Comparative Analysis of Legislative Requirements About Patients' Access to Biotechnological Drugs for Rare Diseases in Central and Eastern European Countries

Objectives: The aim of the study was to compare the access of patients with rare diseases (RDs) to biotechnological drugs in several Central and Eastern European countries (CEECs). We focused on the legislative pricing and reimbursement requirements, availability of biotechnological orphan medicinal products (BOMPs) for RDs, and reimbursement expenditures. Methods: A questionnaire-based survey was conducted among experts from 10 CEECs: Bulgaria, Croatia, Estonia, Greece, Hungary, Poland, Romania, Slovakia, Serbia, and Macedonia. The legal requirements for reimbursement and pricing of BOMPs were collected. All BOMPs and medicines without prior orphan designations were extracted from the European list of orphan medicinal products, 2017. The reimbursement status of these medicinal products in 2017 in the public coverage of the included CEECs as well as the share of their costs in relation to the total public pharmaceutical spending for the period from 2014 to 2016 were defined. Results: Our survey revealed that some differences in the legal requirements for pricing and reimbursement of BOMPs amongst the countries included in the study. All European Union countries have developed and implemented pharmacoeconomic guidelines with or without some specific reimbursement requirements for orphan medicinal products. Cost-effectiveness analysis, cost-utility analysis, Markov models, meta-analysis, and discount levels of costs and results were required only in Bulgaria, Poland and Hungary. The number of reimbursed BOMPs and biotechnological medicinal products for RDs without prior orphan designation was the highest in Hungary (17 and 40, respectively). Patient-based reimbursement schemes were available only in Hungary for 11 out of 17 BOMPs. Poland and Greece have the highest pharmaceutical expenditure of reimbursed BOMPs with are ~214 million and 180 million EUR, respectively in the observed period from 2014 to 2016. High proportion of the pharmaceutical expenditure on the reimbursed biotechnological medicinal products for RDs for the observed period 2014-2016 is presented in Bulgaria and Slovakia. Conclusions: The non-European Union CEECs face a significant delay in the legal implementation of pharmacoeconomic guideline for assessment of BOMPs. The access to BOMPs is similar among the observed CEECs and the countries with the best access are Hungary and Greece. The influence of BOMP expenditures on the budget in the individual countries is significant.

Quality of Life and Cost Study of Rheumatoid Arthritis Therapy With Biological Medicines

Biological medicines are considered as a cornerstone in the therapy of rheumatoid arthritis (RA). They change the course of the disease and improve the quality of life of patients. To this date there has been no study comparing the quality of life of and cost of RA therapy in Bulgaria. This fact is what provoked our interest toward this research. The aim of this study is to analyse the cost and quality of life of patients with RA threated with biological medicines in Bulgaria. This is an observational, real life study of 124 patients treated with biological medicines during 2012-2016 at the University hospital "St. Ivan Riskli" in Sofia, specialized in rheumatology disease therapy. Patients were recruited after their consecutive transfer from non-biological to biological medicines. The yearly pharmacotherapy cost was calculated with tocilizumab (n = 30), cetrolizmab (n = 16), golimumab (n = 22), etanercept (n = 20), adalimumab (n = 20), rituximab (n = 16). Three measurements of the quality of life (QoL) were performed with EQ5D-at the beginning of the therapy, after 6 months and after 1 year of therapy. Both section of EQ5D were used-VAS and EQ5D questionnaire. Cost-effectiveness was calculated for unit of improvement in EQ5D score for a one year period and decision model was built with TreeAgePro software. The observed cost of therapy varied between 12 thousand Euros for tocilizumab to 6 thousand Euros for rituximab. All biological medicines let to substantial increase in the quality of life of the patients. Patients on tocilizumab increased their QoL from 0.43 to 0.63 after 1 year; on cetrolizumab from 0.32 to 0.56; on golimumab from 0.41 to 0.67; on etanercept from 0.45 to 0.62; on adalimumab from 0.43 to 0.57; on rhituximab from 0.46 to 0.66. The cost-effectiveness estimates of different biological therapies also varied between 66 to 30 thousand Euros for unit of improvement in the EQ5D during one the course of the year. Therapy with biological medicines improves statistically significant the quality of life of patients, measured through VAS and EQ5D scales. Despite the improvement in the quality of life all biological medicines appears not to be note cost-effective due to their high incremental cost-effectiveness ration (ICER). Rituximab's incremental ratio has (ICER) falls closer to the three times gross domestic product per capita threshold and should be considered as preferred alternatives for RA therapy. In general we can conclude that the treatment of rheumatoid arthritis with biologicals improves quality of life significantly. Only rituximab was cost-effective.

