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Bilbao 20121
The influence of different initiatives to enhance prescribing efficiency for CV drugs, PPIs and
atypicals in Scotland; implications for the future
Marion Bennie, Iain Bishop, Brian Godman and
Stephen Campbell
Bilbao 20122
Healthcare expenditure represents a significant proportion of national expenditure
Pharmaceutical expenditure typically the largest component in ambulatory care - up to 60% of total healthcare expenditure in some countries
Alongside this, national health services in Europe strive to maintain comprehensive and equitable healthcare, which has resulted in multiple reforms to obtain low prices for generics and enhance their prescribing vs. originators (ATC Level 5) and patented products in a class (ATC Level 4)
However, intensity of reforms can vary across classes and countries. Analysis of reforms within and across countries including atypicals can provide guidance for the future
There is increasing focus on drug expenditure. Analysis of reforms provide future direction
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Objectives Analyse whether prescribing efficiency for PPIs and statins extended
beyond 2007 in Scotland Analyse influence of reforms to enhance atypical antipsychotic
prescribing efficiency Contrast with other classes including PPIs, statins and ACEIs/ ARBs
and suggest additional reforms if needed
Methodology Retrospective observational DU study of the influence of reforms on
PPI and statin utilisation and expenditure 2001 to 2010, ACEIs/ ARBs 2001 to 2007, and atypical antipsychotics 2005 to 2010, using NHS Scotland Warehouse data
Clozapine not included as reserved for resistant patients Demand side measures collated under the 4 Es Reforms taken from previous publications as well as in-house data,
and validated
Study objectives and methodology
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The definition of the 4Es and examples include:
Ref: Wettermark, Godman et al 2009; Godman, Shrank et al 2010,2011; Godman, Wettermark, Bishop et al 2012
4 E category Definition Examples Education Programmes that
influence prescribing through dissemination of material, which can be passive or active
Examples include: simple distribution of printed treatment guidance intensive strategies such as educational outreach visits
building on guidance for instance from Drugs and Therapeutic Committees
Subsequent monitoring of prescribing against agreed guidance or guidelines coupled with feedback
Engineering Organizational or managerial interventions
Examples include: price: volume agreements for existing drugs disease management programmes prescribing targets, e.g. the % of prescriptions for generic
omeprazole versus all PPIs and % generic simvastatin versus all statins and goals for INN prescribing when this is not obligatory or enforced
Economics Financial interventions (positive and negative)
Examples include: patient co-payments for more expensive drugs than the
current reference molecule positive and negative financial incentives for physicians devolved budgets to physicians
Enforcement Regulations including those enforced by law
Examples include: mandatory generic substitution in pharmacies prescribing restrictions such as prior authorisation
schemes, e.g. atorvastatin in Austria; alternatively prescribing restrictions with follow-up only where concerns, e.g. Norway and Sweden
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NHS Scotland, Health Boards and SIGN have introduced multiple demand-side measures in recent years. These include the following for PPIs and CV drugs:
Measure Examples of initiatives categorised under the 4Es Education Physicians typically trained in medical school to prescribe by INN name with fo llow up in the
community coupled with IT systems. Follow up includes decision support software as well as monitoring the prescribing of generics, which is seen as good-quality prescribing. This has resulted in current INN prescribing rates averaging over 80% across all products, rising to over 98% for generic simvastatin and generic lisinopril
National guidance and guidelines (SIGN) for dyspepsia National guidance and guidelines (SIGN) for primary and secondary prevention including
patients with diabetes Regional formularies for PPIs and statins such as the Lothian and Greater Glasgow
formularies advocating generic omeprazole and generic simvastatin; the latter as 40mg generic simvastatin
General monitoring of prescribing, benchmarking and academic detailing Engineering Better Care Better Value’ indicators to enhance the prescribing of low cost statins and PPIs
versus single sourced statins and PPIs Quality targets for statin prescribing as part of Audit Scotland in 2003 Quality and Outcome Framework targets including those for diabetes, hypertension, stroke
and CHD Therapeutic switching by Health Board pharmacists when working with GPs
