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Long-Term Costs and Health Consequences of Issuing Shorter Duration Prescriptions for Patients with Chronic Health Conditions in the English NHS

Abstract

Background

The National Health Service (NHS) in England spends over £9 billion on prescription medicines dispensed in primary care, of which over two-thirds is accounted for by repeat prescriptions. Recently, GPs in England have been urged to limit the duration of repeat prescriptions, where clinically appropriate, to 28 days to reduce wastage and hence contain costs. However, shorter prescriptions will increase transaction costs and thus may not be cost saving. Furthermore, there is evidence to suggest that shorter prescriptions are associated with lower adherence, which would be expected to lead to lower clinical benefit. The objective of this study is to estimate the cost-effectiveness of 3-month versus 28-day repeat prescriptions from the perspective of the NHS.

Methods

We adapted three previously developed UK policy-relevant models, incorporating transaction (dispensing fees, prescriber time) and drug wastage costs associated with 3-month and 28-day prescriptions in three case studies: antihypertensive medications for prevention of cardiovascular events; drugs to improve glycaemic control in patients with type 2 diabetes; and treatments for depression.

Results

In all cases, 3-month prescriptions were associated with lower costs and higher QALYs than 28-day prescriptions. This is driven by assumptions that higher adherence leads to improved disease control, lower costs and improved QALYs.

Conclusion

Longer repeat prescriptions may be cost-effective compared with shorter ones. However, the quality of the evidence base on which this modelling is based is poor. Any policy rollout should be within the context of a trial such as a stepped-wedge cluster design.

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References

  1. Health and Social Care Information Centre. Prescription cost analysis fact sheet, England, 2015. Fact sheet.  http://www.hscic.gov.uk/catalogue/PUB20200/pres-cost-anal-eng-2015-fact.pdf. Accessed 1 Mar 2018.

  2. NHS Employers. Pharmaceutical services negotiating committee, general practitioners committee. Guidance for the implementation of repeat dispensing: NHS Employers; 2013.

  3. Pharmaceutical Services Negotiating Committee. Medicines wastage and 28 day prescribing guidance. London: Pharmaceutical Services Negotiating Committee; 2007.

    Google Scholar 

  4. NHS Cambridgeshire. Repeat medication for 28 Days. Cambridge: Cambridgeshire Primary Care Trust; 2009.

  5. NHS North East Essex. Prescribing interval policy. Clacton-on-Sea: North East Essex Primary Care Trust; 2010.

  6. NHS Dorset Clinical Commissioning Group. Medicines code chapter 15: policy for repeat prescribing and medication review.  Poole: NHS Dorset Clinical Commissioning Group; 2013.

  7. National Audit Office. Prescribing costs in primary care. London: National Audit Office; 2007.

    Google Scholar 

  8. Trueman P, Lowson K, Blighe A, Meszaros A, Wright D, Glanville J, et al. Evaluation of the scale, causes and costs of waste medicines—final report: York Health Economics Consortium and The School of Pharmacy University of London; 2010.

  9. White KG. UK interventions to control medicines wastage: a critical review. Int J Pharm Pract. 2010;18:131–40.

    PubMed  Google Scholar 

  10. Domino ME, Olinick J, Sleath B, Leinwand S, Byrns PJ, Carey T. Restricting patients’ medication supply to one month: saving or wasting money? Am J Health-Syst Pharm. 2004;61(13):1375–9.

    PubMed  Google Scholar 

  11. Mitchell AL, Hickey B, Hickey JL, Pearce SH. Trends in thyroid hormone prescribing and consumption in the UK. BMC Public Health. 2009;9:132.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Wong MC, Tam WW, Wang HH, Cheung CS, Tong EL, Cheung N, et al. Duration of initial antihypertensive prescription and medication adherence: A cohort study among 203,259 newly diagnosed hypertensive patients. Int J Cardiol. 2015;182:503–8.

