety. They emphasize that pill-splitting must be implemented with careful controls and begin with a doctor-patient conversation.
"When properly implemented, pill-splitting can be a safe, viable cost-saving strategy," said Randall Stafford, MD, PhD, a researcher at the Stanford Center for Research in Disease Prevention and lead author of an article published in the August issue of the American Journal of Managed Care. "Physicians should consider using pill-splitting with selected medications and patients, and patients may want to bring it up with their doctors."
Many prescription drugs are available at increased dosages for the same or similar costs as smaller dosages. When physicians prescribe half as many higher-strength pills and have the patient split them to achieve the desired dosage, the cost of certain medications can be reduced as much as 50 percent.
Using pharmacy claims data from a commercial managed-care plan in Massachusetts, Stafford and colleagues examined how often pill-splitting was used. They found the practice was relatively infrequent, accounting for annual savings of $6,200 in the health plan.
Researchers then used a systematic screening process to determine which medications were appropriate for pill-splitting. Starting with the 265 medications most commonly prescribed nationally and within the specific health plan, they narrowed the list in stages. First they eliminated drugs that came prepackaged, weren't available in tablets or were available in only one dosage. They then eliminated medications in which pill-splitting yielded savings of less than 25 percent, based on the average wholesale price. Finally, they eliminated medications in which altering the drug's physical properties could reduce its effectiveness - such as compounds that could become chemically unstable if split.
This screening process yielded a list of 11 medications commonly used by physicians in the health plan, which the researchers determined could be split safely and effectively with significant cost savings (see chart). The average potential savings for each drug, over varying dosages, ranged from 23 to 50 percent. A patient taking a 10-mg tablet of lisinopril daily, for example, would have annual medication costs of $340. By prescribing half the number of 20-mg tablets and splitting them, medication costs would drop to $180 annually.
"As a cost-saving approach, pill-splitting has significant potential," said Stafford, who is an assistant professor of medicine at the Stanford School of Medicine. He calculated that if pill-splitting were fully implemented within the health plan he studied, the plan would save $259,500 annually.
The researchers emphasized that pill-splitting must be implemented with drug-specific and patient-specific criteria to ensure patient safety. Just as certain types of medications are unsuitable for pill-splitting - including extended-release medications and those with enteric coatings - certain patients may be unable to split tablets consistently and accurately. Such patients may include those with poor eyesight, loss of a limb, tremors, debilitating arthritis, dementia or psychosis. The researchers noted that results are best when the patient uses a pill-splitting device and is trained to use it.
Pill-splitting should be embarked upon only after a discussion between physician and patient, Stafford explained. "We're not advocating this as a global solution. It needs to be conducted in the context of doctor-patient communication." He noted that the list of 11 medications he identified for pill-splitting isn't exhaustive and may differ depending on local practices and prices.
The researchers acknowledged that some physicians are reluctant to suggest pill-splitting because of concerns that patients may be unwilling or unable to split pills accurately. Stafford's research suggests that pill-splitting is likely to be safe and effective with appropriate screening, but he said further research is needed on this question.
He noted that pill-splitting would help those who pay for prescription drugs out-of-pocket, including the uninsured and some Medicare beneficiaries. For them, pill-splitting "may make newer, more expensive medications available to people who might not otherwise afford them."
Potential cost savings from pill-splitting:
Clonazepam (Klonopin)/Panic disorder; epilepsy: 41 percent savings*
Doxazosin (Cardura)/Hypertension; prostate enlargement: 46 percent savings
Citalopram (Celexa)/Depression: 46 percent savings
Atorvastatin (Lipitor)/High cholesterol: 33 percent savings
Paroxetine (Paxil)/Depression; anxiety: 46 percent savings
Pravastatin (Pravachol)/High cholesterol: 23 percent savings
Nefazodone (Serzone)/Depression: 49 percent savings
Sildenafil (Viagra)/Impotence: 50 percent savings
Lisinopril (Zestril)/Congestive heart failure; hypertension: 38 percent savings
Sertraline (Zoloft)/Depression: 46 percent savings
Olanzapine (Zyprexa)/Schizophrenia; bipolar disorder: 31 percent savings
*average potential cost savings of pill-splitting, in percentage terms, over varying dosages of each medication
Stanford University Medical Center integrates research, medical education and patient care at its three institutions -- Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital at Stanford. For more information, please visit the Web site of the medical center's Office of Communication & Public Affairs at http://mednews.