Pharmaceutical penetration of new drug and pharmaceutical market structure in Taiwan: hospital-level prescription of thiazolidinediones for diabetes

Barriers and facilitators to the uptake of new medicines into clinical practice: a systematic review

BACKGROUND

Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the uptake of new medicines into practice faces a wide range of obstacles. Earlier reviews provided insights into determinants for new medicine uptake (such as medicine, prescriber, patient, organization, and external environment factors). However, the methodological approaches used had limitations (e.g., single author, narrative review, narrow search, no quality assessment of reviewed evidence). This systematic review aims to identify barriers and facilitators affecting the uptake of new medicines into clinical practice and identify areas for future research.

METHOD

A systematic search of literature was undertaken within seven databases: Medline, EMBASE, Web of Science, CINAHL, Cochrane Library, SCOPUS, and PsychINFO. Included in the review were qualitative, quantitative, and mixed-methods studies focused on adult participants (18 years and older) requiring or taking new medicine(s) for any condition, in the context of healthcare organizations and which identified factors affecting the uptake of new medicines. The methodological quality was assessed using QATSDD tool. A narrative synthesis of reported factors was conducted using framework analysis and a conceptual framework was utilised to group them.

RESULTS

A total of 66 studies were included. Most studies (n = 62) were quantitative and used secondary data (n = 46) from various databases, e.g., insurance databases. The identified factors had a varied impact on the uptake of the different studied new medicines. Differently from earlier reviews, patient factors (patient education, engagement with treatment, therapy preferences), cost of new medicine, reimbursement and formulary conditions, and guidelines were suggested to influence the uptake. Also, the review highlighted that health economics, wider organizational factors, and underlying behaviours of adopters were not or under explored.

CONCLUSION

This systematic review has identified a broad range of factors affecting the uptake of new medicines within healthcare organizations, which were grouped into patient, prescriber, medicine, organizational, and external environment factors. This systematic review also identifies additional factors affecting new medicine use not reported in earlier reviews, which included patient influence and education level, cost of new medicines, formulary and reimbursement restrictions, and guidelines.

REGISTRATION

PROSPERO database (CRD42018108536).

Differential diffusion of pharmaceutical innovations in a mixed market middle - income economy

Background

Policymakers are faced with the challenge of balancing patient’s access for effective and affordable medicines to sustain the rising healthcare costs. In a mixed healthcare market such as Malaysia, coverage decisions of new medicines are different: public funded health system has a formulary listing process whereas for private sector, which is a market-based economy, depends on patient’s willingness to pay and insurance coverage. There is little overlap between public and private healthcare service delivery with access to new innovative medicines, as differentiated by sources of funding. The objectives of this study were to examine the diffusion of New Chemical Entities (NCEs) into the public and private healthcare market between 2010 and 2014, and determine the factors explaining the diffusion.

Methods

We matched medicines from the product registration database by medicine formulation to medicines in IQVIA National Pharmaceutical Audit database for each year. The price per Defined Daily Dose (DDD), market concentration and generic utilization share variables were calculated. A panel fixed effect model was performed to measure diffusion of NCEs for each year and test possible determinants of diffusion of NCEs for overall market and sector specifics.

Results

The utilization of NCEs was larger in the private sector compared to the public sector but the speed of diffusion over time was higher in the public sector. Price per DDD was negatively associated with diffusion of NCEs, while generic utilization share was significantly regressive in the public sector. Market concentration was negatively associated with utilization of NCEs, however result tends to be mixed according to sector and Anatomical Therapeutic Chemical (ATC) category.

Conclusions

Understanding key aspects of sectoral variation in diffusion of NCEs are crucial to reduce the differences of access to new medicines within a country and ensure resources are used on cost effective treatments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06786-6.

The structure of the pharmaceutical market in Iran using concentration indices

BACKGROUND AND OBJECTIVE

The efficiency and function of the pharmaceutical sector, as a vital portion of the health system, have a significant effect on intermediate and final indices of health. In this research, the structure of the pharmaceutical market in Iran was examined through the calculation of concentration indices in 2011.

METHODS

In this cross-sectional study, the needed data was gathered from the Food and Drug Administration in the year 2011. Data were analyzed using SPSS software version 20 and Microsoft Office Excel software. Finally, two common measures of market concentration, the Concentration Ratio and the Herfindahl-Hirschman Index, were calculated.

