Eur J Clin Pharmacol (2013) 69:18371843

DOI 10.1007/s00228-013-1540-6

PHARMACOEPIDEMIOLOGY AND PRESCRIPTION

Adherence to hospital drug formularies and cost of drugs

in hospitals in Denmark
Hanne T. Plet & Jesper Hallas & Lene J. Kjeldsen

Received: 30 January 2013 / Accepted: 21 May 2013 / Published online: 14 June 2013
# Springer-Verlag Berlin Heidelberg 2013

Abstract
Purpose To investigate adherence rates to hospital drug
formularies (HDFs) and cost of drugs in hospitals.
Methods Data on drugs used during 2010 were analyzed for
ten hospitals (two hospitals from each of the five regions),
constituting 30 % of hospitals and 45 % of hospital beds in
Denmark. Drug use data from individual hospitals were
retrieved from the hospital pharmacies. Adherence to the
HDFs was analyzed for selected substances characterised by
extensive use both in primary and secondary sectors (ATC
codes A10, B03, C03, C07, C08, C09, C10, J01, N02, N05
and R03). Within each group, we also identified the drugs
constituting 90 % of the volume (= DU90%) and the adherence to the HDF in this segment (Index of Adherence).
Results Substances used by hospitals varied between 598
and 1,093. The proportion of used substances that were on
the HDF varied between 14 % and 44 %. University hospitals used a significantly higher total number of substances
(median 165 vs. 139, p = 0.019) and cost/DDD [(median 5
vs. 2 Euros, p = 0.033), p = 0.033] in the DU90% segment
than the regional hospitals. Index of adherence varied between 43 % and 91 %. For the selected ATC codes, the
index of adherence was between 76 % and 100 %.
Conclusions Adherence to the selected ATC groups was
high, which means that the most commonly used substances
are included in the HDFs, even though a variation existed. A
large variation existed between the hospitals in the number
of substances at HDFs.

H. T. Plet (*) : J. Hallas

Department of Clinical Pharmacology, Faculty of Health Sciences,
University of Southern Denmark, J.B. Winsloews Vej 19,2,
5000 Odense, Denmark
e-mail: hanne@bundgaarden.dk
H. T. Plet : L. J. Kjeldsen
SAFE, Amgros I/S, 2100 Copenhagen, Denmark

Keywords Drug utilization . DU90 % . Adherence .

Hospital . Hospital drug formulary

Introduction
Drug expenditure in hospitals in Denmark, as well as in
other countries is increasing [14]. To avoid excessive drug
costs and to ensure optimal quality of drug treatment, drug
formularies (DFs) may be used as a tool to promote rational
drug use [4, 5].
DFs contain lists of essential drugs specific for health
care, and are widely used to promote rational pharmacotherapy, and are hence based on evidence, costs and safety [6].
DFs are developed and implemented as management tools
in primary health care as well as in hospitals [79]. The
quality of the prescribed drugs and adherence to guidelines
has been evaluated at different levels (cross-national, hospital, primary care) [1015], demonstrating a large diversity in
how drugs are selected in the formulary and how the formulary was developed and implemented [2, 1619].
In Denmark, a DF is developed at the national level, and
each of the five regions develops their own DF aimed at
primary care based on the national DF; DFs aimed at the
hospitalshospital drug formularies (HDFs)are developed,
implemented and monitored at the regional or hospital level
[20]. Guidelines for the most expensive drugs used at the
hospitals are developed at the national level, and implemented
at the regional level [21]. The DFs for primary and secondary
care are harmonized for drugs that are extensively used in both
sectors.
No standards for monitoring and evaluating use of HDFs
exist. Adherence to HDFs can be used to monitor and evaluate
the quality of prescribing, guideline implementation, and to
compare within or between hospitals and regions. Hence, the
purpose of this study was to investigate adherence rates to
hospital drug formularies and cost of drugs in hospitals.

