Drug utilisation research as a tool to promote rational prescribing - the Swedish experience
Björn WettermarkM.Sc.Pharm, Associate professor
CPE, Karolinska Institutet Stockholm County Council
Chair of the Swedish Society for Pharmacoepidemiology
Outline
A little about Sweden and the data we use Promoting rational prescribing Drug utilisation data and research in…
- monitoring utilisation and expenditure - understanding regional variation- prescribing quality indicators - feedback on prescribing patterns- assessing the impact of interventions- forecasting drug expenditure
The Swedish experience…
Swedish healthcare
Financed by taxes Organized in independent counties (“landsting”) Traditionally most healthcare publicly owned Traditionally dominated by hospitals GP not a gatekeeper, mainly group practices Sophisticated reimbursement system Drug budget devolution ongoing Pharmacy deregulation ongoing Law on Drug and Therapeutics Committees
Läkemedelsstatistik/Elisabet Torell/Läkemedelstrender© Apoteket Farmaci AB v. 1.02 2011-05-12 Sida 5
Expenditure on drugs in Sweden 2009AUP exkl moms
Inpatient 18%
Precriptions 72%
OTC 9%
Other 1%35,5
billion SEK
Källa: Xplain, Apoteket AB
Drug utilisation in the population
Hovstadius. BMC Clinical pharmacology 2009
In the beginning, there was nothing. No data were available to study theprescribing and use of drugs…
Data availability
Sources of drug utilisation data
Wholesaler Dispensed prescriptions
Hospital sales
OTC sales
Prescriber
Questionnaires to patients/population
TDM
EMD
Drug industry
Pharmacy
Hospital records
Strategies to promote rational prescribing
EducationEngineeringEconomics Enforcement
Wettermark et al. Soft regulations paper 2009
All strategies have their limitations
Recent Swedish reformsto promote rational drug use
National• Transfer of cost-
responsibility from state to counties
• Generic substitution• TLV/LFN
- value based pricing- reviewing reimbursement
• National quality registers & quality indicators
Wettermark et al 2008 Godman et al 2009
Regional• Drug and Therapeutics
Committee• Wise Drug list • Electronic decision
support systems• Feedback on prescribing
patterns• Prescribing targets• Incentives & budgets
DU as a tool in promoting rational use
continuous monitoring of utilisation and expenditure describing and understanding regional variation of drug use development and use of prescribing quality indicators academic detailing programmes and
feedback on prescribing patterns forecasting future drug utilisation and expenditure quasi-experimental studies to assess the impact of interventions record linkage of drug exposure to clinical data to further assess
the effectiveness of drug therapy in real life
Monitoring volume and expenditure
Aggregated data, patient identity drug dispensing data & data derived from medical records
Time trends Top-ten-lists Variation between practices Gender differences Feedback to prescribers
included in academic detailingprogrammes
Regional variation
AntidepressantsAntibiotics
Neovius et al 2010
Utilisation of TNF-alpha per county
Diffusion of bevacizumab (Avastin)
Wilking N et al 2010
Heibert-Arnlind et al 2009
WTD for antiasthmatics, Sweden 18-44yrs
Heibert-Arnlind et al 2009
Concomitant dispensing of betablockers
Heibert-Arnlind et al 2009
Initiation on fixed combinations without prior use of antiasthmatics
Prescribing quality indicators
Structure, process or outcome Drug oriented and disease oriented
Indicated drug choice Ratios and targets, e.g. ”Wise Advice” DU90% method Open comparisons
Ratio of ARB to all RAAS-drugs (DDD)
Wettermark et al 2009
No correlation between ARB use and BP control
Norman et al 2009
DU90%
DU90% prescribing profiles
Wettermark et al 2009
Evaluating the impact of interventions
Initiations of antihypertensive drugs
Use of ARB and prior use of ACEi
Forecasting
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Patent expiries Biosimilars OTC switches Reimbursement restrictions Drug budgets and
incentives• Alternative terapies• Guidelines
Forecasting
Expenditures for the coming two years estimated… Regression analyses for all pharmacological groups Adjusted for newly registered drugs
and new indications and drugs expected to be launched
Adjusted based on position in ”life cycle”
Discussions with expert groups and various experts.
Forecast for 2010-2011
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Wettermark et al 2010
Stockholm model to introduce new drugs in healthcare
Possibilities to monitor drug utilization and effectiveness in “real life”
Reality Availabledata sets
Furu et al 2010
Critical evaluation of pharmaco-epidemiological studies
Thank you for your attention
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