Economic incentives in outpatient care and patient demand for pharmaceuticals. A study of antibiotics and addictive drugs prescriptions

The questions asked in this thesis relate to the economic incentives and characteristics of the health care market, which may result in suboptimal drug prescription. We consider two types of pharmaceuticals, such as antibiotics and addictive drugs. These pharmaceuticals are interesting because their use/misuse is associated with costs both at the individual and societal levels. The decision about the prescription of both antibiotics and addictive drugs is ideally made by a doctor, and over-the-counter sales are not available. A good share of the prescriptions is made in outpatient care or primary care (a part of outpatient care). This market is characterised by asymmetric information and may suffer from economic disincentives, which, together with patient-induced demand, may result in drug misuse. Thus there is a need for solutions aimed to facilitate optimal drug consumption, i.e. reducing consumption to a minimum consumption level, given that patients are effectively treated. This thesis considers several characteristics of the outpatient care market, such as free choice of provider, competition, and financial incentives within a health care centre to be important factors contributing to drug misuse. Knowledge about driving mechanisms is important for understanding how policies for more efficient antibiotic and addictive drugs consumption can be achieved. The first paper in the thesis relates to the ownership type of health care centres. It finds that private health care centres in the Västerbotten county of Sweden have a higher share of prescriptions for antibiotics than public ones. The second paper focuses on the competition between general practitioners and antibiotic prescription in Norwegian municipalities. The paper shows that the level of competition may be an important factor contributing to a more frequent antibiotic prescription. The third paper relates to the presence of free choice of the health care provider and uses the prescription data from Västerbotten county of Sweden to investigate patients' demand for addictive drugs and how a strategy to switch providers may affect individual drug consumption

Effects of ‘doctor shopping’ behaviour on prescription of addictive drugs in Sweden

Free choice of health care providers is aimed to improve the quality of health care by increasing both access to it and the competition between providers. However, it may also give patients possibilities for doctor shopping (DS) behaviour, i.e., visiting different providers to receive illicit drug prescriptions. Abuse of prescribed addictive drugs is a growing problem worldwide and is associated with increased mortality, lower quality of life and other problems on both the individual and societal level. We study DS behaviour for three categories of addictive drugs – opioid painkillers, benzodiazepine anxiolytics, and z-hypnotic sleeping drugs, in the outpatient care sector in V¨ asterbotten County, Sweden. Our dataset contains all drug prescriptions purchased by the residents of V¨ asterbotten in the period from January 2014 to April 2016 (approximately 160,000 observations). To identify signs of addictive prescription drugs abuse by DS, we analyse overlapping prescriptions. We use ‘Defined Daily Doses’ (DDDs), which is the average treatment dose of a specific drug per day for adults, as a proxy for the treatment duration. To control for medically legitimate overlaps, we compare overlapping prescriptions within a clinic with overlapping prescriptions between different clinics. Our empirical results suggest that there is a significant and positive relationship between the number of overlapping doses and the number of unique providers in the overlap. More specifically, we find that visiting different providers on average gives patients up to three additional DDDs per day. This is three times higher than the standard treatment dose. We discuss policy implications in the concluding discussion

Can Private Provision of Primary Care Contribute to the Spread of Antibiotic Resistance? : A Study of Antibiotic Prescription in Sweden

Background: Growing rates of antibiotic resistance, caused by increasing antibiotic use, pose a threat by making antibiotics less effective in treating infections. Objective: We aimed to study whether physicians working at privately and publicly owned health centres differed in the likelihood of prescribing antibiotics and choosing broad-spectrum over narrow-spectrum antibiotics. Methods: To estimate the effect of ownership on the probability of a prescribed drug being an antibiotic, we analysed all 4.5 million prescriptions issued from 2011 to 2015 at primary health centres in Västerbotten, Sweden. We controlled for patient age, sex, number of prescriptions per patient, and month of prescription, and used a maximum likelihood logit estimator. We then analysed how ownership affected the likelihood of a prescribed antibiotic being broad spectrum. We also used aggregated data to estimate the impact of the number of private health centres on the number of antibiotic prescriptions per inhabitant and the proportion of broad-spectrum antibiotics. Results: Holding other factors constant, private physicians were 6% more likely to prescribe antibiotics and 9% more likely to choose broad-spectrum antibiotics. An increase by one additional private health centre was positively associated with an increase in the number of antibiotic prescriptions per inhabitant and a higher proportion, although not significant, of broad-spectrum antibiotic prescriptions. Conclusion: Our findings suggest that private physicians prescribe more antibiotics, especially broad-spectrum antibiotics, than public physicians. Therefore, it is crucial to provide health centres with incentives to follow guidelines for antibiotic prescription, especially when the level of private provision of primary healthcare is high

Influence of Accidental Impurities on the Spectroscopic and Luminescent Properties of ZnWO₄ Crystal

Special techniques for deep purification of ZnO and WO3 have been developed in this work. A ZnWO4 single crystal has been grown by the Czochralski method using purified ZnO and WO3 chemicals, along with the ZnWO4 crystal-etalon, which has been grown at the same conditions using commercially available 5N ZnO and WO3 chemicals. The actual accidental impurities compositions of both the initial chemicals and the grown crystals have been measured by inductively coupled plasma mass-spectrometry. A complex of comparative spectroscopic studies of the crystals has been performed, including optical absorption spectra, photo-, X-ray-, and cathodoluminescence spectra and decay kinetics, as well as the photoluminescence excitation spectra. The revealed differences in the measured properties of the crystals have been analyzed in terms of influence of the accidental impurities on these properties