Over-the-Counter Medicine Utilization by Beneficiaries Under Medical Schemes in South Africa.

BACKGROUND: South African medical insurance schemes (known as medical schemes) cover about 17% of the population. Within these schemes, access to medicines for a defined set of chronic diseases is mandated by legislation. However, much of the responsibility for treatment of minor conditions with non-prescription over-the-counter (OTC) medicines has been transferred to the individuals within the medical schemes. The overall expenditure on pharmacist-assisted therapy (PAT)/OTC medicines in South Africa is considerable and medical schemes endeavor to limit amounts paid out by devising strategies that will limit their financial exposure. AIM: To investigate how benefit design and other factors within two medical schemes influenced access to and payment for OTC medicines and to explore whether access to OTC medicines by individuals impacted on utilization of other health-care services. METHODS: Medical scheme data were obtained from a leading administrator for two health plans: one with comprehensive benefits covering 4593 beneficiaries (designated HI) and the other with lower benefits covering 54,374 beneficiaries (LO). Extracted data included beneficiary demographics, OTC medicines prescribed by doctors and/or dispensed by pharmacists, and monetary amounts claimed by individuals and paid by the medical schemes. Doctor consultations, costs and payments were also extracted, as were beneficiaries' records of their chronic disease(s) and any episode(s) requiring hospitalization. RESULTS: Some 60-70% of beneficiaries submitted claims for OTC medicines accessed directly or recommended by a pharmacist, and 80-90% claimed OTC medicines that were prescribed by a doctor during a consultation. Amounts claimed and percentages of original products prescribed were substantially higher when accessed directly by beneficiaries or recommended by pharmacists than when doctors prescribed the medicines. In multivariate analysis, there was no clear advantage of offering access to OTC medicines in order to reduce visits to general practitioners, although in the LO plan it appeared that beneficiaries with chronic diseases made less use of the OTC benefit and more use of medical specialists. CONCLUSION: Within these two plans, there were higher costs and greater use of original products when beneficiaries or pharmacies accessed OTC medicines than when these medicines were prescribed by doctors. A key question is whether access to these medicines and the costs thereof would be managed better if paid for directly by individuals and not as insured benefits through the medical scheme.

Cost of ADHD treatment using methylphenidate and atomoxetine in the South African private healthcare sector.

Introduction: The prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD) has risen over the last two decades, with a corresponding increase in the cost of its medication. Drug utilization studies in South Africa focusing on ADHD are limited.Areas covered: The primary aim was to determine the cost of methylphenidate and atomoxetine (used for ADHD). The Intercontinental Marketing Service (IMS) database which contains data of the private healthcare sector was interrogated from 2013 to 2016 (48-month period) focussing on methylphenidate and atomoxetine. Drug consumption was expressed in number of DDDs, DDDs/1000 inhabitants/day and cost in Rands.Expert opinion: Methylphenidate-containing products constituted a considerably higher percentage of the market share when compared to atomoxetine (90.30% versus 9.70%). The DDD/1000 inhabitants/day for methylphenidate was 6.010 with an annual cost for R266 691 778 in 2013, which increased to 7.827 DDDs/1000 inhabitants/day with an annual cost of R436 041 506 in 2016. Consumption of both methylphenidate and atomoxetine increased from 2013 to 2016. There was a preference for long-acting extended-release methylphenidate tablets even though the unit costs were higher when compared to the short-acting formulations. Despite increases in unit costs, the spend in South Africa showed an upward trend for methylphenidate and atomoxetine.

Review of adult attention-deficit/hyperactivity disorder in South Africa.

INTRODUCTION: Recently, there has been a greater focus on adults with Attention-Deficit/Hyperactivity Disorder (ADHD) given that the symptoms persist in two-thirds of patients into adulthood. Areas covered: A systematic review of articles reporting on adult ADHD in SA was undertaken. From the database search, 1209 articles were identified, with 29 articles included in this analysis. Expert commentary: Fourteen of the 29 studies reviewed were exploratory, 10 were reviews/commentaries, four were developmental studies and one was a phenomenological study. More than half (58.62%) of the articles were published in local South African journals, 13.79% were published in African journals (excluding South Africa), and 27.59% of the articles were published in international journals. The impact factor for nine of the journals were not stated and the remaining 11 have impact factors ranging from 0.207 to 6.78. In 2004, only one article on adult ADHD was published in SA and by 2015, the number of publications increased to six. Adult ADHD is gaining interest in South Africa, however, there have been a limited number of studies conducted thus far. It is recommended that further studies are conducted in this new and developing field.

