Measuring and Evaluating Indicators of Appropriate Prescribing in Older. Populations

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1 HRB PhD Scholar Division of Population Health Sciences RCSI Measuring and Evaluating Indicators of Appropriate Prescribing in Older Cost-Effective Proton Pump Populations Potential Strategies for more Cahir Rational C., Teeling Prescribing M., Teljeur C., Bennett K., Fahey T. Cahir C, Fahey T, Teljeur C, Tilson L, Bennett K HRB PhD Scholar Division of Population Health Sciences RCSI Inhibitor Prescribing:

2 Disclosures Nothing to declare The Health Services Research Institute - the Irish Health Research Board s (HRB) Cross-Institution PhD Scholars Programme in Health Services Research HRB Centre for Primary Care Research

3 Background Proton pump inhibitors (PPI)- effective treatment for a range of gastric symptoms and disorders (Gastro-oesophageal reflux disease (GORD), NSAID-induced ulceration and peptic ulcer disease) Studies show PPIs are over prescribed worldwide 25% to 70% of patients no appropriate indication 7 billion globally in 2006

4 Background Proton pump inhibitors cost more than other acid inhibiting agents and prescribing guidelines have been drafted in several countries UK national guidelines (NICE 2000,2004,revised 2005)- regular review of patients to assess the continuing need for PPIs and stepping down to a maintenance dose Maintenance dose of most PPIs prevents recurrent GORD symptoms in 70-80% of patients

5 Background NICE guidelines- Least expensive appropriate PPI should be used In Ireland total expenditure on PPIs has increased from approximately 7 million in 1995 to 110 million in 2008 (based on pharmacy claims data) PPIs are one of the most expensive drug group reimbursed accounting for approximately10% of overall drug expenditure

6 Objectives 1. Investigate trends in the duration and dose of PPI prescribing in a national community drug scheme in Ireland in a one year period Determine potential cost savings in a one year period ( ) by changes in prescribing patterns according to clinical and cost-effectiveness guidelines

7 Method The National Shared Services Primary Care Reimbursement Service of the Health Service Executive in Ireland (HSE-PCRS) general medical card scheme - 32% of the Irish population (1,352,120) in 2008 HSE-PCRS pharmacy claims database- details of dispensed medication -WHO ATC, defined daily doses (DDD), strength, quantity, net ingredient cost, total expenditure, gender and age All claimants on PPI therapy (ATC code A02BC) for 3 or more consecutive months in 2007 with a one year follow up

8 Method Five distinct scenarios were identified according to clinical guidelines for more effective and economical PPI prescribing Each scenario estimates potential cost savings by substituting the dispensed PPI for an alternative PPI (e.g. cheaper/generic/lower dose etc) Dose -Maximum-40mg/daily omeprazole, pantoprazole and esomeprazole. 30mg/daily lansoprazole and 20mg/daily rabeprazole. Maintenance-20mg/daily omeprazole, pantoprazole, esomeprazole 15mg/daily lansoprazole and 10mg/daily rabeprazole

9 Method Five scenarios 1. Cheapest PPI at initiation (cheapest brand/generic) At 3 months 2. Therapeutic switching (cheaper brand/generic equivalent) 3. Dose reduction (maintenance) 4. Therapeutic switching and dose reduction (maintenance) 5. Therapeutic substitution (H2 antagonist)

10 RESULTS Trends in PPI prescribing

11 Trends in PPI prescribing 167,747 patients (13% of eligible population) were prescribed PPIs for 3 consecutive months in ,475 (60%) were prescribed PPIs at maximum therapeutic dosage for 3 consecutive months in 2007

12 Trends in PPI prescribing

13 Trends in PPI prescribing by age group Percentage of patients prescribed PPIs 3m in 2007 (by age distribution of the HSE-PCRS population) Age Bands % 3 months Proportion max dosage years years years years years years years years

14 RESULTS Potential Cost Savings

15 Potential cost savings The total net ingredient cost for patients on PPI therapy 3 months in 2007 was 88,153,174 Most frequently prescribed PPI in 2007 lansoprazole -proprietary drug with a generic equivalent; max dose; monthly cost 42 16% of PPI prescribing was generic in 2007

16 Estimated annual cost savings and % reduction for effective and economical PPI prescribing (5 scenarios) Scenarios (1 to 5) Cost Savings NIC 1 PPI initiation (cheapest brand) 36,943, Therapeutic switching (cheaper brand, same dose) % 29,568, Dose reduction (maintenance) 21,289, Therapeutic switching and dose reduction 40,505, Therapeutic substitution (H2 Antagonist) 34,991,

17 Estimated annual cost savings for the 5 scenarios by age group (by age distribution of the HSE-PCRS population)

18 Limitations No detailed diagnosis information in database Estimated cost savings are maximum cost savingssensitivity analysis

19 Summary and implications The five scenarios identify opportunities for more economical PPI prescribing based on current clinical evidence Regular review of patients to assess their continuing need for PPIs and the use of step down therapy and more cost-effective PPIs may result in significant savings for prescribing budgets Regular review is time consuming- facilitated by prescription software systems, prescription data analysis, prescribing advice and support, incentives

20 Summary and implications Side-effects not to be overlooked but fortunately rare- clostridium difficile (double risk of infection), pneumonia, headache Acceptability to patients- PPIs superior efficacyuse of intermittent or on demand treatment rather than continuous medication Swedish study- 27% able to discontinue PPIs after 4 years of PPI therapy