The role of Health Insurance Companies in optimising drug prescription in Primary Care; The example of acid suppressing drugs

Abstract

The use of Acid-suppressing drugs (ASDs) in the Netherlands increases more than 10% annually and of the Dutch population 3.5% uses ASD on a daily basis. However, indications for long term use of ASDs for gastrointestinal complaints are often not evidence based and many patients might be able to stop or to switch to a symptom-guided ‘on-demand’ use. In today’s market oriented health care insurance companies have a major role in maintaining the balance between costs and quality of care. Pharmacotherapy, responsible for 25% of the national health care budget, has always been a major focus. Insurance companies can increase cost-effectiveness of drug prescription by the implementation of managed care programmes. Agis, one of the leading insurance companies, has initiated a programme to optimise ASD prescription. In order to identify the optimal implementation method the programme was introduced using different strategies. In this thesis we report the scientific evaluation of this Agis ASD reduction programme, and evaluate its effect on volume and costs of ASD prescription. In two pre-studies reported in this thesis we analysed the prevalence and the indications of ASD consumption in the Netherlands. The annual increase was mainly correlated to elderly women and the use of non-steroidal anti-inflammatory drugs (NSAIDs). We reviewed also the international literature to assess the best implementation strategy for the programme. The use of active interventions seemed obviously a pre-condition to achieve a reduction of ASD prescriptions. Next we tested the ASD managed care programme in a pilot study among GPs and evaluated the experiences of patients with this programme. GPs received a ‘stop protocol’ with additional practice supportive instruments and compared to the control group 4,1% more patients reduced ASD use. In the patients’ questionnaire a majority (70%) was willing to participate in the ASD programme, but three quarter of them that did participate was dissatisfied with the received support from the GP. With the results from the pilot study and the patient survey the ASD reduction programme was improved and its effectiveness was evaluated in a clustered randomised clinical trial among nearly 1000 GPs in the Agis region. Of three different implementation strategies, the first passive distribution of the ASD programme was not effective in changing volume and costs of ASD. In the second the programme was introduced together with telephone support patients had a 25% higher chance to reduce ASD. The third strategy with support by practice visits demonstrated no significant reduction, probably due to a too short observation time. Concluded is that active implementations of the ASD programme had more effect than the passive one. As most evaluations were done with data from the Agis Health Database (AHD) we finally evaluated the possibilities of this AHD for scientific research in a broader perspective. In the closure of this thesis is concluded that among GPs and patients there is sufficient support for an active role of the health insurance company, although the ASD reduction programme needs more refinement of its implementation strategy to improve the results