1
|
Gay HC, Yu J, Persell SD, Linder JA, Srivastava A, Isakova T, Huffman MD, Khan SS, Mutharasan RK, Petito LC, Feinstein MJ, Shah SJ, Yancy CW, Kho AN, Ahmad FS. Comparison of Sodium-Glucose Cotransporter-2 Inhibitor and Glucagon-Like Peptide-1 Receptor Agonist Prescribing in Patients With Diabetes Mellitus With and Without Cardiovascular Disease. Am J Cardiol 2023; 189:121-130. [PMID: 36424193 PMCID: PMC9908071 DOI: 10.1016/j.amjcard.2022.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP1-RAs) reduce cardiovascular events and mortality in patients with type 2 diabetes mellitus (T2DM). We sought to describe trends in prescribing for SGLT2is and GLP1-RAs in diverse care settings, including (1) the outpatient clinics of a midwestern integrated health system and (2) small- and medium-sized community-based primary care practices and health centers in 3 midwestern states. We included adults with T2DM and ≥1 outpatient clinic visit. The outcomes of interest were annual active prescription rates for SGLT2is and GLP1-RAs (separately). In the integrated health system, 22,672 patients met the case definition of T2DM. From 2013 to 2019, the overall prescription rate for SGLT2is increased from 1% to 15% (absolute difference [AD] 14%, 95% confidence interval [CI] 13% to 15%, p <0.01). The GLP1-RA prescription rate was stable at 10% (AD 0%, 95% CI -1% to 1%, p = 0.9). In community-based primary care practices, 43,340 patients met the case definition of T2DM. From 2013 to 2017, the SGLT2i prescription rate increased from 3% to 7% (AD 4%, 95% CI 3% to 6%, p <0.01), whereas the GLP1-RA prescription rate was stable at 2% to 3% (AD 1%, 95% CI -1 to 1%, p = 0.40). In a fully adjusted regression model, non-Hispanic Black patients had lower odds of SGLT2i or GLP1-RA prescription (odds ratio 0.56, 95% CI 0.34 to 0.89, p = 0.016). In conclusion, the increase in prescription rates was greater for SGLT2is than for GLP1-RAs in patients with T2DM in a large integrated medical center and community primary care practices. Overall, prescription rates for eligible patients were low, and racial disparities were observed.
Collapse
Affiliation(s)
- Hawkins C Gay
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Jingzhi Yu
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois
| | - Stephen D Persell
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois; Department of Medicine-General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Jeffrey A Linder
- Department of Medicine-General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Anand Srivastava
- Department of Medicine-Nephrology, and Northwestern University, Chicago, Illinois
| | - Tamara Isakova
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois; Department of Medicine-Nephrology, and Northwestern University, Chicago, Illinois
| | - Mark D Huffman
- Department of Medicine-Cardiology, Washington University in St. Louis, St. Louis, Missouri; Global Health Center, Washington University in St. Louis, St. Louis, Missouri; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sadiya S Khan
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - R Kannan Mutharasan
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Lucia C Petito
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matthew J Feinstein
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Sanjiv J Shah
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Clyde W Yancy
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois
| | - Abel N Kho
- Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois; Department of Medicine-General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Faraz S Ahmad
- Department of Medicine-Cardiology, Northwestern University, Chicago, Illinois; Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois.
| |
Collapse
|
2
|
Dankers M, van den Berk-Bulsink MJE, van Dalfsen-Slingerland M, Nelissen-Vrancken H, Mantel-Teeuwisse AK, van Dijk L. Non-adherence to guideline recommendations for insulins: a qualitative study amongst primary care practitioners. BMC PRIMARY CARE 2022; 23:150. [PMID: 35698052 PMCID: PMC9189803 DOI: 10.1186/s12875-022-01760-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/01/2022] [Indexed: 11/24/2022]
Abstract
Background Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines. Methods Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence. Results Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified. Conclusions The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.
Collapse
|
3
|
De Zarate MO, Mentzakis E, Fraser SD, Roderick P, Rutter P, Ornaghi C. Price versus clinical guidelines in primary care statin prescribing: a retrospective cohort study and cost simulation model. J R Soc Med 2021; 115:100-111. [PMID: 34793261 PMCID: PMC8981530 DOI: 10.1177/01410768211051713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To investigate the relative impact of generic entry and National Institute for Health and Care Excellence clinical guidelines on prescribing using statins as an exemplar. DESIGN Retrospective analysis of statin prescribing in primary care and cost simulation model. SETTING Royal College of General Practitioners Research and Surveillance Centre (RCGP R&SC) database and Prescription Cost Analysis (PCA) database. PARTICIPANTS New patients prescribed statins for the first time between July 2003 and September 2018. RESULTS General trends of statin' prescriptions were largely driven by a decrease in acquisition costs triggered by patent expiration, preceding NICE guidelines which themselves did not seem to affect prescription trends. Significant heterogeneity is observed in the prescription of the most cost-effective statin across GPs. A cost simulation shows that, between 2004 and 2018, the NHS could have saved £2.8bn (around 40% of the £6.3bn spent on statins during this time) if all GP practices had prescribed only the most cost-effective treatment. CONCLUSIONS There is potential for large savings for the NHS if new and, whenever possible, ongoing patients are promptly switched to the first medicine that becomes available as generic within a therapeutic class as long as it has similar efficacy to still-patented medicines.
Collapse
Affiliation(s)
- Matias Ortiz De Zarate
- Department of Economics, Faculty of Social Sciences, University of Southampton,Southampton SO17 1BJ, UK
| | - Emmanouil Mentzakis
- Department of Economics, Faculty of Social Sciences, University of Southampton,Southampton SO17 1BJ, UK
| | - Simon Ds Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Paul Roderick
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Paul Rutter
- School of Pharmacy and Biomedical Sciences, Faculty of Health and Science, 6697University of Portsmouth, Portsmouth PO1 2UP, UK
| | - Carmine Ornaghi
- Department of Economics, Faculty of Social Sciences, University of Southampton,Southampton SO17 1BJ, UK
| |
Collapse
|
4
|
Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing. BMC FAMILY PRACTICE 2021; 22:225. [PMID: 34781877 PMCID: PMC8591810 DOI: 10.1186/s12875-021-01574-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 11/02/2021] [Indexed: 11/21/2022]
Abstract
Background How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. Method The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. Results Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. Conclusion Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01574-x.
Collapse
|
5
|
Medlinskiene K, Tomlinson J, Marques I, Richardson S, Stirling K, Petty D. Barriers and facilitators to the uptake of new medicines into clinical practice: a systematic review. BMC Health Serv Res 2021; 21:1198. [PMID: 34740338 PMCID: PMC8570007 DOI: 10.1186/s12913-021-07196-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023] Open
Abstract
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).
Collapse
Affiliation(s)
- Kristina Medlinskiene
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Justine Tomlinson
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Iuri Marques
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
| | - Sue Richardson
- Department of Management, Huddersfield Business School, University of Huddersfield, Huddersfield, HD1 3DH UK
| | - Katherine Stirling
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Duncan Petty
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
| |
Collapse
|
6
|
Md Hamzah N, See KF. Differential diffusion of pharmaceutical innovations in a mixed market middle - income economy. BMC Health Serv Res 2021; 21:1119. [PMID: 34663311 PMCID: PMC8524869 DOI: 10.1186/s12913-021-06786-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Nurhafiza Md Hamzah
- Planning Division, Ministry of Health Malaysia, Federal Administrative Centre, Level 3, Block E6, E Complex, 62590, Putrajaya, Malaysia.
| | - Kok Fong See
- Economics Programme, School of Distance Education, Universiti Sains Malaysia, 11800, Minden, Pulau Pinang, Malaysia.
| |
Collapse
|
7
|
GPs' perceptions of their relationship with the pharmaceutical industry: a qualitative study. BJGP Open 2021; 5:BJGPO.2021.0057. [PMID: 34353789 PMCID: PMC8596315 DOI: 10.3399/bjgpo.2021.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/24/2021] [Indexed: 12/03/2022] Open
Abstract
Background The pharmaceutical industry invests heavily in promoting medications to physicians. This promotion may influence physicians’ prescribing behaviour and lead to inappropriately increased prescribing rates. Aim To understand GPs’ experience of interacting with the pharmaceutical industry, and explore their views and perceptions of the impact of this interaction in general practice in Ireland. Design & setting A qualitative design was used, and GPs practicing in Ireland were eligible. Method A combination of purposive and snowball sampling techniques was applied and semi-structured interviews were conducted. Thematic analysis was used to develop themes from the data. Results Twenty-one GPs and one GP trainee participated. Five themes were developed: 1) GP and pharmaceutical industry interface; 2) the industry’s methods of influence; 3) the uncomfortable relationship between GPs and industry; 4) GPs’ perceptions of being unconsciously influenced; and 5) GPs’ lack of knowledge of relevant regulations. Participants interacted with pharmaceutical representatives in their surgery and through continuing professional development (CPD). Reported methods of influence included biased information and the offer of gifts. Most participants felt their prescribing was unconsciously influenced. A minority felt that they were only influenced in a way that improved their prescribing. Conclusion The study shows that there can be a lack of clarity among GPs about relevant regulations and about the potential impact on prescribing of interactions with the pharmaceutical industry. Education of trainees and GPs has the potential to address this. Restrictions on interactions with the pharmaceutical industry may also play a role, although alternative CPD funding sources would need to be established.
Collapse
|
8
|
Tudball J, Reddel HK, Laba TL, Jan S, Flynn A, Goldman M, Lembke K, Roughead E, Marks GB, Zwar N. General practitioners' views on the influence of cost on the prescribing of asthma preventer medicines: a qualitative study. AUST HEALTH REV 2020; 43:246-253. [PMID: 29754592 DOI: 10.1071/ah17030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 01/19/2018] [Indexed: 12/25/2022]
Abstract
Objective Out-of-pocket costs strongly affect patient adherence with medicines. For asthma, guidelines recommend that most patients should be prescribed regular low-dose inhaled corticosteroids (ICS) alone, but in Australia most are prescribed combination ICS-long-acting β2-agonists (LABA), which cost more to patients and government. The present qualitative study among general practitioners (GPs) explored the acceptability, and likely effect on prescribing, of lower patient copayments for ICS alone. Methods Semistructured telephone interviews were conducted with 15 GPs from the greater Sydney area; the interviews were transcribed and thematically analysed. Results GPs reported that their main criteria for selecting medicines were appropriateness and effectiveness. They did not usually discuss costs with patients, had low awareness of out-of-pocket costs and considered that these were seldom prohibitive for asthma patients. GPs strongly believed that patient care should not be compromised to reduce cost to government. They favoured ICS-LABA combinations over ICS alone because they perceived that ICS-LABA combinations enhanced adherence and reduced costs for patients. GPs did not consider that lower patient copayments for ICS alone would affect their prescribing. Conclusion The results suggest that financial incentives, such as lower patient copayments, would be unlikely to encourage GPs to preferentially prescribe ICS alone, unless accompanied by other strategies, including evidence for clinical effectiveness. GPs should be encouraged to discuss cost barriers to treatment with patients when considering treatment choices. What is known about the topic? Australian guidelines recommend that most patients with asthma should be treated with low-dose ICS alone to minimise symptom burden and risk of flare ups. However, most patients in Australian general practice are instead prescribed combination ICS-LABA preventers, which are indicated if asthma remains uncontrolled despite treatment with ICS alone. It is not known whether GPs are aware that the combination preventers have a higher patient copayment and a higher cost to government. What does this paper add? This qualitative study found that GPs favoured combination ICS-LABA inhalers over ICS alone because they perceived ICS-LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs' views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. What are the implications for practitioners? This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be aware that differential patient copayments for ICS preventer medicines are unlikely to act as an incentive for GPs to preferentially prescribe ICS alone preventers, unless the position of these preventers in guidelines and evidence for their clinical effectiveness are also reiterated.
