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Understanding adherence to therapeutic guidelines: a multilevel analysis of statin prescription in the Skaraborg Primary Care Database

  • Pharmacoepidemiology and Prescription
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Purpose

In Skaraborg, Sweden, the economic responsibility for tax-financed prescription drug costs was transferred from the regional administrative level to the local level (health care centre; HCC) in 2003. The aim of this study was to investigate the impact of this decentralization of economic responsibility on adherence to guidelines for prescribing lipid-lowering drugs.

Methods

Data from all 24 public HCCs in Skaraborg on prescriptions for lipid-lowering drugs during 2003 and 2005 were extracted from the Skaraborg Primary Care Database (SPCD). Multilevel regression analysis (MLRA) was used to disentangle the variances at different levels of data (patient, physician, HCC). The outcome variable on the patient level was the prescription of the recommended statin (yes/no). Sex and age of the patients and sex, age and occupational status of the physician were included as fixed effects. The variance was expressed as the median odds ratio (MOR).

Results

The prevalence of adherence to guidelines for the prescription of statins increased from 77% in 2003 to 84% in 2005. The MLRA showed that in 2003 the variance was equally distributed between the HCC and physician levels (MORHCC2003 = 1.89 vs. MORPHYSICIAN2003 = 1.88). The variance between physicians and between HCCs decreased considerably between 2003 and 2005. The inclusion of individual and physician characteristics did not explain any of the remaining variance.

Conclusion

The decentralized budget appears to have increased adherence to guidelines and reduced inefficient variation in prescribing.

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References

  1. Grimshaw J, Thomas R, Maclennan G, Fraser C, Ramsay C, Vale L et al (2004) Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 8(6)

  2. Socialstyrelsen (ed) (2006) God vård—om ledningssystem för kvalitet och patientsäkerhet I hälso—och sjukvården. (Appropriate care—about management for quality and patient security in health and medical care) (in Swedish). Stockholm: Socialstyrelsen

  3. Brindis RG, Sennett C (2003) Physician adherence to clinical practice guidelines: does it really matter? Am Heart J 145(1):13–15

    Article  PubMed  Google Scholar 

  4. Koutsavlis AT (2001) Disseminating practice guidelines to physicians. Institut National de Santé Publique du Québec, Québec City

    Google Scholar 

  5. Thorsen T, Mäkelä M (eds) (1999) Changing professional practice—theory and practice of clinical guidelines implementation. Danish Institute for Health Services Research and Development, Copenhagen

  6. Socialstyrelsen (ed) (2007) En uppföljning av läkemedelskommitéernas arbete. Hur påverkas läkemedelsanvändningen (A follow-up of the effort of the drug committees. How does it affect the drug use?) (in Swedish). Socialstyrelsen, Stockholm

  7. Kasje WN, Denig P, Stewart RE, de Graeff PA, Haaijer-Ruskamp FM (2005) Physician, organisational and patient characteristics explaining the use of angiotensin converting enzyme inhibitors in heart failure treatment: a multilevel study. Eur J Clin Pharmacol 61(2):145–151

    Article  PubMed  CAS  Google Scholar 

  8. Ohlsson H, Lindblad U, Lithman T, Ericsson B, Gerdtham UG, Melander A et al (2005) Understanding adherence to official guidelines on statin prescribing in primary health care-a multi-level methodological approach. Eur J Clin Pharmacol 61(9):657–665

    Article  PubMed  CAS  Google Scholar 

  9. Ohlsson H, Merlo J (2007) Understanding the effects of a decentralized budget on physicians compliance with guidelines for statin prescription; a multilevel methodological approach. BMC Health Serv Res 7:68

    Article  PubMed  Google Scholar 

  10. Sjöqvist F, Dahl M-L, Gustafsson L, Hensjö L-O (2002) Drug therapeutics committees: a Swedish experience. WHO Drug Inf 16:207–213

    Google Scholar 

  11. Socialdepartementet. Lag (1996:1157) om läkemedelskommittéer. [Law (1996:1157) about drug committees] (in Swedish). Stockholm

  12. Ohlsson H, Chaix B, Merlo J (2009) Therapeutic traditions, patient socio-economic characteristics and physicians’ early new drug prescribing—a multilevel analysis of rosuvastatin prescription in South Sweden. Eur J Clin Pharmacol 65(2):141–150

    Article  PubMed  Google Scholar 

  13. Ohlsson H, Merlo J (2009) Is physician adherence to prescription guidelines a general trait of health care practices or dependent on drug type?—a multilevel logistic regression analysis in South Sweden. Pharmacoepidemiol Drug Saf 18(8):682–690

    Article  PubMed  Google Scholar 

  14. Hjerpe P, Merlo J, Ohlsson H, Bengtsson-Boström K, Lindblad U (2010) Validity of registration of ICD codes and prescriptions in a research database in Swedish primary care a cross-sectional study in Skaraborg primary care database (SPCD). BMC Med Inform Decis Mak 10:23

