The effects of mandatory prescribing of thiazides for newly treated, uncomplicated hypertension: interrupted time-series analysis

Atle Fretheim, Kari Havelsrud, Graeme MacLennan, Doris Tove Kristoffersen, Andrew D Oxman

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Abstract

Background: The purpose of our study was to evaluate the effects of a new reimbursement rule for antihypertensive medication that made thiazides mandatory first-line drugs for newly treated, uncomplicated hypertension. The objective of the new regulation was to reduce drug expenditures.

Methods and Findings: We conducted an interrupted time-series analysis on prescribing data before and after the new reimbursement rule for antihypertensive medication was put into effect. All patients started on antihypertensive medication in 61 general practices in Norway were included in the analysis. The new rule was put forward by the Ministry of Health and was approved by parliament. Adherence to the rule was monitored only minimally, and there were no penalties for non-adherence. Our primary outcome was the proportion of thiazide prescriptions among all prescriptions made for persons started on antihypertensive medication. Secondary outcomes included the proportion of patients who, within 4 mo, reached recommended blood-pressure goals and the proportion of patients who, within 4 mo, were not started on a second antihypertensive drug. We also compared drug costs before and after the intervention. During the baseline period, 10% of patients started on antihypertensive medication were given a thiazide prescription. This proportion rose steadily during the transition period, after which it remained stable at 25%. For other outcomes, no statistically significant differences were demonstrated. Achievement of treatment goals was slightly higher (56.6% versus 58.4%) after the new rule was introduced, and the prescribing of a second drug was slightly lower (24.0% versus 21.8%). Drug costs were reduced by an estimated Norwegian kroner 4.8 million (Euro0.58 million, US$ 0.72 million) in the first year, which is equivalent to Norwegian kroner 1.06 per inhabitant (Euro0.13, US$ 0.16).

Conclusions: Prescribing of thiazides in Norway for uncomplicated hypertension more than doubled after a reimbursement rule requiring the use of thiazides as the first- choice therapy was put into effect. However, the resulting savings on drug expenditures were modest. There were no significant changes in the achievement of treatment goals or in the prescribing of a second antihypertensive drug.

Original languageEnglish
Article numbere232
Number of pages9
JournalPLoS Medicine
Volume4
Issue number7
DOIs
Publication statusPublished - 10 Jul 2007

Keywords

  • primary-care RAPP
  • intervention

Cite this

The effects of mandatory prescribing of thiazides for newly treated, uncomplicated hypertension : interrupted time-series analysis. / Fretheim, Atle; Havelsrud, Kari; MacLennan, Graeme; Kristoffersen, Doris Tove; Oxman, Andrew D.

In: PLoS Medicine, Vol. 4, No. 7, e232, 10.07.2007.

Research output: Contribution to journalArticle

Fretheim, Atle ; Havelsrud, Kari ; MacLennan, Graeme ; Kristoffersen, Doris Tove ; Oxman, Andrew D. / The effects of mandatory prescribing of thiazides for newly treated, uncomplicated hypertension : interrupted time-series analysis. In: PLoS Medicine. 2007 ; Vol. 4, No. 7.
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abstract = "Background: The purpose of our study was to evaluate the effects of a new reimbursement rule for antihypertensive medication that made thiazides mandatory first-line drugs for newly treated, uncomplicated hypertension. The objective of the new regulation was to reduce drug expenditures. Methods and Findings: We conducted an interrupted time-series analysis on prescribing data before and after the new reimbursement rule for antihypertensive medication was put into effect. All patients started on antihypertensive medication in 61 general practices in Norway were included in the analysis. The new rule was put forward by the Ministry of Health and was approved by parliament. Adherence to the rule was monitored only minimally, and there were no penalties for non-adherence. Our primary outcome was the proportion of thiazide prescriptions among all prescriptions made for persons started on antihypertensive medication. Secondary outcomes included the proportion of patients who, within 4 mo, reached recommended blood-pressure goals and the proportion of patients who, within 4 mo, were not started on a second antihypertensive drug. We also compared drug costs before and after the intervention. During the baseline period, 10{\%} of patients started on antihypertensive medication were given a thiazide prescription. This proportion rose steadily during the transition period, after which it remained stable at 25{\%}. For other outcomes, no statistically significant differences were demonstrated. Achievement of treatment goals was slightly higher (56.6{\%} versus 58.4{\%}) after the new rule was introduced, and the prescribing of a second drug was slightly lower (24.0{\%} versus 21.8{\%}). Drug costs were reduced by an estimated Norwegian kroner 4.8 million (Euro0.58 million, US$ 0.72 million) in the first year, which is equivalent to Norwegian kroner 1.06 per inhabitant (Euro0.13, US$ 0.16). Conclusions: Prescribing of thiazides in Norway for uncomplicated hypertension more than doubled after a reimbursement rule requiring the use of thiazides as the first- choice therapy was put into effect. However, the resulting savings on drug expenditures were modest. There were no significant changes in the achievement of treatment goals or in the prescribing of a second antihypertensive drug.",
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T1 - The effects of mandatory prescribing of thiazides for newly treated, uncomplicated hypertension

