Eur J Clin Pharmacol (1994) 47:213-219
Y. Tomson - A. Wessling 9G. Tomson
General practitioners for rational use of drugs
Examplesfrom Sweden
Received: 2June 1994/Accepted: 14July 1994
Abstract In the south west region of Stockholm a
group of 125 general practitioners (GPs) at 27 health
centres asked about the extent to which the drug formu-
lary of the University Hospital was useful in their practi-
ces. To answer this question, the GPs asked their local
pharmacies for prescribing data.
When presented this started a process towards ra-
tional prescribing from within the group of GPs, includ-
ing repeated prescribing surveys, starting with health
centres as the unit of analysis and proceeding to indivi-
dual prescribing analyses on request by the GPs.
As the prescribing data revealed major differences
between health centres, the GPs arranged two work-
shops on drug use in primary health care. They devel-
oped a list of 167 recommended drugs based on drug
statistics and morbidity in general practice. Signs of in-
creased cost cautiousness could be shown.
There was a clear trend towards both smaller vol-
umes and cost per prescription item for the health cen-
tres in the study area. Compared to the national pre-
scribing pattern, prescribing practice in the study area
represented a 20 per cent lower drug cost.
Although the GPs decided on a drug list separate from
that of the hospital, collaboration between the Drug and
Therapeutic Committee at the hospital and the GPs in-
creased as a result of their increased engagement in
drug management, thereby also bridging the gap be-
tween primary health care and clinical pharmacology.
Y.Tomson ( ~ )
Department of Clinical Neuroscience and Family Medicine,
Section of Family Medicine, Karolinska Instituter, DiagnosvSgen
8 NB, S-141 54 Huddinge, Sweden
A. Wessling
National Corporation of SwedishPharmacies, Stockholm, Sweden, den more rational are the Drug and Therapeutic Com-
and Department of Clinical Pharmacology, Karolinska Institutet, mittees (DTCs) [9]. Initially, the DTCs were set up to
Huddinge Hospital, Huddinge, Sweden
G. Tomson
Department of International Health and Social Medicine, Unit of scribing in primary care. DTCs, however, are still locat-
International Health Care Research (IHCAR), Karolinska
Institutet, Stockholm, Sweden
9 Springer-Verlag 1994
Key words General practice, Drug prescription;
clinical pharmacology, drug information, health
economy, essential drug list
In health care drug therapy is the most common and im-
portant treatment. Variation in the types of drugs used
and in the way they are used is considerable even when
comparing small adjacent areas, and in comparing phy-
sicians working within the same area [1, 2]. Therefore
questions concerning the rational use of drugs are of in-
creasing interest among medical and pharmaceutical
professionals, policy makers, health administrators and
researchers [3].
In Sweden General Practitioners (GP) in public pri-
mary care represent about 15% of prescribers, but
their share of drug prescribing amounts to about 45 %
both of the number of prescriptions and prescription
costs [4]. Thus, they have a crucial role to play in any de-
velopment towards rational use of drugs. Few GPs in
Sweden up to now have worked outside the public sec-
tor [5]. GPs are, in general, little engaged in drug man-
agement work, and in the U.S.A. have been shown to
be more willing to follow commercial information than
scientifically-based treatment recommendations [6].
A vast number of drugs is available to prescribers - in
Sweden more than 3000 pharmaceutical specialities re-
presenting some 800 active substances [7]. Even a full-
time clinical pharmacologist can hardly aspire to com-
prehensive knowledge of all drugs today, so what hope is
there for a busy general practitioner? It has been suggest-
ed that a practitioner should have detailed knowledge of
about 50 drugs and be familiar with another 150 [8].
