Transcript trends in prescribing promotional targeted drugs

Abstract
Impact of the National Healthcare Reform on Prescribing Patterns of
Promotional Targeted Drugs among Thai Physicians
Layton MR*, Chadbunchachai S*,Thinkhamrop B**,Tangcharoensathien V***
*Faculty of Pharmaceutical Sciences, Khon Kaen University, Thailand.
**Faculty of Public Health, Khon Kaen University, Thailand.
***International Health Policy Program, Ministry of Public Health, Thailand.
Problem Statement: Worldwide, the 1990’s witnessed the introduction of many
promotional targeted drugs (PTD). Despite the fact that these newer drugs have been
rapidly adopted in the global therapeutic practice, little is known about the prescribing
patterns of PTD among Thai physicians, especially since the enactment of the national
health care reform.
Objective: To assess the impact of the reform on prescribing patterns of PTDs among
Thai physicians at a teaching hospital.
Design: Retrospective outpatient prescription records of PTDs between 1998 – 2003
were reviewed and compared with data of the established drugs in their respective
categories. In addition, a qualitative study on how the PTD were enlisted in the hospital
formulary was incorporated. The study was approved by the Institutional Review
Board, Khon Kaen University.
Setting: Outpatient department at a teaching hospital in Thailand.
Study Population: Based on the PTD definition stated in the inclusion criteria, two new
drugs – a Statin (PTD-M1) and a COX-2 inhibitor (PTD-O1) were identified as PTDs.
The electronic outpatient dispensing data from the pharmacy department were
retrieved. Qualitative data from in-depth interviews with the secretary team of the
Pharmacy & Therapeutic Committee (PTC) including documents on the PTD drug
approval process were also assembled.
Outcome measures: The data of both PTDs and related drugs on daily dose prescribed,
total numbers of prescriptions and days supplied, total sales volume and value, payment
scheme, and descriptive information on the PTC approval process were compared with
the respective prescribing departments.
Results: The data of both PTDs showed significant increases in drug use even after the
new healthcare policy was enacted. The majority of the drug costs was cash payment either paid out-of-pocket by the patients or by other reimbursable insurance schemes.
While there was evidence that many physicians complied with the cost containment
policy, the data also reflected that some of the PTC’s prescribing restrictions were
commonly violated.
Conclusion: This exploratory study at a teaching and training hospital reveals an urgent
need for further in-depth investigation on critical factors influencing physician
prescribing behavior of a promoted drug. Ultimately, it may be necessary to consider
any practical policies to curb the escalating drug cost and promote rational drug use in
the country.
Background &
Significance
 The 1990’s witnessed the introduction of many
promotional targeted drugs (PTD) worldwide
with visibly increasing promotional budget
 In October 2001, the Universal Coverage Reform
was enacted and viewed as a threat to the
pharmaceutical market, especially to the globalbranded industry
 Some prescribing restrictions such as requirement
of authorized physicians’ signatures and license
no., only designated list of specialists
 In 2003, Thailand Total Pharmaceutical Market
Value was 44,800 M.Baht (+13% growth), which
the market shares of the global and local brands
in the medical channel were 67% (+21%growth)
and 33% (+9%), respectively
Objective
 To assess the impact of health care
reform on PTD prescribing pattern
among Thai physicians at a teaching
school hospital where the training
site & modeling for the future doctors’
prescribing pattern is located
 Based on the PTD inclusion criteria
(ie. Relatively new and launched in both global and Thai
markets, Global-branded product, Expensive,Visible/known
promotional activities, Potentially cause some drug-related
problems),
a Statin (PTD-M1) and a COX-2
inhibitor (PTD-O1) were identified
as PTDs
Methods
 A retrospective review of electronic outpatient
prescription records of the PTDs at a teaching
hospital in Thailand before and after the
enactment of the national healthcare reform was
examined and compared with data of the
established drugs in their respective categories
e.g. (O2-Branded, M2-Branded, and M3-Generic)
 In addition, in-depth interviews with the secretary
team of the Pharmacy & Therapeutic Committee
(PTC) including documents on the PTD drug
approval process were also assembled
 Approval from both the Institutional Review
Board as well as the Director of the hospital were
obtained prior to the study
Results 1: PTD-O1 and
Other COX-2 Inhibitors
PTD - O1
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
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
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Date of PTC approval
Duration of data analysis
Drug category
Current unit price
Total no. of prescriptions
Total sales volume (Tab/Cap)
Total sales value (Baht)
Average daily dose prescribed
(Tab/Cap)
Avg. quantity prescribed / visit
Avg. no. of days supplied
Avg. price per prescription
Payment type:
Cash
Social Security
30 Baht Scheme
CSMBS
Others
Nov 2001
2001-2003
Non ED
30 Baht
1,760
84,198
1,830,225
1.3
O2
Jul 2000
2000-2003
ED
17 Baht
11,902
438,049
5,601,125
1.2
34.3
27.6
1,030.50
27.5
23.0
468.50
70.8%
3.4%
0.2%
28.6%
-
67.4%
3.8%
3.0%
24.2%
1.6%
Figure 1: Total
- Sales Value of Cox-2
(2000-2003)
฿350
,000
฿300
,000
October 2001: Starting Healthcare Reform
฿250
,000
฿200
,000
PTD – O 1
O2
฿150
,000
฿100
,000
฿50,000
฿0
Months/Years
Results 2: PTD-M1 and
Other Statins
PTD - M1
20mg
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





