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Sampling in primary care to promote the safe and appropriate prescribing of Proton Pump Inhibitors (PPIs).

Karen Jacobs – Project Manager, Access and Optimal Use team PHARMAC (Pharmaceutical Management Agency, New Zealand)

recognise

review

reduce

relief

Background

Growth in the use of proton pump inhibitors is an international concern. In New Zealand there are approximately 220,000 people (PYE) prescribed a Proton Pump Inhibitor (PPI) each year, of which 35,000 are new patients1. The cost per annum after rebate contract effects is $16m. International and national evidence indicates there is a lack of cutthrough with the usual promotional information to prescribers about the over use of PPIs in primary care2.

Some key results:

Growth in the PPI market continues to decrease. The higher dose 30mg40mg of PPIs has decreased by 6% over the 2007 year. The number of units (tablets) has also decreased in line with prescriptions.

Sampling

• Sampling was launched in November 2007, after a four month delay with registration. Uptake was favourable in the first two months. Awareness needs to be maintained, letting GPs and pharmacists know the starter packs of ranitidine samples can be ordered.

Year-Month

Data title

18% 16% 14% 12%

Declining growth in PPI market

16% 14% 13% 13%

Sum of Packets Doctor Other Sum of Tablets Doctor Other Total Sum of Packets

Nov-07 12,140 4,740 121,400 47,400 16,880 168,800

Dec-07 2,940 640 29,400 6,400 3,580 35,800

Jan-08 360 140 3,600 1,400 500 5,000

Feb-08 20 40 200 400 60 600

Mar-08 80 60 800 600 140 1,400

Grand Total 15,540 5,620 155,400 56,200 21,160 211,600

The campaign

The Gut Reaction campaign was developed to better manage prescribing of PPIs and manage patient expectations. The campaign sets out to decrease the growth rate of PPI prescribing by doctors, by 4% over the first year of the campaign; decrease the number of new patients introduced to a PPI and a decrease in the expenditure on PPIs. General Practictioners (GPs) are encouraged to review their patients while pharmacists are encouraged to intervene where necessary by way of patient education. Pharmacists are provided training and education which offers an incentive for conducting patient reviews and provides useful practice and patient tools to manage patient expectations.

10% 8% 6% 4% 2% 0% 2004 2005 2006 Year ending December 2007

PPI 10-20mg PPI 30-40mg

9% 7% 5% 5%

Total Sum of Tablets

• There has been a favourable response to the supply of starter packs of ranitidine. Positive feedback has been received by way of response cards inserted into sample packs and market research survey.

Objectives

1 To encourage the safe and appropriate prescribing of PPIs by GPs, by offering them a choice of patient management tools and providing new information at presentations given by Gastroenterologist, Professor Gil Barbezat. 2 To promote review and step-down regimen of patients already taking a PPI and offer alternatives where a new patient presents with symptoms that clearly do not warrant a PPI3. 3 To provide free samples of the H2 Receptor Antagonists (H2RAs) ranitidine 150mg in sample packs of 10 tablets to help patient management. A variety of different channels have been employed as well as professional organisations to conduct training & education, and to convey the key messages of the campaign. Advertising in medical journals and Key Opinion Leader presentations to Primary healthcare staff have also played a major role in the impact this campaign has had.

Market research

• There is high unprompted awareness of the campaign with pharmacists and GPs ( 85% and 48% respectively) Total = 57%. • Nearly 60% of GPs who responded (519) to a market survey questionnaire have decreased their prescribing of PPIs in the response to the key messages of this campaign.

Number of ranitidine tablets (150mg) ordered by doctors and pharmacists

56,200 155,400

Doctors Pharmacists

Number of packs ordered by GPs and pharmacist in first five months of sampling

5,620 packets of 10x ranitidine 150mg)

27% 73%

GP’s prescribing response to campaign

Nearly 60% of GPs report that the Gut Reaction campaign has reduced their prescribing of PPIs.

Which of the following is the best description of your response to the Gut Reaction campaign?

(15,540 packets of 10x ranitidine 150mg)

Increased prescibing PPIs No difference to prescibing PPIs Decreased prescibing PPIs to a small extent Decreased prescibing PPIs to a large extent

1% 38% 57% 2%

0% 20% 40% 60% 80%

Conclusions

• A multi-channel, multi disciplinary approach can effect change. • Consistent messages via many different channels helps to keep awareness high. • Sampling may help to shift of perception and habit of prescribers.

Next steps

Continue funding the Gut Reaction campaign to, • Cover the cost of supply of samples; • Keep awareness high; • Support the provision of toolkits to prescribers and patients;and • Conduct a pilot between a selected hospital and community to investigate the best interventions to manage the amount of PPI prescriptions being dispensed into the community.

1 Pharmhouse data-2006 2 Literature review- Dr Osman Mansoor-Public Health Consulting, New Zealand 3 New Zealand Guidelines Group- Dyspepsia and Heartburn Management Guidelines- 2004