WHO Drug Information Vol. 16, No. 3, 2002
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Drug and therapeutics committees: a Swedish experience

Folke Sjöqvist, Ulf Bergman, Marja-Liisa Dahl, Lars L. Gustafsson, and Lars-Olof Hensjö, Department of Medical Laboratory Sciences and Technology of the Karolinska Institute (Division of Clinical Pharmacology), WHO Collaborating Center for Drug Utilization Research and Clinical Pharmacological Services, Huddinge University Hospital, Stockholm, Sweden, and the Regional Drug Committee (LÄKSAK), Stockholm (correspondence: Folke.Sjoqvist@labtek.ki.se)


The development of drug and therapeutics committees (DTCs) in hospitals and for primary health care varies markedly from one country to another within Europe (1) but has been particularly strong in the Nordic countries. Since 1997, Swedish law requires that all twenty-one regions have a drug and therapeutics committee. These committees have played an increasingly important role in implementing the rational use of drugs.

For 40 years, hospital drug formulary committees have existed in Sweden to develop guidelines for the selection of the pharmacotherapeutic armamen-tarium. Committees were primarily established to evaluate drugs available for use in routine care and to recommend drugs of choice for common diseases. Selection was based on therapeutic value, therapeutic tradition, and price. The right of an individual physician to prescribe according to his own judgement was fully recognized as a fundamental element of health care delivery, but the difficulty of maintaining oversight of the increasing number of drugs on the market was also acknowledged (2). The committee's primary objective was thus to improve rational use while decreasing the cost of drug treatment.

Four important prerequisites relating to the work of the committee were emphasized (2):

• Work should be a collaborative effort between clinicians, pharmacists and clinical pharmacologists.

• Selection of recommended drugs should be based on relevant statistics on the use of drugs in a hospital setting.

• The committee should work through “ambassadors” to inform prescribers about committee evaluations and conclusions.

• The drug committee should inspire a sophisticated and intense pharmacotherapeutic debate in hospitals.


The success of the first committees within university hospitals was instrumental in extending rational use throughout the country. As a result of initial work, the number of standard solutions for infusion was reduced from 25 to four, and the number of pharmacotherapeutic hypnotics from 37 to six (2). During the early seventies, follow-up of the outcome of drug recommendations through drug utilization statistics was emphasized, and educational initiatives were implemented when prescribing was found to deviate from recommendations (3). By 1975, the concept of generic substitution had been successfully introduced in Stockholm hospitals. Major events in the development of drug selection are summarized in Table 1 on page 208.

In the 1980s, a special guideline focusing on drug choices in primary health care was developed to increase the commitment of general practitioners. In 2000, a single guideline with some 200 recommended first-line drugs for the most common diseases was agreed upon for the entire population of 1.8 million inhabitants in Stockholm. During the early 1990s, the scope of the committees was broadened to include drug information and education of prescribers. The number of committees in Sweden now reached almost one hundred.

In 1997, drug and therapeutics committees became obligatory under law and instructions were issued (see Table 2 on page 208). Counties now had to provide a budget to support committee activities. The number of coordinating DTCs was reduced to 21 regional committees, performing their work through expert groups on different diseases and through local committees.

Functions of drug and therapeutics committees

Since the 1997 Swedish Drug Reform Act, the function of drug and therapeutics committees has been regulated by the local county councils as the main providers of public health care. As the principal source of expertise, the overall aim of the committees is to promote the rational use of drugs at all levels of the health care system, whether at specialized clinics or primary health care centres. The committees have become a core facility for evidence-based principles of drug therapy within the health care system. Clinical pharmacologists, pharmacists, and district nurses (who have restricted prescribing rights in Sweden) are also represented. Members must declare any conflict of interest and acting as a consultant to industry is not allowed if this would lead to the promotion of an individual drug product. However, scientific collaboration at the institutional level is acceptable and even desirable.

Table 1. Major development of drug and therapeutics committees in Sweden

1961

First committee set up at the Karolinska Hospital, Stockholm.

1970s

Follow-up of the impact of drug recommendations on prescribing. Drug utilization statistics.

1975

Generic substitution encouraged.

