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

[Speaker] Jaran Eriksen:1,2
[Co-author] Lars L Gustafsson:1, Kristina Ateva:3, Pia Bastholm-Rahmner:4, Marie-Louise Ovesjoe:1,5, Maria Juhasz-Haverinen:3,8, Gerd Laerfars:6, Rickard E Malmstroem:7, Bjorn Wettermark:1,3, Eva Andersen-Karlsson:6
1:Clinical Pharmacology at Department of Laboratory Sciences, Karolinska Instiutet, Sweden, 2:Department of Public Health, Karolinska Institutet, Stockholm, Sweden, 3:Stockholm Drug and Therapeutics Committee, Public Healthcare Services Committee, Stockholm, Sweden, 4:Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden, 5:Department of Quality and Development, Soedersjukhuset, Stockholm, Sweden, 6:Department of Clinical Science and Education, Soedersjukhuset, Internal Medicine, Karolinska Institutet, Stockholm, Sweden, 7:Department of Clinical Pharmacology, Karolinska University Hospital & Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden, 8:Ms Malena Jirlow, Stockholm Drug and Therapeutics Committee, Public Healthcare Services Committee, Stockholm, Sweden

Background: Inappropriate use of medicines increases the risk of therapeutic failure, adverse events, antimicrobial resistance, and is a waste of resources. This was a driving force behind the establishment of Drug and Therapeutics Committees (DTC) and the Essential Medicines concept in the 1970s. A joint formulary for Stockholm Healthcare Region was first issued in 2000. The formulary, called the "Wise List" ("Kloka Listan" in Swedish), consists of recommended core and complementary medicines for treatment of common diseases in primary and specialist care. We aimed to assess adherence to the "Wise List" recommendations over a 15-year period.

Methods: Retrospective analysis of all prescription data in the Stockholm Healthcare Region (population 2.3 million) between 2000 and 2015 related to the Wise List recommendations in the same time-period, measuring the number of substances included in the Wise List, adherence to recommendations by Anatomic Therapeutic Chemical (ATC) 1st level using Defined Daily Doses (DDDs) adjusted to DDD for 2015, adherence to recommendations over time measured by dispensed prescriptions yearly.

Results: The number of recommended core substances was rather stable over time (175 to 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) and the variability in adherence between practices decreased (32% to 13%). Hospital prescriber adherence to core medicine recommendations was stable but increased for the combination of core and complementary medicines from 77% to 88% (2007 to 2015). Adherence varied between the four 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.
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