Multiple initiatives continue to enhance the prescribing efficiency for the proton pump inhibitors and statins in Scotland

Evidence on the effectiveness of policies promoting price transparency - A systematic review

Policies promoting price transparency may be an important approach to control medicine prices and achieve better access to medicines. As part of a wider review, we aimed to systematically determine whether policies promoting price transparency are effective in managing the prices of pharmaceutical products. We searched for studies published between January 1, 2004 and October 10, 2019, comparing policies promoting price transparency against other interventions or a counterfactual. Eligible study designs included randomized trials, and non-randomized or quasi-experimental studies such as interrupted time-series (ITS), repeated measures (RM), and controlled before-after studies. Studies were eligible if they included at least one of the following outcomes: price (or expenditure as a proxy for price and volume), volume, availability or affordability of pharmaceutical products. The quality of the evidence was assessed using the GRADE methodology. A total of 32011 records were retrieved, two of which were eligible for inclusion. Although based on evidence from a single study, public disclosure of medicine prices may be effective in reducing prices of medicines short-term, with benefits possibly sustained long-term. Evidence on the impact of a cost-feedback approach to prescribers was inconclusive. No evidence was found for impact on the outcomes volume, availability or affordability. The overall lack of evidence on policies promoting price transparency is a clear call for further research.

Antibiotic Utilization during COVID-19: Are We Over-Prescribing?

The aims of this study were to analyze the utilization of antibiotics before (2018, 2019) and during the COVID-19 pandemic (2020) and the practice of prescribing antibiotics in outpatient settings for COVID-19 patients during the 2020-2022 period. The Anatomical Therapeutic Chemical Classification/Defined Daily Dose methodology was used for the analysis of outpatient antibiotic utilization in the Republic of Srpska. The data was expressed in DDD/1000 inhabitants/day. The rate of antibiotics prescribed to COVID-19 outpatients was analyzed using medical record data from 16,565 patients registered with B34.2, U07.1, and U07.2 World Health Organization International Classification of Diseases 10th revision codes. During 2020, outpatient antibiotic utilization increased by 53.80% compared to 2019. At least one antibiotic was prescribed for 91.04%, 83.05%, and 73.52% of COVID-19 outpatients during 2020, 2021, and the first half of 2022, respectively. On a monthly basis, at least one antibiotic was prescribed for more than 55% of COVID-19 outpatients. The three most commonly prescribed antibiotics were azithromycin, amoxicillin/clavulanic acid, and doxycycline. The trend of repurposing antibiotics for COVID-19 and other diseases treatment might be a double-edged sword. The long-term effect of this practice might be an increase in antimicrobial resistance and a loss of antibiotic effectiveness.

Drug Utilization and Drug Pricing in the Private Primary Healthcare System in Malaysia: An Employer Price Control Mechanism

Uncontrolled drug pricing in the private healthcare system in Malaysia leads to high drug prices; however, its impact on employee drug utilization and employer reimbursement coverage is unclear. This study examined patterns of drug pricing and drug utilization among employees covered by employer medical insurance. A drug price control mechanism was also devised for the employer to ensure fair benefits to all parties without compromising the quality of patient care. This retrospective study was conducted among International Islamic University Malaysia (IIUM) community members who sought outpatient treatment at the IIUM panel of health clinics serviced by general practitioners from January 2016 to September 2019. Prescription data (drug type, dose, quantity, duration, price, and manufacturer), patient characteristics (age, sex, and diagnosis) and total charges were extracted from the claims database of PMCare, the insurance company managing IIUM medical claims. Patterns of commonly prescribed drugs, drug pricing, profit margins, and total charges per clinic visit were evaluated. Descriptive statistics were used, and all analyses were performed using Stata v15.1. There were a total of 161,146 prescriptions for 10,150 patients in the IIUM community during the study period (48.85% women, mean ± standard deviation; age: 26.33 ± 17.63 years). The most commonly prescribed drug was paracetamol (25.3%), followed by chlorpheniramine (9.46%), cetirizine (7.3%), diphenhydramine (6.13%), loratadine (4.57%), and diclofenac (4.36%). Generic paracetamol (500 mg), which serves as a prime example for details on drug pricing, is commonly charged between Ringgit Malaysia (RM) 5 and 10 for 10 tablets with a profit between 2,400 and 4,900% according to the average cost price of RM 0.20 per 10 tablets. Most patients were charged within the approved coverage limit of RM 45 per clinic visit, with only 2.41% of patients being charged with costs that exceeded this limit. Uncontrolled drug pricing in the private healthcare system in Malaysia indicates that drug prices differ greatly across private healthcare providers most of the prices were charged with high profit margins. Employers may consider a multilayer capping system to prevent inappropriate drug pricing, which will inevitably benefit patients clinically and economically and provide greater patient access to better drug treatment.

Proton pump inhibitor utilisation and potentially inappropriate prescribing analysis: insights from a single-centred retrospective study

OBJECTIVES

This study aimed to characterise the prescribing patterns and evaluate the appropriateness of the prescribed proton pump inhibitors (PPIs) in adult patients via a review of electronic medical records in a single-centred hospital.

DESIGN

All patients admitted to the outpatient department of Jinshan Hospital, Fudan University, Shanghai, between 1 January 2018 and 31 December 2018 were evaluated. Individuals aged 18 years or above and with at least one dispensing for PPIs were identified as PPI users. New PPI users were defined as a subject who did not receive any dispensing for PPIs in the year prior to the index date. Baseline characteristics of PPI users and their therapies were described by treatment indication, economic indicators and co-prescription, overall and separately.

