title: Comparing policies to enhance prescribing efficiency in Europe through increasing generic utilization: changes seen and global implications.
abstract: OBJECTIVE
  The aim of this article was to evaluate the influence of different demand-side measures to enhance the prescribing of generics in ambulatory care based on cross-national comparisons.
  
  
  METHODS
  An observational retrospective study was conducted using administrative databases from across Europe, documenting changes in reimbursed utilization and expenditure of different proton pump inhibitors (PPIs) and statins between 2001 and 2007, alongside different reforms to enhance prescribing efficiency. Utilization was converted to defined daily doses (DDDs) and expenditures were converted to euros. Demand-side measures were collated under the '4 Es'--education, engineering, economics and enforcement--to enable comparisons on the nature and intensity of reforms between countries.
  
  
  RESULTS
  There were considerable differences in the utilization of generics and patent-protected PPIs and statins among Western European countries. Decreased utilization of omeprazole and simvastatin, alongside increased utilization of esomeprazole, atorvastatin and rosuvastatin, was seen in countries with limited demand-side measures to counteract commercial pressures. Prescribing restrictions, or a combination of education, prescribing targets and financial incentives, had the greatest influence on enhancing the utilization of omeprazole and simvastatin. For example, there was a threefold reduction in the utilization of atorvastatin in Austria following prescribing restrictions. Multiple demand-side interventions generally had a greater influence than single interventions, with the impact appearing additive. Multiple interventions coupled with initiatives to lower prices of generics considerably enhanced prescribing efficiency.
  
  
  CONCLUSIONS
  This cross-national study has demonstrated considerable variation in the utilization and expenditure of PPIs and statins across Europe, providing opportunities to further improve prescribing efficiency. The '4 Es' do provide an understandable methodology to document and compare the influence of different demand-side measures, with the influence varying by their extent and intensity. Further reforms are essential given current financial pressures. Consequently, further research will concentrate on the potential to develop a scoring system to help predict the possible impact of different demand-side measures on future utilization patterns.
authors.affiliation: Institute for Pharmacological Research 'Mario Negri', Via Giuseppe La Masa 19, 20156 Milan, Italy. godman@marionegri.it
authors.forename: Brian
authors.initials: B
authors.lastname: Godman
authors.forename: William
authors.initials: W
authors.lastname: Shrank
authors.forename: Morten
authors.initials: M
authors.lastname: Andersen
authors.forename: Christian
authors.initials: C
authors.lastname: Berg
authors.forename: Iain
authors.initials: I
authors.lastname: Bishop
authors.forename: Thomas
authors.initials: T
authors.lastname: Burkhardt
authors.forename: Kristina
authors.initials: K
authors.lastname: Garuoliene
authors.forename: Harald
authors.initials: H
authors.lastname: Herholz
authors.forename: Roberta
authors.initials: R
authors.lastname: Joppi
authors.forename: Marija
authors.initials: M
authors.lastname: Kalaba
authors.forename: Ott
authors.initials: O
authors.lastname: Laius
authors.forename: Diane
authors.initials: D
authors.lastname: McGinn
authors.forename: Vita
authors.initials: V
authors.lastname: Samaluk
authors.forename: Catherine
authors.initials: C
authors.lastname: Sermet
authors.forename: Ulrich
authors.initials: U
authors.lastname: Schwabe
authors.forename: Inês
authors.initials: I
authors.lastname: Teixeira
authors.forename: Lesley
authors.initials: L
authors.lastname: Tilson
authors.forename: F Cankat
authors.initials: FC
authors.lastname: Tulunay
authors.forename: Vera
authors.initials: V
authors.lastname: Vlahović-Palčevski
authors.forename: Kamila
authors.initials: K
authors.lastname: Wendykowska
authors.forename: Björn
authors.initials: B
authors.lastname: Wettermark
authors.forename: Corinne
authors.initials: C
authors.lastname: Zara
authors.forename: Lars L
authors.initials: LL
authors.lastname: Gustafsson
mesh_terms: D000553:Ambulatory Care; D016208:Databases, Factual; D016527:Drug Costs; D016568:Drugs, Generic / Q000191:economics / Q000627:therapeutic use*; D005060:Europe; D018166:Health Care Reform; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000191:economics / Q000627:therapeutic use; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000639:trends; D054328:Proton Pump Inhibitors / Q000191:economics / Q000627:therapeutic use; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies
chemical_list: D016568:Drugs, Generic; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D054328:Proton Pump Inhibitors