Elevated cholesterol levels can cause long-term damage to the heart and circulatory system. If e.g. If, for example, the values can no longer be brought under control by changing eating habits, the use of drug therapies is recommended. Among the cholesterol and lipid-lowering drugs, statins are primarily prescribed in outpatient settings. In addition, preparations containing ezetimibe are becoming increasingly important. Based on a complete survey of all GKV prescriptions billed in pharmacy data centers, INSIGHT Health examined the lipid-lowering drug prescriptions and the differences between the major health insurance companies. In some cases, large differences become visible.

>> Numerous epidemiological studies show a close connection between cardiovascular disease and high cholesterol levels. Nevertheless, cholesterol is only one of several risk factors. The significance of a patient's cholesterol levels being outside the norm must therefore be assessed taking into account other existing risks for cardiovascular diseases. In addition to the age and gender of the patient, these include, in particular, high blood pressure and diabetes mellitus. But obesity, lack of exercise, alcohol and nicotine consumption as well as a genetic predisposition are also important risk factors (see S3 guideline “Chronic CHD” 2010).
Various options are available for pharmacological therapy. In addition to the widely used statins (also known as CSE inhibitors, cholesterol synthesis enzyme inhibitors) with the lead substance simvastatin, these include: the active ingredient ezetimibe and the combination of these two substances. Of downstream relevance in drug therapy are fibrates, nicotinic acid preparations, anion exchangers and fish oil capsules, which are primarily used in cases of statin intolerance (cf. S3 guideline “Chronic CHD” 2010). Drug therapy for the purpose of primary prevention is generally not recommended. In the sense of secondary prevention in high-risk patients, the recommendation for statin therapy applies (cf. KV Westfalen-Lippe 2009), in particular for the prevention of progressive arteriosclerosis and due to a positive effect on cardiovascular events (cf. DEGAM Guideline No. 8, Stroke, p. 42 ).
Not all statins are the same
The statins differ significantly from each other - in terms of their price, their pharmacological characteristics, their therapeutic features and other differences that have been proven in numerous studies. Nevertheless, they are grouped together in a fixed amount group. The statins atorvastatin (trade name: Sortis) and rosuvastatin (trade name: Crestor) are still under patent protection (atorvastatin until May 2012, rosuvastatin until 2016; INSIGHT Health: Patent Database). The price demanded by the companies is far above the reimbursement amount, which is why SHI patients currently have to make significant co-payments. Simvastatin, on the other hand, is subject to intense generic discount competition. In the past year, 84 percent of all simvastatin prescriptions within the GKV were discounted (INSIGHT Health: NVI-KT, MAT June 2011, ie period July 2010 to June 2011).
In the following, the market for lipid-lowering drugs (ATC group C10) will be presented in more detail using current data from INSIGHT Health on prescriptions within the GKV (MAT June 2011). In addition to a general market observation, abnormalities are analyzed at the level of the largest statutory health insurance companies. Manufacturer discounts as well as discount contracts are included in the sales or Cost values based on pharmacy sales prices (AVP) are not taken into account.
GKV: 1.7 billion daily doses pa
In Germany in the current year (July 2010 to June 2011) around 1.7 billion daily therapy doses (defined daily doses - DDD) of lipid-lowering drugs with a value of 676 million euros (according to AVP) were prescribed within the statutory health insurance system. The current issue volume has fallen by 6.5 percent compared to the same period of the previous year, whereas the billed quantity component - measured in DDD - has increased by 4.0 percent. With atorvastatin's expected patent expiration next year, average DDD costs are expected to continue to decline.
The therapy options differ noticeably in terms of their relevance to expenditure. The average cost of a daily therapy dose of lipid-lowering drugs is 40 cents. While generic statins are comparatively inexpensive therapy options, the new, patent-protected active ingredients are comparatively more expensive therapy options. This is one of the reasons why the targets in the drug agreements between the health insurance companies and the health insurance associations focus on keeping the DDD share of inexpensive statins high and the share of ezetimibe-containing preparations low. On the one hand, the DDD proportion of the lead substance simvastatin among statins is said to be on average over 86 percent (Table 1). On the other hand, in Schleswig-Holstein, for example, preparations containing ezetimibe should not exceed a proportion of 3 percent of statins and preparations containing ezetimibe (cf. KV SH 2011).
Per capita DDD at Knappschaft is three times as high as at TK
An analysis of the major payers with more than a million insured persons shows clear differences with regard to drug therapy with lipid-lowering drugs: While at TK, statistically speaking, an insured person only receives around 15 daily therapy doses (ATC: C10), at Knappschaft there are 46 DDD. Within the GKV, each insured person receives an average of 24 daily doses. However, this does not allow any conclusions to be drawn about the average number of daily therapy doses per patient. per chronicler too. In this analysis, chronic patients were defined as patients who received at least one prescription of a lipid-lowering drug per quarter of the study period. Overall, the range of fluctuation between the health insurance companies analyzed was between 373 and 419 DDD per chronic person defined in this way. The two health insurance companies with the highest DDD rates per insured person were once at the upper end of the fluctuation range (AOK Nordost with 419 DDD) and once at the lower end (Knappenschaft with 374 DDD) (see Fig. 1).
Around 80 percent of all SHI patients who are continuously treated with lipid-lowering drugs are older than 60 years. However, the average age also varies considerably here - analogous to the insured structure of the health insurance companies. At just under 68, TK patients and IKK classic patients are a good five years younger than patients who are insured with the Knappschaft.
The proportion of daily doses with the active ingredient ezetimibe including fixed combinations varies among the largest statutory health insurance companies between 4.4 percent for the AOK Hessen and the IKK classic with 8.2 percent (see Fig. 2). These health insurance funds are also above the GKV average when it comes to the proportion of prescriptions for ezetimibe; TK is the leader here among the “large health insurance companies” examined (2.3% vs. GKV: 1.7 %). The DDD proportion of simvastatin in all lipid-lowering drugs (C10) varies almost in the opposite direction and is between 74.3 percent in TK and 82.7 percent in AOK Rheinland/Hamburg (GKV: 78.1 %).
outlook
In further health care analyses, the reasons for the different prescriptions in the individual health insurance companies should be examined in more detail. So would u. an age- and gender-adjusted comparison between health insurance companies, an examination of regional characteristics and the analysis of the prescribing behavior of different specialist groups of interest. In addition, especially in light of the recent publications by IQWiG on the topic of “ezetimibe in hypercholesterolemia” (cf. IQWiG 2011), health care research studies should examine in more detail the additional benefits of the more expensive therapy regimens depending on the clinical pictures including comorbidities. This would then also be information that could flow into the drug agreements between associations of statutory health insurance physicians and the health insurance associations. <<

Literature from the authors

by: Dr. Andre Kleinfeld
Christian Bensing*