SETTING

The prescription database was retrieved from the hospital information system of Jinshan Hospital, Fudan University.

RESULTS

Among 18 435 identified PPI users in 2018, 14 219 patients (aged 18 years or above) who had at least one dispensing PPIs were new users (77%), and among them, men accounted for 47%. The mean treatment duration was 23 days. Omeprazole was the most commonly prescribed drug. PPIs are inappropriately prescribed in 50% (13 589/25 850) of prescriptions. Prescription appropriateness analysis indicated that the unapproved indications for PPI new users accounted for 47%; among them, the proportion of gastritis diagnosis was 34%. The proportion of PPI new users with co-prescription of glucocorticosteroids (GCs) who have risk factors accounted for 24% and lower than other co-prescription. A majority of PPI users (73%) reported high-dose PPI prescription. The defined daily dose of oral pantoprazole was the highest, and injectable omeprazole had the highest defined daily cost. In contrast, only the drug utilisation index value of oral esomeprazole was less than 1.0.

CONCLUSION

The results indicate the challenge of PPI use was accompanied by unapproved indications, frequent inappropriate co-prescription with GCs and excessive dosages. Efforts should be paid to promote rational use and ensure the choice of suitable PPI therapy in the future.

An Educational Intervention to Improve Statin Use: Cluster RCT at the Primary Care Level in Argentina

INTRODUCTION

Statins are essential drugs for high cardiovascular disease (CVD) risk management; however, there is still low adherence to good clinical practice guidelines for statin use at the primary care level in low- and middle-income countries. This study aimed to test whether a complex intervention targeting physicians improves treatment and control of hypercholesterolemia among patients with moderate to high CVD risk in Argentina.

STUDY DESIGN

Cluster RCT.

SETTING/PARTICIPANTS

Ten primary care centers from the public healthcare system of Argentina.

INTERVENTION

Primary care physicians in the intervention group received an educational program with three main components: (1) an intensive 2-day training workshop; (2) educational outreach visits; and (3) a mobile health application installed on the physician's smartphones.

MAIN OUTCOME MEASURES

Reduction in mean low-density lipoprotein cholesterol level, reduction in mean Framingham risk score, proportion of patients receiving an appropriate statin dose, and mean annual number of primary care center visits.

RESULTS

Data were analyzed in 2017-2018. Between April 2015 and April 2016, a total of 357 participants were enrolled (179 patients in the intervention group and 178 in the control group). The global follow-up rate was 97.2%. At the end of the follow-up period, there was no difference in low-density lipoprotein cholesterol levels in any of the follow-up points among the groups. Mean CVD risk had a significant net difference in the first 6 months in the intervention group versus the control group (-4.0, 95% CI = -6.5, -1.5). At the end of follow-up, there was an absolute 41.5% higher rate of participants receiving an appropriate statin dose in the intervention group versus the control group.

CONCLUSIONS

Although the intervention did not reach a reduction in cholesterol levels, it had a significant positive impact on the promotion of adequate use of clinical practice guidelines.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02380911.

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.

Effectiveness and prescription pattern of lipid-lowering therapy and its associated factors among patients with type 2 diabetes mellitus in Malaysian primary care settings

Background

Cardiovascular diseases (CVDs) are the main complication leading to morbidity and mortality among patients with type 2 diabetes mellitus (T2DM). There is a large amount of evidence to support the use of lipid-lowering therapy (LLT) for the prevention of CVD. This study aimed to assess the effectiveness and prescription quality of LLT among T2DM patients and to identify its associated factors.

Methods

A multicenter cross-sectional study included 816 T2DM patients from four different primary care centers in Pahang, Malaysia. We involved LLT-eligible T2DM patients as per the national clinical practice guidelines (CPG). The assessment of therapy effectiveness focused on the attainment of target lipid measures stated in the CPG. Evaluation of the prescription quality was classified into appropriate, potentially inappropriate, and inappropriate, based on the compliance with guidelines and existence of potential safety concerns. Binomial logistic regression was employed to identify the predictors of LLT effectiveness and prescription quality.

Results

The overall percentage of T2DM patients receiving statin therapy was 87.6% (715/816). Statin therapy was appropriately prescribed in 71.5% of the cases. About 17.5% of the LLT prescriptions have at least one significant drug interaction with co-prescribed medications. The achievement of the primary target of low-density lipoprotein cholesterol (LDL-C) levels was observed in only 37% of T2DM patients. The LLT indication and appropriateness of prescription were significantly associated with the attainment of LDL-C treatment goals. Primary prevention, Malay race, and hypertension were identified as predictors for appropriate prescribing of LLT among T2DM subjects.

Conclusion

There is a need to enhance the quality of LLT prescribing in the primary care setting to cover all eligible high-risk patients and ensure patient safety. Strategies to improve the achievement of LDL-C goals among patients with T2DM, such as investigating the potential role of the combination therapy and high-intensity statin therapy, are required.

