Potential savings without compromising the quality of care

SUMMARY Aims: This study was designed to analyse the association between adherence to guidelines for rational drug use and surrogate outcome markers for hypertension, diabetes and hypercholesterolaemia. Methods: The study used a cross-sectional ecological design. Data from dispensed prescriptions and medical records were analysed from 24 primary healthcare centres with a combined registered population of 330,000 patients in 2006. Guideline adherence was determined calculating the proportion of the prescribed volume of antidiabetic agents, antihypertensives and lipid-lowering agents representing the 14 different drugs included in the guidelines for these three areas. Patient outcome was assessed using surrogate marker data on HbA1C, blood pressure (BP) and s-cholesterol. The association between the guidelines adherence and outcomes measures was analysed by logistic regression. Results: The proportion of guideline antidiabetic drugs in relation to all antidiabetic drugs prescribed varied between 80% and 97% among the practices, the ratio of angiotensin converting enzyme (ACE)-inhibitors to all renin–angiotensin drugs 40–77% and the ratio of simvastatin to all statins 58–90%. The proportion of patients reaching targets for HbA1C, BP and s-cholesterol varied between 34% and 66%, 36% and 57% and 46% and 71% respectively. No significant associations were found between adherence to the guidelines and outcome. The expenditures for antihypertensives and lipid-lowering drugs could potentially be reduced by 10% and 50% respectively if all practices adhered to the guidelines as the top performing practices. Conclusion: A substantial amount of money can be saved in primary care without compromising the quality of care by using recommended first-line drugs for the treatment diabetes, hypertension and hypercholesterolaemia. What's known • There are substantial price differences between branded and off-patent drugs for the treatment of diabetes, hypertension and hypercholesterolaemia. • There is a wide variation in adherence to prescribe targets in primary healthcare. • There is a limited knowledge on the relation between adherence to prescribing targets or guidelines, patient outcomes and potential savings that could be achieved. What's new • No significant associations were found at a practice level between adherence to the guidelines and outcomes in terms of patients reaching target levels for surrogate markers. • A substantial amount of money can be saved in primary care without compromising the quality of care by using recommended off-patent drugs for the treatment of diabetes, hypertension and hypercholesterolaemia

Usage, Risk, and Benefit of Weight-Loss Drugs in Primary Care

Purpose. To investigate the use of the weight-loss drugs rimonabant, sibutramine, and orlistat in primary care and to characterize the patients receiving the drugs. Methods. In this retrospective, descriptive study, 300 randomly selected patients having started weight-loss drug treatment at 15 primary care centres were investigated using the patient's medical records and their complete drug purchase data. Results. Even though 48% of the patients specifically demanded drug treatment, 77% continued treatment less than one year. 28% of rimonabant patients and 32% of sibutramine patients had a history of depression or antidepressant treatment. 41% of sibutramine patients had a history of hypertension and/or cardiovascular disease. 36% had no documented weight after treatment initiation. Conclusions. These results suggest that weight-loss drug treatment was often initiated upon patient request but was of limited clinical benefit as it was managed in a large portion of Swedish primary carecenters

Sibship and dispensing patterns of asthma medication in young children : a population based study

Purpose: Our aim was to study the association between sibship and dispensing patterns of asthma medication in young children, focusing on incidence and persistence, and taking sibship status, asthma diagnoses, and siblings’ medication into account. Methods: A register-based cohort study including all children (n=50,546) born in Stockholm, Sweden 2006–2007, followed up during 2006–2014. Exposure was sibling status; outcome was incidence of dispensed asthma medication and persistence over time. A Cox-model was used to study the association between sibship and asthma medication. Persistence was defined using two different time windows (4- and 18-months) in a refill sequence model including siblings’ and unrelated control children’s medication. Results: After one year of age, the adjusted hazard ratio of dispensed asthma medication was 0.85 (95%CI 0.80–0.90) among children with siblings compared to singletons. The estimated proportion of children with persistent controller medication was 7.2% (4-month model) and 64.5% (18-month model). When including the siblings’ controller medication, the estimated proportion was 8.8% (4-months) and 7.8% for control children (relative risk, RR 0.89, 95%CI 0.81-0.98). The persistence was lower for those with siblings compared to singletons (adj. RR 0.72, 95%CI 0.62-0.85 for 4-months) with similar estimates for older, younger, and full siblings and regardless of asthma diagnoses. Conclusions: Siblings have different dispensing patterns of asthma medications compared to singletons regardless of asthma diagnoses. After including the siblings’ asthma medication and compared with control children, the proportion of children with persistent medication increased which may indicate that siblings share asthma medications.Swedish Research Council for Health, Working Life and WelfareStrategic Research Program in EpidemiologyStockholm County CouncilSwedish Heart Lung FoundationSwedish Research CouncilAccepte

Estimating environmental exposure to analgesic drugs: A cross-sectional study of drug utilization patterns in the area surrounding Sweden’s largest drinking water source