T2 - interrupted time-series analysis

AU - Fretheim, Atle

AU - Havelsrud, Kari

AU - MacLennan, Graeme

AU - Kristoffersen, Doris Tove

AU - Oxman, Andrew D

PY - 2007/7/10

Y1 - 2007/7/10

N2 - Background: The purpose of our study was to evaluate the effects of a new reimbursement rule for antihypertensive medication that made thiazides mandatory first-line drugs for newly treated, uncomplicated hypertension. The objective of the new regulation was to reduce drug expenditures. Methods and Findings: We conducted an interrupted time-series analysis on prescribing data before and after the new reimbursement rule for antihypertensive medication was put into effect. All patients started on antihypertensive medication in 61 general practices in Norway were included in the analysis. The new rule was put forward by the Ministry of Health and was approved by parliament. Adherence to the rule was monitored only minimally, and there were no penalties for non-adherence. Our primary outcome was the proportion of thiazide prescriptions among all prescriptions made for persons started on antihypertensive medication. Secondary outcomes included the proportion of patients who, within 4 mo, reached recommended blood-pressure goals and the proportion of patients who, within 4 mo, were not started on a second antihypertensive drug. We also compared drug costs before and after the intervention. During the baseline period, 10% of patients started on antihypertensive medication were given a thiazide prescription. This proportion rose steadily during the transition period, after which it remained stable at 25%. For other outcomes, no statistically significant differences were demonstrated. Achievement of treatment goals was slightly higher (56.6% versus 58.4%) after the new rule was introduced, and the prescribing of a second drug was slightly lower (24.0% versus 21.8%). Drug costs were reduced by an estimated Norwegian kroner 4.8 million (Euro0.58 million, US$ 0.72 million) in the first year, which is equivalent to Norwegian kroner 1.06 per inhabitant (Euro0.13, US$ 0.16). Conclusions: Prescribing of thiazides in Norway for uncomplicated hypertension more than doubled after a reimbursement rule requiring the use of thiazides as the first- choice therapy was put into effect. However, the resulting savings on drug expenditures were modest. There were no significant changes in the achievement of treatment goals or in the prescribing of a second antihypertensive drug.

AB - Background: The purpose of our study was to evaluate the effects of a new reimbursement rule for antihypertensive medication that made thiazides mandatory first-line drugs for newly treated, uncomplicated hypertension. The objective of the new regulation was to reduce drug expenditures. Methods and Findings: We conducted an interrupted time-series analysis on prescribing data before and after the new reimbursement rule for antihypertensive medication was put into effect. All patients started on antihypertensive medication in 61 general practices in Norway were included in the analysis. The new rule was put forward by the Ministry of Health and was approved by parliament. Adherence to the rule was monitored only minimally, and there were no penalties for non-adherence. Our primary outcome was the proportion of thiazide prescriptions among all prescriptions made for persons started on antihypertensive medication. Secondary outcomes included the proportion of patients who, within 4 mo, reached recommended blood-pressure goals and the proportion of patients who, within 4 mo, were not started on a second antihypertensive drug. We also compared drug costs before and after the intervention. During the baseline period, 10% of patients started on antihypertensive medication were given a thiazide prescription. This proportion rose steadily during the transition period, after which it remained stable at 25%. For other outcomes, no statistically significant differences were demonstrated. Achievement of treatment goals was slightly higher (56.6% versus 58.4%) after the new rule was introduced, and the prescribing of a second drug was slightly lower (24.0% versus 21.8%). Drug costs were reduced by an estimated Norwegian kroner 4.8 million (Euro0.58 million, US$ 0.72 million) in the first year, which is equivalent to Norwegian kroner 1.06 per inhabitant (Euro0.13, US$ 0.16). Conclusions: Prescribing of thiazides in Norway for uncomplicated hypertension more than doubled after a reimbursement rule requiring the use of thiazides as the first- choice therapy was put into effect. However, the resulting savings on drug expenditures were modest. There were no significant changes in the achievement of treatment goals or in the prescribing of a second antihypertensive drug.

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KW - intervention

U2 - 10.1371/journal.pmed.0040232

DO - 10.1371/journal.pmed.0040232

M3 - Article

VL - 4

JO - PLoS Medicine

JF - PLoS Medicine

SN - 1549-1277

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