Economics Practice based financial incentives Payment by results
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Scottish Intercollegiate Guidelines Network (SIGN) Clinical guidelines applicable
to NHS in Scotland Guidelines developed by
multidisciplinary, nationally representative groups Enhanced “buy in”
Originally criticised for not costing consequences of guideline implementation
Now include cost effective drug choices to enhance their usage with all key stakeholder groups expected to follow the guidance
Scottish Intercollegiate Guidelines Network (SIGN) well respected in Scotland and Internationally
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PPIs Typically generic omeprazole first line (98% total omeprazole) Expenditure in 2010 56% below 2001 levels despite 3 fold increase in
utilisation - helped by generic omeprazole 9% of pre-patent loss prices in 2010. Expenditure will fall further with generic esomeprazole
Statins Typically generic simvastatin first line (98% total simvastatin) Increasingly 40mg - recommended following Heart Protection Study and to
achieve QoF targets Expenditure in 2010 only 7% above 2001 levels despite 6.2 fold increase in
utilisation since 2001, helped by generic simvastatin only 3% of pre-patent loss prices. Expenditure now falling with generic atorvastatin
ACEIs/ ARBs Both seen as equally effective – fewer side-effects with ARBs Prescribing targets for ACEIs/ ARBs in 2003 to limit ARB prescribing Only 20% increase in expenditure 2007 vs. 2001 despite 159% increase in
volume
Multiple supply- and demand-side measures have enhanced efficiency for PPIs and CV drugs
Ref: Vončina, Strizrep, Godman et al 2011; Bennie, Godman, Bishop et al 2012
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Combined activities increased use of omeprazole. Without measures PPI expenditure GB£159mn higher in 2012
Generic omeprazole reimbursed
Ref: Bennie, Godman, Bishop et al 2012
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Measures also increased use of simvastatin. Without these, statin expenditure GB£290mn higher in 2010
Generic simvastatin reimbursed
Ref: Bennie, Godman, Bishop et al 2012
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Intensive education, economics and engineering measures successful in Scotland to enhance ACEIs
Ref: Voncina, Strizrep, Godman et al 2011
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Generic oral risperidone
In contrast, stabilisation in overall use of risperidone since oral generic launched in April 2008 ....
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Generic risperidone
In more detail, again stabilisation in utilisation of risperidone versus other atypical antipsychotics ....
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Generic oral risperidone
.. appreciably limited savings from the availability of oral generic risperidone at 16% of pre-patent loss prices in 2010
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Multiple supply- and demand-side measures have appreciably enhanced prescribing efficiency for the PPIs, statins and ACEIs/ ARBs in Scotland, providing direction to other countries for areas for disinvestment with growing economic pressures
However, there has been no increased utilisation of risperidone since the availability of oral risperidone at appreciably lower prices than patent protected atypical anti-psychotics
This reflects a more complex disease area with no opportunities for switching. In addition, again emphasising specific measures are needed to enhance prescribing efficiency with limited ‘hawthorne’ effect
Specific measures now include prescribing targets for oral versus patented dispersible risperidone
Multiple measures are needed to enhance prescribing efficiency confirming others
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Linking changes in prescribing patterns with health policy and other initiatives, including quality initiatives, from those implementing and analysing the changes, enhances the robustness of the data and discussion on future measures
NHS Scotland (over 90% of the population with unique identifiers) Estimates of incidence and prevalence (drug specific to a given
condition) and linkage with other registers Prescribing history broken down by age, sex and deprivation Extent of co-prescribing, e.g. statins in patients over 40 with
diabetes Actual sequencing of drug use, e.g. Extent of therapeutic switching Extent of persistence rate/ switch rate in practice Link with other datasets such as Hospital admissions, A & E, and
out-patients (event linking for pharmacovigilance studies) Actual usage of drugs in children for potential paediatric licences
Opportunities with data from health authority sources, e.g. NHS Scotland, to inform decisions
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Thank You
Any Questions!
[email protected]; [email protected]; Brian.Godman@ ki.se; [email protected]; [email protected]