1980s

Committees for primary health care and hospitals join forces. Stronger influence from primary health care. Newsletters.

1986

“Drug watcher” - drug bulletins and academic detailing.

1990s

Broadened scope towards drug education and problem-oriented drug information - 100 committees in Sweden.

1997

Drug and therapeutic committees required by law. Instructions issued, budget provided. Number of committees reduced to 21 regional committees.

2000

Information campaigns to public about recommended drugs of choice.

Regional DTCs gather and evaluate knowledge on drugs and drug therapies through screening of scientific documentation systematically retrieved from the literature. Local networks of experts representative of the various health care levels are responsible for implementation of the recommendations. The committees are urged to improve the quality of drug therapy at all levels of health care within a given county, including the private sector, and collaborate with other experts from regional clinical pharmacology departments, telepharmaco-logical services, local pharmacies, the Medical Products Agency, the pharmaceutical industry, and drug formulary committees. Other important functions are to provide the county council administrations with medical expertise in drug purchasing, develop policy documents for drug information, and provide education and follow-up on drug utilization and prescription patterns.

Table 2: Swedish law concerning drug and therapeutics committees (28 November 1996)

1. There shall be one or several drug committees in each county.

2. Each drug committee shall engage medical and pharmaceutical expertise.

3. A drug committee shall work towards the rational use of drugs through its recommendations to health care personnel. The recommendations should be based on scientific evidence and well-tried experience.

4. The National Corporation of Swedish Pharmacies shall provide drug committees with drug utilization statistics. If the committee realizes that there are shortcomings in the use of drugs it should provide education to prescribers.

5. Each committee shall, when required, collaborate with other committees and with relevant authorities and universities.

6. The County shall issue an instruction for the drug committee.

Selection of recommended drugs

Selected drugs should be well documented and appropriate from the pharmaceutical, pharmacological and therapeutic point of view, and considered essential in the treatment of common diseases. Evaluation of documentation follows the principles of evidence-based medicine. In order to gather experience about the safety of the compound, a new drug should have been registered and available on the market for at least two years. However, there is a trend towards quicker decisions and earlier acceptance of new drugs if they have shown potential to improve therapy.

Treatment costs are taken into account and an economic evaluation is demanded both for initial drug cost and the total treatment schedule. Recommended drugs should have high delivery guarantees from the producer/distributor, with relevant and up-to-date product information. Maintaining drug selection requires continuous follow-up of newly registered drugs, evaluation of the literature with respect to new guidelines, clinical trials and reports on adverse reactions. Expert groups are expected to stay in touch with specialist organizations preparing national treatment guidelines as well as with the Medical Products Agency, which regularly initiates and coordinates workshops.

Education and information

The rapidly expanding number of new drugs and treatment principles has created an increased need for independently evaluated drug information and education. The drug and therapeutics committee plays a central role here and supports a bilateral exchange of information with prescribers. Education is mostly problem-oriented, being initiated and organized by the medical community based on the needs of prescribers. Different models are being tested and an important idea is “drug education by prescribers for prescribers”. Primary health care physicians in academic drug detailing have been engaged at primary health care centres as “Drug Watchers” (4).

Regional drug information centres based within clinical pharmacology departments provide independent and evaluated problem-oriented drug information to prescribers (5) through a database - Drugline - containing more than 10 000 evaluated documents on drug-related issues (6).

In several counties, DTCs regularly inform the public of their recommendations. In Stockholm, mass media campaigns focusing on the list of recommended drugs have been directed at prescribers and their patients. The campaigns have helped to establish the regional committee as an independent and reliable expert organization. Both DTCs and the regional drug information centres collaborate actively with the Medical Products Agency, which publishes excellent monographs on individual drugs and reviews on the treatment of different diseases.

Electronic prescribing

In Stockholm, a computer-based prescription support system, JANUS telepharmacology, has been developed (http://www.janusinfo.org) aimed at providing all prescribers within a county with easily accessible, clinically relevant and updated information on drugs. The system includes (mainly in Swedish):

• information and recommendations from the regional and local drug committees in the county;

• recent guidelines from the Medical Products Agency;

• links to the Physicians Desk Reference (FASS) and Drugline; and

• recent drug news with comments and evaluations by specialists.


