Patterns of prescription antihypertensive drug utilization and adherence to treatment guidelines in the city of Novi Sad
Abstract
Background/Aim. Hypertension is one of the leading causes of cardiovascular morbidity and mortality and more than a half of all health insurance expenditures for reimbursed medicines are allocated to antihypertensive drugs in Serbia. The aim of this study was to identify the antihypertensive drug utilization patterns among hypertensive outpatients in the city of Novi Sad, Serbia, determine the adherence to clinical guidelines and address the economic aspects of current prescribing practices. Methods. This retrospective observational study was conducted in Novi Sad over a period of six months. The data on the number of packages, size their, and retail price of antihypertensives issued on prescription in outpatients with the diagnosis of essential arterial hypertension was collected from all state-owned pharmacies in Novi Sad. Drug consumption was analyzed using the Anatomical Therapeutic Chemical (ATC)/ defined daily dose (DDD) methodology. Results. Total consumption of antihypertensives issued on prescription over a 6-month period in the city of Novi sad, Serbia was 283.48 DDD per 1,000 inhabitans per day (DID). Angiotensin converting enzyme inhibitors (ACEi) were most commonly prescribed drugs, and were used 3 times more often than calcium channel blockers and 5 times more than beta-blockers. The consumption of diuretics and angiotensin receptor antagonists was low within all the groups of outpatients. Both national and international guidelines state superiority and effectiveness of diuretics in treatment of hypertension in the elderly, but their consumption was unreasonable low despite the fact that over 70% of all antihypertensive drugs in the city of Novi Sad were dispensed in people aged > 60. The use of more expensive ACEi was observed despite the guidelines deeming all the drugs of this class equally effective in treatment of hypertension. Conclusion. Large differences in utilization of different groups of antihypertensive agents were noted in this study. Underutilization of valuable, efficacious, and cost-effective thiazide diuretics and overuse of expensive ACE inhibitors is unjustifiable. There is a potential for large savings with switching to low-price ACEi, modeling the practice of Scandinavian countries.
References
Institute of Public Health of Serbia. Health statistical yearbook of Republic of Serbia, 2012. 2012. Available from: http://www.batut.org.rs/download/publikacije/pub2011.pdf
Čatić-Begović B. Outpatient antihypertensive drug utilization in Canton Sarajevo during five years period, and adherence to treatment guidelines assessment. Bosn J Basic Med Sci 2011; 11(2): 97−102.
World Health Organization. Noncommunicable diseases country profiles 2011. Available from: http://www.who.int/nmh/publications/ncd_profiles_report.pdf
World Health Organization. WHO report on the global tobacco epidemic 2013. Available from: http://apps.who.int/iris/bitstream/10665/85380/1/9789241505871_eng.pdf
Ministry of Health of Republic of Serbia. National health survey Serbia - 2013. 2014. Available from: http://www.zdravlje.gov.rs/downloads/2014/jul2014/Jul2014IzvestajPreliminarni.pdf (Serbian)
Falaschetti E, Mindell J, Knott C, Poulter N. Hypertension manage-ment in England: a serial cross-sectional study from 1994 to 2011. Lancet 2014; 383(9932): 1912−9.
Lakić D, Tasić L, Kos M. Economic burden of cardiovascular diseases in Serbia. Vojnosanit Pregl 2014; 71(2): 137−43.
Ivanova A, Lakic D, Andric V, Petrova G. Cost of outpatient hypertension pharmacotherapy: comparative study between Bulgaria and Serbia. Pharm Pract 2009; 7(2): 108−12.
Kahan NR, Chinitz DP, Blackman S, Waitman D, Vardy DA. Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authoriza-tion requirements for losartan. Brit J C Pharmaco 2011; 72(6): 997−1001.
Grujić V, Dragnić N, Kvrgić S, Sušnjević S, Grujić J, Travar S. Epi-demiology of hypertension in Serbia: results of a National Sur-vey. J Epidemiol 2012; 22(3): 261−6.
World Health Organization Collaborating Centre for Drug Statistics Methodology. The ATC/DDD system. 2012. Availa-ble from: http://www.whocc.no/atcddd
Bergman U, Popa C, Tomson Y, Wettermark B, Einarson TR, Aberg H, et al. Drug utilization 90% - a simple method for assessing the quality of drug prescribing. Eur J Clin Pharmacol 1998; 54(2): 113−8.
