Small-area variations in sales of TNF inhibitors in Sweden between 2000 and 2009.
OBJECTIVE
To measure small-area variations in sales per capita of tumour necrosis factor (TNF) inhibitors.


METHODS
For 2000-2009, sales data on etanercept, infliximab, and adalimumab were retrieved from the Swedish National Corporation of Pharmacies, which keeps data on drugs dispensed in ambulatory care and hospitals. As points of reference, data were retrieved on all drugs, non-biologic treatments for chronic inflammatory disorders (sulfasalazine, methotrexate, azathioprine), and for a biologic used in a different therapeutic area (trastuzumab). As a corollary measure to sales per capita, penetration of biologics in the rheumatoid arthritis (RA) population was calculated using nationwide registers. Small areas were defined as the 21 counties of Sweden.


RESULTS
From 2000 to 2009, annual TNF inhibitor sales increased 9-fold from 195 to 1779 million SEK (0.7-5.0% of total drug expenditure). The county variation in sales per capita, initially 6.2-fold (coefficient of variation 42%), decreased to 2.3-fold in 2009 (24%). During the same period, total drug expenditure per capita remained at a 1.2-fold county variation (4-6%). Sales per capita variations of non-biologic treatments against chronic inflammatory diseases ranged from 1.5 to 1.8 (12-16%). For trastuzumab, a 3.2-fold variation (30%) was observed in 2009. At the patient level, there was a 2-fold county variation (from 10% to 21%) in biologic penetration in RA. County-specific sales per capita were associated with mean RA duration (r = -0.52, p = 0.015) and C-reactive protein at treatment initiation (r = -0.49, p = 0.025), while pain was borderline significant (r = -0.43, p = 0.055).


CONCLUSIONS
Despite universal access to treatment, substantial but decreasing small-area variations were observed. Although geographic variations are anticipated initially, their persistence calls for investigation of patient equity and treatment appropriateness as counties seem to have different initiation thresholds.
Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm. Martin.Neovius@ki.se
M
M
Neovius
A
A
Sundström
Jf
J
Simard
B
B
Wettermark
T
T
Cars
N
N
Feltelius
J
J
Askling
L
L
Klareskog
D000068879:Adalimumab; D000911:Antibodies, Monoclonal / Q000191:economics; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents / Q000191:economics* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D016527:Drug Costs; D004345:Drug Industry / Q000191:economics; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D000068800:Etanercept; D006801:Humans; D007074:Immunoglobulin G / Q000191:economics; D000069285:Infliximab; D018124:Receptors, Tumor Necrosis Factor; D017062:Small-Area Analysis; D013548:Sweden; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab; D000068800:Etanercept