Prescription Patterns and the Cost of Migraine Treatments in German General and Neurological Practices.

OBJECTIVES: The aim of this study was to analyze prescription patterns and the cost of migraine treatments in general practices (GPs) and neurological practices (NPs) in Germany. METHODS: This study included 43,149 patients treated in GPs and 13,674 patients treated in NPs who were diagnosed with migraine in 2015. Ten different families of migraine therapy were included in the analysis: triptans, analgesics, anti-emetics, beta-blockers, antivertigo products, gastroprokinetics, anti-epileptics, calcium channel blockers, tricyclic antidepressants, and other medications (all other classes used in the treatment of migraine including homeopathic medications). The share of migraine therapies and their costs were estimated for GPs and NPs. RESULTS: The mean age was 44.4 years in GPs and 44.1 years in NPs. Triptans and analgesics were the 2 most commonly prescribed families of drugs in all patients and in the 9 specific subgroups. Interestingly, triptans were more commonly prescribed in NPs than in GPs (30.9% to 55.0% vs. 30.0% to 44.7%), whereas analgesics were less frequently given in NPs than in GPs (11.5% to 17.2% vs. 35.3% to 42.4%). Finally, the share of patients who received no therapy was higher in NPs than in GPs (33.9% to 58.4% vs. 27.5% to 37.9%). The annual cost per patient was €66.04 in GPs and €94.71 in NPs. Finally, the annual cost per patient increased with age and was higher in women and in individuals with private health insurance coverage than in men and individuals with public health insurance coverage. CONCLUSION: Triptans and analgesics were the 2 most commonly prescribed drugs for the treatment of migraine. Furthermore, approximately 30% to 40% of patients did not receive any therapy. Finally, the annual cost per patient was higher in NPs than in GPs.

Prescriptions of homeopathic remedies at the expense of the German statutory health insurance from 1985 to 2021: scientific, legal and pharmacoeconomic analysis.

The prescription of homeopathic remedies at the expense of the statutory health insurance (SHI) system in Germany has been criticized for years due to a lack of evidence. Now, on the planned abolition of the reimbursement of homeopathic medicines in Germany, the debate on this topic has been reignited. The aim of this paper is to show the costs and their development over time incurred by homeopathic remedies in the healthcare system from 1985 to 2021. For this purpose, 15 selected homeopathic medicines were chosen from the drug prescription report (Arzneiverordnungsreport) and analyzed with regard to their development of DDD (Defined Daily Dose) using data from the Wissenschaftliches Institut der Ortskrankenkassen (WidO, Scientific Institute of the General Local Health Insurance Funds) and compared with their respective rational pharmacological alternatives. The price comparison was based on the DDD costs and the pharmacy retail price of the smallest packaging in each case. The clinical study situation for the preparations was also analyzed. For this purpose, the clinical studies provided by the manufacturer and those on PubMed were divided into evidence levels and analyzed. In addition, the presentation of homeopathic remedies on company websites, in online pharmacies, in specialist information and package leaflets was analyzed with regard to side effects, interactions, indication, and information on the alleged effect/proof of efficacy. In many media, information on homeopathic medicines remained incomplete, and non-compliance with the Therapeutic Product Advertising Act (Heilmittelwerbegesetz) was noted. Naming of the products if often very suggestive, too. Manufacturers' claims of efficacy go far beyond what can be considered proven in terms of evidence-based medicine and the quality of most clinical studies is poor. Homeopathic remedies are on average significantly more expensive than their rational pharmacological alternatives. Furthermore, DDD costs have continued to rise over the years analyzed. In aggregate, from a pharmacoeconomic, legal, and scientific perspective, abolition of reimbursement of homeopathic medicines in Germany at the expense of the SHI system is well justified.

Economic evaluation of Sinfrontal in the treatment of acute maxillary sinusitis in adults.

