Applied Health Economics and Health Policy

, Volume 11, Issue 3, pp 205–218 | Cite as

Multilevel Analysis of the Influence of Patients’ and General Practitioners’ Characteristics on Patented Versus Multiple-Sourced Statin Prescribing in France

  • Sylvain Pichetti
  • Catherine SermetEmail author
  • Brian Godman
  • Stephen M. Campbell
  • Lars L. Gustafsson
Original Research Article



The French National Health Insurance and the Ministry of Health have introduced multiple reforms in recent years to increase prescribing efficiency. These include guidelines, academic detailing, financial incentives for the prescribing and dispensing of generics drugs as well as a voluntary pay-for-performance programme. However, the quality and efficiency of prescribing could be enhanced potentially if there was better understanding of the dynamics of prescribing behaviour in France.


To analyse the patient and general practitioner characteristics that influence patented versus multiple-sourced statin prescribing in France.


Statistical analysis was performed on the statin prescribing habits from 341 general practitioners (GPs) that were included in the IMS-Health Permanent Survey on Medical Prescription in France, which was conducted between 2009 and 2010 and involved 14,360 patients. Patient characteristics included their age and gender as well as five medical profiles that were constructed from the diagnoses obtained during consultations. These were (1) disorders of lipoprotein metabolism, (2) heart disease, (3) diabetes, (4) complex profiles and (5) profiles based on other diagnoses. Physician characteristics included their age, gender, solo or group practice, weekly workload and payment scheme.


Patient age had a statistically significant impact on statin prescribing for patients in profile 1 (disorders of lipoprotein metabolism) and profile 3 (complex profiles) with a greater number of patented statins being prescribed for the youngest patients. For instance, patients older than 76 years with a complex profile were prescribed fewer patented statins than patients aged 68–76 years old with the same medical profile (coefficient: −0.225; p = 0.0008). By contrast, regardless of the patient’s age, the medical profile did not affect the probability of prescribing a patented statin except in young patients with heart diseases who were prescribed a greater number of patented statins (coefficient: 0.3992; p = 0.0007). Prescribing was also statistically influenced by physician features, e.g., older male physicians were more likely to prescribe patented statins (coefficient: 0.245; p = 0.0417) and GPs practicing in groups were more likely to prescribe multiple sourced statins (coefficient: −0.178; p = 0.0338), which is an important finding of the study. GPs with a lower workload prescribed a greater number of patented statins.


There is significant variability in the prescribing of different statins among patient and physician profiles as well as between solo and group practices. Consequently, there are opportunities to target demand-side measures to enhance the prescribing of multiple-sourced statins. Further studies are warranted, in particular in other therapeutic classes, to provide a counter-balance to the considerable marketing activities of pharmaceutical companies.


Statin Atorvastatin Rosuvastatin Continuous Medical Education Group Practice 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The study was based on data that were acquired by the Directorate for Research, Studies, Evaluation and Statistics of the Ministry of Health (DREES) in France. This work was in part funded by grants provided by the Karolinska Institutet (LG and BG).

The authors have no other relevant affiliations or financial involvement with any organisation or entity that potentially could be in financial conflict with the subject or materials discussed in the manuscript.

There is no relevant conflict of interest to disclose.

The plan for the analysis of data was designed by Sylvain Pichetti, Catherine Sermet and Brian Godman in collaboration and with inputs from the two other authors. Sylvain Pichetti conducted the statistical analysis and wrote a substantial proportion of the manuscript. He is the guarantor for the overall content of the manuscript. Catherine Sermet was responsible for the construction of the medical variables in the database. She wrote a substantial proportion of the manuscript and was also in charge of coordinating the manuscript preparation and submission process. Brian Godman wrote the first draft of the paper and provided the conceptual framework for the pharmaceutical regulation policies as well as most of the references. Stephen Campbell and Lars L Gustafsson provided editorial and content oversight. All of the authors critically reviewed drafts of the manuscript prior to submission.

