title: Combination of prescribing restrictions and policies to engineer low prices to reduce reimbursement costs.
abstract: OBJECTIVE
  To primarily document the influence of recent changes in the pricing policies for generics and originators in Norway, coupled with prescribing restrictions for both the proton pump inhibitors (PPIs) and statins, on subsequent prescribing efficiency, to provide possible examples to other countries. Second, to review the impact of prescribing restrictions on ezetimibe utilization in Norway compared with other European countries, again to provide guidance.
  
  
  METHODS
  A retrospective observational study using data from the Norwegian Drug Wholesales Statistics to evaluate changes in utilization patterns for the PPIs and statins from 2001 to 2009, and the Norwegian Prescription Database for expenditure data from January 2004 to 2009. Reforms validated with key personnel at the Norwegian Medicines Agency.
  
  
  RESULTS
  Atorvastatin utilization as measured by defined daily doses decreased after prescribing restrictions. This, coupled with increased utilization of generic simvastatin at only 15% of prepatent loss prices in recent years, led to a 55% decrease in statin expenditure in Norway between 2004 and 2009 despite appreciably increased utilization. Utilization of esomeprazole also fell following prescribing restrictions, but to a lesser extent. This reduction, coupled with low prices for generics as a result of recent pricing policies, resulted in PPI expenditure decreasing by 27% during the same period despite again appreciably increased utilization.
  
  
  CONCLUSIONS
  Policies to reduce the price of generics have been successfully introduced in Norway despite its small population size versus a number of other Western European countries. Prescribing restrictions have also been successfully introduced, mirroring the influence with multifaceted reforms in other European countries. The same applies to ezetimibe with utilization at only 1.9% of total statin and ezetimibe utilization in 2009. However, the difference in subsequent utilization patterns for atorvastatin versus esomeprazole makes it a challenge for health authorities to predict the ultimate impact of such measures. This requires further research.
authors.affiliation: Prescribing Research Group, University of Liverpool Management School, Chatham Street, Liverpool, L69 7ZH, UK. brian.godman@ki.se
authors.forename: Brian
authors.initials: B
authors.lastname: Godman
authors.forename: Solveig
authors.initials: S
authors.lastname: Sakshaug
authors.forename: Christian
authors.initials: C
authors.lastname: Berg
authors.forename: Björn
authors.initials: B
authors.lastname: Wettermark
authors.forename: Alan
authors.initials: A
authors.lastname: Haycox
mesh_terms: D000924:Anticholesteremic Agents / Q000191:economics / Q000627:therapeutic use; D001384:Azetidines / Q000191:economics / Q000627:therapeutic use; D016568:Drugs, Generic / Q000191:economics / Q000627:therapeutic use*; D000069438:Ezetimibe; D018166:Health Care Reform; D006291:Health Policy; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000191:economics / Q000627:therapeutic use; D007356:Insurance, Pharmaceutical Services / Q000191:economics; D009664:Norway; D010818:Practice Patterns, Physicians' / Q000592:standards*; D054328:Proton Pump Inhibitors / Q000191:economics / Q000627:therapeutic use; D012051:Reimbursement Mechanisms; D012189:Retrospective Studies
chemical_list: D000924:Anticholesteremic Agents; D001384:Azetidines; D016568:Drugs, Generic; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D054328:Proton Pump Inhibitors; D000069438:Ezetimibe