Sinfrontal, a complex homeopathic medication, is popular in Germany for the treatment of ear, nose and throat and respiratory tract infections. Unlike many other homeopathic or herbal medications, the efficacy and safety of Sinfrontal has been demonstrated in a number of clinical studies of patients with sinusitis. To assess the cost effectiveness of Sinfrontal versus placebo in the treatment of adults with acute maxillary sinusitis (AMS) in Germany. A secondary objective was to assess the cost effectiveness of Sinfrontal versus standard treatment with antibacterials. Sinfrontal was compared with placebo in a cost-utility analysis based on data from a randomized controlled clinical trial over 3 weeks (Sinfrontal group: n = 57; placebo group: n = 56). Trial data were analysed from a societal perspective; resource use was valued with German unit costs for 2005. In a secondary analysis, the longer-term cost utility of Sinfrontal versus placebo was estimated over a total of 11 weeks based on an 8-week post-treatment observational phase. In addition, the cost effectiveness of Sinfrontal versus antibacterials was determined based on an indirect comparison of placebo-controlled trials. Sinfrontal led to incremental savings of euro 275 (95% CI 433, 103) per patient compared with placebo over 22 days, essentially due to the markedly reduced absenteeism from work (7.83 vs 12.9 workdays). Incremental utility amounted to 0.0087 QALYs (95% CI 0.0052, 0.0123), or 3.2 quality-adjusted life-days (QALDs). Bootstrapping showed that these findings were significant, with Sinfrontal being dominant in 99.9% of simulations. The results were robust to a number of sensitivity analyses. In the secondary analysis, Sinfrontal led to incremental cost savings of euro 511 and utility gains of 0.015 QALYs or 5.4 QALDs compared with placebo. Compared with antibacterials, Sinfrontal had a significantly higher cure rate (11% vs 59%; p < 0.001) at similar or lower costs. The results of this economic evaluation indicate that Sinfrontal may be a cost-effective treatment for AMS in adults.

Is use of homeopathy associated with poor prescribing in English primary care? A cross-sectional study.

Objectives Prescribing of homeopathy still occurs in a small minority of English general practices. We hypothesised that practices that prescribe any homeopathic preparations might differ in their prescribing of other drugs. Design Cross-sectional analysis. Setting English primary care. Participants English general practices. Main outcome measures We identified practices that made any homeopathy prescriptions over six months of data. We measured associations with four prescribing and two practice quality indicators using multivariable logistic regression. Results Only 8.5% of practices (644) prescribed homeopathy between December 2016 and May 2017. Practices in the worst-scoring quartile for a composite measure of prescribing quality (>51.4 mean percentile) were 2.1 times more likely to prescribe homeopathy than those in the best category (<40.3) (95% confidence interval: 1.6-2.8). Aggregate savings from the subset of these measures where a cost saving could be calculated were also strongly associated (highest vs. lowest quartile multivariable odds ratio: 2.9, confidence interval: 2.1-4.1). Of practices spending the most on medicines identified as 'low value' by NHS England, 12.8% prescribed homeopathy, compared to 3.9% for lowest spenders (multivariable odds ratio: 2.6, confidence interval: 1.9-3.6). Of practices in the worst category for aggregated price-per-unit cost savings, 12.7% prescribed homeopathy, compared to 3.5% in the best category (multivariable odds ratio: 2.7, confidence interval: 1.9-3.9). Practice quality outcomes framework scores and patient recommendation rates were not associated with prescribing homeopathy (odds ratio range: 0.9-1.2). Conclusions Even infrequent homeopathy prescribing is strongly associated with poor performance on a range of prescribing quality measures, but not with overall patient recommendation or quality outcomes framework score. The association is unlikely to be a direct causal relationship, but may reflect underlying practice features, such as the extent of respect for evidence-based practice, or poorer stewardship of the prescribing budget.

Economic manifestations of opiate addiction: evidence from historical data from colonial Indonesia.

The aim of this paper is to demonstrate, using an example, the utility of historical data to illuminate important questions in the field of drug dependence research. The literature on the consumption of addictive substances often characterizes users as being one of two types: "addicts" and "casual users." An econometric characterization of the responses of opium consumers in the late-colonial Netherlands Indies to changes in the price of opium and other important variables is provided, which explicitly acknowledges the existence of different types of opium smokers, as modeled in the underlying theory. The results reveal systematic differences between the behavior of groups of high-intensity consumers and groups of low-intensity consumers. While the findings show that both groups showed similar total price elasticities, the high-intensity consumers were affected predominantly via changes in the number of users rather than in per capita consumption. In the course of the analysis, various analytic methods that are new to the field of drug dependence research are introduced.