Exploring knowledge and perceptions on generic drugs of final year pharmacy school students in Greece

Objectives: The economic crisis in Greece has triggered an extensive public debate about the use of generic drugs (generics). Despite their cost-saving potential, generic market penetration remains very low. This raises questions on awareness of, perception on and preference for generics by health-care professionals and patients. This is a descriptive study on the level of knowledge and attitudes towards generics of final year pharmacy school students in Greece. Methods: An electronic questionnaire was distributed to 173 senior pharmacy school students in three Universities in Greece. Responses were submitted electronically. Results: The majority of students knew that generics contain the same active ingredient as the originator products and are cheaper. Students were somehow concerned with safety and efficacy of generics. The majority of students agreed that pharmacists should probably recommend the use of generics, and indicated that prescribing and dispensing practices would largely depend on the profit margin. Despite more than half of the students expressing a positive attitude towards generics, they were inadequately educated on their features. Conclusion: It is critical to improve knowledge of and preference for generics amongst health-care professionals from early on if to build the trust required to increase generic market penetration and achieve measurable savings in pharmaceutical expenditure.

Projecting Pharmaceutical Expenditure in EU5 to 2021: Adjusting for the Impact of Discounts and Rebates

BACKGROUND

Within (European) healthcare systems, the predominant goal for pharmaceutical expenditure is cost containment. This is due to a general belief among healthcare policy makers that pharmaceutical expenditure-driven by high prices-will be unsustainable unless further reforms are enacted.

OBJECTIVE

The aim of this paper is to provide more realistic expectations of pharmaceutical expenditure for all key stakeholder groups by estimating pharmaceutical expenditure at 'net' prices. We also aim to estimate any gaps developing between list and net pharmaceutical expenditure for the EU5 countries (i.e. France, Germany, Italy, Spain, and the UK).

METHODS

We adjusted an established forecast of pharmaceutical expenditure for the EU5 countries, from 2017 to 2021, by reflecting discounts and rebates not previously considered, i.e. we moved from 'list' to 'net' prices, as far as data were available.

RESULTS

We found an increasing divergence between expenditure measured at list and net prices. When the forecasts for the five countries were aggregated, the EU5 (unweighted) average historical growth (2010-2016) rate fell from 3.4% compound annual growth rate at list to 2.5% at net. For the forecast, the net growth rate was estimated at 1.5 versus 2.9% at list.

CONCLUSIONS

Our results suggest that future growth in pharmaceutical expenditure in Europe is likely to be (1) lower than previously understood from forecasts based on list prices and (2) below predicted healthcare expenditure growth in Europe and in line with long-term economic growth rates. For policy makers concerned about the sustainability of pharmaceutical expenditure, this study may provide some comfort, in that the perceived problem is not as large as expected.

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.

Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments

BACKGROUND

Rates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement.

METHODS

This was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines.

RESULTS

We identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics).

CONCLUSIONS

We identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.

Recent Initiatives in the Republic of Srpska to Enhance Appropriate Use of Antibiotics in Ambulatory Care; Their Influence and Implications

Introduction: There are increasing concerns world-wide with growing rates of antibiotic resistance necessitating urgent action. There have been a number of initiatives in the Republic of Srpska in recent years to address this and improve rational antibiotic prescribing and dispensing despite limited resources to fund multiple initiatives. Objective: Analyse antibiotic utilization patterns in the Republic of Srpska following these multiple initiatives as a basis for developing future programmes in the Republic if needed. Methods: Observational retrospective study of total outpatient antibiotic utilization from 2010 to 2015, based on data obtained from the Public Health Institute, alongside documentation of ongoing initiatives to influence utilization. The quality of antibiotic utilization principally assessed according to ESAC, ECDC, and WHO quality indicators and DU 90% (the drug utilization 90%) profile as well as vs. neighboring countries. Results: Following multiple initiatives, antibiotic utilization remained relatively stable in the Republic at 15.6 to 18.4 DIDs, with a decreasing trend in recent years, with rates comparable or lower than neighboring countries. Amoxicillin and the penicillins accounted for 29-40 and 50% of total utilization, respectively. Overall, limited utilization of co-amoxiclav (7-11%), cephalosporins, macrolides, and quinolones, as well as low use of third and fourth generation cephalosporins vs. first and second cephalosporins. However, increasing utilization of co-amoxiclav and azithromycin, as well as higher rates of quinolone utilization compared to some countries, was seen. Conclusions: Multiple interventions in the Republic of Srpska in recent years have resulted in one of the lowest utilization of antibiotics when compared with similar countries, acting as an exemplar to others. However, there are some concerns with current utilization of co-amoxiclav and azithromycin which are being addressed. This will be the subject of future research activities.

The economic impact of switching from Synthroid for the treatment of hypothyroidism

AIMS

To compare hypothyroidism-related costs for patients who continuously used Synthroid and patients who switched from Synthroid to alternative therapies.

MATERIALS AND METHODS

Truven's Health Analytics MarketScan Commercial Claims and Encounters database from January 1, 2007 to June 30, 2014 was queried for US adults diagnosed with hypothyroidism who initiated Synthroid and adhered to such therapy for at least 6 months. Propensity score matching matched continuous users of Synthroid to patients who switched from Synthroid to alternative levothyroxine agents. Kruskal-Wallis tests assessed differences between the matched cohorts in several categories of costs, including disease-related drug costs, non-drug medical costs, and total direct medical costs.

RESULTS

There were 10,159 individuals included in the study, with 7,991 continuous users of Synthroid and 2,168 switchers. After matching (n = 2,052 for each cohort), continuous use of Synthroid was associated with significantly lower hypothyroidism-related non-drug medical costs ($595 vs $1,023; p = .003) and reduced hypothyroidism-related total medical costs ($757 vs $1,132; p = .010), despite being associated with significantly higher drug costs ($161 vs $109; p < .001). Hypothyroidism-related total medical costs rose as the number of switches of hypothyroidism treatment increased, with continuous users having significantly lower hypothyroidism-related total medical costs ($757) compared with patients who switched twice ($1,179; p = .001) or three or more times ($1,268; p = .004).