    Article  PubMed  Google Scholar 

  13. King S, Miani C, Exley J, Larkin J, Kirtley A, Payne RA. The impact of issuing longer versus shorter duration prescriptions: a systematic review. Br J Gen Pract. 2018.

  14. Doble B, Payne R, Harshfield A, Wilson EC. Retrospective, multicohort analysis of the Clinical Practice Research Datalink (CPRD) to determine differences in the cost of medication wastage, dispensing fees and prescriber time of issuing either short (< 60 days) or long (≥ 60 days) prescription lengths in primary care for common, chronic conditions in the UK. BMJ Open. 2017;7(12):e019382.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Batal HA, Krantz MJ, Dale RA, Mehler PS, Steiner JF. Impact of prescription size on statin adherence and cholesterol levels. BMC Health Serv Res. 2007;7:175.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. 4th ed. Oxford: Oxford University Press; 2015.

    Google Scholar 

  17. Curtis L, Burns A. Unit Costs of Health and Social Care 2016. Canterbury: Personal Social Services Research Unit, The University of Kent; 2016.

    Google Scholar 

  18. National Institute for Health and Clinical Excellence. Hypertension in adults: diagnosis and management. London: National Institute for Health and Clinical Excellence; 2011.

    Google Scholar 

  19. Hermes M, Gleason PP, Starner CI. Adherence to chronic medication therapy associated with 90-day supplies compared with 30-day supplies. J Manag Care Pharm. 2010;16(2):141–2.

    Google Scholar 

  20. Taitel M, Fensterheim L, Kirkham H, Sekula R, Duncan I. Medication days’ supply, adherence, wastage, and cost among chronic patients in Medicaid. Medicare Medicaid Res Rev. 2012;2(3):E1–13.

    Article  Google Scholar 

  21. NHS Business Services Authority on behalf of the Department of Health. Electronic drug tariff. Part IIIA -Professional Fees (Pharmacy Contractors) August 2016 . London: NHS Business Services Authority; 2016. http://www.drugtariff.nhsbsa.nhs.uk/#/00336026-DD_1/DD00336022/Home. Accessed 1 Aug 2016.

  22. NHS Business Services Authority. Prescription Cost Analysis Data. 2015. http://www.nhsbsa.nhs.uk/PrescriptionServices/3494.aspx. Accessed 1 Aug 2016.

  23. National Collaborating Centre for Mental Health. National Institute for Health and Clinical Excellence.  London: The British Psychological Society and The Royal College of Psychiatrists; 2010 (updated 2016).

  24. Pfeiffer PN, Szymanski BR, Valenstein M, McCarthy JF, Zivin K. Trends in antidepressant prescribing for new episodes of depression and implications for health system quality measures. Med Care. 2012;50(1):86–90.

    Article  PubMed  Google Scholar 

  25. Bhatnagar P, Wickramasinghe K, Williams J, Rayner M, Townsend N. The epidemiology of cardiovascular disease in the UK 2014. Heart. 2015;3:2015.

    Google Scholar 

  26. Elliott RA, Tanajewski L, Gkountouras G, Avery AJ, Barber N, Mehta R, et al. Cost effectiveness of support for people starting a new medication for a long-term condition through community pharmacies: an economic evaluation of the new medicine service (NMS) compared with normal practice. Pharmaco Econ. 2017:1–19.

  27. Parikh S, Dishman B, Smith T. Ninety-day versus thirty-day drug-dispensing systems. Am J Health-Syst Pharm. 2001;58(1):1190–1.

    CAS  PubMed  Google Scholar 

  28. Rabbani A, Alexander GC. Cost savings associated with filling a 3-month supply of prescription medicines. Appl Health Econ Health Policy. 2009;7(4):255–64.

    Article  PubMed  Google Scholar 

  29. Walton S, Arondekar B, Johnson N, Schumock G. A model for comparing unnecessary costs associated with various prescription fill-quantity policies: illustration using VA data. J Managed Care Pharm. 2001:384–90.