Collapse
Affiliation(s)
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, 431 Glebe Point Rd, Glebe, NSW 2037, Australia. Email
| | - Tracey-Lea Laba
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5, 1 King Street, Newtown NSW 2042, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5, 1 King Street, Newtown NSW 2042, Australia.
| | - Anthony Flynn
- Asthma Australia Ltd, Level 13, 799 Pacific Hwy, Chatswood NSW 2067, Australia.
| | - Michele Goldman
- Asthma Australia Ltd, Level 13, 799 Pacific Hwy, Chatswood NSW 2067, Australia.
| | - Kirsty Lembke
- NPS MedicineWise, PO Box 1147 Strawberry Hills NSW 2012. Email
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, CEA-19, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia. Email
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, 431 Glebe Point Rd, Glebe, NSW 2037, Australia. Email
| | - Nick Zwar
- School of Public Health and Community Medicine, University of New South Wales Sydney, NSW 2052, Australia
| |
Collapse
|
9
|
Karampli E, Souliotis K, Polyzos N, Chatzaki E. Why do physicians prescribe new antidiabetic drugs? A qualitative study in the Greek healthcare setting. HEALTH POLICY AND TECHNOLOGY 2020. [DOI: 10.1016/j.hlpt.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
10
|
Vázquez-Mourelle R, Carracedo-Martínez E, Figueiras A. Impact of a change of bronchodilator medications in a hospital drug formulary on intra- and out-of-hospital drug prescriptions: interrupted time series design with comparison group. Implement Sci 2020; 15:33. [PMID: 32410686 PMCID: PMC7227340 DOI: 10.1186/s13012-020-00996-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospital drug formularies are reduced lists of drugs designed to optimise inpatient care. Adherence to the drugs included in such formularies is not always 100% but is generally very high. Little research has targeted the impact of a change in these formularies on outpatient drug prescriptions. This study therefore sought to evaluate the impact of a change affecting bronchodilator medications in a hospital drug formulary on intra- and out-of-hospital drug prescriptions in a region in north-western Spain. Two new drugs belonging to this same class were brought onto the out-of-hospital market, overlapping with the intervention. METHODS We used a natural before-after quasi-experimental design with control group based on monthly data. The intervention evaluated was the modification of a hospital drug formulary, which involved withdrawing salmeterol/fluticasone in order to retain formoterol/budesonide as the sole inhaled corticosteroid and long-acting beta-agonist (ICS/LABA). Using official data sources, we extracted the following dependent variables: defined daily doses (DDD) per 1000 inhabitants per day, DDD per 100 bed-days, and cost per DDD. RESULTS Intra-hospital use showed a 173.2% rise (95% CI 47.3-299.0%) in the medication retained in the formulary, formoterol/budesonide, and a 94.9% drop (95% CI 77.9-111.9%) in the medication withdrawn from the formulary, salmeterol/fluticasone. This intervention led to an immediate reduction of 75.9% (95% CI 82.8-68.9%) in the intra-hospital cost per DDD of ICS/LABA. No significant changes were observed in out-of-hospital use. CONCLUSIONS Although this intervention was cost-effective in the intra-hospital setting, the out-of-hospital impact of a change in the drug formulary cannot be generalised to all types of medications and situations.
Collapse
Affiliation(s)
- Raquel Vázquez-Mourelle
- Galician Health Service (Servicio Gallego de Salud - SERGAS), Galicia Regional Authority, Administrativo San Lázaro s/n, 15703, Santiago de Compostela, Galicia, Spain.
| | - Eduardo Carracedo-Martínez
- Santiago de Compostela Health Area Authority, Galician Health Service, Rúa da Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Galicia, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), and Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), University of Santiago de Compostela, Praza Seminario de Estudos Galegos, s/n, 15705, Santiago de Compostela, Galicia, Spain
| |
Collapse
|
11
|
Godman B, Bucsics A, Vella Bonanno P, Oortwijn W, Rothe CC, Ferrario A, Bosselli S, Hill A, Martin AP, Simoens S, Kurdi A, Gad M, Gulbinovič J, Timoney A, Bochenek T, Salem A, Hoxha I, Sauermann R, Massele A, Guerra AA, Petrova G, Mitkova Z, Achniotou G, Laius O, Sermet C, Selke G, Kourafalos V, Yfantopoulos J, Magnusson E, Joppi R, Oluka M, Kwon HY, Jakupi A, Kalemeera F, Fadare JO, Melien O, Pomorski M, Wladysiuk M, Marković-Peković V, Mardare I, Meshkov D, Novakovic T, Fürst J, Tomek D, Zara C, Diogene E, Meyer JC, Malmström R, Wettermark B, Matsebula Z, Campbell S, Haycox A. Barriers for Access to New Medicines: Searching for the Balance Between Rising Costs and Limited Budgets. Front Public Health 2018; 6:328. [PMID: 30568938 PMCID: PMC6290038 DOI: 10.3389/fpubh.2018.00328] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/26/2018] [Indexed: 01/26/2023] Open
Abstract
Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases, and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growth in both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated to finance new medicines as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimize the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective. Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective. Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability. Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need.
Collapse
Affiliation(s)
- Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,Health Economics Centre, University of Liverpool Management School, Liverpool, United Kingdom.,Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden.,School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Anna Bucsics
- Mechanism of Coordinated Access to Orphan Medicinal Products (MoCA), Brussels, Belgium
| | - Patricia Vella Bonanno
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom
| | - Wija Oortwijn
- Ecorys, Rotterdam, Netherlands.,Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Celia C Rothe
- Department of Drug Management, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Alessandra Ferrario
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, United States
| | | | - Andrew Hill
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Antony P Martin
- Health Economics Centre, University of Liverpool Management School, Liverpool, United Kingdom.,HCD Economics, The Innovation Centre, Daresbury, United Kingdom
| | - Steven Simoens
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Mohamed Gad
- Global Health and Development Group, Imperial College, London, United Kingdom
| | - Jolanta Gulbinovič
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Angela Timoney
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,NHS Lothian, Edinburgh, United Kingdom
| | - Tomasz Bochenek
- Department of Drug Management, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | | | - Iris Hoxha
- Department of Pharmacy, Faculty of Medicine, University of Medicine, Tirana, Albania
| | - Robert Sauermann
- Hauptverband der Österreichischen Sozialversicherungsträger, Vienna, Austria
| | - Amos Massele
- Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Augusto Alfonso Guerra
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Av. Presidente Antônio Carlos, Belo Horizonte, Brazil.,SUS Collaborating Centre - Technology Assessment & Excellence in Health (CCATES/UFMG), College of Pharmacy, Federal University of Minas Gerais. Av. Presidente Antônio Carlos, Belo Horizonte, Brazil
| | - Guenka Petrova
- Department of Social Pharmacy and Pharmacoeconomics, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Zornitsa Mitkova
- Department of Social Pharmacy and Pharmacoeconomics, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | | | - Ott Laius
- State Agency of Medicines, Tartu, Estonia
| | | | - Gisbert Selke
- Wissenschaftliches Institut der AOK (WIdO), Berlin, Germany
| | - Vasileios Kourafalos
- EOPYY-National Organization for the Provision of Healthcare Services, Athens, Greece
| | - John Yfantopoulos
- School of Economics and Political Science, University of Athens, Athens, Greece
| | - Einar Magnusson
- Department of Health Services, Ministry of Health, Reykjavík, Iceland
| | - Roberta Joppi
- Pharmaceutical Drug Department, Azienda Sanitaria Locale of Verona, Verona, Italy
| | - Margaret Oluka
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Hye-Young Kwon
- Division of Biology and Public Health, Mokwon University, Daejeon, South Korea
| | | | - Francis Kalemeera
- Department of Pharmacology and Therapeutics, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Joseph O Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University, Ado-Ekiti, Nigeria
| | | | - Maciej Pomorski
- Agency for Health Technology Assessment and Tariff System (AOTMiT), Warsaw, Poland
| | | | - Vanda Marković-Peković
- Ministry of Health and Social Welfare, Banja Luka, Bosnia and Herzegovina.,Department of Social Pharmacy, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Ileana Mardare
- Public Health and Management Department, Faculty of Medicine, "Carol Davila", University of Medicine and Pharmacy Bucharest, Bucharest, Romania
| | - Dmitry Meshkov
- National Research Institution for Public Health, Moscow, Russia
| | | | - Jurij Fürst
- Health Insurance Institute, Ljubljana, Slovenia
| | - Dominik Tomek
- Faculty of Medicine, Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Corrine Zara
- Drug Territorial Action Unit, Catalan Health Service, Barcelona, Spain
| | - Eduardo Diogene
- Vall d'Hebron University Hospital, Fundació Institut Català de Farmacologia, Barcelona, Spain
| | - Johanna C Meyer
- School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Rickard Malmström
- Department of Medicine Solna, Karolinska Institutet and Clinical Pharmacology Karolinska University Hospital, Stockholm, Sweden
| | - Björn Wettermark
- Department of Medicine Solna, Karolinska Institutet and Clinical Pharmacology Karolinska University Hospital, Stockholm, Sweden.,Department of Healthcare Development, Stockholm County Council, Stockholm, Sweden
| | | | - Stephen Campbell
- Division of Population Health, Health Services Research and Primary Care, Centre for Primary Care, University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Alan Haycox
- Health Economics Centre, University of Liverpool Management School, Liverpool, United Kingdom
| |
Collapse
|
12
|
Pinto D, Heleno B, Rodrigues DS, Papoila AL, Santos I, Caetano PA. Effectiveness of educational outreach visits compared with usual guideline dissemination to improve family physician prescribing-an 18-month open cluster-randomized trial. Implement Sci 2018; 13:120. [PMID: 30185197 PMCID: PMC6126017 DOI: 10.1186/s13012-018-0810-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 08/20/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Educational outreach visits are meant to improve the practice of health professionals by promoting face-to-face visits to deliver educational contents. They have been shown to change prescription behavior, but long-term effects are still uncertain. This trial aimed to determine if they improve family physician prescribing compared with passive guideline dissemination. METHODS Parallel, open, superiority, and cluster-randomized trial. National Health Service primary care practices (clusters) were recruited in the Lisbon region-Portugal between March 2013 and January 2014. They could enter if they had at least four family physicians willing to participate and not planning to retire in the follow-up period. Three national guidelines were chosen for dissemination: acid secretion modifiers, non-steroidal anti-inflammatory drugs, and antiplatelets. Physicians in the intervention group received one 15 to 20 min educational outreach visit at their workplace for each guideline. Physicians in the control group had access to guidelines through the Directorate-General for Health's website (passive dissemination). Primary outcomes were the proportion of COX-2 inhibitors prescribed within the NSAID class and the proportion of omeprazole within the PPI class at 18 months after the intervention. A cost-benefit analysis was performed. Practices were randomized by minimization. Data analyses were done at individual physician level using generalized mixed-effects regression models. Participants could not be blinded. RESULTS Thirty-eight practices with 239 physicians were randomized (120 to intervention and 119 to control). Of 360 planned visits, 322 were delivered. No differences were found between physicians in the intervention and control groups regarding the proportion of omeprazole prescribed among PPIs 18 months after the visit (46.28 vs 47.15%, p = 0.971) or the proportion of COX-2 inhibitors among NSAIDs (12.07 vs 13.08%, p = 0.085). All secondary outcome comparisons showed no effect. There was no difference in cumulative drug costs at 18 months (3223.50€/1000 patients in the intervention group and 3143.92€/1000 patients in the control group, p = 0.848). CONCLUSIONS Educational outreach visits were unsuccessful in improving compliance with guideline recommendations among Portuguese family physicians. No effects were observed at 1, 6, and 18 months after the intervention, and there were no associated cost savings. TRIAL REGISTRATION ClinicalTrials.gov NCT01984034 . Registered 7 November 2013.