LIMITATIONS

The analyses focused on continuously insured patients who were adherent to Synthroid for at least 6 months and results may not be generalizable. The reliance on claims data does not allow for clinical examination of hypothyroidism or inclusion of some factors that may be associated with outcomes. The analyses assume that all prescriptions filled are taken as prescribed.

CONCLUSIONS

Results indicate that there are significant direct economic healthcare costs associated with switching from Synthroid to alternative levothyroxine therapies, and that these costs increase as patients switch therapies more frequently.

Drug promotional activities in Nigeria: impact on the prescribing patterns and practices of medical practitioners and the implications

OBJECTIVE

Pharmaceutical companies spend significant amount of resources on promotion influencing the prescribing behavior of physicians. Drug promotion can negatively impact on rational prescribing, which may adversely affect the quality of patient care. However, little is known about these activities in Nigeria as the most populous country in Africa. We therefore aimed to explore the nature of encounters between Nigerian physicians and pharmaceutical sales representatives (PSRs), and how these encounters influence prescribing habits.

METHODS

Cross-sectional questionnaire-based study conducted among practicing physicians working in tertiary hospitals in four regions of Nigeria.

RESULTS

176 questionnaires were completed. 154 respondents (87.5%) had medicines promoted to them in the previous three months, with most encounters taking place in outpatients' clinics (60.2%), clinical meetings (46%) and new medicine launches (17.6%). Information about potential adverse effects and drug interactions was provided in 41.5%, and 27.3% of cases, respectively. Food, in the form of lunch or dinner, was the most common form of incentive (70.5%) given to physicians during promotional activities. 61% of physicians felt motivated to prescribe the drug promoted to them, with the quality of information provided being the driving factor. Most physicians (64.8%) would agree to some form of regulation of the relationship between medical doctors and the pharmaceutical industry.

CONCLUSION

Interaction between PSRs and physicians is a regular occurrence in Nigeria, influencing prescribing practices. Meals and cheap gifts were the most common items offered to physicians during their encounters with PSRs. The need for some form of regulation by professional organizations and the government was expressed by most respondents to address current concerns.

Non-guideline-recommended prescribing of proton pump inhibitors: implications for the future and reducing over usage

Drs Godman and Fadare review the paper by Mares-Garcia and colleagues in Spain regarding the extent of non-guideline recommended prescribing (NGRP) of proton pump inhibitors (PPIs) in ambulatory care. NGRP of PPIs is an increasing public health concern given the implications of overuse of PPIs on infection rates, osteoporosis and chronic kidney disease as well as increasing polypharmacy rates. Costs are less of an issue especially where there are low prices for generic PPIs; the main focus is on improving the quality of PPI prescribing. Encouragingly, Mares-Garcia and colleagues identified key factors associated with NGRP, providing direction to others.

Price and utilisation differences for statins between four countries

INTRODUCTION

Australia, England, France and New Zealand use different policies to regulate their medicines market, which can impact on utilisation and price.

OBJECTIVES

To compare the prices and utilisation of statins in Australia, England, France and New Zealand from 2011 to 2013.

METHODS

Utilisation of statins in the four countries was compared using Defined Daily Doses (DDD) per 1000 inhabitants per year. Pairwise Laspeyres and Paasche index comparisons were conducted comparing the price and utilisation of statins.

RESULTS

The results showed that the price of statins in New Zealand was the cheapest. The price of statins in Australia was most expensive in 2011 and 2012 but France was more expensive in 2013. There were large differences between the Laspeyres index and Paasche index when comparing the price and utilisation of England with Australia and France.

DISCUSSION

The policies that regulate the New Zealand and England medicines markets were more effective in reducing the price of expensive statins. The relative utilisation of cheaper statins was greatest in England and had a large effect on the differences between the two index results. The pricing policies in Australia have been only partly effective in reducing the price of statins compared to other countries.

Has cost inhibited the uptake of more potent statins in England?

BACKGROUND

The use of statins has increased substantially over the last 2 decades in England and represents a significant cost burden to the National Health Service. Therefore, it is important to understand what influences prescribers' choice.

OBJECTIVES

This study examines the changes in use pattern of all statins in England (1998-2015). The study focuses on the use of simvastatin and atorvastatin before and after their patent expiry and rosuvastatin, to investigate the impact of the reduced acquisition costs on prescribing.

METHODS

Interrupted time series analysis of primary care use data from the health and social care information centre database from 1998 to 2015.

RESULTS

Primary care expenditure on statins increased by 125% during the period 1998 to 2004 driven by branded simvastatin and atorvastatin. Before 2003, the rate of use of more potent branded atorvastatin exceeds branded simvastatin. Between 2004 and 2011, the less potent but less expensive agent generic simvastatin has the higher utilisation rate (66%). Since 2012, the more potent agent but less expensive generic atorvastatin has the higher utilisation rate (50%). The more potent branded rosuvastatin failed to make a significant impact on the English statins market.

CONCLUSIONS

The availability of generic statins has reduced overall expenditure significantly. When there is a significant price difference, acquisition cost appears to be the main influencing factor in prescribing statins, but, when costs are similar, potency is a key factor. This suggests that English prescribers are cost sensitive and appear to be prepared to trade marginal benefit for savings.