Important tools in making drug prescribing in Swe-
monitor drug prescribing within hospitals only, and la-
ter, their responsibility was widened to include drug pre-
ed at hospitals and are dominated by clinical pharma-
cology, other clinical subspecialities and hospital phar-
214
Table 1 Top-10-products for one of the health centres in terms of the number or prescriptions, number of defined daily doses and value
(SEK) for drugs prescribed in April 1990
Product Prescriptions Product Defined daily Product Value (SEK)
doses
Calciopen~,b 77 Furosemida,b 4.613 Naprosyn 9.983
(Penicillin-V) (Frusemide) (Naproxen)
Distalgesic 68 Moduretic~'b 3.280 Lunelaxb 5.816
(Dextropropoxyphe- (Amiloride + (Ispaghula husk)
nene + paracetamol) hydrochlorthiazide)
SobriP,b 41 Salures-K 3.100 Calciopen~,b 5.035
(Oxazepam) (Bendroflumethia- (Penicillin-V)
zide + potassium)
Otrivin 39 Lunelaxb 2.507 Selokena'b 4.697
(Xylometazoline) (Ispaghula husk) (Metoprolol)
Nezeril~'b 36 Naprosyn 2.435 Moduretic~,b 4.093
(Oxymetazoline) (Naproxen) (Amiloride + hydro-
chlorthiazide)
Moduretica,b 33 Nitrong 2.366 Adalat a'b 4.028
(Amiloride + (Glyceryl trinitrate) (Nifedipine)
hydrochlorthiazide)
Naprosyn 33 Kalium Duretter 2.300 Distalgesic 3.740
(Naproxen) (Potassium SR) (Dextropropoxy-
phene + paracetamol)
Lunelaxb 32 Distalgesic 2.019 BricanyP,b 3.125
(Ispaghula husk) (Dextropropoxy- (Terbutaline)
phene + paracetamol)
Wellcoprimu 31 Saluresa'u 1.800 Theo-Dura,b 2.805
(Trimethoprim) (Bendroflumethiazide) (Theophylline SR)
Kalium-Duretter 31 Theo-Dura'b 1.675 Vibramycin~,b 2.603
(Potassium SR) (Theophylline SR) ~ (Doxycycline)
a Recomended by the Drug and Therapeutic Committee in primary health care; b at the hospital

macists, even though some nowadays also include pri-
mary care physicians. Based on criteria of efficacy, safe-
ty, cost and therapeutic tradition, DTCs usually select
some 200 essential drugs. Doctors working outside the
hospitals have been less inclined to follow the recom-
mendations of the DTC [10], arguing that the selected
drugs are less appropriate for their practices.
General practitioners in one health care region of the
Stockholm county questioned the usefulness of the re-
commended drug list of the university hospital. When
offered prescribing statistics by their local pharmacies,
they started discussions about how to use the statistics
and how to improve their prescribing. Collaboration in
practice between physicians and pharmacists has not so
far been well developed in spite of the increasing recog-
nition in theory of the value of such collaboration [11].
The objectives of this study are to describe the process
by which general practitioners became successively in-
volved in drug issues and to assess the impact of this pro-
cess.
Material and methods
All 27 health centres in one of the health care regions of the Stock-
holm county participated in the project. The population in the re-
gion amounted to 335 000 inhabitants and there were 120 GPs at
the 27 health centres. The computer facilities at the 24 community
pharmacies enabled registration of all prescriptions issued at the
health centres and dispensed at the pharmacies during the registra-
tion periods [12]. Prescriptions were registered from February-
April 1987 and from April 1989 and 1990. The number of physi-
cians working there and the number of patient visits to each health
centre was obtained from the appropriate health centre.
Initially, health centres, i.e. groups of prescribers instead of in-
dividual prescribers, were chosen as the unit of analysis [13]. In
this way individual confidentiality was protected, enabling com-
parisons of practices to be made without highlighting individuals
during group discussions. Many practitioners were initially reluc-
tant to discuss their own prescribing habits and this was a way to
overcome the problem.
Prescribing profiles were presented as numbers of prescriptions
issued and number of defined daily doses (DDD) distributed by
drug product or groups of drugs (according to the ATC classifica-
tion).
Data from the recorded prescriptions in 1990 were also used to
analyse the volume and cost of prescribing within groups of drugs
chosen to represent common primary health symptom complexes.
The average number of DDD and the average cost per prescrip-
tion for all health centres in the study area were compared with
the corresponding national data. The latter were obtained from a
representative national sample of prescriptions [14].