Collapse
Affiliation(s)
- Daniel Pinto
- Grupo de Investigação Académica Independente - Chronic Diseases Research Center, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.
| | - Bruno Heleno
- Grupo de Investigação Académica Independente - Chronic Diseases Research Center, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - David S Rodrigues
- Grupo de Investigação Académica Independente - Chronic Diseases Research Center, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Ana Luísa Papoila
- Department of Biostatistics and Informatics, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Isabel Santos
- Grupo de Investigação Académica Independente - Chronic Diseases Research Center, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Pedro A Caetano
- Grupo de Investigação Académica Independente - Chronic Diseases Research Center, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| |
Collapse
|
13
|
Meier R, Muheim L, Senn O, Rosemann T, Chmiel C. The impact of financial incentives to improve quality indicators in patients with diabetes in Swiss primary care: a protocol for a cluster randomised controlled trial. BMJ Open 2018; 8:e023788. [PMID: 29961043 PMCID: PMC6042619 DOI: 10.1136/bmjopen-2018-023788] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION There is only limited and conflicting evidence on the effectiveness of Pay-for-Performance (P4P) programmes, although they might have the potential to improve guideline adherence and quality of care. We therefore aim to test a P4P intervention in Swiss primary care practices focusing on quality indicators (QI) achievement in the treatment of patients with diabetes. METHODS AND ANALYSIS This is a cluster-randomised, two-armed intervention study with the primary care practice as unit of randomisation. The control group will receive bimonthly feedback reports containing last data of blood pressure and glycated haemoglobin (HbA1c) measurements. The intervention group will additionally be informed about a financial incentive for each percentage point improved in QI achievement. Primary outcomes are differences in process (measurement of HbA1c) and clinical QI (blood pressure control) between the two groups. Furthermore, we investigate the effect on non-incentivised QIs and on sustainability of the financial incentives. Swiss primary care practices participating in the FIRE (Family Medicine ICPC Research using Electronic Medical Record) research network are eligible for participation. The FIRE database consists of anonymised structured medical routine data from Swiss primary care practices. According to power calculations, 70 of the general practitioners contributing to the database will be randomised in either of the groups. ETHICS AND DISSEMINATION According to the Local Ethics Committee of the Canton of Zurich, the project does not fall under the scope of the law on human research and therefore no ethical consent is necessary. Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN13305645; Pre-results.
Collapse
Affiliation(s)
- Rahel Meier
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Leander Muheim
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| |
Collapse
|
14
|
The changing multiple sclerosis treatment landscape: impact of new drugs and treatment recommendations. Eur J Clin Pharmacol 2018; 74:663-670. [PMID: 29429031 PMCID: PMC5893684 DOI: 10.1007/s00228-018-2429-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/01/2018] [Indexed: 11/03/2022]
Abstract
PURPOSE The purpose of this study is to describe the utilization of disease-modifying treatments (DMTs) in relapsing-remitting multiple sclerosis (MS) and assess the impact of both the introduction of new drugs and treatment recommendations (local recommendation on rituximab use issued at the largest MS clinic in Stockholm and regional Drug and Therapeutics Committee (DTC) recommendation on how dimethyl fumarate should be used). METHODS Interrupted time series analyses using monthly data on all MS patients treated with DMTs in the Stockholm County, Sweden, from January 2011 to December 2017. RESULTS There were 4765 individuals diagnosed with MS residing in the Stockholm County from 2011 to 2017. Of these, 2934 (62%) were treated with an MS DMT. Since 2011, fingolimod, alemtuzumab, teriflunomide, dimethyl fumarate, peginterferon beta-1a, and daclizumab were introduced. Only fingolimod and dimethyl fumarate significantly impacted MS DMT utilization. In parallel, the use of rituximab off-label increased steadily, reaching 58% of all DMT-treated MS patients by the end of the study period. The local recommendation on rituximab was associated with an increase in rituximab use. The regional DTC recommendation on dimethyl fumarate was associated with a decrease in dimethyl fumarate use. CONCLUSIONS Three MS DMTs-fingolimod, dimethyl fumarate, and rituximab off-label-impacted MS DMT utilization in the Stockholm County. The associations between the treatment recommendations and the subsequent changes in MS DMT utilization indicate that such interventions can influence the uptake and utilization of new drugs used in the specialized care setting.
Collapse
|
15
|
Physicians’ relationship with the pharmaceutical industry and its reflection in introduction of a new drug. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2017. [DOI: 10.1108/ijphm-09-2016-0048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This study aims to examine the attitudes of physicians towards the pharmaceutical industry and investigates how these are reflected when a new drug is introduced.
Design/methodology/approach
The qualitative theme-interview study adopts the innovation diffusion perspective and is conducted with 22 general practitioners and specialists.
Findings
Physicians’ positive relationship orientation and active interaction can result in early adoption of new drugs with product advantage. In comparison, negatively oriented and passively interacting physicians will adopt a new drug later based on research evidence- and experience-based reasoning and opinions of their colleagues.
Research limitations/implications
The objective was to obtain a deeper understanding of the research themes. Further qualitative studies in different countries and health care environments with a larger sample size would improve generalizability of results.
Practical implications
It’s necessary to find an optimal win – win situation that fulfils both parties’ needs, while decreasing unnecessary and time-consuming marketing activities and avoiding waste of limited resources and allowing physicians to participate in activities that better serve their primary needs. Managers in pharmaceutical companies should ensure their sales representatives act in appropriate and professional ways, interact openly and reciprocally and provide accurate and objective information.
Originality/value
The study demonstrates that the physician–pharmaceutical industry relationship has developed from being ethically precarious and having non-professional related personal benefits, towards becoming a more sustainable collaboration. The mutually beneficial collaboration supports physicians’ professional development, enabling better patient care and relieving strain on limited resources.
Collapse
|
16
|
Komen J, Forslund T, Hjemdahl P, Wettermark B. Factors associated with antithrombotic treatment decisions for stroke prevention in atrial fibrillation in the Stockholm region after the introduction of NOACs. Eur J Clin Pharmacol 2017; 73:1315-1322. [PMID: 28664360 PMCID: PMC5612279 DOI: 10.1007/s00228-017-2289-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 06/12/2017] [Indexed: 12/26/2022]
Abstract
Purpose The purpose of this study was to investigate the influence of patient characteristics such as age and stroke and bleeding risks on decisions for antithrombotic treatment in patients with atrial fibrillation (AF). Methods This was a retrospective, population-based study including AF patients initiated with either warfarin, dabigatran, rivaroxaban, apixaban, or low-dose aspirin (ASA) between March 2015 and February 2016. Multivariate models were used to calculate adjusted odds ratios (aOR) for factors associated with treatment decisions. Results A total of 6765 newly initiated patients were included, most with apixaban (46.4%) and least with ASA (6.7%). There were more comorbidities in patients initiated with ASA or warfarin compared to the cohort average. Patients with high stroke risks had higher chances of receiving ASA (CHA2DS2-VASc ≥5 vs 0; aOR 2.01; 95% confidence interval (CI) 1.12–3.33). Among patients receiving oral anticoagulants, patients with high bleeding risks more often received warfarin (ATRIA score 5–10 vs 0–3; aOR 1.40; CI 1.20–1.64). Among NOACs, apixaban was preferred for patients with higher stroke risks (aOR 1.78; CI 1.31–2.41), high bleeding risks (aOR 1.54; CI 1.26–1.88) and high age (age group ≥85 vs 0–65; aOR 1.84; CI 1.44–2.35). Conversely, dabigatran treatment was associated with lower ages and lower risks. Conclusions High stroke and bleeding risks favored choices of warfarin or ASA. Among patients receiving NOACs, apixaban was favored for elderly and high-risk patients whereas dabigatran was used in lower risk patients. The inadvertent use of ASA, especially among those with high stroke risks, should be further discouraged. Electronic supplementary material The online version of this article (doi:10.1007/s00228-017-2289-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Joris Komen
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, T2, 171 76, Stockholm, Sweden. .,Department of Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584, CG, Utrecht, the Netherlands.
