Jessica Fraeyman

Multiple policies to enhance prescribing efficiency for established medicines in Europe with a particular focus on demand-side measures : findings and future implications

Introduction: The appreciable growth in pharmaceutical expenditure has resulted in multiple initiatives across Europe to lower generic prices and enhance their utilization. However, considerable variation in their use and prices. Objective: Assess the influence of multiple supply and demand-side initiatives across Europe for established medicines to enhance prescribing efficiency before a decision to prescribe a particular medicine. Subsequently utilize the findings to suggest potential future initiatives that countries could consider. Method: An analysis of different methodologies involving cross national and single country retrospective observational studies on reimbursed use and expenditure of PPIs, statins, and renin-angiotensin inhibitor drugs among European countries. Results: Nature and intensity of the various initiatives appreciably influenced prescribing behavior and expenditure, e.g., multiple measures resulted in reimbursed expenditure for PPIs in Scotland in 2010 56% below 2001 levels despite a 3-fold increase in utilization and in the Netherlands, PPI expenditure fell by 58% in 2010 vs. 2000 despite a 3-fold increase in utilization. A similar picture was seen with prescribing restrictions, i.e., (i) more aggressive follow-up of prescribing restrictions for patented statins and ARBs resulted in a greater reduction in the utilization of patented statins in Austria vs. Norway and lower utilization of patented ARBs vs. generic ACEIs in Croatia than Austria. However, limited impact of restrictions on esomeprazole in Norway with the first prescription or recommendation in hospital where restrictions do not apply. Similar findings when generic losartan became available in Western Europe. Conclusions: Multiple demand-side measures are needed to influence prescribing patterns. When combined with supply-side measures, activities can realize appreciable savings. Health authorities cannot rely on a “spill over” effect between classes to affect changes in prescribing.

The potential influence of various initiatives to improve rational prescribing for proton pump inhibitors and statins in Belgium

Background: Proton pump inhibitors (PPIs) and statins have been among the top three most prescribed medicines in Belgium for more than a decade. Multiple demand-side measures have been introduced to improve rational prescribing generally, as well as for these two classes. Objectives: First, assessing the influence of general and specific reforms introduced in Belgium since 1997 on utilization and expenditure of the PPIs and statins. Second, suggesting additional measures to further improve rational prescribing based on experiences in other European countries. Methods: A retrospective observational study for assessing the influence of multiple initiatives in Belgium on utilization and expenditure of the PPIs and statins from 1997 to 2009 was carried out. Data were extracted from the administrative database Pharmanet. Utilization was measured in terms of defined daily doses (DDDs) and DDDs/thousand inhabitants per day. Results: Multiple reforms, including co-payments and reference pricing, appreciably enhanced rational prescribing for both PPIs and statins following generic availability. There was an eightfold increase in PPI utilization between 1997 and 2009, but only a twofold increase in reimbursed expenditure, helped by decreasing expenditure/DDD for the PPIs from €1.91 in 1997 to €0.52 in 2009. Similarly, a 20-fold increase was observed in statin utilization between 1997 and 2009, but only a fivefold increase in reimbursed expenditure, helped again by reimbursed expenditure/DDD decreasing from €2.05 in 1997 to €0.57 in 2009. Reduced co-payments for larger packs enhanced their prescription. Conclusion: Multiple reforms influenced utilization patterns and expenditure for the PPIs and statins, as well as the pack sizes dispensed. Additional demand-side measures are needed to further enhance rational prescribing, which can build on the experiences in other countries. These can be potentially transferred to other classes.

