Norman Evans

1
Norman Evans
Finding The Resources The Cost Challenge

• Chief Pharmacist
• Wandsworth PCT
• South West London

2
The panel were concerned about the increase in
prescribing costs

• Surrey LMC 1911

3
RCGP Good Clinical Care

• The Excellent Doctor
• Only prescribes treatment that makes an effective
  contribution to the patients overall management
• Takes resources into account when choosing
  between treatments of similar effectiveness
• The Unacceptable Doctor
• Consistently prescribes unnecessary or
  ineffective treatments
• Takes no account of resources when choosing
  between similar treatments
• Refuses to register patients who are costly

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Some variables in prescribing

• Population lt5yrs, gt65yrs
• Number of practice partners
• Marketing those who see reps, new drugs
• Repeat prescribing
• Waste/concordance N. Ireland 40, Aberdeen 43
  per patient per year
• Miscellaneous single parent, unemployment,
  single handed, non-trainer

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NICE Guidance

• Mild symptoms of dyspepsia step up or down. No
  long term PPI
• Confirmed ulcer eradicate H. pylori. No long
  term PPI
• Ulcer caused by other drugs PPI and lowest dose
  to control symptoms
• Mild GORD symptoms antacids, alginates. May not
  need PPIs
• Severe GORD full dose PPI until symptom control
  then regular maintenance
• Least expensive PPI
• Review patients on PPIs, assess dose, stop where
  appropriate
• If fully implemented will have real benefits for
  patients as there is no advantage in taking more
  of a drug than needed
• A reduction in usage of PPIs of at least 15 and
  savings of 40 to 50 million a year

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National GORD data
PPI Increase 8,281,855
IMS MAT 2003
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National GORD data
PPI Increase 850,963 Rx (7.9)
IMS MAT 2003
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PPI national maintenance versus treatment -
volume split
Source IMS mthly
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Long term PPI reasons for use

• An initial short course of a PPI is the treatment
  of choice in GORD with severe symptoms(1)

• Recorded reasons for long-term PPIs

Oesophagitis(2) 17 Reflux 40 Non-specific
dyspepsia 30 Peptic ulcer disease 3 Esophag
eal ulcer/stricture 2 Non-GI problems 1
Refs (1) BNF September 2003, (2) Hungin APS,
Rubin GP et al, 1999 Martin RM, Lim AG, 1998
Bashford JH, Norwood J, 1998
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Long term usage of PPIs

• PPIs on repeat
• In 1995, 77 of PPIs were attributable to
  repeat Rx(1)
• In 2003, 85 of PPIs were attributable to
  repeat Rx(2)
• Treatment dose 84
• Maintenance dose 90
• In 1999 45 of patients were discovered on
  long-term PPIs
• i.e. an average of 9 Rxs per year
• Do patients take their treatment regularly?
• In June 1999, 71 reported taking their PPIs
  regularly(3)
• However, average number of repeats is 9(3)
• Long term treatment for symptom relief is
  contentious(3)

Refs (1) Bashford JN, Norwood J, et al. BMJ
1998 (2) MDI MAT data June 2003 (3) Hungin
APS, Rubin GP et al. Br J Gen Pract, 1999
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Implementing a protocol for managing dyspepsia

• Aim To review PPI use and the feasibility of
  cost reduction by
• Stepping down appropriate patients from treatment
  to maintenance dose PPI
• Stepping off appropriate patients from
  maintenance PPIs to alginate

Prescriber, Feb. 2003
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Process

• Establish disease register
• Database search
• Identify patients from inclusion criteria
• Letter to all patients explaining changes to
  medication and offering nurse led dyspepsia
  clinic
• Step off maintenance PPI to alginate
• Step down PPI treatment to maintenance dose

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Protocol

• Inclusion criteria
• Mild reflux
• Mild oesophagitis (grade I or II)
• Hiatus hernia
• Healing post ulcer gt6 months

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Protocol

• Exclusion criteria
• Healing dose of PPI within 6 months
• Review at gastro clinic or awaiting referral
• Awaiting endoscopy or review
• Patients taking NSAIDs or high dose steroids
• Patients gt90 years
• Patients with Barretts
• Immunosuppressed patients
• Terminal illness

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Nurse led clinic

• 15 minutes per appointment
• Complete patient template
• Explain GORD
• Role of PPIs
• NICE guidance
• Explain acid rebound
• Lifestyle advice

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Step down/step off protocol

• Confirmed diagnosis of RO
• PPI healing dose for 6 to 8 weeks
• PPI maintenance dose for 6 to 8 weeks
• Alginate e.g. Gaviscon Advance 5-10mL for 8 weeks
  qds pc and nocte

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Results

• Step off
• Up to 58 patients remained on Gaviscon Advance
  after 10 months
• Step down
• 90 patients remained on maintenance dose PPI
  from high dose after 7 months
• Cost savings projected 9,467 pa (10,000
  patient practice, step off only)

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Dyspepsia Treatment Cost Model

• Savings from Step Down and Step Off
• Step Down savings up to 39 million
• Step Off savings up to 29 million
• Total potential savings 68 million

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20 leading cost drugs 2002/03EBM vs VFM?

• Drug m total
  Increase
• Simvastatin 3.2 4.6
  37
• Atorvastatin 1.9 2.8
  34
• Amlodipine 1.9 2.8
  9
• Lansoprazole 1.8 2.6
  25
• Olanzapine 1.4 2.0
  17
• Omeprazole 1.3 1.9
  -8
• Nutrition 1.1 1.6
  21
• Beclometasone 1.0 1.5
  7
• Ramipril 0.9 1.3
  68
• Pravastatin 0.9 1.2
  15
• Lisinopril 0.85 1.2
  2

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Leading cost drugs continued

• Drug m
  Increase
• Salmeterol 0.8 12
• Dressings 0.7 15
• Paroxetine 0.7 -12
• Doxazosin 0.7 4
• Losartan 0.7 35
• Venlalaxine 0.7 45
• Seretide 0.7
  59
• Salbutamol 0.6 8
• Fluticasone 0.6 17