The impact of drug price policy on prescribing behaviors and patients right--Analysis of antidepressants
Date Issued
2007
Date
2007
Author(s)
Li, Zong-Jhen
DOI
zh-TW
Abstract
Background：Depression is a chronic mental disorder with high social burden due to its high prevalence rate and significant disability. Currently, drug therapy is the major strategy toward the depression treatment. Among those antidepressants, the second generation antidepressants quickly became the first drug choice in clinical therapy since they have less side effect profile and have similar efficacy when compared to tricyclic antidepressants (TCA) and monoamine oxidase inhibitor (MAOI). The reimbursement price of the 20 mg/tab branded fluoxetine (Prozac®) was reduced from NTD 43.8 to NTD 18.7 by the Bureau of National Health Insurance (BNHI) in March 1, 2003, but not to the other second generation antidepressants. It led to the redistribution of antidepressants market in Taiwan. Can this drug price reduction in deed achieve the goal to reduce the health insurance fee? Will this policy affect the usage of selective serotonin reuptake inhibitors (SSRI)?
Objective：Part I: To collect the papers related to the efficacy of second generation antidepressants and to compare the efficacy of them. Part II: Take fluoxetine as an example to analyze the impacts of dramatic price reduction in single SSRI antidepressant upon the doctor prescribing behaviors and patients benefits.
Methods：Part I: The clinical efficacy of second generation antidepressants was analyzed through a systematic review of literature searched from Medline. Part II: The Patients Medical Claim Dataset with Fluoxetine (PMCDF) in Taiwan provided by BNHI was used for data analysis. Patients prescribed with Prozac® or generic fluoxetine more than or equal to 7 days in both January and February of 2003 with no prescription of any other antidepressants at the same time were retrieved. The changes of antidepressant prescriptions were analyzed after the implementation of fluoxetine price reduction policy on March,1 2003. Drug change ratio and the continuous use ratio for patients in Prozac® group and in generic fluoxetine group were calculated. In both groups, patients under changed prescription or continuous use were further sub-grouped into 2 antidepressant utilization cohorts: (1) continuous use and (2) drug change. The total number of medical visit, medical resource consumptions of those patients were then compared between the two antidepressant utilization cohorts for Prozac® patient group and generic fluoxetine patient group.
Results：Part I: After literature search, the meta analysis for major depressive disorder (MDD), including 46 head to head clinical trials as indicated in the paper by Hansen RA et al. and 5 newly found head to head trials, were carried out. The rate of being a responder at study end did not differ significantly between fluoxetine and paroxetine (relative benefit,1.09 [95% CI, 0.97 to 1.21]). The efficacy of citalopram and escitalopram is similar. (relative benefit,1.06 [95% CI, 0.9 to 1.25]). A modest additional treatment effect (relative benefit, 1.10 [95% CI, 1.01 to 1.22]) for sertraline compared with fluoxetine; and modest additional treatment effect (relative benefit, 1.12 [95% CI, 1.02 to 1.23]) for venlafaxine compared with fluoxetine, were recognized. Part II: A total of 5025 patients and 8739 patients were included for Prozac® group and generic fluoxetine group, respectively. There were more woman in both two groups(56.75％ and 57.57％) in both groups. The mean age of these patients in two groups was 47.0 year old and 48.8 year old. In drug change cohorts of both groups, more than 90％ patients’ fluoxetine prescriptions were replaced by one other drug. The drug for replacement were mainly the SSRIs (50.86％) for Prozac® group and TCA+TeA (50.92％) for generic fluoxetine group. The prescription change patterns are different for both groups and depend on the type of medical institutions. In Prozac® group, the mean number of total medical visit in drug change cohorts was significantly higher than that in continuous use cohorts (general department, psychiatric department, emergency department, hospital admissions and psychiatric admissions). In generic fluoxetine group, there were no significant difference between the drug change cohorts and continuous use cohorts in terms of medical visits. In Prozac® group, the mean medical resource consumptions in drug change cohorts were significantly higher than those in continuous use cohorts. However, in generic fluoxetine group, the mean medical resource consumptions in drug change cohorts were significantly higher than those in continuous use cohorts with no significant difference.
Conclusions：Part I: In MDD, the clinical efficacy in SSRIs is similar and the clinical efficacy between SNRIs SNRI, NaSSA, NDRI and SSRIs is similar. Part II: The policy of dramatic drug price reduction for single agent had significantly affect the prescription switched for the first three months after the policy implemented. There was a high percentage of the antidepression prescriptions switching to the other SSRIs with higher drug price profit. This is not necessarily beneficial for the use and distribution of BNHIs’ medical resources. Besides, different type of medical institution, different drug payment system and different drug inclusion principles may also influence doctors’ prescribing behaviors. For instance, the fixed-drug daily payment may lead doctors in clinics to use drugs with lower prices such as TCA with TeA. For patients and their family, they may not be informed with the change of antidepressant prescription, even worse that, such change may result in more medical visits and hence have impact on patients’ benefits.
Subjects
藥價政策
處方行為
健保資料庫
抗憂鬱劑
選擇性血清促進素再吸收抑制劑
Drug price policy
prescribing behaviors
national health insurance database
antidepressants
selective serotonin reuptake inhibitor
SDGs
Type
text
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