Combination of prescribing restrictions and policies to engineer low prices to reduce reimbursement costs

The Effects of the National Centralized Drug Purchasing Pilot Program on Nucleos(t)ide Analogs in Shenzhen City: An Interrupted Time Series Analysis

Objectives: To assess the effects of the National Centralized Drug Purchasing Pilot Program on nucleos(t)ide analogs (NAs) in Shenzhen city. Methods: Drugs procurement records in medical institutions were analyzed covering the period from January 2018 to December 2019. An interrupted time series (ITS) analysis was used to evaluate the impact of the "4+7" pilot policy on NAs in Shenzhen city. The outcome measures were usage volume, expenditures, daily cost, and distribution structure of NAs. Findings: After the introduction of the "4+7" pilot policy, the defined daily doses (DDDs) of NA drugs increased by 76.48%, the expenditures and defined daily dose cost (DDDc) of NAs decreased by 45.43 and 69.08%, respectively. The proportion of winning products in Entecavir and Tenofovir Fumarate DDDs was increased by 64.21 and 19.20%, respectively. The post-intervention period witnessed a significant increase in the regression level for NAs DDDs (level coefficient: β₂ = 631.87, p < 0.05). The expenditures (trend coefficient: β₃ = 392.24, p < 0.05) and DDDc (level coefficient: β₂ = -6.17, p < 0.001; trend coefficient: β₃ = -0.21, p < 0.05) of NAs showed decreasing trend in the post-intervention period. The expenditures of original products and generic products both showed a decreasing trend in the post-intervention period (trend coefficient: β₃ = -372.78, p < 0.05, trend coefficient: β₃ = -130.78, p < 0.05, respectively). The DDDc of original products in the policy-related varieties was a significant decrease in the regression slope and level (level coefficient: β₂ = -2.18, p < 0.05; trend coefficient: β₃ = -0.32, p < 0.01). Conclusion: After the implementation of the"4+7" policy, the DDDc of NAs decreased, the accessibility of policy-related drugs was improved, and the usage of generic medicine was promoted.

Utilisation Trend of Long-Acting Insulin Analogues including Biosimilars across Europe: Findings and Implications

BACKGROUND

Diabetes mellitus rates and associated costs continue to rise across Europe enhancing health authority focus on its management. The risk of complications is enhanced by poor glycaemic control, with long-acting insulin analogues developed to reduce hypoglycaemia and improve patient convenience. There are concerns though with their considerably higher costs, but moderated by reductions in complications and associated costs. Biosimilars can help further reduce costs. However, to date, price reductions for biosimilar insulin glargine appear limited. In addition, the originator company has switched promotional efforts to more concentrated patented formulations to reduce the impact of biosimilars. There are also concerns with different devices between the manufacturers. As a result, there is a need to assess current utilisation rates for insulins, especially long-acting insulin analogues and biosimilars, and the rationale for patterns seen, among multiple European countries to provide future direction. Methodology. Health authority databases are examined to assess utilisation and expenditure patterns for insulins, including biosimilar insulin glargine. Explanations for patterns seen were provided by senior-level personnel.

RESULTS

Typically increasing use of long-acting insulin analogues across Europe including both Western and Central and Eastern European countries reflects perceived patient benefits despite higher prices. However, activities by the originator company to switch patients to more concentrated insulin glargine coupled with lowering prices towards biosimilars have limited biosimilar uptake, with biosimilars not currently launched in a minority of European countries. A number of activities were identified to address this. Enhancing the attractiveness of the biosimilar insulin market is essential to encourage other biosimilar manufacturers to enter the market as more long-acting insulin analogues lose their patents to benefit all key stakeholder groups.

CONCLUSIONS

There are concerns with the availability and use of insulin glargine biosimilars among European countries despite lower costs. This can be addressed.

Current utilization patterns for long-acting insulin analogues including biosimilars among selected Asian countries and the implications for the future

INTRODUCTION

Prevalence rates for diabetes mellitus continue to rise, which, coupled with increasing costs of complications, has appreciably increased expenditure in recent years. Poor glycaemic control including hypoglycaemia enhances complication rates and associated morbidity, mortality and costs. Consequently, this needs to be addressed. Whilst the majority of patients with diabetes have type-2 diabetes, a considerable number of patients with diabetes require insulin to help control their diabetes. Long-acting insulin analogues were developed to reduce hypoglycaemia associated with insulin and help improve adherence, which can be a concern. However, their considerably higher costs have impacted on their funding and use, especially in countries with affordability issues. Biosimilars can help reduce the costs of long-acting insulin analogues thereby increasing available choices. However, the availability and use of long-acting insulin analogues can be affected by limited price reductions versus originators and limited demand-side initiatives to encourage their use. Consequently, we wanted to assess current utilisation rates for long-acting insulin analogues, especially biosimilars, and the rationale for patterns seen, across multiple Asian countries ranging from Japan (high-income) to Pakistan (lower-income) to inform future strategies.

METHODOLOGY

Multiple approaches including assessing utilization and prices of insulins including biosimilars among six Asian countries and comparing the findings especially with other middle-income countries.

RESULTS

Typically, there was increasing use of long-acting insulin analogues among the selected Asian countries. This was especially the case enhanced by biosimilars in Bangladesh, India, and Malaysia reflecting their perceived benefits. However, there was limited use in Pakistan due to issues of affordability similar to a number of African countries. The high use of biosimilars in Bangladesh, India and Malaysia was helped by issues of affordability and local production. The limited use of biosimilars in Japan and Korea reflects limited price reductions and demand-side initiatives similar to a number of European countries.

CONCLUSIONS

Increasing use of long-acting insulin analogues across countries is welcomed, adding to the range of insulins available, which increasingly includes biosimilars. A number of activities are needed to enhance the use of long-acting insulin analogue biosimilars in Japan, Korea and Pakistan.

Evidence-based public policy making for medicines across countries: findings and implications for the future

Aim: Global expenditure on medicines is rising up to 6% per year driven by increasing prevalence of non-communicable diseases (NCDs) and new premium priced medicines for cancer, orphan diseases and other complex areas. This is difficult to sustain without reforms. Methods: Extensive narrative review of published papers and contextualizing the findings to provide future guidance. Results: New models are being introduced to improve the managed entry of new medicines including managed entry agreements, fair pricing approaches and monitoring prescribing against agreed guidance. Multiple measures have also successfully been introduced to improve the prescribing of established medicines. This includes encouraging greater prescribing of generics and biosimilars versus originators and patented medicines in a class to conserve resources without compromising care. In addition, reducing inappropriate antibiotic utilization. Typically, multiple measures are the most effective. Conclusion: Multiple measures will be needed to attain and retain universal healthcare.