Potential impact of policy regulation and generic competition on sales of cholesterol lowering medication, antidepressants and acid blocking agents in Belgium

Abstract Background: Pharmaceutical expenditures are increasing as a proportion of health expenditures in most rich countries. Antidepressants, acid blocking agents and cholesterol lowering medication are major contributors to medicine sales around the globe. Methods: We aimed to document the possible impact of policy regulations and generic market penetration on the evolution of sales volume and average cost per unit (Defined Daily Doses and packages) of antidepressants, acid blocking agents and cholesterol lowering medication. We extracted data from the IMS health database regarding the public price and sales volume of the antidepressants (selective serotonin reuptake inhibitors (SSRI’s), monoamine oxidase inhibitors (MAOI’s) and tricyclic and remaining antidepressants (TCA’s)), acid blocking agents (proton pump inhibitors (PPI’s) and H2 receptor antagonists) and cholesterol lowering medication (statins and fibrates) in Belgium between 1995 and 2009. We describe these sales data in relation to various national policy measures which were systematically searched in official records. Results: Our analysis suggests that particular policy regulations have had immediate impact on sales figures and expenditures on pharmaceuticals in Belgium: changes in reimbursement conditions, a public tender and entry of generic competitors in a reference pricing system. However, possible sustainable effects seem to be counteracted by other mechanisms such as marketing strategies, prescribing behaviour, brand loyalty and the entry of pseudogenerics. It is likely that demand-side measures have a more sustainable impact on expenditure. Conclusion: Compared with other European countries, generic penetration in Belgium remains low. Alternative policy regulations aimed at enlarging the generic market and influencing pharmaceutical expenditures deserve consideration. This should include policies aiming to influence physicians’ prescribing and a shared responsibility of pharmacists, physicians and patients towards expenditures.

How is an Electronic Screening and Brief Intervention Tool on Alcohol Use Received in a Student Population? A Qualitative and Quantitative Evaluation

Background A previous study among Antwerp college and university students showed that more male (10.2%–11.1%) than female (1.8%–6.2%) students are at risk for problematic alcohol use. The current literature shows promising results in terms of feasibility and effectiveness for the use of brief electronic interventions to address this health problem in college and university students. We evaluated this type of intervention and cite existing literature on the topic. Objective To develop a website, www.eentjeteveel.be, to motivate college and university students with problematic alcohol use to reduce alcohol consumption and increase their willingness to seek help. Method The website contained a questionnaire (Alcohol Use Disorders Identification Test [AUDIT]) for students to test their alcohol use. According to their answers, the students immediately received personalized feedback (personal AUDIT score and additional information on risks associated with alcohol use) and a suggestion for further action. Afterward, students could send an email to a student counselor for questions, guidance, or advice. To obtain in-depth qualitative information on the opinions and experiences of students, we held 5 focus group discussions. The topics were publicity, experiences, impressions, and effects of the website. We analyzed the quantitative results of the online test in SPSS 15.0. Results More than 3500 students visited www.eentjeteveel.be; over half were men (55.0%). A total of 34 students participated in the focus group discussions. The mixture of quantitative and qualitative methods to evaluate the intervention allowed a thorough analysis and provided complementary results. The intervention was well received by the student population. However, some minor aspects should be reconsidered, such as website publicity and providing students with options that were added after intermediate evaluation. The intervention increased the motivation of students to think about their alcohol use but could not stimulate them to change their behavior. The website attracted relatively more male than female students and more students in the high-risk group than in the low-risk group. The high-risk group was more inclined to seek advice or guidance (23/400, 6%; χ2 2 = 32.4, P < .001) than the low-risk group (34/1714, 2%; χ2 2 = 32.4, P < .001). Conclusions We gained unique insight into students’ experiences, opinions, and perceptions with regard to the intervention. The results show that the intervention was positively received in the population, and the willingness to seek help was increased. However, real behavior change needs further research. The results of this study can assist health providers and researchers in better understanding college and university students’ perceptions of eHealth initiatives.

