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  • 1. The influence of different initiatives to enhance prescribing efficiency for CV drugs, PPIs andatypicals in Scotland; implications for the future Marion Bennie, Iain Bishop, Brian Godman and Stephen Campbell1 Bilbao 2012
  • 2. There is increasing focus on drug expenditure.Analysis of reforms provide future direction 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 future2 Bilbao 2012
  • 3. Study objectives and methodologyObjectives 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 neededMethodology 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 validated3 Bilbao 2012
  • 4. The definition of the 4Es and examples include: 4 E category Definition Examples Education Programmes that Examples include: influence • simple distribution of printed treatment guidance prescribing through • intensive strategies such as educational outreach visits dissemination of building on guidance for instance from Drugs and material, which can Therapeutic Committees be passive or active • Subsequent monitoring of prescribing against agreed guidance or guidelines coupled with feedback Engineering Organizational or Examples include: managerial • price: volume agreements for existing drugs interventions • 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 Examples include: interventions • patient co-payments for more expensive drugs than the (positive and current reference molecule negative) • positive and negative financial incentives for physicians • devolved budgets to physicians Enforcement Regulations Examples include: including those • mandatory generic substitution in pharmacies enforced by law • 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 Sweden4 Bilbao 2012 Ref: Wettermark, Godman et al 2009; Godman, Shrank et al 2010,2011; Godman, Wettermark, Bishop et al 2012
  • 5. 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 4EsEducation • Physicians typically trained in medical school to prescribe by INN name with follow 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 detailingEngineering • 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 GPsEconomics • Practice based financial incentives • Payment by results 5 Bilbao 2012
  • 6. Scottish Intercollegiate Guidelines Network (SIGN) Scottish Intercollegiatewell respected in Scotland and Internationally  Guidelinesapplicable Clinical guidelines Network (SIGN) 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 6 Bilbao 2012
  • 7. Multiple supply- and demand-side measureshave enhanced efficiency for PPIs and CV drugsPPIs 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 esomeprazoleStatins 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 atorvastatinACEIs/ 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 volume7 Bilbao 2012 Ref: Vončina, Strizrep, Godman et al 2011; Bennie, Godman, B
  • 8. Combined activities increased use of omeprazole. Withoutmeasures PPI expenditure GB£159mn higher in 2012 Generic omeprazole reimbursed 8 Bilbao 2012 Ref: Bennie, Godman, Bishop et al 2012
  • 9. Measures also increased use of simvastatin. Withoutthese, statin expenditure GB£290mn higher in 2010 Generic simvastatin reimbursed 9 Bilbao 2012 Ref: Bennie, Godman, Bishop et al 2012
  • 10. Intensive education, economics and engineeringmeasures successful in Scotland to enhance ACEIs10 Bilbao 2012 Ref: Voncina, Strizrep, Godman et al 2011
  • 11. In contrast, stabilisation in overall use of risperidonesince oral generic launched in April 2008 .... Generic oral risperidone11 Bilbao 2012
  • 12. In more detail, again stabilisation in utilisation ofrisperidone versus other atypical antipsychotics .... Generic risperidone12 Bilbao 2012
  • 13. .. appreciably limited savings from the availability oforal generic risperidone at 16% of pre-patent lossprices in 2010 Generic oral risperidone13 Bilbao 2012
  • 14. Multiple measures are needed to enhanceprescribing efficiency confirming others 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 risperidone14 Bilbao 2012
  • 15. Opportunities with data from health authority sources, e.g. NHS Scotland, to inform decisions 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 measuresNHS 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 15 Bilbao 2012
  • 16. Thank You Any Questions! iain.bishop@nhs.net; NSS.ISD-SPECIFY@nhs.net; Brian.Godman@ ki.se; godman@marionegri.it; mail@briangodman.co.uk16 Bilbao 2012