Workshops with the intention to serve as a community oriented
DTC with a focus on actual practice in the community were held in
November 1988 and in January 1990. Each health centre was repre-
sented by at least one GE Representatives of the community phar-
macists and a few resource persons representing clinical pharma-
cology, epidemiology and public health also participated. As a ba-
 215
Table 2 Top-15-products for all health centres with regard to number or prescriptions, number of defined daily doses and value (SEK)
for drugs prescribed in April 1990
Product Prescriptions Product Defined daily Product Value (SEK)
doses
Kavepenin~ 1.052 Teldanex u 39.595 Lomudal~'b 183.974
(Penicilli'n-V) (Terfenadine) (Sodiumcromoglycate)
Lomudal a,b 1.044 Furosemid a.b 29.978 Lomudal Nasal 145.720
(Sodiumcromoglycate) (Frusemide) (Sodiumcromoglycate)
Calciopen a'b 880 Lasix 28.615 Teldanex b 115.422
(Penicillin-V) (Frusemide) (Terfenadine)
Teldanex b 723 Rhinocort Aqua a'b 23.966 BricanyP. b 84.122
(Terfenadine) (Budesonide) (Terbutaline)
Lomudal Nasal a,b 600 Bricanyl a'b 23.850 Rhinocort Aqua a,b 79.852
(Sodiumcromoglycate) (Terbutaline) (Budesonide)
Bricanyl a,b 594 Lomudal Nasala'b 20.404 Kgtvepenina 77.569
(Terbutaline) (Sodiumcromoglycate) (Penicillin-V)
Mollipect b 546 Naproxena,b 16.655 Zantac ~,b 70.143
(Bromhexine + (Naproxen) (Ranitidine)
ephedrine)
Vibramycin a'u 532 Clarityn 16.060 Calciopen a,b 64.138
(Doxycycline) (Loratidine) (Penicillin-V)
Nezeril a,b 507 Ventoline a'b 15.890 Imacillin a,b 57.729
(Oxymetazoline) (Salbutamol) (Amoxicillin)
imacillin a,b 430 Salures-K 15.748 Seloken Zoc a,b 57.308
(Amoxicillin) (Bendroflumethia- (Metoprotol SR)
zide + potassium)
Distalgesic 414 Moduretic ~'b 14.840 Vibramycin a,b 51.994
(Dextropropoxy- (Amiloride + hydro- (Doxycycline)
phene + paracetamol) chlorthiazide)
Alvedon a,b 384 Mogadon 14.280 Naproxena,b 49.324
(Paracetamol) (Nitrazepam) (Naproxen)
SobriD b 348 Lanacrist a'b 13.756 Mucomyst 47.103
(Oxazepam) (Digoxin) (Acetylcysteine)
Trimetoprima 339 Levaxin~'b 13.467 Clarityn 46.403
(Trimethoprim) (Levothyroxine) (Loratidine)
Ventoline a,b 332 Theo-Dur~'b 13.388 Tenormina,b 45.318
(Salbutamol) (Theophylline SR) (Atenolol)
Recomended by the Drug and Therapeutic Committee inprimary health care," b at the hospital

sis for the work the GPs used their prescribing statistics for thera-
peutic discussions including non-pharmacological treatment alter-
natives.
Results and comments
A n i m p o r t a n t initial step in the process of involving the
GPs in decisions regarding choice of drugs and drug
e c o n o m y was presentation to t h e m of the results f r o m
the prescription study in 1987.
Results f r o m the first prescription study
In this study period 736 different drug products were
prescribed, with a range between health centres of
175 to 448 products. There was a positive correlation
b e t w e e n the n u m b e r of drugs prescribed and the num-
ber of doctors working at the health centre; health
centres with the same n u m b e r of practitioners ranged
b e t w e e n 229 and 391 different b r a n d products pre-
scribed. O f the 736 products, 40 were c o m m o n to all
27 health centres. Regarding benzodiazepines, one
health centre restricted its prescribing to six different
products whereas two others used twelve of the
13 products then available on the Swedish market.
