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Abstract
Introduction: Evidence has shown that utilization of antiosteoporotic medications does not correspond with risk, and studies on other therapies have shown that adequacy of pharmaceutical prescribing might vary between regions. Nevertheless, very few studies have addressed the variability in osteoporotic drug consumption. We aimed to describe variations in pharmaceutical utilization and spending on osteoporotic drugs between Health Areas (HA) in Spain.Methods: Population-based cross-sectional ecological study of expenditure and utilization of the five therapeutic groups marketed for osteoporosis treatment in Spain in 2009. Small area variation analysis (SAVA) methods were used. The units of analysis were the 168 HA of 13 Spanish regions, including 7.2 million women aged 50 years and older. The main outcomes were the defined daily dose (DDD) per 1000 inhabitants and day (DDD/1000/Day) dispensed according to the pharmaceutical claims reimbursed, and the expenditure on antiosteoporotics at retail price per woman ≥50 years old and per year.Results: The average osteoporosis drug consumption was 116.8 DDD/1000W/Day, ranging from 78.5 to 158.7 DDD/1000W/Day between the HAs in the 5th and 95th percentiles. Seventy-five percent of the antiosteoporotics consumed was bisphosphonates, followed by raloxifene, strontium ranelate, calcitonins, and parathyroid hormones including teriparatide. Regarding variability by therapeutic groups, biphosphonates showed the lowest variation, while calcitonins and parathyroid hormones showed the highest variation. The annual expenditure on antiosteoporotics was €426.5 million, translating into an expenditure of €59.2 for each woman ≥50 years old and varying between €38.1 and €83.3 between HAs in the 5th and 95th percentiles. Biphosphonates, despite accounting for 79% of utilization, only represented 63% of total expenditure, while parathyroid hormones with only 1.6% of utilization accounted for 15% of the pharmaceutical spending.Conclusion: This study highlights a marked geographical variation in the prescription of antiosteoporotics, being more pronounced in the case of costly drugs such as parathyroid hormones. The differences in rates of prescribing explained almost all of the variance in drug spending, suggesting that the difference in prescription volume between territories, and not the price of the drugs, is the main source of variation in this setting. Data on geographical variation of prescription can help guide policy proposals for targeting areas with inadequate antiosteoporotic drug use.
Highlights
Evidence has shown that utilization of antiosteoporotic medications does not correspond with risk, and studies on other therapies have shown that adequacy of pharmaceutical prescribing might vary between regions
Biphosphonates, despite accounting for 78.7% of utilization, only represented 62.9% of total expenditure on osteoporosis drugs, while parathyroid hormones with only 1.6% of utilization accounted for 14.9% of the osteoporosis pharmaceutical spending
We found that variation in drug utilization was transferred almost entirely to variation in expenditure per capita and rates of prescribing explained almost all of the variance in drug spending
Summary
Evidence has shown that utilization of antiosteoporotic medications does not correspond with risk, and studies on other therapies have shown that adequacy of pharmaceutical prescribing might vary between regions. Previous studies suggest that various countries including Spain are seeing a massive use of osteoporotic treatments in young women with a very low risk of fracture, while there is a significant underuse in women (and men) at a high risk of fracture, including those who have already suffered a major osteoporotic fracture (de Felipe et al, 2010; Sanfélix-Genovés et al, 2013b; Wang et al, 2013; Yu, 2017) This might be due to the existence of considerable uncertainty about how to quantify the risk, who should receive densitometry testing, who should be treated, what treatment should be used, and for how long (Bolland and Grey, 2010; Sanfélix-Genovés et al, 2013a; Hurtado et al, 2014). Beyond the evidence provided by clinical trials and the agreements reached by expert consensus panels, treatment decisions and the choice of a particular treatment may be influenced by patient characteristics, physician, and organizational factors, pharmaceutical promotion, and healthcare system characteristics such as copayment, accessibility, or others (Eisenberg, 2002)
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