title: Multiple policies to enhance prescribing efficiency for established medicines in Europe with a particular focus on demand-side measures: findings and future implications.
abstract: BACKGROUND
  The appreciable growth in pharmaceutical expenditure has resulted in multiple initiatives across Europe to lower generic prices and enhance their utilization. However, considerable variation in their use and prices.
  
  
  OBJECTIVE
  Assess the influence of multiple supply and demand-side initiatives across Europe for established medicines to enhance prescribing efficiency before a decision to prescribe a particular medicine. Subsequently utilize the findings to suggest potential future initiatives that countries could consider.
  
  
  METHODS
  An analysis of different methodologies involving cross national and single country retrospective observational studies on reimbursed use and expenditure of PPIs, statins, and renin-angiotensin inhibitor drugs among European countries.
  
  
  RESULTS
  Nature and intensity of the various initiatives appreciably influenced prescribing behavior and expenditure, e.g., multiple measures resulted in reimbursed expenditure for PPIs in Scotland in 2010 56% below 2001 levels despite a 3-fold increase in utilization and in the Netherlands, PPI expenditure fell by 58% in 2010 vs. 2000 despite a 3-fold increase in utilization. A similar picture was seen with prescribing restrictions, i.e., (i) more aggressive follow-up of prescribing restrictions for patented statins and ARBs resulted in a greater reduction in the utilization of patented statins in Austria vs. Norway and lower utilization of patented ARBs vs. generic ACEIs in Croatia than Austria. However, limited impact of restrictions on esomeprazole in Norway with the first prescription or recommendation in hospital where restrictions do not apply. Similar findings when generic losartan became available in Western Europe.
  
  
  CONCLUSIONS
  Multiple demand-side measures are needed to influence prescribing patterns. When combined with supply-side measures, activities can realize appreciable savings. Health authorities cannot rely on a "spill over" effect between classes to affect changes in prescribing.
authors.affiliation: Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge Stockholm, Sweden ; Medicines Use and Health, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde Glasgow, UK ; Liverpool Health Economics Centre, University of Liverpool Management School Liverpool, UK.
authors.forename: Brian
authors.initials: B
authors.lastname: Godman
authors.affiliation: Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge Stockholm, Sweden ; Centre for Pharmacoepidemiology, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden ; Department of Healthcare Development, Public Healthcare Services Committee, Stockholm County Council Stockholm, Sweden.
authors.forename: Bjorn
authors.initials: B
authors.lastname: Wettermark
authors.affiliation: Dutch Institute for Rational Use of Medicines Utrecht, Netherlands.
authors.forename: Menno
authors.initials: M
authors.lastname: van Woerkom
authors.affiliation: Epidemiology and Social Medicine, Research Group Medical Sociology and Health Policy, University of Antwerp Antwerp, Belgium.
authors.forename: Jessica
authors.initials: J
authors.lastname: Fraeyman
authors.affiliation: Medicines Use and Health, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde Glasgow, UK.
authors.forename: Samantha
authors.initials: S
authors.lastname: Alvarez-Madrazo
authors.affiliation: Division of Epidemiology, Department of Pharmacoepidemiology, Norwegian Institute of Public Health Oslo, Norway.
authors.forename: Christian
authors.initials: C
authors.lastname: Berg
authors.affiliation: Public Health and Intelligence Business Unit, National Services NHS Scotland Edinburgh, UK.
authors.forename: Iain
authors.initials: I
authors.lastname: Bishop
authors.affiliation: Department of Finance, Faculty of Business, Economics and Statistics, University of Vienna Vienna, Austria ; Department of Reimbursement, Hauptverband der Österreichischen Sozialversicherungsträger Vienna, Austria.
authors.forename: Anna
authors.initials: A
authors.lastname: Bucsics
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester Manchester, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Campbell
authors.affiliation: Green Templeton College, University of Oxford Oxford, UK.
authors.forename: Alexander E
authors.initials: AE
authors.lastname: Finlayson
authors.affiliation: Health Insurance Institute Ljubljana, Slovenia.
authors.forename: Jurij
authors.initials: J
authors.lastname: Fürst
authors.affiliation: Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, University of Vilnius Vilnius, Lithuania ; Medicines Reimbursement Department, National Health Insurance Fund Vilnius, Lithuania.
authors.forename: Kristina
authors.initials: K
authors.lastname: Garuoliene
authors.affiliation: Kasemarzliche Vereinigung Hessen Frankfurt am Main, Germany.
authors.forename: Harald
authors.initials: H
authors.lastname: Herholz
authors.affiliation: Department of Medicines and Pharmacoeconomics, Republic Fund for Health Insurance Belgrade, Serbia.
authors.forename: Marija
authors.initials: M
authors.lastname: Kalaba
authors.affiliation: State Agency of Medicines Tartu, Estonia.
authors.forename: Ott
authors.initials: O
authors.lastname: Laius
authors.affiliation: Department of Reimbursement, Hauptverband der Österreichischen Sozialversicherungsträger Vienna, Austria.
authors.forename: Jutta
authors.initials: J
authors.lastname: Piessnegger
authors.affiliation: IRDES Paris, France.
authors.forename: Catherine
authors.initials: C
authors.lastname: Sermet
authors.affiliation: Institute of Pharmacology, University of Heidelberg Heidelberg, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Schwabe
authors.affiliation: Department of Clinical Pharmacology, University Hospital Rijeka Rijeka, Croatia.
authors.forename: Vera V
authors.initials: VV
authors.lastname: Vlahović-Palčevski
authors.affiliation: Faculty of Medicine, University of Banja Luka Banja Luka, Republic Srpska, Bosnia and Herzegovina ; Ministry of Health and Social Welfare Banja Luka, Republic Srpska, Bosnia and Herzegovina.
authors.forename: Vanda
authors.initials: V
authors.lastname: Markovic-Pekovic
authors.affiliation: Ministry of Health Republic of Croatia, Zagreb, Croatia.
authors.forename: Luka
authors.initials: L
authors.lastname: Vončina
authors.affiliation: Department of Epidemiology and Health Promotion, Public Health School Warsaw, Poland ; Drug Management Department, National Health Fund Warsaw, Poland.
authors.forename: Kamila
authors.initials: K
authors.lastname: Malinowska
authors.affiliation: Barcelona Health Region, Catalan Health Service Barcelona, Spain.
authors.forename: Corinne
authors.initials: C
authors.lastname: Zara
authors.affiliation: Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge Stockholm, Sweden.
authors.forename: Lars L
authors.initials: LL
authors.lastname: Gustafsson
keywords: PPIs; demand-side measures; drug utilization studies; generics; renin-angiotensin inhibitor drugs; statins