Self-monitoring blood glucose test strip use with diabetes medicines in people with types 1 and 2 diabetes in New Zealand.

AIMS: (1) To identify actual dispensings of publicly funded blood glucose test strips (SMBG) in New Zealand according to severity of disease, as proxied by the type of medicines prescribed; and (2) To compare these rates with published consensus guidelines on SMBG usage. METHOD: All dispensings of diabetes medicines and blood glucose test strips (SMBG) in 2011 were identified and matched to patients, using encrypted National Health Index numbers (NHIs). Five hierarchical treatment groups were identified, as the use of: -Insulins without oral hypoglycaemic agents (OHs); -Insulins with OHs; -Sulphonylurea-containing OH regimens without insulins (with or without other diabetes medicines); -Metformin alone, with or without glitazones or acarbose; and -No diabetes medication but accessing SMBGs. The average SMBG dispensings to patients in each of these groups was then calculated. The calculation was performed only for 'steady-state' patients, i.e. patients assumed stabilised on the same medication regimen for at least one year. Differences between actual and expected dispensings were calculated from expected daily strip use for each group. RESULTS: An estimated 183,000 patients were dispensed diabetes medicines and/or SMBG during 2011. Of these, 122,000 were identified as 'steady-state' patients. Patient numbers and median ages varied widely across treatment groups and by gender and ethnicity. Dispensing rates for SMBG varied by treatment group, with probable over-dispensing in some groups and under-dispensing in others when compared with published guidelines. In particular there appeared to be relatively large under-dispensing of SMBG in patients requiring insulin (especially the 25-44 age-group or Maori and Pacific peoples) and a high over-dispensing in those using metformin alone or on no diabetic medication. CONCLUSION: There are appreciable variations in the use of SMBG between treatment groups. Adherence to published guidelines may improve efficacy and health outcomes for those using insulin and reduce pain, anxiety and disruption for those using metformin or diet alone for control of their diabetes.

Usage and equity of access to isotretinoin in New Zealand by deprivation and ethnicity.

AIMS: Oral isotretinoin, for severe acne, was until March 2009 fully funded in New Zealand only if the prescription was written by a vocationally registered dermatologist. This funding restriction was argued on the basis of complexity of management and an appreciable risk of teratogenicity if given during pregnancy or within a month of conception. However, this funding restriction had the potential to create inequitable access barriers. This study was an audit examining the use of isotretinoin by deprivation level and ethnicity, in order to examine potential inequities in use. METHOD: Dispensed prescription data for funded isotretinoin, for the year ending June 2008, held in a national repository was analysed using simple descriptive methods based on ethnicity and deprivation level. The same analysis was carried out for cyproterone acetate with ethinyloestradiol, another acne pharmaceutical available on prescription with no funding restrictions. There was demographic data on 60% of prescriptions based on the health identification number NHI. RESULTS: People living in more deprived areas (as defined by NZDep Index) were less likely to use isotretinoin, as were Maori and Pacific people. The association with deprivation level was not present for cyproterone acetate with ethinyloestradiol, although disparities in use by ethnicity remained. CONCLUSIONS: Given there is no evidence for lower rates of acne for Maori and Pacific people, the reasons may include financial and other barriers.

Do pharmaceutical score cards give us the answers we seek?

Few countries can afford to fund all pharmaceuticals for all of their people all of the time, and the current international economic climate brings this into clearer focus. Various agencies have tried to solve the problem in different ways, varying from funding a restricted list that applies to the whole population, to funding most medicines but with a significant part charge, or as in the United States, funding for only selected groups and leaving others to fend for themselves other than in an emergency. For countries like New Zealand and Australia who have universal health coverage but restricted (and different) lists of funded pharmaceuticals, comparisons of those lists can occur, but are problematic. Comparisons need to be interpreted with caution as systems and policies vary between countries. That one country funds more new medicines than the other is one thing, but the more important questions are whether one country gets more health gains and more value for precious health dollars than the other.

Terminations of pregnancy associated with isotretinoin use in New Zealand.

AIMS: Oral isotretinoin is a highly-effective treatment for severe acne. It is also highly teratogenic. Recently, funded access was widened (from vocationally registered dermatologists only) to include vocationally trained general practitioners and nurse practitioners acting within their scope of practice. This decision has caused some debate. While it is hoped that it will increase access to those living in more deprived areas, there are concerns that there will be an increase in the number of affected pregnancies. This study aims to report on terminations of pregnancy occurring while using isotretinoin in New Zealand. METHOD: Using NHI numbers, termination of pregnancy admissions were matched to recent isotretinoin prescriptions. RESULTS: This study has revealed that there appears to have been more unintended pregnancies related to isotretinoin use than previously thought. A total of 39 terminations of pregnancy related to isotretinoin use were identified in the year ending June 2008. This gave a crude termination of pregnancy rate of 73 per 10,000 females aged 10-44 years. CONCLUSIONS: While there are some limitations to this study, the results are consistent with recent international research suggesting previous pregnancy rates on isotretinoin have been underestimates. Widening funding of isotretinoin will likely increase the absolute numbers of pregnancies but also has the potential to increase relative numbers. As such, it will be vital that primary care is alert to the risks of isotretinoin use and gain experience in its day-to-day usage. Although access has been widened, all requests for funding will now be recorded on a national database (Special Authority database) to enable closer monitoring of isotretinoin usage.