Medical evidence and health policy: a marriage of convenience? The case of proton pump inhibitors

Changes in prescription patterns of acid-suppressant medications by Belgian pediatricians: analysis of the national database, [1997-2009]

OBJECTIVE

The aim of this study was to examine the trend in the prescribing of proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H2-RAs) for children in Belgium from 1997 to 2009 to encourage discussion regarding appropriate clinical use.

METHODS

Monthly claim-based data for PPIs and H2-RAs were obtained from the national health insurance database (Pharmanet 1997-2009).

RESULTS

The total monthly volume of all reimbursed antireflux medications, prescribed by Belgian pediatricians, increased 7-fold from 20,782 daily defined doses (DDDs) in January 1997 to 142,912 DDDs in June 2009. During this study period, reimbursed volume of H2-RAs increased from 2575 to 38,996 DDDs and of PPIs from 3472 to 103,926 DDDs per month.

CONCLUSIONS

PPI use has increased substantially in children. Its use does not seem to be commensurate with the prevalence of gastroesophageal reflux disease in children. This study encourages clinical discussion regarding well-considered use of these drugs in children.

Evolutions in both co-payment and generic market share for common medication in the Belgian reference pricing system

BACKGROUND

In Belgium, a co-insurance system is applied in which patients pay a portion of the cost for medicines, called co-payment. Co-payment is intended to make pharmaceutical consumers more responsible, increase solidarity, and avoid or reduce moral hazards.

OBJECTIVE

Our objective was to study the possible influence of co-payment on sales volume and generic market share in two commonly used medicine groups: cholesterol-lowering medication [statins (HMG-CoA reductase inhibitors) and fibrates] and acid-blocking agents (proton pump inhibitors and histamine H2 receptor antagonists).

METHODS AND DATA

The data were extracted from the Pharmanet database, which covers pharmaceutical consumption in all Belgian ambulatory pharmacies. First, the proportion of sales volume and costs of generic products were modelled over time for the two medicine groups. Second, we investigated the relation between co-payment and contribution by the national insurance agency using change-point linear mixed models.

RESULTS

The change-point analysis suggested several influential events. First, the generic market share in total sales volume was negatively influenced by the abolishment of the distinction in the maximum co-payment level for name brands and generics in 2001. Second, relaxation of the reimbursement conditions for generic omeprazole stimulated generic sales volume in 2004. Finally, an increase in co-payment for generic omeprazole was associated with a significant decrease in omeprazole sales volume in 2005. The observational analysis demonstrated several changes over time. First, the co-payment amounts for name-brand and generic drugs converged in the observed time period for both medicine groups under study. Second, the proportion of co-payment for the total cost of simvastatin and omeprazole increased over time for small packages, and more so for generic than for name-brand products. For omeprazole, both the proportion and the amount of co-payment increased over time. Third, over time the prescription of small packages shifted to an emphasis on larger packages.

CONCLUSIONS

As maximum co-payment levels decreased over time, they overruled the reference pricing system in Belgium. The changes in co-payment share over time also significantly affected sales volume, but whether physicians or patients are the decisive actors on the demand side of pharmaceutical consumption remains unclear.

Population-based trend analysis of laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

BACKGROUND

The Nissen and Toupet fundoplications are the most commonly used techniques for surgical treatment of gastroesophageal reflux disease. To date, no population-based trend analysis has been reported examining the choice of procedure and short-term outcomes. This study was designed to analyze trends in the use of Nissen versus Toupet fundoplications, and corresponding short-term outcomes during a 10-year period between 1995 and 2004.

METHODS

A trend analysis was performed of 873 patients (Toupet: 254 patients, Nissen: 619 patients) prospectively enrolled in the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery.

RESULTS

The frequency of the performed techniques remained stable during the observation period (p value for trend 0.206). The average postoperative and total length of hospital stay both significantly decreased during the 10-year period from 5.6 to 4.0 days and 6.8 to 4.8 days, respectively (both p values for trend <0.001). The average duration of surgery decreased significantly from 141 minutes to 121 minutes (p value for trend <0.001). There was a trend towards less complications in later years (2000-2004) compared to early years (1995-1999, p = 0.058). Conversion rates were significantly lower in later years compared with early years (p = 0.004).

CONCLUSIONS

This is the first trend analysis in the literature reporting clinical outcomes of 873 prospectively enrolled patients undergoing Nissen and Toupet fundoplications during a 10-year period. The proportion of laparoscopic Nissen versus Toupet fundoplications remained stable over time, indicating that literature reports of the advantages of one procedure over the other had minimal influence on surgeons' choice of technique. Length of hospital stay, duration of surgery, morbidity, and conversion rate decreased over time, reflecting the learning curve. Clearly, patient outcomes have much improved during the 10-year observation period.