1838

Methods

Eur J Clin Pharmacol (2013) 69:18371843

&

Settings and study design

Denmark is divided into five administrative regions. The main
responsibility of each region is health care, secondary care
(hospital services, both somatic and psychiatric) and activities
related to primary care physicians. University hospitals are
represented in four regions, and each region has a DTC that
develops a hospital drug formulary. Nevertheless, the DTCs
are organized differently [20]. The hospitals for this study were
selected to represent one university and one regional hospital
from each region, and in the one region without university
hospitals, two regional hospitals were selected instead.
The study was designed as a cross-sectional comparison
study and included drug sales data from 10 hospitals in
Denmark in 2010. In total, four university hospitals and six
regional hospitals are represented. This cohort constitutes of
30 % of hospitals and 45 % of hospital-beds in Denmark.
Hospital drug formularies
DTCs are responsible for developing HDFs that mainly consist of drugs used at most wards. Only one HDF contained
specialist drugs [20]. At the hospitals, each ward have a
wardlist, defined as a list of drugs used routinely on the wards,
which comprises drugs from the HDF and specialty drugs
used specifically at that ward but are not on the HDF [22].
Information on each drug includes product name, dispensing
form, ATC code, generic name, and strength. Indications were
only available for a limited number of drugs, and prices were
not available. The physicians had access to the HDF electronically. Four regions had a regional HDF aimed at all hospitals
in the region, and in one one region, each hospital developed
their own HDF.
Data
HDFs from 2010 were collected from the drug and therapeutics committees (DTCs) in Denmark. Numbers of beds and
bed-days were retrieved from the Danish Health and Medicines Authority. Data on drugs sold to the 10 hospitals in 2010
were retrieved from BiWeb, which is a database containing
data on all drugs delivered from hospital pharmacies in Denmark to hospital wards. ATC code, generic name, product
name, strength, dispensing form, package size, DDDs, number
of each products used, and costs were available for each drug.
The following products (substances) were included in the
analysis:
&

Substances with an assigned, official ATC code at fifthlevel according to the World Health Organization
(WHO) [23].

Substances with a non-official ad hoc ATC code at fifthlevel, assigned jointly by the hospital pharmacies for
drugs manufactured specifically for hospital use, e.g.
A12C### Phosphat oral solution with blackcurrant taste;
N02AG##_ MorfinAtropinPapaverin suppositories.

The following products (substances) were excluded from

the analysis:
&

Products that were assigned ATC code V (Various) and

sublevel. This group comprises many different types of
drugs and other types of products. Very few DDDs were
assigned in this group, and they were considered to be of
little relevance to the analysis. In total, 75 substances
from this group were excluded.

Data analyses
Data were analyzed at hospital level and the Anatomical
TherapeuticChemical (ATC) classification system, and the
defined daily dose (DDD) technology recommended by the
WHO was used to classify drugs and to measure volume of
drug use [23].
The drugs sold for each hospital was compared with HDF
for the particular hospital, and drugs were marked as HDFdrug if the ATC code were on the HDF. The ATC code was
used because generic substitution was practiced during the
year.
The total number of substances, DDDs and cost (in Euros)
for all drugs and for HDF-drugs used were calculated for each
hospital. The percentages of HDF substances used of total
number of substances at the 10 hospitals were calculated.
Adherence to the HDFs was analyzed at substance level
using the drug utilization 90 % (DU90 %). The DU % segment
is the drugs constituting 90 % of the volume as measured in
DDD and the adherence to the HDFs in this segment is termed
the Index of Adherence [24]. First, substances that had an
assigned DDD were identified, then the number of substances
that account for 90 % of the total volume of DDDs (=DU %)
were calculated, and at last the index of adherence were
calculated (number of DDDs for substances in HDF divided
by the total number of DDDs within the DU %-segment).
In order to compare the drug costs between the hospitals,
cost/DDD was calculated for the DU % segment and for the
remaining 10 %. Cost expressed as % of total costs were
calculated for DU % segment, remaining 10 % and where
DDD=0.
To presents the variations in percentage of substances
used of the total number of drugs, median and interquartile
range was calculated for the hospitals.
Drugs prescribed in primary care have an impact on
drugs used in hospitals, and as a consequence used widely
in hospitals. We thus found it of particular interest to analyse

Eur J Clin Pharmacol (2013) 69:18371843

1839

adherence for drugs that were extensively used in both

sectors, i.e., ATC groups A10, B03, C03, C07, C08, C09,
C10, J01, N02, N05 and R03).
Statistics
Standard descriptive statistical measures were used. Differences were tested by MannWhitney U-test. A value of
p<0.05 was considered significant. Analyses were carried
out using STATA/IC 12.0 (StataCorp, College Station, Texas
77845, USA, Copyright 19852011).

