title: Prescribing efficiency of proton pump inhibitors in China: influence and future directions.
abstract: BACKGROUND
  Pharmaceutical expenditure is currently rising by 16% per annum in China, greater in recent years. Initiatives to moderate growth include drug pricing regulations, essential medicine lists and encouraging generic prescribing. These are principally concentrated in hospitals, which currently account for over 80% of total pharmaceutical expenditure. However, no monitoring of prescribing and perverse incentives encouraging physicians and hospitals to profit from drug procurement encourages irrational prescribing. This includes greater utilisation of originators versus generics as well as injectables when cheaper oral equivalents are available. The objective of the paper is to assess changes in proton pump inhibitor (PPI) utilisation and expenditure in China as more generics become available including injectables.
  
  
  METHODS
  Observational retrospective study of PPI utilisation and procured expenditure between 2004 and 2013 in the largest teaching hospital in Chongqing District as representative of China.
  
  
  RESULTS
  Appreciable increase in PPI utilisation during the study period rising 10.4 fold, with utilisation of generics rising faster than originators. Oral generics reached 84% of total oral preparations in 2013 (defined daily dose basis), with generic injectables 93% of total injectables by 2013. Injectables accounted for 42% of total PPI utilisations in 2008 and 2009 before falling to below 30%. Procured prices for oral preparations reduced over time (-34%). Generic oral omeprazole in 2010 was 87% below 2004 originator prices, mirroring reductions seen in Western Europe. Injectable prices also decreased over time (-19%). However, injectables typically 4.3 to 6.8 fold more expensive than equivalent orals - highest for injectable lansoprazole at 13.4 to 18.0 fold. High utilisation of more expensive oral PPIs as well as injectables meant that PPI expenditure increased 10.1 fold during the study period. Lower use of injectables, and only oral generic omeprazole, would result in accumulated savings of CNY249.65 million, reducing total accumulated expenditure by 84%.
  
  
  CONCLUSIONS
  Encouraging to see high utilisation of generic PPIs and low prices for oral generics. However, considerable opportunities to enhance prescribing efficiency through greater use of oral generic omeprazole.
authors.affiliation: School of Management, Chongqing Jiaotong University, No.66 Xuefu Road, Nan'an District, Chongqing, 400074, China. wenwin99@sina.com.
authors.forename: Wenjie
authors.initials: W
authors.lastname: Zeng
authors.affiliation: Green Templeton College, University of Oxford, Oxford, UK. alexanderfinlayson@gmail.com.
authors.forename: Alexander E
authors.initials: AE
authors.lastname: Finlayson
authors.affiliation: Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Headington, Oxford, OX3 9DU, UK. sshanko@googlemail.com.
authors.forename: Sushma
authors.initials: S
authors.lastname: Shankar
authors.affiliation: Department of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands. w.f.debruijn@students.uu.nl.
authors.forename: Winnie
authors.initials: W
authors.lastname: de Bruyn
authors.affiliation: Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, SE-141 86, Sweden. Brian.Godman@ki.se.|Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK. Brian.Godman@ki.se.|Liverpool Health Economics Centre, Liverpool University, Chatham Street, Liverpool, L69 7ZH, UK. Brian.Godman@ki.se.
authors.forename: Brian
authors.initials: B
authors.lastname: Godman
mesh_terms: D000284:Administration, Oral; D002681:China; D016527:Drug Costs; D004363:Drug Utilization; D016568:Drugs, Generic / Q000191:economics / Q000627:therapeutic use; D005544:Forecasting; D005764:Gastroesophageal Reflux / Q000188:drug therapy / Q000191:economics; D005102:Health Expenditures; D006801:Humans; D007275:Injections, Intravenous; D009853:Omeprazole / Q000627:therapeutic use*; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000639:trends*; D054328:Proton Pump Inhibitors / Q000191:economics / Q000627:therapeutic use*; D012189:Retrospective Studies
chemical_list: D016568:Drugs, Generic; D054328:Proton Pump Inhibitors; D009853:Omeprazole