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future

Background: Diabetes mellitus rates continue to rise, which coupled with increasing costs of associated complications has appreciably increased global expenditure in recent years. The risk of complications are enhanced by poor glycaemic control including hypoglycaemia. Long-acting insulin analogues were developed to reduce hypoglycaemia and improve adherence. Their considerably higher costs though have impacted their funding and use. Biosimilars can help reduce medicine costs. However, their introduction has been affected by a number of factors. These include the originator company dropping its price as well as promoting patented higher strength 300 IU/ml insulin glargine. There can also be concerns with different devices between the manufacturers. Objective: To assess current utilisation rates for insulins, especially long-acting insulin analogues, and the rationale for patterns seen, across multiple countries to inform strategies to enhance future utilisation of long-acting insulin analogue biosimilars to benefit all key stakeholders. Our approach: Multiple approaches including assessing the utilisation, expenditure and prices of insulins, including biosimilar insulin glargine, across multiple continents and countries. Results: There was considerable variation in the use of long-acting insulin analogues as a percentage of all insulins prescribed and dispensed across countries and continents. This ranged from limited use of long-acting insulin analogues among African countries compared to routine funding and use across Europe in view of their perceived benefits. Increasing use was also seen among Asian countries including Bangladesh and India for similar reasons. However, concerns with costs and value limited their use across Africa, Brazil and Pakistan. There was though limited use of biosimilar insulin glargine 100 IU/ml compared with other recent biosimilars especially among European countries and Korea. This was principally driven by small price differences in reality between the originator and biosimilars coupled with increasing use of the patented 300 IU/ml formulation. A number of activities were identified to enhance future biosimilar use. These included only reimbursing biosimilar long-acting insulin analogues, introducing prescribing targets and increasing competition among manufacturers including stimulating local production. Conclusions: There are concerns with the availability and use of insulin glargine biosimilars despite lower costs. This can be addressed by multiple activities.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

Impact of removal and restriction of me-too medicines in a hospital drug formulary on in- and outpatient drug prescriptions: interrupted time series design with comparison group

BACKGROUND

The study covered in- and out-of-hospital care in a region in north-western Spain. The intervention evaluated took the form of a change in the hospital drugs formulary. Before the intervention, the formulary contained four of the five low molecular weight heparins (LMWHs) marketed in Spain. The intervention consisted of withdrawing two LMWHs (bemiparin and dalteparin) from the formulary and restricting the use of another (tinzaparin), leaving only enoxaparin as an unrestricted prescription LMWH. Accordingly, the aim of this study was to evaluate the effect on in- and outpatient drug prescriptions of removing and restricting the use of several LMWHs in a hospital drugs formulary.

METHODS

We used a natural, before-after, quasi-experimental design with a control group and monthly data from January 2011 to December 2016. Based on data drawn from official Public Health Service sources, the following dependent variables were extracted: defined daily doses (DDD) per 1000 inhabitants per day (DDD/TID), DDD per 100 stays per day, and expenditure per DDD.

RESULTS

The two compounds that were removed from the formulary registered an immediate decrease at both an intra- and out-of-hospital level (66.6% and 55.6% for bemiparin and 73.0% and 92.2% for dalteparin, respectively); similarly, the compound that was restricted also registered an immediate decrease (36.1% and 9.0% at the in- and outpatient levels, respectively); in contrast, the remaining LMWH (enoxaparin) registered an immediate, significant increase at both levels (44.9% and 32.6%, respectively). The intervention led to an immediate reduction of 6.8% and a change in trend in out-of-hospital cost/DDD; it also avoided an expenditure of €477,317.1 in the 21 months following the intervention.

CONCLUSIONS

The results indicate that changes made in a hospital drugs formulary towards more efficient medications may lead to better use of pharmacotherapeutic resources in its health catchment area.

Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence

Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.

Changes in prescription pattern, pharmaceutical expenditure and quality of care after introduction of reimbursement restriction in diabetes in Korea

Background

To ensure effective prescription practices and reduce diabetes-related pharmaceutical expenditures, Korea adopted a clinical practice guideline for the reimbursement system. Health care providers cannot receive reimbursement from National Health Insurance(NHI) unless it is for an appropriate prescription under the predefined clinical condition. The aim of this study was to evaluate prescription patterns in oral hypoglycemic agents, costs and effects on patient care since the introduction of the diabetes reimbursement restriction.

Methods

We used claim data from 2008 to 2013, which included 26 315 diabetes patients and 9907 hospitals. An interrupted time series study design using generalized estimating equations was used to evaluate changes in patterns of single and combination therapy, brand name drug prescriptions, cost and hospital admission following the reimbursement restriction.

Results

Following reimbursement restriction initiation, we found a statistically significant decrease in the average prescription rate of brand name drugs (-6.2%), whereas single therapy prescription increased (9.9%). There was also a reduction in trend change in the monthly prescription rate for combination therapy (-1.7%) and brand name drugs (-0.8%). For single therapy, the trend change in prescription rate increased after the intervention (0.8%). A reduction of trend change in pharmaceutical costs (-0.3%) was observed. However, we did not find a significant change in hospital admission for diabetes.

Conclusions

Reimbursement restriction affects both pharmaceutical costs and physicians' decisions to prescribe oral hypoglycemic agents. We did not observe a significant reduction in quality of care following the intervention. Collectively, these findings indicate that reimbursement restriction has improved effective drug utilization and decreased health expenditures.