Results
The hospitals had used 1,587 different substances, of which
149 substances were excluded from the analysis according
to the criteria given above. Consequently, 1,438 substances
were included in the analysis, and of these, 134 substances
had no assigned DDD. Total drug costs for the 10 hospitals
were 481 million Euros, and HDF-drugs accounted for 76

million Euros (16 %). Cost of drugs with DDD=0 were 44

million Euros (9 %), and of these drugs, substances from
ATC code L (antineoplastic and immunomodulating agents)
accounted for 40 million Euros (91 %).
Regarding the individual hospitals, the median number of
substances used was 851, and the median percentage of used
substances also found on the HDF was 24 % (n=185)
(Table 1). The median number of substances on the HDFs
was 193, with a university hospital having the highest number
of substances of 528 (Table 1). This hospital also had the
highest use of HDF-substances 448 (44 %) (Table 1). The
number of substances used by the university hospitals tended
to be higher than for regional hospitals (median 969 vs. 794,
p=0.055). The costs per 100 bed days were significantly
higher for drugs used at university hospital than for regional
hospitals (median 36,104 vs. 9,429 Euros, p=0.011). The
median number of substances on the HDF was 193 for both
university and regional hospitals.
The median index of adherence was 52 % (range 4391).
The outlier with a high adherence rate of 91 % also had the
highest number of substances (n=528) on the HDFs and the

Table 1 Information on hospitals, hospital drug formularies (HDFs), number of substances used and costs
Hospital
type

University

Region

Hospital

HDF
typea

Median
Min
Max
Total
Median
Minimum
Maximum

Substances

Cost

On
HDFb
(n)

Total
used
(n)

HDF
used
(n)

Used on
HDF
(%)

Per hospital
(EUR)

Per 100
bed days

% of cost
on HDF
substances

1
2
3
5

1
3
5
9

R
R
H
R

808
847
946
908
878
808
946

183
203
528
155
193
155
528

910
849
1,028
1,093
969
849
1,093

181
200
448
152
191
152
273

20
24
44
14
22
14
44

45,209,682
72,410,323
75,664,423
162,054,356
74,037,373
45,209,682
162,054,356

19,556
54,192
24,842
47,367
36,104
19,556
54,192

8
4
65
4
6
4
65

1
2
3
4
4
5

2
4
6
7
8
10

R
R
H
R
R
R

386
560
431
1,113
982
576
568
386
1,113

183
203
179
282
282
155
193
155
282

598
776
791
853
926
796
794
598
926

177
189
175
269
273
149
183
149
273

30
24
22
32
29
19
27
19
32

5,378,529
15,310,876
15,275,331
28,938,020
43,945,765
17,153,329
16,232,103
5,378,529
43,945,765

5,048
10,272
10,927
9,555
9,304
6,660
9,429
5,048
10,927

14
6
10
15
12
10
11
6
15

828
386
1,113

193
155
528

851
598
1,093

185
149
448

24
14
44

36,441,893
5,378,529
162,054,356

10,600
5,048
54,192

10
4
65

Median
Min
Max
Regional

Number of beds

The hospital drug formulary (HDF) is developed; at the regional level (R), and is the same for all the hospitals in the region; or at the hospital level (H)

