The Wise List experience in Stockholmand resulting Drug Utilization studies

Björn WettermarkM.Sc.Pharm, Associate professor

Karolinska Institutet and

Stockholm County Council

Outline

A little about Sweden Reforms and activities to

promote rational prescribing Drug utilisation studies

in promoting quality of prescribing

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Swedish healthcare

Financed by taxes Organized in independent counties Healthcare responsibilities divided

at the national, regional and local level Most healthcare publicly owned,

but this is rapidly changing Traditionally dominated by hospitals Historically strong in clinical research Many recent pharmaceutical reforms

Drug expenditure in Sweden

Swedish reforms to promote rational drug use

National

• Transfer of cost-responsibility from state to regions

• Generic substitution• TLV (reimburs. agency)

- 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

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Impact of generic substitution

Godman et al 2009

• Issued by the regional Drug and Therapeutics Committee• Focus on the rational choice of drugs for common diseases in outpatient care• Drugs selected by 20 expert groups with GPs, specialists, pharmacists & clinical pharmacologists

• Information campaigns towards prescribers (and patients/the public)• Website www.janusinfo.se

Kloka Listan - the Wise Drug list

Drug utilization studies as a tool in promoting rational drug use

continuous monitoring of utilization and expenditure describing and understanding (regional) variation in 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

drug utilization, effectiveness and safety in real life

Qualitative studies on how physicians and patients think…

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Data sources

Prescriber Pharmacy Patient

Monitoring volume and expenditure

Aggregated data, patient identity drug dispensing data & data derived from medical records

Time trends Top-ten-lists Various quality indicators Variation between practices Feedback to prescribers

included in academic detailingprogrammes & linked to incentives

Drug Utilization 90% (DU90%)Number of drugs accounting for 90% of the use in DDDs

Products in rank order of DDDs

No

of

De

fin

ed

Da

ily

Do

se

s

DU90%

Theoretical relationship between DU90% and quality

DU90% - number of drugs

Qua

lity

DU90%

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DU90% prescribing profiles

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Academic detailing in a PHC

EXAMPLES OF DU-STUDIES

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Practice variation

Adherence to the Wise List between different PHCs in Stockholm 2003 & 2009

Correlation between adherence To Wise List and expenditure/DDD

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2007-12-17Hälso- och sjukvårdsnämndens förvaltning 23

” If a man take no thought about what is distant, he will find sorrow near at hand”

Konfucius (555 - 479 Bc)

Medicinskt kunskapscentrum

024

68

101214

161820

Läkemedel A

2007

2008

2009

2010

Forecasting

•Utilization data•Expenditure•Four years

Medicinskt kunskapscentrum

Forecasting

•Regression

0

5

10

15

20

25

30

Läkemedel A

2007

2008

2009

2010

P 2011

P2012

Medicinskt kunskapscentrum

Forecasting

Adjusting for likely…•Patent expiries•Guidelines•Reimbursemen reviews•New drugs•Organizational changes

02

46

810

1214

1618

20

Läkemedel A

2007

2008

2009

2010

P 2011

P2012

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Great potentials for Pharmacoepidemiological research in Sweden…

We have a limited knowledge on how patients actually use the drugs…

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Some key references

Wettermark B et al. Soft regulations in pharmaceutical policymaking - an overview of current approaches and their consequences. Appl Health Econ Health Pol 2009;7:1-11

Godman B et al. Swedish experience in ambulatory care with multifaceted national and regional drug reforms and initiatives: global relevance. Expert Review of Pharmacoeconomics and Outcomes Research 2009;9:65-83

Gustafsson L et al for the Regional Drug Expert Consortium. The “Wise List”- a comprehensive concept to select, communicate and achieve adherence to recommendations of essential drugs in ambulatory care in Stockholm. Basic & Clinical Pharmacology & Toxicology 2011;108:224-33

Wettermark B et al. Financial incentives linked to self-assessment of prescribing patterns - a new approach for quality improvement of drug prescribing in primary care. Quality in Primary Care 2009;17:179-89

Godman B et al. Policies to enhance prescribing efficiency in Europe: findings and future implications. Frontiers in Pharmacology 2011;1:1-16

Furu K et al. The Nordic Countries as a Cohort for Pharmacoepidemiological Research. Basic Clin Pharmacol Toxicol. 2010;106:86-94

Wettermark B et al for the Regional Drug Expert Consortium. Forecasting drug use and expenditures in a metropolitan health region. BMC Health Service research 2010;10:128

Wettermark B, Vlahovic-Palcevski V, Laing R, Bergman U. Adherence to WHOs Essential Medicines List in two European countries. WHO Drug Information 2006;20:78-85

Thank you for your attention