RESULTS

The largest and the smallest shares of the industry were 5.57% and 0.01%, respectively. The average industry share was 1.09%. The share range was calculated to be 5.56%. The Herfindahl-Hirschman Index was 248.5, which indicates a very low concentration of the pharmaceutical market in Iran. Also, based on the Concentration Ratio of 4 companies (18.39%), the concentration of the pharmaceutical market has been too low.

CONCLUSION

The pharmaceutical market in Iran has a very low concentration and it does not have an exclusive mode in terms of market structure. Therefore, it can be attributed to the competitive model. The policy makers in this area can use this characteristic as a leverage to improve efficiency, fairness, revenue and health indices.

Decision to adopt medical technology under the National Health Insurance System in Taiwan: case study of new molecular targeted drugs among non-small cell lung cancer patients

RATIONALE, AIMS AND OBJECTIVES

Molecular targeted drugs (MTD), gefitinib and erlotinib, have been proven to provide clinical benefits to advanced stage non-small cell lung cancer (NSCLC) patients. Therefore, access to such medical innovations in time is critical for patients with the right indications. The aim of this study was to explore determinants of the adoption of MTD among NSCLC patients under Taiwan's National Health Insurance (NHI) system.

METHODS

Using Taiwan's Longitudinal Health Insurance Database and Cancer Registry database as the data source, we identified 1555 newly diagnosed NSCLC patients who started their cancer treatment between 2004 and 2009. Patients were categorized into 'non-MTD' and 'MTD' groups based on the cancer treatment they received. Hierarchical logistic regression was used to explore potential determinants associated with the adoption of MTD by adjusting for patient-, disease-, doctor-, hospital-level characteristics and changes of reimbursement schemes.

RESULTS

During the study period, 562 (36%) NSCLC patients were classified as the 'MTD group and 993 (64%) patients were the 'non-MTD' group. Hierarchical logistic regression model showed that the elderly were less likely to receive MTD (OR = 0.41; 95% CI: 0.28-0.60). In contrast, patients whose cancer type was adenocarcinoma (OR = 2.99; 95% CI: 2.09-4.26) were more likely to receive MTD. Those who went to private hospitals (OR = 1.75; 95% CI: 1.01-3.03) and hospitals with higher economic scale (OR = 3.00; 95% CI: 1.72-5.25) were more likely to receive MTD as well.

CONCLUSIONS

Our findings suggest that both patient- and hospital-level characteristics significantly affected the adoption of MTD among NSCLC patients.

Thiazolidinedione use in elderly patients with type 2 diabetes: with and without heart failure

PURPOSE

To compare the prescribing patterns of thiazolidinediones (TZDs) in elderly patients with type 2 diabetes with and without heart failure (HF).

METHODS

The national health insurance claims database from the Health Insurance Review & Assessment Service (HIRA), Korea was used. Elderly patients with type 2 diabetes taking at least one hypoglycemic agent were studied between July 1, 2005 and June 30, 2006. Patients were grouped according to the presence of HF. The proportion of patients receiving TZDs were compared between the two groups, and stratified by their diabetes medication regimen (monotherapy and combination therapy). The difference in the patterns of TZD prescribed was studied across all health care levels including: primary, secondary, and tertiary care facilities.

RESULTS

Among 357,855 elderly patients with type 2 diabetes, 24,746 patients had HF. TZDs were prescribed to 10.4% of the patients with HF and 8.8% of the patients without HF (p < 0.01). In the combination therapy group, the proportion of patients receiving TZDs was 17.9% and 14.4% in patients with and without HF, respectively (p < 0.01). In the primary care setting, the proportion of TZD prescriptions in patients with HF was 5.6% and it was 4.6% in patients without HF (p < 0.01).

CONCLUSIONS

TZDs were frequently prescribed to patients with HF, even though the TZDs were contraindicated in patients with HF. Health care professionals should consider alternative therapies for patients with type 2 diabetes mellitus. In addition, they should carefully monitor the impact of TZD use in patients with HF.