Number of substances on the hospital drug formulary

1840

Eur J Clin Pharmacol (2013) 69:18371843

highest DU90 % (n=195) (Table 2). The percentage of total

costs in the DU90 % segment was not significantly higher
for university hospitals than for regional hospitals (median
50 % vs. 58 %, p=0.09). The total number of substances
used in the DU90 % segment were significantly higher for
university hospitals than for regional hospitals (median 165
vs. 139, p=0.019) and cost/DDD in DU90 % segment were
significantly higher for university hospitals than for regional
hospitals (median 5 Euros vs. 2 Euros, p=0.033).
The median cost for substances with no assigned DDD
was 247,348 Euros (range 10,10020,046,182 Euros). Two
university hospitals had 22.7 % and 26.5 % of total cost for
substances without a DDD value, which was considerable
higher than for the other hospitals (range 0.15.1 %) (Table 2).
Substances with assigned ATC code L (antineoplastic and
immunomodulating agents) resulted in the highest cost for
drugs with no assigned DDD, the median cost for this ATC
group was 41,799 Euros (range 70119,511,387 Euros), for the
same two university hospitals it was respectively 15,762,733
and 19,511,387 Euros.
Figure 1 present adherence measured as the median percentage of HDF-substances used of the total number of

substances, and the interquartile range for the 10 hospitals.

Most of the substances used at the hospitals are non-HDFs.
ATC group G (genitourinary system and sex hormones), L
(antineoplastic and immunomodulating agents), M (musculoskeletal system), P (antiparasitic products, insecticides and
repellents) and S (sensory organs) had the lowest median
adherence rate about or below 20 %. From ATC group L
examples of most expensive non-HDF substances used were:
university hospitalssubstances from ATC group L01XC
(monoclonal antibodiesL01XC03 traztuzumab, L01XC02
rituximab); regional hospitalssubstances from L04AB (tumor necrosis factor alpha (TNF-?) inhibitorL04AB04
adalimumab, L04AB02 infliximab).
The median index of adherence for substances within the
selected ATC codes used both in primary and secondary
care varied from 76100 % (Table 3). ATC group N05
(psycholeptics) had the lowest index of adherence (median
76; range 5791 %), and the DU90 % segment consisted of
eight substances. This group also included the highest number of substances used (median 37). The median DU90 %
segment for ATC groups C03 (diuretics), C07 (betablocking agents), C08 (calcium channel blockers), C10

Table 2 Cost and adherence to hospital drug formulary presented by DU90 %

Hospital
type

University

Median
Minimum
Maximum
Regional

Median
Minimum
Maximum
Total
Median
Minimum
Maximum

Hospital

No. of substances
(DDD>0)

Index of
adherenceb

Cost/DDD (EUR)

Cost (% of total costs)

DU90 %
segment

Remaining
10 %

DU90 %
segment

Remaining
10 %

DDD=0

Total

DU90 %a

1
3
5
9

872
760
931
1,017

160
156
195
169

55
50
91
47

3.0
6.0
3.5
6.3

24.1
29.5
15.8
40.5

50.3
49.9
48.9
56.4

44.6
27.4
24.6
40.6

5.1
22.7
26.5
3.0

2
4
6
7
8
10

902
760
1,017
581
769
710
816
874
757
763
581
874

165
156
195
105
149
138
140
159
128
139
105
159

53
47
91
54
43
50
70
60
50
52
43
70

4.8
3.0
6.3
1.9
3.0
2.0
2.1
3.2
2.2
2.2
1.9
3.2

26.8
15.8
40.5
4.9
16.5
18.2
18.5
19.8
14.4
17.3
4.9
19.8

50.1
48.9
56.4
76.4
62.2
49.3
50.3
59.1
56.8
58.0
49.3
76.4

34.0
24.6
44.6
22.3
37.8
49.2
49.4
40.7
41.7
41.2
22.3
49.4

13.9
3.0
26.5
1.2
0.1
1.5
0.3
0.2
1.6
0.8
0.1
1.6

793
581
1,017

153
105
195

52
43
91

3.03
1.89
6.28

18.36
4.91
40.49

53.3
48.9
76.4

40.7
22.3
49.4

1.5
0.1
26.5

DU90 %: number of substances constituting 90 % of the volume in DDDs

Index of adherence: percentage adherence to guideline within the DU90 % segment

Eur J Clin Pharmacol (2013) 69:18371843

1841

Fig. 1 Box-and-whiskers plot

of percent of hospital drug
formulary substances used of
total number of substances at
the 10 hospitals. The graph
indicates the median,
interquartile range and total
range for all major drug classes