  30. Domino ME, Martin BC, Wiley-Exley E, Richards S, Henson A, Carey TS, et al. Increasing time costs and copayments for prescription drugs: an analysis of policy changes in a complex environment. Health Serv Res. 2011;46(3):900–19.

    Article  PubMed  PubMed Central  Google Scholar 

  31. NHS Choices. NHS in England - help with health costs. 2016. http://www.nhs.uk/NHSEngland/Healthcosts/Pages/Prescriptioncosts.aspx. Accessed Aug 2016.

  32. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management (NG28). London: National Institute for Health and Care Excellence; 2015.

    Google Scholar 

  33. National Institute for Health and Care Excellence. Depression in adults: recognition and management (CG90). London: National Institute for Health and Care Excellence; 2016.

    Google Scholar 

  34. Clarke P, Gray A, Holman R. Estimating utility values for health states of type 2 diabetic patients using the EQ-5D (UKPDS 62). Med Decis Mak. 2002;22(4):340–9.

    Article  Google Scholar 

  35. Sapin C, Fantino B, Nowicki M-L, Kind P. Usefulness of EQ-5D in assessing health status in primary care patients with Major depressive disorder. Health Qual Life Outcomes. 2004;2(1):1–8.

    Article  Google Scholar 

  36. Cipriani A, Furukawa T, Salanti G, Geddes J, Higgins J, Churchill R, et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet. 2009;373(9665):746–58.

    CAS  Article  PubMed  Google Scholar 

  37. Clarke P, Gray A, Legood R, Briggs A, Holman R. The impact of diabetes-related complications on healthcare costs: results from the United Kingdom Prospective Diabetes Study (UKPDS Study No. 65). Diabet Med. 2003;20(6):442–50.

    CAS  Article  PubMed  Google Scholar 

  38. Murphy G, Simons A, Wetzel R, Lustman P. Cognitive therapy and pharmacotherapy. Singly and together in the treatment of depression. Arch Gen Psychiatry. 1984;41(1):33–41.

    CAS  Article  PubMed  Google Scholar 

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Acknowledgements

The authors wish to thank the authors of the decision models for allowing us to use their work in our analysis. The models were originally developed by the NICE internal guideline team and the National Guideline Centre (NGC) (case studies 1 and 2) and the National Collaborating Centre for Mental Health (NCCMH) (case study 3). The authors of this paper are responsible for the adaptations to the decision models. The authors also wish to thank Rachel Elliot (University of Manchester), Catherine Meads (Anglia Ruskin University), Jon Sussex (Cambridge Centre for Health Services Research, RAND Europe) and other colleagues at the Cambridge Centre for Health Services Research (RAND Europe and University of Cambridge) for providing valuable input and advice. The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR or the Department of Health.

Data Availability Statement

The decision models used in this study were developed and shared with the authors by third parties (NGC and NCCMH). Whilst not publicly available, they were provided to the journal’s peer reviewers for their reference when reviewing this paper and may be requested from the corresponding author [AM].

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Authors

Contributions

All authors contributed to the conception and design of this study. Adam Martin and Edward Wilson led the adaptations of the decision models and the reporting of results. All authors were involved in drafting and commenting on the paper and have approved the final version. Adam Martin is the guarantor of the study.

Corresponding author

Correspondence to Adam Martin.

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Conflict of interest

Adam Martin, Rupert Payne and Edward Wilson declare that they have no conflict of interest.

Funding

This research was supported by a grant from the National Institute for Health Research (NIHR), Health Technology Assessment funding stream (Grant Reference: NIHR HTA 14/159/07).

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Martin, A., Payne, R. & Wilson, E.C. Long-Term Costs and Health Consequences of Issuing Shorter Duration Prescriptions for Patients with Chronic Health Conditions in the English NHS. Appl Health Econ Health Policy 16, 317–330 (2018). https://doi.org/10.1007/s40258-018-0383-9

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  • DOI: https://doi.org/10.1007/s40258-018-0383-9