Regional variation and adherence to guidelines for drug treatment of asthma

Temporal and geographical variation in low carbon inhaler dispensing in England, 2016 to 2021: an ecological study

OBJECTIVES

In 2019-2020, four national recommendations were published in the United Kingdom to encourage use of low carbon inhalers. This study aimed to investigate whether these were associated with a change in primary care dispensing in England and to explore associations between geographical variation and clinical commissioning group (CCG) characteristics.

DESIGN

Ecological study using aggregated publicly available data.

SETTING

All CCGs in England (March 2016 to February 2021).

PARTICIPANTS

not applicable.

MAIN OUTCOME MEASURES

Percentage of low carbon inhalers dispensed.

RESULTS

The percentage of low carbon inhalers dispensed was 26.3% in 2020-2021 (of 8.8 million inhalers). This decreased over the study period for short-acting beta-agonist (SABA), inhaled corticosteroid (ICS) and ICS+long-acting beta-agonist (LABA) inhalers. The same trend was seen for LABA and ICS+LABA+long-acting muscarinic antagonist inhalers from 2019. The SABA and ICS classes were less often dispensed as low carbon inhalers (⁓6% versus 35-45%). Interrupted time series analyses found slight increases in low carbon inhaler percentage in the SABA, LABA and ICS classes after April 2019, which were soon erased by the long-term trend. There was also geographical variation, with the north-west, Birmingham and London consistently dispensing more low carbon inhalers. The presence of advice on climate change in CCG formularies/guidelines, the prevalence of asthma and population age profile were associated with significant variation in low carbon inhaler percentage for some classes.

CONCLUSIONS

The percentage of low carbon inhalers dispensed in England remains low and continues to decrease. Greater use of low carbon inhalers is achievable, but is more likely with locally implemented initiatives.

Stepped treatment algorithm using budesonide-formoterol for chronic respiratory diseases: A single arm interventional study

Background

While the safety and efficacy of inhaled budesonide-formoterol, used as-needed for symptoms, has been established for patients with asthma, it has not been trialed in undifferentiated patients with chronic respiratory diseases. We aimed to assess the feasibility of a pragmatic intervention that entails a stepped algorithm using inhaled budesonide-formoterol (dry powder inhaler, 160μg/4.5μg per dose) for patients presenting with chronic respiratory diseases to three rural district hospitals in Hanoi, Vietnam.

Methods

We recruited patients with evidence of airflow obstruction on spirometry and/or symptoms consistent with asthma. The algorithm consisted of three steps: 1. as-needed inhaled budesonide-formoterol for symptoms, 2. maintenance plus as-needed inhaled budesonide-formoterol, and 3. referral to a higher-level healthcare facility. All participants started at step 1, with escalation to the next step at review visits if there had been exacerbation(s) or inadequate symptom control. Patients were followed for 12 months.

Results

Among 313 participants who started the treatment algorithm, 47.2% had ≥ 1 episode of acute respiratory symptoms requiring a visit to hospital or clinic and 35.4% were diagnosed with an exacerbation. Twelve months after enrolment, 50.7% still adhered to inhaled budesonide-formoterol at the recommended treatment step. The mean and median number of doses per day was 1.5 (standard deviation 1.2) doses and 1.3 (interquartile range 0.7–2.3) doses, respectively. The proportion of patients taking more than 800μg budesonide per day was 3.8%.

Conclusion

This novel therapeutic algorithm is feasible for patients with chronic respiratory diseases in a rural setting in Vietnam. Further studies are required to establish the effectiveness, safety and cost-effectiveness of similar approaches in different settings.

Trial registration

ACTRN12619000554167.

Compliance with the clinical guidelines for managing asthma by primary care physicians: An ambispective observational study

OBJECTIVE

To assess the degree of compliance with the recommendations of the 2009 and 2015 versions of the Spanish guidelines for managing asthma (Guía Española para el Manejo del Asma [GEMA]) and the effect of this compliance on controlling the disease.

MATERIAL AND METHODS

We conducted an observational ambispective study between September 2015 and April 2016 in which 314 primary care physicians and 2864 patients participated.