Supplementary material

40258_2013_14_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 31 kb)


  1. 1.
    Sermet C, Andrieu V, Godman B, et al. Ongoing pharmaceutical reforms in France: implications for key stakeholder groups. Appl Health Econ Health Policy. 2010;8(1):7–24.PubMedCrossRefGoogle Scholar
  2. 2.
    Godman B, Bucsics A, Burkhardt T, et al. Insight into recent reforms and initiatives in Austria: implications for key stakeholders. Expert Rev Pharmacoecon Outcomes Res. 2008;8(4):357–71.PubMedCrossRefGoogle Scholar
  3. 3.
    Wettermark B, Godman B, Andersson K, et al. Recent national and regional drug reforms in Sweden: implications for pharmaceutical companies in Europe. Pharmacoeconomics. 2008;26(7):537–50.PubMedCrossRefGoogle Scholar
  4. 4.
    Godman B, Shrank W, Andersen M, et al. Comparing policies to enhance prescribing efficiency in Europe through increasing generic utilization: changes seen and global implications. Expert Rev Pharmacoecon Outcomes Res. 2010;10(6):707–22.PubMedCrossRefGoogle Scholar
  5. 5.
    Godman B, Shrank W, Andersen M, et al. Policies to enhance prescribing efficiency in europe: findings and future implications. Front Pharmacol. 2010;1:141.PubMedCentralPubMedGoogle Scholar
  6. 6.
    Godman B, Malmstrom RE, Bennie M, et al. Prescribing restrictions—a necessary strategy among some European countries to enhance future prescribing efficiency? Rev Health Care. 2012;3:5–16.Google Scholar
  7. 7.
    Garattini S, Bertele’ V, Godman B, et al. Enhancing the rational use of new medicines across European health care systems. Eur J Clin Pharmacol. 2008;64(12):1137–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Godman B, Wettermark B, Hoffmann M, et al. Multifaceted national and regional drug reforms and initiatives in ambulatory care in Sweden: global relevance. Expert Rev Pharmacoecon Outcomes Res. 2009;9(1):65–83.PubMedCrossRefGoogle Scholar
  9. 9.
    McGinn D, Godman B, Lonsdale J, et al. Initiatives to enhance the quality and efficiency of statin and PPI prescribing in the UK: impact and implications. Expert Rev Pharmacoecon Outcomes Res. 2010;10(1):73–85.PubMedCrossRefGoogle Scholar
  10. 10.
    Godman B, Shrank W, Wettermark B, et al. Use of generics—a critical cost containment measure for all healthcare professionals in Europe? Pharmaceuticals. 2010;3:2470–94.CrossRefGoogle Scholar
  11. 11.
    Garuoliene K, Godman B, Gulbinovic J, et al. European countries with small populations can obtain low prices for drugs: Lithuania as a case history. Expert Rev Pharmacoecon Outcomes Res. 2011;11(3):343–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Coma A, Zara C, Godman B, et al. Policies to enhance the efficiency of prescribing in the Spanish Catalan region: impact and future direction. Expert Rev Pharmacoecon Outcomes Res. 2009;9(6):569–81.PubMedCrossRefGoogle Scholar
  13. 13.
    Godman B, Wettermark B, Bishop I, et al. European payer initiatives to reduce prescribing costs through use of generics. GABI. 2012;1:22–7.CrossRefGoogle Scholar
  14. 14.
    Pettersson B, Hoffmann M, Wandell P, et al. Utilization and costs of lipid modifying therapies following health technology assessment for the new reimbursement scheme in Sweden. Health Policy. 2012;104(1):84–91.PubMedCrossRefGoogle Scholar
  15. 15.
    Vrijens F, Van de Voorde C, Farfan-Portet MI et al. Patient socioeconomic determinants for the choice of the cheapest molecule within a cluster: evidence from Belgian prescription data. Eur J Health Econ. 2012; 13(3):315–325.Google Scholar
  16. 16.
    Wettermark B, Godman B, Neovius M, et al. Initial effects of a reimbursement restriction to improve the cost-effectiveness of antihypertensive treatment. Health Policy. 2010;94(3):221–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Wettermark B, Pehrsson A, Juhasz-Haverinen M, et al. Financial incentives linked to self-assessment of prescribing patterns: a new approach for quality improvement of drug prescribing in primary care. Qual Prim Care. 2009;17(3):179–89.PubMedGoogle Scholar