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


Date of PTC approval
7/2001
Duration of data analysis 2001-2003
Drug category
ED
Current unit price
60 Baht
Total no. of prescriptions
5,556
Total sales volume
193,975
Total sales value
13.3 M
Average daily mg prescribed 709.2
Avg. quantity per visit
40.2
Avg. no. of days supplied
55.1
Avg. price per prescription
2,426
Payment type:
Cash
73.4%
Social Security
0.6%
30 Baht Scheme
0.3%
CSMBS
25.7%
Others
-
M2
40mg
M3
10mg
11/ 2001 11/2001
1998-2003 2001-2003
ED
ED
42 Baht 3.50 Baht
9,857 13,690
438,049 1,779,044
16.0 M 4.3 M
796.1
1,301.5
34.3
77.4
48.0
56.5
1,631
318.9
66.4%
1.5%
0.1%
31.7%
0.3%
70.5%
3.1%
8.4%
16.2%
1.8%
Figure 2: Total Sales Value of
Statins (1998 – 2003)
฿700,000
October 2001: Starting Health Care Reform
฿600,000
)
Sales Value Baht
฿500,000
฿400,000
M2
M3
฿300,000
PTD-M1
฿200,000
฿100,000
฿0
1998
1999
2000
Year
2001
2002
2003
Figure 3: Ratio of Adjusted Sales Volume PTD-O1 to O2
(2001-2003)
90
Ratio to O-2
80
70
Trend line of
PTD-O1 to O2
60
50
40
30
20
10
0
Figure 4: Ratio of Adjusted Sales Volume PTD-M1 to M2 & M3
(2000-2003)
15
10
5
Ratio to
M2
Ratio to M3
Trend line of M3
0.5
0.2
Trend line of M2
Summary
 Both of the observed PTDs showed significant
increases in drug use even after the new
healthcare policy was enacted.
 Except comparing with the generic ED, the PTDs
showed higher rate of sales off take than the
traditional existing drugs
 The majority of the drug costs were cash payment
and CSMBS ie. either paid out-of-pocket by the
patients or by other reimbursable insurance
schemes, thus could be burdensome to the society
as a whole
 While there was evidence that many physicians
complied with the hospital’s cost containment
policy, the data also reflected that some of the
PTC’s prescribing restrictions were commonly
violated
Limitation &
Discussion
 An exploratory study at only one
site, a teaching hospital in
Thailand. Other setting ie. Regional
and Private hospitals may reflect
different outcomes due to different
nature of both patients and hospital
policy management
 Using OPD dispensing data at the
hospital pharmacy only with lack
of records on prescribers and
diagnosis
Conclusion &
Implication
 Various marketing strategies and
promotional efforts have been
successfully exercised by multinational
companies to sustain the drug product
life cycle even facing the market threat
like the national healthcare reform
 Out of pocket payment by UC members
for ambulatory care is not uncommon if
UC beneficiaries perceived low quality of
generic products
 It may be critical to consider any
practical policies to curb the drug cost
and promote rational drug use in the
country