The most c o m m o n l y prescribed classes of drugs were
antibiotics, cardiovascular drugs, analgesics and hypno-
tics/sedatives together representing two thirds of the
total volume. E a c h health centre was p r e s e n t e d with
a list of their Top-10-products in terms of the num-
bers of prescriptions, D D D and value; an example is
given in Table 1. The Top-15-products for all health
centres are presented in Table 2. The high ranking of
antiallergic drugs is due to the period of registration,
April, when the trees are in bloom. On average, the
health centres prescribed 4 2 % of the drug products
216
in accordance with the recommended drug list of the
hospital DTC.
The quantities of drugs prescribed, measured both as
average number of D D D per visit and the number of
DDD/1000 inhabitants/day (the number of persons liv-
ing in the catchment area of the health centre being the
denominator), showed a three-fold variation between
the health centres. The cost of drug prescribing,
calculated as the average per doctor per health centre,
varied between 2?000 and 106000 SEK for the three
month period.
From discussions to action
Presentation of the above mentioned data, including the
variation between the health centres, led to intense dis-
cussions among some of the GPs, and they decided to
arrange the first workshop. All GPs present at the work-
shop 1988 took part in discussions strongly oriented to
drug utilisation as shown by the statistics, and related
to morbidity as presented and registered at the health
centres in the study area. They decided on a list of 167
drugs recommended for use in primary health care.
The drug list from the hospital DTC included 207 drugs
and the two lists had 116 drugs in common. In addition
to the basic criteria of efficacy, safety and cost, they se-
lected drugs on the list with regard to the results of the
discussions, which, amongst other things, were focused
on the therapeutic traditions of the study area. The list
was published and widely circulated with financial sup-
port from the pharmacies. It was revised in 1990.
Requests for individual prescribing data
Although the drug list was the most obvious result of the
process, a second result was the number of GPs asking
to have their own prescription data monitored in the
second and third prescription surveys - in 1989 and
1990, respectively. In the second survey, 19 GPs asked
for individual registration, compared to 64 in the third
survey. Furthermore, the GPs expressed interest in
data linking diagnosis to the prescribed drugs, and a
group of GPs and pharmacists constituting a "Prescrip-
tion Survey Working Group" initiated a pilot study in
1992 in order to develop a model for computerised diag-
nosis-prescription linking. The process is ongoing and
developing.
Signs of increased cost cautiousness
The drug prescribing in the study area exhibited pat-
terns which were quite similar to those of drug prescrib-
ing at the national level [7]. At the same time, important
differences were shown in the third survey in 1990. For
example, the average prescription cost for the group of
drugs used in the treatment of hyperacidity, gastric ul-
cers, and gastritis was 237 SEK in the study area com-
pared with 328 SEK in all Sweden (Table 3). If one
looks at the various drugs within the group, it will be
seen that the average amount (DDD) and the average
cost was lower in the study area. The example also
shows that the study area had a more conservative pre-
scription policy for those drugs than Sweden as a
whole, as indicated by the higher proportion of antacids
and lower proportion of omeprazole, a drug which was
not among the 167 recommended drugs in 1988, be-
cause of the limited experience of this compound at the
time.
Differences in prescribing costs were seen also for
other groups of drugs, and there was a clear trend to-
wards both smaller volume and cost per prescription
item in the health centres in the study area (Table 4).
Compared to national prescribing practice prescribing
pattern in the study area represented a 20% lower
drug cost.
Cost of the project
In estimating the cost of the project there were three
main components to look at, registration and proces-
sing of prescription data, workshops, and printing, distri-
bution and dissemination of the drug list. The cost of re-
gistration was almost negligible, since most of the data
were available from what is routinely recorded in the
pharmacies. The computer processing costs and the
costs of preparing the data for presentation mainly com-
prised working time, and were estimated to equal one
working month for a pharmacist. Workshop costs main-
ly comprised working time for those planning and lead-
ing the workshop; they were estimated to equal one
week for a physician. For GPs participating as health
centre representatives, the workshops could be seen as
natural elements of an already established programme
of continuing education in the region. The drug list
printing costs and workshop boarding costs were the
only out-of-pocket costs for the process, in total less
than SEK 125 000.
