1. The influence of different initiatives to enhance
prescribing efficiency for CV drugs, PPIs and
atypicals in Scotland; implications for the future
Marion Bennie, Iain Bishop, Brian Godman and
Stephen Campbell
1 Bilbao 2012

2. There is increasing focus on drug expenditure.
Analysis of reforms provide future direction
 Healthcare expenditure represents a significant proportion of
national expenditure
 Pharmaceutical expenditure typically the largest component in
ambulatory care - up to 60% of total healthcare expenditure in
some countries
 Alongside this, national health services in Europe strive to
maintain comprehensive and equitable healthcare, which has
resulted in multiple reforms to obtain low prices for generics
and enhance their prescribing vs. originators (ATC Level 5) and
patented products in a class (ATC Level 4)
 However, intensity of reforms can vary across classes and
countries. Analysis of reforms within and across countries
including atypicals can provide guidance for the future
2 Bilbao 2012

3. Study objectives and methodology
Objectives
 Analyse whether prescribing efficiency for PPIs and statins
extended beyond 2007 in Scotland
 Analyse influence of reforms to enhance atypical antipsychotic
prescribing efficiency
 Contrast with other classes including PPIs, statins and ACEIs/
ARBs and suggest additional reforms if needed
Methodology
 Retrospective observational DU study of the influence of
reforms on PPI and statin utilisation and expenditure 2001 to
2010, ACEIs/ ARBs 2001 to 2007, and atypical antipsychotics
2005 to 2010, using NHS Scotland Warehouse data
 Clozapine not included as reserved for resistant patients
 Demand side measures collated under the 4 Es
 Reforms taken from previous publications as well as in-house
data, and validated
3 Bilbao 2012

4. The definition of the 4Es and examples include:
4 E category Definition Examples
Education Programmes that Examples include:
influence • simple distribution of printed treatment guidance
prescribing through • intensive strategies such as educational outreach visits
dissemination of building on guidance for instance from Drugs and
material, which can Therapeutic Committees
be passive or active • Subsequent monitoring of prescribing against agreed
guidance or guidelines coupled with feedback
Engineering Organizational or Examples include:
managerial • price: volume agreements for existing drugs
interventions • disease management programmes
• prescribing targets, e.g. the % of prescriptions for generic
omeprazole versus all PPIs and % generic simvastatin
versus all statins and goals for INN prescribing when this
is not obligatory or enforced
Economics Financial Examples include:
interventions • patient co-payments for more expensive drugs than the
(positive and current reference molecule
negative) • positive and negative financial incentives for physicians
• devolved budgets to physicians
Enforcement Regulations Examples include:
including those • mandatory generic substitution in pharmacies
enforced by law • prescribing restrictions such as prior authorisation
schemes, e.g. atorvastatin in Austria; alternatively
prescribing restrictions with follow-up only where
concerns, e.g. Norway and Sweden
4 Bilbao 2012 Ref: Wettermark, Godman et al 2009; Godman, Shrank et al 2010,2011; Godman, Wettermark, Bishop et al 2012

5. NHS Scotland, Health Boards and SIGN have
introduced multiple demand-side measures in recent
years. These include the following for PPIs and CV
drugs:
Measure Examples of initiatives categorised under the 4Es
Education • Physicians typically trained in medical school to prescribe by INN name with follow up in the
community coupled with IT systems. Follow up includes decision support software as well as
monitoring the prescribing of generics, which is seen as good-quality prescribing. This has
resulted in current INN prescribing rates averaging over 80% across all products, rising to
over 98% for generic simvastatin and generic lisinopril
• National guidance and guidelines (SIGN) for dyspepsia
• National guidance and guidelines (SIGN) for primary and secondary prevention including
patients with diabetes
• Regional formularies for PPIs and statins such as the Lothian and Greater Glasgow
formularies advocating generic omeprazole and generic simvastatin; the latter as 40mg
generic simvastatin
• General monitoring of prescribing, benchmarking and academic detailing
Engineering • Better Care Better Value’ indicators to enhance the prescribing of low cost statins and PPIs
versus single sourced statins and PPIs
• Quality targets for statin prescribing as part of Audit Scotland in 2003
• Quality and Outcome Framework targets including those for diabetes, hypertension, stroke
and CHD
• Therapeutic switching by Health Board pharmacists when working with GPs
Economics • Practice based financial incentives
• Payment by results
5 Bilbao 2012

