Academic journal article Applied Health Economics and Health Policy

Influence of Patient Co-Payments on Atypical Antipsychotic Choice in Poland

Academic journal article Applied Health Economics and Health Policy

Influence of Patient Co-Payments on Atypical Antipsychotic Choice in Poland

Article excerpt


There have been growing levels of prescribing of atypical antipsychotics in the management of schizophrenia across the US and Europe.[1-4] As a result, worldwide sales of atypicals have been over $US5 billion per year since 2000.[2]

The increased prescribing of atypical antipsychotics has been driven by meta-analyses suggesting that they have greater efficacy and functional recovery and lower adverse effects (particularly extrapyramidal adverse effects) than typical antipsychotics.[1,5,6] The improved adverse-effect profile and efficacy of atypical antipsychotics has also led to improved compliance and persistence.[7,8] However, other authors have not seen improved compliance.[9] As a result of a number of studies, the UK National Institute for Health and Clinical Excellence (NICE) endorsed the prescribing of atypicals for patients experiencing problems with typicals and as an alternative first-line treatment, despite acquisition costs significantly higher than typicals.[1,10] More recently, NICE have stated that "For people with newly diagnosed schizophrenia, offer oral antipsychotic medication. Provide information and discuss the benefits and side-effect profile of each drug with the service user. The choice of drug should be made by the service user and healthcare professional together, considering:

* the relative potential of individual antipsychotic drugs to cause extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other side effects (including unpleasant subjective experiences)

* the views of the carer where the service user agrees."[11]

In 2001, the Italian Reimbursement Agency also agreed to fully reimburse atypicals for approved indications; atypicals were previously only reimbursed for patients intolerant to typicals.[2]

The debate about the quality of evidence has continued,[10] with reviews critical of the real-life differences in efficacy between typical and atypical antipsychotics (except for clozapine[12,13]) as well as their overall cost effectiveness.[12-14] This debate has increased, with a recent meta-analysis critical of many studies that have typically compared second-generation (atypical) antipsychotics with high-potency haloperidol, building on earlier studies, which biases the results,[15,16] and only a limited number of studies comparing atypicals and medium-potency first-generation antipsychotics.[16] Alongside this, greater levels of weight gain, hyperlipidaemia and type 2 diabetes mellitus have been seen with atypical antipsychotics than with first-generation antipsychotics.[2,12,13,16] However, others believe the modest health gains achieved with atypical antipsychotics, as sometimes reported in the literature, do not adequately reflect the perceptions of patients, clinicians and carers regarding the improved quality of life (QOL) with atypicals versus typicals.[17]

Despite these controversies, sales of atypical antipsychotics continue to grow[1,2,4,5] and they are endorsed by psychiatrists and patient associations,[10,17] reflecting improvements in QOL in reality.[17] This is likely to remain, certainly in the short to medium term, reflecting real-life experiences even if additional meta-analyses are published questioning the actual extent of differences between the first- and second-generation antipsychotics.[6,15,16] Risperidone and olanzapine are the most commonly prescribed atypical antipsychotics,[2,8,17,18] with clozapine reserved in view of its impact on agranulocytosis.[12] In reality, there appears to be limited clinical difference between risperidone and olanzapine, with head-to-head studies typically favouring the sponsor's drug.[19] There is a similar picture when considering the overall costs of each drug.[18,20]

As a result of this similarity, in Poland, Zyprexa® (olanzapine) and Rispolet® (risperidone) were initially included in one reference group by the National Health Fund, with the price of Rispolet® setting the reimbursed price on a defined daily dose (DDD) basis[21] for both products. …

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