High adherence to the 'Wise List' treatment recommendations in Stockholm: a 15-year retrospective review of a multifaceted approach promoting rational use of medicines

Abstract

Objectives: To present the 'Wise List' (a formulary of essential medicines for primary and specialised care in Stockholm Healthcare Region) and assess adherence to the recommendations over a 15-year period.

Design: Retrospective analysis of all prescription data in the Stockholm Healthcare Region between 2000 and 2015 in relation to the Wise List recommendations during the same time period.

Setting: All outpatient care in the Stockholm Healthcare Region.

Participants: All prescribers in the Stockholm Healthcare Region.

Main outcome measures: The number of core and complementary substances included in the Wise List, the adherence to recommendations by Anatomic Therapeutic Chemical (ATC) 1st level using defined daily doses (DDDs) adjusted to the DDD for 2015, adherence to recommendations over time measured by dispensed prescriptions yearly between 2002 and 2015.

Results: The number of recommended core substances was stable (175-212). Overall adherence to the recommendations for core medicines for all prescribers increased from 75% to 84% (2000 to 2015). The adherence to recommendations in primary care for core medicines increased from 80% to 90% (2005 to 2015) with decreasing range in practice variation (32% to 13%). Hospital prescriber adherence to core medicine recommendations was stable but increased for the combination core and complementary medicines from 77% to 88% (2007 to 2015). Adherence varied between the 4 therapeutic areas studied.

Conclusions: High and increasing adherence to the Wise List recommendations was seen for all prescriber categories. The transparent process for developing recommendations involving respected experts and clinicians using strict criteria for handling potential conflicts of interests, feedback to prescribers, continuous medical education and financial incentives are possible contributing factors. High-quality evidence-based recommendations to prescribers, such as the Wise List, disseminated through a multifaceted approach, will become increasingly important and should be developed further to include recommendations and introduction protocols for new expensive medicines.

Keywords: Adherence; Drug and therapeutics committee; Essential medicines; Health systems; Rational Use of Medicines; prescribing.

Figure 1

Number of substances included in the Stockholm Healthcare Region's Wise List over time. Core medicines, essential medicines for common illnesses, used in primary and hospital care. Complementary medicines, additional essential medicines to be used primarily for specialised care.

Figure 2

Adherence to recommendations (DU90%) in the Wise List for different prescriber categories in Stockholm Healthcare Region between 2003 and 2015. Data on complementary medicines available only from 2007. ‘Others’ includes psychiatry, geriatrics, rehabilitation, school health, occupational health and private practitioners in various specialties.

Figure 3

Prescribing patterns for statins in Stockholm Healthcare Region between 2002 and 2015 showing all statin prescriptions dispensed to the inhabitants in the region each year. The letter ‘R’ signifies that the drug was a core recommendation in the Wise List that year. DDD/TID, defined daily dose/1000 inhabitants/day.

Figure 4

Prescribing pattern for proton pump inhibitors (PPI) in Stockholm Healthcare Region between 2002 and 2015 showing all PPI prescriptions dispensed to the inhabitants in the region each year. The letter ‘R’ signifies that the drug was a core recommendation in the Wise List that year. DDD/TID, defined daily dose/1000 inhabitants/day.

Figure 5

Prescribing pattern for selective serotonin receptor uptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) in Stockholm Healthcare Region between 2002 and 2015 showing all SSRI and SNRI prescriptions dispensed to the inhabitants in the region each year. The letter ‘R’ signifies that the drug was a core recommendation in the Wise List that year. (‘Others’ includes duloxetine, fluoxetine, paroxetine). DDD/TID, defined daily dose/1000 inhabitants/day.

Figure 6

Prescribing pattern for COX inhibitors in Stockholm Healthcare Region between 2002 and 2015 showing all COX inhibitor prescriptions dispensed to the inhabitants in the region each year. The letter ‘R’ signifies that the drug was a core recommendation in the Wise List that year. (‘Others’ includes aceclofenac, dexibuprofen, phenylbutazone, indomethacin, ketorolac, lornoxicam, meloxicam, nabumetone, piroxicam, sulindac, tenoxicam). DDD/TID, defined daily dose/1000 inhabitants/day.