| | - Tomas Forslund
- Public Healthcare Services Committee, Department of Healthcare Development, Stockholm County Council, Box 6909, 102 39, Stockholm, Sweden.,Department of Medicine Solna, Clinical Epidemiology/Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, L7:03, 171 76, Stockholm, Sweden
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology/Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, L7:03, 171 76, Stockholm, Sweden
| | - Björn Wettermark
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, T2, 171 76, Stockholm, Sweden.,Public Healthcare Services Committee, Department of Healthcare Development, Stockholm County Council, Box 6909, 102 39, Stockholm, Sweden
| |
Collapse
|
17
|
Bullock A, Barnes E, Morris ZS, Fairbank J, de Pury J, Howell R, Denman S. Getting the most out of knowledge and innovation transfer agents in health care: a qualitative study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BackgroundKnowledge and innovation transfer (KIT) is recognised internationally as a complex, dynamic process that is difficult to embed in organisations. There is growing use of health service–academic–industry collaborations in the UK, with knowledge brokers linking producers with the users of knowledge and innovation.AimFocusing on KIT ‘agent’ roles within Academic Health Science Networks in England and Partnerships in Wales, we show how individual dispositions, processes and content contribute to desired outcomes.MethodsWe studied the KIT intentions of all Academic Health Science Networks in England, and the South East Wales Academic Health Science Partnership. Using a qualitative case study design, we studied the work of 13 KIT agents purposively sampled from five networks, by collecting data from observation of meetings, documentation, KIT agent audio-diaries, and semistructured interviews with KIT agents, their line managers and those they supported (‘Links’). We also used a consensus method in a meeting of experts (nominal group technique) to discuss the measurement of outcomes of KIT agent activity.FindingsThe case study KIT agents were predominantly from a clinical background with differing levels of experience and expertise, with the shared aim of improving services and patient care. Although outside of recognised career structures, the flexibility afforded to KIT agents to define their role was an enabler of success. Other helpful factors included (1) time and resources to devote to KIT activity; (2) line manager support and a team to assist in the work; and (3) access and the means to use data for improvement projects. The organisational and political context could be challenging. KIT agents not only tackled local barriers such as siloed working, but also navigated shifting regional and national policies. Board-level support for knowledge mobilisation together with a culture of reflection (listening to front-line staff), openness to challenges and receptivity to research all enabled KIT agents to achieve desired outcomes. Nominal group findings underscored the importance of relating measures to specific intended outcomes. However, the case studies highlighted that few measures were employed by KIT agents and their managers. Using social marketing theory helped to show linkages between processes, outcomes and impact, and drew attention to how KIT agents developed insight into their clients’ needs and tailored work accordingly.LimitationsLevel of KIT agent participation varied; line managers and Links were interviewed only once; and outcomes were self-reported.ConclusionsSocial marketing theory provided a framework for analysing KIT agent activity. The preparatory work KIT agents do in listening, understanding local context and building relationships enabled them to develop ‘insight’ and adapt their ‘offer’ to clients to achieve desired outcomes.Future workThe complexity of the role and the environment in which it is played out justifies more research on KIT agents. Suggestions include (1) longitudinal study of career pathways; (2) how roles are negotiated within teams and how competing priorities are managed; (3) how success is measured; (4) the place of improvement methodologies within KIT work; (5) the application of social marketing theory to comparative study of similar roles; and (6) patients as KIT agents.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Alison Bullock
- The Cardiff Unit for Research and Evaluation in Medical and Dental Education (CUREMeDE), Cardiff University, Cardiff, UK
| | - Emma Barnes
- The Cardiff Unit for Research and Evaluation in Medical and Dental Education (CUREMeDE), Cardiff University, Cardiff, UK
| | | | | | | | - Rosamund Howell
- Aneurin Bevan University Health Board, Clinical Research and Innovation Centre, St Woolos Hospital, Newport, UK
| | - Susan Denman
- School of Medicine, Cardiff University, Cardiff, UK
| |
Collapse
|
18
|
Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A, Peacock R, Murray E. Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci 2016; 11:40. [PMID: 27001107 PMCID: PMC4802575 DOI: 10.1186/s13012-016-0396-4] [Citation(s) in RCA: 280] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/28/2016] [Indexed: 12/02/2022] Open
Abstract
Background This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care. Design This study is a systematic review of reviews. Methods MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis. Results Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation. Conclusions This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here. Systematic review registration PROSPERO CRD42014009410 Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0396-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Rosa Lau
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, Upper 3rd floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Fiona Stevenson
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, Upper 3rd floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Bie Nio Ong
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Hazel Everitt
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Nadeem Qureshi
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | | | - Elizabeth Murray
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, Upper 3rd floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| |
Collapse
|
19
|
Abstract
Early switch (ES) from intravenous (IV) to oral antibiotic therapy programmes is increasingly included as a component of hospital antimicrobial stewardship initiatives that aim to optimize antimicrobial therapy while limiting toxicity and resistance. In terms of prioritizing the most cost-effective stewardship interventions, ES has been seen as a 'low-hanging fruit', which refers to selecting the most obtainable targets rather than confronting more complicated issues. Administration of highly bioavailable oral antibiotics should be considered for nearly all non-critically ill patients and has been recommended as an effective and safe strategy for over two decades. However, to accrue the most benefit from ES, it should be combined with an early discharge (ED) plan, protocol, or care pathway. Benefits of this combined approach include improved patient comfort and mobility, reduced incidence of IV-line-related adverse effects, reduced IV antimicrobial preparation time, decreased hospital stays, reduced antimicrobial purchasing and administration costs, decreased patient deconditioning, and shortened recovery times. Results from published studies document decreases in healthcare resource use and costs following implementation of ES programmes, which in most studies facilitate the opportunity for ED and ED programmes. Barriers to the implementation of these programmes include clinician misconceptions, practical considerations, organizational factors, and a striking lack of awareness of IV to oral switch guidance. These and other barriers will need to be addressed to maximize the effectiveness of ES and ED programmes. As national antimicrobial stewardship programmes dictate the inclusion of ES and ED programmes within healthcare facilities, programmes must be developed and success must be documented.
Collapse
|
20
|
Chang YP, Yang CH, Chou MC, Chen CH, Yang YH. Clinical compliance of donepezil in treating Alzheimer's disease in taiwan. Am J Alzheimers Dis Other Demen 2015; 30:346-51. [PMID: 25380803 PMCID: PMC10852549 DOI: 10.1177/1533317514556875] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
BACKGROUND/RATIONALE Adherence to cholinesterase inhibitor (ChEI) is associated with treatment effectiveness in the treatment of Alzheimer's disease (AD). We investigated the clinical adherence to donepezil in Taiwan. METHODS This was a retrospective study. Patients treated with donepezil were recruited from Kaohsiung Medical University Hospital and Kaohsiung Municipal Ta-Tung Hospital from February 2004 to April 2013. We analyzed their treatment duration in months. RESULTS A total of 273 patients were included in our analysis. Sixty-seven patients withdrew from donepezil treatment with mean treatment duration of 28.0 ± 25.9 months. Better initial scores on the Mini-Mental Status Examination (P = .007), Cognitive Abilities Screening Instrument (P = .003), and the Clinical Dementia Rating Scale (CDR) Sum of Boxes (P = .011) were positively associated with clinical adherence. The clinical adherent rate was higher in the CDR-0.5 group than in the CDR-2.0 group with significant difference. CONCLUSION Although there are some limitations in our study, these findings indicate that early intervention with ChEI in patients with AD should be emphasized and may lead to a better clinical adherence.
Collapse
Affiliation(s)
- Yun-Ping Chang
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chiu-Hsien Yang
- Department of Family Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan Division of Community Medicine, Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Chuan Chou
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Chun-Hung Chen
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yuan-Han Yang
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan Department of and Master's Program in Neurology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
21
|
Abstract
RATIONALE, AIMS AND OBJECTIVES Increased awareness of the gap between controlled research and medical practice has raised concerns over whether the special attention of doctors to probability estimates from clinical trials really improves the care of individuals. Evidence-based medicine has acknowledged that research results are not applicable to all kinds of patients, and consequently, has attempted to overcome this limitation by introducing improvements in the design and analysis of clinical trials. METHODS A clinical case is used to highlight the premises required to support reasonable extrapolations from controlled research to individuals. Then, the prospects of two key methodological improvements - pragmatic randomized controlled trials and subgroup analysis - are critically appraised. RESULTS A principle to guide therapeutic inferences is suggested. According to this principle, the probabilities of interest for purposes of therapeutic decision making are those of the set defined by everything that is relevant to the patient and the outcome of interest at the time of the decision. It is argued that the conditions necessary to authorize automatic extrapolations of research results to specific patients are highly demanding. Furthermore, these requirements are rarely accomplished in real practice, even in the event that probability estimates come from samples generally taken as representative and are derived from specific subsets of patients. CONCLUSIONS Clinicians should generally avoid unreflective extrapolations from research and address, as explicitly as possible, the challenge of estimating probabilities for individual patients. A key element of this task is the integration of data from research and non-research sources.
Collapse
Affiliation(s)
- Luis Flores
- Department of Philosophy, School of Arts and Humanities, King's College London, London, UK; Department of Psychiatry, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| |
Collapse
|
22
|
Hitz A, Prevel Katsanis L. A consumer adoption model for personalized medicine: an exploratory study. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2014. [DOI: 10.1108/ijphm-07-2013-0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose
– The purpose of this research is to identify factors linked to the potential acceptance of personalized medicine (PM) by consumers. Roger’s diffusion of innovation model (1995) and the work of Duguay et al. (2003) on transgenic biopharmaceuticals contributed to the development of the proposed conceptual model.
Design/methodology/approach
– The study design was an exploratory cross-sectional survey that used a Canadian national online panel of 307 respondents.
Findings
– The results suggest that the most important factors leading to consumer adoption of PM are knowledge, relative advantage and compatibility with existing values. The level of homophilus traits was negatively related to the acceptance of PM.
Originality/value
– Marketers will need to provide documented evidence of PM’s benefits over existing therapy based on improved efficacy and reduced side effects. Further, concerns about higher price, product distribution and drug reimbursement policies may limit its acceptance. This is the first study to examine the potential adoption and acceptance of PM by consumers.
