title: The impact of the 'Better Care Better Value' prescribing policy on the utilisation of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for treating hypertension in the UK primary care setting: longitudinal quasi-experimental design.
abstract: BACKGROUND
  In April/2009, the UK National Health Service initiated four Better Care Better Value (BCBV) prescribing indicators, one of which encouraged the prescribing of cheaper angiotensin-converting enzyme inhibitors (ACEIs) instead of expensive angiotensin receptor blockers (ARBs), with 80 % ACEIs/20 % ARBs as a proposed, and achievable target. The policy was intended to save costs without affecting patient outcomes. However, little is known about the actual impact of the BCBV indicator on ACEIs/ARBs utilisation and cost-savings. Therefore, this study aimed to evaluate the impact of BCBV policy on ACEIs/ARBs utilisation and cost-savings, including exploration of regional variations of the policy's impact.
  
  
  METHODS
  This cross-sectional study used data from the UK Clinical Practice Research Datalink. Segmented time-series analysis was applied to monthly ACEIs prescription proportion, adjusted number of ACEIs/ARBs prescriptions and costs.
  
  
  RESULTS
  Overall, the proportion of ACEIs prescription decreased during the study period from 71.2% in April/2006 to 70.7% in March/2012, with a small but a statistically significant pre-policy reduction in its monthly trend of 0.02% (p < 0.001). Instantly after its initiation, the policy was associated with a sudden reduction in the proportion of ACEIs prescription; however, it resulted in a statistically significant increase in the post-policy monthly trend of ACEIs prescription proportion of 0.013% (p < 0.001), resulting in an overall post-policy slope of -0.007%. Despite this post-policy induced increment, the policy failed to achieve the 80% target, which resulted in missing a potential cost-saving opportunity. The pre-policy trend of the adjusted number of ACEIs/ARBs prescriptions was increasing; however, their trends declined after the policy implementation. The policy affected neither total ACEIs/ARBs cost nor individual ACEIs or ARBs costs.
  
  
  CONCLUSIONS
  ACEIs/ARBs utilisation was not affected by the BCBV policy. The small increase in post-policy ACEIs prescription proportion was not associated with any savings. This study represents a case study of a failed or ineffective policy and thus provides key learning lessons for other healthcare authorities. Given the existing opportunity of potential cost-savings from achieving the 80 % target, specific measures would be needed to enhance the policy implementation and uptake; however, this must be balanced against other cost-saving policies in other high-priority areas.
authors.affiliation: Division for Social Research in Medicines and Health, School of Pharmacy, University of Nottingham, East Drive, University Park, Nottingham, NG7 2RD, UK. paxaib@nottingham.ac.uk.|Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq. paxaib@nottingham.ac.uk.
authors.forename: Amanj
authors.initials: A
authors.lastname: Baker
authors.affiliation: Division for Social Research in Medicines and Health, School of Pharmacy, University of Nottingham, East Drive, University Park, Nottingham, NG7 2RD, UK. Li-Chia.Chen@nottingham.ac.uk.
authors.forename: Li-Chia
authors.initials: LC
authors.lastname: Chen
authors.affiliation: Division for Social Research in Medicines and Health, School of Pharmacy, University of Nottingham, East Drive, University Park, Nottingham, NG7 2RD, UK. Rachel.Elliott@nottingham.ac.uk.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Elliott
authors.affiliation: Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital, Huddinge, Stockholm, Sweden. briangodman@btinternet.com.|Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK. briangodman@btinternet.com.
authors.forename: Brian
authors.initials: B
authors.lastname: Godman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D017046:Cost Savings / Q000191:economics*; D003430:Cross-Sectional Studies; D016527:Drug Costs; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D055553:Prescription Drugs / Q000191:economics*; D011320:Primary Health Care / Q000191:economics*; D012107:Research Design; D013222:State Medicine / Q000191:economics*; D006113:United Kingdom; D055815:Young Adult
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D055553:Prescription Drugs