EudraVigilance Medicines Safety Database: Publicly Accessible Data for Research and Public Health Protection

The analysis of safety data from spontaneous reporting systems has a proven value for the detection and analysis of the risks of medicines following their placement on the market and use in medical practice. EudraVigilance is the pharmacovigilance database to manage the collection and analysis of suspected adverse reactions to medicines authorised in the European Economic Area. EudraVigilance first operated in December 2001, with access to the database being governed by the EudraVigilance access policy. We performed a literature search including data up to December 2016 to demonstrate how the data from EudraVigilance has been used in scientific publications. We describe the results, including by type of publication, research topics and drugs involved. In 50% of the publications, the data are used to describe safety issues, in 44% to analyse methodologies used in pharmacovigilance activities and in 6% to support clinical perspectives. We also outline a description of the use of the database by the European Union regulatory network. Driven by the full implementation of the 2010 pharmacovigilance legislation, EudraVigilance has undergone further enhancements together with a major revision of its access policy, taking into account the use of the new individual case safety report standard developed by the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use and the International Organization for Standardization. The aim of the broadened access is to facilitate more effective safety monitoring of authorised medicines, to make more data available for research and to provide better access to information on suspected adverse reactions for healthcare professionals and patients. In November 2017, the new full functionalities of EudraVigilance were launched, including the extensive web access to data on suspected adverse drug reactions and the possibilities for academic research institutions to request a more extensive dataset for the purposes of health research. The main objective of this article is to describe the new access to the database together with the opportunities that this new access can bring for research. It is intended to promote an appropriate use of the data to support the safe and effective use of medicines.

Statin use in Brazil: findings and implications

INTRODUCTION AND OBJECTIVES

Statins have become an integral part of treatment to reduce cardiac events in patients with cardiovascular disease. However, their use within the public healthcare system in Brazil is unknown. Consequently, we sought to determine and characterize statin use in primary healthcare delivered by the public health system (SUS) in Brazil and evaluate associated patient factors to improve future use.

METHODS

Cross-sectional study with a national representative sample from five Brazilian regions, derived from the National Survey on Access, Use and Promotion of Rational Use of Medicines using a multi-stage complex sampling plan. Patients over 18 years old were interviewed from July 2014 to May 2015. The prevalences of statin use and self-reported statin adherence were determined amongst medicine users. The associations between statin use and sociodemographic/health condition variables were assessed using logistic regression.

RESULTS

A total of 8803 patients were interviewed, of whom 6511 were medicine users. The prevalence of statin use was 9.4% with simvastatin (90.3%), atorvastatin (4.7%) and rosuvastatin (1.9%) being the most used statins. Poor adherence was described by 6.5% of patients. Statin use was significantly associated with age ≥65 years old, higher educational level, residence in the South, metabolic and heart diseases, alcohol consumption and polypharmacy.

CONCLUSIONS

This is the first population based study in Brazil to assess statin use in SUS primary healthcare patients. Addressing inequalities in access and use of medicines including statins is an important step in achieving the full benefit of statins in Brazil, with the findings guiding future research and policies.

Analysis of the influence of recent reforms in China: cardiovascular and cerebrovascular medicines as a case history to provide future direction

BACKGROUND

Pharmaceutical expenditure has grown by 16% per annum in China, enhanced by incentives for physicians and hospitals. Hospital pharmacies dispense 80% of medicines in China, accounting for 46% of total hospital expenditure. Principal measures to moderate drug expenditure growth include pricing initiatives as limited demand-side measures.

OBJECTIVE

Assess current utilization and expenditure including traditional Chinese medicines (TCMs) between 2006 and 2012.

METHODS

Uncontrolled retrospective study of medicines to treat cardiovascular and cerebrovascular diseases in one of the largest hospitals in southwest China.

RESULTS

Utilization increased 3.3-fold for cerebrovascular medicines, greatest for TCMs, with expenditure increasing 4.85-fold. Low prices for generics were seen, similar to Europe. However, there was variable utilization of generics at 29-31% of total product volumes in recent years. There continued to be irrationality in prescribing with high use of TCMs, and the utilization of different medicines dropping significantly once they achieved low prices.

CONCLUSION

Prices still have an appreciable impact on utilization in China. Potential measures similar to those implemented among western European countries could improve prescribing rationality and conserve resources.

Effects of drug price reduction and prescribing restrictions on expenditures and utilisation of antihypertensive drugs in Korea

OBJECTIVES

To evaluate the quantitative effects of the drug price reduction on pharmaceutical expenditures and the new guidelines to restrict prescribing on drug utilisation for antihypertensive drugs.

DESIGN

We used an interrupted time series design with the National patient sample data of Health Insurance Review and Assessment Service in South Korea.

METHODS

54,295 participants who were with primary hypertension from the National patient sample data of Health Insurance Review and Assessment Service were included. The study period was from March 2011 to December 2013. The dependent variables were antihypertensive drug costs, antihypertensive drug cost per prescribing day, daily drug utilisation, average number of drugs per month, percentage of original drugs per prescription, drug overutilisation and prohibited combinations. Segmented regression analysis was used.

RESULTS

The drug price reduction reduced expenditure (US$-1.51, -10.2%), and the new guidelines reduced expenditures even more (US$-2.13; -16.2%). These policies saved US$4.22 (28%) of antihypertensive drug costs per patient in December 2013 compared to March 2012. Drug price reduction policy was introduced in April 2012. We established the policy effect by comparing it before (March 2012) with after(21 months later-December 2012). The effects of the guidelines decreased expenditures, daily drug utilisation and the average number of drugs per month more than did the drug price reduction.

CONCLUSIONS

Both policies saved money. The guidelines were more effective over time and had fewer side effects such as increasing daily drug utilisation and number of drugs than the effects of drug price reduction.

Quality and efficiency of statin prescribing across countries with a special focus on South Africa: findings and future implications

INTRODUCTION

Statins are recommended first-line treatment for hyperlipidemia, with published studies suggesting limited differences between them. However, there are reports of under-dosing. South Africa has introduced measures to enhance generic utilization. Part one documents prescribed doses of statins in 2011. Part two determines the extent of generics versus originator and single-sourced statins in 2011 and their costs.

RESULTS

Underdosing of simvastatin in 2011 with average prescribed dose of 23.7 mg; however, not for atorvastatin (20.91 mg) or rosuvastatin (15.02 mg). High utilization of generics versus originators at 93-99% for atorvastatin and simvastatin, with limited utilization of single-sourced statins (22% of total statins - defined daily dose basis), mirroring Netherlands, Sweden and UK. Generics priced 33-51% below originator prices.

DISCUSSION

Opportunity to increase simvastatin dosing through education, prescribing targets and incentives. Opportunity to lower generic prices with generic simvastatin 96-98% below single-sourced prices in some European countries.

Measures to improve angiotensin receptor blocker prescribing efficiency in the UK: findings and implications

BACKGROUND

Generic losartan provides an opportunity to enhance angiotensin receptor blocker (ARB) prescribing efficiency, with all ARBs essentially being similar. Initially, there was limited activity in NHS Bury (UK). This changed in March 2011 with therapeutic switching and other measures encouraging the prescribing of losartan following generics to enhance its utilization versus patented ARBs.