Collapse
|
23
|
Lublóy Á. Factors affecting the uptake of new medicines: a systematic literature review. BMC Health Serv Res 2014; 14:469. [PMID: 25331607 PMCID: PMC4283087 DOI: 10.1186/1472-6963-14-469] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 09/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The successful diffusion of new drugs is crucial for both pharmaceutical companies and patients-and of wider stakeholder concern, including for the funding of healthcare provision. Micro-level characteristics (the socio-demographic and professional characteristics of medical professionals), meso-level characteristics (the prescribing characteristics of doctors, the marketing efforts of pharmaceutical companies, interpersonal communication among doctors, drug attributes, and the characteristics of patients), and macro-level characteristics (government policies) all influence the diffusion of new drugs. This systematic literature review examines the micro- and meso-level characteristics of early prescribers of newly introduced drugs. Understanding the characteristics of early adopters may help to speed up the diffusion process, promote cost-efficient prescribing habits, forecast utilisation, and develop targeted intervention strategies. METHODS The PubMed and Scopus electronic databases were chosen for their extensive coverage of the pertinent literature and used to identify 205 potentially relevant studies by means of a four-layered search string. The 35 studies deemed eligible were then synthetized carefully and critically, to extract variables relevant to this review. RESULTS Early adoption of new drugs is not a personal trait, independent of drug type, but early adopters share both micro- and meso-level characteristics. At prescriber level, doctors' interest in particular therapeutic areas, participation in clinical trials, and volume of prescribing-either in total or within the therapeutic class of the new drug-increase the likelihood of early adoption. The marketing efforts of pharmaceutical companies and doctors' professional and social interactions leading to prescribing contagion are very powerful predictors of new drug uptake. At patient level, doctors with younger patients, patients with higher socioeconomic statuses and/or patients with poorer health statuses are more inclined to prescribe new drugs early. In contrast, the socio-demographic characteristics of prescribers and many practice-related factors play little role in the adoption process. CONCLUSIONS The most powerful predictors of new drug uptake include the doctors' strong scientific commitment, high prescribing volume in total or in within the therapeutic class of the new drug, high exposure to marketing, and intense communication with colleagues.
Collapse
Affiliation(s)
- Ágnes Lublóy
- Department of Finance, Institute of Finance and Accounting, Corvinus University of Budapest, Fővám tér 8, Budapest 1093, Hungary.
| |
Collapse
|
24
|
Burn D, May S, Edwards L. General Practitioners' Views About an Orthopaedic Clinical Assessment Service. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2014; 19:176-85. [DOI: 10.1002/pri.1581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 12/03/2013] [Accepted: 02/13/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Damon Burn
- Trauma Orthopaedic and Musculoskeletal Services; Walsall Healthcare NHS Trust; Walsall UK
| | - Stephen May
- Faculty of Health and Wellbeing; Sheffield Hallam University; Sheffield UK
| | | |
Collapse
|
25
|
Godman B, Shrank W, Andersen M, Berg C, Bishop I, Burkhardt T, Garuoliene K, Herholz H, Joppi R, Kalaba M, Laius O, McGinn D, Samaluk V, Sermet C, Schwabe U, Teixeira I, Tilson L, Tulunay FC, Vlahović-Palčevski V, Wendykowska K, Wettermark B, Zara C, Gustafsson LL. Comparing policies to enhance prescribing efficiency in Europe through increasing generic utilization: changes seen and global implications. Expert Rev Pharmacoecon Outcomes Res 2014; 10:707-22. [DOI: 10.1586/erp.10.72] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
26
|
Variations in primary care prescribing: lessons to be learnt for GP commissioners. Prim Health Care Res Dev 2014; 15:111-6. [DOI: 10.1017/s1463423613000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
27
|
Huang C, Siu M, Vu L, Wong S, Shin J. Factors influencing doctors' selection of dabigatran in non-valvular atrial fibrillation. J Eval Clin Pract 2013; 19:938-43. [PMID: 22834964 DOI: 10.1111/j.1365-2753.2012.01886.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2012] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES This study was designed to examine the factors that influence doctors' decision in initiating or switching from warfarin to dabigratran. METHOD A survey questionnaire was sent to 181 doctors who were most likely to prescribe dabigatran (e.g. cardiologists and general internists) at the University of California, San Francisco Medical Center between November 2011 and February 2012. Survey participants were asked to complete an electronic or a paper version of the questionnaire, which consisted of 17 multiple-choice questions. Fisher's exact test and Cochran-Mantel-Haenszel test were used to compare survey responses between cardiologists and general internists. RESULTS A total of 65 survey responses were received (35.9% response rate). There were 13 cardiologists and 51 general internists who participated in the study. Cost (25%), renal function (21%) and CHADS2 score (18%) were the three factors doctors considered most often to determine a patient's eligibility for dabigatran in warfarin-naïve patients. On the other hand, histories of unstable international normalized ratio (37%) and missed appointments (17%) along with cost (19%) were most often considered in patients on warfarin. Cardiologists had prescribed dabigatran more often and had a significantly higher level of comfort with prescribing the drug than general internists (P = 0.003; 77% vs. 27%). CONCLUSIONS Cost was the most important factor influencing doctors' decision to prescribe dabigatran. Safety and effectiveness of dabigatran as well as patient preference were additional factors influencing their decision. General internists were less comfortable with prescribing dabigatran than cardiologists.
Collapse
Affiliation(s)
- Cindy Huang
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | |
Collapse
|
28
|
O'Neill P, Mestre-Ferrandiz J, Puig-Peiro R, Sussex J. Projecting expenditure on medicines in the UK NHS. PHARMACOECONOMICS 2013; 31:933-957. [PMID: 24037786 DOI: 10.1007/s40273-013-0082-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Expenditure on medicines is a readily identifiable element of health service costs. It is the focus of much attention by payers, not least in the UK even though the cost of medicines represents less than 10 % of total UK National Health Service (NHS) expenditure. Projecting future medicines spending enables the likely cost pressure to be allowed for in planning the scale and allocation of NHS resources. Simple extrapolations of past trends in expenditure fail to account for changes in the rate and mix of new medicines becoming available and in the scope for windfall savings when some medicines lose their patent protection. The objective of this study is to develop and test an improved method to project NHS pharmaceutical expenditure in the UK for the period 2012-2015. METHODS We have adopted a product-by-product, bottom-up approach, which means that our projections are built up from individual products to the total market. Our projections of the impact of generic and biosimilars entry on prices and quantities of medicines sold, and of the rate of uptake of newly launched medicines, have been obtained from regression analysis of UK data. To address uncertainty, we have created a baseline and two other illustrative scenarios. We have compared our projections with actual expenditure for 2012. RESULTS Our projections estimate that, between 2011 and 2015, with no change in policy or price regulation, the UK total medicines bill would increase at an average compound annual growth rate (CAGR) of between 3.1 and 4.1 %. Total NHS spending on branded medicines and total NHS spending on generics are projected to increase at average CAGRs of 0.5-1.8 and 10.0-11.0 %, respectively, over the same time period. For the total market, the actual growth rate for 2012 lay within our projected range. CONCLUSIONS Our methodology provides a useful framework for projecting UK NHS medicines expenditure over the medium term and captures the impacts of existing medicines losing exclusivity and of new medicines being launched onto the market.
Collapse
Affiliation(s)
- Phill O'Neill
- Office of Health Economics, 7th Floor, Southside, 105 Victoria Street, London, SW1E 6QT, UK
| | | | | | | |
Collapse
|
29
|
Patel AC. Clinical relevance of target identity and biology: implications for drug discovery and development. ACTA ACUST UNITED AC 2013; 18:1164-85. [PMID: 24080260 DOI: 10.1177/1087057113505906] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many of the most commonly used drugs precede techniques for target identification and drug specificity and were developed on the basis of efficacy and safety, an approach referred to as classical pharmacology and, more recently, phenotypic drug discovery. Although substantial gains have been made during the period of focus on target-based approaches, particularly in oncology, these approaches have suffered a high overall failure rate and lower productivity in terms of new drugs when compared with phenotypic approaches. This review considers the importance of target identity and biology in clinical practice from the prescriber's viewpoint. In evaluating influences on prescribing behavior, studies suggest that target identity and mechanism of action are not significant factors in drug choice. Rather, patients and providers consistently value efficacy, safety, and tolerability. Similarly, the Food and Drug Administration requires evidence of safety and efficacy for new drugs but does not require knowledge of drug target identity or target biology. Prescribers do favor drugs with novel mechanisms, but this preference is limited to diseases for which treatments are either not available or suboptimal. Thus, while understanding of drug target and target biology is important from a scientific perspective, it is not particularly important to prescribers, who prioritize efficacy and safety.
Collapse
Affiliation(s)
- Anand C Patel
- 1Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
30
|
Ashiru-Oredope D, Kessel A, Hopkins S, Ashiru-Oredope D, Brown B, Brown N, Carter S, Charlett A, Cichowka A, Faulding S, Gallagher R, Johnson A, McNulty C, Moore M, Patel B, Puleston R, Richman C, Ridge K, Robotham J, Sharland M, Stephens P, Stokle L, Towers K, Underhill J, West T, Whitney L, Wight A, Woodford N, Young T. Antimicrobial stewardship: English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR). J Antimicrob Chemother 2013; 68:2421-3. [DOI: 10.1093/jac/dkt363] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
|
31
|
Fukada C, Kohler JC, Boon H, Austin Z, Krahn M. Prescribing gabapentin off label: Perspectives from psychiatry, pain and neurology specialists. Can Pharm J (Ott) 2013; 145:280-284.e1. [PMID: 23509590 DOI: 10.3821/145.6.cpj280] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of the study was to explore the experiences of physicians prescribing gabapentin off label. METHODS We used a case study approach to explore the experiences of physicians prescribing gabapentin for off-label indications. Semi-structured interviews were conducted with 10 physicians (psychiatry, pain and neurology specialists) in the Greater Toronto Area. Data were collected to the point of saturation of key themes and analyzed using interpretive content analysis. KEY FINDINGS Key informants appeared to rely primarily on informal information from colleagues and meetings, putting into question the accuracy of their information about the potential off-label uses of gabapentin. Our findings suggest the need for more evidence-based information on off-label drug use. CONCLUSION There is a need for greater understanding of off-label prescribing practices as an important step toward improving rational prescribing and ultimately toward improving patient safety and health outcomes.