RESULTS

Using retrospective data, we found that 81 of the 314 physicians (25.8%; 95% CI 21.3-30.9) stated that they complied with the GEMA2009 recommendations. At the start of the study, 88 of the 314 physicians (28.0%; 95% CI 23.4-33.2) complied with the GEMA2015 recommendations. Poorly controlled asthma (OR, 0.19; 95% CI 0.13-0.28) and persistent severe asthma at the start of the study (OR, 0.20; 95% CI 0.12-0.34) were negatively associated with having well-controlled asthma by the end of the follow-up. In contrast, compliance with the GEMA2015 recommendations was positively associated with a greater likelihood that the patient would have well-controlled asthma by the end of the follow-up (OR, 1.70; 95% CI 1.40-2.06).

CONCLUSIONS

Low compliance with the clinical guidelines for managing asthma is a common problem among primary care physicians. Compliance with these guidelines is associated with better asthma control. Actions need to be taken to improve primary care physician compliance with the asthma management guidelines.

Compliance with the clinical guidelines for managing asthma by primary care physicians: An ambispective observational study

OBJECTIVE

To assess the degree of compliance with the recommendations of the 2009 and 2015 versions of the Spanish guidelines for managing asthma (Guía Española para el Manejo del Asma [GEMA]) and the effect of this compliance on controlling the disease.

MATERIAL AND METHODS

We conducted an observational ambispective study between September 2015 and April 2016 in which 314 primary care physicians and 2864 patients participated.

RESULTS

Using retrospective data, we found that 81 of the 314 physicians (25.8%; 95% CI 21.3-30.9) stated that they complied with the GEMA2009 recommendations. At the start of the study, 88 of the 314 physicians (28.0%; 95% CI 23.4-33.2) complied with the GEMA2015 recommendations. Poorly controlled asthma (OR, 0.19; 95% CI 0.13-0.28) and persistent severe asthma at the start of the study (OR, 0.20; 95% CI 0.12-0.34) were negatively associated with having well-controlled asthma by the end of the follow-up. In contrast, compliance with the GEMA2015 recommendations was positively associated with a greater likelihood that the patient would have well-controlled asthma by the end of the follow-up (OR, 1.70; 95% CI 1.40-2.06).

CONCLUSIONS

Low compliance with the clinical guidelines for managing asthma is a common problem among primary care physicians. Compliance with these guidelines is associated with a better asthma control. Actions need to be taken to improve primary care physician compliance with the asthma management guidelines.

Use of Natural Products in Asthma Treatment

Asthma, a disease classified as a chronic inflammatory disorder induced by airway inflammation, is triggered by a genetic predisposition or antigen sensitization. Drugs currently used as therapies present disadvantages such as high cost and side effects, which compromise the treatment compliance. Alternatively, traditional medicine has reported the use of natural products as alternative or complementary treatment. The aim of this review was to summarize the knowledge reported in the literature about the use of natural products for asthma treatment. The search strategy included scientific studies published between January 2006 and December 2017, using the keywords "asthma," "treatment," and "natural products." The inclusion criteria were as follows: (i) studies that aimed at elucidating the antiasthmatic activity of natural-based compounds or extracts using laboratory experiments (in vitro and/or in vivo); and (ii) studies that suggested the use of natural products in asthma treatment by elucidation of its chemical composition. Studies that (i) did not report experimental data and (ii) manuscripts in languages other than English were excluded. Based on the findings from the literature search, aspects related to asthma physiopathology, epidemiology, and conventional treatment were discussed. Then, several studies reporting the effectiveness of natural products in the asthma treatment were presented, highlighting plants as the main source. Moreover, natural products from animals and microorganisms were also discussed and their high potential in the antiasthmatic therapy was emphasized. This review highlighted the importance of natural products as an alternative and/or complementary treatment source for asthma treatment, since they present reduced side effects and comparable effectiveness as the drugs currently used on treatment protocols.

Season of birth, childhood asthma and allergy in a nationwide cohort-Mediation through lower respiratory infections

BACKGROUND

Previous studies have suggested an association between season of birth and risk of childhood asthma and allergic disease. The association may be modified by birth year and region, or mediated by respiratory tract infections.

OBJECTIVE

We aimed to estimate the association between season of birth and risk of childhood asthma/wheeze or allergic rhinoconjunctivitis in a population-based setting, and the mediating effect of lower respiratory infections.