A retrospective analysis of long-term use of nondepolarizing neuromuscular blocking agents in the intensive care unit, and guidelines for drug selection.

Nondepolarizing neuromuscular blocking agents (NNMBAs) are frequently administered to patients in the intensive care unit (ICU). We conducted a retrospective study of patients in intensive care who received infusions (> 48 hrs) of commonly used NNMBAs. The goals were to describe NNMBA use in our ICUs, determine patient characteristics, and assess the cost of the individual drugs. We found that atracurium was prescribed for 68% of study patients; 68% of the patients did not have renal, hepatic, or cardiovascular disease; dosages of NNMBAs varied; a statistically significant increase in dosage requirements over time occurred with atracurium; assessment of neuromuscular blockade was 100% subjective; and 41% and 17% of patients receiving atracurium and vecuronium, respectively, experienced prolonged neuromuscular weakness documented subjectively. As a result of this study, guidelines for agent selection were developed to facilitate cost effective use of NNMBA in our ICUs. Using these guidelines would potentially significantly decrease drug expenditures in this setting.

Is Cerazette the minipill of choice?

Around 5% of women aged 16-49 years in Great Britain use a progestogen-only pill (POP; 'minipill') as contraception. These pills are used as alternatives to combined oral contraceptives (COCs), compared to which they are less reliable at preventing pregnancy: the estimated contraceptive failure rate of POPs is 0.5 pregnancies per 100 woman-years when used consistently and correctly, compared with 0.1 per 100 woman-years for COCs. Cerazette (Organon), a new POP, is being promoted by the company as "the first oestrogen free pill to consistently inhibit ovulation", as having "the efficacy of a combined pill, with the reassurance of an oestrogen free pill" and offering "reliable contraception for women of any reproductive age". Here, we consider whether Cerazette offers advantages over established POPs.

The impact of price labeling of muscle relaxants on cost consciousness among anesthesiologists.

STUDY OBJECTIVE: To determine whether placing price labels on the vial caps of muscle relaxants increases cost consciousness among anesthesiologists. DESIGN: Retrospective study. SETTING: University hospital departments of anesthesia and pharmacy. MEASUREMENTS AND MAIN RESULTS: We placed price labels on the vial caps of all muscle relaxants for a study period of 1 year. At the beginning of the investigation, we informed the anesthesiologists of the study, discussed the prices for different muscle relaxants, and encouraged utilizing less expensive muscle relaxants whenever possible without compromising patient care. The price labels on the vial caps served as visual reminders of the various costs of muscle relaxants during daily practice. We compared the total amount spent on each muscle relaxant during the period from October 1993 to September 1994 with the period from October 1994 to September 1995. The total number of surgical cases from October 1993 to September 1994 and from October 1994 to September 1995 was unchanged and equaled 20,389 and 20,358 cases, respectively. Expenditures for pancuronium increased 104.1%. Total expenditure decreased by 12.5%, with a net savings of $47,111. CONCLUSION: Expenditures for the less costly pancuronium increased while expenditures for vecuronium and atracurium decreased. Price labeling of muscle relaxants in conjunction with education reduces total pharmacy expenditure on muscle relaxants.

Economic considerations in the use of neuromuscular blocking drugs.

The acceptance of new and increasingly expensive technologies is a major component of the rising costs of health care. While the practice of anesthesia has been relatively immune from the effects of cost containment, it is inevitable that practitioners will have to justify costly practices. Available pharmacoeconomic methods can be applied to the use of all anesthetic drugs, particularly neuromuscular blocking drugs. Cost-effectiveness analysis allows the practicing anesthesiologist to prioritize the use of neuromuscular blocking drugs to maximize their benefit while reducing unnecessary costs.

[In vitro fertilization in France: economic aspects and influence of the gonadotropin choice (urinary vs. recombinant) on cost]. / La fécondation in vitro en France. Approche économique et influence du choix des gonadotrophines (urinaires ou recombinantes) sur le coût.

