Patients' views on cost effectiveness of drugs are important

EDITOR—The report by the National Institute for Clinical Excellence on the use of proton pump inhibitors for treating dyspepsia sets the target of at least a 15% reduction in prescribing of these drugs in England and Wales, with consequent savings of £40m-£50m a year.1

We carried out a qualitative study of patients' and general practitioners' views of long term use of proton pump inhibitors. Patients commonly expressed concerns about long term use of the drugs but said that they could not manage without them. 2 3 Most of the general practitioners were already trying to reduce their prescribing, much in line with the institute's guidelines. They did not consider themselves to be prescribing proton pump inhibitors profligately or inappropriately. Recognising their patients' need for an effective means of controlling severe and unpleasant symptoms, they often found it difficult to get patients to stop taking the drugs or to take a reduced dose.

Cost is an important concern, but the general practitioners in our study considered that their primary obligation was to respond effectively to their patients' needs. Clinical concerns outweighed the price of treatment. The poor fit between the severity of symptoms and the underlying pathology of gastric disorders is well established. Regardless of diagnosis, many patients said that they could not manage without proton pump inhibitors to control their symptoms.

The report by the National Institute for Clinical Excellence does not focus on what is most important to patients—that is, effective relief from painful and debilitating symptoms, and the ability to fulfil adequately their economic and social roles and obligations. Pressure to reduce costs is likely to raise the prescribing threshold for proton pump inhibitors. The legitimacy of patients' need for health care is being arbitrarily redefined in terms of cost considerations, and without any open consultation with patients.

We argue that patients' perspective on the cost effectiveness of proton pump inhibitors (and other medicines) should feature prominently in any discussion of prescribing policy. Patients have no control over the cost of proton pump inhibitors, and those in our study had no other means of effectively treating their discomfort. Patients, doctors, and health service administrators all support the aim of avoiding unnecessary prescribing and medicine taking, and eliminating unnecessary expenditure in the NHS. But patients' evaluation of the benefit to be derived from treatment, and the value for money that this represents, must be an important consideration in prescribing policy.