METHODS

Two population-based cohorts were identified from the nationwide Swedish Medical Birth, Patient and Prescribed Drug Registers. The association between birth month/season and asthma/wheeze incidence was analysed using Cox proportional regression in the younger cohort born 2005-2010 (n = 582 494) and asthma/allergic rhinoconjunctivitis prevalence during the 7th year of life using log-binomial models in the older cohort born 2001-2004 (n = 367 583). Interactions were formally tested. Mediation analyses to address the effect of lower respiratory infections were performed in the older cohort using the R package "medflex."

RESULTS

Children born during fall and winter had an increased risk of asthma/wheeze after 2 years of age in the younger cohort: hazard ratio 1.24 (95% confidence interval, CI 1.17, 1.33) for winter and risk of prevalent asthma during their 7th year of life in the older cohort; prevalence ratio (PR) 1.12 (95% CI 1.08, 1.16) for winter. These estimates were partly mediated by lower respiratory infections; the indirect effect for winter compared with summer was PR 1.03 (95% CI 1.03, 1.04). The association was similar for allergic rhinoconjunctivitis in the 7th year of life, but not mediated by respiratory infections.

CONCLUSION

We found that the association between season of birth and risk of childhood asthma/wheeze, but not allergic rhinoconjunctivitis, is partly mediated through lower respiratory infections.

CLINICAL RELEVANCE

This has important implications for patient care, such as asthma management programmes to notify timing of seasonality for viral respiratory tract infections.

Different Policy Measures and Practices between Swedish Counties Influence Market Dynamics: Part 1-Biosimilar and Originator Infliximab in the Hospital Setting

Background

Decentralisation of healthcare budgets and issuance of local guidelines means that the use of biosimilars can vary by region within a particular country, for example between the 21 counties of Sweden.

Objectives

This study aimed to analyse the county-level market dynamics of biosimilar and originator infliximab, which are hospital products, and to examine how local policy measures and practices, in addition to national policy, influenced market dynamics.

Methods

We first conducted a literature review on (biosimilar) policies in Sweden, then analysed market data provided by IQVIA™ on uptake of originator and biosimilar infliximab within the different counties (Q2 2012 to Q4 2017), including discounts from (tender) contracts. Biosimilar market shares were calculated with volume data (measured as defined daily doses [DDDs]). We then discussed our findings in semi-structured interviews with the national pricing and reimbursement agency, key experts within the county councils of Skåne, Västra Götaland, and Stockholm, and an industry representative.

Results

Market shares of biosimilar infliximab vary widely between counties (range 18–96% in 2017). The initial uptake of biosimilar infliximab was slow and variable, with abrupt increments in biosimilar market shares coinciding with expiration of contracts for the originator product. Different approaches taken by counties to achieve a low cost per DDD of infliximab were identified, i.e., a rapid switch to the biosimilar (Skåne), a delayed switch to the biosimilar (Stockholm), or no switch to the biosimilar when a favourable price on the originator product could be obtained (Västra Götaland). Quantitative analysis showed that 59% of the variability in biosimilar market shares could be explained by the relative difference in discounted price between the biosimilar and the originator product. In addition, qualitative analysis indicated the presence of key opinion leaders, local guidelines and initiatives, and whose budget it affects as drivers in the decision-making process.

Conclusions

Variations in the market share of biosimilar infliximab between the Swedish counties is largely explained by the discounted price difference between biosimilar and originator product, and counties used different strategies to leverage such biosimilar competition. Additionally, the presence of key opinion leaders, local guidelines and gainsharing arrangements appeared to play a role in infliximab market dynamics in counties.

The Significance of Asthma Follow-Up Consultations for Adherence to Asthma Medication, Asthma Medication Beliefs, and Asthma Control

Objective. The aim was to investigate adherence to asthma medication treatment, medication beliefs, and asthma control in relation to asthma follow-up consultations in asthmatics in the general population. A further aim was to describe associations between adherence, medication beliefs, and asthma control. Method. In the population-based West Sweden Asthma Study, data allowing calculation of adherence for 4.5 years based on pharmacy records were obtained from 165 adult asthmatics. Additional data were collected through questionnaires and structured interviews. Results. The mean adherence value for filled prescriptions for regular asthma medication was 68% (median 55.3%) but varied over the year under study. Adherence to combination inhalers with corticosteroids and long-acting beta(2) agonists was higher than adherence to single inhalers with corticosteroids only. More than one-third of participants reported not having seen an asthma nurse or physician for several years. Regular asthma follow-up consultations were associated with both higher adherence and the belief that asthma medication was necessary but were not associated with asthma control. Conclusions. Adherence to asthma medication treatment was low and varied over the year under study. The current study suggests that quality improvements in asthma care are needed if adherence to asthma medication is to be improved.