Adaptive Pathways: Possible Next Steps for Payers in Preparation for Their Potential Implementation

Medicines receiving a conditional marketing authorization through Medicines Adaptive Pathways to Patients (MAPPs) will be a challenge for payers. The "introduction" of MAPPs is already seen by the European Medicines Agency (EMA) as a fait accompli, with payers not consulted or involved. However, once medicines are approved through MAPPs, they will be evaluated for funding by payers through different activities. These include Health Technology Assessment (HTA) with often immature clinical data and high uncertainty, financial considerations, and negotiations through different types of agreements, which can require monitoring post launch. Payers have experience with new medicines approved through conditional approval, and the fact that MAPPs present additional challenges is a concern from their perspective. There may be some activities where payers can collaborate. The final decisions on whether to reimburse a new medicine via MAPPs will have more variation than for medicines licensed via conventional processes. This is due not only to increasing uncertainty associated with medicines authorized through MAPPs but also differences in legal frameworks between member states. Moreover, if the financial and side-effect burden from the period of conditional approval until granting full marketing authorization is shifted to the post-authorization phase, payers may have to bear such burdens. Collection of robust data during routine clinical use is challenging along with high prices for new medicines during data collection. This paper presents the concept of MAPPs and possible challenges. Concerns and potential ways forward are discussed and a number of recommendations are presented from the perspective of payers.

Pricing and Reimbursement of Biosimilars in Central and Eastern European Countries

Objectives: The aim of this study was to review the requirements for the reimbursement of biosimilars and to compare the reimbursement status, market share, and reimbursement costs of biosimilars in selected Central and Eastern European (CEE) countries.

Methods: A questionnaire-based survey was conducted between November 2016 and January 2017 among experts from the following CEE countries: Bulgaria, Czech Republic, Croatia, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, and Romania. The requirements for the pricing and reimbursement of biosimilars were reviewed for each country. Data on the extent of reimbursement of biologic drugs (separately for original products and biosimilars) in the years 2014 and 2015 were also collected for each country, along with data on the total pharmaceutical and total public health care budgets.

Results: Our survey revealed that no specific criteria were applied for the pricing and reimbursement of biosimilars in the selected CEE countries; the price of biosimilars was usually reduced compared with original drugs and specific price discounts were common. Substitution and interchangeability were generally allowed, although in most countries they were at the discretion of the physician after a clinical assessment. Original biologic drugs and the corresponding biosimilars were usually in the same homogeneous group, and internal reference pricing was usually employed. The reimbursement rate of biosimilars in the majority of the countries was the same and amounted to 100%. Generally, the higher shares of expenditures were shown for the reimbursement of original drugs than for biosimilars, except for filgrastim, somatropin, and epoetin (alfa and zeta). The shares of expenditures on the reimbursement of biosimilar products ranged from 8.0% in Estonia in 2014 to 32.4% in Lithuania in 2015, and generally increased in 2015. The share of expenditures on reimbursement of biosimilars in the total pharmaceutical budget differed between the countries, with the highest observed value for Slovakia and Hungary and the lowest—for Croatia.

Conclusions: The requirements for the pricing and reimbursement of biosimilar products as well as the access of patients to biologic treatment do not differ significantly between the considered CEE countries. Biosimilar drugs significantly influence the reimbursement systems of these countries, and the expenditure on the reimbursement of biosimilars is increasing as they are becoming more accessible to patients.

[Contemporary opinion about anticholinergics use in premedication]

The article deals with the analysis of publications which discuss anticholinergics use in premedication. The article briefly says about the use history and characteristics of anticholinergics. In conclusion the article stresses the need to abandon the routine anticholinergics use. Intravenous anticholinergics application is preferable if there are indications for its use. New inhalation and intravenous anaesthetics promote to prescribe the anticholinergics individually

Hypertension and common complications --analysis of the ambulatory treatment cost

AIM

Retrospective analysis of the prescribing practice and cost of ambulatory treatment of hypertension and its common complications--heart failure, sequelae of cerebrovascular disease, and angina pectoris.

METHODS

Analysis of 3,240 reimbursable ambulatory prescriptions for hypertension, heart failure, sequelae of cerebrovascular disease and angina pectoris according to the complexity of the therapy and frequency of the prescribed medicines. Modeling and calculation of the expected monthly cost for outpatient therapy by using the "decision tree model". Sensitivity analysis is performed within the +/- 30% interval.

RESULTS

65% of the prescription were for the hypertension, and 35% for the observed complications. 1,297 prescriptions for hypertension include one medicine, 647 include two medicines, and only 8% of prescriptions were for three medicines. ACE inhibitors have been prescribed in 41% of all hypertension prescriptions, followed by beta-blockers (19%), Ca channel blockers (16%), diuretics (15%) etc. The prescriptions for hypertension complications are more diverse as therapeutic groups. The expected monthly cost of prescribed medicines per patient with hypertension alone is 6.90 Euro and in case of complications it is 10.71 Euro according to the prevalence of the complexity of therapy, and weighted monthly cost of medicines. The overall ambulatory cost is expected to be around 148 million Euro per year for near 1.5 million patients with 44% reimbursement. The cost of the therapy is sensitive more to changes in the medicine's prices than to its complexity.