Identification of potential drug-drug interactions between antiretroviral drugs from prescriptions in the private health-care sector in South Africa.

The aim of this study was to identify potential drug-drug interactions (DDIs) between antiretroviral drugs (ARVs) and to determine whether prescribed daily doses (PDDs) from prescriptions can be used in the evaluation of these interactions. A quantitative, retrospective drug utilization study was performed on 49,995 and 81,096 ARV prescriptions from a South African pharmacy benefit management company, which were prescribed to 7664 and 10,162 HIV patients for 2005 and 2006, respectively. Potential DDIs identified across different age groups were 778 for 2005 and 1155 for 2006; the majority occurred in patients aged 19 to ≤45 years. The potential DDIs identified between ARVs were all interacting at clinical significance level 2 according to guidelines indicated by Tatro. These results demonstrate that potential DDIs were identified between ARVs mostly in three ARV combinations: Kaletra(®) (lopinavir/ritonavir) and efavirenz, lopinavir/ritonavir and nevirapine and combinations of indinavir and ritonavir. There is a need for more education on the prescribing protocols for ARVs in the treatment of HIV-infected patients in the private health-care sector in South Africa.

Prescribing for migraine with the focus on selective 5HT1-receptor agonists: a pharmacy database analysis.

OBJECTIVE: The primary aim was to determine the prescribing patterns and cost of drugs for migraine focusing on selective 5HT1-receptor agonists (triptans) in a primary care patient population. METHODS: A retrospective drug utilization consumption study was conducted. Data were obtained from a South African national private pharmacy group. The database consisted of all central nervous system prescriptions dispensed by the pharmacy group for 2008. RESULTS: A total of 22,102 patients (71.05% females) received 43,144 items for migraine a cost of R3,622,552 (average cost of R83.96 per item). The average age of patients was 44.90 (SD = 13.83) years, with 70.76% of patients between 30 and 59 years of age. A two-sample t-test assuming equal variances was conducted to compare prescribing to females and males. There was a significant difference. There were proportionally more females in the younger age groups and proportionately more males over 60 years. Patients were prescribed an average of 1.95 items for migraine over the year. The Lorenz curve was used to illustrate skewness in prescribing. Clonidine was the most frequently prescribed active ingredient (46.15%), followed by the combination of cyclizine, ergotamine and caffeine (29.62%). The agents for the prophylaxis of migraine (clonidine, flunarizine and pizotifen) accounted for 50.48% of prescribing frequency, but only 29.04% of cost. The triptans accounted for 18.94% of prescribing frequency and 53.54% of cost. Rizatriptan was the most frequently prescribed triptan. CONCLUSIONS: The findings were generally in agreement with other studies, but a lower prescribing rate for triptans was observed.

Prevalence of possible drug-drug interactions between antiretroviral agents in different age groups in a section of the private health care sector setting in South Africa.

BACKGROUND: The chronic nature of human immunodeficiency virus (HIV) infection requires lifelong highly active antiretroviral (ARV) therapy (HAART) to continuously suppress HIV-1 viral replication, thus reducing morbidity and mortality. HAART is restricted by complex dosing, drug-drug interactions (DDIs) and toxicities. OBJECTIVE: To determine the prevalence of possible DDIs between ARV drugs in different age groups in a section of the private primary health care sector in South Africa. METHODS: A quantitative, retrospective drug utilization review was performed on 47 085 ARV prescriptions claimed through a national medicine claims database during 2006. Possible DDIs identified were classified according to a clinical significance rating as described by Tatro [Drug Interaction Facts 2005. St Louis, MO: Facts and Comparisons (2005)]. RESULTS: The total number of patients who received prescriptions that were claimed through the medicine claims database was 275 424, of whom 25.11% were males, 28.28% were females and the gender of 46.61% patients was unknown. Of the total number of patients, 3.27% were HIV patients of which an average of 5.23 +/- 3.86 ARV prescriptions (n = 47 085) per patient were claimed for representing 4.73% of the total number of prescriptions claimed during the study period (N = 993 804). HIV patients received an average of 2.36 +/- 0.61 ARVs per prescription. Only 4.95% of the prescriptions had one ARV medicine item, 56.04% two, 37.10% three, 1.75% four and <1% had more than four. Of 960 DDIs identified, 1.88% were for patients < or =6 years, 4.27% for patients >6 years and < or =12 years, 0.63% for patients >12 and < or =19 years, 32.40% for patients <19 years and < or =40 years, 60.21% for patients <40 years and < or =60 years and 0.63% for patients >60 years with patients <40 years and < or =60 years having the highest number of DDIs and patients older than 60 years the lowest. The majority of DDIs between the ARVs presented in significance levels 2 and 4. The most important interactions were between: indinavir (IDV) and ritonavir (n = 199); efavirenz (EFV) and lopinavir/ritonavir (n = 65) and EFV and IDV (n = 60) all interacting at level 2. CONCLUSION: The importance of using drug utilization study as an identification tool to provide insight into the prescribing and utilization patterns of ARV drugs, to provide optimal therapy for patients infected with HIV is emphasized.