Collapse
|
32
|
Paudyal V, Hansford D, Cunningham S, Stewart D. Pharmacists' adoption into practice of newly reclassified medicines from diverse therapeutic areas in Scotland: a quantitative study of factors associated with decision-making. Res Social Adm Pharm 2013; 10:88-105. [PMID: 23665077 DOI: 10.1016/j.sapharm.2013.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 04/01/2013] [Accepted: 04/01/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the UK, over 90 medicines that were previously available only through prescription have been reclassified to allow over-the-counter (OTC) availability via pharmacies. Pharmacists are personally responsible for undertaking or supervising the sales and supplies of these OTC 'pharmacy only' (P) medicines. Reclassification facilitates pharmacy management of a wide range of conditions. OBJECTIVE This research aimed to evaluate Scottish community pharmacists' perspectives of newly reclassified 'P' medicines from diverse therapeutic areas and to identify factors associated with their adoption into practice of these medicines. METHODS A cross-sectional postal survey of all community pharmacies in Scotland (N = 1138) was undertaken. The questionnaire was mailed to the pharmacist responsible for OTC medicines. Four newly reclassified 'P' medicines: omeprazole, naproxen, simvastatin and chloramphenicol eye drops were evaluated. Outcomes of interests included pharmacist support for the reclassified status, perceived adoption into practice of these medicines (i.e., how often they supplied each of these medicines) and factors associated with decision-making. Analyses included descriptive, bivariate correlation, principal component factor and binary regression. RESULTS Five hundred sixty-three pharmacists responded (response rate: 49.5%). Newly reclassified medicines studied had been adopted into practice by the respondent pharmacists to varying degrees. A high majority of the respondents expressed support for the reclassified status (82.4%) and perceived that the level of adoption into practice of OTC chloramphenicol was high (92.1%). In contrast, over 80% of respondents had not yet made a supply of OTC simvastatin to patients, mainly owing to pharmacists' perceptions of lack of evidence of efficacy of the OTC dose and patient demand. Decision-making was influenced by factors such as perceived benefits to patients and pharmacy practice; e.g., respondents who agreed that reclassified naproxen was a good opportunity to develop their professional role were significantly more likely to rate their support for the reclassified status highly than those who were unsure or disagreed (odds ratio = 3.7 (95% confidence interval: 2.1-6.7); P value <0.001). CONCLUSIONS Key factors informing decisions to adopt the reclassified medicines into pharmacists' practice relate to perceptions regarding the benefits of reclassification to patient care and their professional roles. The results have relevance to future reclassification decisions.
Collapse
Affiliation(s)
- Vibhu Paudyal
- School of Pharmacy and Life Sciences, Robert Gordon University, Schoolhill, Aberdeen, AB10 1FR, UK
| | | | | | | |
Collapse
|
33
|
Virdee SK, Greenfield SM, Fletcher K, McManus RJ, Hobbs FDR, Mant J. Would primary healthcare professionals prescribe a polypill to manage cardiovascular risk? A qualitative interview study. BMJ Open 2013; 3:e002498. [PMID: 23533217 PMCID: PMC3612792 DOI: 10.1136/bmjopen-2012-002498] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 02/19/2013] [Accepted: 02/22/2013] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES A 'polypill' containing both blood pressure-lowering and cholesterol-lowering drugs could prevent up to 80% of cardiovascular disease events. Since little is known about the attitudes of primary healthcare professionals to use of such a pill for cardiovascular disease prevention, this study aimed to investigate opinions. DESIGN Semistructured interviews were conducted with participants. A qualitative description approach was used to analyse and report the results. SETTING Participants were recruited from nine primary care practices in Birmingham. PARTICIPANTS Sixteen healthcare professionals (11 primary care physicians and 5 practice nurses) were selected through purposive sampling to maximise variation of characteristics. OUTCOME MEASURES Outcome measures for this study were: the attitude of healthcare professionals towards the use of a polypill for primary and secondary cardiovascular disease prevention; their views on monitoring the drug; and the factors influencing their willingness to prescribe the medication. RESULTS Healthcare professionals expressed considerable concern over using a polypill for primary prevention for all people over a specific age, although there was greater acceptance of its use for secondary prevention. Regularly monitoring patients taking the polypill was deemed essential. Evidence of effectiveness, patient risk level and potential medicalisation were key determinants in willingness to prescribe such a pill. CONCLUSIONS Primary healthcare professionals have significant concerns about the use of a polypill, particularly in the prevention of cardiovascular disease in people who are not regarded as being at 'high risk'. If a population-based polypill strategy is to be successfully implemented, healthcare professionals will need to be convinced of the potential benefits of a drug-based population approach to prevention.
Collapse
Affiliation(s)
- Satnam K Virdee
- Department of Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Sheila M Greenfield
- Department of Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Kate Fletcher
- Department of Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Richard J McManus
- Department of Primary Care Health Sciences, NIHR National School for Primary Care Research, University of Oxford, Oxford, UK
| | - F D Richard Hobbs
- Department of Primary Care Health Sciences, NIHR National School for Primary Care Research, University of Oxford, Oxford, UK
| | - Jonathan Mant
- Primary Care Unit, Strangeways Research Laboratory, University of Cambridge, Worts Causeway, Cambridge, UK
| |
Collapse
|
34
|
Kühlein T, Freund T. [Infections of the airways]. MMW Fortschr Med 2012; 154:51-56. [PMID: 23297541 DOI: 10.1007/s15006-012-1691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Thomas Kühlein
- Abteilung Allgemeinmedizin und Versorgungsforschung Universitätsklinikum Heidelberg.
| | | |
Collapse
|
35
|
Bourke J, Roper S. In with the new: the determinants of prescribing innovation by general practitioners in Ireland. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2012; 13:393-407. [PMID: 21503785 DOI: 10.1007/s10198-011-0311-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 03/25/2011] [Indexed: 05/30/2023]
Abstract
An important element of the process by which new drugs achieve widespread use is their adoption by GPs. In this paper, we explore the factors that shape the timing of the first prescription of six new drugs by General Practitioners in Ireland. Our analysis is based on a dataset that matches prescription data with data on GP characteristics. We then use duration analysis to explore both equilibrium and non-equilibrium determinants of prescribing innovation. Our study highlights a range of commonalities across all of the drugs considered and suggests the importance of GP and practice characteristics in shaping prescribing decisions. We also find strongly significant, and consistently signed, stock and order effects across these drugs: GPs who have a track record of early adoption tend also to be early adopters of other new drugs; and, the larger the proportion of GPs which have already adopted a new drug the slower is subsequent adoption. Epidemic and learning effects are also evident with slower adoption by rural practices and among those GPs with narrower prescribing portfolios.
Collapse
Affiliation(s)
- Jane Bourke
- Department of Economics, University College Cork, Cork, Ireland.
| | | |
Collapse
|
36
|
Paudyal V, Hansford D, Cunningham S, Stewart D. Over-the-counter prescribing and pharmacists' adoption of new medicines: diffusion of innovations. Res Social Adm Pharm 2012; 9:251-62. [PMID: 22835710 DOI: 10.1016/j.sapharm.2012.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 05/07/2012] [Accepted: 05/07/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND More than 90 medicines in the United Kingdom alone have been reclassified from "prescription only" to "pharmacy" availability, and many of these have further been deregulated to "general sales" status. Pharmacist perspectives of reclassified medicines adoption into practice are important to inform future reclassifications. OBJECTIVES The aim of this research was to explore the factors associated with adoption into practice of newly reclassified medicines by community pharmacists based on the theoretical framework of diffusion of innovations. METHODS Focus groups and qualitative interviews with 20 community pharmacists selected randomly from 4 Health Boards in Scotland were conducted. Results were analyzed using a framework method for thematic analysis. RESULTS Factors associated with pharmacists' decision making regarding adoption into practice of newly reclassified medicines related to pharmacists' perceived attributes of newly reclassified medicines such as evidence of benefits and risks to patients (ie, efficacy and safety); organizational contextual factors such as sources of information and training; external factors, such as support from wider stakeholders; and adopter characteristics such as pharmacists' perception toward adopting new behaviors. Many newly reclassified medicines were highlighted by participants to have been highly adopted into practice or were less/not adopted based on these diverse factors. Decisions at organizational level to stock new medicines did not necessarily translate into adoption at practitioner level. CONCLUSIONS Pharmacists' decision making regarding adoption of newly reclassified medicines is a complex and multidimensional process. This is the first study of this sort, and results of this qualitative study will aid development of a research instrument aimed at quantifying the importance of the factors identified.
Collapse
Affiliation(s)
- Vibhu Paudyal
- School of Pharmacy and Life Sciences, Robert Gordon University, Schoolhill, Aberdeen, AB10 1FR, UK.
| | | | | | | |
Collapse
|
37
|
Garjón FJ, Azparren A, Vergara I, Azaola B, Loayssa JR. Adoption of new drugs by physicians: a survival analysis. BMC Health Serv Res 2012; 12:56. [PMID: 22401169 PMCID: PMC3353238 DOI: 10.1186/1472-6963-12-56] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 03/08/2012] [Indexed: 11/10/2022] Open
Abstract
Background New drugs often substitute others cheaper and with a risk-benefit balance better established. Our aim was to analyse the diffusion of new drugs during the first months of use, examining the differences between family physicians and specialists. Methods Prescription data were obtained of cefditoren, duloxetine, etoricoxib, ezetimibe, levocetirizine, olmesartan, pregabalin and tiotropium 36 months after their launching. We obtained the monthly number of prescriptions per doctor and the number prescribers of each drug by specialty. After discarding those with less than 10 prescriptions during this period, physicians were defined as adopters if the number of prescriptions was over the 25th percentile for each drug and level (primary or secondary care). The diffusion of each drug was studied by determining the number of adopter family physicians throughout the study period. Among the group of adopters, we compared the month of the first prescription by family physicians to that of other specialists using the Kaplan-Meier method. Results The adoption of the drugs in primary care follows an exponential diffusion curve that reaches a plateau at month 6 to 23. Tiotropium was the most rapidly and widely adopted drug. Cefditoren spread at a slower rate and was the least adopted. The diffusion of etoricoxib was initially slowed down due to administrative requirements for its prescription. The median time of adoption in the case of family physicians was 4-6 months. For each of the drugs, physicians of a specialty other than family physicians adopted it first. Conclusions The number of adopters of a new drug increases quickly in the first months and reaches a plateau. The number of adopter family physicians varies considerably for different drugs. The adoption of new drugs is faster in specialists. The time of adoption should be considered to promote rational prescribing by providing timely information about new drugs and independent medical education.
Collapse
Affiliation(s)
- Francisco Javier Garjón
- Servicio Navarro de Salud, Servicio de Prestaciones Farmacéuticas, Plaza de la Paz s/n, E-31002 Pamplona, Spain.
| | | | | | | | | |
Collapse
|
38
|
Paudyal V, Hansford D, Cunningham S, Stewart D. Community pharmacists' adoption of medicines reclassified from prescription-only status: a systematic review of factors associated with decision making. Pharmacoepidemiol Drug Saf 2012; 21:396-406. [PMID: 22362493 DOI: 10.1002/pds.3219] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 12/18/2011] [Accepted: 12/22/2011] [Indexed: 12/31/2022]
Abstract
PURPOSE Subsequent to reclassification of legal status, more than 90 prescription-only medicines have become available in the UK alone without a prescription. Similar changes are taking place internationally. The aim was to systematically review studies reporting factors associated with community pharmacists' decision making around adoption of these reclassified medicines into practice. METHOD A systematic review of English language peer-reviewed published literature from 1990 to 2010 was conducted. Literature was identified through MEDLINE, EMBASE, IPA, CINAHL, BSP, Cochrane Library and PsychINFO databases and other sources including key conference abstracts. RESULTS A total of 38 studies were included. Twenty-eight factors associated with pharmacists' decision making were identified. Medicine safety was consistently shown to be one of the key factors; however, the importance of evidence base and financial benefits of reclassification were less obvious. A paucity of high-quality studies limits generalisation of findings. CONCLUSIONS Patient safety appears to be the key to pharmacists' decision making. However, the study quality limitations indicate the need for further robust research. The 28 factors identified in this systematic review from international literature can aid rigorous research instrument development for future evaluations.
