ENDEP : A virtual network to provide
evidence on pharmaceutical policies
CHANG MAI ICIUM APRIL 2004
Professor Christine Huttin
Health scientist and research professor
Endep research group coordinator and
Endep US research inc
IAE Aix en Provence and CNRS Paris
ENDEP : What is it ?
• A virtual think tank created in december 1994, as a research activity
discussed with EU representatives.
• Aim: to provide evidence to decision makers on the impact of
pharmaceutical policies
• Evaluation research based on different methodologies
• Combine different policy levels: national and European levels
• A multi country, interdisciplinary team, variable according to projects
• Building partnerships with commercial consulting firms (SKIM)
• Centralisation of data sets and institutionalisation of the research
consortium in the European research area.
• Internationalisation and links with global networks
Examples of drug policy areas researched
by the Endep research group
• Pricing policies: price controls, reference pricing
• Deregulation policies: switching policies
• Copayments and user fees : use of scenario analysis, economic and
pharmacoepidemiological step models, adaptation of reversed conjoint
designs
• Incentives mechanisms to physicians (positive and negative, use of
experimental designs)
• Referral system analysis and rational drug prescribing (link with the
DURG group)
• Comparison of subjective and objective measures of risk perceptions
cardio vascular diseases (link with Ghent/Brussels research
consortium), comparison of theoretical and practical knowledge par
sex
OBJECTIVES OF THE BIOMED PROJECT
• To examine whether and how cost to the patient
through different reimbursement systems in Europe
influence physicians treatment choices and patient
behaviours
• To disentangle prescribing decisions and consumer
decisions
• To generate potential primary data on primary care
services for insertion in health information systems of
the EU monitoring framework (e.g. with the fourth
group on health systems of the ECHI 36 indicators)
Prevalent copayment systems in Europe
Countries Type of charge and level Deductible and ceiling on patients
of charge
AUSTRIA Fixed charge 3.15 per pack
FINLAND Graduated above a fixed 0;25; 50% above deductible
cost deductible
FRANCE Graduated 0;35;65% of drug cost
ITALY Fixed charge
GERMANY Fixed charge 1.56;2.60;3.64 depending on pack
size
UK Fixed charge
Patient charges and patients and
physicians’decision making process
(METHODS)
• In-depth analysis of the influence of various
reimbursement systems on decision making process of
physicians and patients
• Disease specific approach on chronic and acute conditions
(hypertension, hay fever, dyspepsia and hormone
replacement therapy)
• Combination of qualitative focus groups) and surveys
(adapted conjoint designs and patient surveys)
• Internationalisation process (e.g. consensus building)
Patient charges and physicians’decision
making process
The conceptual basis: an adaptation of the Lens model
(Brunswick, 52; Cooksey, 90), Hammond,95:theoretical
background of probability functionalism)
Patient cues Economic cues
True State Judged State
Corrected weights Clinical cues
Judged weights
Cost sensitivity analysis of European
primary care physicians
2. Final design administered by SKIM Analytical (market
survey company)
Given a patient profile:
Patient characteristics: patient affordability,patient requestfor cheaper treatment,
severity of disease (hay fever) or risk factors (hypertension), patients’expenses
on other diseases
Q1: How would you treat this patient ?
Q2: To what extent did you take patient cost into account when you decided how to treat
this Patient ? (scale 1-7)
PATIENT CHARGE AND
PHYSICIANS’COST SENSITIVITY
MAIN RESULTS
Results country A: average utility values
other prescr FF 200
other prescr FF 50
no other disease
all season severe/ 40 cigarettes father died 52
all season/40 cigarettes
certain days/5 cigarettes
patient asks cheaper
patient doesn’t ask
poor/no insurance
poor/insurance
good income/insurance
-1 -0,5 0 0,5 1
hay fever hypertension
Results country B : average utility values
3 other prescr
1 other prescr
no other disease
all season severe/ 40 cigarettes father died 52
all season/40 cigarettes
certain days/5 cigarettes
patient asks cheaper
patient doesn’t ask
low income
moderate income
good income
-1 -0,5 0 0,5 1
hay fever hypertension
Results country C: average utility values
3 other prescr
1 other prescr
no other disease
all season severe/ 40 cigarettes father died 52
all season/40 cigarettes
certain days/5 cigarettes
patient asks cheaper
patient doesn’t ask
low income
moderate income
good income
-1 -0,5 0 0,5 1
hay fever hypertension
Results country D : average utility values
3 other prescr
1 other prescr
no other disease
all season severe/ 40 cigarettes father died 52
all season/40 cigarettes
certain days/5 cigarettes
patient asks cheaper
patient doesn’t ask
low income
moderate income
good income
-1 -0,5 0 0,5 1
hay fever hypertension
LINKING COST SENSITIVTY INDEX FOR
EACH INDIVIDUAL PHYSICIAN WITH
PRESCRIBING INTENTION SHIFTS
PRESCRIBING INTENTION SHIFTS
FOR HYPERTENSION IN COUNTRY A
Diurétiques
IEC(s)
Inhibiteurs
calciques
Antagonistes
angiotensine 2
Beta bloqueurs
-0,15 -0,10 -0,05 0,00 0,05 0,10 0,15
PRESCRIBING INTENTION SHIFTS
FOR HYPERTENSION IN COUNTRY B
diuretic
ACE inhibitor
calcium antagonist
beta blocker
other drug treatment
no drug treatment at
all
1 month
2-3 months
-0,10 -0,05 0,00 0,05 0,10
PRESCRIBING INTENTION SHIFTS
FOR HAY FEVER IN COUNTRY A
CLARITYNE
ZYRTEC
ALLERGODIL
OPTICRON
NASACORT
BECONASE
VIRLIX
NASONEX
MIZOLLEN
NASALIDE
DERINOX
FLIXONASE
TELFAST
PRIMALAN
LOMUSOL
-0,10 -0,05 0,00 0,05 0,10
PRESCRIBING INTENTION SHIFTS
FOR HAY FEVER IN COUNTRY B
non-sedating antihistamine
nasal steroid
eye drops
no drug treatment at all
1 month
2-3 months
-0,20 -0,10 0,00 0,10 0,20
The type of copayment or user fee has also
greatly influenced
other clinical strategies’ dimensions
Cost reduction strategies have been classified in three
categories: the 3 « P »
P: Patient cost related strategies
P: Physician cost related strategies
P: Pharmacist cost related strategies
According to health care systems, decision points where
cost issues are discussed differ
In fixed prescription charge systems, the
prescription of longer supply is the most
used clinical strategies to reduce cost to the
patient
80
70
60
50
40
30
20
10
0
Fin Fr Aus Frg I UK
French, British, Italian and Finnish cost
conscious patients
are high users of strategies where they
ask pharmacist's advice
70
60
use S1
50
use S2
40
use S3
30
use S4
20
use S5
10
use S6
0
Fin Fr Aus Frg I UK
THIS NEW METHOD CAN BE USED
AS A DECISION AID FOR
POLICYMAKERS TO TAILOR USER
FEES AND CONTROL FOR
POTENTIAL EFFECTS ON
INAPPROPRIATE PRESCRIBING OR
MOST COST EFFECTIVE DRUGS
CHANG MAI ICIUM APRIL 2004
Professor Huttin
www.marquiswhoswho/christinehuttin.net
Email: chris.huttin@comcast.net
Endep asbl coordinator and Endep US
research inc Director