N.Kadyrova, B.Waning, C.Cashin

1. ICUM 2004, Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 KYRGYZSTAN OUTPATIENT DRUG (OPD) BENEFIT PROGRAM:USE OF AUTOMATED CLAIMS DATA TO EVALUATE THE IMPACT OF THE ODP BENEFIT PROGRAM ON RATIONAL DRUG PRESCRIBING BY PHYSICIANS AND GENERIC DRUG USE BY PATIENTS N.Kadyrova, B.Waning, C.Cashin Mandatory Health Insurance Fund under the Ministry of Health of the Kyrgyz Republic Boston University

2. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Background information: Code book for reimbursement by HIF • Main goal of the OPD Benefit Program is to improve access of insured population to medicines at primary care through reimbursement for drugs prescribed by family physicians on generic names • Main principles of the OPD BP: • Mandatory prescription of medicines by physicians under Generics • Patient’s choice of a pharmacy and most reasonable medicine within prescribed generic • Patient’s co-payment for medicines • Training of physicians • Inclusion of reimbursement medicines for primary care sensitive conditions according to clinical guidelines • Collecting data about prescribed medicines from Family group practices, data about sold medicines from participating pharmacies, data about reimbursement medicines from TDs MHIF Generics Brands Prescription form 8 4 0 2 0 5 Generic Code Brand code Code of sold drug

3. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Objectives of the study: • Study of prescribing behavior of physicians • Study of generic using by consumers • Study of determinants of the rational drug use such as prescribing injections, adherence of clinical protocols in clinical practice • Study of OPD BP/ADP utilization for primary care sensitive conditions

4. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Methodology: • Using automated information system for ADP • Collection and analysis of Data provided by Family Group Practices, private participating pharmacies, TDs MHIF that include more than 800 thousands prescriptions records and all information about sold and reimbursed medicines • Transfer of data to Excels’ pivot tables and using statistic methods for analysis • Quantitative analysis of the computerized ADP Data base • ABC analysis of ADP

5. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program : Results Share of prescribed medicines using Generic names, 2000-2003 • Changing in Physicians behavior: • – adherence to clinical guidelines, • prescribing drugs on generics • in general reducing share of prescribed injections Share of prescribed injections and oral medicines, 2000-2003,% Sources: MHIF ADP Data, 2004

6. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Results • In some cases patients used injectable medicines (Antibiotics, Diclofenacum) • Prescription of Ampicillinum in injec. for children under 5 in almost 15% of cases Sources: MHIF ADP Data, 2004

7. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program : ABC analysis, 2000 Results • ABC analysis shows that 80% of reimbursement cover more than 1/3 of medicines from reimbursement list • There are no differences in use of Generics among working population and pensioners ABC analysis, 2003 Sources: MHIF ADP Data, 2004

8. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program : Results • In most of cases patients prefer to buy Generics, that are chipper than Brands • In some cases using Generics by patients depends on medicine promotion at the market (Enalaprilum), and doesn’t depend on prices Using Generics and Brands (Metronidazolum andEnalaprilum) by patient Sources: MHIF ADP Data, 2004

9. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program : Results • Implementation of the clinical protocols in practice improves using of Generics by patients especially for primary care sensitive conditions Using Generics by patient according to clinical guidelines Sources: MHIF ADP Data, 2004

10. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Conclusions • Coordinating list of reimbursed drugs with standard treatment guidelines promotes rational prescribing of medicines • Generic drug use is maximized when mandatory generic prescribing is combined with co-payment structures favoring the use of generics • Providing outpatient medicines increases access to primary care, especially for primary care sensitive conditions • High level of prescription and use of antibiotics particularly by children under 5 • Aggressive marketing by pharmaceutical companies has profound impact on patient choices when purchasing drugs Sources: MHIF ADP Data, 2004

11. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Key lessons learned: • Routinely collected automated claims data are very useful for evaluating drug use at prescriber, dispenser and patient level • Focusing on medicines most appropriate for use at primary level contributes to improvement of health care quality and rational prescribing of medicines in accordance with clinical protocols for PHC sensitive conditions • Choice of the medicine bought by a patient in a pharmacy depends on doctor’s and pharmacist’s behavior as well as aggressive marketing on the part of pharmaceutical companies and low awareness of patients

12. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Implications of ADP • The database simplifies monitoring of rational use of medicines and behavior both of doctors, pharmacists and patients • The database on ADP gives an opportunity to provide analysis of prices on generic and trade names of medicines with various dosage forms and improve policy on the rational use of medicines • Introduction of the ADP has an impact on doctors’ behavior in rational prescribing of medicines • Introduction of the ADP with mandatory prescription of medicines by generic has an impact on patient’s behavior in choice of the medicine • Sale of medicines by prescription improves control over use of medicines

13. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program Specific studies for future research agenda: • Providing a survey on rational use of antibiotics, injections in particular by children under 5 in the framework of the IMCI Program • Study of factors having an impact on choice of the medicine by a patient through interviewing at prescriber, dispenser and patient level • Impact of ADP on rate of hospital admissionson monitored conditions, study of the ADP’s cost-effectiveness in the long-term period

14. ICUM 2004 Second International Conference on Improving Use of Medicines , Chiang Mai, Thailand, March 30-April 2, 2004 Kyrgyzstan Outpatient Drug Benefit Program http://foms.med.kg