Ever dispense of prescribed allergy medication in children growing up close to traffic: a registry-based birth cohort

Background

Epidemiologic studies have shown conflicting results regarding the role of traffic pollution in the development of allergic disease. This study investigated the relationship between living close to traffic and ever dispense of prescribed oral antihistamines or nasal anti-allergic medication, among young children. The underlying aim was to investigate if children growing up close to traffic pollution are at higher risk of developing allergy in early childhood.

Methods

We investigated a birth cohort in southern Sweden, consisting of N = 26 128 children (0–6 years) with health outcome and exposure data. Of these children, N = 7898, had additional covariate information. Traffic intensity and yearly averages of dispersion-modeled concentrations of NO_X (100 × 100 m grid) at residential addresses, were linked with registry data on dispensed allergy medication (the Swedish Prescribed Drug Register). Individual level covariate information was obtained from questionnaires distributed to parents at Child Health Care-center visits, eight months after birth. Cox proportional hazards regression was used for the statistical analyses.

Results

Living in close proximity to a road with equal to or greater than 8640 cars/day (compared to 0–8639 cars/day), was not associated with higher incidence of ever dispensed oral antihistamine or nasal anti-allergic medication, with or without adjustment for confounders (sex, breastfeeding, parental allergy, parental origin, season, and year of birth). Similar results were found in relation to NO_X.

Conclusions

Traffic-related exposure was not associated with higher incidence of ever dispensed medication against allergy, in children 0–6 years in southern Sweden. These results indicates that traffic-related exposure may not be a risk factor for early onset allergy in children in southern Sweden. However, children with dispense of prescribed allergy medication may be a selected subgroup, and the results for this group may not be generalizable to all children with allergy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2356-3) contains supplementary material, which is available to authorized users.

Prescribing of long-acting beta-2-agonists/inhaled corticosteroids after the SMART trial

Background

After the SMART trial evaluating the safety of salmeterol (long-acting beta-2-agonist (LABA)) in asthma patients, regulatory actions were taken to promote a guideline-adherent prescribing of LABA only to patients receiving inhaled corticosteroids (ICS). We aim to analyse LABA- and ICS-related prescription patterns after the SMART trial in Germany.

Methods

Patients documented in the Bavarian Association of Statutory Health Insurance Physicians database (approximately 10.5 million people) were included if they had a diagnosis of asthma and at least one prescription of LABA and/or ICS between 2004 and 2008. Annual period prevalence rates (PPRs) were estimated and Cochrane Armitage tests were used for time trend analyses.

Results

Highest annual PPRs were found for budesonide and the fixed combination of salmeterol/fluticasone. The proportion of “concomitant LABA and ICS users” increased from 52.0 to 57.6% within the study period, whereas for “LABA users without ICS” a slight decrease from 6.5 to 5.4% was found. In 2008, the proportion of patients with at least one quarter with a LABA prescription without concomitant ICS was highest in elderly, male patients (≈20%). In the majority of these patients, a concomitant diagnosis of COPD (i.e. asthma-COPD overlap syndrome [ACOS]) was present.

Conclusions

Between 2004 and 2008, we found a moderate increase in guideline-adherent LABA prescribing in a representative German population. Elderly men received a significant number of LABA prescriptions without concomitant ICS probably due to ACOS.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0051-x) contains supplementary material, which is available to authorized users.

Factors associated with concordance between parental-reported use and dispensed asthma drugs in adolescents: findings from the BAMSE birth cohort

PURPOSE

Pharmacological treatment is important in asthma care, but there are methodological challenges in measuring how drugs are used by patients. The aim of this study was to investigate the concordance between register data on dispensed drugs and parental-reported use of asthma drugs in adolescents.

METHODS

A cross-sectional study comparing data on dispensed drugs from the Swedish Prescribed Drug Register with data on parental-reported use of asthma drugs among 3 316 adolescents (age 11-14 years) in a population-based birth cohort in Sweden. Sensitivity, specificity, and positive predicted value for different time windows (3, 6, 12, 18, and 24 months) for dispensing in the register were computed. Logistic regression was used to explore factors associated with concordance.

