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15 October 2010
A report has considered the extent and causes of variations in drug usage among 14 developed countries. It found that although some emerge as generally high or low users, there is no uniform pattern across disease areas or categories of drugs. The UK ranked highly in three of these, including acute MI care and statin uptake; intermediately in six, including cancer drugs launched between six and ten years ago; and relatively low in others, including cancer drugs launched outside that period. Overall, the UK ranked 8th out of the 14 countries studied.
Action
The report stresses that its findings should be treated with caution, and it includes no judgement as to whether a high or low level of usage would represent good clinical practice. However, stakeholders involved in improving services in the disease areas studied are encouraged to assess the report’s findings and consider whether the levels of usage seen in the UK are appropriate.
Background
Although there is little good quality evidence to support the view, it is perceived in some quarters that the UK is a relatively low user of newer drugs, compared with other countries. As a result of this, the Secretary of State for Health commissioned a study to determine the extent and causes of any international variations. This study measured the levels of uptake for 14 different categories of drug, across different medical conditions, in 14 different countries. These included 10 western European countries, Australia, New Zealand, Canada and the USA. The report steering group was co-chaired by Professor Sir Mike Richards, NHS National Cancer Director, and John Melville, General Manager, Roche UK. The Steering group included clinicians, senior civil servants from the DH, and representatives of the pharmaceutical industry, NICE and patients.
This report details the initial findings of the study. It does not attempt to identify a correct level of drug usage, but rather to identify where variations exist and offer potential explanations for those variations.
What did the report find?
As with most other countries included in the study, the UK’s ranking across disease areas and drug categories was not consistent. The UK ranked highly in three disease areas or drug categories (acute myocardial infarction [MI], respiratory distress syndrome and statins) whereas a low rank was seen in seven others (cancer drugs launched within the last five years, cancer drugs launched more than 10 years ago, dementia, hepatitis C, multiple sclerosis, rheumatoid arthritis and second generation antipsychotics). For the four remaining areas an intermediate rank was seen (cancer hormones, cancer drugs launched between six and 10 years ago, osteoporosis and wet age-related macular degeneration).
Many factors were considered as possibly having an impact on drug usage. Although the level of spending on health was suggested as a potential cause of variations, it does not appear to be a strong determinant. Put simply, countries that spend the most on health do not always have the highest levels of medicines usage and countries spending less on their total health budget can be high users of medicines. Health technology assessment processes and outcomes can have a significant impact on levels of usage, as can service planning, organisation and direction. However, clinical culture and attitudes towards treatment remain important determinants in levels of uptake.
Explanations for the high ranking of the UK for thromobolytic treatment for MI and statins for cardiovascular disease (CVD) include international variations in the prevalence of CVD and risk factors, including diet and lifestyle factors; impact of established guidelines and incentives; effective service organisation and delivery etc. Explanations for the low ranking of the use of cancer drugs include:-
- the possibility that clinicians’ and patients’ may be more toxicity-averse than those in other countries
- the impact of NICE guidance
- the relative cost of drugs and impact of purchase deals
- survival rates for some of the cancers between countries, which may impact on the length of time the drugs are used.
So what?
The data have many limitations, which are discussed in some detail within the report. There are, for example, differences in the methods, extent and accuracy of data collection; difficulties interpreting the data; differences in demographics and epidemiology of disease between countries; differences in availability of drugs, their licensed indications and dosages etc. In addition, there is often no consensus about what the optimum level of medicines usage is, and the appropriate level of usage may vary because of different factors at work in different health economies. For some disease areas high usage may be a sign of weakness at other points in the care pathway (e.g. second generation antipsychotics for dementia) and low usage may be a sign of effective disease prevention (e.g. statins for CVD). For others, low usage may suggest that patient’s needs are not being met effectively (e.g. cancer drugs) and high usage may imply that patients are receiving the best treatment (e.g. thromobolytics for acute MI and use of statins for CVD). A previous report found that in England the use of new medicines approved by NICE was higher than expected in seven of the 12 appraisals where a comparison could be made.
In spite of the limitations of the data, the findings presented in the report will be useful to those with a stake in improving services in the disease areas that have been studied to assist in the evaluation of changes which have already been implemented and help inform the development of policy and practice.
Some stakeholders may also wish to consider the initial report produced by the NPC as part of the Quality, Innovation, Productivity and Prevention (QIPP) agenda involving medicines. It gives an initial list of therapeutic topics for early consideration, which offer opportunities for maintaining or improving quality and enhancing value for money. More information is available on the NPC website.
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