Proton pump inhibitors utilisation in older people in New Zealand from 2005 to 2013

BACKGROUND

The prescriptions for proton pump inhibitors (PPI) to treat acid-related disorders continue to rise internationally and in New Zealand. Concerns have been raised regarding its widespread use, costs and potential adverse effects in older people.

AIMS

This study aimed to characterise the utilisation of PPI by older people (aged 65 years and older) in New Zealand from 2005 to 2013.

METHODS

Repeated cross-sectional analysis of population-level dispensing data was conducted from 1 January 2005 to 31 December 2013. Dispensing data for all PPI prescriptions from 2005 to 2013 were obtained from the Ministry of Health, New Zealand. Utilisation was measured in defined daily doses (DDD) per 1000 older people per day using the World Health Organization Collaborating Centre for Drug Statistics Methodology anatomic, therapeutic and chemical classification system. Utilisation was standardised by sex, age, ethnicity and district health board.

RESULTS

Overall PPI utilisation showed a 26.7% increase from 2005 to 2013, from 273.41 to 346.53 DDD/1000/day. The greatest utilisation was observed in individuals aged between 80 and 84 years. Middle Eastern/Latin American/African utilised more PPI compared with other ethnic groups.

CONCLUSIONS

Utilisation of PPI among older people in New Zealand increased by a fifth from 2005 to 2013. Given the concerns surrounding the long-term PPI use in older people, the appropriateness of the increased utilisation needs to be continuously re-evaluated by prescribers and health policy makers.

The prescribing of generic medicines in Nigeria: knowledge, perceptions and attitudes of physicians

Generic medicines have the same efficacy and safety as originators at lower prices; however, there are concerns with their utilization in Nigeria. Objective was to evaluate physicians' understanding and perception of generics. A questionnaire was administered among physicians working in tertiary healthcare facilities in four geo-political regions of Nigeria. Questionnaire response was 74.3% (191/257) among mainly males (85.9%). The mean knowledge score regarding generics was 5.3 (maximum of 9) with 36.6%, 36.1% and 27.2% having poor, average and good knowledge respectively. Cross-tabulation showed statistical significance (p = 0.047) with the duration of practice but not with position, subspecialty or sex. The majority of respondents did not believe that generic medicines are of lower quality than branded medicines. Therapeutic failure was a major concern in 82.7%, potentially discouraging the prescribing of generics, and a majority (63.9%) did not support generic substitution by pharmacists. Knowledge gaps were identified especially with the perception of generics, which need to be addressed.

The impact of the 'Better Care Better Value' prescribing policy on the utilisation of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for treating hypertension in the UK primary care setting: longitudinal quasi-experimental design

Background

In April/2009, the UK National Health Service initiated four Better Care Better Value (BCBV) prescribing indicators, one of which encouraged the prescribing of cheaper angiotensin-converting enzyme inhibitors (ACEIs) instead of expensive angiotensin receptor blockers (ARBs), with 80 % ACEIs/20 % ARBs as a proposed, and achievable target. The policy was intended to save costs without affecting patient outcomes. However, little is known about the actual impact of the BCBV indicator on ACEIs/ARBs utilisation and cost-savings. Therefore, this study aimed to evaluate the impact of BCBV policy on ACEIs/ARBs utilisation and cost-savings, including exploration of regional variations of the policy’s impact.

Methods

This cross-sectional study used data from the UK Clinical Practice Research Datalink. Segmented time-series analysis was applied to monthly ACEIs prescription proportion, adjusted number of ACEIs/ARBs prescriptions and costs.

Results

Overall, the proportion of ACEIs prescription decreased during the study period from 71.2 % in April/2006 to 70.7 % in March/2012, with a small but a statistically significant pre-policy reduction in its monthly trend of 0.02 % (p < 0.001). Instantly after its initiation, the policy was associated with a sudden reduction in the proportion of ACEIs prescription; however, it resulted in a statistically significant increase in the post-policy monthly trend of ACEIs prescription proportion of 0.013 % (p < 0.001), resulting in an overall post-policy slope of −0.007 %. Despite this post-policy induced increment, the policy failed to achieve the 80 % target, which resulted in missing a potential cost-saving opportunity. The pre-policy trend of the adjusted number of ACEIs/ARBs prescriptions was increasing; however, their trends declined after the policy implementation. The policy affected neither total ACEIs/ARBs cost nor individual ACEIs or ARBs costs.

Conclusions

ACEIs/ARBs utilisation was not affected by the BCBV policy. The small increase in post-policy ACEIs prescription proportion was not associated with any savings. This study represents a case study of a failed or ineffective policy and thus provides key learning lessons for other healthcare authorities. Given the existing opportunity of potential cost-savings from achieving the 80 % target, specific measures would be needed to enhance the policy implementation and uptake; however, this must be balanced against other cost-saving policies in other high-priority areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1013-y) contains supplementary material, which is available to authorized users.

Are new models needed to optimize the utilization of new medicines to sustain healthcare systems?

Medicines have made an appreciable contribution to improving health. However, even high-income countries are struggling to fund new premium-priced medicines. This will grow necessitating the development of new models to optimize their use. The objective is to review case histories among health authorities to improve the utilization and expenditure on new medicines. Subsequently, use these to develop exemplar models and outline their implications. A number of issues and challenges were identified from the case histories. These included the low number of new medicines seen as innovative alongside increasing requested prices for their reimbursement, especially for oncology, orphan diseases, diabetes and HCV. Proposed models center on the three pillars of pre-, peri- and post-launch including critical drug evaluation, as well as multi-criteria models for valuing medicines for orphan diseases alongside potentially capping pharmaceutical expenditure. In conclusion, the proposed models involving all key stakeholder groups are critical for the sustainability of healthcare systems or enhancing universal access. The models should help stimulate debate as well as restore trust between key stakeholder groups.