AIM

This study aims to assess the impact of multiple measures on losartan utilization, its price and total ARB expenditure.

METHODS

An interrupted time series analysis was performed. Utilization was measured as prescription items dispensed, typically 28 days.

RESULTS

No immediate change in losartan utilization was observed following generics. This changed after the multiple initiatives with losartan accounting for 65% of all single ARB items dispensed by the study end. ARB expenditure was 59% below prestudy levels by the study end, which was helped by a 92% reduction in expenditure per item for losartan. Annual net savings from the program were estimated at just under GB£290,000, which is over eight-times the cost of implementation.

CONCLUSION

Multiple measures can enhance prescribing efficiency. Health authorities cannot rely on a 'spillover' effect from other classes in order to affect changes in physician prescribing habits.

Ongoing measures to enhance the efficiency of prescribing of proton pump inhibitors and statins in The Netherlands: influence and future implications

BACKGROUND

Multiple reforms have recently been introduced in The Netherlands to improve prescribing efficiency. These include preference pricing policies for multiple sourced products, guidelines, and quality and efficiency targets, as well as regular pharmacotherapy meetings.

OBJECTIVES

Assess the influence of these multiple measures on prescribing efficiency.

METHODS

Retrospective observational study of all reimbursed prescriptions for proton pump inhibitors and statins between 2000 and 2010 using the Genees-en hulpmiddelen Informatie Project (Health Insurance) database. Utilization measured in defined daily doses. Narrative review of reforms.

RESULTS

Reimbursed expenditure for the proton pump inhibitors fell by 58% in 2010 versus 2000 despite a threefold increase in utilization, helped by increasing utilization of generic omeprazole at only 2% of the prepatent loss price in 2010. Similarly, reimbursed expenditure for the statins fell by 14% in 2010 versus 2000 despite a 3.8-fold increase in utilization. Again, this was helped by increasing utilization of generic simvastatin at only 2% of the prepatent loss originator price.

CONCLUSION

Multiple supply and demand measures, including the preference pricing policy, appear to have appreciably enhanced proton pump inhibitor and statin prescribing efficiency, providing examples to other countries.

Possible ways to enhance renin-angiotensin prescribing efficiency: Republic of Serbia as a case history?

BACKGROUND

Multiple reforms have been instigated across Europe to enhance prescribing efficiency. Supply-side reforms in the Republic of Serbia include measures to lower the price of generics and originators, with demand-side measures including patient copayments and prescribing restrictions. Specific measures for renin-angiotensin inhibitor drugs include a 50% copayment for angiotensin receptor blockers (ARBs) versus approximately 50 cents per prescription for established angiotensin-converting enzyme inhibitors (ACEIs), as there is no perceived difference in effectiveness between the two classes.

OBJECTIVES

To assess the influence of these measures on ARB utilization, as well as reimbursed prices of ACEIs and ARBs over time.

METHOD

Observational retrospective case study of all ambulatory care patients in the Republic of Serbia's Health Insurance Fund database who were dispensed at least one ACEI or ARB alone or in combination (fixed dose combination [FDC]) between 2005 and 2011. Utilization measured in defined daily doses (DDDs) and only reimbursed expenditure (overall and expenditure/DDD) as Health Insurance perspective.

RESULTS

There was a 1.8-fold increase in renin-angiotensin inhibitor drug utilization, rising to 207.4 DDDs/1000 inhabitants per day in 2011. This is driven principally by a 19.6-fold increase in ACEI FDCs. There was only limited utilization of ARBs at just 2% of total renin-angiotensin inhibitor drugs in 2011. Reimbursed expenditure increased 2.54-fold due to an appreciable increase in ACEI FDC utilization at approximately twice the cost of ACEIs in recent years. Alongside this, we noted considerable differences in expenditure/DDD for different ACEIs. CONCLUSION & FUTURE PERSPECTIVE: High patient copayments for ARBs appreciably limited their utilization in Serbia, which mirrors the findings from other studies. Potential future measures to enhance prescribing efficiency include reference pricing for ACEIs based on the lowest price of an established ACEI. In addition, reference pricing for FDCs should be based on the reference price of the individual components combined. This builds on recent reforms restricting the reimbursement of FDCs until 3 months after individual components have been prescribed separately.

Multiple policies to enhance prescribing efficiency for established medicines in Europe with a particular focus on demand-side measures: findings and future implications

INTRODUCTION

The appreciable growth in pharmaceutical expenditure has resulted in multiple initiatives across Europe to lower generic prices and enhance their utilization. However, considerable variation in their use and prices.

OBJECTIVE

Assess the influence of multiple supply and demand-side initiatives across Europe for established medicines to enhance prescribing efficiency before a decision to prescribe a particular medicine. Subsequently utilize the findings to suggest potential future initiatives that countries could consider.

METHOD

An analysis of different methodologies involving cross national and single country retrospective observational studies on reimbursed use and expenditure of PPIs, statins, and renin-angiotensin inhibitor drugs among European countries.

RESULTS

Nature and intensity of the various initiatives appreciably influenced prescribing behavior and expenditure, e.g., multiple measures resulted in reimbursed expenditure for PPIs in Scotland in 2010 56% below 2001 levels despite a 3-fold increase in utilization and in the Netherlands, PPI expenditure fell by 58% in 2010 vs. 2000 despite a 3-fold increase in utilization. A similar picture was seen with prescribing restrictions, i.e., (i) more aggressive follow-up of prescribing restrictions for patented statins and ARBs resulted in a greater reduction in the utilization of patented statins in Austria vs. Norway and lower utilization of patented ARBs vs. generic ACEIs in Croatia than Austria. However, limited impact of restrictions on esomeprazole in Norway with the first prescription or recommendation in hospital where restrictions do not apply. Similar findings when generic losartan became available in Western Europe.

CONCLUSIONS

Multiple demand-side measures are needed to influence prescribing patterns. When combined with supply-side measures, activities can realize appreciable savings. Health authorities cannot rely on a "spill over" effect between classes to affect changes in prescribing.

The influence of hospital drug formulary policies on the prescribing patterns of proton pump inhibitors in primary care

AIM

This study had two aims: Firstly, to describe how prescriptions for proton pump inhibitor (PPI) in primary care were influenced by a change of the hospital drug policy, and secondly, to describe if a large discount on an expensive PPI (esomeprazole) to a hospital would influence prescribing patterns after discharge.

