Prescribing Indicators Examples from Germany

Transcription

1 Prescribing Indicators Examples from Germany The Managed Introduction of New Medicines Second Piperska Workshop March 2012, Ljubljana Gisbert W. Selke

2 Agenda The QISA indicator set Case examples: drug-drug interactions, PIMs National target value framework Quality Indicators: Example from Germany 2

3 Set of indicators to assess quality and economy QISA indicators for quality and economy Quality Indicator System for Ambulatory care Comprehensive approach not limited to drugs sector Developed by AQUA institute (Prof. Szecsenyi) and AOK Main target: evaluating primary care subscription/ selective contracting schemes As such, always referring to inscribed sub-population only but could also be applied more broadly Quality Indicators: Example from Germany 3

4 QISA drug-related indicators: economy (1) Share of drug recipients Drug cost per head Share of generic scripts Share of reference price scripts Share of me-too scripts Wissenschaftliches Institut der AOK According to Fricke/Klaus classification published in Arzneiverordnungs-Report ( the Orange Book ) Might be amended by results of rapid assessments (IQWiG) Only those on the market for 3 years or less Share of me-too scripts with high potential savings According to one of a number of regional lists maintained by physicians' associations All those still covered by patent Quality Indicators: Example from Germany 4

5 QISA drug-related indicators: economy (2) Wissenschaftliches Institut der AOK Cost per DDD for certain ATC groups where patent drugs compete with generic substances PPIs selective beta blockers alpha1 blockers SSRIs bisphosphonates triptanes CSE inhibitors ACE inhibitors ACE inhibitors plus diuretics dihydropyridines inhalative steroids nitrates oral antidiabetics antidepressants NSAIDs systemic steroids low-molecular heparines loop diuretics Quality Indicators: Example from Germany 5

6 QISA drug-related indicators: quality (1) Wissenschaftliches Institut der AOK Share of scripts of negotiated regional formulary (think Kloka Listan) Might be amended using DU90 methodology Share of scripts of glibenclamide, metformin, human insulins within total antidiabetic sector Could be extended to other diseases Share of patients with concomitant use of drugs prone to undesired interactions Details discussed later Share of patients with high use (> 30 DDD/quarter) of anxiolytics, sedatives, hypnotics (within all patients receiving such) In addition, monitor use of SSRI, Z drugs Possibly focus on sub-groups (women; long-term care) Quality Indicators: Example from Germany 6

7 QISA drug-related indicators: quality (2) Wissenschaftliches Institut der AOK Share of patients with high use (> 75 DDD per quarter) of NSAIDs (within all patients receiving such) check for PPI co-medication? check for renal function? Share of elderly patients (>= 65 years) with polypharmacy (> 5 different agents per quarter) Might be amended to check hospitalisation rate Share of elderly patients receiving potentially inadequate medication (PIMs) Details discussed later Possibly extend to other groups: children; women (including pregnant, breast-feeding); patients with reduced renal function Quality Indicators: Example from Germany 7

8 QISA application example: polypharmacy Wissenschaftliches Institut der AOK Polypharmacy cases (>= 10 ATCs, >= 15 days) Number of cases control group intervention group Quality Indicators: Example from Germany 8

9 QISA: Implementation status Remember: we are (still) only just starting First applications show: selective contracting schemes produce less cost at basically constant quality (as measured by subset of indicators) => more efficiency Relation of indicators to outcomes has not (yet) been researched but compare, e.g., Campbell for UK Quality Indicators: Example from Germany 9

10 Agenda The QISA indicator set Case examples: drug-drug interactions, PIMs National target value framework Quality Indicators: Example from Germany 10

11 Case example: drug-drug interactions Poorly researched area Wissenschaftliches Institut der AOK Number of interactions increases with number of agents to which a patient is exposed (quadratic? linear?) Cannot just use ATCs (topic use usually ok) Danger of over-alerting! Cannot use information from industry because these tend to over-report for liability law reasons Concentrate on interactions with higher probability and more serious problems Be prepared to tackle only certain areas (for a start) We use a rather comprehensive (non-public domain) list (Prof Haefeli, Heidelberg university) just starting... Quality Indicators: Example from Germany 11

