‘No-Frills Prils’: GPs’ views on drug costs and therapeutic interchange of angiotensin-converting enzyme inhibitors: a qualitative study
Hok Lim
A C , Lena Sanci A , Susan Webster A , Alyce N. Wilson B and Phyllis Lau A
A Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Level 3, 780 Elizabeth Street, Melbourne, Vic. 3010, Australia.
B International Development, Burnet Institute, 85 Commercial Road, Prahran, Vic. 3181, Australia.
C Corresponding author. Email: hokl@unimelb.edu.au
Australian Journal of Primary Health 27(2) 152-157 https://doi.org/10.1071/PY20208
Submitted: 10 September 2020 Accepted: 2 December 2020 Published: 9 March 2021
Abstract
Medications form a significant portion of spending in primary health care. Angiotensin-converting enzyme inhibitors (ACE-Is) are among the most prescribed blood pressure medications in general practice. Medications within this class are considered therapeutically equivalent, but the cost of each ACE-I varies. Our aim was to explore cost and other factors that influence general practitioners (GPs) to prescribe a specific ACE-I and understand their views on therapeutic interchange within this drug class. We conducted a qualitative study of Australian GPs using thematic analysis. We found that GPs were aware of therapeutic equivalency within the ACE-I class, but unaware of the cost differences. Although GPs tended to adopt a prescribing preference, they were open to fewer prescribing options if there was a decreased cost to patients and the PBS, or potential to minimise prescribing error. Our findings have immediate relevance for national prescribing policies and the Pharmaceutical Benefits Scheme (PBS). The wide selection of ACE-Is that are available results in diverse prescribing patterns and may not be cost-effective for patients or the PBS. Restricting the number of drug options within the ACE-I class in primary care appears to be an acceptable drug cost-containment strategy according to our sample of GPs.
Keywords: ACE inhibitors, drug cost, general practice, primary care, therapeutic interchange.
References
Australian Medicines Handbook Pty Ltd (2019) ‘Australian Medicines Handbook 2019.’ (Australian Medicines Handbook Pty Ltd: Adelaide, SA, Australia)Australian Prescriber (2018) Top 10 drugs 2017–18. Australian Prescriber 41, 194
| Top 10 drugs 2017–18.Crossref | GoogleScholarGoogle Scholar | 30670888PubMed |
Bahiru E, De Cates AN, Farr MR, Jarvis MC, Palla M, Rees K, Ebrahim S, Huffman MD (2017) Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular diseases. Cochrane Database of Systematic Reviews CD009868
| Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular diseases.Crossref | GoogleScholarGoogle Scholar |
Baluch WM, Gardner JS, Krauss RH, Scholes D (1999) Therapeutic interchange of conjugated and esterified estrogens in a managed care organization. American Journal of Health-System Pharmacy 56, 537–542.
| Therapeutic interchange of conjugated and esterified estrogens in a managed care organization.Crossref | GoogleScholarGoogle Scholar | 10192688PubMed |
Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101.
| Using thematic analysis in psychology.Crossref | GoogleScholarGoogle Scholar |
Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, Pan Y, Charles J, Pollack AJ, Wong C (2016) General practice activity in Australia 2015–16. Sydney University Press, Sydney, NSW, Australia.
Cumming J, Mays N, Daubé J (2010) How New Zealand has contained expenditure on drugs. BMJ (Clinical Research Ed.) 340, c2441
Department of Health (2019) Pharmaceutical Benefits Scheme (Report on the Collection of Under Co-payment Data 2017–18). (Department of Health: Canberra, ACT, Australia) Available at http://www.pbs.gov.au/info/statistics/under-co-payment/ucp-data-report [Verified 1 May 2019]
Duckett S, Breadon PJ (2015) Premium policy? Fixing the policy for switching drugs. (Grattan Institute: Melbourne, Vic., Australia) Available at https://grattan.edu.au/wp-content/uploads/2015/06/823-Premium-Policy4.pdf [Verified 1 May 2019]
Faulkner SL, Trotter SP (2017) Data saturation. In ‘The international encyclopedia of communication research methods’. (Eds J Matthes, CS Davis, RF Potter) pp. 1–2.