METHODS

This register study was conducted at Odense University Hospital, Denmark, and by use of pharmacy dispensing data and a hospital-based pharmacoepidemiological database, the medication regimens of patients were followed across hospitalisation. The influence of hospital drug policy on prescribings in primary care was measured by the likelihood of having a high-cost PPI prescribed before and after change of drug policy.

RESULTS

In total, 9,341 hospital stays in 2009 and 2010 were included. The probability of a patient to be prescribed an expensive PPI after discharge decreased from 33.5 to 9.4%, corresponding to a risk ratio of 0.28. In primary care after discharge, 13.4% of esomeprazole use was initiated in the hospital, and this was 8.4% for PPIs in general. After the change of hospital drug policy, this decreased to 6.5% for esomeprazole and increased for the recommended PPIs pantoprazole and lansoprazole to 14.6 and 26.1%, respectively. The effect of a large discount on expensive PPI to hospital was 14.7%, and this decreased to 2.6% when coordinating drug policy in hospital and primary care.

CONCLUSION

The likelihood of having an expensive PPI prescribed after hospital stay decreased when coordinating drug policy and the influence of a large discount to hospital could be minimised.

Insulin glargine in a Brazilian state: should the government disinvest? An assessment based on a systematic review

INTRODUCTION AND OBJECTIVE

The costs of the insulin analogue (insulin glargine) have been growing appreciably in the State of Minas Gerais in Brazil, averaging 291% per year in recent years. This growth has been driven by an increasing number of successful law suits and a 536% price difference between insulin glargine and neutral protamine Hagedorn (NPH) insulin. One potential way to address this is to undertake a systematic review assessing the efficacy and safety of insulin glargine analogue compared with NPH insulin in patients with type 1 diabetes mellitus (T1DM), and, as a result, provide published data to support future recommended activities by the State of Minas Gerais. These could include maintaining it on the list of the Public Health System (SUS) provided there is a price reduction. Alternatively, the review could provide potential arguments to defend against future law suits should the authorities decide to delist insulin glargine.

METHODS

A systematic review of published studies researching the effectiveness of insulin glargine in patients with T1DM between January 1970 and July 2009 in MEDLINE (PubMed), the Latin American and Caribbean Centre on Health Sciences Information, the Cochrane Controlled Trials Databases and the National Health Service Centre for Reviews and Dissemination. Inclusion criteria included insulin glargine on its own or combined with other insulin formulations. Only randomised controlled clinical trials were included. Initially, the titles of all studies were assessed by two independent reviewers before being potentially discarded, with the quality of papers assessed using a modified Jadad scale. The outcome measures included blood levels of glycated haemoglobin, episodes of hypoglycaemia, adverse effects and the reduction of microvascular and macrovascular end-organ complications of T1DM.

RESULTS

Out of 803 studies found in the selected databases, only eight trials met the inclusion criteria. Most of the studies were of poor methodological quality or had a high risk of bias, with a mean score of 2.125 on the Jadad scale. No study could be classified as double-blind, and only one study documented the increased efficacy of insulin glargine in relation to both glycaemic control and hypoglycaemic episodes. Typically, there was no significant difference between insulin glargine and NPH insulins.

CONCLUSIONS

This systematic review showed no therapeutic benefit of insulin glargine over other insulin formulations studied when analysing together glycaemic control and the frequency and severity of hypoglycaemia. We therefore recommend to the State Authority to delist insulin glargine or renegotiate a price reduction with the manufacturer. This systematic review provides support for this decision as well as documentation to combat potential law suits if discussions are unsatisfactory.

Generic atypical antipsychotic drugs in Belgium: their influence and implications

Introduction: Generic atypical antipsychotic drugs should be a focus of attention given their expenditure. However, there is a recognized need to tailor treatments. There were no specific measures in Belgium to enhance the prescribing of oral risperidone following generics in January 2008. Prescribing restrictions have remained for long-acting risperidone injections throughout. Objective: Assess changes in risperidone utilization before and after oral generics were reimbursed, as well as the utilization and expenditure of the various risperidone preparations. Method: Principally a retrospective observational study and interrupted time series design. Results: As expected, no increased utilization of oral risperidone after generics. Both originator and generic oral risperidone prescribed, with the originator reducing its price. Generic risperidone was 59% below prepatent loss prices by September 2012. Conclusion: Authorities cannot rely on a ‘spill over’ of learning from other disease areas to affect changes in physician prescribing habits. Specific measures are needed to encourage generic risperidone where appropriate. However, their influence will be limited by the complexity of the disease area.

A price and use comparison of generic versus originator cardiovascular medicines: a hospital study in Chongqing, China

BACKGROUND

Developed countries use generic competition to contain pharmaceutical expenditure. China, as a developing and transitional country, has not yet deemed an increase in the use of generic products as important; otherwise, much effort has been made to decrease the drug prices. This paper aims to explore dynamically the price and use comparison of generic and originator drugs in China, and estimate the potential savings of patients from switching originator drugs to generics.

METHODS

A typical hospital in Chongqing, China, was selected to examine the price and use comparisons of 12 cardiovascular drugs from 2006 to 2011.

RESULTS

The market share of the 12 generic medicines studied in this paper was 34.37% for volume and 31.33% for value in the second half of 2011. The price ratio of generic to originator drugs was between 0.34 and 0.98, and the volume price index of originators to generics was 1.63. The potential savings of patients from switching originator drugs to generics is 65%.

CONCLUSION

The market share of the generics was lowering and the weighted mean price kept increasing in face of the strict price control. Under the background of hospitals both prescribing and dispensing medicines, China's comprehensive healthcare policy makers should take measures from supply and demand sides to promote the consumption of generic medicines.

Influence of multiple initiatives in Sweden to enhance ARB prescribing efficiency following generic losartan; findings and implications for other countries

BACKGROUND

Encouraging the prescribing of ACEIs first line vs. angiotensin receptor blockers (ARBs) has been a health authority focus with generic ACEIs as ACEIs and ARBs have similar effectiveness and there is limited coughing with ACEIs. This includes Sweden with its multiple initiatives keeping expenditure on renin-angiotensin inhibitor drugs similar between 2001 and 2007 despite appreciably increased volumes. Generic losartan became available and was reimbursed in March 2010 providing further opportunities for the authorities in Sweden to save costs with all ARBs seen as similar in managing hypertension and CHF at appropriate doses.

