Primary non-adherence in general practice: a Danish register study

New-generation antidiabetic medications and dementia risk in older adults with type 2 diabetes: A retrospective cohort study

BACKGROUND

New-generation antidiabetic medications may have therapeutic potential for dementia, beyond their glycemic effects. However, information from observational studies exploring the association between new-generation antidiabetic use and dementia risk is limited.

OBJECTIVES

To examine the association between new-generation antidiabetic medication use and dementia risk.

DESIGN

Retrospective cohort study using electronic health records of a large non-profit health maintenance organization.

PARTICIPANTS

84,798 dementia-free individuals aged ≥65y with type 2 diabetes.

MEASUREMENTS

Antidiabetic medication exposure was based on purchased prescriptions and was used as a time-varying variable. Exposure periods were defined as periods in which either dipeptidyl peptidase-4 inhibitors (DPP-4i), sodium-glucose cotransporter-2 inhibitors (SGLT-2i), or glucagon-like peptide-1 analogs (GLP-1a) or their combinations were used, otherwise unexposed. Dementia classification was based on the International Classification of Diseases, Ninth Revision codes or antidementia medication prescriptions. Cox regression models were fitted to quantify the association between antidiabetic medication use and incident dementia. Models were adjusted for 13 potential sources of confounding using inverse-probability weighting.

RESULTS

Among 84,798 individuals with a mean diabetes onset age of 66.4 ± 7.5 years, the median follow-up for dementia risk was 8.7 years (Q1-Q3: 5.4-12.8). Dementia was diagnosed in 11,642 (13.7%) individuals. New-generation medication use was associated with reduced dementia risk (HR = 0.69; 95% CI, 0.66-0.73) and by drug classes (DPP-4i, HR 0.67 [95% CI 0.63-0.71]; SGLT-2i, 0.63 [95% CI 0.56-0.70], GLP-1a, 0.61 [95% CI 0.54-0.69].

CONCLUSIONS

The results of this large-scale study suggest that new-generation antidiabetic medication use may be associated with lower dementia risk in older adults with T2D.

Medication use patterns among older patients in temporary stays in Denmark

PURPOSE

Patients in temporary stays are typically older individuals with frailty and multimorbidity. However, limited knowledge exists about their medication use. This study aimed to describe prescription drug use among patients in temporary stays in Denmark.

METHODS

We conducted a drug utilisation study on 11,424 patients in public healthcare-operated temporary stay units across 14 Danish municipalities between 2016 and 2023 (median age 81 years; 54% women). Prescription data were sourced from the Danish National Prescription Registry.

RESULTS

Patients used a median of six drug classes (interquartile range [IQR] 4-10) in the four months before moving into a temporary stay facility; 68% used ≥ 5 drug classes, and 26% used ≥ 10. The most commonly used drug classes were paracetamol (49%), statins (30%), and proton pump inhibitors (29%). The monthly rate of new drug use increased from 23/100 patients six months before move-in to a peak of 262/100 patients in the first month after move-in, driven primarily by laxatives, analgesics, and antibiotics. High-risk drug use increased from 70 to 83% following move-in, with 49% of patients initiating at least one new high-risk drug, most commonly opioids (28%), potassium (17%), and anticoagulants and platelet inhibitors (15%). General practitioners initiated 60-70% of treatments and maintained 80-90%. Hospital physician prescriptions increased around move-in, peaking at 55% for initiation and 25% for maintenance in the first month after move-in.

CONCLUSION

Patients in temporary stays in Denmark demonstrate high medication use, including high-risk drugs, with a notable increase in treatment initiations around the time of move-in.

General practice variation in peptic ulcer prophylaxis: a nationwide register-based study

BACKGROUND

Incidence of peptic ulcer bleeding can be substantially reduced by prophylactic use of proton pump inhibitors (PPIs) in patients at risk, but use of PPI varies among risk patients, and substantial under-prescribing may exist. The variation in prophylactic prescribing among general practices remains unknown.

METHODS

A nationwide register-based cross-sectional study analyzing the proportion of patients at risk of ulcer bleeding receiving PPI treatment within Danish general practices. Using logistic regression, we analyze associations between general practice characteristics and prophylactic treatment among patients at risk of ulcer bleeding listed with the general practice.

RESULTS

In most general practices, less than 40% of the patients at increased risk of ulcer bleeding were covered by PPI. Geographical variation was present, where practice location outside the capital area was associated with higher odds of PPI coverage among their risk patients. Partnership practices with GPs with a mean age ≥65 years or with only female GPs were associated with higher odds of providing prophylaxis among their risk patients compared to practices with a mean GP age <45 years or with only male GPs. Similar associations were not found for single-handed practices.