RESULTS

The prevalence of parental-reported use of asthma drugs in the past year was 10.7% (n = 356) compared with 8.1% (n = 269) for dispensed drugs according to the register (p ≤ 0.001). The sensitivity increased with an extended time window in the register, whereas the specificity remained high up to 18 months. Although 90% of the adolescents with asthma had parental-reported use of asthma drugs, 30% of them had no such drugs dispensed in the preceding 18 months. The highest concordance was seen for adolescents with severe asthma (OR 4.6, CI 1.2-17.6).

CONCLUSIONS

An 18-month window is preferable when using dispensing data to study the use of asthma drugs. Still, many adolescents with reported drug use had not purchased any asthma drug in this period. The concordance between parental-reported use and dispensed drugs is higher for adolescents with severe asthma.

Using decision support for population tracking of adherence to recommended asthma guidelines

OBJECTIVE

Decision support systems linked to administrative databases provide a unique opportunity to monitor adherence to guidelines and target disease management strategies towards patients not receiving guideline-based therapy. The objective of this study was to evaluate the discrepancy between actual asthma treatments prescribed by primary care physicians compared to those recommended by evidence-based guidelines using a decision support tool linked to a provincial health administrative database.

DESIGN

The drug and medical services information of individuals with asthma was identified from the provincial health database and was pushed through an asthma decision support system (ADSS). Recommendations aimed at optimising asthma treatment were generated on two index dates, 15 September 2007 (index date 1) and 15 March 2008 (index date 2).

SETTING

Primary care settings in a large Canadian metropolitan area.

PARTICIPANTS

Individuals with asthma and provincial health insurance primary and secondary outcome measures: well controlled asthma.

RESULTS

16 803 eligible individuals were identified on index date 1, and 18 103 on index date 2. The distribution of recommendation categories was similar on both index dates. 94% were classified as well controlled and 7% as not well controlled. Among well-controlled individuals, the largest proportion was in the maintain treatment category (63.8%), followed by the maintain/decrease treatment category (28.2%) and the decrease treatment category (2.7%). Almost all individuals who were not well controlled had the recommendation to increase treatment (88%) with a small proportion in the refer category (1%).

CONCLUSIONS

The ADSS was able to identify subgroups of patients from an administrative database that could benefit from a medication review and possible change. Decision support systems linked to an administrative database can be used to identify individuals with uncontrolled asthma or prescriptions that deviate from recommended treatment. When connected to the point of care, this can provide an opportunity for physicians to intervene early.

Asthma incidence in children growing up close to traffic: a registry-based birth cohort

BACKGROUND

Recent reviews conclude an association between traffic-related pollution and incidence of asthma in children, but not all studies agree. Studies have almost exclusively relied on parental-reported symptoms or parental-reported diagnoses of asthma and wheeze. Our aim was to investigate if traffic exposure is associated with higher incidence of early onset asthma, using registry-based outcome data.

METHODS

We investigated a birth cohort in southern Sweden, consisting of N = 26,128 children with outcome and exposure data (born July 2005-2010). Of these children, N = 7898 had additional covariate information. The cohort was followed to the end of 2011.Traffic intensity, and dispersion-modeled concentrations of NOX (100×100 m grid), at residential addresses, were linked with registry data on dispensed asthma medication (the Swedish Prescribed Drug Register), and hospital and primary health care diagnoses of bronchiolitis, obstructive bronchitis and asthma (The Scania Health Care Register).Covariate information was obtained from questionnaires distributed to parents at Child Health Care-centre visits, eight months after birth. Cox proportional hazards regression was used for the statistical analyses.

RESULTS

Living in close proximity to a road with ≥8640 cars/day (compared to 0-8640 cars/day), was not associated with higher incidence of first purchase of inhaled β2-agonist (adjusted hazard ratio (adj.HR) = 0.9, 95% CI: 0.8-1.0); third year purchase of inhaled β2-agonist (adj.HR = 0.7, 95% CI: 0.6-0.9); bronchiolitis (adj.HR = 0.7, 95% CI: 0.6-0.9), obstructive bronchitis (adj.HR = 1.0, 95% CI: 0.9-1.2), or asthma (adj.HR = 0.7, 95% CI: 0.6- 0.9). Similar results were found for inhaled corticosteroids, and in relation to NOX.

