New ways of working releasing general practitioner capacity with pharmacy prescribing support: a cost-consequence analysis.

BACKGROUND: General practice in the United Kingdom is experiencing a workforce crisis. Greater multidisciplinary working, including more general practice pharmacists, is seen as part of the solution. However, it is unknown what impact and cost-consequences that pharmacists may have in freeing general practitioner (GP) capacity. OBJECTIVE: To evaluate the cost-consequences of additional pharmacists in releasing GP capacity. METHODS: This cost-consequences evaluation of a prospective observational cohort study in 15 urban practices involving 69 GPs in 1 locality serving a population of 82,000 people. GPs recorded the time they spent addressing key targeted prescribing activities during 5 distinct 2-week audit periods. Pharmacists performed these key prescribing activities to release GP capacity. An additional 225 h of pharmacists' time per week was committed to the locality. Standardized staff costings were used to estimate the financial impact. Prescribing indicator performance was assessed against the other 7 localities within the health board. RESULTS: When compared with employing extra nonsalaried GPs this required an estimated additional investment of £16.73 (range £5.97-20.87) per h to free GP capacity. This achieved a sustainable 47% (73 h per week, F(4,56) = 16.05, P < 0.001) reduction in GP time spent on key prescribing activities; equating to 4.9 h (95% confidence interval 3.1-6.7) per practice per week. No significant step changes in locality safety and quality prescribing measures, and no negative effects on locality-level prescribing cost-efficiency work were observed. CONCLUSION: Appropriately resourced general practice pharmacy teams delivered prescribing cost-efficiencies as well as sustainably freeing GP capacity by performing key prescribing activities.

General practice in the United Kingdom is experiencing a workforce crisis, and is struggling to deliver services. Pharmacists have been shown to be effective in freeing general practitioner (GP) capacity. However, it is unknown how much it costs to do this. Therefore, we aimed to assess the cost-consequences of releasing GP capacity. All practices in 1 region took part. GPs recorded the time it routinely took them to address key prescribing activities, Spring 2016. Pharmacists then delivered the key prescribing activities. The region got an extra 225 h of pharmacists' time to do these activities. Then in Spring 2018, the GPs and pharmacists recorded the time took to do the key prescribing activities. Standard salary costs were used to estimate how much money was needed to free GP capacity with pharmacists. The impact on routine cost-effective work was also assessed. Pharmacists delivering key prescribing activities freed 73 h per week of GP time. This equalled an average of 5 h per week per practice. Freeing GP capacity was estimated to cost an extra £16.73 (range £5.97­20.87) per h. There were no negative effects on cost-efficiency work. Appropriately resourcing general practice with pharmacists delivers sustainable prescribing cost-efficiencies and frees GP capacity.

Utilisation Trend of Long-Acting Insulin Analogues including Biosimilars across Europe: Findings and Implications.

BACKGROUND: Diabetes mellitus rates and associated costs continue to rise across Europe enhancing health authority focus on its management. The risk of complications is enhanced by poor glycaemic control, with long-acting insulin analogues developed to reduce hypoglycaemia and improve patient convenience. There are concerns though with their considerably higher costs, but moderated by reductions in complications and associated costs. Biosimilars can help further reduce costs. However, to date, price reductions for biosimilar insulin glargine appear limited. In addition, the originator company has switched promotional efforts to more concentrated patented formulations to reduce the impact of biosimilars. There are also concerns with different devices between the manufacturers. As a result, there is a need to assess current utilisation rates for insulins, especially long-acting insulin analogues and biosimilars, and the rationale for patterns seen, among multiple European countries to provide future direction. Methodology. Health authority databases are examined to assess utilisation and expenditure patterns for insulins, including biosimilar insulin glargine. Explanations for patterns seen were provided by senior-level personnel. RESULTS: Typically increasing use of long-acting insulin analogues across Europe including both Western and Central and Eastern European countries reflects perceived patient benefits despite higher prices. However, activities by the originator company to switch patients to more concentrated insulin glargine coupled with lowering prices towards biosimilars have limited biosimilar uptake, with biosimilars not currently launched in a minority of European countries. A number of activities were identified to address this. Enhancing the attractiveness of the biosimilar insulin market is essential to encourage other biosimilar manufacturers to enter the market as more long-acting insulin analogues lose their patents to benefit all key stakeholder groups. CONCLUSIONS: There are concerns with the availability and use of insulin glargine biosimilars among European countries despite lower costs. This can be addressed.

Prescribing trends of inhaler treatments for asthma and chronic obstructive pulmonary disease within a resource-constrained environment in the Scottish national health service: findings and implications.