  18. 18.
    Gustafsson LL, Wettermark B, Godman B, et al. 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. 2011;108(4):224–33.PubMedCrossRefGoogle Scholar
  19. 19.
    Martikainen JE, Saastamoinen LK, Korhonen MJ, et al. Impact of restricted reimbursement on the use of statins in Finland: a register-based study. Med Care. 2010;48(9):761–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Voncina L, Strizrep T, Godman B, et al. Influence of demand-side measures to enhance renin-angiotensin prescribing efficiency in Europe: implications for the future. Expert Rev Pharmacoecon Outcomes Res. 2011;11(4):469–79.PubMedCrossRefGoogle Scholar
  21. 21.
    Godman B, Sakshaug S, Berg C, et al. Combination of prescribing restrictions and policies to engineer low prices to reduce reimbursement costs. Expert Rev Pharmacoecon Outcomes Res. 2011;11(1):121–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Sjoborg B, Backstrom T, Arvidsson LB, et al. Design and implementation of a point-of-care computerized system for drug therapy in Stockholm metropolitan health region–Bridging the gap between knowledge and practice. Int J Med Inform. 2007;76(7):497–506.PubMedCrossRefGoogle Scholar
  23. 23.
    Ostini R, Hegney D, Jackson C, et al. Systematic review of interventions to improve prescribing. Ann Pharmacother. 2009;43(3):502–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Freemantle N. Implementation strategies. Fam Pract. 2000;17(Suppl 1):S7–10.PubMedCrossRefGoogle Scholar
  25. 25.
    O’Brien MA, Rogers S, Jamtvedt G et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007;(4):CD000409.Google Scholar
  26. 26.
    Wettermark B, Godman B, Jacobsson B, et al. Soft regulations in pharmaceutical policy making: an overview of current approaches and their consequences. Appl Health Econ Health Policy. 2009;7(3):137–47.PubMedCrossRefGoogle Scholar
  27. 27.
    Godman B, Abuelkhair M, Vitry A, et al. Payers endorse generics to enhance prescribing efficiency; impact and future implications, a case history approach. GABI. 2012;1(2):69–83.CrossRefGoogle Scholar
  28. 28.
    Cour des Comptes. Rapport annuel sur la sécurité sociale. La maîtrise des dépenses de médicaments 2010. 2011. Available at Accessed 18 Mar 2013.
  29. 29.
    Godman B, Paterson K, Malmstrom RE, et al. Improving the managed entry of new medicines: sharing experiences across Europe. Expert Rev Pharmacoecon Outcomes Res. 2012;12(4):439–41.PubMedCrossRefGoogle Scholar
  30. 30.
    Convention nationale organisant les rapports entre les médecins libéraux et l’Assurance maladie JORF n°0223 du 25 septembre 2011, page 16080 texte n°16.Google Scholar
  31. 31.
    Weng TC, Yang YH, Lin SJ, et al. A systematic review and meta-analysis on the therapeutic equivalence of statins. J Clin Pharm Ther. 2010;35(2):139–51.PubMedCrossRefGoogle Scholar
  32. 32.
    Norman C, Zarrinkoub R, Hasselstrom J, et al. Potential savings without compromising the quality of care. Int J Clin Pract. 2009;63(9):1320–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Usher-Smith J, Ramsbottom T, Pearmain H, et al. Evaluation of the clinical outcomes of switching patients from atorvastatin to simvastatin and losartan to candesartan in a primary care setting: 2 years on. Int J Clin Pract. 2008;62(3):480–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Boh M, Opolski G, Poredos P, et al. Therapeutic equivalence of the generic and the reference atorvastatin in patients with increased coronary risk. Int Angiol. 2011;30(4):366–74.PubMedGoogle Scholar
  35. 35.
    French National Authority for Health. Efficacité et efficience des hypolipémiants: une analyse centrée sur les statines. 2012. Available at Accessed 18 Mar 2013.
  36. 36.