Switching among Equivalents in Chronic Cardiovascular Therapies: 'Real World' Data from Italy

Since August 2012, Italian general practitioners are required to prescribe the generic name of medicines, except for refill of chronic therapy. We evaluated the extent of switching among equivalents in chronic cardiovascular therapies, the influence of the 2012 regulatory intervention and of patient-related or drug-related factors. Prescriptions of off-patent anti-arrhythmics, oral antidiabetics and ACE inhibitors dispensed from August 2011 to August 2013 within the Bologna Local Health Authority (870,000 inhabitants) was collected. The rate of actual switching among equivalents was evaluated monthly. The effect of the regulatory intervention was estimated by interrupted-time-series analysis. Adjusted odds ratios (aORs) of switching were calculated for the following: age, gender, number of different equivalents available for each drug and change in dispensing pharmacy between subsequent refills. The average monthly rates of switches were 9.6%, 16.3% and 16.3% for anti-arrhythmics, antidiabetics and ACE inhibitors, respectively. Values significantly increased soon after the regulatory intervention for ACE inhibitors (+1.81%, p < 0.01), anti-arrhythmics (+1.46%, p = 0.01) and antidiabetics (+1.09%, p = 0.01), and no significant decreasing trends were observed in the following 12 months. For all drug classes, odd of switching was higher in case of change in dispensing pharmacy (up to aOR = 4.31, 95 CI = 4.26-4.35 for ACE inhibitors) and availability of ≥5 different equivalents (up to aOR = 7.82, 95 CI = 7.39-8.28 for antidiabetics). Switching was lower for age ≥65 for antidiabetics and ACE inhibitors (aOR = 0.92, 95 CI = 0.90-0.93; 0.87, 0.86-0.88, respectively). The Italian regulatory intervention generated an immediate increase, not sustained in time, in switching among equivalents of cardiovascular therapies. Young age, high number of available equivalents and changes in dispensing pharmacy between subsequent refills were associated with switching.

Key Components of Increased Drug Expenditure in South Korea: Implications for the Future

BACKGROUND

The cost of pharmaceuticals has increased rapidly in Korea in recent years. Expenditure is likely to grow further with the policy of expanding National Health Insurance coverage for the following four disease areas: cerebrovascular and cardiovascular disease, rare diseases, and cancer. Consequently, there is a need to analyze the different components leading to this increased expenditure as a basis for suggesting future reforms in Korea.

OBJECTIVE

To quantify the impact of new and established drugs on the growth of total drug spending in South Korea in recent years, specially focusing on the differentiated components of drug spending. These include treatment expansion and drug-mix effects (switching from cheaper drugs to expensive ones and vice versa).

METHODS

A model was proposed and used to assess the impact of both new and existing drugs on changes in price, quantity, and drug mix over the 5-year period in Korea from 2006 to 2010. The database used was the National Health Insurance claims data, which covers about 97% of the total population of Korea.

RESULTS

Overall drug spending increased 1.43-fold from 2006 to 2010. Drug-mix effect (ε_t = 1.32) was the main factor contributing to increased drug spending, followed by increased drug utilization (Q_t = 1.26). For existing drugs, treatment expansion (Q_I) and drug-mix effect (ε_I) were measured at 1.28 and 1.24, respectively, while those of new drugs were 1.02 (Q_N) and 1.03 (ε_N). Therefore, existing drugs have a much greater effect on drug spending than do new drugs. According to the Anatomical Therapeutic Classification, drug spending rose most significantly for the "sensory organs" class of drugs (E_t = 1.78) followed by the "various" class (E_t = 1.68). For existing drugs in the sensory organs class (S), drug-mix effect (ε_I) was measured at 0.96. This implies that expensive drugs among existing drugs were replaced by cheaper ones. However, the quantity prescribed (Q_I) substantially increased by 1.88-fold. New drugs within this class that were more expensive than existing ones were also prescribed (ε_N = 1.09), further increasing drug expenditure in Korea.

CONCLUSIONS

We found contrasting results from previous studies. The drug-mix effect and existing drugs made the largest contribution to drug spending growth rather than new drugs. Policies targeting drug mix, such as promoting cost-effective prescription and rational use of drugs, including the use of cheaper cost generics without compromising care, should be primarily considered to help contain future drug expenditure.

Societal value of generic medicines beyond cost-saving through reduced prices

OBJECTIVE

This paper aims to provide an overview of the added societal value of generic medicines beyond their cost-saving potential through reduced prices. In addition, an observational case study will document the impact of generic entry on access to pharmacotherapy in The Netherlands and an illustrative exercise was carried out to highlight the budget impact of generic entry.

METHODS

A narrative literature review was carried out to explore the impact of generic medicines on access to pharmacotherapy, innovation and medication adherence. Data from the Medicines and Medical Devices Information Project database in The Netherlands were used for the case study in which the impact of generic medicine entrance on the budget and the number of users was calculated as an illustrative exercise.

RESULTS

Generic medicines have an additional societal value beyond their cost-saving potential through reduced prices. Generic medicines increase access to pharmacotherapy, provide a stimulus for innovation by both originator companies and generic companies and, under the right circumstances, have a positive impact on medication adherence.