A-alimentary tract and metabolism

B-blood and blood forming organs
C-cardiovascular system
D-dermatologicals
G-genito urinary system and sex hormones
H-systemic hormonal preparations, excl. sex hormones and insulins
J-antiinfectives for systemic use
L-antineoplastic and immunomodulating agents
M-musculoskeletal system
N-nervous system
P-antiparasitic products, insecticides and repellents
R-respiratory system
S-sensory organs

20

40

60

% HDF-substances
excludes outside values

(lipid modifying agents) was low (1 to 3 substances),

even though the median of the total number of substances used was between 9 and 11. For ATC groups
B03 (antiaenemic preparations), and J01 (antibacterials
for systemic use), the median DU90 %s were 3 and 14
substances, and the median index of adherence were
86 % and 93 %. The range for index of adherence
varied considerably (range 46100 %), especially ATC
code C09 (agents acting on the reninangiotensin

system) and J01. For university hospitals, the DU90 %

segment for ATC groups J01 and R03 (drugs for obstructive airway disease) consisted of a significantly
higher number of substances than for regional hospitals
(16 vs. 13, p=0.030 and 8 vs. 6, p=0.038, respectively). Similarly, the total number of substances used from
ATC groups J01 (median 46 vs. 39, p=0.014) and N02
(median 22 vs. 20, p=0.015) were significantly higher
for university hospitals than for regional hospitals.

Table 3 Adherence to hospital drug formularies at 10 hospitals for selected ATC codes
ATC code 2nd level

DU90 %a
(n)
Median

A10
B03
C03
C07
C08
C09
C10

Drugs used in diabetes

Antianemic preparations
Diuretics
Beta-blocking agents
Calcium channel blockers
Agents acting on rennin-angiotensin system
Lipid modifying agents

J01
N02
N05
R03

Antibacterials for systemic use

Analgesics
Psycholeptics
Drugs for obstructive airway diseases

6
3
2
3
2
7
1
14
4
8
6

Index of adherenceb
(n)

Substances totalc
(n)

Substances on
HDFd (%)

Range

Median

Range

Median

Range

Median

Range

(58)
(24)
(13)
(24)
(24)
(38)
(12)

100
86
100
97
89
93
100

(68100)
(72100)
(91100)
(86100)
(70100)
(46100)
(78100)

23
11
11
11
9
26
10

(1728)
(913)
(813)
(812)
(711)
(2131)
(812)

33
44
30
32
22
16
15

(2036)
(3354)
(2355)
(2036)
(1145)
(824)
(850)

(1219)
(35)
(714)
(58)

93
92
76
100

(57100)
(85100)
(5791)
(85100)

42
21
37
20

(3349)
(1726)
(3444)
(1723)

43
27
27
53

(3558)
(1838)
(2239)
(4575)

