Influence of demand-side measures to enhance renin-angiotensin prescribing efficiency in Europe: Implications for the future

European countries strive to enhance prescribing efficiency. This includes renin-angiotensin drugs following the availability of generic angiotensin-converting enzyme inhibitors (ACEIs). Aims: To compare angiotensin receptor blocker utilization and expenditure patterns in Austria and Croatia following prescribing restrictions, as well as with other European countries introducing different supply- and demand-side measures. Lastly, to appraise the impact of generic losartan in Croatia on utilization of patented angiotensin receptor blockers. Method: Observational retrospective study principally between 2001 and 2007, using defined daily doses and (sic)/1000 inhabitants/year. Demand-side measures were based on the four 'E's-education, engineering, economics and enforcement. Results: Greater intensity of follow-up of prescribing restrictions in Croatia enhanced utilization of ACEIs versus Austria. There was high utilization of ACEIs in Scotland following intensive demand-side measures, similar to Austria and Croatia. Demand-side measures in Spain (Catalonia) and Sweden also appeared to moderate angiotensin receptor blockers utilization. The combination of measures helped stabilize expenditure on renin-angiotensin drugs when adjusted for population sizes despite appreciable increases in volumes. The only exception was Portugal, with less intensive measures. Conclusion: Multiple and intensive demand-side measures enhanced prescribing efficiency. The more intense follow-up of ARB prescribing restrictions in Croatia had a greater influence on subsequent utilization patterns than Austria. Both findings confirm earlier studies. Reforms also favorably enhanced the prescribing of generic losartan once available