Pitfalls associated with the therapeutic reference pricing practice of asthma medication

BMC Pulm Med. 2012 Jul 20;12:35. doi: 10.1186/1471-2466-12-35.


Background: Therapeutic reference pricing (TRP) based on the WHO daily defined dose (DDD) is a method frequently employed for the cost-containment of pharmaceuticals. Our objective was to compare average drug use in the real world with DDD and to evaluate whether TRP based on DDD could result in cost savings on maintenance medication and the total direct health expenditures for asthma patients treated with Symbicort Turbuhaler (SYT) and Seretide Diskus (SED) in Hungary.

Methods: Real-world data were derived from the Hungarian National Health Insurance Fund database. Average doses and costs were compared between the high-dose and medium-dose SYT and SED groups. Multiple linear regressions were employed to adjust the data for differences in the gender and age distribution of patients.

Results: 27,779 patients with asthma were included in the analysis. Average drug use was lower than DDD in all groups, 1.38-1.95 inhalations in both SED groups, 1.28-1.97 and 1.74-2.49 inhalations in the medium and high-dose SYT groups, respectively. Although the cost of SED based on the DDD would be much lower than the cost of SYT in the medium-dose groups, no difference was found in the actual cost of the maintenance therapy. No significant differences were found between the groups in terms of total medical costs.

Conclusions: Cost-containment initiatives by payers may influence clinical decisions. TRP for inhalation asthma drugs raises special concern, because of differences in the therapeutic profile of pharmaceuticals and the lack of proven financial benefits after exclusion of the effect of generic price erosion. Our findings indicate that the presented TRP approach of asthma medications based on the daily therapeutic costs according to the WHO DDD does not result in reduced public healthcare spending in Hungary. Further analysis is required to show whether TRP generates additional expenditures by inducing switching costs and reducing patient compliance. Potential confounding factors may limit the generalisability of our conclusions.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Inhalation
  • Adolescent
  • Adrenal Cortex Hormones / administration & dosage
  • Adrenal Cortex Hormones / economics*
  • Adrenal Cortex Hormones / therapeutic use*
  • Adult
  • Aged
  • Aged, 80 and over
  • Albuterol / administration & dosage
  • Albuterol / analogs & derivatives*
  • Albuterol / economics
  • Albuterol / therapeutic use
  • Androstadienes / administration & dosage
  • Androstadienes / economics*
  • Androstadienes / therapeutic use*
  • Asthma / drug therapy*
  • Budesonide / administration & dosage
  • Budesonide / economics*
  • Budesonide / therapeutic use*
  • Budesonide, Formoterol Fumarate Drug Combination
  • Cost Control / economics
  • Costs and Cost Analysis
  • Dose-Response Relationship, Drug
  • Drug Combinations
  • Drug Substitution / economics
  • Ethanolamines / administration & dosage
  • Ethanolamines / economics*
  • Ethanolamines / therapeutic use*
  • Fees, Pharmaceutical / standards*
  • Female
  • Fluticasone-Salmeterol Drug Combination
  • Humans
  • Hungary
  • Linear Models
  • Male
  • Middle Aged
  • Patient Compliance
  • Reference Standards
  • Retrospective Studies
  • World Health Organization*
  • Young Adult


  • Adrenal Cortex Hormones
  • Androstadienes
  • Budesonide, Formoterol Fumarate Drug Combination
  • Drug Combinations
  • Ethanolamines
  • Fluticasone-Salmeterol Drug Combination
  • Budesonide
  • Albuterol