DU90 %: number of substances constituting 90 % of the volume in DDDs

Index of adherence: percentage adherence to guideline within the DU90 %-segment

Substances total: total number of substances (DDD>0) within the ATC group

Substances on HDF: % of substances (DDD>0) on hospital drug formulary

1842

Discussion
This study showed a large variation in adherence to HDFs,
the number of substances used, number of HDF-substances
used, and differences in costs. One of the reasons for variations in adherence and cost could be a consequence of
differences in HDFs and formulary management in the regions DTCs [20]. Another reason could be that many therapeutic equivalent drugs existed and therefore may pose a
problem in the interface management between primary care
and hospitals regarding number of non-HDF drug used. The
results can be used to prioritize main area of actions within
selected ATC groups where most used substances are nonHDF (ATC group G, L, M, P and S).
The main strength of the study is that we were able to
collect data for a variety of hospitals across different regions,
different status regarding secondary or tertiary care and were
able to compare university and regional hospitals. Another
strength is that the data source used, BiWeb, employs the ATC
and DDD coding system, which allowed us to aggregate data
and compare costs and volumes on virtually any level of
detail. A minor part of the products did not have official ATCs
or DDDs assigned from the WHO. These products could be
handled by use of the provisional ATC codes and DDDs
assigned by the Danish hospital pharmacies.
Formularies should be the basis for management of drug
use, and influence the drugs used in primary care and hospitals. Variations in the number of substances on the HDFs
between hospitals in this, and other studies have been reported
previously [2, 19, 25]. The HDF of one hospital contained a
much higher number of substances than the remaining nine
hospitals. The result from this study showed a low median
number of substances on the HDFs among the 10 hospitals.
The median number of substances on HDF was nearly the
same as the number of substances on the Wise List, a
formulary developed by the Stockholm County Council
aimed at physicians both in primary care and hospitals, however, it only included few specialist drug used in hospitals [5].
When compared to Dutch HDFs the median number of substances on HDF was considerable lower both for regional and
university hospital [19]. Awide range of number of substances
on the HDFs existed, even though evidence methods were
used developing HDFs in Denmark [20]. Gallini et al. showed
variations in the number and nature of HDF drugs within
selected ATC codes, even though rather similar criteria for
drug selection in the different hospital were used [2].
The costs of HDF-substances were low for nine hospitals,
while one hospital also had specialist drug on the HDF and
this hospital also had the highest cost on HDF-substances.
University hospitals had significantly higher costs and used
more substances than regional hospitals. Use of more substances at university hospital has also been reported in other
studies [19, 25], and it is likely that this higher use of

Eur J Clin Pharmacol (2013) 69:18371843

number of substances and higher costs can be explained

by the fact that they have more special and expensive
treatments, particularly from ATC code L (antineoplastic and
immunomodulating agents).
In this study DU90 % and index of adherence was used,
even though this methodology were intended for primary care,
however it has been used in hospital settings, and shown to
suitable to access prescribing [11]. The median number of
substances within the DU90 % were low, however, one hospital had nearly twice as high index of adherence as the other
hospitals, and about 25 % more substances used in the
DU90 % segment. The cost of the DU90 % segment was
approximately 50 % for all hospitals. The cost/DDD within
the DU90 % was low compared with the cost/DDD in the
DU10 % segment for all hospitals. The adherence rates measured as the percentage of total use accounted for by HDFsubstances use were low. A variation in percentage of HDFsubstances used within ATC code first level by the 10 hospitals also existed, and the percentage of non-HDF substances
used was relatively high. The selected drugs used in both
primary and secondary care had a high adherence rate, compared to the adherence rate for all substances used. Hospital
pharmacies contributed to adherence to HDF [20], which
probably influenced favorably on the adherence rate for the
selected ATC codes. The collaboration between primary care
and hospitals to harmonize drugs used for basic treatment
could also have influenced favorably. However, many nonHDF substances were used, which can be explained by the
fact that pre-admission drug therapy have an impact on nonHDF drug request [26]. Variations in adherence rates have
also been reported in other studies [10, 11]. It has been shown
that a multifaceted intervention can increase the level of
adherence to the formulary on drugs used for basic treatment
in primary care [5, 10].
Adherence to the selected ATC groups was high, which
means that the bulk of the used substances are at the HDFs,
even though a variation existed. Despite the fact that variations in the presentation of HDFs existed, a carefully selected
drug formulary should guide the clinicians in choosing the
safest and most effective agents for treating specific medical
problems.

