Jonathan Guillemot is a part-time PhD student at the Institute of Gerontology – King’s College London. He is also a research analyst at the Health Economics and Outcomes Research Department, at Amaris, a consulting company. He graduated from King’s College London in 2011 (M.Sc. Gerontology) and from the Institute of Political Science, University of Lille, France that same year.
His interests include the understanding of health economics in the context of ageing, especially in regard to health care rationing and its practical application by Western States. In association with political sociology, he is also interested in political behaviours of older people with a M.Sc. dissertation questioning the political activation of people at a later stage of life in the case of 2011 London demonstrations. In a more general perspective, Jonathan is interested in the social life and socialisation within healthcare institutions with an M.A. dissertation focusing on the social analysis of a nursing home in northern France.
His research originated from the collaboration with Amaris and results from the needs to improve health economics services in the perspective of ageing, both in terms of qualitative and quantitative research. The study aims to understand prescribing trends and patterns of osteoporosis drugs in France and in England. More precisely, the study looks at differences in policices and prescription behaviour. Methods include comparative documentary analysis, international comparative social policy, quantitative and qualitative data analysis.
Hello, I’m Nigel Warburton. Joining me today is Jonathan Guillemot, a PhD candidate at the department of Global Health and Social Medicine at King’s College London. Jonathan, you’ve been researching prescribing trends in this area [osteoporosis] for a while, what sorts of patterns have you found?
Osteoporosis drugs have been a lot more prescribed over the last twenty years, especially starting in the early 2000s, we look at a really steep increase of prescribing patterns for osteoporosis drugs and that peaks around 2008, after which we start to see a slight decline until the date that I have, around 2012, 2013.
And you are talking about specific countries here or the whole world?
I’m looking a two countries in particular: England and France.
Why do you think there has been this increase?
Well, I assume there are many factors influencing this increase in trend, but the major one is an awakening of public health to the issue of factures in older people and then as a consequence, osteoporosis in older people. The other factor that has strongly influenced the increase of prescribing is the arrival of actual options to mitigate osteoporosis on the market, around that time of the mid-1990s.
Perhaps we should just get clear what osteoporosis is.
Osteoporosis is the embrittlement of bones and it is usually associated with age. It means as such that you are at increased risk of fracturing if you fall or if you have a low trauma in your daily living.
And it’s only recently that there has been medical treatments that are effective?
It’s only been recent that there is evidence that they are efficient. There has been one drug that arrived on the market [before alendronate, the number one osteoporosis drug], but it had a very low uptake. There is another reason for this drug not to have a high uptake is that this period of medical history was strongly influenced by hormone replacement therapies, which were heavily given to women until the end of the 1990s, when there was the Women Health Study, that proved an association between hormone replacement therapy and breast cancer.
Why would this pattern of prescription of therapy affect what happens with osteoporosis?
Hormone replacement therapy was given to women as an overall solution to older age issues [mainly menopause] in women, among them the lowering of bone mineral density.
Was it effective?
From the data I have, it was effective. It was greatly effective, the only issue was that a lot of women would get breast cancer, which is a side effect that was largely ignored for a long time until this Women Health Study, which really changed people’s view on the issue of hormone replacement therapy.
Then, when did another effective treatment of osteoporosis kick in?
That happened a bit before the change of views on hormone replacement therapies. The big change came in 1995 with the arrival of alendronate on the European market.
Presumably this was a drug which was patented by the pharmaceutical industry?
Yes, it was. And it had the strong asset of providing hard evidence showing that this drug increased the bone mineral density [for both hip and spine, while etidronate could only provide efficacy on the spine] and therefore helped older people with fractures.
Now you are comparing France and England in prescribing policies. What are the factors that make these two countries different?
In terms of prescribing trends, from what I have looked at, there is one key difference, it is the diversity in prescribing in France compared to England. The England market for osteoporosis drugs is a lot more homogeneous than the French market. Overall they prescribe quite the same, so they had that same steep increase from the early 2000s to 2008 and they seem to have the same patterns of decrease since 2008.
Number of things going on there. By diversity you mean there was a range of treatments that were used by different doctors.
Over years, several drugs entered the market. I think at the moment there are more than 10 on the market.
In both France and England. Where we see the difference, is that alendronatre makes up more than two thirds of the English market while it makes about a third in France and the rest of the market is taken by a broad diversity of drugs, not a second key drug.