    Bennie M, Godman B, Bishop I, et al. Multiple initiatives continue to enhance the prescribing efficiency for the proton pump inhibitors and statins in Scotland. Expert Rev Pharmacoecon Outcomes Res. 2012;12(1):125–30.PubMedCrossRefGoogle Scholar
  37. 37.
    Bejean S, Peyron C, Urbinelli R. Variations in activity and practice patterns: a French study for GPs. Eur J Health Econ. 2007;8(3):225–36.PubMedCrossRefGoogle Scholar
  38. 38.
    Davis P, Gribben B, Lay-Yee R, et al. How much variation in clinical activity is there between general practitioners? A multi-level analysis of decision-making in primary care. J Health Serv Res Policy. 2002;7(4):202–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Steffensen FH, Sorensen HT, Olesen F. Diffusion of new drugs in Danish general practice. Fam Pract. 1999;16(4):407–13.PubMedCrossRefGoogle Scholar
  40. 40.
    Tamblyn R, McLeod P, Hanley JA, et al. Physician and practice characteristics associated with the early utilization of new prescription drugs. Med Care. 2003;41(8):895–908.PubMedCrossRefGoogle Scholar
  41. 41.
    Tollen L. Physician organization in relation to quality and efficiency of care. A synthesis of recent literature. 2008. Kaiser Permanente Institute for Health Policy, the Commonwealth Fund.Google Scholar
  42. 42.
    Mehrotra A, Epstein AM, Rosenthal MB. Do integrated medical groups provide higher-quality medical care than individual practice associations? Ann Intern Med. 2006;145(11):826–33.PubMedCrossRefGoogle Scholar
  43. 43.
    Wong IC, Murray ML, Camilleri-Novak D, et al. Increased prescribing trends of paediatric psychotropic medications. Arch Dis Child. 2004;89(12):1131–2.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Pichetti S, Sorasith C, Sermet C. Analysis of the impact of removing mucolytics and expectorants from the list of reimbursable drugs on prescription rates: a time-series analysis for France 1998–2010. Health Policy. 2011;102(2–3):159–69.PubMedCrossRefGoogle Scholar
  45. 45.
    Paterson L, Goldstein H. New statistical methods for analysing social structures : an introduction to multilevel models. British Educational Res J. 1991;17:387–93.CrossRefGoogle Scholar
  46. 46.
    Geleedst-De VM, Maitland-van der Zee AH, Schalekamp T et al. Statin prescribing in the elderly in the Netherlands: a pharmacy database time trend study. Drugs Aging. 2010; 27(7):589–596.Google Scholar
  47. 47.
    Heck R, Thomas S. An introduction of multilevel modelling technics. New York: Routledge; 1999.Google Scholar
  48. 48.
    Raudenbush S, Bryk A. Hierarchical linear models. Applications and data analysis methods. SAGE Publications Inc.: Osborne; 2002.Google Scholar
  49. 49.
    Pfeffermann D, Skinner CJ, Holmes DJ, et al. Weighting for unequal selection probabilities in multilevel models. J R Stat Soc Ser B (statistical methodology). 1998;60(1):23–40.CrossRefGoogle Scholar
  50. 50.
    Templeton L, Deehan A, Taylor C, et al. Surveying general practitioners: does a low response rate matter? Br J Gen Pract. 1997;47(415):91–4.PubMedCentralPubMedGoogle Scholar
  51. 51.
    Hummers-Pradier E, Scheidt-Nave C, Martin H, et al. Simply no time? Barriers to GPs’ participation in primary health care research. Fam Pract. 2008;25(2):105–12.PubMedCrossRefGoogle Scholar
  52. 52.
    Grande D, Frosch DL, Perkins AW, et al. Effect of exposure to small pharmaceutical promotional items on treatment preferences. Arch Intern Med. 2009;169(9):887–93.PubMedCrossRefGoogle Scholar
  53. 53.
    Kyle GJ, Nissen LM, Tett SE. Pharmaceutical company influences on medication prescribing and their potential impact on quality use of medicines. J Clin Pharm Ther. 2008;33(5):553–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Fischer MA, Keough ME, Baril JL, et al. Prescribers and pharmaceutical representatives: why are we still meeting? J Gen Intern Med. 2009;24(7):795–801.PubMedCentralPubMedCrossRefGoogle Scholar