CONCLUSION

Generic medicines offer more to society than just their cost-saving potential through reduced prices. As such, governments must not focus only on the prices of generic medicines as this will threaten their long-term sustainability. Governments must therefore act appropriately and implement a coherent set of policies to increase the use of generic medicines.

Review of ongoing initiatives to improve prescribing efficiency in China; angiotensin receptor blockers as a case history

INTRODUCTION

Pharmaceutical expenditure is rising by 16% per annum in China and is now 46% of total expenditure. Initiatives to moderate growth include drug pricing regulations and encouraging international non-proprietary name prescribing. However, there is no monitoring of physician prescribing quality and perverse incentives.

OBJECTIVES

Assess changes in angiotensin receptor blocker (ARB) utilization and expenditure as more generics become available; compare findings to Europe.

METHODOLOGY

Observational retrospective study of ARB utilization and expenditure between 2006 and 2012 in the largest hospital in Chongqing district.

RESULTS

Variable and low use of generics versus originators with a maximum of 31% among single ARBs. Similar for fixed dose combinations. Prices typically reduced over time, greatest for generic telmisartan (-54%), mirroring price reductions in some European countries. However, no preferential increase in prescribing of lower cost generics. Accumulated savings of 33 million CNY for this large provider if they adopted European practices.

CONCLUSION

Considerable opportunities to improve prescribing efficiency in China.

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.

Different initiatives across Europe to enhance losartan utilization post generics: impact and implications

Introduction: There is an urgent need for health authorities across Europe to fully realize potential savings from increased use of generics to sustain their healthcare systems. A variety of strategies were used across Europe following the availability of generic losartan, the first angiotensin receptor blocker (ARB) to be approved and marketed, to enhance its prescribing vs. single-sourced drugs in the class. Demand-side strategies ranged from 100% co-payment for single-sourced ARBs in Denmark to no specific measures. We hypothesized this heterogeneity of approaches would provide opportunities to explore prescribing in a class following patent expiry.

Objective: Contrast the impact of the different approaches among European countries and regions to the availability of generic losartan to provide future guidance.

Methodology: Retrospective segmented regression analyses applying linear random coefficient models with country specific intercepts and slopes were used to assess the impact of the various initiatives across Europe following the availability of generic losartan. Utilization measured in defined daily doses (DDDs). Price reductions for generic losartan were also measured.

Results: Utilization of losartan was over 90% of all ARBs in Denmark by the study end. Multiple measures in Sweden and one English primary care group also appreciably enhanced losartan utilization. Losartan utilization actually fell in some countries with no specific demand-side measures. Considerable differences were seen in the prices of generic losartan.

Conclusion: Delisting single-sourced ARBs produced the greatest increase in losartan utilization. Overall, multiple demand-side measures are needed to change physician prescribing habits to fully realize savings from generics. There is no apparent “spill over” effect from one class to another to influence future prescribing patterns even if these are closely related.

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.

Distribution and trends in outpatient utilization of generic versus brand name psychopharmaceuticals during a ten-year period in Croatia

BACKGROUND

Drug costs increasingly pose a burden upon the otherwise inadequate health care resources and rational drug utilization is an important segment of every national health policy. Optimal patient care should be the goal of rational pharmacotherapy, whereby the economic burden of treatment is just one of the elements to be considered on choosing appropriate therapy.The aim of this study was to determine distribution and trends in the outpatient utilization of generic versus brand name psychopharmaceuticals and to evaluate the rationality of prescribing psychopharmaceuticals during a ten-year period.

METHODS

Using the World Health Organization Anatomical-Therapeutic-Chemical classification/Defined Daily Doses (ATC/DDD) methodology, the number of DDD was calculated from data collected from pharmacies on the number and size of drug packages. The ratio of generic and brand name drug costs served as an indicator on assessing the rationality of drug utilization.

RESULTS

Total cost for psychopharmaceuticals increased by 20.1%, more for brand name than for generic agents (32.7% vs. 7.4%). The highest share of generic psychopharmaceuticals as compared with brand name drugs according to DDD per 1000 inhabitants per day (DDD/1000/day) was in the group of psycholeptics (83.6% in 2001 vs. 82.2% in 2010), most in hypnotics and sedatives, and least in antipsychotics. The share of generic psychopharmaceuticals in total drug utilization according to financial indicators decreased by 9.6% and according to DDD/1000/day by 12%. The greatest decrease was in antidepressants, i.e. by 33.8% according to financial indicators and by 46% according to DDD/1000/day; and in antipsychotics by 30.9% according to DDD/1000/day, while showing an increase by 8.5% according to financial indicators. In the therapeutic subgroup of mood stabilizers, the share of generic drugs in total drug utilization declined by 32% according to DDD/1000/day, but increased by 25.1% according to financial indicators.

CONCLUSIONS

The lack of uniform national guidelines and the still strong impact of pharmaceutical industry marketing continue favoring the rise in prescribing brand name antidepressants and antipsychotics. Depression, schizophrenia and bipolar diseases are complex diseases. As a result, specific measures are needed to encourage the prescribing of generic psychopharmaceuticals.

Perspectives of physicians practicing in low and middle income countries towards generic medicines: a narrative review

OBJECTIVES

This review was conducted to document published literature related to physicians' knowledge, attitudes, and perceptions of generic medicines in low- and middle-income countries (LMICs) and to compare the findings with high-income countries.

