Pharmacists appreciably improving sartan prescribing efficiency in the UK; implications for other classes and countries

Transcription

1 Pharmacists appreciably improving sartan prescribing efficiency in the UK; implications for other classes and countries Brian Godman, Andrew Martin, Jeanette Tilstone and Nigget Saleem (KI Sweden and NHS Bury) Presented by Dr Brian Godman 1

2 1. Introduction and objective 2. Methodology and results 3. Conclusions and future implications 2

3 A number of initiatives have been successfully implemented in the UK to enhance efficiency There have been a number of initiatives in the UK in recent years to improve prescribing efficiency. These include national and regional (PCT activities) National programmes include the M and W scheme to lower generic prices. These have resulted in generic prices as low as 2% to 3% of pre-patent loss originator price (national) Programmes have also been instigated to enhance the prescribing of generics vs. originators and patented products in a class/ related class, e.g. PPIs, statins and ACEIs/ ARBs These include the training of doctors to prescribe by INN name, benchmarking and academic detailing, guidelines, Better Care Better Value indicators and practice based financial incentive schemes (national and regional) 3 Ref: McGinn, Godman et al 2010; Bennie, Godman et al 2012; Godman, Bennie et al 2012

4 Generic losartan recently became available providing further opportunities for savings Generic losartan and its listing in Category M in July 2010 providing an opportunity to enhance ARB prescribing efficiency This is because all ARBs are essentially similar for hypertension and for heart failure, although greater care may be needed when switching patients with heart failure Initially, there was limited activity in NHS Bury to enhance the utilisation of losartan versus other ARBs for hypertension This changed in March 2011 with active switching programmes (therapeutic substitution), practice based financial incentive schemes and other measures. This was endorsed by inclusion of losartan in UK Quality Improvement suggestions (QIPP) in July 2011/ February Ref: Heran, Wong et al 2008; Moon, Flett, Godman et al 2011; NICE 2011; Godman, Bennie et al 2012

5 The principal objective study was to assess the impact of the active programme in NHS Bury Principal objective - assess the impact of the multiple initiatives on subsequent utilisation and expenditure of losartan and other ARBs for patients with hypertension in NHS Bury Secondly, assess the price reduction for generic losartan over time following its inclusion in Category M Thirdly, assess potential savings from the multiple measures and appraise any additional measures that could potentially be implemented in NHS Bury if needed to further enhance ARB prescribing efficiency Prescribing efficiency defined as increased prescribing of losartan versus other ARBs - with all ARBs similar for hypertension 5

6 Multiple measures instigated in NHS Bury including pharmacists and pharmacy technicians Demand-side Specific initiatives category Education Educating physicians that all ARBs are similarly effective in the management of hypertension in practice meetings, along with prescribing guidance and follow-up letters Continued educational input to ensure high INN prescribing of losartan Engineering Generic losartan included in the prescribing targets for ARBs in the 2011 to 2012 prescribing incentive scheme (85% of all reninangiotensin items prescribed were either an ACEI or losartan) Instigation of programmes in March 2011 with agreed SOPs whereby pharmacists and pharmacy technicians would work with GPs in NHS Bury to actively switch hypertensive patients on other ARBs to losartan Economics Devolved drug budgets taking into account generic losartan 15% of prescribing incentive monies available for meeting prescribing targets for ACEIs and generic losartan 20% of the prescribing incentive scheme allocated to practices for coming within their indicative prescribing amount 6

7 1. Introduction and objective 2. Methodology and results 3. Conclusions and future implications 7

8 The principal methodology was a retrospective interrupted time series design Principally a retrospective interrupted time series analysis of ARB utilisation before and after the availability of generic losartan as well as before and after the instigation of multiple demand side measures in NHS Bury in March 2011 In addition, a retrospective observational analysis of the changes in monthly reimbursed prescription items for all patients in Bury PCT prescribed at least one fixed dose ARB combination (FDC) from November 2009 to October 2011 (different design as limited FDC utilisation envisaged also seen in practice at 5% to 10% of all ARB items dispensed; only 3% of all losartan items dispensed by October 2011) Utilisation measured in prescription items, which is typically 28 days (typical NHS metric) 8

9 Generic losartan listed in Category M Multiple measures for losartan instigated in NHS Bury losartan 65% of all ARBs by Oct

10 Significant change in utilisation of losartan after active switch programmes but not before 10

11 Switching programme in March 2011 further lowered ARB expenditure in NHS Bury 11

12 Active national and regional programmes appreciably reduced ARB expenditure ARB expenditure in NHS Bury by October 2011 was 59% below expenditure prior to the availability of generic losartan This was helped by a 92% reduction in expenditure/ item for generic losartan vs. pre-patent loss prices (in line with other price reductions for generics) Annual net savings from the programme for NHS Bury were estimated at over GB 290,000 per year for the 186,000 population Savings estimated at eight times the cost of implementing the educational activities and switching programmes. Further enhanced with more ARBs losing their patents 12

13 Annualised savings would have been greater with earlier instigation of active switching In more detail: Estimated that the cost of implementing the programme was UK (10% of a Medication Review Pharmacist s Time Band 8a for the year) and 25% of three Medicines Management Technician s time. 20% for overheads increased this to Annual ARB expenditure was reduced by just over GB 323,000 after the implementation of the switching programme compared with the eight months following the listing of losartan in Category M Consequently, annualised savings of just over GB 290,000 for NHS Bury population of 186,000. This would have been nearly GB 489,000/ per year if the switch programme and other activities had been instigated soon after the listing of generic losartan in Category M 13

14 1. Introduction and objective 2. Methodology and results 3. Conclusions and future implications 14

15 Active demand-side measures needed to effect change in physician prescribing habits Multiple demand-side measures are needed to improve prescribing efficiency with no apparent cross over between classes, i.e. no Hawthorne effect. This is seen in other countries/ regions and classes This may be exacerbated in this situation by greater complexity in the message, i.e. from encouraging the prescribing of generic ACEIs vs. ARBs to generic ACEIs plus low cost ARBs vs. patented ARBs The results demonstrate that Medicine Management technicians can initiate therapeutic switch programmes under guidance to appreciably enhance NHS prescribing efficiency No further programmes are planned in NHS Bury as more ARBs lose their patents 15

16 Thank You Any Questions! marionegri.it; ki.se; 16