1. FINANCIAL IMPACT OF JUDICIOUS USE OF MEDICINE IN PRIMARY CARE Zuo, Yeqin; Morrell, Stephen; Dartnell, Jonathan; Wu Fred; Weekes, Lynn NPS: Better Choices, Better Health Australia

2. BACKGROUND Medicine is expensive! Proportion of national health budgets spent on medicines: 10% - 20% in developed countries 20% - 40% in developing countries Inappropriate use of medicine higher medicine cost: The inclusion of unnecessary or inappropriate medicine therapy Unnecessarily expensive medicine Unnecessarily high doses or long treatment periods

3. Fig 2 Expenditure on drugs and other medical non-durables as a proportion of total health spending in selected OECD countries, 1987-2007 ( data are incomplete for some countries)1. Cumming J et al. BMJ 2010;340:bmj.c2441 ©2010 by British Medical Journal Publishing Group

4. QUM PROGRAM IN AUSTRALIA Australian health care system Pharmaceutical Benefits System NPS NPS Program for GPs Academic detailing (educational visit) Case studies Clinical audits and feedback Group discussions Workshops

5. KEY MESSAGES FOR GPS (Relevant to reducing prescribing) Reserve clopidogrel for those unable to take aspirin Avoid fixed-dose combination products in the initiation of antihypertensives Limit the role of tramadol for mild to moderate pain management Use psychological therapies as first-line treatments in mild depression Step down the dosage of PPIs to intermittent, symptom-driven therapy

6. STUDY OBJECTIVE & METHODS Objective To assess the financial impact of NPS programs on PBS expenditures for targeted drug groups (2007-2009) Study design Interrupted time series analysis to assess the correlation between NPS intervention and PBS expenditure on medicines of interest. Data source: PBS data from Medicare Australia Outcome measure: difference in PBS expenditure on targeted medicines with and without intervention

10. PPIs TIME SERIES ANALYSIS (2008/2009) Low strength PPIsHigh strength PPIs Significant variablesEstimate (SE)P-valueSignificant variablesEstimate (SE)P-value Square root of Linear Time Trend 150252 (190032) 0.4316 Square root of Linear Time Trend 2509814 (220680) <.0001 Cumulative GP 296.58 (102.20) 0.0049Cumulative GP 1490 (509.17) 0.0044 Square root of Trend after Esomeprazolie listed 805176 (200279) 0.0001 Cumulative GP X Square root of Trend -223.35 (73.05) 0.0030 Jan-05 24% copayment increase -1152054 (234701) <.0001 Jan-05 24% copayment increase -2735747 (739848) 0.0004 Jan-06 Safety net 20- day rule -1032470 (214814) <.0001 Jan-06 Safety net 20- day rule -2425461 (732106) 0.0014 Apr-06 12.5% price reduction and copayment changes -816965 (202905) 0.0001 Apr-06 12.5% price reduction and copayment changes -3224952 (719861) <.0001 Introduced cost $11.6M - $21.2Savings$30.3M - $45.3

11. KEY FINDINGS Significant correlation between GP participation and decreased PBS cost Significant increase in the effect of interventions in the initial period following implementation 2 years after implementation, the PPI program of waning. showed signs Mean annual PBS expenditure reduction of 16% (AU$18.4 million) per program per drug group attributable to NPS interventions.

12. PBS COST SAVING ATTRIBUTABLE TO NPS PROGRAMS

13. PBS COST SAVINGS 2007–2009 ProgramExpected PBS expenditure without NPS intervention ($AUD Millions) Expected PBS expenditure with NPS intervention ($AUD Millions) Savings proportionSavings ($AUD millions) 2006–07 Antithrombotics159.9142.211%16.6–17.8 ACE combination61.540.035%18.3-21.5 Angiotensin II107.278.527%23.9–28.7 2007–08 Antidepressants253.5235.87%10.4–17.7 Proton pump inhibitors (PPIs)264.1236.013%24.9–28.2 2008–09 Antidepressants266.5232.513%29.9–35.1 PPIs430.3406.312%18.7–24.1 Tramadol27.720.825%5.3–7.0 Total savings (2007–09)148–180

14. EVALUATION STUDY STRENGTH & LIMITATIONS S trength Multiple time points covers >10 years National level data cover Australian population Intervention onset and completion clearly defined L imitations No data on indications of prescribing Aggregated GP prescribing data without information on patient journey Possible unknown other relevant environment factors

15. CONCLUSION & IMPLICATIONS Comprehensive educational programs in primary care could reduce inappropriate prescribing. Program may need refresher interventions every 2–3 years to sustain the impact. Well designed educational intervention could lead to substantial national cost savings on medicine expenditure. Robust cost-saving analysis provides strong argument to decision makers.

16. Thank You