CONCLUSION

This study is a first step in providing information for evidence-based cost containment measures or policy decisions at ambulatory level in Bulgaria and for the assessment of the share of complications' therapy on the overall hypertension cost.

Pilot project for education of patients with type 2 diabetes by pharmacists

The objective was to adapt and test an educational programme for type 2 diabetes patients. The sample consisted of 24 individuals with type 2 diabetes between 31 and 75 years of age that did not require insulin, without severe complications of diabetes. A patient satisfaction questionnaire was applied in the beginning and at the end of the survey. A five-month education was conducted on: hypo- and hyperglycaemia, nourishing and physical activity, feet care, eye care and possible adverse drug reaction. The costs of the education and the pharmacological treatment were calculated. Improvement was observed in patients' diabetes knowledge and there was a decrease in the frequency of hypo- and hyperglycaemic incidents (about 60% less). At the end of the programme no incidents were matched, saving Euro 10/patient. The benefit to cost ratio is about 1:1 (Euro 140:Euro 142.80). The patients' quality of life improved by about 5% according to the Diabetes Questionnaire (IMG). The educational approach has the potential to decrease diabetes complications and therefore the economic cost of type 2 diabetes. Introduction of the programme will benefit diabetes patients, promote pharmacies as a source of independent drug information and recognise pharmacists as competent healthcare providers.

Assessment of patient and pharmacists attitudes in Bulgaria regarding herbal medicinal products

The study aimed at analyzing patients and pharmacists attitudes regarding herbal medicinal products (HMP) in Bulgaria and focus on two main questions: why patients or pharmacists prefer or do not prefer HMP; what are the main sources of information for patient and pharmacists. The inquire research is organized with two similar questions (for patients and for pharmacists) in 10 randomly selected country areas in 5 types of pharmacies. The results shows that HMP are preferred more in aging patients groups suffering from chronic diseases or careful to their healthy condition. In case of acute diseases patients are more disposed to buy modern medicine. The high level of positive attitudes towards HMP (60% of patients and 73% of pharmacists) could explain the growth in their market share during the last 10 years but did not correspond with the low volume of HMP kept on stock. It also did not correspond to the preference in 56% of all cases towards modern medicines. In general pharmacists also recommend HMP for chronic diseases or in case of light disorders. Availability and reliability of information for HMP is insufficient for patients and pharmacists as well. They need more independent sources of information especially for newly registered HMP with herbs from different geographic origins. Scientists and regulatory agencies should expand their efforts in providing appropriate and reliable information to the society and professionals.

Prescription patterns analysis--variations among Bulgaria, Romania, Macedonia and Bosnia Herzegovina

The objective of the study is analysis of the prescription patterns in Bulgaria, Romania, Macedonia and Bosnia Herzegovina (BiH). The study discusses the relevance between prescription and morbidity and the rationality of the drug prescription in terms of Essential Drug Concept (EDC). For the assessment of the morbidity influence on the prescription official statistical information was reviewed and prevailing causes of diseases in the observed countries were calculated. To study the patterns geographically selected regions from the countries under consideration were observed during 1998-2000. In all the countries under consideration respiratory tract, nervous system and cardiovascular diseases are playing the leading role. The prescription of cardiovascular drugs, anti-infectious nervous and respiratory system drugs also predominate. Comparison between prescription and morbidity patterns shows a significant relationship between the morbidity and prescription patterns. Prescription matches the morbidity requirements for the prevailing diseases. The proportion of the essential drug prescribing is higher in countries with officially adopted national EDL as Romania and BiH. No policy promoting rational drug prescription exists and countries use different indicators for the combinations, injections and drugs prescribed per prescription.

Prescribing patterns analysis in Bulgaria

This study was developed to assess the prescribing patterns in the reimbursable and non-reimbursable prescriptions during 1996-2000 and their relevance to morbidity patterns in Bulgaria. It was manually collected 2266 reimbursable and 2330 non-reimbursable prescriptions with 4132 and 4291 prescribed drugs, respectively. The results shows that the leading causes for morbidity during 1995-99 were respiratory tract diseases with 40% relative share, followed by nervous system diseases with 12% share, cardiovascular diseases 10% share, digestive tract diseases, genito-urinary, skin and subcutaneous tissue diseases. All mentioned groups of diseases together with injuries and poisoning perform 70% of the total morbidity of the population. The prevailing causes for the mortality of the population were found to be cardiovascular, respiratory tract diseases, injuries and poisoning. The analysis of the collected prescriptions evaluated as mot often prescribed cardiovascular drugs (35%), drugs acting on digestive system (18%), nervous system (12%), respiratory system (11%) and anti-infective drugs (10%). In spite of the relevance among the prescribing and morbidity a lot of other factors are considered to be important as reimbursement system, pricing, and legislation.

