[Prescription drug consumption recovery following the co-payment change: Evidence from a regional health service]

The impact of an easy access drug supply management policy law on the consumption and abuse of opioids in Catalonia: A population-based study

BACKGROUND

Over the last two decades, the rise in opioid prescription has worsened health outcomes worldwide, increasing both levels of abuse and mortality rates. In order to reduce the scale of this public health problem, new policies have been implemented in many countries. In 2012, Spain adopted new legislation on opioid prescription (the ROE law), which meant that practitioners no longer needed to obtain extra authorisation in order to prescribe strong opioids. The objective of the paper is to assess the impact of this law on opioid use and abuse in Catalonia, Spain.

METHODS

We established two measures of the use of strong and weak opioids: DDDs, and abuse. We used benzodiazepines and antidepressants as controls, and adjusted for age, sex, drug co-payment level, death or near death, cancer diagnosis, morbidity group, and type of prescription. The data were obtained from administrative and dispensing drug databases in a population of 7.5 million inhabitants. We estimated two-way fixed effects using difference in difference models.

RESULTS

The ROE law impacted reducing the monthly use of strong opioids by 0.903 DDDs, representing a 3.15% decrease in the mean monthly use of strong opioids. However, abuse rose 1.86 times compared with the average pre-ROE value, which represents an increase of 11,190 months of opioid abuse (i.e., an 11.33% of all monthly opioids use).

CONCLUSION

The abolition of the duplicate prescription programme for strong opioids led to a reduction in the average monthly use of strong opioids, but an increase in abuse.

Influence of Pharmaceutical Copayment on Emergency Hospital Admissions: A 1978-2018 Time Series Analysis in Spain

No studies have evaluated the influence of pharmaceutical copayment on hospital admission rates using time series analysis. Therefore, we aimed to analyze the relationship between hospital admission rates and the influence of the introduction of a pharmaceutical copayment system (PCS). In July 2012, a PCS was implemented in Spain, and we designed a time series analysis (1978–2018) to assess its impact on emergency hospital admissions. Hospital admission rates were estimated between 1978 and 2018 each month using the Hospital Morbidity Survey in Spain (the number of urgent hospital admissions per 100,000 inhabitants). This was conducted for men, women and both and for all-cause, cardiovascular and respiratory hospital discharges. Life expectancy was obtained from the National Institute of Statistics. The copayment variable took a value of 0 before its implementation (pre-PCS: January 1978–June 2012) and 1 after that (post-PCS: July 2012–December 2018). ARIMA (Autoregressive Integrated Moving Average) (2,0,0)(1,0,0) models were estimated with two predictors (life expectancy and copayment implementation). Pharmaceutical copayment did not influence hospital admission rates (with p-values between 0.448 and 0.925) and there was even a reduction in the rates for most of the analyses performed. In conclusion, the PCS did not influence hospital admission rates. More studies are needed to design health policies that strike a balance between the amount contributed by the taxpayer and hospital admission rates.

[Pharmaceutical copayment in Spain after the 2012 reform from the user's perspective. Evidence of inequity?]

OBJECTIVE

Identify what are the characteristics of the part of the population that says they cannot buy all the medicines prescribed by a public health doctor, relating them to the criteria that define the pharmaceutical co-payment system established by Royal Decree 16/2012, with the purpose of guiding changes that eliminate possible inequities.

METHOD

Association study and causal relationship between the difficulty to buy prescription drugs that users expressed through the survey called Health Barometer and a set of variables that reflect the degree of need for health services and the economic capacity, that is also part of the co-payment criteria, using multiple correspondence and regression analysis techniques.

RESULTS

After the analysis of the data corresponding to the years 2013-2017, evidence has been found in favour of the hypothesis that the poorest users, as well as the working ones and those with worst health show greater difficulties in accessing the medicines which have been prescribed by a public health doctor and, consequently, changes are proposed in the copayment system aimed at eliminating or, at least, reducing such differences.

CONCLUSIONS

The results obtained are compatible with the hypothesis that the current copayment is perceived as a barrier to access necessary medicines by some sectors of the population. Although certain actions aimed at reducing this barrier can be derived from the work, more research that considers the opinion of the users is needed.