    Article  PubMed  Google Scholar 

  15. World Health Organization (WHO). About the ATC/DDD system. Available at: http://www.whocc.no/atcddd/. WHO, Geneva

  16. Goldstein H (2003) Multilevel statistical models. 3rd ed. Hodder Arnold, London

    Google Scholar 

  17. Snijders T, Bokser R (1999) Multilevel analysis: an introduction to basic and advanced multilevel modeling. Sage Publications, Thousand Oaks

    Google Scholar 

  18. Larsen K, Merlo J (2005) Appropriate assessment of neighborhood effects on individual health: integrating random and fixed effects in multilevel logistic regression. Am J Epidemiol 161(1):81–88

    Article  PubMed  Google Scholar 

  19. Larsen K, Petersen JH, Budtz-Jorgensen E, Endahl L (2000) Interpreting parameters in the logistic regression model with random effects. Biometrics 56(3):909–914

    Article  PubMed  CAS  Google Scholar 

  20. Rasbash J, Steele F, Browne W (2003) A user's guide to MLwiN, version 2.0 Documentation version 2.1e. London: Centre for Multilevel Modelling, Institute of Education, University of London

  21. Brookhart MA, Solomon DH, Wang P, Glynn RJ, Avorn J, Schneeweiss S (2006) Explained variation in a model of therapeutic decision making is partitioned across patient, physician, and clinic factors. J Clin Epidemiol 59(1):18–25

    Article  PubMed  Google Scholar 

  22. Braumoeller B (2006) Explaining variance; or, stuck in a moment we can’t get out of. Polit Anal 14:268–290

    Article  Google Scholar 

  23. Merlo J (2003) Multilevel analytical approaches in social epidemiology: measures of health variation compared with traditional measures of association. J Epidemiol Community Health 57(8):550–552

    Article  PubMed  CAS  Google Scholar 

  24. Rasbash J, Browne W, Goldstein H, Yang M, Plewis I, Healy M et al (2003) Modelling the variance as a function of explanatory variables. A user's guide to MLwiN. version 2.0. Documentation version 2.1e. Institute of Education, University of London, London

  25. Merlo J, Chaix B, Yang M, Lynch J, Råstam L (2005) A brief conceptual tutorial of multilevel analysis in social epidemiology—interpreting neighbourhood differences and the effect of neighbourhood characteristics on individual health. J Epidemiol Community Health 59:1022–1028

    Article  PubMed  Google Scholar 

  26. Black N (1996) Why we need observational studies to evaluate the effectiveness of health care. Br Med J 312(7040):1215–1218

    CAS  Google Scholar 

  27. Merlo J, Chaix B (2006) Neighbourhood effects and the real world beyond randomized community trials: a reply to Michael J Oakes. Int J Epidemiol 35(5):1361–1363

    Article  PubMed  Google Scholar 

  28. Schneeweiss S (2007) Developments in post-marketing comparative effectiveness research. Clin Pharmacol Ther 82(2):143–156

    Article  PubMed  CAS  Google Scholar 

  29. Sorensen G, Emmons K, Hunt MK, Johnston D (1998) Implications of the results of community intervention trials. Annu Rev Public Health 19:379–416

    Article  PubMed  CAS  Google Scholar 

  30. LaRosa JC, He J, Vupputuri S (1999) Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials. J Am Med Assoc 282(24):2340–2346

    Article  CAS  Google Scholar 

  31. Mehner A, Lindblad U, Rastam L, Bostrom KB (2008) Cholesterol in women at high cardiovascular risk is less successfully treated than in corresponding men. The Skaraborg hypertension and diabetes project. Eur J Clin Pharmacol 64(8):815–820

    Article  PubMed  Google Scholar 

  32. Crump B (2007) The good indicators guide: understanding how to use and choose indicators. NHS Institute for Innovation and Improvement, Coventry, UK

    Google Scholar 

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Acknowledgements

This research was funded by the Skaraborg Research and Development Council, Skaraborg primary care research and development council and the Skaraborg Institute, Skövde, Sweden, The Swedish Research Council (Juan Merlo, Dnr 2004-6155 and The Centre for Economic Demography), the Swedish Council for Working Life and Social Research (Juan Merlo, Dnr: 2007-1772) and by an ALF Government Grant Research programme (Juan Merlo, Dnr M: B 39 977)

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. R&D Centre, Skaraborg Primary Care, Skövde, Sweden

    Per Hjerpe & Kristina Bengtsson Boström

  2. Social Epidemiology, Department of Clinical Science, Faculty of Medicine, Lund University, Malmö, Sweden

    Per Hjerpe, Henrik Ohlsson & Juan Merlo

  3. Department of Public Health and Community Medicine/Primary Health Care, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden

    Ulf Lindblad

  4. FoU-centrum Primärvården Skaraborg, Storgatan 18, 541 30, Skövde, Sweden

    Per Hjerpe

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  1. Per Hjerpe
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Correspondence to Per Hjerpe.

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Hjerpe, P., Ohlsson, H., Lindblad, U. et al. Understanding adherence to therapeutic guidelines: a multilevel analysis of statin prescription in the Skaraborg Primary Care Database. Eur J Clin Pharmacol 67, 415–423 (2011). https://doi.org/10.1007/s00228-010-0973-4

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  • DOI: https://doi.org/10.1007/s00228-010-0973-4

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