Discussion
The objective of the study was to develop a process
which involved GPs in decisions regarding choice of
drugs and drug economy, and to assess the impact of
this on prescribing. Since the prescribing of drugs is
such an essential part of the GP's work, one might ques-
tion the need for special efforts to make them more en-
gaged in drug issues. There was certainly an interest in
drugs and drug prescribing among the GPs in the study
area, but it was at an individual level. The GPs had two
representatives in the DTC at the hospital, but GPs in
general were not involved in analyses, evaluations and
decisions about drug prescribing in primary care. Drug
utilization studies in the Nordic countries have general-
 217
Table 3 Prescribing of drugs used in the treatment of hyperacidity, peptic ulcer, gastritis etc at health centres in the study group (Stock-
holm) and in all of Sweden (Sweden) during April 1990; average number of defined daily doses (DDD) and average cost (SEK) per pre-
scription item, and % of prescription items
Drug substance or ATC code Stockholm Sweden
corresponding DDD/ SEK/ Prescription DDD/ SEK/ Prescription
prescription prescription items % prescription prescription items %
item item item item
Compound
preparations of
aluminium, calcium
and magnesium
compunds A02AD00 19 107 27 21 111 20
Antacids with
sodium bicarbonate A02AH00 ~ < 1 46 74 1

Cimetidine A02BA01 37 340 8 47 427 ll

Ranitidine A02BA02 35 503 20 42 605 22
Famotidine A02BA03 47 588 1 47 585 3
Omeprazole A02BC01 31 664 4 33 809 7
Sucralfate A02BX02 27 211 11 33 271 9
Alginic acid A02EA01 20 127 11 24 158 13
Benzilone A03AB01 a < 1 52 120 1

Glycopyrronium A03AB02 a < 1 42 83 < 1

Propantheline A03AB05 a a <1 39 72 1

Mepenzolate A03AB12 a < 1 30 71 1

Papaverine A03AD01 45 25 9 50 29 5
Moxaverine A03AD30 a ~ < 1 72 82 < 1

Hyoscyamine A03BA03 32 82 3 27 73 2
Clinidinum + A03CA02 26 67 3 25 64 5
psycholeptics
Oxiphencyclimine +
psycholeptics A03CA03 39 58 1 50 72 1
Total 29 237 100 34 328 100
Number of
prescription items 670 90562
Data not presented due to small number of observation

ly been on a large scale and have been register orien-
tated more than practice orientated [15]. A recent
Swedish government investigation called for closer col-
laboration with clinicians [16].
Experience has shown that guidelines can be effec-
tive in improving clinical practice, but they should be
constantly reinforced as part of a continuing pro-
gramme of improving quality [17]. Experience has also
shown that merely providing prescribing statistics in
the form of computerised lists without suggestions for
change are of limited value [18]. Furthermore, change
is more likely if the physicians have participated in the
process rather than having it imposed on them. Audit,
defined as "searching examination of the way in which
drugs are used in clinical practice carried out at inter-
vals frequent enough to maintain a generally accepted
standard of prescribing" [19], may be one way of achiev-
ing this.
Our study shows that local prescribing statistics re-
vealing the differences in prescribing profiles between
health centres generated interest in a group of busy
Swedish general practitioners in their own prescribing.
According to our experience, the prescribers were will-
ing to b e c o m e active in drug audit. A prerequisite was
that the statistics were complemented by other ele-
ments to permit useful interaction with practice. It has
been stated that incentives must operate at the local
level to change actual practice [20]. Peer review of your
own prescribing practices in group discussions is a
rather sensitive issue. One way to overcome ethical and
practical problems can be to use the health facility as
the unit of analyses [13]. During the later phase of our
study, many GPs expressed interest in having their indi-
vidual prescribing registered, an interest which has sus-
tained. This must be regarded as a positive outcome of
the group interactions and as recognition of the useful-
ness of this type of approach.