6. Scottish Intercollegiate Guidelines Network (SIGN)
Scottish Intercollegiate
well respected in Scotland and Internationally
 Guidelinesapplicable
Clinical guidelines Network (SIGN)
to NHS in Scotland
 Guidelines developed by
multidisciplinary, nationally
representative groups
 Enhanced “buy in”
 Originally criticised for not
costing consequences of
guideline implementation
 Now include cost effective
drug choices to enhance
their usage with all key
stakeholder groups
expected to follow the
guidance
6 Bilbao 2012

7. Multiple supply- and demand-side measures
have enhanced efficiency for PPIs and CV drugs
PPIs
 Typically generic omeprazole first line (98% total omeprazole)
 Expenditure in 2010 56% below 2001 levels despite 3 fold increase in
utilisation - helped by generic omeprazole 9% of pre-patent loss
prices in 2010. Expenditure will fall further with generic esomeprazole
Statins
 Typically generic simvastatin first line (98% total simvastatin)
 Increasingly 40mg - recommended following Heart Protection Study
and to achieve QoF targets
 Expenditure in 2010 only 7% above 2001 levels despite 6.2 fold
increase in utilisation since 2001, helped by generic simvastatin only
3% of pre-patent loss prices. Expenditure now falling with generic
atorvastatin
ACEIs/ ARBs
 Both seen as equally effective – fewer side-effects with ARBs
 Prescribing targets for ACEIs/ ARBs in 2003 to limit ARB prescribing
 Only 20% increase in expenditure 2007 vs. 2001 despite 159%
increase in volume
7 Bilbao 2012
Ref: Vončina, Strizrep, Godman et al 2011; Bennie, Godman, B

8. Combined activities increased use of omeprazole. Without
measures PPI expenditure GB£159mn higher in 2012
Generic omeprazole
reimbursed
8 Bilbao 2012
Ref: Bennie, Godman, Bishop et al 2012

9. Measures also increased use of simvastatin. Without
these, statin expenditure GB£290mn higher in 2010
Generic simvastatin
reimbursed
9 Bilbao 2012
Ref: Bennie, Godman, Bishop et al 2012

10. Intensive education, economics and engineering
measures successful in Scotland to enhance ACEIs
10 Bilbao 2012
Ref: Voncina, Strizrep, Godman et al 2011

11. In contrast, stabilisation in overall use of risperidone
since oral generic launched in April 2008 ....
Generic oral risperidone
11 Bilbao 2012

12. In more detail, again stabilisation in utilisation of
risperidone versus other atypical antipsychotics ....
Generic risperidone
12 Bilbao 2012

13. .. appreciably limited savings from the availability of
oral generic risperidone at 16% of pre-patent loss
prices in 2010
Generic oral risperidone
13 Bilbao 2012

14. Multiple measures are needed to enhance
prescribing efficiency confirming others
 Multiple supply- and demand-side measures have appreciably
enhanced prescribing efficiency for the PPIs, statins and ACEIs/
ARBs in Scotland, providing direction to other countries for
areas for disinvestment with growing economic pressures
 However, there has been no increased utilisation of risperidone
since the availability of oral risperidone at appreciably lower
prices than patent protected atypical anti-psychotics
 This reflects a more complex disease area with no opportunities
for switching. In addition, again emphasising specific measures
are needed to enhance prescribing efficiency with limited
‘hawthorne’ effect
 Specific measures now include prescribing targets for oral
versus patented dispersible risperidone
14 Bilbao 2012

15. Opportunities with data from health authority
sources, e.g. NHS Scotland, to inform decisions
 Linking changes in prescribing patterns with health policy and
other initiatives, including quality initiatives, from those
implementing and analysing the changes, enhances the
robustness of the data and discussion on future measures
NHS Scotland (over 90% of the population with unique identifiers)
 Estimates of incidence and prevalence (drug specific to a given
condition) and linkage with other registers
 Prescribing history broken down by age, sex and deprivation
 Extent of co-prescribing, e.g. statins in patients over 40 with
diabetes
 Actual sequencing of drug use, e.g. Extent of therapeutic
switching
 Extent of persistence rate/ switch rate in practice
 Link with other datasets such as Hospital admissions, A & E, and
out-patients (event linking for pharmacovigilance studies)
 Actual usage of drugs in children for potential paediatric licences
15 Bilbao 2012

16. Thank You
Any Questions!
iain.bishop@nhs.net; NSS.ISD-SPECIFY@nhs.net;
Brian.Godman@ ki.se; godman@marionegri.it;
mail@briangodman.co.uk
16 Bilbao 2012