1. Norman Evans Chief Pharmacist Wandsworth PCT South West London Finding The Resources – The Cost Challenge

2. The panel were concerned about the increase in prescribing costs Surrey LMC 1911

3. RCGP Good Clinical Care The Excellent Doctor : –Only prescribes treatment that makes an effective contribution to the patient’s overall management –Takes resources into account when choosing between treatments of similar effectiveness The Unacceptable Doctor –Consistently prescribes unnecessary or ineffective treatments –Takes no account of resources when choosing between similar treatments –Refuses to register patients who are costly

4. Some variables in prescribing Population : 65yrs Number of practice partners Marketing : those who see reps, new drugs Repeat prescribing Waste/concordance : N. Ireland 40%, Aberdeen £43 per patient per year Miscellaneous : single parent, unemployment, single handed, non-trainer

5. NICE Guidance Mild symptoms of dyspepsia : step up or down. No long term PPI Confirmed ulcer : eradicate H. pylori. No long term PPI Ulcer caused by other drugs : PPI and lowest dose to control symptoms Mild GORD symptoms : antacids, alginates. May not need PPIs Severe GORD : full dose PPI until symptom control then regular maintenance Least expensive PPI Review patients on PPIs, assess dose, stop where appropriate If fully implemented will have real benefits for patients as there is no advantage in taking more of a drug than needed A reduction in usage of PPIs of at least 15% and savings of £40 to £50 million a year

6. National GORD data IMS MAT 2003 PPI Increase = £8,281,855

7. National GORD data IMS MAT 2003 PPI Increase = 850,963 Rx (7.9%)

8. PPI national maintenance versus treatment - volume split Source IMS mthly

9. Long term PPI reasons for use Oesophagitis (2) 17% Reflux40% Non-specific dyspepsia30% Peptic ulcer disease3% Esophageal ulcer/stricture2% Non-GI problems1% Refs: (1) BNF September 2003, (2) Hungin APS, Rubin GP et al, 1999: Martin RM, Lim AG, 1998: Bashford JH, Norwood J, 1998 An initial short course of a PPI is the treatment of choice in GORD with severe symptoms (1) Recorded reasons for long-term PPI’s

10. Long term usage of PPI’s PPI’s on repeat In 1995, 77% of PPI’s were attributable to repeat Rx (1) In 2003, 85% of PPI’s were attributable to repeat Rx (2) Treatment dose 84% Maintenance dose 90% In 1999 45% of patients were discovered on long-term PPI’s i.e. an average of 9 Rx’s per year Do patients take their treatment regularly? In June 1999, 71% reported taking their PPI’s regularly (3) However, average number of repeats is 9 (3) Long term treatment for symptom relief is contentious (3) Refs: (1) Bashford JN, Norwood J, et al. BMJ 1998; (2) MDI MAT data June 2003; (3) Hungin APS, Rubin GP et al. Br J Gen Pract, 1999

11. Implementing a protocol for managing dyspepsia* Aim : To review PPI use and the feasibility of cost reduction by: Stepping down appropriate patients from treatment to maintenance dose PPI Stepping off appropriate patients from maintenance PPIs to alginate *Prescriber, Feb. 2003

12. Process Establish disease register Database search Identify patients from inclusion criteria Letter to all patients explaining changes to medication and offering nurse led dyspepsia clinic Step off maintenance PPI to alginate Step down PPI treatment to maintenance dose

13. Protocol Inclusion criteria –Mild reflux –Mild oesophagitis (grade I or II) –Hiatus hernia –Healing post ulcer >6 months

14. Protocol Exclusion criteria –Healing dose of PPI within 6 months –Review at gastro clinic or awaiting referral –Awaiting endoscopy or review –Patients taking NSAIDs or high dose steroids –Patients >90 years –Patients with Barrett’s –Immunosuppressed patients –Terminal illness

15. Nurse led clinic 15 minutes per appointment Complete patient template Explain GORD Role of PPIs NICE guidance Explain acid rebound Lifestyle advice

16. Step down/step off protocol Confirmed diagnosis of RO PPI healing dose for 6 to 8 weeks PPI maintenance dose for 6 to 8 weeks Alginate e.g. Gaviscon Advance 5-10mL for 8 weeks qds pc and nocte

17. Results Step off : –Up to 58% patients remained on Gaviscon Advance after 10 months Step down : –90% patients remained on maintenance dose PPI from high dose after 7 months –Cost savings : projected £9,467 pa (10,000 patient practice, step off only)

18. Dyspepsia Treatment Cost Model Savings from Step Down and Step Off –Step Down savings up to £39 million –Step Off savings up to £29 million –Total potential savings £68 million

19. 20 leading cost drugs 2002/03 EBM vs VFM? Drug £m % total % Increase Simvastatin 3.2 4.6 37 Atorvastatin 1.9 2.8 34 Amlodipine 1.9 2.8 9 Lansoprazole 1.8 2.6 25 Olanzapine 1.4 2.0 17 Omeprazole 1.3 1.9 -8 Nutrition 1.1 1.6 21 Beclometasone 1.0 1.5 7 Ramipril 0.9 1.3 68 Pravastatin 0.9 1.2 15 Lisinopril 0.85 1.2 2

20. Leading cost drugs continued Drug £m % Increase Salmeterol 0.8 12 Dressings 0.7 15 Paroxetine 0.7 -12 Doxazosin 0.7 4 Losartan 0.7 35 Venlalaxine 0.7 45 Seretide 0.7 59 Salbutamol 0.6 8 Fluticasone 0.6 17