OBJECTIVES: The objective of the study was to make an economic evaluation of in vitro fertilization and to determine the impact of some factors on its cost, particularly the choice between recombinant follicle stimulating hormone (r-FSH) and urinary FSH (u-FSH) for ovarian stimulation. PATIENTS AND METHODS: Costs were calculated in a Public Health view, by studying two phases: the stimulation cycle (including down-regulation) and the pregnancy (including the neonatal period). The calculation has included the side effects and the frozen embryos transfers. Economic data came from various sources: the French nomenclature on medical treatments (NGAP), the French drugs dictionary (Vidal) and the French Information system medical plan (PMSI). FSH costs were computed according to the currently marketed products, i.e., Fostimon (Laboratoires Genévrier, Sophia-Antipolis, France) for urinary FSH, and Gonal-F (Laboratoires Serono, Boulogne-Billancourt, France) and Puregon (Laboratoires Organon, Puteaux, France) for recombinant FSH. Two different ways of efficacy between u-FSH and r-FSH were considered for the calculations, those reported in Daya's meta-analysis (3.7% in favour of r-FSH for the clinical pregnancy rate per initiated cycle) and in the only double-blind study (Frydman et al., no difference). RESULTS: The annual cost of ART reaches approximately 130 million Euros in France, for the cycles only, and 170 million Euros when including the pregnancy costs. Urinary FSH is much cheaper than recombinant FSH. Whereas the number of administered FSH units was higher in u-FSH, this results in a mean lower cost of 500 Euros per cycle (2422 Euros for u-FSH and 2959 Euros for r-FSH). For one complete year, in France, the potential over cost of recombinant products reaches 24 million Euros when considering only the cycles (128.4 vs. 104.0 million Euros) and 24-31 million Euros when pregnancies and babies (neonatal period) are considered (171.4 vs 140.7 and 147.0 million Euros, respectively). The IVF per baby cost can be estimated at 16 463 Euros for r-FSH and at 14 116 Euros (in case of equivalence between the two drugs) to 15 805 Euros (in case of a difference of 3.7% pregnancy per oocyte recovery) for u-FSH. CONCLUSION: This gives Public Health lighting to the choices in the matter of ovulation stimulation. It shows the economic impact of the choice in the FSH type.

Under pressure: homeopathy UK and its detractors.

Though homeopathy has been in successful and continuous use for well over 200 years, in the United Kingdom it is under growing pressure, from scientific detractors and sections of the media. As such, homeopathy's free National Health Service provision is threatened because it is derided as 'unproven', 'unscientific', and even 'deadly'. While refuting these and other detractions, this paper considers possible reasons for the current plight of homeopathy UK. Thus, the current attacks against homeopathy should be viewed more in the context of the globalised pharmaceutical industry which is itself in crisis, and a succession of UK governments seemingly supine in the face of legislation originating from the European Union.

[Economic aspects of allergies: status and prospects for Austria]. / Volkswirtschaftliche Aspekte von Allergien. Ausgangslage und Ausblick für Osterreich.

According to epidemiological studies there has been an increase of allergic diseases and corresponding costs. Health economics analyses intend to offer decision guidance towards a more efficient and effective resource distribution, in the conflicting relationship of medicine and economics. In analogy with the "Global Initiative for Asthma (GINA)-study", one arrives at costs of Euro 227.7-455.4 million for the Austrian health system in 2004 for asthma. Direct costs of allergies in general are in part available from health insurance carriers. Between 1998 and 2005 the number of nasal preparations and antiobstructive therapies prescribed rose by 15% and 50% respectively, whilst the costs of these drugs dramatically increased by 96% and 70% respectively. Expenditure on anti-histamines rose by 31% between 2002 and 2004, whereas costs of topical and systemic anti-allergic drugs remained constant. Costs of allergies also include additional costs carried by the individuals affected, which must be added to those covered by the national health insurance carriers. Furthermore, patients with allergies more frequently turn to alternative and complimentary medicine to treat their condition (above all homeopathic remedies, massages and ointments) than people not suffering from allergies. Indirect costs due to allergies are, for instance, those caused by sick leave and loss of productivity. A continual systematic evaluation of available data on allergies in Austria could contribute to more effective implementation of medicines.

