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