Collapse
Affiliation(s)
- Vibhu Paudyal
- School of Pharmacy and Life Sciences, Faculty of Health and Social Care, The Robert Gordon University, Aberdeen, UK
| | | | | | | |
Collapse
|
39
|
Skoglund I, Björkelund C, Mehlig K, Gunnarsson R, Möller M. GPs' opinions of public and industrial information regarding drugs: a cross-sectional study. BMC Health Serv Res 2011; 11:204. [PMID: 21867497 PMCID: PMC3224368 DOI: 10.1186/1472-6963-11-204] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 08/25/2011] [Indexed: 11/13/2022] Open
Abstract
Background General Practitioners {GP} in Sweden prescribe more than 50% of all prescriptions. Scientific knowledge on the opinions of GPs regarding drug information has been sparse. Such knowledge could be valuable when designing evidence-based drug information to GPs. GPs' opinions on public- and industry-provided drug information are presented in this article. Methods A cross-sectional study using a questionnaire was answered by 368 GPs at 97 primary-health care centres {PHCC}. The centres were invited to participate by eight out of 29 drug and therapeutic committees {DTCs}. A multilevel model was used to analyse associations between opinions of GPs regarding drug information and whether the GPs worked in public sector or in a private enterprise, their age, sex, and work experience. PHCC and geographical area were included as random effects. Results About 85% of the GPs perceived they received too much information from the industry, that the quality of public information was high and useful, and that the main task of public authorities was to increase the GPs' knowledge of drugs. Female GPs valued information from public authorities to a much greater extent than male GPs. Out of the GPs, 93% considered the main task of the industry was to promote sales. Differences between the GPs' opinions between PHCCs were generally more visible than differences between areas. Conclusions Some kind of incentives could be considered for PHCCs that actively reduce drug promotion from the industry. That female GPs valued information from public authorities to a much greater extent than male GPs should be taken into consideration when designing evidence-based drug information from public authorities to make implementation easier.
Collapse
Affiliation(s)
- Ingmarie Skoglund
- Primary Care Unit, Department of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden.
| | | | | | | | | |
Collapse
|
40
|
Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev 2011; 2011:CD009255. [PMID: 21735443 PMCID: PMC4204491 DOI: 10.1002/14651858.cd009255] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is considerable interest in the effectiveness of financial incentives in the delivery of health care. Incentives may be used in an attempt to increase the use of evidence-based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive, diagnostic and treatment decisions, or both. Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way. Since there are numerous reviews performed within the healthcare area describing the effects of various types of financial incentives, it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals' behaviour and patient outcomes. OBJECTIVES To conduct an overview of systematic reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes. METHODS We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting. MAIN RESULTS We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review). AUTHORS' CONCLUSIONS Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.
Collapse
Affiliation(s)
- Gerd Flodgren
- University of OxfordDepartment of Public HealthRosemary Rue BuildingOld Road CampusHeadingtonOxfordUKOX3 7LF
| | - Martin P Eccles
- Newcastle UniversityInstitute of Health and SocietyBadiley Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Sasha Shepperd
- University of OxfordDepartment of Public HealthRosemary Rue BuildingHeadingtonOxfordOxfordshireUKOX3 7LF
| | - Anthony Scott
- The University of MelbourneMelbourne Institute of Applied Economic and Social ResearchLevel 7, Alan Gilbert BuildingBarry StreetCarlton, MelbourneVICAustralia3053
| | - Elena Parmelli
- University of Modena and Reggio EmiliaDepartment of Oncology, Hematology and Respiratory DiseasesVia del Pozzo 71ModenaItaly41100
| | - Fiona R Beyer
- University of YorkCentre for Reviews and DisseminationYorkUKYO10 5DD
| | | |
Collapse
|
41
|
Wan Md Adnan WAH, Zaharan NL, Bennett K, Wall CA. Trends in co-prescribing of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in Ireland. Br J Clin Pharmacol 2011; 71:458-66. [PMID: 21284706 DOI: 10.1111/j.1365-2125.2010.03835.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS (i) To examine the trends in co-prescribing of angiotensin converting enzyme inhibitor (ACEI) and angiotensin-II receptor blocker (ARB) therapy and (ii) to examine the influence of major clinical trials (CALM, COOPERATE, VALIANT and ONTARGET) on co-prescribing. METHODS The Irish HSE-Primary Care Reimbursement Services database was used to identify patients ≥16 years old co-prescribed ACEIs and ARBs between January 2000 and April 2009 (n= 266 554 prescriptions). The rate of prescribing per 1000 general medical services (GMS) scheme population was calculated for each month. Patients with diabetes, hypertension, heart failure and ischaemic heart disease were also identified by prescribing of certain medications. A linear trend test was used to examine prescribing trends. Logistic regression was used to examine prescribing according to patient characteristics. The effects of the major trials on prescribing were examined using segmented regression analysis for 12 months pre- and post-trials. RESULTS There was a significant linear trend in overall ACEI and ARB co-prescribing over the study period (P < 0.001). Rate of co-prescribing in January 2000 and April 2009 was 0.16 and 5.72, per 1000 eligible population, respectively. Those 45-64 years old (OR = 2.88, 95% confidence interval (CI) 2.71, 3.06) and ≥65 years (OR = 2.52, 95% CI 2.36, 2.68) were more likely to receive dual therapy compared with those <45 years old. Those with hypertension (OR = 8.85, 95% CI 8.45, 9.27), diabetes (OR = 4.10, 95% CI 3.97, 4.23) and heart failure (OR = 1.78, 95% CI 1.72, 1.84) were more likely to receive dual therapy compared with the general population. Significant increases in prescribing were observed only after the CALM (P= 0.03) and VALIANT (P= 0.007) trials. CONCLUSION Increased co-prescribing of ACEIs and ARBs was observed in Ireland during 2000-09. Prescribing patterns did not appear to be affected by results from major trials.
Collapse
Affiliation(s)
- Wan A H Wan Md Adnan
- Department of Renal Medicine, Adelaide & Meath Hospital Incorporating National Children Hospital (AMNCH), Dublin 24, Ireland.
| | | | | | | |
Collapse
|
42
|
Forslund T, Raaschou P, Hjemdahl P, Krakau I, Wettermark B. Usage, risk, and benefit of weight-loss drugs in primary care. J Obes 2011; 2011:459263. [PMID: 21785716 PMCID: PMC3139204 DOI: 10.1155/2011/459263] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 04/12/2011] [Indexed: 12/02/2022] Open
Abstract
Purpose. To investigate the use of the weight-loss drugs rimonabant, sibutramine, and orlistat in primary care and to characterize the patients receiving the drugs. Methods. In this retrospective, descriptive study, 300 randomly selected patients having started weight-loss drug treatment at 15 primary care centres were investigated using the patient's medical records and their complete drug purchase data. Results. Even though 48% of the patients specifically demanded drug treatment, 77% continued treatment less than one year. 28% of rimonabant patients and 32% of sibutramine patients had a history of depression or antidepressant treatment. 41% of sibutramine patients had a history of hypertension and/or cardiovascular disease. 36% had no documented weight after treatment initiation. Conclusions. These results suggest that weight-loss drug treatment was often initiated upon patient request but was of limited clinical benefit as it was managed in a large portion of Swedish primary carecenters.
Collapse
Affiliation(s)
- Tomas Forslund
- Gröndal Primary Care Centre, P. O. Box 470 43, 100 74 Stockholm, Sweden
- *Tomas Forslund:
| | - Pauline Raaschou
- Department of Clinical Pharmacology, Karolinska University Hospital, Solna, 141 86 Stockholm, Sweden
| | - Paul Hjemdahl
- Department of Clinical Pharmacology, Karolinska University Hospital, Solna, 141 86 Stockholm, Sweden
| | - Ingvar Krakau
- Centre for Family and Community Medicine, Karolinska Institutet and Stockholm County Council, Huddinge, Sweden
| | | |
Collapse
|
43
|
Sermet C, Andrieu V, Godman B, Van Ganse E, Haycox A, Reynier JP. Ongoing pharmaceutical reforms in France: implications for key stakeholder groups. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2010; 8:7-24. [PMID: 20038190 DOI: 10.1007/bf03256162] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The rapid rise in pharmaceutical costs in France has been driven by new technologies and the growing prevalence of chronic diseases as well as considerable prescribing freedom and choice of physician among patients. This has led to the introduction of a number of reforms and initiatives in an attempt to moderate expenditure whilst ensuring universal coverage and rewarding innovation. These reforms include accelerating access to and granting average European prices for new innovative drugs, delisting drugs where there are concerns over their value and instigating rebates for excessive prescribing. Alongside this, ongoing initiatives to improve the quality and efficiency of prescribing include programmes to enhance generic prescribing and dispensing as well as to reduce antibacterial and anxiolytic/hypnotic prescribing. However, there have been few publications documenting the impact of specific reforms on the overall costs and quality of care, which have been exacerbated by compartmentalization of budgets. Estimates suggest savings of over 27 million euro/year by decreasing antibacterial prescribing, 450 million euro/year by not reimbursing ineffective drugs, 670 million euro/year from pharmaceutical company rebates and approximately 1 billion euro/year from increased prescribing and dispensing of generics (year 2003-7 values). Additional savings of at least 1.5 billion euro/year are seen as being possible from increased use of generics such as generic proton pump inhibitors, statins (HMG-CoA reductase inhibitors) and ACE inhibitors instead of current branded products such as angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]). Delisting drugs when there are concerns about their value provides an example to other countries with currently limited demand-side measures. Other possible examples include price : volume agreements and multifaceted campaigns to enhance generic prescribing and dispensing and reduce antibacterial prescribing. Possible future initiatives could include adopting more stringent criteria for categorizing new drugs as innovative as well as further reductions in the prices of generics. Other initiatives could include further enhancement of the quality and efficiency of prescribing, including formal auditing of physician prescribing, as well as increasing efforts to monitor the risk : benefit ratio of new drugs post-launch in real-world practice.
