A Real-World Study of Electronic Prescriptions and Medication Adherence in Bulgaria

Background: The implementation of electronic prescriptions in Bulgaria since 2023 provides new opportunities for real-world data analysis of prescribing practices and medication adherence particularly for chronic diseases such as diabetes. Objective: To evaluate prescribing patterns medication adherence and National Health Insurance Fund (NHIF) coverage in patients with diabetes across three major Bulgarian regions using 6-month electronic prescription (e-prescription) data from January to June 2024. Materials and Methods: Data were collected from community pharmacies in Sofia, Plovdiv, and Dobrich and Stara Zagora. Prescriptions were categorized by diabetes type (type 1 or type 2), therapy class (traditional vs. innovative), refill frequency, and NHIF reimbursement. Adherence was estimated using refill frequency and the Proportion of Days Covered (PDC) method. Results: A total of 1071 prescriptions were analyzed. In Sofia, type 1 patients (n = 13) had high rates of adherence (mean: 6.5 refills; 54% refill-based adherence), while type 2 patients (n = 138) showed more variability (mean: 4.55 refills; 27.5% with PDC ≥ 80%). Innovative therapies (e.g., DPP-4, SGLT2 inhibitors) were more frequently used in Sofia, reflected by higher NHIF reimbursement costs. In contrast, Dobrich, Stara Zagora, and Plovdiv predominantly relied on traditional medications (e.g., metformin, sulfonylureas) with lower adherence and limited use of innovative therapies. Conclusions: E-prescription data provides valuable insights into real-world diabetes management and shows substantial regional differences in adherence and treatment intensity. In the bigger cities there is better adherence and access to modern therapies, while smaller regions are slower in adopting these treatments. These findings support the need for national policies to ensure equitable access to innovative therapies and enhanced digital support for chronic disease management. From clinical practice point of view adherence follow-up is a key for treatment success and healthcare decision-making.