JANUS also provides access to information on drug interactions, with evaluated literature references to each interaction (7). The key objective is to provide appropriate information and prescribing tools to simplify the selection and dosage of drugs.

Graphic presentations of local drug prescription patterns are also included to allow quick feedback to and between prescribers. Within the next few years, electronic prescribing is expected to replace old-fashioned prescriptions, and the prescriber will then have access to real time information while prescribing. Integrated into the JANUS prescription system is a website (http://www.janusinfo.org) that serves as the electronic channel for all DTCs in Stockholm. Representative examples of the site pages in JANUS are set out in Figures 1 and 2.

Follow-up and feedback of drug utilization

Increasing drug costs, together with the transfer of the drug budget from the government to the county councils, emphasizes the need for follow-up of drug use, prescription patterns and cost trends. Drug committees play a key role in developing pharmacoepidemiological tools. The 1997 Drug Reform Act required bar codes for prescriptions, indicating workplace and prescriber identity. The feedback provided serves as an ideal self-audit system for primary health care centres, clinics, and individual prescribers (10).

Local auditing of prescription patterns and cost development in relation to the committee’s recommendations is an important strategy and stimulates feedback on rationality, prescribing and cost-awareness. Such data also form the basis for revision of drug recommendations, educational and informational activity needs, or intervention studies. Before drug reform, physicians were relatively unaware of the costs that prescribing generated, since the government paid the bill. This will now change dramatically and drug costs will become an integrated and visible part of the entire budget for a clinic or primary health care centre.


Fig. 1. JANUS prescription system:

Drug statistics:

Drug sales (1 million Swedish Kroner= 0.1 million Euros) by ACT class for 1st. quarter 1995-2000 in Stockholm. This function is updated monthly at the webiste: http://www.janusinfo.org


A new indicator of the quality of drug prescribing has recently been introduced in Stockholm County (8): Drug Utilization 90% (DU90%). The term refers to the number of drugs accounting for 90% of drug use, measured in defined daily doses (DDDs). The Swedish Medical Quality Council (9) has suggested using the DU90% as a general quality indicator of drug prescribing, and this has also been adopted in Stockholm (10). Adherence to guideline recommendations or other consensus documents is reflected by the percentage of recommended drugs within the DU90% segment. This measure can easily be used for comparisons over time between hospitals, clinics, primary health care centers and geographical regions and may identify problem areas where educational interventions are required. The method can be applied to all drugs or to different therapeutic classes (ATC groups). It also provides data for economic follow-up and analysis, as the drug costs are also included. By sorting on “costs” the corresponding Drug Costs 90% - DC90% - profile is obtained.


Fig. 2. JANUS prescription system:

The JANUS prescribing tool contains 24 different drug information databases. Patient data are automatically retrieved from electronic records. A bullet shows that the drug is recommended by the drug and therapeutics committee (arrow a). Arrow b indicates an automatic pregancy alert for drugs with potential effects on the foetus. Arrow c shows an automatic interaction alert for warfarin. http://www.janusinfo.org


The combined DU90%/DC90% profile has turned out to be of considerable interest to prescribers and physicians responsible for health care costs, including drugs. Figure 3 on page 212 describes DU90% profile by brand name based on prescriptions dispensed to the population of Stockholm during the three months of October-December 2000 ranked by number of defined daily doses (DDD), according to the recommendations by the Swedish Medical Quality Council (9). The drug utilization 90% (DU90%) segment (the area below the curve) corresponds to 311 of a total of 1,317 brand names with DDDs dispensed at pharmacies. Adherence to Guideline 2000 issued in January 2000 was 59% in the DU90% segment. The technical unit of comparison (DDD) is given in mg, or number of tablets, etc. Rx = number of prescription items. Cost (SEK) in Swedish kronor. Corresponding ranking by cost provides a drug cost 90% profile - DC90%. SEK/ DDD is the actual costs per DDD.