AIMS

The main aim of this study was to assess changes in the utilisation of losartan vs. other single ARBs after generic losartan alongside accompanying demand-side measures. Additional aims were to (i) assess changes in the price of generic losartan and single ARB expenditure over time; (ii) suggest additional programmes, if needed; and (iii) analyse utilisation of ARB FDCs and compare with ACEI FDCs.

METHODS

Retrospective observational study using an interrupted time series design.

RESULTS

Multiple demand-side measures introduced among the 21 Counties in Sweden significantly enhanced the utilisation of generic losartan, growing from 26% to 27% of total ARBs (DDD basis) before generic losartan to 40% by August 2011. Losartan was principally generics (97% by August 2011). Expenditure/DDD for generic losartan was 10% of the pre-patent loss price in August 2011. This reduced total single ARB expenditure by 26% by the study end despite a 16% increase in utilisation. Greater utilisation of ARB FDCs than seen with ACEI FDCs. This may be due to similarities in prices between single and FDC ARBs.

DISCUSSION

Multiple demand-side measures appreciably enhanced ARB prescribing efficiency, mirroring other studies. No significant increase in losartan utilisation following generics was seen in European countries where no specific measures were instigated. Losartan price reduction was in line with expectations.

CONCLUSION

Multiple and intensive demand-side measures are needed to change physician prescribing habits. Authorities cannot rely on physicians transferring their activities from one class to another without interventions.

Changes in the utilization of venlafaxine after the introduction of generics in Sweden

BACKGROUND

There has been an appreciable increase in the prescribing efficiency of proton pump inhibitors, statins, and renin-angiotensin inhibitor drugs in Sweden in recent years. This has been achieved through multiple reforms encouraging the prescription of generics at low prices versus patented drugs in the same class. Generic venlafaxine also presents an opportunity to save costs given the prevalence of depression. However, depression is more complex to treat, with physicians reluctant to change prescriptions if patients are responding to a particular antidepressant.

OBJECTIVES

We assessed (a) changes in the utilization pattern of venlafaxine versus other newer antidepressants before and after the availability of generic venlafaxine and before and after the initiation of prescription restrictions for duloxetine limiting its prescription to refractory patients, (b) utilization of generic versus original venlafaxine after its availability, and (c) price reductions for generic venlafaxine and the subsequent influence on total expenditure on newer antidepressants over time.

METHODOLOGY

We performed interrupted time series analysis of changes in monthly reimbursed prescriptions using defined daily doses (DDDs) of patients dispensed at least one newer antidepressant from January 2007 to August 2011. DDDs was defined as the average maintenance dose of a drug when used in its major indication in adults. This included 19 months after the availability of generic venlafaxine and before initiation of prescription restrictions for duloxetine to 13 months after prescription restrictions. Total expenditure and expenditure/DDD for venlafaxine were measured over time.

RESULTS

No appreciable change in the utilization pattern for venlafaxine was observed after generic availability when no appreciable demand-side activities by the regions (counties) were implemented to encourage its use. The utilization of venlafaxine significantly increased after prescription restrictions for duloxetine. Generic venlafaxine was dispensed once available, reaching 99.6 % of total venlafaxine (DDD basis) by August 2011. There was an appreciable fall in expenditure for newer antidepressants in Sweden after generic venlafaxine despite increased utilization, helped by a 90 % reduction in expenditure/DDD for venlafaxine by the end of the study versus prepatent loss prices.

CONCLUSION

Multiple demand-side measures are needed to change physician prescribing habits. Authorities should not rely on a spillover effect between drug classes to effect change. Limited influence of prescription restrictions on the subsequent utilization of duloxetine reflects the complexity of this disease area. This is exacerbated by heterogeneous indications for duloxetine.

Multilevel analysis of the influence of patients' and general practitioners' characteristics on patented versus multiple-sourced statin prescribing in France

BACKGROUND

The French National Health Insurance and the Ministry of Health have introduced multiple reforms in recent years to increase prescribing efficiency. These include guidelines, academic detailing, financial incentives for the prescribing and dispensing of generics drugs as well as a voluntary pay-for-performance programme. However, the quality and efficiency of prescribing could be enhanced potentially if there was better understanding of the dynamics of prescribing behaviour in France.

OBJECTIVE

To analyse the patient and general practitioner characteristics that influence patented versus multiple-sourced statin prescribing in France.

METHODOLOGY

Statistical analysis was performed on the statin prescribing habits from 341 general practitioners (GPs) that were included in the IMS-Health Permanent Survey on Medical Prescription in France, which was conducted between 2009 and 2010 and involved 14,360 patients. Patient characteristics included their age and gender as well as five medical profiles that were constructed from the diagnoses obtained during consultations. These were (1) disorders of lipoprotein metabolism, (2) heart disease, (3) diabetes, (4) complex profiles and (5) profiles based on other diagnoses. Physician characteristics included their age, gender, solo or group practice, weekly workload and payment scheme.

RESULTS

Patient age had a statistically significant impact on statin prescribing for patients in profile 1 (disorders of lipoprotein metabolism) and profile 3 (complex profiles) with a greater number of patented statins being prescribed for the youngest patients. For instance, patients older than 76 years with a complex profile were prescribed fewer patented statins than patients aged 68-76 years old with the same medical profile (coefficient: -0.225; p = 0.0008). By contrast, regardless of the patient's age, the medical profile did not affect the probability of prescribing a patented statin except in young patients with heart diseases who were prescribed a greater number of patented statins (coefficient: 0.3992; p = 0.0007). Prescribing was also statistically influenced by physician features, e.g., older male physicians were more likely to prescribe patented statins (coefficient: 0.245; p = 0.0417) and GPs practicing in groups were more likely to prescribe multiple sourced statins (coefficient: -0.178; p = 0.0338), which is an important finding of the study. GPs with a lower workload prescribed a greater number of patented statins.

CONCLUSION

There is significant variability in the prescribing of different statins among patient and physician profiles as well as between solo and group practices. Consequently, there are opportunities to target demand-side measures to enhance the prescribing of multiple-sourced statins. Further studies are warranted, in particular in other therapeutic classes, to provide a counter-balance to the considerable marketing activities of pharmaceutical companies.

