Understanding the effects of a decentralized budget on physicians' compliance with guidelines for statin prescription--a multilevel methodological approach

Abstract

Background: Official guidelines that promote evidence-based and cost-effective prescribing are of main relevance for obvious reasons. However, to what extent these guidelines are followed and their conditioning factors at different levels of the health care system are still insufficiently known. In January 2004, a decentralized drug budget was implemented in the county of Scania, Sweden. Focusing on lipid-lowering drugs (i.e., statins), we evaluated the effect of this intervention across a 25-month period. We expected that increased local economic responsibility would promote prescribing of recommended statins.

Methods: We performed two separate multilevel regression analyses; on 110,827 individual prescriptions issued at 136 publicly-administered health care centres (HCCs) nested within 14 administrative areas (HCAs), and on 72,012 individual prescriptions issued by 115 privately-administered HCCs. Temporal trends in the prevalence of prescription of recommended statins were investigated by random slope analysis. Differences (i.e., variance) between HCCs and between HCAs were expressed by median odds ratio (MOR).

Results: After the implementation of the decentralized drug budget, adherence to guidelines increased continuously. At the end of the observation period, however, practice variation remained high. Prescription of recommended statins presented a high degree of clustering within both publicly (i.e., MORHCC = 2.18 and MORHCA = 1.31 respectively) and privately administered facilities (MORHCC = 3.47).

Conclusion: A decentralized drug budget seems to promote adherence to guidelines for statin prescription. However, the high practice differences at the end of the observation period may reflect inefficient therapeutic traditions, and indicates that rational statin prescription could be further improved.

Figure 1

The structure of the health care system in the Scania County council.

Figure 2

Percentage of recommended statins among initial statin prescription in the health care districts of the county of Scania, public health care centres (right) and private health care centres (left).

Figure 3

Predicted probabilities for prescribing recommended statins at public (left) and private (right) health care centres in Scania.

Figure 4

Differences (i.e. residuals) between health care centres obtained from the model including random parameters together with time (unfilled circles) and the model also including age, sex, health care districts, information campaign, presence of specialist physician other than general practitioners, and degree of decentralization (filled circles). Public administrative health care areas (top), public health care centres (middle), and private health care centres (bottom).