PARADEROS DE COLECTIVOS Y MICROBUSES

Given the substantial cost that wasted medication represents, disparities in the evidence, and the ambiguity in national dispensing guidelines for GPs, the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme has commissioned research to synthesise and assess the evidence on the clinical effectiveness and cost-effectiveness of shorter (28-day) versus longer (3-month) duration prescriptions in terms of patients’health outcomes and health system costs.

TABLE 1 The 20 most commonly prescribed medicines dispensed in the community in England (2015)

BNF chemical name

Items prescribed,

n(millions)

NIC, £

(millions)a _{Class of item/example(s) of conditions it can treat}

Simvastatin 34.4 46.5 HMG CoA reductase inhibitor/hypercholesterolaemia, primary prevention CVD

Omeprazole 30.1 64.8 PPI/gastro-oesophageal reflux, peptic ulceration Levothyroxine sodium 29.7 104.5 Thyroid hormone therapy/hypothyroidism Aspirin 28.0 27.3 Antiplatelet agent/secondary prevention of stroke,

myocardial infarction

Atorvastatin 27.2 53.8 HMG CoA reductase inhibitor/hypercholesterolaemia, primary prevention of CVD

Ramipril 26.7 42.7 ACE/hypertension, heart failure

Amlodipine 25.4 31.9 Calcium channel blocker/hypertension, angina Lansoprazole 22.9 41.6 PPI/gastro-oesophageal reflux, peptic ulceration Paracetamol 22.9 87.6 Analgesic/mild to moderate pain

Salbutamol 21.9 62.4 Bronchodilator/asthma

Colecalciferol 19.9 90.6 Secosteroid/osteoporosis

Metformin hydrochloride 19.8 120.4 Antihyperglycaemic agent/diabetes mellitus Bisoprolol fumarate 19.4 26.1 Beta blocker/angina, heart failure

Co-codamol 15.7 97.6 Analgesic/mild to moderate pain Citalopram hydrobromide 14.4 17.8 SSRI/depression, panic disorder Bendroflumethiazide 13.5 14.8 Thiazide diuretic/hypertension

Furosemide 12.5 13.9 Loop diuretic/oedema

Amitriptyline hydrochloride 12.4 23.1 Tricyclic antidepressant/neuropathic pain (unlicensed)

Amoxicillin 11.9 18.4 Antibiotic/infection

Warfarin sodium 11.6 23.1 Anticoagulant/prevention of stroke in atrial fibrillation ACE, angiotensin-converting enzyme; BNF,British National Formulary; CVD, cardiovascular disease; HMG CoA, 3-hydroxy-3- methylglutaryl coenzyme; NIC, net ingredient cost; PPI, proton pump inhibitor; SSRI, selective serotonin reuptake inhibitor. a Net ingredient cost (NIC) refers to the cost of the drug before discounts and does not include any dispensing costs or

fees. It does not include any adjustment for income obtained where a prescription charge is paid at the time the prescription is dispensed or where the patient has purchased a pre-payment certificate.

Source: Adapted from NHS Digital (2016).4

Copyright © 2016, Re-used with the permission of NHS Digital. All rights reserved.

INTRODUCTION

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The aim of this study is to provide a high-quality reference on the clinical effectiveness and cost-effectiveness of primary care physicians issuing longer duration versus shorter duration (3-month vs. 28-day) prescriptions in patients with stable chronic diseases. This study is intended to help inform prescribing policy. In addition, this study is directly relevant to patient groups with stable, chronic conditions who require regular repeat prescriptions. In order to provide a comprehensive and transparent assessment of the impact of different prescription lengths on a relevant set of outcomes, the following approaches have been used:

l a systematic review of the clinical effectiveness and cost-effectiveness evidence, incorporating any relevant clinical and cost outcomes

l a cost analysis based on available secondary data

l disease-specific decision-analytic models.

Table 2presents the full list of the potential outcomes of interest, as well as a brief description of each one and an indication of which approach(es) was used to examine it.

TABLE 2 Outcomes of interest

Outcome Description Method

Disease-specific health outcomes

Any health outcomes that measure the impact of a particular disease or condition on an individual’s health and well-being, for example disease management measures such as glycosylated haemoglobin level or cholesterol measures

Systematic review

Generic health outcomes Any health outcome measures that can be applied across diseases or conditions, and that could be used to estimate QALYs

Systematic review, decision models Adverse events Any outcome that measures untoward medical occurrence

in a patient, for example adverse drug reaction, unplanned hospitalisation including A&E attendance as well as admission for ambulatory care sensitive conditions, death

Systematic review

Errors Any outcome that measures preventable adverse effect of care, for example prescription error, drug monitoring error

Systematic review Adherence Any outcomes that measure the extent to which a patient is

dispensed the medication as prescribed and takes the prescribed medication as intended; this broad definition includes measures of compliancea

Systematic review

Costs associated with adherence

Drug wastage Any outcome used to measure medicines issued to a patient but not consumeda

Systematic review, cost analysis Costs associated with wastage

Professional administration time/costs

For example, time to write, renew or process the prescription and costs associated with administration time

Systematic review, cost analysis Pharmacists’time/costs For example, time to renew or process the prescription and costs

associated with pharmacists’time

Systematic review, cost analysis Patient experience/satisfaction Any measure used to elicit feedback from patients on their views

of care and services

Systematic review Patient costs Any measure of personal expenses incurred by patients during the

course of their care, for example out-of-pocket payments and travel costs

Systematic review

Costs to the NHS Longer-term health service costs Decision model A&E, accident and emergency; QALY, quality-adjusted life-year.

a Adherence and wastage are implicitly linked: when patients are dispensed a prescription but do not take the medication, there is both non-adherence and wastage. Conversely, when patients are not dispensed a prescription, they will be non-adherent but no wastage will be incurred. Note, however, that it is possible for a medication to be deliberately stopped before the supply runs out, leading to wastage but not non-adherence. Similarly, a patient may take a medicine less frequently than prescribed (non-adherence) but collect medicines less often (resulting in less wastage).

DOI: 10.3310/hta21780 HEALTH TECHNOLOGY ASSESSMENT 2017 VOL. 21 NO. 78

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