The effect of a change in co-payment on prescription drug demand in a National Health System: The case of 15 drug families by price elasticity of demand

Objectives

To test the heterogeneity of the effect of a change in pharmaceutical cost-sharing by therapeutic groups in a Spanish region.

Methods

Data: random sample (provided by the Canary Islands Health Service) of 40,471 people covered by the Spanish National Health System (SNHS) in the Canary Islands. The database includes individualised monthly-dispensed medications (prescribed by the SNHS) from one year before (August 2011) to one year after (June 2013) the Royal Decree Law 16/2012 (RDL 16/2012). Sample: two intervention groups (low-income pensioners and middle-income working population) and one control group (low-income working population). Empirical model: quasi-experimental difference-in-differences design to study the change in consumption (measured in number of monthly Defined Daily Dose (DDDs) per individual) among 13 therapeutic groups. The policy break indicator (three-level categorical variable) tested the existence of stockpiling between the reform’s announcement and its implementation. We ran 16 linear regression models (general, by therapeutic groups and by comorbidities) that considered whether the exclusion of some drugs from public provision impacted on consumption more than the co-payment increase.

Results

General: Reduction (-13.04) in consumption after the reform’s implementation, which was fully compensated by a previous increase (16.60 i.e., stockpiling) among low-income pensioners. The middle-income working population maintained its trend of increasing consumption. Therapeutic groups: Reductions in consumption after the reform’s implementation among low-income pensioners in 7 of the 13 groups, which were fully compensated for by a previous increase (i.e., stockpiling) in 4 groups and partially compensated for in the remaining 3. The analysis without the excluded medicines provided fewer negative coefficients. Comorbidities: Reduction in consumption that was only slightly compensated for by a previous increase (i.e., stockpiling).

Conclusions

The negative impact of cost-sharing produced, among low-income pensioners, a risk of loss of adherence to treatments, which could deteriorate the health status of individuals, especially among pensioners within the most inelastic therapeutic groups (associated with chronic diseases) and patients with comorbidities (also, associated with chronic diseases). Notwithstanding the above, this risk was more related to the exclusion of some drugs from provision than to the cost-sharing increase.

Analysis of changes in trends in the consumption rates of benzodiazepines and benzodiazepine-related drugs

Background

To analyse trends in the rates of consumption of benzodiazepine (BZD) anxiolytics, BZD hypnotics and non-BZD hypnotics and the association with contextual factors.

Methods

Descriptive time series study. Units of analysis were monthly dose per inhabitant per day (DID) and dose per medical card per day(DCD) of benzodiazepine(BZD anxiolytics(BZD-A), BZD hypnotics(BZD-H) and non-BZD hypnotics(Non-BZD-H) between January 2006-December 2015. We analysed 6 primary healthcare districts(PHD) and used defined daily doses (DDDs) to calculate the monthly DIDs(overall and by ATC group). Trends and monthly percentage change (MPC) were analysed through joinpoint regression.

Results

The annual DID increased by 26% overall, the trend was different across ATC groups. Consumption in BZD-A and BZD-H increased (27.1%,61.9%), consumption in Non-BZD-H decreased by 35%. There was high variability in DCD across the PHD, with an overall increase of 10.2%(5.7%-22.9%). By ATC, DCD increased by 10.4% in BZD-A(4.2%-22.2%) and by 44.2% in BZD-H(33.2%-76.5%). The overall DCD in the Non-BZD-H decreased by 42.1%(19.7%-50.8%). We found an initial upward trend in consumption of BZD-A until April/2008(monthly percentage change -MPC- +0.5%), followed by a slightly slower increase (+0.1%). No changes in trend were detected in BZD-H. In Non-BZD-H, we observed an upward trend until February/2013(+0.1%), followed by a sharp decrease until August/2013(-6.3%), and finally a slight decrease(-0.3%).

Conclusions

BZD consumption has increased in the last decade, with variability across areas. The changes in trends do not coincide with the financial crisis, introduction of prescriptions by active ingredient, electronic prescriptions or copayment. The only decrease in the Non-BZD-H may be linked to an intervention.