Fig. 3. DU90% Drug use profile

1. (Trombyl = ASA; 2. Levaxin = levothyroxine; 3. Zocord = simvastatin; 4. Plendil = felodipine; 5. Cipramil = citalopram; 6. Renitec = enalapril; 7. Seloken ZOC = metoprolol; 8. Imovane = zoplicone; 9. Lasix Retard = furosemide; 10. Lipitor = atorvastatin; 11. Furix =f urosemide; 12. Pulmicort Turbuhaler = budesonide;13. Pro-pavan = propiomazine; 14. Triatec = ramipril; 5. Furosemid NM = furosemide; 16. Imdur = isosorbide mononitrate; 17. Losec MUPS = omeprazole; 18. Behepan = cyanocobalamin; 19.Zoloft=sertralinehydrochloride;20.Tenormin = atenolol; 21. Stilnoct= zolpidem; 22. Bricanyl Turbuhaler = terbutaline; 23. Desolett = deso-gestrel; 24. Lanzo= lansoprazole; 25. Citodon = paracetamol; 26 Atrovent = ipratropium bromide; 27. Calcichew-D3=calciumcarbonate; 28. Fludent = sodium fluoride; 29. Alvedon = paracetamol; 30. Laktulos P&U = lactulose)


PHARM. PRODUCT

(DDD)

DDD

%

Rx

COST (SEK)

SEK/ DDD

1. TROMBYL

1 tabl.

6,569,005

4.5%

64,425

2,186,994

0.33

2. LEVAXIN

0.15 mg

2,952,441

2.0%

41,535

3,059,630

1.04

3. ZOCORD

15 mg

2,816,558

1.9%

24,749

25,618,330

9.10

4. PLENDIL

5 mg

2,409,584

1.7%

23,319

11,072,443

4.60

5. CIPRAMIL

20 mg

2,372,289

1.6%

27,362

19,325,240

8.15

6. RENITEC

10 mg

2,335,146

1.6%

18,642

9,841,277

4.21

7. SELOKEN ZOC

0.15 g

2,304,272

1.6%

47,073

12,493,554

5.42

8. IMOVANE

7.5 mg

2,097,315

1.4%

42,237

4,831,678

2.30

9. LASIX RETARD

40 mg

1,957,065

1.4%

19,505

2,666,956

1.36

10. LIPITOR

10 mg

1,935,550

1.3%

12,783

13,528,542

6.99

11. FURIX

40 mg

1,863,001

1.3%

10,919

751,774

0.40

12. PULMICORT TURBUH.

0.8 mg

1,779,825

1.2%

22,903

11,065,400

6.22

13. PROPAVAN

25 mg

1,640,487

1.1%

20,353

1,791,482

1.09

14. TRIATEC

2.5 mg

1,558,301

1.1%

6,778

4,615,226

2.96

15. FUROSEMID NM

40 mg

1,525,293

1.1%

7,629

549,500

0.36

16. IMDUR

40 mg

1,498,186

1.0%

11,996

3,645,951

2.43

17. LOSEC MUPS

20 mg

1,464,548

1.0%

23,961

23,312,114

15.92

18. BEHEPAN TABL.

1 mg

1,445,912

1.0%

13,635

2,106,438

1.46

19. ZOLOFT

50 mg

1,404,284

1.0%

15,813

13,158,324

9.37

20. TENORMIN

75 mg

1,303,954

0.9%

19,172

1,863,095

1.43

21. STILNOCT

10 mg

1,234,150

0.9%

27,991

3,918,260

3.17

22. BRICANYL TURBUH.

2 mg

1,179,700

0.8%

22,369

3,696,018

3.13

23. DESOLETT

*

1,114,876

0.8%

6,255

1,182,517

1.06

24. LANZO

30 mg

1,005,654

0.7%

23,132

10,677,362

10.62

25. CITODON

3 t/supp

985,687

0.7%

33,107

3,013,438

3.06

26. ATROVENT

*

971,489

0.7%

10,421

3,914,818

4.03

27. CALCICHEW D3

2 tabl

953,640

0.7%

12,257

2,963,622

3.11

28. FLUDENT

1.1 mg

925,260

0.6%

4,564

411,151

0.44

29. ALVEDON

3 g

922,590

0.6%

34,307

2,247,339

2.44

30. LAKTULOS P&U

6.7 g

919,890

0.6%

8,732

909,068

0.99

             

DU90%

1-311

 

130,278,408

90.0%

2,022,457

555,509,919

4.26

 

312-1317

 

14,464,452

10.0%

439,649

282,849,843

19.55

             

TOTAL

1-1317

 

144,742,860

100.0%

2,462,106

838,359,762

5.79

Resources

The drug and therapeutics committees have an annual budget which varies between the 21 regions. In the most progressive counties it has been considered appropriate to invest a sum corresponding to 1% of the total drug expenditure. The annual budget for the DTCs in Stockholm is about 4 million Euros, with drug expenditure about 0.4 billion Euros annually.