CONCLUSIONS

Traffic-related exposure was not associated with higher incidence of asthma medication, or diagnoses of asthma, bronchiolitis, or obstructive bronchitis, in children 0-6 years in southern Sweden. This may depend on the low levels of traffic pollution in the area, mainly well below the WHO-guideline for NO2.

Socioeconomic status and the quality of prescribing asthma drugs in Sweden

INTRODUCTION

Socioeconomic status (SES) is strongly associated with morbidity as well as with health care utilization and expenditure. The association between SES and quality of prescribing of asthma drugs is less studied.

OBJECTIVES

The aim of this study was to examine the association between socioeconomic factors, i.e. education, income and country of birth, and the prevalence, incidence and adherence to guidelines for antiasthmatic drugs.

METHODS

This registry study includes all Swedish citizens aged 25-44 years who redeemed at least one prescription of an antiasthmatic drug during 2010. Incidence and prevalence was calculated. The adherence to guidelines was studied using two defined quality indicators. Heavy users were also assessed.

RESULTS

Incidence for antiasthmatic drugs was 18.4 per 1000 person-years and the prevalence 50.9 per 1000 inhabitants. Previously untreated patients who redeemed fixed combination ranged from 45% to 49%. Patients who purchase long-acting beta-2-adrenoceptor agonists (LABA) without inhaled corticosteroid ranged from 43% to 59%. Six percent of the population was classified as heavy users.

CONCLUSION

The study showed a high incidence and prevalence of asthma drug use with a poor adherence to guidelines for rational drug prescribing. Fixed combination as first line asthma treatment as well as purchasing LABA without concomitant ICS was more common in patients born outside Scandinavia. Heavy users of short-acting bronchodilators were associated with male sex, high age, low income levels and low levels of education.

Validation of asthma and eczema in population-based Swedish drug and patient registers

PURPOSE

Validated measures of asthma and eczema at the population level remain a challenge. Our aim was to ascertain if register-based information on asthma/eczema medication can function as a proxy for an asthma/eczema diagnosis and to validate register-based asthma diagnoses.

METHODS

Information was requested on all 0-45-year-old individuals with reported asthma/eczema medication and/or diagnoses in the Swedish Prescribed Drug Register and National Patient Register, between July 2005 and December 2009 (N = 250 691). Medical records for 1952 randomly selected individuals were reviewed to estimate the proportion of individuals with the following: (1) asthma/eczema medication that fulfilled predefined criteria of asthma/eczema (positive predictive value (PPV)) and (2) a register-based asthma diagnosis verified as asthma by predefined criteria.

RESULTS

Positive predictive value for asthma by predefined criteria ranged between 0.75 (95%CI: 0.70-0.78) to 0.94 (95%CI: 0.91-0.96), depending on age group. In pre-school children, PPV for asthma in combination with obstructive bronchitis was 0.87 (95%CI: 0.83-0.90), and PPV for eczema was estimated to 0.45 (95%CI: 0.38-0.51). Eighty percent of children 0-4.5 years and 99% of children >4.5-17 years with a register-based diagnosis of asthma were verified as asthmatics.

CONCLUSION

Asthma medication is a suitable proxy for asthma in older children and adults; the same approach is insufficient for eczema. This validation study of two Swedish registers opens for future large nation-wide register-based studies on asthma.

A review of geographic variation and Geographic Information Systems (GIS) applications in prescription drug use research

BACKGROUND

While understanding geography's role in healthcare has been an area of research for over 40 years, the application of geography-based analyses to prescription medication use is limited. The body of literature was reviewed to assess the current state of such studies to demonstrate the scale and scope of projects in order to highlight potential research opportunities.

OBJECTIVE

To review systematically how researchers have applied geography-based analyses to medication use data.

METHODS

Empiric, English language research articles were identified through PubMed and bibliographies. Original research articles were independently reviewed as to the medications or classes studied, data sources, measures of medication exposure, geographic units of analysis, geospatial measures, and statistical approaches.

RESULTS

From 145 publications matching key search terms, forty publications met the inclusion criteria. Cardiovascular and psychotropic classes accounted for the largest proportion of studies. Prescription drug claims were the primary source, and medication exposure was frequently captured as period prevalence. Medication exposure was documented across a variety of geopolitical units such as countries, provinces, regions, states, and postal codes. Most results were descriptive and formal statistical modeling capitalizing on geospatial techniques was rare.