12 Case example: first indicative findings Wissenschaftliches Institut der AOK Number of incidents Agents involved Severity 5: contraindication and/r high risk combination omeprazole, clopidogrel 4824 simvastatin, clarithromycin 3342 intraveinous calcium, digitoxin 795 aliskiren, verapamil 595 simvastatin, fluconazole Severity 4: clinically severe allopurinol, ramipril allopurinol, enalapril ibuprofen, aspirin ramipril, spironolacton lisinopril, torasemide Severity 3: potentially clinically relevant medium-severe interaction ramipril, certain other ACE or ARB combinations with diuretics ramipril, torasemide enalapril, certain other ACE or ARB combinations with diuretics ramipril, NSAID NSAID, diuretic Preliminary findings. Top 5 incident numbers of top severity levels Quality Indicators: Example from Germany 12

13 Case example: PIMs for the elderly Another poorly researched area Problem is compounded by high polypharmacy prevalence A number of lists (US: Beers (recent update!); Canada, France, CZ, ) Substantial differences in drug availability between countries, so cross-national transfer not easy Priscus 2010: PIM list for the German market (Delphi method, government-funded) 83 drugs from 18 areas many psycho-active substances NSAIDs/analgesics heart and circulation (in German) Quality Indicators: Example from Germany 13

14 Case example: use of PIM in one patient Wissenschaftliches Institut der AOK 67 years, male Prescription Pack date size Drug Trimipramin AL 100 mg PARACETAMOL COMP. STADA (codein/paracetamol combination) Oxybutynin-ratiopharm 5 mg (quick release) Levofloxacin-ratiopharm 500 mg PARACETAMOL COMP. STADA (codein/paracetamol combination) ergotam 5.0 von ct retard (dihydroergotamin mesilate) bromazep 6 von ct (Bromazepam) Ciprobeta 500 (ciprofloxacin) TRANXILIUM 20 (Dikalium clorazepate) CARVEDILOL-TEVA 12,5 mg DUSODRIL RETARD (naftidrofuryl) bromazep 6 von ct (Bromazepam) PARACETAMOL COMP. STADA (codein/paracetamol combination) Priscus drugs are marked in red. (All prescriptions by a single physician within three months.) Source: AOK 2011 Quality Indicators: Example from Germany 14

15 Case example: Share of patients receiving PIM Source: AOK patients, 2011 Quality Indicators: Example from Germany 15

16 Case example: Regional differences in PIM patients Schleswig-Holstein Hamburg Bremen 21,6 % 22,5 % 23,5 % Mecklenburg- Vorpommern 24,8 % Saarland 27,1 % Nordrhein-Westfalen 24,6% Rheinland- Pfalz 27,4 % Niedersachsen Hessen 22,9 % 25,1 % Thüringen 20,8 % Sachsen- Anhalt 20,7 % Brandenburg 20,6 % Sachsen 20,8 % Berlin 21,3 % West 24,4 % Ost: 21,2 % Gesamt: 23,6 % Baden- Württemberg 24,7 % Bayern 24,2 % Source: AOK patients, 2011 Quality Indicators: Example from Germany 16

17 Agenda The QISA indicator set Case examples: drug-drug interactions, PIMs National target value framework Quality Indicators: Example from Germany 17

18 Targets for economic prescribing (2012 national framework) Preferred substance quotas Substance group Preferred substance(s) Target (minimum share of DDD) Statins simvastatin 86,0% Selective beta-blockers bisoprolol, metoprolol 88,0% Alpha1 blockers for use in BPH tamsulosin 80,0% SSRIs citalopram 54,0% Bisphosphonates for use in osteoporosis alendronic acid 78,0% ACE inhibitors enalapril, lisinopril, ramipril 95,0% NSAIDs diclofenac, ibuprofen 87,0% Antidiabetics, excluding insulins sulfonyl ureic acids, metformin 89,0% Loop diuretics furosemide, torasemide 98,0% Calcium antagonists amlodipine, nitrendipine 76,0% NSMRIs amitriptyline 34,0% Maximum quotas Substance group Subgroup Target (maximum share of DDD) Statins and ezetimibe-containing drugs ezetimibe-containing drugs 7,0% Antidiabetics, excluding insulins GLP-1 analogs 1,5% Opioids (oral, transdermal) transdermal forms 50,0% Opioids (oral) oral morphine 40,0% Erythropoiesis-stimulating drugs biosimilar erythropoetins 35,0% Quality Indicators: Example from Germany 18

19 Thank you for your attention! Gisbert W. Selke Visit us on the Internet (if you read German)