In Stockholm, the budget is spent on salaries and for engaging clinical expertise. With the existing financial system for the health care budget it is impossible to engage clinical experts for this intellectual work unless they can have leave of absence from their pressing daily work with patients. Much of the budget is spent on continuing education of prescribers and to implement the recommendations of the drug committee.

The committees can also use the competence of existing units in clinical pharmacology as well as regional and local pharmacies. The regional drug information centres (6) offer a service to retrieve, evaluate and summarize the documentation of different drug products.

The future of drug and therapeutics committees

A number of circumstances make it clear that the individual prescriber will be in great need of unbiased, consultative support in the selection and use of drugs in the future. The aims of drug treatment should be that the right drug is prescribed to the right patient in the right dose with the right information and at the right (affordable) cost (11). This implies competence, integrity and cost-awareness on behalf of the prescriber.

Prescribers, then, will accept advice from the organization paying the drug bill and not from the manufacturer alone, while providers of health care have to take responsibility for the continued drug education of the prescribers. This will probably be an invaluable investment in view of the alarming annual increase of expenditure for drugs, and adverse drug effects now reported worldwide.

For drug and therapeutics committees to be effective, it is vital to broadly engage the prescribing professions in the work and to base the selection of the therapeutic choice on advice from the most competent experts in pharmacotherapeutics.

References

1. Fijn, R., Brouwers, J.R., Knaap, J.R. et al. Drug and therapeutics (D & T) committees in Dutch hospitals: a nationwide survey of structure, activities, and drug selection procedure. British Journal of Clinical Pharmacology, 48: 239-246 (1999).

2. Barkman, R., Boréus, L.O., Böttiger, L.E. et al. Läkemedelskommittén - Service i rutinsjukvård. Läkartidningen, 26: 2491-2496 (1966).

3. Bergman, U., Christenson, I., Jansson, B. et al. Auditing hospital drug utilization by means of defined daily doses per bed-day. A methodological study. European Journal of Clinical Pharmacology, 17:183-187 (1980).

4. Stålsby Lundborg, C., Hensjö, L-O., Gustafsson, L.L. Academic drug-detailing: from project to practice in a Swedish urban area. European Journal of Clinical Pharmacology, 52: 167-172 (1997).

5. Alván, G., Öhman, B., Sjöqvist, F. Problem-oriented drug information: A clinical pharmacological service. Lancet, 2: 1410-1412 (1983)

6. Öhman, B., Lyrvall, H., Alván, G. Use of Drugline - A question and answer database. Annals of Pharmaco-therapy, 27: 278-284 (1993).

7. Sjöqvist, F. Interaktion mellan läkemedel - systematisk översikt. In: Läkemedel i Sverige. FASS: 1583-1653 (2001).

8. Bergman, U., Popa, C., Tomson, Y. et al. Drug utilization 90% - a simple method for assessing the quality of drug prescribing. European Journal of Clinical Pharmacology, 54: 113-118 (1998).

9. Bergman, U., Andersson, D., Friberg, A. et al. Kvalitets-utveckling: Kvalitetsindikatorer för läkemedelsförskrivning och-hantering. Svensk Medicin, Svenska Läkaresälls-kapet och Spri 1999. No. 66.

10. Nyman, K., Bergens, A., Björin, A.S. et al. Återföring av förskrivningsprofiler vid en vårdcentral. Viktigt inslag i kvalitetssäkringen av läkemedelsförskrivningen. Läkartidningen, 98: 160-164 (2001).

11. Sjöqvist, F. The past, present and future of clinical pharmacology. European Journal of Clinical Pharmacology, 55: 553-557 (1999).

 

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