Prevalence of drug-drug interactions of antiretroviral agents in the private health care sector in South Africa.

OBJECTIVES: Human immunodeficiency virus (HIV) infection can be effectively treated with highly active antiretroviral therapy (HAART), requiring concomitant administration of three to four different agents, often with a high potential for drug-drug interactions (DDIs). This study aimed to determine the prevalence of possible DDIs between antiretrovirals (ARVs) themselves and other drugs. DESIGN: Retrospective drug utilisation study using data from a national medicine claims database for the period 1 January to 31 December 2004. SETTING: A section of the private health care sector in South Africa. SUBJECTS: All ARV prescriptions (N=43 482) claimed during 2004. The possible DDIs found were classified according to a clinical significance rating described by Tatro (2005) in his book Drug Interaction Facts. RESULTS: A total of 5 305 882 medicine items were prescribed; of these, 1.92% (N=101 938) were ARVs. Of the total number of 2 595 254 prescriptions, 1.68% (N=43 482) contained ARVs. A total number of 18 035 DDIs (81 different types) were identified; of these, 83.89% (N=15 130) were DDIs between ARVs and other drugs, while 16.11% (N=2 905) were DDIs between ARVs themselves. Possible DDIs with a clinical significance level of 1 (major, N=17) and 2 (moderate, N=1 436) represented 8.06% (N=1 453) of the total number of identified interactions. CONCLUSIONS: Since concomitant use of ARVs and other drugs used to treat HIV complications is increasing, there is a need to understand and anticipate these DDIs and to overcome them by dose adjustments and patient education, so that they are not life threatening to HIV/AIDS patients.

Methylphenidate: prescribing patterns in a South African primary care patient population.

BACKGROUND AND OBJECTIVE: Sales figures have indicated that there has been a steady increase in the use of methylphenidate in South Africa. The primary aim of the study was to investigate the prescribing of methylphenidate (indicated for Attention Deficit Hyperactivity Disorder in children, and narcolepsy) in a South African primary care patient population. METHODS: A retrospective, exposure cohort drug utilization study was conducted in the South African private health care sector. Data were obtained from a medical aid administrator and were analysed for all patients who received one or more prescriptions for methylphenidate (N06B A04) during 2002. RESULTS AND DISCUSSION: A total of 106 patients received one or more prescriptions for methylphenidate during the year. Ninety of the 106 patients (84.9%) were under 25 years of age (average age 10.51 years, SD=3.92 years). These 90 patients were all single and the majority of them (75.6%) were males. The Lorenz curve was used to illustrate skewness in the prescribing of methylphenidate to the patient population. Patients under the age of 25 years received on average 3.46 prescriptions for methylphenidate during the year. The most common chronic diagnosis category was 'Hyperkinetic Syndrome of Childhood'. Most of the prescriptions were obtained from pharmacies, followed by dispensing doctors and rehabilitation services. CONCLUSION: The results were in agreement with a previous South African study conducted in 1996. Further studies are recommended, especially into the quality of life of patients before and after receiving methylphenidate.

Ethical issues related to retrospective drug utilization studies in South Africa.