Serbian professional committee for preparation and implementation of guidelines for good clinical practice for the diagnosis and treatment of arterial hypotension. Belgrade: (Agency for Acreditation of Health Care Institutions in Serbia) 2011. (Serbian)
Mancia G, de Backer G, Dominiczak A, Cifkova R, Fagard R, Ger-mano G, et al. 2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2007; 28(12): 1462−536.
National Institute for Health and Clinical Excellence, NICE. Clinical guideline 127- Hypertension Clinical management of primary hypertension in adults. 2011. Available from: http://www.nice.org.uk/nicemedia/live/13561/56008/56008.pdf
Perić D, Milijašević D, Tomić N, Knežević A, Bukumirović N, Milijašević B. Use of ACE-Inhibitors in Serbia in 2009 and 2010. Hosp Pharmacol 2014; 1(3): 122−9.
Kažić T, Ostojić M. Cardiovascular drugs: Handbook for thera-py. Beograd: Integra; 2011. (Serbian)
Republic Fund for Health Insurance Serbia. List A - List of prescrip-tion drugs Issued at the expense of compulsory health insur-ance. 2012. Available from: http://www.rfzo.rs/download/04022013_Lista%20A.pdf
Republic Fund for Health Insurance Serbia. List A1 - List of pre-scription drugs with therapeutic parallel in List A. 2012. Avail-able from: http://www.rzzo.rs/download/lista_A1.pdf
Barron J, Wahl P, Fisher M, Plauschinat C. Effect of prescription copayments on adherence and treatment failure with oral anti-diabetic medications. Pharm Therap 2008; 33(9): 532−53.
Neugut AI, Subar M, Wilde ET, Stratton S, Brouse CH, Hillyer GC, Association Between Prescription Co-Payment Amount and Compliance With Adjuvant Hormonal Therapy in Women With Early-Stage Breast Cancer. J Clin Oncol 2011; 29(18): 2534−42.
Gibson TB, Mark TL, Mcguigan KA, Axelsen K, Wang S. The ef-fects of prescription drug copayments on statin adherence. Am J Manag C 2006; 12(9): 509−17.
Heagerty A. Optimizing hypertension management in clinical practice. J Hum Hypertens 2006; 20(11): 841−9.
Norwegian Institute for Public Health. Drug Consumption in Nor-way 2004–2008. 2014. Available from: http://www.legemiddelforbruk.no/english
National Agency for Medicines, Finland. Drug consumption statis-tics. 2014. Available from: http://raportit.nam.fi/raportit/kulutus/laakekulutus_e.pdf
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al. The Seventh Report of the Joint National Com-mittee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289(19): 2560−72.
Roush GC, Kaur R, Ernst ME. Diuretics: a review and update. Cardiovasc Pharmacol Ther 2014; 19(1): 5−13.
Veličković-Radovanović RM, Janković SM, Avramović MŽ, Kostić S. The use of cardiovascular drugs in Niš region of Serbia. Facta Univ Med Biol 2006; 13(2): 94−7.
Sakač D, Sabo A, Jakovljević V, Stanulović M, Sakač V. Drug uti-lization in the therapy of cardiovascular diseases at the teritory of Novi Sad. Pharm Iugoslav 1995; 33(3−4): 66−8.
Stimac D, Culig J, Vukusić I, Sostar Z, Tomić S, Bucalić M. Outpa-tient utilization patterns of the six main ATC drug groups in Republic of Croatia, city of Zagreb, and Croatia counties in 2004. Coll Antropol 2009; 33(4): 1197−204.
Stolk P, van Wijk BL, Leufkens HG, Heerdink ER. Between-country variation in the utilization of antihypertensive agents: guidelines and clinical practice. J Hum Hypertens 2006; 20(12): 917−22.
Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood pressure control among United States adults with hypertension: the National Health And Nu-trition Examination Survey, 2001 to 2010. Circulation 2012; 126(17): 2105−14.
Radonjic V. Trade and consumption of the medicinal products – annual report 2012 Belgrade: Medicines and Medical Devices Agency of Serbia; 2013. (Serbian)
Sabo A, Tomić Z, Stilinović N, Milijašević B, Mikov M, Vukmirović S, et al. Consumption of serum lipid-reducing drugs in Serbia compared with Scandinavian countries: a population-based study, 2004-2008. Pharmacoepidemiol Drug Saf 2010; 20(1): 45−9.