Prescribing efficiency of proton pump inhibitors in China: influence and future directions

Abstract

BackgroundPharmaceutical expenditure is currently rising by 16% per annum in China, greater in recent years. Initiatives to moderate growth include drug pricing regulations, essential medicine lists and encouraging generic prescribing. These are principally concentrated in hospitals, which currently account for over 80% of total pharmaceutical expenditure. However, no monitoring of prescribing and perverse incentives encouraging physicians and hospitals to profit from drug procurement encourages irrational prescribing. This includes greater utilisation of originators versus generics as well as injectables when cheaper oral equivalents are available. The objective of the paper is to assess changes in proton pump inhibitor (PPI) utilisation and expenditure in China as more generics become available including injectables.MethodsObservational retrospective study of PPI utilisation and procured expenditure between 2004 and 2013 in the largest teaching hospital in Chongqing District as representative of China.ResultsAppreciable increase in PPI utilisation during the study period rising 10.4 fold, with utilisation of generics rising faster than originators. Oral generics reached 84% of total oral preparations in 2013 (defined daily dose basis), with generic injectables 93% of total injectables by 2013. Injectables accounted for 42% of total PPI utilisations in 2008 and 2009 before falling to below 30%. Procured prices for oral preparations reduced over time (−34%). Generic oral omeprazole in 2010 was 87% below 2004 originator prices, mirroring reductions seen in Western Europe. Injectable prices also decreased over time (−19%). However, injectables typically 4.3 to 6.8 fold more expensive than equivalent orals - highest for injectable lansoprazole at 13.4 to 18.0 fold. High utilisation of more expensive oral PPIs as well as injectables meant that PPI expenditure increased 10.1 fold during the study period. Lower use of injectables, and only oral generic omeprazole, would result in accumulated savings of CNY249.65 million, reducing total accumulated expenditure by 84%.ConclusionsEncouraging to see high utilisation of generic PPIs and low prices for oral generics. However, considerable opportunities to enhance prescribing efficiency through greater use of oral generic omeprazole.

Ongoing Initiatives in China to Enhance Prescribing Efficiency: Impact and Proposals for Improvement

“…Here, the unit of utilisation employed were package units as there is currently no reliable source for DDDs for traditional Chinese medicines, most physicians use the package unit as the charging unit when calculating their patients' expenditure and the specifications of the products typically did not change during the study period [49,52]. The Chinese currency Renminbi "yuan" (CNY) was used in these four studies to determine expenditure over time [21,49,53,54]. Expenditure was typically not converted to either US$ or Euros in the quoted studies as the authors did not want pricing data influenced by currency fluctuations especially during the recent financial crises in Europe and the US.…”

“…In addition, pharmaceutical expenditure in hospitals accounted for approximately 40% to 50% of their total income during the past decade [1,4,5,[17][18][19][20]. This arose because the financial support from the Chinese government to public hospitals declined steadily from approximately 60% of hospital revenues in the 1980s to 8.2% by 2003 or lower [5,21]. As a consequence, hospitals in China must necessarily use the revenues from drug procurement and dispensing for their sustainability [3,5,8,17,22].…”

“…However, there are currently few initiatives among public insurers to monitor the quality of prescribing in China [20,23]. There were reforms specifying that prescriptions should be written by generic (INN) name but limited enforcement to date [1,17,21]. As a consequence, physicians tend to write prescriptions with the generic (INN) name and simultaneously indicate the brand or manufacturer's name; alternatively, they simply choose medicines listed in hospitals' information technology (IT) systems with the corresponding brand name or manufacturer [1,17,21].…”

“…There were reforms specifying that prescriptions should be written by generic (INN) name but limited enforcement to date [1,17,21]. As a consequence, physicians tend to write prescriptions with the generic (INN) name and simultaneously indicate the brand or manufacturer's name; alternatively, they simply choose medicines listed in hospitals' information technology (IT) systems with the corresponding brand name or manufacturer [1,17,21]. This situation is not helped by similar patient co-payments for an originator or a generic as well as physicians and hospitals necessarily using the profits from medicine procurement for their sustainability [4,5,21,23].…”

Initiatives to increase the prescribing of low cost generics; the case of Scotland in the international context

“…generic statins accounted for only 9% to 10 % of total statins in recent years in hospitals in China international context (175). The low use of generics is exacerbated by the need for hospitals to make money from drug procurement for their sustainability and physicians to supplement their income, with this incentive system also stimulating overuse of injections (174,(176)(177)(178) Box 2 -Potential requirements to successfully implement a generic substitution policy (adapted from (118)).…”