Dabigatran - a case history demonstrating the need for comprehensive approaches to optimize the use of new drugs

BACKGROUND

There are potential conflicts between authorities and companies to fund new premium priced drugs especially where there are safety and/or budget concerns. Dabigatran, a new oral anticoagulant for the prevention of stroke in patients with non-valvular atrial fibrillation (AF), exemplifies this issue. Whilst new effective treatments are needed, there are issues in the elderly with dabigatran due to variable drug concentrations, no known antidote and dependence on renal elimination. Published studies have shown dabigatran to be cost-effective but there are budget concerns given the prevalence of AF. There are also issues with potentially re-designing anticoagulant services. This has resulted in activities across countries to better manage its use.

OBJECTIVE

To (i) review authority activities in over 30 countries and regions, (ii) use the findings to develop new models to better manage the entry of new drugs, and (iii) review the implications for all major stakeholder groups.

METHODOLOGY

Descriptive review and appraisal of activities regarding dabigatran and the development of guidance for groups through an iterative process.

RESULTS

There has been a plethora of activities among authorities to manage the prescribing of dabigatran including extensive pre-launch activities, risk sharing arrangements, prescribing restrictions, and monitoring of prescribing post-launch. Reimbursement has been denied in some countries due to concerns with its budget impact and/or excessive bleeding. Development of a new model and future guidance is proposed to better manage the entry of new drugs, centering on three pillars of pre-, peri-, and post-launch activities.

CONCLUSION

Models for introducing new drugs are essential to optimize their prescribing especially where there are concerns. Without such models, new drugs may be withdrawn prematurely and/or struggle for funding.

Are specific initiatives required to enhance prescribing of generic atypical antipsychotics in Scotland?: International implications

BACKGROUND

National and regional authorities in Scotland have introduced multiple measures to appreciably enhance prescribing efficiency for the proton pump inhibitors (PPIs), statins and renin-angiotensin inhibitor drugs. Generic oral risperidone recently became available in Scotland; however, schizophrenia is a complex disease with advice from respected authorities suggesting that treatment should be individualised.

AIMS

To assess (i) changes in atypical antipsychotic drug (AAP) utilisation and expenditure following the availability of oral generic risperidone in Scotland; (ii) to determine (a) current INN prescribing rates for risperidone following generic availability and (b) decrease in expenditure/DDD for generic risperidone; (iii) to suggest additional measures that could possibly be introduced in Scotland to further enhance prescribing of generic AAPs; and (iv) to provide guidance to NHS Scotland as well as other European authorities on the implications.

METHODS

Retrospective observational study and an interrupted time series design.

RESULTS

No appreciable change in the utilisation patterns of risperidone pre- and postgeneric availability. Appreciable INN prescribing averaged 93-98% of total oral risperidone. Generic risperidone was 84% below prepatent loss prices by study end, reducing annual expenditure for oral risperidone in 2010 by GB£3.19mn compared with prepatent loss situation. However, overall expenditure on AAPs increased by 42% from 2005 to 2010.

DISCUSSION

As expected, there was no change in utilisation patterns for risperidone, although potential to influence prescribing patterns. Continued high INN prescribing suggests no problems with generic risperidone in practice. Costs will start to decrease as more AAPs lose their patents (olanzapine and quetiapine). There is the possibility to accelerate this reduction through educational activities.

CONCLUSION

There is potential to realise some savings with generic AAPs. However, this is limited by the complexity of the disease area. Any measures introduced must aim at increasing the prescribing of generic AAPs first line in suitable patients.

Potential to enhance the prescribing of generic drugs in patients with mental health problems in austria; implications for the future

BACKGROUND

Scrutiny over pharmaceutical expenditure is increasing leading to multiple reforms. This includes Austria with measures to lower generic prices and enhance their utilization. However the situation for newer antidepressants and atypical antipsychotic medicines (AAPs) is different to PPIs, statins, and renin-angiotensin inhibitor drugs with greater tailoring of therapy and no wish to switch products in stable patients. Authorities welcome generics though given the high costs particularly of single-sourced AAPs.

OBJECTIVE

Assess (a) changes in utilization of venlafaxine versus other newer antidepressants before and after availability of generics, (b) utilization of generic versus originator venlafaxine, (c) price reductions of venlafaxine over time and their influence on total expenditure, (d) utilization of risperidone versus other AAPs, (e) suggest potential additional reforms that could be introduced if pertinent to further enhance the use of generics.

METHODOLOGY

A quasi-experimental study design with a segmented time series and an observational study. Utilization measured in defined daily doses (DDDs) and total expenditure per DDD and over time.

RESULTS

No appreciable changes in the utilization of venlafaxine and risperidone after generics. The reduction in expenditure/DDD for venlafaxine decreased overall expenditure on newer antidepressants by 5% by the end of the study versus just before generics despite a 37% increase in utilization. Expenditure will further decrease if reduced prescribing of duloxetine.

CONCLUSION

Depression, schizophrenia, and bipolar diseases are complex diseases. As a result, specific measures are needed to encourage the prescribing of generic risperidone and venlafaxine when multiple choices are appropriate. Authorities cannot rely on a "Hawthorne" effect between classes to enhance the use of generics. Measures may include prescribing restrictions for duloxetine. No specific measures planned for AAPs with more multiple-sourced AAPs becoming available.

Proton pump inhibitors: potential cost reductions by applying prescribing guidelines

BACKGROUND

There are concerns that proton pump inhibitors (PPI) are being over prescribed in both primary and secondary care. This study aims to establish potential cost savings in a community drug scheme for a one year period according to published clinical and cost-effective guidelines for PPI prescribing.

METHODS

Retrospective population-based cohort study in the Republic of Ireland using the Health Services Executive (HSE) Primary Care Reimbursement Services (PCRS) pharmacy claims database. The HSE-PCRS scheme is means tested and provides free health care including medications to approximately 30% of the Irish population. Prescription items are WHO ATC coded and details of every drug dispensed and claimants' demographic data are available. Potential cost savings (net ingredient cost) were estimated according to UK NICE clinical guidelines for all HSE-PCRS claimants on PPI therapy for ≥3 consecutive months starting in 2007 with a one year follow up (n=167,747). Five scenarios were evaluated; (i) change to PPI initiation (cheapest brand); and after 3 months (ii) therapeutic switching (cheaper brand/generic equivalent); (iii) dose reduction (maintenance therapy); (iv) therapeutic switching and dose reduction and (v) therapeutic substitution (H2 antagonist).