Conclusion
A large variation between the hospitals in the number of
substances at HDFs existed, and results from this study indicate differences in development and implementation. The low
adherence probably reflects the low number of substances at
the HDFs for the hospitals; specialist drugs were mostly not at
the HDFs. Treatment guidelines are now developed for drugs
with the highest cost at the hospital at the national level, they
are implemented at the regional level, and it is mandatory to

Eur J Clin Pharmacol (2013) 69:18371843

follow these guidelines. DTCs can focus on quality of prescribing of drugs that are not included in the treatment guidelines. Continuing the collaboration between primary care and
hospitals in developing a common formulary, could be the
way forward to optimize the interface management. Discussion at the national level of new ways to develop, implement
and evaluate HDFs may be needed to improve adherence.
Acknowledgments The authors would like to thank the hospital
pharmacies in Denmark and Amgros I/S for given access to BiWeb.
This made it possible to retrieve the data used for this study.
Conflict of interest None declared.

References
1. Statens Serum Institut (SSI) (2012) Lgemiddelstatistik i Danmark
20072011. http://www.ssi.dk/Sundhedsdataogit/Dataformidling/
Laegemiddelstatistikker/~/media/Indhold/DK%20-%20dansk/
Sundhedsdata%20og%20it/NSF/Dataformidling/5%20aars%
20statistik/Samlet%20salg%20af%20lgemidler%202007%
202011.ashx. Accessed 1 December 2013
2. Gallini A, Juillard-Condat B, Saux MC, Taboulet F (2011) Drug
selection in French university hospitals: analysis of formularies for
nine competitive pharmacological classes. Br J Clin Pharmacol
72:823831. doi:10.1111/j.1365-2125.2011.03997.x
3. Wettermark B, Pehrsson A, Juhasz-Haverinen M, Veg A, Edlert M,
Tornwall-Bergendahl G, Almkvist H, Godman B, Granath F,
Bergman U (2009) Financial incentives linked to self-assessment
of prescribing patterns: a new approach for quality improvement of
drug prescribing in primary care. Qual Prim Care 17:179189
4. Lapointe-Shaw L, Fischer HD, Newman A, John-Baptiste A,
Anderson GM, Rochon PA, Bell CM (2012) Potential savings of
harmonising hospital and community formularies for chronic disease medications initiated in hospital. PLoS One 7:e39737.
doi:10.1371/journal.pone.0039737
5. Gustafsson LL, Wettermark B, Godman B, Andersen-Karlsson E,
Bergman U, Hasselstrom J, Hensjo LO, Hjemdahl P, Jagre I,
Julander M, Ringertz B, Schmidt D, Sjoberg S, Sjoqvist F, Stiller
CO, Tornqvist E, Tryselius R, Vitols S, von Bahr C (2011) The
wise list- a comprehensive concept to select, communicate and
achieve adherence to recommendations of essential drugs in ambulatory care in Stockholm. Basic Clin Pharmacol Toxicol
108:224233. doi:10.1111/j.1742-7843.2011.00682.x
6. Halloway K., Green T, Carandang E, Hogerzeil H, Aing R, Lee D
(2003) Drug and Therapeutics Commitees - A practical guide. WHO
World Health Organisation. http://apps.who.int/medicinedocs/en/d/
Js4882e/. Accessed 12 January 2013
7. Scroccaro G (2000) Formulary management. Pharmacotherapy
20:317S321S
8. Tyler LS, Cole SW, May JR, Millares M, Valentino MA, Vermeulen
LC Jr, Wilson AL (2008) ASHP guidelines on the pharmacy and
therapeutics committee and the formulary system. Am J Health Syst
Pharm 65:12721283
9. Fijn R, Brouwers JR, Knaap RJ, de Jong-van den Berg LT (1999)
Drug and Therapeutics (D & T) committees in Dutch hospitals: a
nation-wide survey of structure, activities, and drug selection procedures. Br J Clin Pharmacol 48:239246

