Possible ways to enhance renin-Angiotensin prescribing efficiency: Republic of Serbia as a case history?

Marija Kalaba*, Brian Godman, Aleksandar Vuksanović, Marion Bennie, Richard E. Malmström

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

10 Citations (Scopus)


Background: Multiple reforms have been instigated across Europe to enhance prescribing efficiency. Supply-side reforms in the Republic of Serbia include measures to lower the price of generics and originators, with demand-side measures including patient copayments and prescribing restrictions. Specific measures for renin-Angiotensin inhibitor drugs include a 50% copayment for angiotensin receptor blockers (ARBs) versus approximately 50 cents per prescription for established angiotensin-converting enzyme inhibitors (ACEIs), as there is no perceived difference in effectiveness between the two classes. Objectives: To assess the influence of these measures on ARB utilization, as well as reimbursed prices of ACEIs and ARBs over time. Method: Observational retrospective case study of all ambulatory care patients in the Republic of Serbia's Health Insurance Fund database who were dispensed at least one ACEI or ARB alone or in combination (fixed dose combination [FDC]) between 2005 and 2011. Utilization measured in defined daily doses (DDDs) and only reimbursed expenditure (overall and expenditure/DDD) as Health Insurance perspective. Results: There was a 1.8-fold increase in renin-Angiotensin inhibitor drug utilization, rising to 207.4 DDDs/1000 inhabitants per day in 2011. This is driven principally by a 19.6-fold increase in ACEI FDCs. There was only limited utilization of ARBs at just 2% of total renin-Angiotensin inhibitor drugs in 2011. Reimbursed expenditure increased 2.54-fold due to an appreciable increase in ACEI FDC utilization at approximately twice the cost of ACEIs in recent years. Alongside this, we noted considerable differences in expenditure/DDD for different ACEIs. Conclusion & future perspective: High patient copayments for ARBs appreciably limited their utilization in Serbia, which mirrors the findings from other studies. Potential future measures to enhance prescribing efficiency include reference pricing for ACEIs based on the lowest price of an established ACEI. In addition, reference pricing for FDCs should be based on the reference price of the individual components combined. This builds on recent reforms restricting the reimbursement of FDCs until 3 months after individual components have been prescribed separately.

Original languageEnglish
Pages (from-to)539-549
Number of pages11
JournalJournal of Comparative Effectiveness Research
Issue number6
Publication statusPublished - Nov 2012
Externally publishedYes


  • Serbia
  • demand-side reforms
  • drug utilization studies
  • generics
  • renin-Angiotensin inhibiting drugs
  • supply-side reforms


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