Background: There is an increasing prevalence of asthma and chronic obstructive pulmonary disease (COPD) worldwide, leading to increased inhaler use. However, there are concerns with inhaler compliance resulting in different patented inhalers and longer-acting formulations. As a result, inhalers are now among the highest expenditure items in ambulatory care in Scotland leading to multiple initiatives to keep within budget without compromising care. Method: This study assesses inhaler utilization and expenditure between 2001 and 2017 alongside health authority initiatives. Results: There was an increase by 137% in inhaler utilization between 2001 and 2017, and a two-fold increase in expenditure, driven by the increasing use of patented combination inhalers to address concerns. This is very different to the oral markets where expenditure on proton pump inhibitors, statins, and antihypertensives have fallen considerably recently despite increased volumes due to the increasing use of low-cost generics. However, inhaler expenditure has started to fall with an increasing use of lower cost combinations and initiatives to reduce the steroid burden alongside monitoring patient care. Conclusion: Challenges with using and changing inhalers has meant this market has not followed other high-volume drug classes following patent loss. This is starting to change, with the situation monitored to enhance efficient prescribing alongside continued good quality care.

Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence.

Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.

Ongoing activities to optimize the quality and efficiency of lipid-lowering agents in the Scottish national health service: influence and implications.

BACKGROUND: Prescribing of lipid-lowering agents (LLAs) has increased worldwide including in Scotland with increasing prevalence of coronary heart disease, and higher dose statins have been advocated in recent years. There have also been initiatives to encourage prescribing of generic versus patented statins to save costs without compromising care. There is a need to document these initiatives and outcomes to provide future direction. METHOD: Assessment of utilization (items dispensed) and expenditure of key LLAs (mainly statins) between 2001 and 2015 in Scotland alongside initiatives. RESULTS: Multiple interventions over the years have increased international nonproprietary name prescribing (99% for statins) and preferential prescribing of generic versus patented statins, and reduced inappropriate prescribing of ezetimibe. This resulted in a 50% reduction in expenditure of LLAs between 2001 and 2015 despite a 412% increase in utilization, increased prescribing of higher dose statins (71% in 2015) especially atorvastatin following generic availability, and reduced prescribing of ezetimibe (reduced by 72% between 2010 and 2015). As a result, the quality of prescribing has improved. CONCLUSION: Generic availability coupled with multiple measures has resulted in appreciable shifts in statin prescribing behavior and reduced ezetimibe prescribing, resulting in improvements in both the quality and efficiency of prescribing.

Quality indicators as a tool in improving the introduction of new medicines.

Quality indicators are increasingly used as a tool to achieve safe and quality clinical care, cost-effective therapy, for professional learning, remuneration, accreditation and financial incentives. A substantial number focus on drug therapy but few address the introduction of new medicines even though this is a burning issue. The objective was to describe the issues and challenges in designing and implementing a transparent indicator framework and evaluation protocol for the introduction of new medicines and to provide guidance on how to apply quality indicators in the managed entry of new medicines. Quality indicators need to be developed early to assess whether new medicines are introduced appropriately. A number of key factors need to be addressed when developing, applying and evaluating indicators including dimensions of quality, suggested testing protocols, potential data sources, key implementation factors such as intended and unintended consequences, budget impact and cost-effectiveness, assuring the involvement of the medical professions, patients and the public, and reliable and easy-to-use computerized tools for data collection and management. Transparent approaches include the need for any quality indicators developed to handle conflict of interests to enhance their validity and acceptance. The suggested framework and indicator testing protocol may be useful in assessing the applicability of indicators for new medicines and may be adapted to healthcare settings worldwide. The suggestions build on existing literature to create a field testing methodology that can be used to produce country-specific quality indicators for new medicines as well as a cross international approach to facilitate access to new medicines.

Do quality incentives change prescribing patterns in primary care? An observational study in Scotland.

BACKGROUND: The 2004 General Medical Services (GMS) contract introduced financial incentives for the management of chronic illnesses in 10 clinical areas. The effect of the scheme on prescribing is unknown. OBJECTIVES: To quantify the impact of the latest GMS contract, which incorporates additional payments for quality outcomes, on prescribing patterns in GP practices. METHODS: This retrospective observational study of prescribing compared the defined daily doses (DDDs) for drugs mentioned or implied within the Quality and Outcomes Framework (QOF) of the latest GMS contract (QOF drugs) to the DDDs for all other drugs listed within the first 10 chapters on the British National Formulary (non-QOF drugs) for four financial years; two before and two after the introduction of the latest GMS contract. These measures were calculated for 92 GP practices of 100 in the Lothian region of Scotland, and the rate of change of prescribing was calculated from regression slopes within the log-scale interrupted time series analyses. RESULTS: The prescribing of QOF drugs increased significantly faster than the non-QOF drugs both before and after the introduction of the latest GMS contract but the rate of increase for the QOF drugs slowed significantly after April 2005 unlike prescribing of non-QOF drugs. CONCLUSIONS: The prescribing of relevant drugs increased before the introduction of the 2004 GMS contract; the increase continued in the first 2 years of the new contract but at a significantly lower level.