The determinants of the adoption of pharmaceutical innovation: evidence from Taiwan

In recent years, a substantial amount of technological progress in medicine has taken the form of pharmaceutical innovation. This paper uses the launch of a series of new drugs designed for treating type 2 diabetic patients as an example to investigate the determinants that affect the diffusion of new medical technology. Based on prescription-level data that are obtained from the national health insurance program in Taiwan, we find that the probability of prescribing new drugs declines as more competing products enter the pharmaceutical market. Meanwhile, physicians are less likely to prescribe new drugs to treat their patients as the provider market becomes less concentrated. These results suggest that the providers' incentives for cost reduction dominate incentives for quality improvement as markets become more competitive and hence an increase in market competition is associated with a decrease in the diffusion of new drugs. As a result, access to new drugs is not uniform among patients in a country with universal coverage for prescription drugs. An important implication of our study is that profit-seeking behavior among providers can become an access barrier to new medical technology.

Diffusion patterns of new anti-diabetic drugs into hospitals in Taiwan: the case of thiazolidinediones for diabetes

Background

Diffusion of new drugs in the health care market affects patients' access to new treatment options and health care expenditures. We examined how a new drug class for diabetes mellitus, thiazolidinediones (TZDs), diffused in the health care market in Taiwan.

Methods

Assuming that monthly hospital prescriptions of TZDs could serve as a micro-market to perform drug penetration studies, we retrieved monthly TZD prescription data for 580 hospitals in Taiwan from Taiwan's National Health Insurance Research Database for the period between March 1, 2001 and December 31, 2005. Three diffusion parameters, time to adoption, speed of penetration (monthly growth on prescriptions), and peak penetration (maximum monthly prescription) were evaluated. Cox proportional hazards model and quantile regressions were estimated for analyses on the diffusion parameters.

Results

Prior hospital-level pharmaceutical prescription concentration significantly deterred the adoption of the new drug class (HR: 0.02, 95%CI = 0.01 to 0.04). Adoption of TZDs was slower in district hospitals (HR = 0.43, 95%CI = 0.24 to 0.75) than medical centers and faster in non-profit hospitals than public hospitals (HR = 1.79, 95%CI = 1.23 to 2.61). Quantile regression showed that penetration speed was associated with a hospital's prior anti-diabetic prescriptions (25%Q: 18.29; 50%Q: 25.57; 75%Q: 30.97). Higher peaks were found in hospitals that had adopted TZD early (25%Q: -40.33; 50%Q: -38.65; 75%Q: -32.29) and in hospitals in which the drugs penetrated more quickly (25%Q: 16.53; 50%Q: 24.91; 75%Q: 31.50).

Conclusions

Medical centers began to prescribe TZDs earlier, and they prescribed more TZDs at a faster pace. The TZD diffusion patterns varied among hospitals depending accreditation level, ownership type, and prescription volume of Anti-diabetic drugs.

The potentially inappropriate prescription of new drug: thiazolidinediones for patients with type II diabetes in Taiwan

PURPOSE

To examine the potentially inappropriate prescription of thiazolidinediones (TZD).

METHODS

Data on TZD prescriptions were collected from Taiwan's National Health Insurance dataset from 2001 to 2006. TZDs were considered inappropriately prescribed when they were prescribed to patients who were (1) under 18 years old, (2) pregnant, who had (3) type 1 diabetes, (4) severe heart failure, (5) hepatic insufficiency, or (6) renal insufficiency and taking TZD + metformin in combination. We aggregated potentially inappropriate prescriptions of TZD for each health-care institution in each month starting from March 2001, when TZD was introduced to Taiwan's market.

RESULTS

The potentially inappropriate prescription of TZD increased from 9.41% in 2001 to 12.50% in 2006. Prior inappropriate prescription led to a 0.06% (95%CI: 0.04-0.08) further increase in its later inappropriate prescription. Accumulated months of experience prescribing TZD was found associated with higher proportion of inappropriate prescription of TZD (0.03%, 95%CI: 0.01-0.05). However, it was negatively associated with new incidence of inappropriate prescription of TZD (-0.20, 95%CI: -0.22 to -0.18). The greater the volume of prior TZD prescription (-0.87%, 95%CI: -0.93 to -0.81) and the greater the number of accumulated months since adoption (-0.14%, 95%CI: -0.16 to -0.12), the greater the decrease in rates of new inappropriate prescriptions.

CONCLUSIONS

Along with the quick penetration of the new DM drug came an increased possibility that it would be prescribed inappropriately, a trend that persisted over time.