METHODS

A systematic search of articles published in peer-reviewed journals from January 2001 to February 2013 was performed. The search comprised nine electronic databases. The search strategy involved using Boolean operators for combinations of the following terms: generic medicines, generic medications, generic drugs, generic, generic substitution, generic prescribing, international non-proprietary, prescribers, doctors, general practitioners, physicians, and specialists.

RESULTS

Sixteen articles were included in this review. The majority (n=11) were from high income countries and five from LMICs. The main difference between high income countries and LMICs is that physicians from high income countries generally have positive views whereas those from LMICs tend to have mixed views regarding generic medicines. Few similarities were identified among different country income groups namely low level of physicians' knowledge of the basis of bioequivalence testing, cost of generic medicines as an encouraging factor for generic medicine prescribing, physicians' concerns towards safety and quality of generic medicines and effect of pharmaceutical sales representative on generic medicine prescribing.

CONCLUSION

The present literature review revealed that physicians from LMICs tend to have mixed views regarding generic medicines. This may be due to differences in the health care system and pharmaceutical funding system, medicine policies, the level of educational interventions, and drug information sources in countries of different income levels.

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.

Analysis of Spanish generic medicines retail market: recommendations to enhance long-term sustainability

The use of generic medicines in Spain is traditionally low compared to other European countries, despite efforts of the Spanish government in the past. This paper provides a perspective on the Spanish generic medicines retail market and how the current policy environment may affect the long-term sustainability. The Spanish government's focus on prices of generic medicines (e.g., mandatory price cuts, reference price set at the lowest level) have made them amongst the lowest in Europe. In our opinion, this combination of continuous pressure on prices and limited diffusion of generic medicines may undermine the long-term sustainability of the Spanish generic medicines retail market. The unique experience in Spain shows the impact of demand-side policies on the use of generic medicines. Because a sustainable generic medicines retail market is important to maintain future competition in the off-patent medicines market, this perspective paper rounds off with recommendations to increase its sustainability.

An analytical framework for assessing drug and therapeutics committee structure and work processes in tertiary Brazilian hospitals

University teaching hospitals usually provide tertiary care and are subject to early adoption of new technologies, which may compromise healthcare systems when uncritically adopted. Knowledge on the decision-making process - drug selection by drug selection committees or DTCs - is crucial to improve the quality of care. There are no models for studying the selection of drugs in Brazilian healthcare services. This study aims to discuss DTC structure and the processes regarding adoption of medicines in tertiary university hospitals in Brazil and to propose an analytical structure for providing direction for the future. State of the art content regarding drug selection processes and DTC procedures was reviewed in three databases. Information on the medicine selection process in a Brazilian gold standard teaching hospital was collected through observations and a review of existing procedures. A structured discussion on medicine selection and DTC procedures in tertiary hospitals ensued. This discussion resulted in findings that were organized in three dimensions, composing an analytical framework for the application in tertiary Brazilian hospitals (i) motivations for the adoption of drugs; (ii) necessary structural and organizational aspects for decision-making; and (iii) criteria and methods employed by the decision-making process. We believe that the suggested framework is compatible with tertiary Brazilian hospitals, because a gold standard in the country was able to conduct all its procedures in the light of WHO and international recommendations. We hope to contribute in producing knowledge which may hopefully be adopted in tertiary hospitals across Brazil.

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.

Impact of delisting ARBs, apart from losartan, on ARB utilisation patterns in Denmark: implications for other countries

INTRODUCTION

Renin-angiotensin inhibitor drugs have been a target for health authority initiatives across Europe with the potential for substantial savings once generic angiotensin-converting enzyme inhibitors (ACEIs) became available without compromising care. Recently, losartan was the first angiotensin receptor blocker (ARB) to lose its patent. In Denmark, the authorities removed all other ARBs from the reimbursement list, apart from losartan, as they were all seen as essentially similar for the management of hypertension or congestive heart failure at appropriate doses, but more expensive. Similarly, all other ARB fixed-dose combinations (FDCs), apart from losartan, were removed from the reimbursement list.

OBJECTIVE

The aims of the study were to (i) assess the impact of these reimbursement changes on the subsequent utilisation of losartan and other ARBs alone or as FDCs; (ii) assess changes in the prices of losartan and other ARBs post-generic losartan to calculate potential savings; and (iii) compare the impact of the policies in Denmark with other European countries to provide guidance.

METHODOLOGY

This was a retrospective segmented regression analysis of an interrupted time-series design comparing utilisation patterns before and after the changes in ARB reimbursement status. Utilisation was measured in defined daily doses (DDDs). Changes in total expenditure and expenditure/DDD were also assessed over time.

RESULTS

Losartan utilisation grew from 31 to 33 % of total single ARB utilisation before generic losartan, to 93 % by October 2011. There was a corresponding decrease in the utilisation of all other ARBs. Both changes were significant (p < 0.001). Total expenditure on single ARBs in 2011 was 77 % below 2009 levels despite a 16 % increase in utilisation. Estimated savings were 290.5 million Danish Kroner (DKK). A similar trend was seen for losartan FDCs, which was also significant (p < 0.001).

DISCUSSION

Losartan utilisation grew appreciable following the changes. The change was much greater than seen in countries that had eased prescribing restrictions for losartan but not the other ARBs. Active therapeutic switching programmes plus education and financial incentives also significantly enhanced losartan utilisation following generics in two countries and regions; however, the increase in losartan utilisation was less than that seen in Denmark.

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.