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The Wise List experience in Stockholm
and resulting Drug Utilization studies
Björn Wettermark
M.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
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Transfer of costresponsibility from state to
regions
Generic substitution
TLV (reimburs. agency)
- value based pricing
- reviewing reimbursement
National quality registers
& quality indicators
Regional
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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
Impact of generic substitution
Godman et al 2009
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Kloka Listan - the Wise Drug 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
Drug utilization studies as a tool
in promoting rational drug use
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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…
Data sources
Prescriber
Björn Wettermark
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 detailing
programmes & linked to
incentives
Drug Utilization 90% (DU90%)
No of Defined Daily Doses
Number of drugs accounting for 90% of the use in DDDs
DU90%
Products in rank order of DDDs
Quality
Theoretical relationship between
DU90% and quality
DU90% - number of drugs
DU90%
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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” 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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Forecasting
•Utilization data
•Expenditure
•Four years
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2007
2008
2009
2010
Läkemedel A
Medicinskt kunskapscentrum
Forecasting
•Regression
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2007
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2008
2009
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2010
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P 2011
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P2012
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Läkemedel A
Medicinskt kunskapscentrum
Forecasting
Adjusting for
likely…
•Patent expiries
•Guidelines
•Reimbursemen
reviews
•New drugs
•Organizational
changes
Medicinskt kunskapscentrum
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2007
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P 2011
P2012
Läkemedel A
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Great potentials for Pharmacoepidemiological
research in Sweden…
We have a limited knowledge on how
patients actually use the drugs…
Some key references
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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;20:7885
Björn Wettermark
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Thank you for your attention