CONCLUSION

Despite the extensive research on small area variation analysis in healthcare, there are a limited number of studies that have examined geographic variation in medication use. Clearly, there is opportunity to collaborate with geographers and GIS professionals to harness the power of GIS technologies and to strengthen future medication studies by applying more robust geospatial statistical methods.

Referral rate to oncologists and its variation by hospital for colorectal cancer patients

BACKGROUND

Recent population-based studies in Alberta, Canada, found that approximately 50% of patients with stage III colon or stages II/III rectal adenocarcinoma did not receive guideline-recommended treatment (surgery plus chemotherapy or chemoradiation); a primary reason was not having an oncologist consult. We assessed the relationship between the hospital where the surgery was performed and the probability of a patient not having an oncologist consult.

METHODS

All patients diagnosed with stage III colon or stage II/III rectal adenocarcinoma between 2002 and 2005 in Alberta who had surgery were identified from the Alberta Cancer Registry and included in the study. Multivariable logistic regression modeling with hospitals as random effects was used to estimate cancer-type-specific odds ratios of not having an oncologist consult for each hospital, adjusted for age, sex, and comorbidities, relative to the overall nonconsultation rate.

RESULTS

Overall, 21% of stage III colon, 25% of stage II rectal, and 13% of stage III rectal adenocarcinoma patients did not have an oncologist consult. Rates varied appreciably across hospitals and between cancer types within hospitals, even after the case-mix adjustment (adjusted odds ratios of nonconsultation ranged from 0.4 to 8.1). Small hospitals that performed 12 or fewer surgeries had nearly 100% consultation rates.

CONCLUSIONS

The variation in oncologist-consult rates, particularly for stage II rectal cancer patients, is concerning. We are presenting the findings to the surgical community and discussing interventions to improve oncologist-consult rates.

[Is "evidence-based medicine" followed by "confidence-based medicine"?]

In an appeal concerning accusations of defamation, the England and Wales Court of Appeal Decisions determined that evidence-based statements are to be judged as opinions and not statements of fact. Since the authors consider it probable that this legal judgment will exert influence on physicians' decisions about the provision of health care services, they have compiled the implications of the judgment and discuss its consequences. The own analyses and considerations lead to the conclusion that confidence-based medicine follows evidence-based medicine. This extension is necessary because evidence-based medicine has not been able to generate the required trust. Therefore, it will be demanded to underpin the existing concept with additional data. These data will be necessary because it is no longer sufficient to convince scientists with data which are obtained under ideal conditions, but to convince critical members of society with additional data which have been obtained under everyday conditions.

Increased use of inhaled corticosteroids among young Danish adult asthmatics: an observational study

OBJECTIVE

This population-based longitudinal study aimed to investigate trends in use of inhaled corticosteroids (ICS) and determinants of ICS use in young Danish adults with asthma.

METHODS

106 757 users, aged 18-44 years, of anti-asthmatic drugs were identified in the Danish Register of Medical Product Statistics during 1997-2006. One year prevalences of ICS use were calculated in categories of gender, age, and annual consumption of inhaled beta-2-agonists (IBA) in defined daily doses (DDD) per year. Determinants of ICS use were estimated by logistic regression models.

RESULTS

The one year prevalence of ICS use was constant, approximately 64%, during 1997-2000. An annual increase was observed from 67% in 2001 to 77% in 2006. This trend also existed when stratifying on gender, age and IBA use. Using 1997 as baseline, the adjusted odds ratios (ORs) of ICS use in 2000 was 0.98 (95% CI 0.96-1.01) compared to 1.12 (95% CI 1.09-1.15) in 2001, and 1.81 (95% CI 1.75-1.87) in 2006. Other determinants of high ICS use were female gender, young age, and high annual IBA consumption. Among those using at least 400 DDD of IBA per year (corresponding to 4.4 powder inhalations daily), nearly 20% had no ICS prescriptions in 2006.

CONCLUSION

Treatment with ICS among young Danish adult asthmatics has increased since 2001. This apparent improvement was associated with the introduction of fixed dose combination inhalers with ICS and inhaled long-acting beta-2-agonists. However, there is still room for improvement.