Quality in Primary Care Open Access

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Financial incentives linked to self-assessment of prescribing patterns: a new approach for quality improvement of drug prescribing in primary care

Bjorn Wettermark, Ake Pehrsson, Maria Juhasz-Haverinen, Aniko Veg, Maria Edlert, Gunilla Tornwall-Bergendahl, Henrik Almkvist, Brian Godman, Fredrik Granath, Ulf Bergman

Background Financial incentives have been suggested to be effective in increasing the quality and efficiency of drug prescribing. Concern has been raised in relation to potential negative consequences on the quality of care. Aims To describe and analyse the impact of an incentives model linking payment with adherence to drug and therapeutics committee (DTC) guidelines and self-reflection of prescribing pattern in a ‘prescribing quality report’. Methods The study was performed in the county of Stockholm, Sweden, with 139 (out of 154) primary healthcare centres (PHCs) participating in the project and 15 PHCs not participating. The study consisted of two parts: a quantitative observational study of prescribing patterns and a qualitative analysis of the submitted prescribing quality reports. All prescriptions issued from PHCs and dispensed at pharmacies during October to December 2005 andOctober to December 2006 were analysed, using adherence to the regional DTC guidelines as the main outcome measure. Adherence was assessed using the drug utilisation 90% methodology, i.e. focusing on drugs constituting 90% of the prescribed volume and the proportion of drugs included in the guidelines. The qualitative analysis focused on reports on the quality of drug prescribing submitted by each PHC in early 2007. Results The 139 PHCs participating in the programme accounted for 85% of all prescriptions issued in primary care during October to December 2006. Mean adherence to guidelines increased among participating practices by 3.3 percentage units (95% confidence interval (CI) 2.9–3.7%) to 83% (82.6–83.7%) during the year. The adherence among practices not participating increased by 3.1 percentage units (95% CI 1.7–4.4%) to 78.8% (95% CI 76.7–80.9%). The higher adherence achieved during the year corresponded to savings estimated at five times greater than the cost of running the programme including the financial incentives. In addition, many areas for improving prescribing were identified, such as limiting the prescribing of drugs with uncertain safety profiles and documentation as well as reporting adverse drug reactions. Conclusion Although no causal effect can be attributed without a control group, we have shown the feasibility of a model linking payment to DTC adherence. This approach with its own quality assessment and goal setting offers an example to other regions and countries of how to increase the quality and efficiency of drug prescribing within limited resources.