Cost-effective reduction of neuromuscular-blocking drug expenditures.

BACKGROUND: Anesthetic drug expenditures have been a focus of cost-containment efforts. The aim of this study was to determine whether expenditures for neuromuscular-blocking agents could be reduced without compromising outcome, and to determine whether such a cost-effective pattern of neuromuscular blocker use could be sustained. METHODS: Education, practice guidelines, and paperwork barriers were used to persuade anesthesiologists to substitute low-cost neuromuscular-blocking drugs (pancuronium or a metocurine-pancuronium combination) for a more costly neuromuscular-blocking drug (vecuronium). Neuromuscular-blocking drug use in all patients during a historical control period (6 months; n = 4,804) was compared with that during two consecutive 1-yr periods of intervention (n = 9,761/n = 10,695). Expenditures for vecuronium and for all neuromuscular-blocking drugs were compared for the control and intervention periods. The rate of complications related to neuromuscular-blocking drugs was determined by an ongoing continuous quality improvement program. RESULTS: Vecuronium use decreased by 76% during the first and second yr of intervention, compared with the historical period (P < 0.01). The cost of neuromuscular-blocking drugs decreased by 31% (P < 0.01) and 47% (P < 0.01) for the first and second yr, respectively. The complication rate related to neuromuscular-blocking drugs was 0.081% in the historical period and 0.11% and 0.093% during the intervention periods (P = 0.29 and 0.41). CONCLUSION: Practice guidelines, education, and paperwork barriers used together substantially reduced the expenditures for neuromuscular-blocking drugs for 2 yr without adversely affecting clinical outcome.

Evaluation of a GP practice based homeopathy service.

This study aimed to evaluate the effect of a GP-led practice-based homeopathy service on symptoms, activity, wellbeing, general practice consultation rate and the use of conventional medications. Data were collected for 97 consecutive patients referred to a homeopathy service between 1 July 2002 and 23 January 2003. Self-rated symptom severity, activity limitation and wellbeing were scored on a seven-point scale at initial homeopathic consultation and via postal questionnaire at a mean follow-up time of 134 days. Primary symptoms improved by a mean of 2.49 points (95% confidence interval (CI) 2.08-2.90; P < 0.0001); secondary symptoms by 2.49 points (95% CI 2.00-2.98; P < 0.0001); ability to undertake activity by 2.43 points (95% CI 1.95-2.91; P < 0.0001) and wellbeing by 1.41 points (95% CI 1.02-1.80; P < 0.0001). Following use of the homeopathy service the mean 6-month general practice consultation rate decreased by 1.18 consultations per patient (95% CI 0.40-1.99; P = 0.004). Fifty-seven per cent of patients reduced or stopped taking their conventional medication, saving 2,807.30 Pounds per year. The main limitation of this study is the absence of a control group. The findings warrant further research including controlled studies and economic analysis.

Does homeopathy reduce the cost of conventional drug prescribing? A study of comparative prescribing costs in general practice.

There is little research on cost-effectiveness of homeopathy in General Practice. This study aimed to compare the costs of homeopathic prescribing with conventional drugs prescribing. Data were collected for 4 years on all patients who were treated homeopathically. Costs of homeopathic remedies and costs of conventional drugs which otherwise would be prescribed for these patients was calculated for the total duration of treatment. Savings were calculated. One hundred patients were included in the study. Average cost savings per patient was pounds 60.40. The majority of patients had improved and most did not report any side-effects. The limitations of this study are that it is based on one GP's work, with a small number of patients so definite and generalisable conclusions cannot be drawn. Moreover, calculated costs in this study are based on drugs only, it does not take into account doctor's time, special investigations and time off sick. Future work needs to be carried out to include all of these points for a comprehensive economic analysis.

The impact of choice of muscle relaxant on postoperative recovery time: a retrospective study.

