1. The Wise List experience in Stockholm and 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 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

5. Drug expenditure 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 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

7. 2007-12-17Hälso- och sjukvårdsnämndens förvaltning7 Impact of generic substitution Godman et al 2009

8. 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

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. 21 maj 2015Björn Wettermark10 Data sources Prescriber PharmacyPatient

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 prescribers included in academic detailing programmes & linked to incentives

14. Theoretical relationship between DU90% and quality

15. DU90%

16. 21 maj 2015Namn Efternamn16 DU90% prescribing profiles

17. 21 maj 2015Björn Wettermark17 Academic detailing in a PHC

18. EXAMPLES OF DU-STUDIES 21 maj 2015Namn Efternamn18

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20. 21 maj 2015Björn Wettermark20 Practice variation Adherence to the Wise List between different PHCs in Stockholm 2003 & 2009

21. Correlation between adherence To Wise List and expenditure/DDD

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23. 2007-12-17Hälso- och sjukvårdsnämndens förvaltning23 ” If a man take no thought about what is distant, he will find sorrow near at hand” Konfucius (555 - 479 Bc)

24. Medicinskt kunskapscentrum Forecasting Utilization data Expenditure Four years

25. Medicinskt kunskapscentrum Forecasting Regression

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

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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. 21 maj 2015Björn Wettermark30 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

31. Thank you for your attention