Is Reclassification of the Oral Contraceptive Pill from Prescription to Pharmacist-Only Cost Effective? Application of an Economic Evaluation Approach to Regulatory Decisions

A qualitative exploration of the over-the-counter availability of oral contraceptive pills in Australia

INTRODUCTION

The prevention of unintended pregnancy is a public health issue affecting women worldwide. In Australia, women are required to get a prescription to obtain the oral contraceptive pill (OCP), which may limit access and be a barrier to its initiation and continuing use. Changing the availability of the OCP from prescription-only to over-the-counter (OTC) is one solution, however, to ensure success policymakers need to understand women's preferences. Telehealth services also might serve as an alternative to obtain prescriptions and increase accessibility to OCPs. This study aims to explore the preferences for OTC OCPs among Australian women, and whether the expansion of telehealth impacted women's preferences.

METHODS

A mixed methods approach was used to explore women's preferences regarding access to the OCP. Focus group discussions (FGDs) were conducted to organically identify the preferences followed by an empirical ranking exercise. Three FGDs in two phases were conducted, pre and post-expansion of telehealth in Australia due to the COVID-19 pandemic. Convenience sampling was employed. The technique of constant comparison was used for thematic analysis where transcripts were analysed iteratively, and codes were allowed to emerge during the process to give the best chance for the attributes to develop from the data.

RESULTS

Thematic analysis revealed that women perceived OTC availability of OCPs as a mechanism to increase the accessibility of contraception by reducing cost, travel time, waiting time, and increasing opening hours. They also believed that it would increase adherence to OCPs. However, some potential safety concerns and logistical issues were raised, including pharmacist training, access to patient's medical history, the ability to discuss other health issues or undertake opportunistic health screening, adherence to checklists, and privacy in the pharmacy environment. Following the expansion of telehealth, accessibility issues such as opening hours, travel time, and location of the facility were considered less important.

CONCLUSIONS

The participants expressed their support for reclassifying OCPs to OTC, particularly for repeat prescriptions, as it would save valuable resources and time. However, some safety and logistical issues were raised. Women indicated they would balance these concerns with the benefits when deciding to use OTC OCPs. This could be explored using a discrete choice experiment. The expansion of telehealth was perceived to reduce barriers to accessing OCPs. The findings are likely to be informative for policymakers deciding whether to reclassify OCPs to OTC, and the concerns of women that need addressing to ensure the success of any policy change.

Self-care with non-prescription medicines to improve health care access and quality of life in low- and middle-income countries: systematic review and methodological approach

Objectives

This study aims to develop a structured framework to capture beneficial effects and determine the value of self-care for individuals and society in low- and middle-income countries (LMICs). A special focus is placed on self-medication with non-prescription medicines.

Methods

PubMed, Google Scholar and websites of associations or organizations were systematically searched for economic studies on self-care and self-medication published between 2000 and 2021. The insights gained from the literature review were incorporated into the development of a decision tree model.

Results

The literature review revealed a lack of research and available data on the role and value of self-care in LMICs. To help close the research gap a methodological framework was developed that defines different settings of self-care, their effects and relevant outcomes and allows a quantification with regard to self-medication in LMICs.

Conclusion

Self-care offers individuals a convenient and reliable way to take care of their own health, especially in LMICs where access to health services can be challenging. In particular it is crucial to improve individuals access to clinically effective, safe and reliable non-prescription medicines.

Application of an economic evaluation approach to making regulatory decisions regarding access to medicines: advantages, challenges and recommendations

Initially patients require a prescription to access most new medicines. Some medicines may later be reclassified, allowing patients to access them without a prescription. Currently, Australian Therapeutic Goods Administration guidelines regarding reclassification decisions focus on patient risk rather than on potential benefits to patient health and the healthcare system. We conducted two extensive case studies demonstrating an economic evaluation approach to medicine reclassification in Australia, which were presented at various conferences and to key stakeholders. This article discusses the advantages and challenges of using an economic evaluation approach to inform medicine reclassification decisions. Advantages identified include systematically and transparently synthesising evidence from multiple sources; predicting the overall expected impact of reclassification on health outcomes and costs before it occurs; considering a broader range of risks and benefits; aggregation of health impacts into a single measure (quality-adjusted life years); identification of drivers of uncertainty; insight into the effects of different regulatory decisions; and improved consistency of evidence. Challenges include data availability and quality, estimating behavioural changes, model complexity, the lack of an incremental cost-effectiveness ratio threshold, and funding of economic analyses. We recommend that regulatory decision makers use an economic evaluation approach to help inform reclassification decisions, although economic evaluation results should be considered as part of the broader body of evidence. Ultimately, the use of an economic evaluation approach will contribute to helping decision makers maximise population health outcomes in an efficient way.What is known about the topic?In the past, decisions regarding medicine reclassification have generally been made using a deliberative approach focusing on patient risk. However, there are also potential benefits to patient health and effects on the healthcare system. Increasing awareness of these benefits have led to the development of alternative approaches to decision making, including an economic evaluation approach.What does this paper add?This article discusses the advantages and challenges of using an economic evaluation approach to inform medicine reclassification decisions compared with alternative approaches.What are the implications for practitioners?Economic evaluation results should be considered as part of the broader body of evidence regarding the types of health impacts, the extent of the available evidence, who will be affected, and the role of medical practitioners and pharmacists in mitigating any risks. However, awareness of the advantages and challenges of this approach in advance will help mitigate some of the challenges and increase acceptance of the economic evaluation results by decision makers and stakeholders.