  55. 55.
    Greving JP, Denig P, van der Veen WJ, et al. Determinants for the adoption of angiotensin II receptor blockers by general practitioners. Soc Sci Med. 2006;63(11):2890–8.PubMedCrossRefGoogle Scholar
  56. 56.
    Prosser H, Almond S, Walley T. Influences on GPs’ decision to prescribe new drugs-the importance of who says what. Fam Pract. 2003;20(1):61–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Jones MI, Greenfield SM, Bradley CP. Prescribing new drugs: qualitative study of influences on consultants and general practitioners. BMJ. 2001;323(7309):378–81.PubMedCentralPubMedCrossRefGoogle Scholar
  58. 58.
    Tobin L, de Almedia Neto AC, Wutzke S et al. Influences on the prescribing of new drugs. Aust Fam Physician. 2008; 37(1–2): 78–80, 83.Google Scholar
  59. 59.
    Watkins C, Moore L, Harvey I, et al. Characteristics of general practitioners who frequently see drug industry representatives: national cross sectional study. BMJ. 2003;326(7400):1178–9.PubMedCentralPubMedCrossRefGoogle Scholar
  60. 60.
    Prosser H, Walley T. New drug uptake: qualitative comparison of high and low prescribing GPs’ attitudes and approach. Fam Pract. 2003;20(5):583–91.PubMedCrossRefGoogle Scholar
  61. 61.
    Plans-Rubio P. The cost effectiveness of statin therapies in Spain in 2010, after the introduction of generics and reference prices. Am J Cardiovasc Drugs. 2010;10(6):369–82.PubMedCrossRefGoogle Scholar
  62. 62.
    Voncina L, Strizrep T. Croatia 2009/2010. Pharmaceutical pricing and reimbursement reform. Eurohealth. 2011;16:20–2.Google Scholar
  63. 63.
    Mousques J, Renaud T, Scemama O. Is the “practice style” hypothesis relevant for general practitioners? An analysis of antibiotics prescription for acute rhinopharyngitis. Soc Sci Med. 2010;70(8):1176–84.PubMedCrossRefGoogle Scholar
  64. 64.
    Bras PL, Ricordeau P, Roussille B et al. GP’s information on medicines. L’information des médecins généralistes sur le médicament. Rapport de l’IGAS, September 2007.Google Scholar
  65. 65.
    Gibson TB, Ozminkowski RJ, Goetzel RZ. The effects of prescription drug cost sharing: a review of the evidence. Am J Manag Care. 2005;11(11):730–40.PubMedGoogle Scholar
  66. 66.
    Green CJ, Maclure M, Fortin PM et al. Pharmaceutical policies: effects of restrictions on reimbursement. Cochrane Database Syst Rev 2010; (8):CD008654.Google Scholar
  67. 67.
    Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. BMJ. 1998;317(7156):465–8.PubMedCentralPubMedCrossRefGoogle Scholar
  68. 68.
    Barton S. Using clinical evidence. BMJ. 2001;322(7285):503–4.PubMedCentralPubMedCrossRefGoogle Scholar
  69. 69.
    Abernethy D, Birkett D, Brosen K, Cascorbi I, Gustafsson LL, Hoppu K, Maxwll S, Orme M, Rago L, Rawlin M Sir, Reidenberg M, Sjöqvist F, Smith T, Thuerman P, Walubo A. Clinical pharmacology in health care, teaching and research. Joint publication by WHO, CIOMS and IUPHAR (International Union of Pharmacology and Clinical Pharmacology) edited by Orme M, Sjöqvist F and Birkett D, Geneva 2012, Oct 8. Available at Accessed 18 Jan 2013.

Copyright information

© Springer International Publishing Switzerland 2013

Authors and Affiliations

  • Sylvain Pichetti
    • 1
  • Catherine Sermet
    • 1
    Email author
  • Brian Godman
    • 2
    • 3
    • 4
  • Stephen M. Campbell
    • 5
  • Lars L. Gustafsson
    • 2
  1. 1.IRDESParisFrance
  2. 2.Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska InstitutetKarolinska University Hospital HuddingeStockholmSweden
  3. 3.Strathclyde Institute of Pharmacy and Biomedical SciencesStrathclyde UniversityGlasgowScotland
  4. 4.Liverpool Health Economics CentreUniversity of LiverpoolLiverpoolEngland
  5. 5.Centre for Primary Care: Institute of Population HealthUniversity of ManchesterManchesterEngland

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