Calculating the cost for drug treatment including the adverse drug reactions treatment cost (primer for fentanyl TTS in Bulgaria)

This study presents the estimation and comparison of the direct outpatient costs associated with the use of Morphine slow-tard tabul and trans-dermal therapeutic system /TTS/ with Fentanyl for the treatment of the chronic pain in oncological patients. There are compared all outpatients' costs for the medicines under consideration--Morphine slow-tard tabul in two different packages and Fentanyl TTS. The calculation summarizes the price of the drug therapy for 15 days course, costs for care (physician, pharmaceutical, nursing), transport, storage. After the assessment of the costs for prophylactics and treatment of the adverse drug reactions /ADR/ associated with the use of the compared drugs by creating the "Decision tree" the respective cots are added to the direct cost of patients treatment. The direct treatment costs with Fentanyl TTS exceeded those with Morphine slow-tard with 10% and thus reflects the total costs for outpatient practice. The costs of treatment of the ADRs are higher with 69% for Morphine slow-tard due to high probability of appearance of the ADRs, their seriousness and duration.

Monitoring of national drug policies--regional comparison between Bulgaria, Romania, Macedonia, Bosnia Herzegovina

After the profound economic and political changes most of the East European countries started market-oriented reforms. During the last 10 years rapid development of the private pharmaceutical sector and a slow privatisation process was observed. The balance between the private and public sector became very important for achieving NDP goals. The goal of this study is to evaluate the availability and development of the NDP structures in East European countries--Bulgaria (BG). Romania (Rom), Macedonia (Mac), Bosnia Herzegovina (BiH). For the assessment of the availability of NDP structures a questionnaire focused on seven main NDP components was used. These components are: legislation and regulations; essential drug selection and drug registration; drug allocation in the health budget/public sector financing policy; public sector procurement procedures; public sector distribution and logistics; price policy; information and continuing education on drug use. According to the survey the most developed NDP structures are drug legislation and regulations (incl. quality control), drug registration and drug distribution. We can assume that the people have access to different drugs of appropriate quality and in time. The systems for public drug financing, procurement and price policy are under developing or not efficient enough. The financial availability of drugs is difficult. There is a lack of objective drug information and postgraduate education is not oriented on the ED. It means that there is no guarantee for rational drug prescription and usage of drugs on the markets.

Influence of electrode impedance changes on the common-mode rejection ratio in bioimpedance measurements

Bioelectrical impedance in vivo measurements suffer from many potential sources of error due to the patient-instrument interface. The total common-mode rejection ratio (CMRR(T)) was investigated experimentally for three measurement channel circuit versions, including electrode-skin impedance imbalance. The first version was of the 'classical' type. The second one makes use of a differential filter at the input of the instrumentation amplifier. The third circuit was a frequency-converting structure, where the signal was demodulated before being amplified. The differential demodulator was based on synchronous sampling using floating capacitors. The experiments were accomplished with simulated imbalance of the real and imaginary parts of electrode-skin impedances. To reduce unwanted common-mode voltage, a differential accurately balanced current source was used. Considering an application in impedance cardiography, the experiments were carried out at a single frequency of 40 kHz. The results showed the advantage of the circuits using frequency conversion and differential input filter, rendering at least 15 dB higher CMRR(T). The most significant reduction of CMRR(T) resulted from imbalance of the capacitance component of voltage-sensing electrode impedances. The third circuit showed an unexpected behaviour of CMRR(T) improvement with higher imbalance of the electrode-skin impedance resistance component.

Inductively coupled wideband transceiver for bioimpedance spectroscopy (IBIS)

Most measurement devices for bioimpedance spectroscopy are coupled to the measured object (tissue) via electrodes. At frequencies > 500 kHz, they suffer from artifacts due to stray capacitances between electrode leads as well as between the ground and object. The noninvasive measurement of the brain conductivity is hardly possible with surface electrodes. These disadvantages can be obviated by inductive coupling. The aim of this work was the development of a wideband transceiver for inductive impedance spectroscopy. In order to define its specifications, a feasibility study has been carried out with a simulation model for three different coil systems above a homogeneous conducting plate. According to simulation results, all systems render it possible to resolve conductivity changes down to 10(-3) (omega m)-1 at frequencies > 50 kHz. The transceiver electronics must then provide a resolution of > or = 1 microV and an excitation current of up to 1 A. The realized receiver matches these specifications with an S/N ratio of 22 dB at 1 microV in the frequency range of 50 kHz to 5 MHz.