Restricted access for PPIs not a panacea

We read with interest the findings of Marshall and associates,¹ who found that interventions to reduce the cost to the British Columbia government of 2 drug classes (reference-based pricing for histamine-2 receptor antagonists and restricted access through special authority for proton pump inhibitors [PPIs]) led to substantial savings in the 12-month period after implementation.

In 1992 the Australian government introduced a similar policy of special authority for PPIs to control drug costs. In contrast to the Canadian system, in which prescriptions issued by gastroenterologists were exempt from the policy, in Australia all cases of esophagitis for which PPIs were prescribed and dispensed had to be endoscopically proven, and hence specialists were not excluded. Despite the restrictions imposed by the policy, Australia experienced a progressive increase in prescriptions for PPIs, and by 1999 PPIs accounted for 34% of antiulcer prescriptions and 51% of government expenditure on antiulcerants.² Concurrently, rates of upper gastrointestinal endoscopy in New South Wales rose by 40%.³ Ultimately, in 2001 the Australian government removed the prescribing restriction on PPIs.

Although the findings of Marshall and associates¹ will be of great interest to administrators in other health case systems struggling with the cost of these drugs, data on other changes in practice, such as referral to gastroenterologists, are needed to more fully assess the overall financial impact of the Canadian strategy.

Anne E. Duggan Director Department of Gastroenterology John Hunter Hospital Hunter Region, New South Wales, Australia Johanna Westbrook Associate Professor University of New South Wales Kensington, New South Wales, Australia