Proton pump inhibitors: potential cost reductions by applying prescribing guidelines.

BACKGROUND: There are concerns that proton pump inhibitors (PPI) are being over prescribed in both primary and secondary care. This study aims to establish potential cost savings in a community drug scheme for a one year period according to published clinical and cost-effective guidelines for PPI prescribing. METHODS: Retrospective population-based cohort study in the Republic of Ireland using the Health Services Executive (HSE) Primary Care Reimbursement Services (PCRS) pharmacy claims database. The HSE-PCRS scheme is means tested and provides free health care including medications to approximately 30% of the Irish population. Prescription items are WHO ATC coded and details of every drug dispensed and claimants\u27 demographic data are available. Potential cost savings (net ingredient cost) were estimated according to UK NICE clinical guidelines for all HSE-PCRS claimants on PPI therapy for ≥3 consecutive months starting in 2007 with a one year follow up (n=167,747). Five scenarios were evaluated; (i) change to PPI initiation (cheapest brand); and after 3 months (ii) therapeutic switching (cheaper brand/generic equivalent); (iii) dose reduction (maintenance therapy); (iv) therapeutic switching and dose reduction and (v) therapeutic substitution (H2 antagonist). RESULTS: Total net ingredient cost was €88,153,174 for claimants on PPI therapy during 2007. The estimated costing savings for each of the five scenarios in a one year period were: (i) €36,943,348 (42% reduction); (ii) €29,568,475 (34%); (iii) €21,289,322 (24%); (iv) €40,505,013 (46%); (v) €34,991,569 (40%). CONCLUSION: There are opportunities for substantial cost savings in relation to PPI prescribing if implementation of clinical guidelines in terms of generic substitution and step-down therapy is implemented on a national basis

PROJECTING THE IMPACT OF DEMOGRAPHIC CHANGE ON THE DEMAND FOR AND DELIVERY OF HEALTH CARE IN IRELAND. RESEARCH SERIES NUMBER 13 OCTOBER 2009

Primary care is often the first point of contact with the health care system for people requiring care. Primary care is often thought synonymous with general practitioners, but actually encompasses a large range of different professionals and services including nurses/midwives; physiotherapists; occupational therapists; dentists; opticians; chiropodists; psychologists and pharmacists. The list is not exhaustive, but still gives an indication of the wide range of services that can be grouped under the general heading of primary care. Nonetheless, GPs do have a core part to play in primary care as well as performing the role of ‘gate keeper’ to other health services such as accident and emergency or outpatient care in hospitals. The balance of treatment and referral between general practice and secondary care is, therefore, a very important issue and it has been argued that the under development of primary care services in Ireland in recent decades has contributed, and indeed, may be the most important reason, for the over-crowding of accident and emergency services and long waiting lists for elective procedures in Irish health care (Layte et al., 2007b; Tussing and Wren, 2006)

Policies to Enhance Prescribing Efficiency in Europe: Findings and Future Implications

Introduction: European countries need to learn from each other to address unsustainable increases in pharmaceutical expenditures. Objective: To assess the influence of the many supply and demand-side initiatives introduced across Europe to enhance prescribing efficiency in ambulatory care. As a result provide future guidance to countries. Methods: Cross national retrospective observational study of utilization (DDDs – defined daily doses) and expenditure (Euros and local currency) of proton pump inhibitors (PPIs) and statins among 19 European countries and regions principally from 2001 to 2007. Demand-side measures categorized under the “4Es” – education engineering, economics, and enforcement. Results: Instigating supply side initiatives to lower the price of generics combined with demand-side measures to enhance their prescribing is important to maximize prescribing efficiency. Just addressing one component will limit potential efficiency gains. The influence of demand-side reforms appears additive, with multiple initiatives typically having a greater influence on increasing prescribing efficiency than single measures apart from potentially “enforcement.” There are also appreciable differences in expenditure (€/1000 inhabitants/year) between countries. Countries that have not introduced multiple demand side measures to counteract commercial pressures to enhance the prescribing of generics have seen considerably higher expenditures than those that have instigated a range of measures. Conclusions: There are considerable opportunities for European countries to enhance their prescribing efficiency, with countries already learning from each other. The 4E methodology allows European countries to concisely capture the range of current demand-side measures and plan for the future knowing that initiatives can be additive to further enhance their prescribing efficiency

