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!

iain.bishop@nhs.net; NSS.ISD-SPECIFY@nhs.net; Brian.Godman@ ki.se; godman@marionegri.it; mail@briangodman.co.uk