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The Wise List experience in Stockholmand resulting Drug Utilization studies
Björn WettermarkM.Sc.Pharm, Associate professor
Karolinska Institutet and
Stockholm County Council
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Outline
A little about Sweden Reforms and activities to
promote rational prescribing Drug utilisation studies
in promoting quality of prescribing
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18 april 2023Namn Efternamn 3
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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
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Drug expenditure in Sweden
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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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2007-12-17Hälso- och sjukvårdsnämndens förvaltning 7
Impact of generic substitution
Godman et al 2009
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• 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
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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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18 april 2023Björn Wettermark 10
Data sources
Prescriber Pharmacy Patient
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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
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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%
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Theoretical relationship between DU90% and quality
DU90% - number of drugs
Qua
lity
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DU90%
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DU90% prescribing profiles
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Academic detailing in a PHC
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EXAMPLES OF DU-STUDIES
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Practice variation
Adherence to the Wise List between different PHCs in Stockholm 2003 & 2009
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Correlation between adherence To Wise List and expenditure/DDD
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18 april 2023Namn Efternamn 22
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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)
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Medicinskt kunskapscentrum
024
68
101214
161820
Läkemedel A
2007
2008
2009
2010
Forecasting
•Utilization data•Expenditure•Four years
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Medicinskt kunskapscentrum
Forecasting
•Regression
0
5
10
15
20
25
30
Läkemedel A
2007
2008
2009
2010
P 2011
P2012
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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…
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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
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Thank you for your attention