The Wise List experience in Stockholm and resulting Drug Utilization studies

1. The Wise List experience in Stockholmand resulting Drug Utilization studies Björn Wettermark M.Sc.Pharm, Associate professor Karolinska Institutet and Stockholm County Council

2. Outline • A little about Sweden • Reforms and activities to promote rational prescribing • Drug utilisation studies in promoting quality of prescribing

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4. Swedish healthcare Financed by taxes Organized in independent counties Healthcare responsibilities dividedat 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

5. Drugexpenditure in Sweden

6. 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 • Regional • Drug and Therapeutics Committee • Wise Drug list • Electronic decision support systems • Feedback on prescribing patterns • Prescribing targets • Incentives & budgets Wettermark et al 2008, Godman et al 2009

7. Impact of generic substitution Godman et al 2009 Hälso- och sjukvårdsnämndens förvaltning

8. Kloka Listan - the WiseDrug list • 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

9. 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…

10. Data sources Prescriber Pharmacy Patient Björn Wettermark

11. 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 prescribersincluded in academic detailingprogrammes & linked to incentives

14. Theoretical relationship between DU90% and quality

15. DU90%

16. DU90% prescribing profiles Namn Efternamn

17. Academic detailing in a PHC Björn Wettermark

18. Examples of du-studies Namn Efternamn

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20. Practice variationAdherence to the Wise List between different PHCs in Stockholm 2003 & 2009 Björn Wettermark

21. Correlationbetweenadherence To Wise List and expenditure/DDD

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23. ” If a man take no thought about what is distant, he will find sorrow near at hand” Konfucius (555 - 479 Bc) Hälso- och sjukvårdsnämndens förvaltning

24. Forecasting • Utilization data • Expenditure • Four years Medicinskt kunskapscentrum

25. Forecasting • Regression Medicinskt kunskapscentrum

26. Forecasting • Adjusting for likely… • Patent expiries • Guidelines • Reimbursemen reviews • New drugs • Organizational changes Medicinskt kunskapscentrum

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28. Great potentials for Pharmacoepidemiological research in Sweden…

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

30. 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 Björn Wettermark

31. Thank you for your attention