UNLABELLED: To test the hypothesis that the use of long-acting muscle relaxants is associated with prolonged postoperative recovery when compared with the use of shorter-acting relaxants, we undertook a retrospective study of 270 patients with induced paralysis recovering from general anesthesia. We calculated the mean recovery time associated with each muscle relaxant used. Regression analyses were performed to control for potential confounding of the results by length and type of surgery, as well as age and sex. Taking these into account, the adjusted difference in mean recovery time between patients receiving short- and intermediate-acting relaxants (mivacurium, atracurium, and vecuronium) versus those receiving long-acting relaxants (d-tubocurarine, pancuronium, and pancuronium and d-tubocurarine combination) was 30 min (95% confidence interval [CI] 8-53). The adjusted difference in mean recovery time between patients receiving vecuronium and those receiving pancuronium (i.e., the single most frequently used drug in each category) was 33 min (95% CI 1-66). Shortened recovery time accounted for an estimated average $37.95 decrease in recovery room charge per patient when vecuronium was used instead of pancuronium, versus a $22.84 increase in drug cost. Our data and analyses support the hypothesis that the use of long-acting muscle relaxants is associated with prolonged recovery after surgery and provide preliminary evidence that restricting the use of the more expensive, shorter-acting muscle relaxants may represent a false economy. IMPLICATIONS: In this retrospective study, the use of old-fashioned, inexpensive, long-acting paralyzing drugs was found to be associated with prolonged postoperative recovery. This has implications when deciding whether, as an economic measure, to restrict the use of the more expensive, shorter-acting paralyzing drugs, because prolonged recovery also has a price.

Pancuronium infusion for neuromuscular block in children in the pediatric intensive care unit.

When neuromuscular blockade becomes necessary in the intensive care unit, there are several options available in regard to both the drug and the mode of delivery (continuous versus intermittent administration). Despite extensive experience with intermediate acting drugs such as atracurium or vecuronium, these muscle relaxants are costly and may account for a significant portion of the pharmacy charges. We undertook an open label study to evaluate the efficacy and dosing requirements for a less costly drug, pancuronium. The study group included 25 patients ranging in age from 3 mo to 17 yr and in weight from 3.2 to 68 kg. If the patient had not previously received neuromuscular blocking agents (NMBAs), pancuronium was administered as a bolus dose of 0.1 mg/kg followed by a continuous infusion of 0.05 mg.kg-1.h-1. A nerve stimulator was applied to either the ulnar or peroneal nerve and a standard train-of-four (TOF) was monitored every 2 h. In patients that had previously received other NMBAs, no bolus dose of pancuronium was administered and the infusion was started at 0.05 mg.kg-1.h-1. The pancuronium infusion was increased or decreased by increments of 0.01 mg.kg-1.h-1 to maintain one to two twitches of the TOF. In patients that required an increase in the infusion rate, an additional bolus dose equivalent to the current hourly rate was administered and then followed by the increase in the infusion rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Desabastecimento de medicamentos: determinantes, conseqüências e gerenciamento / Drug shortage: determinants, consequences and management

O artigo analisa o desabastecimento de medicamentos como um problema que transcende o aspecto logístico da área de saúde, discutindo suas implicações para a qualidade, segurança e custo da assistência. A cadeia de abastecimento farmacêutico e os fatores que interferem na capilaridade da distribuição e na disponibilidade do medicamento são discutidos. Ressalta a contribuição da comissão de farmácia e terapêutica para a prevenção e gerenciamento do desabastecimento de medicamentos nos estabelecimentos de saúde. Sugestões de medidas para gestão do desabastecimento de medicamentos são apresentadas. Enfatiza-se a necessidade do medicamento ser considerado pelos componentes da cadeia logística um produto de saúde, com tratamento diferenciado dos bens de consumo comuns.

The present study analyzes drug shortage as a problem reaching beyond the logistic aspect of the health field and discusses its consequences with respect to quality, safety and cost of health care delivery. The pharmaceutical supply chain and the factors that determine the distribution and availability of drugs are discussed. The contribution of the Pharmacy and Therapeutics Committee in preventing and managing drug shortage in health institutions is stressed and measures for drug shortage management are suggested. Finally it is emphasized that drugs should be considered health products rather than consumer goods and as such be given a different treatment by the supply chain.