Selecting the essential drugs is one way of involving
GPs in local drug policy work. The list of 167 recom-
m e n d e d drugs constituting an important part of start-
218
Table 4 Prescribing within certain drug groups as health centres in the study group (Stockholm) and in all of Sweden (Sweden) during
April 1990; number of prescription items, average cost (SEK) and average number of defined daily doses (DDD) per prescription item
Group of drug ATC code Stockholm Sweden
No of SEK/ DDD/ No of SEK/ DDD/
prescription prescription prescription prescription prescription prescription
items item item items item item
Hyperacidity, gastric A02-A03 670 237 29 90 562 328 34
ulcers, gastritis etc. (A02D, A03F
excluded)
Diabetes insulin A10A 66 551 95 36052 481 78
Diabetes oral A10B 266 201 76 32259 198 76
Cardio-vascular C01-C04, C07 2545 176 80 523 991 205 80
Infections J01-J06 4417 96 9 308588 128 11
Musculoskeletal
and joint diseases,
analgesics etc. M01-M05, N02 2905 111 33 397347 120 36
Psychic disorders N05-N06 1674 57 40 346 340 79 45
Asthma R03 1454 206 54 182169 256 71
Cough R05 1517 82 23 88881 109 28
Allergic disorders R06 1306 138 54 94216 135 56
Total 16820 2100 405

dard treatment in primary care is one way of defining
drug policy. Similar activities have been reported from
Great Britain [21]. Drug prescribing in the area exhib-
ited patterns quite similar to those of prescribing at the
national level, which could indicate that the GPs had
failed to implement their policy. However, there were
differences, as exemplified by prescribing for hyperacid-
ity, peptic ulcers, gatritis etc. The GPs had chosen a con-
servative approach to recently introduced drugs on the
market, such as anti-ulcer drugs, in line with expert re-
commendations. This is in contrast to earlier findings,
in which GPs were said to be the first to introduce
drugs initially meant for specialists at the hospital level
[9].
In addition to differences in the types of drugs pre-
scribed, there were also differences in the volumes and
costs. Clearly, caution is needed when comparing indivi-
dual health centres with the national average outpatient
prescribing pattern. Having considered this, our results
still indicate potential substantial savings when rational
use of drugs, e.g. for gastric problems, was applied by
the practitioners. Our data indicate that with a partici-
patory approach an interest in this issue can be
achieved, leading to therapeutic choices that are more
cost cautious.
When evaluating the impact of the process described,
one must keep in mind other major sources influencing
the prescribers. First of all there are the marketing acti-
vites of the drug industry. The costs of marketing
amount to 6-7 % of the sales value. Second, there is the
influence of other prescribers, especially in the situa-
tion in which the patient has initially had drugs pre-
scribed by a specialist in hospital. Third, the DTC of
the hospital and its publications have been available for
many years. Finally, there are the demands expressed
by the patient who has been told and has heard about
the "wonder effects" of drugs recently introduced on
the market.
The drug list that was developed by the GPs was
widely disseminated and in fact influenced revision of
the drug list by the DTC at the university hospital. By
empowering the general practitioners through knowl-
edge transfer relevant to the context, their contribution
to the DTC discussions at the university hospital in-
creased. This resulted in a mutual decision to merge
the two lists into one common list. The increased colla-
boration described above resulted in several useful in-
teractive sessions between GPs and hospital physicians.
The DTC had for several years arranged half-day semi-
nars for hospital and primary care physicians. As the
GPs started their drug activities, they also became
more and more involved both in planning and perform-
ing these seminars.
The need to get away from drug orientation towards
utilisation orientation has recently been emphasised
[22]. Information on drug utilisation in the near future
must be better linked to morbidity, and this step in the
process is already under way. It includes selecting a re-
presentative sample of prescriptions with which diagno-
ses are included. User friendly statistics could be used in
a cycle of audit, including standards with drug lists and
treatment guidelines, reviews with validated sampling
techniques and targeted educational interventions in-
cluding peers [5].