Using resource modelling to inform decision making and service planning: the case of colorectal cancer screening in Ireland

Background - Organised colorectal cancer screening is likely to be cost-effective, but cost-effectiveness results alone may not help policy makers to make decisions about programme feasibility or service providers to plan programme delivery. For these purposes, estimates of the impact on the health services of actually introducing screening in the target population would be helpful. However, these types of analyses are rarely reported. As an illustration of such an approach, we estimated annual health service resource requirements and health outcomes over the first decade of a population-based colorectal cancer screening programme in Ireland. Methods - A Markov state-transition model of colorectal neoplasia natural history was used. Three core screening scenarios were considered: (a) flexible sigmoidoscopy (FSIG) once at age 60, (b) biennial guaiac-based faecal occult blood tests (gFOBT) at 55–74 years, and (c) biennial faecal immunochemical tests (FIT) at 55–74 years. Three alternative FIT roll-out scenarios were also investigated relating to age-restricted screening (55–64 years) and staggered age-based roll-out across the 55–74 age group. Parameter estimates were derived from literature review, existing screening programmes, and expert opinion. Results were expressed in relation to the 2008 population (4.4 million people, of whom 700,800 were aged 55–74). Results - FIT-based screening would deliver the greatest health benefits, averting 164 colorectal cancer cases and 272 deaths in year 10 of the programme. Capacity would be required for 11,095-14,820 diagnostic and surveillance colonoscopies annually, compared to 381–1,053 with FSIG-based, and 967–1,300 with gFOBT-based, screening. With FIT, in year 10, these colonoscopies would result in 62 hospital admissions for abdominal bleeding, 27 bowel perforations and one death. Resource requirements for pathology, diagnostic radiology, radiotherapy and colorectal resection were highest for FIT. Estimates depended on screening uptake. Alternative FIT roll-out scenarios had lower resource requirements. Conclusions - While FIT-based screening would quite quickly generate attractive health outcomes, it has heavy resource requirements. These could impact on the feasibility of a programme based on this screening modality. Staggered age-based roll-out would allow time to increase endoscopy capacity to meet programme requirements. Resource modelling of this type complements conventional cost-effectiveness analyses and can help inform policy making and service planning

Pharmaceutical pricing and reimbursement : an Irish perspective

THESIS 7813There has been a five-fold increase in state expenditure on medicines under the Community Drug Schemes in Ireland over the last decade (1994 to 2004). As a result of this marked increase in pharmaceutical expenditure, the issue of obtaining value for money from the drugs budget arises. The research presented in this thesis was undertaken in response to the issues of concern to the Department of Health and Children (DoHC) in relation to pricing and reimbursement of pharmaceuticals in Ireland. The aim of this thesis is to determine the potential impact of implementing various pharmaceutical cost- containment measures in the Irish healthcare system. Similar increases in state expenditure on medicines have occurred across other European Union (EU) Member States, and various policies have been adopted by decision makers to contain this rise in pharmaceutical expenditure, including price controls, restriction of publicly reimbursed drugs by positive or negative lists, promotion of generic markets, prescribing budgets and patient co-payments. It is difficult to establish which of the different cost-containment strategies is most effective as they are rarely applied in isolation and it is often difficult to determine the influence of each in an overall effect. Therefore, before any cost-containment strategy can be introduced, a full assessment of the potential impact is necessary

Estimating Drug Costs in Economic Evaluations in Ireland and the UK: An Analysis of Practice and Research Recommendations

Cost estimates for the drug of interest, its comparator and concomitant drugs are an important component of pharmacoeconomic evaluations. However, whilst in general considerable efforts are made by analysts to ensure valid and accurate parameter inputs, the methods for estimating drug costs are often lacking. We reviewed recent pharmacoeconomic evaluations undertaken in Ireland and the UK and documented the sources of data for drug costs and the methods of cost estimation. Methods were often inadequately described and, where adequate information was available, there was considerable variation and limitations in the methods used, thereby reducing the comparability of studies. Data from a sample of studies from other Northern European countries suggested that the findings from Ireland and the UK were not atypical. In order to improve current practice we suggest a methodological checklist for use in future studies.