Use of pharmaceuticals is continuously increasing globally and their residues are recognized as a risk for the environment. The aim of this study was to investigate drug utilization patterns of analgesics in relation to environmental hazard in the region surrounding Sweden's largest drinking water source, Lake Mälaren. This was examined using sales data on pharmaceuticals from the Swedish E-health Agency. The total sales of analgesics (non-steroidal anti-inflammatory drugs, paracetamol, other non-opioid analgesics, and opioids) for both human and veterinary use in the region were analyzed for the years 2016 to 2020, in relation to the inherent environmental hazard for each active pharmaceutical ingredient (API). We found that a total of 454 tons of analgesics were sold in the region during these 5 years. Classifications of environmental hazard were available for 16 out of the 45 studied APIs, accounting for 98.8% of the total mass in kilograms. Paracetamol, ibuprofen, and acetylsalicylic acid, which are all classified as low-hazard compounds, were the most commonly sold APIs. Diclofenac, the only pharmaceutical classified as high-hazard, was the fifth most commonly sold API, with a total sold mass of 2321 kg. The majority of the total sold mass of analgesics originated from dispensed prescriptions for human use in urban areas. Visualization of drug sales for humans and animals in different settings can be used to identify the environmental burden of pharmaceuticals. Based on our study, we suggest that additional measures to reduce the impacts of pharmaceuticals on the environment should primarily be directed to prescribing physicians in urban areas and campaigns targeted at the high over-the-counter sales of diclofenac. Moreover, it is important to address the fact that many pharmaceuticals currently have limited data on environmental hazard

Validation of asthma and eczema in population-based Swedish drug and patient registers

Purpose: Validated measures of asthma and eczema at the population level remain a challenge. Our aim was to ascertain if register-based information on asthma/eczema medicat ion can function as a proxy for an asthma/eczema diagnosis and to validate register-based asthma diagnoses. Methods: Information was requested on all 0-45 year old individuals with reported asthma/eczema medication and/or diagnoses in the Swedish Prescribed Drug Register and National Patient Register, between July 2005 and December 2009 (N=250,691). Medical records for 1,952 randomly selected individuals were reviewed to estimate the proportion of individuals with 1) asthma/eczema medication that fulfilled p redefined criteria of asthma/eczema (positive predictive value, PPV); 2) a register-based asthma diagnosis verified as asthma by set criteria. Results: PPV for asthma by predefined criteria ranged between 0.75 (95% CI: 0.70-0.78) to 0.94 (95% CI: 0.91-0.96), depending on age-group. In pre-school children, PPV for asthma in combination with obstructive bronchitis was 0.87 (95% CI: 0.83-0.90) and PPV for eczema was estimated to 0.45 (95% CI: 0.38-0.51). Eighty percent of children 0-4.5 years and 99% of children >4.5-17 years with a register-based diagnosis of asthma were verified as asthmatics. Conclusion: Asthma medication is a suitable proxy for asthma in older children and adults; the same approach is insufficient for eczema. This validation study of two Swedish registers opens for future large nation-wide register-based studies on asthma.Swedish Research CouncilVetenskapsrådetALFManuscrip

Enhancing the rational use of new medicines across European health care systems

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PP063—Changes in the utilisation of venlafaxine after the introduction of generics in Sweden: Implications for other countries

2013 e37 Significant but lesser changes in losartan utilization were seen in Austria and Belgium. There was no change in losartan utilization patterns in Scotland or Spain. Losartan typically generic at low prices, leading to appreciable increases in prescribing efficiency in NHS Bury, Sweden, Austria, and Belgium. There were some savings in Scotland with generic losartan. Conclusion: Multiple demand-side measures appreciably enhanced ARB prescribing efficiency. This mirrors previous findings that multiple measures are need to change prescribing habits. No significant increase in losartan utilization following generics where countries have not instigated specific measures suggests authorities cannot rely on a "spillover" effect between classes to change physician prescribing habits. This is the case even with multiple demand-side activities encouraging preferential prescribing of generics in related classes. This may be exacerbated on this occasion by a more complex message; for example, away from ACEIs first line versus ARBs to ACEIs + low cost ARBs first line. Disclosure of Interest: None declared

Did we see it coming? An evaluation of the Swedish early awareness and alert system

Early awareness and alert (EAA) systems have been established in many countries but evidence on their ability to accurately prioritize new medicines (for early assessment) is limited. The purpose of this study is to assess whether the Swedish EAA System identified and prioritized (i.e. produced early assessment reports for) new medicines that would go on to have a substantial economic impact. Methods We adapted a study design commonly used in the assessment of diagnostic test accuracy. The prioritization made by the Swedish EAA System prior to marketing authorization comprised the index test and national drug sales data in the second year post-authorization served as the reference standard. All initial marketing authorization applications for medicinal products processed by the European Medicines Agency (EMA) between 2010 and 2015 (study population) were classified using the index test and the reference standard. Results Two hundred and fifty-three new medicinal products processed by EMA comprised the study population. Of these, 71 were prioritized by the Swedish EAA System and 21 were classified as having a substantial economic impact. The sensitivity and positive predictive value were 76.2% and 22.5%, respectively. Subgroup analyses showed that the accuracy of prioritization, in terms of sensitivity, was 100% for antineoplastic/immunomodulating agents. Conclusions The Swedish EAA System identified all new medicines that would go on to have a substantial economic impact and prioritized most of these medicines. Our findings provide reassurance to decision makers who rely on the outputs of the Swedish EAA System to keep informed about new medicines. Moreover, this study also provides valuable insights to stakeholders willing to establish and/or evaluate their own EAA activities and systems