PURPOSE: The purpose of the manuscript is to discuss the ethical issues related to pharamacoepidemiological research in South Africa, with specific emphasis on three recently performed retrospective drug utilization studies. METHODS: Ethical considerations relating to three retrospective drug utilization studies on hyperlipidaemia, diabetes and tricyclic antidepressants are discussed. RESULTS: Computerized medication records were obtained from three different organizations after formal proposals had been submitted. The information contained in the data sets varied, and in some instances, a fair amount of manual coding had to be performed to make the data useable for research purposes. The research was not sponsored by the private pharmaceutical sector and this minimized the potential for any bias in the studies. Data privacy and confidentiality were maintained at all times. No patient could be traced, and it was also not possible to determine which medical practitioners were involved in the prescribing of the drugs. CONCLUSIONS: Retrospective drug utilization studies are a relatively easy, inexpensive and uncomplicated method to comment on the prescribing of drugs in large patient populations provided that ethical principles related to confidentiality and data privacy are adhered to.

A survey of the treatment of female patients with osteoporosis using drug utilization consumption parameters.

OBJECTIVE: To investigate the drug treatment of female patients who were diagnosed with osteoporosis in South Africa using drug utilization consumption parameters. METHOD: Prescription data over a 2-year period for 1655 female patients with osteoporosis were analysed retrospectively. RESULTS: A total of 157,245 products at a cost of R15,004,643.51 was prescribed. Two-thirds of the patients fell in the age group between 50 and 69 years. A quarter (25.33%) of the products prescribed were identified as products specifically for the treatment and/or prevention of osteoporosis. Calcium supplements were the most frequently prescribed therapeutic subgroup, followed by hormone replacement therapy. The most frequently prescribed product was an effervescent calcium supplement containing 500 mg elemental calcium. Alendronate 10 mg tablets accounted for the highest cost (23.57% of the total cost of products for osteoporosis), but accounted for only 7.36% of the number of products prescribed for osteoporosis. Prescribing differences were observed for patients younger than 50 years, and patients 50 years and older. The DU90% and DC90% segments consisted of 27 and 24 different trade name products, respectively. CONCLUSION: Further studies focusing on the cost of osteoporosis treatment and prevention should be conducted incorporating clinical information.

An investigation into antidiabetic medication prescribing in South Africa.

BACKGROUND: The number of people with diabetes in Africa is expected to triple in the next 15 years, which will have a significant impact on the prescribing and use of antidiabetic medication. OBJECTIVE: The primary aim of this study was to investigate the prescribing patterns of antidiabetic medication that are used on a chronic basis in South Africa. METHOD: Prescribing data of 1100 diabetic patients were retrospectively analysed over a 1-year period. RESULTS: The average age of patients was 53.2 years (SD = 16.4 years), with more male than female patients. The oral antidiabetic drugs accounted for 67.4% of all the antidiabetic products prescribed, with the sulphonylureas the most frequently prescribed antidiabetic therapeutic subgroup. Glicazide was the single most frequently prescribed oral antidiabetic drug, accounting for 38.2% of all oral agents. Biphasic insulin was the most frequently prescribed class of insulin. Fifty-seven patients were using insulin as well as one or more oral antidiabetic drugs. Cardiovascular system drugs, nervous system drugs and drugs acting on the alimentary tract and metabolism together accounted for more than half of the drugs that were prescribed concurrently with antidiabetic medication. CONCLUSION: Further research on the prescribing of antidiabetic medication should be conducted focusing on the qualitative aspects of treatment and treatment costs as well as studies on antidiabetic treatment in the public health sector.

An investigation into compound analgesic prescribing in South Africa, with special emphasis on meprobamate-containing analgesics.

The primary aim of the study was to analyse the prescribing patterns of compound or combination analgesics in four metropolitan areas in South Africa. Prescription data from 50 medical practices in each area were obtained from a medical aid scheme, and were retrospectively analysed for 1995. One-third (33.1%) of all prescriptions for central nervous system (CNS) drugs was for compound analgesics. Compound analgesics represented 81.2% of the total number, and 72.1% of the total cost, of all non-opioid analgesic prescriptions. Children younger than 10 years received 30.2% of all compound analgesics. The most frequently prescribed combination product was an analgesic capsule consisting of paracetamol, codeine phosphate, caffeine and meprobamate. Nearly half of all the meprobamate-containing analgesics prescribed, contained exactly the same dosages of active ingredients. Meprobamate-containing analgesics represented 29.6% of the total number of analgesic prescriptions. Most patients using meprobamate-containing analgesics (48.4%) were females between the ages of 30 and 59 years. Further studies on compound analgesic prescribing should be undertaken, especially in relation to the diagnoses for which they are prescribed, as well as to other medication taken concurrently with analgesic products.