Flemish adolescents' perceptions of cigarette plain packaging: a qualitative study with focus group discussions

Objectives To find out whether there is a potential impact of the appearance of a plain cigarette package on the smoking perceptions and behavioural intentions of Flemish adolescents. Design We performed a cross-sectional study using the qualitative method of focus group discussions. Setting Flemish adolescents. Participants We performed eight focus group discussions, in which 55 adolescents took part, 32 female and 23 male. Inclusion criteria were: Flemish male and female 15-year-olds to 16-year-olds and 17-year-olds to 18-year-olds attending regular high-school education or vocational training who were current or had ever been smokers. Outcome measure (planned as well as measured) The opinions and perceptions of young Flemish smokers regarding the impact of cigarette packaging on their smoking behaviour. Results Plain packages are perceived as less attractive, cheap and unreliable for young people. Because of the unattractiveness of the plain packaging, the health warnings catch the eye much more strongly. Conclusions In this first scientific study in Flanders on this topic, it emerged that plain packaging could be a strong policy tool to reduce the number of adolescents starting smoking. Validation of these findings by conducting a quantitative survey in the same target group is recommended.

The perceptions and perspectives of patients and health care providers on chronic diseases management in rural South Africa: a qualitative study

BackgroundPreventive health care represents the future for health care delivery in South Africa to improve management of chronic diseases as this has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. Individual person’s health is unique, as they move in and out of chronic and acute health care phases, there is need to integrate chronic and acute care constructs to improve continuity of care and maximize health and improve wellbeing. The aim of this study was to determine the perceptions and perspectives of chronic patients’ and nurses regarding chronic disease management in terms of barriers, facilitators and their experiences.MethodsTo meet our aim we used qualitative methods involving the collection of information by means of focus group discussions in Dikgale Health and Demographic Surveillance System (HDSS). All data was recorded, transcribed verbatim and analysed using data-driven thematic analysis.ResultsOur study showed that chronic disease patients have a first contact with health care professionals at the primary health care level in the study area. The main barriers mentioned by both the health care workers and chronic disease patients are lack of knowledge on chronic diseases, shortage of medication and shortage of nurses in the clinics which causes patients to wait for a long periods in a clinic. Health care workers are poorly trained on the management of chronic diseases. Lack of supervision by the district and provincial health managers together with poor dissemination of guidelines has been found to be a contributing factor to lack of knowledge in nurses among the clinics within the study area. Both patients and nurses mentioned the need to involve community health workers and traditional healers and integrate their services in order to early detect and manage chronic diseases in the community.ConclusionsNurses and chronic disease patients mentioned similar barriers to chronic disease management. Concerted action is needed to strengthen the delivery of medications at the clinics, improve the chronic disease knowledge for both nurses and patients by conducting in-service trainings or workshops, increase the involvement of community health workers and establish a link (through formal referral system) with traditional healers.

How to overcome hurdles in opiate substitution treatment? A qualitative study with general practitioners in Belgium

Abstract Background: Opiate substitution treatment (OST) is the administration of opioids (methadone or buprenorphine) under medical supervision for opiate addiction. Several studies indicate a large unmet need for OST in general practice in Antwerp, Belgium. Some hurdles remain before GPs engage in OST prescribing. Objectives: Formulate recommendations to increase engagement of GPs in OST, applicable to Belgium and beyond. Methods: In 2009, an exploratory qualitative research was performed using focus group discussions and interviews with GPs. During data collection and analysis, purposive sampling, open and axial coding was applied. The script was composed around the advantages, disadvantages and conditions of engaging in OST in general practice. Results: We conducted six focus groups and two interviews, with GPs experienced in prescribing OST (n = 13), inexperienced GPs (n = 13), and physicians from addiction centres (n = 5). Overall, GPs did not seem very willing to prescribe OST for opiate users. A lack of knowledge about OST and misbehaving patients creates anxiety and makes the GPs reluctant to learn more about OST. The GPs refer to a lack of collaboration with the addiction centres and a need of support (from either addiction centres or experienced GP-colleagues for advice). Important conditions for OST are acceptance of only stable opiate users and more support in emergencies. Conclusion: Increasing GPs’ knowledge about OST and improving collaboration with addiction centres are essential to increase the uptake of OST in general practice. Special attention could be paid to the role of more experienced colleagues who can act as advising physicians for inexperienced GPs.