And why do you think that is?
From the policies that I have been looking at – so I have been looking at official documents – and it seems that official guidelines published both by England and France, and that are clearly different have had a strong impact on the way prescribers have given the drugs to patients and in England, NICE clearly states that Alendronate is the number one choice for osteoporosis while the HAS, the French equivalent to NICE, only lists the possible options without ranking them.
Why don’t they rank them? Because presumably there must be evidence that some treatments are better than others.
My understanding is that in France there is a choice to give doctors the possibility to select the drug that best fits the purpose in their patients. There is clearly that choice also in England but there is the influence of costs and cost-effectiveness of drugs which in not as applicable to France at the moment, which has encouraged a ranking. The number one being the most cost-efficient drug and the last one being the least cost-efficient.
That’s really interesting. So are you saying that in France, a doctor could choose to spend more money on maybe a less efficient drug because he or she felt that that was the correct drug to use in a particular case?
I would go further than that. Usually doctors don’t know how much a drug costs, so in England they will use the ranking that best fits as per the guidelines, whereas in France they will choose the one they find best. From the interviews I’ve had with doctors, very few knew actually the prices of the drugs they were prescribing [more so in France than in England].
So really it is very different models of how the State intervenes in the process of prescription.
I wouldn’t say widely different because eventually the management of osteoporosis is quite similar although the drugs are quite different but they are choosing a slightly different way of prescribing. Less intervening in France, more intervening in England.
I suppose you could say that in France doctors are given a lot more freedom of choice about how they deal with a particular case.
Yes. I believe this is something that is going to change over the years but at the moment there is more freedom in France than in England in terms of prescribing.
Are there other important factors which determine the prescription practices with osteoporosis.
I’m sure there is a number of factors that influence prescribing of doctors. I look only at two categories, which are first the behaviours of doctors, so, how they feel about prescribing, on the basis of what they choose to prescribe, so that’s on an individual basis and I look at this in a qualitative manner and also I look at policies, whether they are official guidelines, market entry of drugs or new indications for drugs. That’s one way of looking at it. And then there might be many other factors influencing prescribing. We could imagine that marketing, although it is less and less true, considering the decrease of the influence of the pharmaceutical industry over prescribing of doctors but it still has one way or another an impact.
So you talked a bit about different policies between France and England in relation to prescription. Are there different styles of being a doctor do you think, in those two countries?
I would say that there is more diversity between doctors than between both countries. Obviously there are several specialties of doctors that prescribe osteoporosis drugs and there are styles of generations. For example newer doctors I find are a lot more likely to abide by rules given by health authorities while older generations would stick to their freedom of prescribing.
It is interesting to consider different ways to doing things in different countries. Is what you are doing with your research a kind of history of medicine or is it something else?
It is both. There is an objective of history here. We are looking back in time to link doctors’ behaviours but essentially policies with prescribing trends, which is intrinsically historical work, but then there is also the goal of informing policy makers at the moment to see how osteoporosis is handled in two different countries and the links with actual prescribing trends, so that might be an interesting tool for policy makers in order to develop more precise, more specific policies in the future.
If I’ve understood you correctly, you said that in France the doctors can prescribe a range of different drugs without any intervention from the state. In Britain it is more difficult if you go away from the number one choice, you have to have a reason because NICE has given clear guidelines on what the most cost-effective drug in this area is. If you had to choose between those two models, which one would you say is preferable?
I would imagine that if we want a really rational a really effective system, the British system tends towards a more cost-effective healthcare system, but it depends on the quality of the evidence that we have and I think that’s a real work that needs to be done in the very near future on how to make sure that what we give actually is efficient to populations. So, data was very based on clinical trials, but in risk factors, analysing the possibility of a risk factor turning into a real problem, so here in that case the difference between having osteoporosis and actually sustaining a fracture, since it is a rare event, a clinical trial is not the best solution to see efficacy, because even if you have two thousand patients included, which is a very large clinical trial, you may have a very limited number of fractures eventually, so to be able to see if the drug was really efficient, it requires a large number of patients , so observational studies in the future, so looking at patients being prescribed right now on their daily living, might provide real solution for the future to be able to assess drugs a lot more effectively than they are assessed at the moment
Jonathan Guillemot, thank you very much.