Collapse
Affiliation(s)
- Catherine Sermet
- IRDES (Institut de recherche et de documentation en économie de la santé), Paris, France.
| | | | | | | | | | | |
Collapse
|
44
|
Groves KEM, Schellinck T, Sketris I, MacKinnon NJ. Identifying early prescribers of cycloxygenase-2 inhibitors (COX-2s) in Nova Scotia, Canada: Considerations for targeted academic detailing. Res Social Adm Pharm 2009; 6:257-67. [PMID: 20813338 DOI: 10.1016/j.sapharm.2009.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 09/23/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Expenditures on prescribed drugs in Canada are now well past those for all services provided by outpatient physicians ($26.9 billion vs. $21.5 billion in 2007). Government has the opportunity to dedicate resources to continuing medical education of physicians, and effective profiling would assist in the allocation of these educational resources. OBJECTIVE The purpose of this study was to evaluate physician prescribing patterns and establish criteria by which various prescribing profiles may be segmented and identified, so as to better target detailing and continuing medical education resources. METHODS A sample of 925 physicians practicing in Nova Scotia (NS) was characterized by age, sex, rural/urban nature of their practice and specialty. They were subsequently evaluated relative to all prescriptions filled by their patients who were beneficiaries of the NS Department of Health's senior's Pharmacare drug insurance program. The adoption of COX-2 inhibitors (eg, Vioxx) and Celebrex) and their substitution for NS-NSAIDs (non-specific non-steroidal anti-inflammatory drugs, eg, Motrin) from 1999 to 2003 were examined. RESULTS This analysis established the profiles of 2 key groups of physicians. The first consisted of those most likely to comprise the early, high volume COX-2-prescribing universe (profiles based on the absolute number of prescriptions written over a given period). These individuals were likely to be older, more experienced, male general practitioners operating in a rural practice. The second group consisted of those most likely to comprise the early, high-relative, COX-2-prescribing universe (prescribing of COX-2s relative to non-selective, non-steroidal anti-inflammatory drugs (NS-NSAIDs)). These individuals were likely to be younger, less experienced female general practitioners, operating in an urban practice. CONCLUSION This research moves us closer to identifying unique physician segments that account for either the largest volume of prescriptions for new drugs, or the largest relative volume of prescriptions. Use of these physician groups can help continuing medical education providers target specific prescribers with information to assist them in examining and improving their prescribing.
Collapse
Affiliation(s)
- Kent E M Groves
- College of Pharmacy, Dalhousie University, 5968 College St., Halifax NS B3H 3J5 Canada.
| | | | | | | |
Collapse
|
45
|
Verger P, Rolland S, Paraponaris A, Bouvenot J, Ventelou B. Drug reimbursement and GPs' prescribing decisions: a randomized case-vignette study about the pharmacotherapy of obesity associated with type 2 diabetes: how GPs react to drug reimbursement. Fundam Clin Pharmacol 2009; 24:509-16. [PMID: 19840120 DOI: 10.1111/j.1472-8206.2009.00779.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study sought to identify the effect of drug reimbursability--a decision made in France by the National Authority for Health--on physicians' prescribing practices for a diet drug such as rimonabant, approved for obese or overweight patients with type-2 diabetes. A cross-sectional survey of French general practitioners (GPs) presented a case-vignette about a patient for whom this drug is indicated in two alternative versions, differing only in its reimbursability, to two separate randomized subsamples of GPs in early 2007, before any decision was made about reimbursement. The results indicate that (i) more than 20% of GPs in private practice would be willing to prescribe a non-reimbursed diet drug for patients with obesity complicated by type 2 diabetes; (ii) the number of GPs willing to prescribe it would increase by 47.6% if the drug were reimbursed, and (iii) such a drug would be adopted at a higher rate by GPs who have regular contacts with pharmaceutical sales representatives. In France, unlike most other countries, drug reimbursement status is a signal of quality. However, our results suggest that a significant proportion of GPs would spontaneously adopt anti-obesity drugs even if they were not reimbursed. Decisions about reimbursement of pharmaceutical products should be made taking into account that reimbursement is likely to intensify prescription.
Collapse
|
46
|
Does social marketing provide a framework for changing healthcare practice? Health Policy 2009; 91:135-41. [DOI: 10.1016/j.healthpol.2008.11.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 11/18/2008] [Accepted: 11/19/2008] [Indexed: 11/19/2022]
|
47
|
Rahmner PB, Gustafsson LL, Larsson J, Rosenqvist U, Tomson G, Holmström I. Variations in understanding the drug-prescribing process: a qualitative study among Swedish GPs. Fam Pract 2009; 26:121-7. [PMID: 19103613 DOI: 10.1093/fampra/cmn103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A majority of doctor-patient meetings result in the patient getting a prescription. This underlines the need for a high-quality prescription process. While studies have been made on single therapeutic drug groups, a complete study of the physicians' general thought process that comprises the prescription of all drugs still remains to be made. OBJECTIVE To identify variations in ways of understanding drug prescribing among GPs. METHODS A descriptive qualitative study was conducted with 20 Swedish physicians. Informants were recruited purposively and their understandings about prescribing were studied in semi-structured interviews. Data were analysed using a phenomenographic approach. RESULTS Five categories were identified as follows: (A) GP prescribed safe, reliable and well-documented drugs for obvious complaints; (B) GP sought to convince the patient of the most effective drug treatment; (C) GP chose the best drug treatment taking into consideration the patient's entire life situation; (D) GP used clinical judgement and close follow-up to minimize unnecessary drug prescribing and (E) GP prescribed drugs which are cheap for society and environmentally friendly. The categories are interrelated, but have different foci: the biomedical, the patient and the society. Each GP had more than one view but none included all five. The findings also indicate that complexity increases when a drug is prescribed for primary or secondary prevention. CONCLUSIONS GPs understand prescribing differently despite similar external circumstances. The most significant factor to influence prescribing behaviour was the physician's patient relation approach. GPs may need to reflect on difficulties they face while prescribing to enhance their understandings.
Collapse
Affiliation(s)
- Pia Bastholm Rahmner
- Department of Drug Management and Informatics, Stockholm County Council, Stockholm, Sweden.
| | | | | | | | | | | |
Collapse
|
48
|
Wettermark B, Godman B, Jacobsson B, Haaijer-Ruskamp FM. Soft regulations in pharmaceutical policy making: an overview of current approaches and their consequences. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2009; 7:137-147. [PMID: 19799468 DOI: 10.1007/bf03256147] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
It is a challenge to improve public health within limited resources. Pharmaceutical policy making is a greater challenge due to conflicting interests between key stakeholder groups. This paper reviews current and future strategies to help improve the quality and efficiency of care, with special emphasis on demand-side controls for pharmaceutical prescribing. A large number of different educational, organizational, financial and regulatory strategies have been applied in pharmaceutical policy making. However, the effectiveness of most strategies has not been thoroughly evaluated and there is evidence that the behaviour of healthcare professionals is difficult to influence with traditional methods. During the last decades, new modes of governing and new governing constellations have also appeared in healthcare. However, relationships between those who regulate and those regulated are often unclear. New approaches have recently been introduced, including extensive dissemination strategies for guidelines and extensive quality assessment programmes where physicians' performances are measured against agreed standards or against each other. The main components of these 'soft regulations' are standardization, monitoring and agenda setting. However, the impact of these new modes on health provision and overall costs is often unknown, and the increased focus on monitoring may result in a higher conformity and uniformity that may not always benefit all key stakeholders. Alongside this, a substantial growth of auditing associations controlling a diminishing minority of people actually performing the tasks may be costly and counter-productive. As a result, new effective strategies are urgently needed to help maintain comprehensive healthcare without prohibitively raising taxes or insurance premiums. This is especially important where countries are faced with extreme financial problems. Healthcare researchers may benefit from researching other areas of society. However, any potential strategies initiated must be adequately researched, debated and evaluated to enhance implementation. We hope this opinion paper is the first step in the process to develop and implement new demand-side initiatives building on existing 'soft regulations'.
Collapse
Affiliation(s)
- Björn Wettermark
- Department of Clinical Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | | | | | | |
Collapse
|
49
|
Chauhan D, Mason A. Factors affecting the uptake of new medicines in secondary care - a literature review. J Clin Pharm Ther 2008; 33:339-48. [PMID: 18613851 DOI: 10.1111/j.1365-2710.2008.00925.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE The rate of uptake of new medicines in the UK is slower than in many other OECD countries. The majority of new medicines are introduced initially in secondary care and prescribed by specialists. However, the reasons for relatively low precribing levels are poorly understood. This review explores the determinants of uptake of new medicines in secondary care. METHODS Nine electronic databases were searched covering the period 1992-2006. Once the searches had been run, records were downloaded and those which evaluated uptake of new medicines in secondary care were identified. UK studies were of primary interest, although research conducted in other countries was also reviewed if relevant. With the exception of 'think pieces', eligibility was not limited by study design. Studies published in languages other than English were excluded from the review. Determinants of uptake in secondary care were classified using Bonair and Persson's typology for determinants of the diffusion of innovation. RESULTS Almost 1400 records were screened for eligibility, and 29 studies were included in the review. Prescribing of new medicines in secondary care was found to be subject to a number of interacting influences. The support structures which exist within secondary care facilitate access to other colleagues and shape prescribing practices. Clinical trial investigators and physicians who sit on decision-making bodies such as Drug and Therapeutic Committees (DTCs) appear to have a special influence due to their proximity to their research and understanding of evidence base. Pharmaceutical representatives may also influence prescribing decisions through funding of meetings and academic detailing, but clinicians are wary of potential bias. Little evidence on the influence of patients upon prescribing decisions was identified. The impact of clinical guidelines has been variable. Some guidelines have significantly increased the uptake of new medicines, but others have had little discernible impact despite extensive dissemination. However given the increasing influence of the National Institute for Health and Clinical Excellence, guidelines may become more important. The impact of financial prescribing incentives on secondary care prescribing is unclear. Although cost and budget may influence hospital prescribing of new drugs, they are of secondary importance to the safety and effectiveness profile of the medicine. If a drug has a novel mechanism of action, or belongs to a class with few alternatives, clinicians are more likely to consider it favourably as a prescribing option. CONCLUSIONS Although price does not appear to be a primary factor behind prescribing decision-making, in secondary care there has long been a historical need for formal purchasing decisions through the DTC, which differentiates it from primary care. This, in addition to increasing pressures for cost-effectiveness within the NHS means that cost will appear more frequently on clinician consciousness. As a result, guidelines are more likely to be implemented using the strong professional networks in existence within secondary care, and although the influence of patients has not been addressed by the literature, they are likely to have an increasing input into the prescribing decision, given the importance of patient involvement in current UK policy.
Collapse
Affiliation(s)
- D Chauhan
- Office of Health Economics, London, UK.
| | | |
Collapse
|