A WHO working group on clinical pharmacology in
Europe has previously identified a gap between clinical
pharmacology and primary health care, and had called
on general practitioners to act in various ways to foster
 219

collaboration [23]. We see the process described here as 11. Hammarstr6m B, Westerholm B (1988) Pharmacists to the
an attempt to develop a much n e e d e d foundation for a fore. World Health Forum 9:514-518
12. Tomson G, Holmberg K, H~ggmark A, Tomson Y, Westerholm
sustainable, interdisciplinary bridge contributing to-
B (1990) Fffm statistik till handling: f6rskrivning av 1/ikemedel i
wards the rational use of drugs in primary care. prim/irv~rden. (From statistics to action: drug prescribing in
primary health care). Lfikartidningen 87:1483-1484
Acknowledgement The participation of general practitioners, 13. Diwan VK, Eriksson B, Sterky G, Tomson G (1992) Randomi-
pharmacists, and of the National Corporation of Swedish Pharma- zation by group in studying the effect of drug information in
cies is greatfully acknowledged. primary care. Int J Epidemiol 21:124-130
14. Wessling A (1987) Continuous recording of drug prescribing in
Sweden 1974-1983 Methods and examples of utilization of
data. Eur J Clin Pharmacol 33:7-13
References 15. Lee D, Bergman U (1989) Studies of drug utilization. In:
Stroem BL (ed) Pharmacoepidemiology. Churchill Living-
1. M61stad S, Hovelius B, Kroon L, Melander A (1990) Prescrip-
stone, New York, pp 259-274
tion of antibiotics to out-patients in hospital clinics, commu-
16. Anonymous (1992) N~itverk f6r L~kemedelsepidemiologi
nity health centres and private practice. Eur J Clin Pharmacol
NEPI (Network for pharmacoepidemiology) Report. Ministry
39:9-12
of Health and Social Welfare, Stockholm, p 104
2. McGavock H (1991) Peer-review of GP prescribing in
17. Grimshaw JM, Russel IT (1993) Effect of clinical guidelines on
N. Ireland - techniques and results. In: Auditing drug therapy
medical practice: a systematic review of rigorous evaluations.
- approaches towards rationality at reasonable costs. Swedish
Lancet II: 1317-1322
Pharmaceutical Press, Stockholm, pp 93-103
18. Soumerai SB, McLaughlin TJ, Avorn J (1990) Quality assur-
3. Anonymous (1987) The rational use of Drugs. WHO Report of
ance for drug prescribing. Quality Assurance Health Care 2:
the Conference of Experts, Nairobi 25-29November 1985,
37-58
WHO, Geneva
19. Crooks J (1978) Methods of audit in drug use. In: Duch6ne
4. Agen~is I (1985) Consensus om lfikemedelsinformation i pri-
Marullaz P (ed) Advances in pharmacology and therapeutics.
m~irvSrden. (Consensus on drug information in primary health
Proceedings of the 7th International Congress on Pharmacolo-
care). L~ikartidningen 82:510-511
gy, vol 6, Clinical Pharmacology, Paris, pp 189-195
5. Tomson G (1991) Drug utilization and people. A Swedish per-
20. McGavock H (1988) Some patterns of prescribing by urban
spective. Ann Ist Super Sanith 27:239-246
general practitioners. Br Med J 296:900-902
6. Avorn J, Chen M, Hartley R (1982) Scientific versus commer-
21. Grant GB, Gregory DA, Swanenberg TD van (1985) Develop-
cial sources of influence on the prescribing behaviour of physi-
ment of a limited formulary for general practice. Lancet I:
cians. Am J Med 73:4-8
1030-1032
7. Swedish Drug Statistics (1987-1990) National Corporation of
22. SjOqvist F (1992) Auditing drug therapy, why and how? In:
Swedish Pharmacies, Stockholm
Auditing drug therapy. Approaches towards rationality at rea-
8. Block I, Svender O (1986) L/~kemedelsutbildning for distrikt-
sonable costs. Swedish Pharmaceutical Press, Stockholm,
slfikare. (Postgraduate education for GPs about drugs). L~ikar-
pp 28-34
tidningen 83:666-667
23. Dukes G, Lunde PK, Melander A, Orme M, Sj6qvist F, Tognoni
9. Sj6qvist F, Boethius G (1986) Attitudes to development of drug
G, Wesseling H (1990) Clinical pharmacology and primary
therapy in Scandinavia. Br J Clin Pharmaco122: 19s-26s
health care in Europe - a gap to bridge. Eur J Clin Pharmacol
10. Beermann B, Lundberg G (1985) L/~kare i 6ppen vgtrd minst
38:315-318
f61jsamma till lfikemedelskommitt6ernas rekommendationer.
(Primary health care physicians show the least complience to
the recommendations from the DTC.) Lfikartidningen 82:
508-510