1843
10. Wettermark B, Haglund K, Gustafsson LL, Persson PM, Bergman U
(2005) A study of adherence to drug recommendations by providing
feedback of outpatient prescribing patterns to hospital specialists.
Pharmacoepidemiol Drug Saf 14:579588. doi:10.1002/pds.1098
11. Bergman U, Risinggard H, Vlahovic-Palcevski V, Ericsson O (2004)
Use of antibiotics at hospitals in Stockholm: a benchmarking project
using internet. Pharmacoepidemiol Drug Saf 13:465471. doi:10.1002/
pds.898
12. Vlahovic-Palcevski V, Wettermark B, Bergman U (2002) Quality
of non-steroidal anti-inflammatory drug prescribing in Croatia
(Rijeka) and Sweden (Stockholm). Eur J Clin Pharmacol 58:209
214. doi:10.1007/s00228-002-0449-2
13. Wettermark B, Pehrsson A, Jinnerot D, Bergman U (2003) Drug
utilisation 90 % profilesa useful tool for quality assessment of prescribing in primary health care in Stockholm. Pharmacoepidemiol
Drug Saf 12:499510. doi:10.1002/pds.852
14. Calasan J, Mijatovic V, Horvat O, Varga J, Sabo A, Stilinovic N
(2011) The outpatient utilization of non-steroidal anti-inflammatory
drugs in South Backa District, Serbia. Int J Clin Pharm 33:246251.
doi:10.1007/s11096-011-9487-0
15. Mimica MS, Bergman U, Vukovic D, Wettermark B, VlahovicPalcevski V (2010) Impact of restricted amoxicillin/clavulanic acid
use on Escherichia coli resistanceantibiotic DU90 % profiles with
bacterial resistance rates: a visual presentation. Int J Antimicrob
Agents 36:369373. doi:10.1016/j.ijantimicag.2010.05.019
16. Fijn R, de Jong-van den Berg LT, Brouwers JR (1999) Rational
pharmacotherapy in The Netherlands: formulary management in
Dutch hospitals. Pharm World Sci 21:7479
17. Anagnostis E, Wordell C, Guharoy R, Beckett R, Price V (2011) A
national survey on hospital formulary management processes. J
Pharm Pract 24:409416. doi:10.1177/0897190011407777
18. Duran-Garcia E, Santos-Ramos B, Puigventos-Latorre F, Ortega A
(2011) Literature review on the structure and operation of Pharmacy
and Therapeutics Committees. Int J Clin Pharm 33:475483.
doi:10.1007/s11096-011-9501-6
19. Fijn R, Engels SA, Brouwers JR, Knaap RJ, de Jong-van den Berg
LT (2000) Dutch hospital drug formularies: pharmacotherapeutic
variation and conservatism, but concurrence with national pharmacotherapeutic guidelines. Br J Clin Pharmacol 49:254263
20. Plet HT, Hallas J, Nielsen GS, Kjeldsen LJ (2012) Drug and
Therapeutics Committees in Danish Hospitals: a survey of organization, activities and drug selection procedures. Basic Clin Pharmacol
Toxicol. doi:10.1111/bcpt.12028
21. Danske Regioner (2011) RADS: rdet for anvendelse af dyr medicin.
http://www.regioner.dk/Sundhed/Medicin/Rdet+for+Anvendelse+af+
Dyr+Sygehusmedicin+RADS.aspx. Accessed 1 September 2011
22. Danisk Health and Medicines authorities (2009) Analyse af sygehusmedicin. http://www.sum.dk/Aktuelt/Publikationer/~/media/Filer%20%20Publikationer_i_pdf/2009/Analyse%20af%20sygehusmedicin.
ashx. Accessed 12 January 2013
23. WHO Collaborating Centre for Drug Statistics Methodology
(2012) ATC/DDD Index 2010. http://www.whocc.no/atc_ddd_
index/. Accessed 15 January 2013
24. Bergman U, Popa C, Tomson Y, Wettermark B, Einarson TR,
Aberg H, Sjoqvist F (1998) Drug utilization 90 %a simple method for assessing the quality of drug prescribing. Eur J Clin
Pharmacol 54:113118
25. Thurmann PA, Harder S, Steioff A (1997) Structure and activities
of hospital drug committees in Germany. Eur J Clin Pharmacol
52:429435
26. Himmel W, Lonker B, Kochen MM (1998) Nonformulary drug
requests at an academic hospital in Germanythe role of general
practitioners long-term medication. Eur J Clin Pharmacol 54:41
46