Multifaceted national and regional drug reforms and initiatives in ambulatory care in Sweden: global relevance

Abstract

It is a continual challenge trying to improve the quality of prescribing while concurrently trying to address increasing pharmaceutical development, utilization and expenditure. National and regional reforms and initiatives in Sweden have moderated growth in ambulatory drug expenditure to 2.7% per annum in recent years despite increasing volumes. National reforms include mandatory generic substitution and value-based pricing alongside devolution of drug budgets to the regions. Regional initiatives include strengthening the role of the regional Drug and Therapeutic Committees, further budget devolution as well as strategies incorporating prescribing guidance and monitoring coupled with financial incentives. The extent and nature of the regional initiatives vary depending on their characteristics. In this article, we compare initiatives undertaken in two major counties, Stockholm and Östergötland, and their outcomes. Outcomes include annual drug budget savings while achieving agreed quality as well as increased adherence to prescribing targets and guidance; the latter associated with savings. Appraising these multifaceted reforms can provide guidance to other countries and regions in view of their diversity. Future steps must incorporate measures to improve the utilization of new expensive drugs, which should include horizon scanning and forecasting activities as well as post-launch activities involving monitoring of prescribing and registries. This may well require cooperation with other European countries.

Keywords::

• Drug and Therapeutic Committee
• financial incentive
• generic
• healthcare reform
• pharmaceuticals
• pharmacoeconomics
• rational prescribing
• reference price

Acknowledgements

The authors acknowledge the help of Elisabet Torell from Apoteket AB in helping to provide drug sales and volume data, Niklas Hedberg from TLV with his helpful comments regarding TLV activities, and Professor Silvio Garattini from the Institute for Pharmacological Research ‘Mario Negri’ for his helpful comments on earlier drafts.

Financial & competing interests disclosure

Mikael Hoffmann is a deputy member of the TLV board and has acted as a coordinator of drug policies within Östergötland County Council from 2000 to 2007. Lars L Gustafsson is Chairman of the Regional Drug and Therapeutic Committee LÄKSAK. This study was in part supported by funds from Karolinska Institute and the Mario Negri Institute for Pharmacological Research. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Notes

OTC: Over the counter; PBS: Pharmaceutical benefits scheme; SALAR: Swedish Association of Local Authorities and Regions.

Data from [2,101,109,110,115–119,122,137–140].

DTC: Drug and Therapeutic Committee.

Data from [30].

Data from [121].

SIL: Svensk Informationsdatabas.

TLV: The Dental and Pharmaceutical Benefits Agency.

Data from [30,120].

Data from [120].

ACE: Angiotensin-converting enzyme; ARB: Angiotensin II receptor blocker; SNRI: Serotonin–norepinephrine reuptake inhibitor; SSRI: Selective serotonin receptor inhibitor.

Data from [124].

ATC: Anatomical Therapeutic Chemical; PHC: Primary Healthcare Center.

Data from [130].