Gray T, Bertch K, Galt K, Gonyeau M, Karpiuk E, Oyen L, Sudekum MJ, Vermeulen LC (2005) Guidelines for Therapeutic Interchange—2004. Pharmacotherapy 25, 1666–1680.
| Guidelines for Therapeutic Interchange—2004.Crossref | GoogleScholarGoogle Scholar | 16232030PubMed |
Growdon ME, Sacks CA, Kesselheim AS, Avorn J (2019) Potential Medicare savings from generic substitution and therapeutic interchange of ACE inhibitors and angiotensin-II-receptor blockers. JAMA Internal Medicine 179, 1712–1714.
Ioannides-Demos LL, Ibrahim JE, McNeil JJ (2002) Reference-based pricing schemes. PharmacoEconomics 20, 577–591.
| Reference-based pricing schemes.Crossref | GoogleScholarGoogle Scholar | 12141886PubMed |
Larmour I, Pignataro S, Barned K, Mantas S, Korman M (2011) A therapeutic equivalence program: evidence-based promotion of more efficient use of medicines. The Medical Journal of Australia 194, 631–634.
| A therapeutic equivalence program: evidence-based promotion of more efficient use of medicines.Crossref | GoogleScholarGoogle Scholar | 21692719PubMed |
Lee TH (2004) “Me-too” products — friend or foe? The New England Journal of Medicine 350, 211–212.
| “Me-too” products — friend or foe?Crossref | GoogleScholarGoogle Scholar | 14724297PubMed |
McDowell R, Bennett K, Moriarty F, Clarke S, Barry M, Fahey T (2018) An evaluation of prescribing trends and patterns of claims within the Preferred Drugs Initiative in Ireland (2011–2016): an interrupted time-series study. BMJ Open 8, e019315
| An evaluation of prescribing trends and patterns of claims within the Preferred Drugs Initiative in Ireland (2011–2016): an interrupted time-series study.Crossref | GoogleScholarGoogle Scholar | 29858402PubMed |
Pharmacetical Benefits Scheme (PBS) (2019) ‘Pharamaceutical Benefits Scheme’. (Department of Health: Canberra, ACT, Australia) Available at https://www.pbs.gov.au/browse/group-premium#:~:text=THERAPEUTIC%20GROUP%20PREMIUM%20POLICY&text=The%20Australian%20Government%2C%20through%20the,with%20a%20therapeutic%20group%20premium).&text=drug%20interactions%20occurring%20with%20all%20of%20the%20base%2Dpriced%20drugs%3B%20or [Verified 1 May 2019]
Pharmac (2019) ‘Online Pharmaceutical Schedule.’ Available at https://www.pharmac.govt.nz/wwwtrs/ScheduleOnline.php?code=A070701 [Verified 1 May 2019]
Rabbani A, Alexander GC (2008) Out-of-pocket and total costs of fixed-dose combination antihypertensives and their components. American Journal of Hypertension 21, 509–513.
| Out-of-pocket and total costs of fixed-dose combination antihypertensives and their components.Crossref | GoogleScholarGoogle Scholar | 18437141PubMed |
Sacks CA, Lee CC, Kesselheim AS, Avorn J (2018) Medicare spending on brand-name combination medications vs their generic constituents. Journal of the American Medical Association 320, 650–656.
| Medicare spending on brand-name combination medications vs their generic constituents.Crossref | GoogleScholarGoogle Scholar | 30140875PubMed |
Stoysich A, Massoomi F (2002) Automatic interchange of the ACE inhibitors: decision-making process and initial results. Formulary (Cleveland, Ohio) 37, 41–44.
Therapeutic Guidelines Ltd (2019) Angiotensin converting enzyme inhibitors to reduce blood pressure. (Therapeutic Guidelines Ltd: Melbourne, Vic., Australia) Available at https://tgldcdp-tg-org-au.ezp.lib.unimelb.edu.au/viewTopic?topicfile=blood-pressure-reduction#toc_d1e249 [Verified 15 February 2019]
Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 19, 349–357.
| Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.Crossref | GoogleScholarGoogle Scholar | 17872937PubMed |
Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, Depalma SM, Gidding S, Jamerson KA, Jones DW, Maclaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT (2018) 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force. Hypertension 71, 1269–1324.
| 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force.Crossref | GoogleScholarGoogle Scholar | 29133354PubMed |
