Recent initiatives in Scotland to improve the quality and efficiency of prescribing : findings and implications

Background: Changing demographics with an increase in chronic disease prevalence coupled with more aggressive management targets, and the continued launch of new premium priced products, has put considerable strain on healthcare systems to continue providing universal, high quality healthcare. High appropriate use of generics in a class where care is not compromised by prescribing generics versus patented products, combined with quality measures, can help with providing quality healthcare. Objective: Assess the utilisation and costs of lipid lowering therapies (C10), Proton-Pump Inhibitors (PPIs) (A02BC), and Selective Serotonin Reuptake Inhibitors (SSRIs) (N06AB) in ambulatory care in Scotland between 2001 and 2015 alongside reforms to provide future guidance. Methods: Utilisation measured in the number of items dispensed to assess prescriptions and reimbursed expenditure captured in GB pounds from NHS Scotland national database. National and regional initiatives to improve the quality and efficiency of prescribing were captured using standard methodologies (4Es - education, engineering, economics and enforcement). No time series analyses analysis was conducted as multiple interventions over time. Results: Lipid lowering therapies (statins predominantly): multiple initiatives including identifying patients with CHD, encouraging preferential prescribing of generics, reducing ezetimibe prescribing as little evidence of benefit, and encouraging the prescribing of higher dose statins in line with recommendations, resulted in statin expenditure falling by 56% in 2015 vs. 2001 despite a 4.03 fold increase in utilisation. High dose statins now account for 71.3% of total prescriptions, up from 17.3% in 2001. PPIs: similar multiple initiatives resulted in a 68% reduction in expenditure despite a 2.91 fold increase in utilisation. High dose prescribing reduced to 20.3% of all PPIs in 2015, down from 25.8% in 2009, following concerns. SSRIs: similar initiatives and encouraging citalopram vs. escitalopram resulted in expenditure falling by 60.1% despite a 2.12 fold increase in utilisation. Concerns with citalopram in 2012 saw its prescribing fall in recent years whilst the prescribing of sertraline has grown. The prescribing of paroxetine continually fell from 2002 onwards as a result of concerns. Conclusion: Multiple strategies have been successful with improving the quality and efficiency of prescribing in Scotland. These will continue