Het gebruik van diagrammen tijdens de data- analyse Een stapsgewijze methode voor (beginnende) onderzoekers

Inleiding Ondanks een goed uitgeschreven onderzoeksplan worden onderzoekers vaak overweldigd door de veelheid van data bij de start van het proces van kwalitatieve data-analyse. Soms gaat men op zoek naar vooropgestelde manieren van analyse‐ ren die een vrij rigide patroon volgen. Dit is jammer, want dan riskeer je interes‐ sante informatie te missen. Wanneer je anderzijds geen patroon volgt, loop je het risico om jezelf te verliezen in de details. In beide gevallen is het essentieel om het doel (de onderzoeksvraag) als rode draad door de analyse mee te nemen. In deze bijdrage gaan we dieper in op hoe verklarende diagrammen kunnen helpen tijdens de kwalitatieve data-analyse. Het kan een middel zijn om je data op een andere manier te bekijken wanneer je in een bepaald patroon gecodeerd hebt, of het kan je helpen om een overzicht te krijgen wanneer je niet meer wijs wordt uit de details. We willen hiervoor een stap-voor-stapmethode aanbieden die bruikbaar kan zijn voor jonge onderzoekers of voor het aanleren van data-analyse aan stu‐ denten. Het maken van diagrammen in kwalitatief onderzoek kan een hulpmiddel zijn om verder te gaan dan enkel te beschrijven wat je ziet in je data en het proberen te begrijpen. In essentie probeer je op een compacte manier het verhaal van je data te illustreren, zodat iedereen dit kan volgen (Corbin & Strauss, 2008). Het gebruik van diagrammen beperkt zich niet tot een bepaald type van onderzoeks‐ vragen. We bespreken hier hoe je het kan gebruiken in kwalitatief onderzoek.

Evaluating the implementation fidelity of New Medicines Service for asthma patients in community pharmacies in Belgium

Background: In October 2013, a New Medicines Service (NMS) was introduced in community pharmacies in Belgium to support asthma patients who are novice users of inhaler devices with corticosteroids. The protocol‐based intervention used the Asthma Control Test (ACT) and the Medication Adherence Report Scale (MARS) to assess asthma control and medication adherence. The NMS is the first initiative that puts advanced pharmaceutical care into practice in Belgium. The present study evaluated the degree to which the NMS program is delivered as intended, drawing on the concept of implementation fidelity (IF). Methods: The main dimensions of IF and potential moderating and facilitating factors for the implementation of NMS in community pharmacies were evaluated using telephone interviews with pharmacists (n = 497), semi‐structured interviews with patients eligible for NMS (n = 30), focus groups among general practitioners (n = 72) and lung specialists (n = 5), and a work system analysis in community pharmacies (n = 19). Results: The uptake of NMS in Belgian community pharmacies remains low. In addition to practical barriers, pharmacists found it difficult to identify new asthmatic patients when they were not informed about the diagnosis. A lack of commitment from physicians, patients and pharmacists was noted in the early start‐up phase of the program. Many pharmacists did not see how NMS differed from existing pharmaceutical care. Physicians considered this service as part of their own tasks and discouraged ACT for asthma follow‐up in the community pharmacy. Conclusions: The introduction of the NMS program was not sufficiently embedded in the Belgian health care organization, causing low uptake and resistance to its implementation by pharmacists, patients, and other health care professionals. To increase the uptake of this type of service and its possible extension to other patient groups, more collaboration among the different health care professionals during design and implementation is necessary, as well as systematic data collection to monitor the quality of the service, better training of pharmacists, and more information for patients and physicians.

Unintended consequences of co-payment regulations in Belgium: the case of atorvastatin.

Methods We related sales figures to coinciding price evolutions, and broke the costs down by their bearer. On the one hand we analysed a data extraction from IMS Health for Belgium for the period 2007-2013. The IMS Health database contains sales figures of a representative sample of community pharmacies including the number of packages sold (per CNK number) per month. On the other hand, we studied the corresponding unit price tables of the Belgian centre for Pharmaco-therapeutic Information (BCFI, an independent source).