RESULTS

Total net ingredient cost was €88,153,174 for claimants on PPI therapy during 2007. The estimated costing savings for each of the five scenarios in a one year period were: (i) €36,943,348 (42% reduction); (ii) €29,568,475 (34%); (iii) €21,289,322 (24%); (iv) €40,505,013 (46%); (v) €34,991,569 (40%).

CONCLUSION

There are opportunities for substantial cost savings in relation to PPI prescribing if implementation of clinical guidelines in terms of generic substitution and step-down therapy is implemented on a national basis.

Prescribing proton pump inhibitors: is it time to pause and rethink?

Proton pump inhibitors (PPIs) are among the most widely used agents in the world. The prevalence of reflux disease is increasing, as is the incidence of oesophageal adenocarcinoma, a complication that is strongly correlated with chronic reflux disease. Although these agents are generally safe, a number of potential side effects have been described and a careful assessment of the risks and benefits of PPI therapy is required in all patients being prescribed long-term therapy. Overutilization of PPIs is a problem in clinical practice and needs further attention. PPI use has been associated with osteoporosis and bone fracture, hypomagnesaemia, the development of gastric polyps, enteric infections, interstitial nephritis and pneumonia. Patients on long-term therapy should be periodically evaluated for the indications for continued therapy. Despite widespread publicity in the lay press, and regulatory guidance regarding a number of associations, the evidence for serious side effects is poor and the risk of confounding remains a real possibility for many associations. Patients are more concerned about the absolute risk of developing a complication than a relative risk. The absolute risk of all the complications attributed to PPIs is low and patients who need long-term PPI therapy need a clear discussion of the available data on the risk of therapy and also a discussion of the risk of continued reflux.

Imperative to consider multiple initiatives to maximize prescribing efficiency from generic availability: case history from Abu Dhabi

INTRODUCTION

Pharmaceutical expenditure has risen rapidly in Abu Dhabi, resulting in policies surrounding generics. However, various circumstances will reduce potential savings, including pharmacists still being free to dispense either originator or branded generics and be fully reimbursed.

OBJECTIVES

To research the changes in utilization patterns of proton pump inhibitors (PPIs) and lipid-lowering drugs before and after combined reforms on generics; and subsequently, calculate potential savings based on 'best practices' among Western European countries.

METHODS

An uncontrolled before-and-after observational study of utilization and expenditure of PPIs, statins and ezetimibe between 2004 and 2010, as well as up to 12 months before the first generic policy, to 1 year after the second generic policy, was carried out. Utilization was converted to defined daily doses (DDDs; 2011 DDDs) and DDDs/1000 inhabitants per day. Expenditure/DDD was calculated for omeprazole and simvastatin.

RESULTS

PPI utilization rose by 6.5-fold from 2004 to 2010, principally driven by increased utilization of patent-protected PPIs, although more recently stabilization in esomperazole utilization has occurred. Similar changes were seen for statins. Introduction of best practices would reduce PPI expenditure in 2010 by 32.8 million United Arab Emirates dirham (AED; €6.26 million) and statins by over 27 million AED (€5.15 million).

CONCLUSION

Limited demand-side measures led to increased utilization of patent-protected products in Abu Dhabi following the generic reforms. Successful measures will release considerable resources.

Influence of demand-side measures to enhance renin-angiotensin prescribing efficiency in Europe: implications for the future

European countries strive to enhance prescribing efficiency. This includes renin-angiotensin drugs following the availability of generic angiotensin-converting enzyme inhibitors (ACEIs).

AIMS

To compare angiotensin receptor blocker utilization and expenditure patterns in Austria and Croatia following prescribing restrictions, as well as with other European countries introducing different supply- and demand-side measures. Lastly, to appraise the impact of generic losartan in Croatia on utilization of patented angiotensin receptor blockers.

METHOD

Observational retrospective study principally between 2001 and 2007, using defined daily doses and €/1000 inhabitants/year. Demand-side measures were based on the four 'E's - education, engineering, economics and enforcement.

RESULTS

Greater intensity of follow-up of prescribing restrictions in Croatia enhanced utilization of ACEIs versus Austria. There was high utilization of ACEIs in Scotland following intensive demand-side measures, similar to Austria and Croatia. Demand-side measures in Spain (Catalonia) and Sweden also appeared to moderate angiotensin receptor blockers utilization. The combination of measures helped stabilize expenditure on renin-angiotensin drugs when adjusted for population sizes despite appreciable increases in volumes. The only exception was Portugal, with less intensive measures.

CONCLUSION

Multiple and intensive demand-side measures enhanced prescribing efficiency. The more intense follow-up of ARB prescribing restrictions in Croatia had a greater influence on subsequent utilization patterns than Austria. Both findings confirm earlier studies. Reforms also favorably enhanced the prescribing of generic losartan once available.

Role of centralized review processes for making reimbursement decisions on new health technologies in Europe

BACKGROUND

The purpose of this study was to compare centralized reimbursement/coverage decision-making processes for health technologies in 23 European countries, according to: mandate, authority, structure, and policy options; mechanisms for identifying, selecting, and evaluating technologies; clinical and economic evidence expectations; committee composition, procedures, and factors considered; available conditional reimbursement options for promising new technologies; and the manufacturers' roles in the process.

METHODS

A comprehensive review of publicly available information from peer-reviewed literature (using a variety of bibliographic databases) and gray literature (eg, working papers, committee reports, presentations, and government documents) was conducted. Policy experts in each of the 23 countries were also contacted. All information collected was reviewed by two independent researchers.

RESULTS

Most European countries have established centralized reimbursement systems for making decisions on health technologies. However, the scope of technologies considered, as well as processes for identifying, selecting, and reviewing them varies. All systems include an assessment of clinical evidence, compiled in accordance with their own guidelines or internationally recognized published ones. In addition, most systems require an economic evaluation. The quality of such information is typically assessed by content and methodological experts. Committees responsible for formulating recommendations or decisions are multidisciplinary. While criteria used by committees appear transparent, how they are operationalized during deliberations remains unclear. Increasingly, reimbursement systems are expressing interest in and/or implementing reimbursement policy options that extend beyond the traditional "yes," "no," or "yes with restrictions" options. Such options typically require greater involvement of manufacturers which, to date, has been limited.

CONCLUSION

Centralized reimbursement systems have become an important policy tool in many European countries. Nevertheless, there remains a lack of transparency around critical elements, such as how multiple factors or criteria are weighed during committee deliberations.