Physicians' Opinion Regarding Extended Access to Hormonal Contraception in Switzerland

(1) Background: Access to hormonal contraceptives (HC) strongly differs between countries and varies from over the counter (OTC) to prescription-only availability. This study aimed to identify opinions among physicians in Switzerland regarding extended access to HC. (2) Methods: Web-based survey among physicians (gynecologists, general practitioners, and pediatricians) in Switzerland. (3) Results: Hundred sixty-three physicians, mainly gynecologists, participated in this survey and 147 (90%) were included for analysis. A total of 68% (n = 100) answered that prescription-only status could be extended under certain conditions but physicians were concerned about patients' safety (97%, n = 142). Moreover, there was concern about insufficient patient education on HC (93%, n = 136) and that women may forego preventive examinations (80%, n = 118). Participants did not support OTC availability (93%, n = 136). Pharmacists prescribing (including initiation of HC) revealed controversial results, but a combined access model (initial prescription from physician and follow-up prescriptions by pharmacists) found acceptance in 70% (n = 103). (4) Conclusions: Participating physicians stated that prescription-only status for HC could be lifted under certain conditions but also some concerns, e.g., patients' safety or neglection of preventive examinations, were raised. Future research should focus on specific conditions in which extended access to HC could be agreed on.

Development of a pharmacoeconomic registry: an example using hormonal contraceptives

BACKGROUND

Disease-specific registries, documenting costs and probabilities from pharmacoeconomic studies along with health state utility values from quality-of-life studies could serve as a resource to guide researchers in evaluating the published literature and in the conduct of future economic evaluations for their own research. Registries cataloging economic evaluations currently exist, however they are restricted by the type of economic evaluations they include. There is a need for intervention-specific registries, that document all types of complete and partial economic evaluations and auxiliary information such as quality of life studies. The objective of this study is to describe the development of a pharmacoeconomic registry and provide best practices using an example of hormonal contraceptives.

METHODS

An expert panel consisting of researchers with expertise in pharmacoeconomics and outcomes research was convened and the clinical focus of the registry was finalized after extensive discussion. A list of key continuous, categorical and descriptive variables was developed to capture all relevant data with each variable defined in a data dictionary. A web-based data collection tool was designed to capture and store the resulting metadata. A keyword based search strategy was developed to retrieve the published sources of literature. Finally, articles were screened for relevancy and data was extracted to populate the registry. Expert opinions were taken from the panel at each stage to arrive at consensus and ensure validity of the registry.

RESULTS

The registry focused on economic evaluation literature of hormonal contraceptives used for contraception. The registry consisted of 65 articles comprising of 22 cost-effectiveness analyses, 9 cost-utility analyses, 7 cost-benefit analyses, 1 cost-minimization, 14 cost analyses, 10 cost of illness studies and 2 quality of life studies. The best practices followed in the development of the registry were summarized as recommendations. The completed registry, data dictionary and associated data files can be accessed in the supplementary information files.

CONCLUSION

This registry is a comprehensive database of economic evaluations, including costs, clinical probabilities and health-state utility estimates. The collated data captured from published information in this registry can be used to identify trends in the literature, conduct systematic reviews and meta-analysis and develop novel pharmacoeconomic models.

Extended Access to Hormonal Contraception in Pharmacies: A Survey among Swiss Pharmacists

Background: Worldwide the availability to Hormonal Contraceptives (HC) varies from over the counter (OTC) to prescription-only access. In various countries pharmacists are allowed to prescribe HC, although conditions may be different. In Switzerland, HC require a prescription from a physician, although Swiss law allows pharmacists to dispense prescription-only medications in justified exceptional cases without a valid physician’s prescription. This study aimed to identify current dispensing practices for HC in Swiss pharmacies, pharmacists’ knowledge about HC, and their opinion and interest about expanding access to HC. Methods: Web-based survey among Swiss pharmacists. Results: This survey was completed by 397 registered pharmacists and 331 (83%) were included for analysis. The survey showed that 21% of respondents regularly dispense HC without prescription and that a high number of participants are either very interested (57%, n = 189) or rather interested (33%, n = 110) in extended pharmacy access to HC. The majority did not or rather not support physician’s prescription-only status (77%, n = 256) or OTC availability (94%, n = 310). Furthermore, surveyed pharmacists are willing to train for contraception services (90%, n = 299). According to participants, resistance of physicians is the most relevant barrier to this service (88%, n = 292). Conclusion: Surveyed pharmacists are interested in extended access to HC.