The article “Rethinking Your Approach to Prescription ‘Refills'” [November/December 2011; ] lists dangers and precautions, but it misses the patient perspective.

The cost of medical care in the United States, which is the highest in the world, demands cost-lowering efforts. The authors’ suggestion to require an office visit for refills would increase patients’ expenses. Many patients are on multiple medications, some prescribed by their specialist physicians, who often expect the primary physician to continue these medicines, especially if they are for chronic conditions. Requiring an office visit to refill each one is unreasonable. The dates these prescriptions end may well be at random intervals, and continuous tracking of expiration dates can be difficult for some patients, especially the elderly on multiple medications. Additionally, vacations and out-of-town emergencies can make it difficult for patients to assure an adequate supply of their medications, especially with state laws that prohibit pharmacy refill of medicines more than two weeks before the medication should have run out.

Recurrent conditions that have responded well to a previous regimen should not always need an office visit, especially if the frequency of the episodes is not changing and the patient has used the same regimen for a long time (think migraines, asthma attacks, etc.).

The physician should always try to know his or her patients well enough to individualize patient care. For the reasons stated above, the patient can be justly irritated when told by a staff member that “the doctor requires an office visit before refilling a prescription.”

Authors’ response:

We support Dr. Gimlett’s observation that patient perspective is pivotal to practice improvements. We also seek cost-effective solutions to improving care while assuring convenience for patients and doctors. Our article included specific examples of how to do both. A key point is to write and synchronize prescriptions for all chronic medications when you have the patient, chart, consultant’s recommendations, bottles of home medicines, etc., in one place. Ad hoc telephone prescribing based on a receptionist’s message or a pharmacy’s fax is inadequate.

If you write prescriptions with sufficient quantities and refills, stable patients (who are seen at least once a year, as standards of care advise) will always be able to receive their chronic medications from their pharmacy. As we described in our article, a doctor may write a prescription to cover 12 to 24 months of medication (for example, dispense 90 pills with four refills). This approach will drastically reduce, if not eliminate, requests for interval prescriptions. It bears repeating: There is never a need for a patient to request “refills” from a doctor. Refills are provided by pharmacists. They scan and file new prescriptions until needed or until a third-party payer allows their dispensing. Some pharmacies also work with patients to establish home delivery, coordinate dispensing times, and support adherence to complex medication regimens.

For conditions like herpes simplex virus or asthma, it makes more sense to prescribe anticipatory refills for recurrences than to direct patients to reactively call your office when they are in need of more medications, which interrupts the care of others. The patient would then promptly receive the medication directly from the pharmacy rather than indefinitely waiting (while getting worse) for an office protocol to grind out a new prescription.

We reviewed the legal and practical distinctions between new prescriptions and refills, and alerted doctors to the dangers of telephoning new prescriptions instead of providing physician access, proper assessment, and competent decision-making. Misunderstanding the difference between the two fosters a precarious reliance on clerical actions instead of clinical care.

We believe it is safer, more efficient, and less expensive if the prescribing interval for new prescriptions is matched to the clinical need for reevaluation and sufficient quantities of medications are prescribed with refills at the same time. Clerical substitutions for clinical care are distracting, are expensive, and only vaguely parallel clinical evaluations. Along with the unhelpful attitude that “It’s just a refill,” they should be scrapped. Family medicine doctors are highly cost effective, not because of a willingness to skip clinical evaluations but because of their unique, exam-dependent insight to a patient’s complete health.