CONCLUSIONS

A significant under-prescribing of ulcer prophylaxis is common across all general practice characteristics, and only few associations with practice characteristics were present. Most efforts to rationalize PPI prescribing have aimed at reducing overprescribing but the findings point to under-prescribing as a problem as well. Development of new methods to assist GPs in identifying individuals at risk of ulcer complications is needed.

Clinical effects of accreditation in general practice: a pragmatic randomized controlled study

BACKGROUND

Accreditation has been implemented in general practice in many countries as a tool for quality improvement. Evidence of the effects of accreditation is, however, lacking.

AIM

To investigate the clinical effects of accreditation in general practice.

DESIGN AND SETTING

A mandatory national accreditation programme in Danish general practice was rolled out from 2016 to 2018. General practices were randomized to year of accreditation at the municipality level.

METHODS

We conducted a pragmatic randomized controlled study with general practices randomized to accreditation in 2016 (intervention group) and 2018 (control group). Data on patients enlisted with these practices were collected at baseline in 2014 (before randomization) and at follow-up in 2017. We use linear and logistic regression models to compare differences in changes in outcomes from baseline to follow-up between the intervention and control groups. The primary outcome was the number of redeemed medications. Secondary outcomes were polypharmacy, nonsteroidal anti-inflammatory drugs (NSAIDs) without proton pump inhibitors, sleeping medicine, preventive home visits, annual controls, spirometry tests, and mortality.

RESULTS

We found statistically significant effects of accreditation on the primary outcome, the number of redeemed medications, and the secondary outcome, polypharmacy. No other effects were detected.

CONCLUSION

In this first randomized study exploring the effects of accreditation in a primary care context, accreditation was found to reduce the number of redeemed medications and polypharmacy. We conclude that accreditation can be effective in changing behaviour, but the identified effects are small and limited to certain outcomes. Evaluations on the cost-effectiveness of accreditation are therefore warranted.

Prescription drug use in Danish children and adolescents 2005-2023

Continuous monitoring of pediatric drug utilization is important for ensuring rational use and prioritizing research. This study provides an overview of pediatric prescription drug use among Danish children and adolescents from 2005-2023. Using Danish nationwide individual-level dispensing data, we identified all redeemed prescriptions for individuals < 18 years from January 2005-December 2023. We computed overall annual prevalence proportions of users and mean number of prescriptions per child. For all non-antibiotic drugs, we further determined the quantity of drug use measured in defined daily doses (DDDs) and stratified all analyses by age and Anatomical Therapeutic Chemical classification first and forth level. During the study period, the overall yearly prevalence of prescription drug use decreased due to reductions in antibiotic prescribing. When antibiotic prescriptions were disregarded, the prevalence of children with at least one prescription increased from 38% in 2005 to 42% in 2023, while the mean number of prescriptions and DDDs increased from 1.2 prescriptions per child and 51.2 million DDDs in 2005 to 1.5 prescriptions per child and 76.5 million DDDs in 2023. This increase was primarily driven by prescribing of central nervous system drugs to adolescents 12-17 years, with a substantial increase in centrally acting sympathomimetics and melatonin use. Overall pediatric drug prescribing is decreasing due to reduced antibiotic use. Non-antibiotic drug use is, however, rising, especially among adolescents and notably for psychotropic drugs. These findings underscore the importance of ongoing monitoring and call for further research into underlying causes and prescription practices for psychotropics.

Increasing Medication Use and Polypharmacy in Type 2 Diabetes: The Danish Experience From 2000 to 2020

OBJECTIVE

Type 2 diabetes often coexists with other conditions that are amenable to pharmacological treatment. We hypothesized that polypharmacy among individuals with type 2 diabetes has increased since 2000.

RESEARCH DESIGN AND METHODS

Using Danish national registries, we established a cohort of all Danish individuals (aged ≥18 years) with type 2 diabetes between 2000 and 2020. We analyzed their medication use and prevalence of varying degrees of polypharmacy (≥5 or ≥10 medications), stratifying by age, sex, number of chronic diseases, and socioeconomic status.

RESULTS

The cohort grew from 84,917 patients in 2000 to 307,011 in 2020, totaling 461,849 unique patients. The number of daily medications used per patient increased from (mean ± SD) 3.7 ± 2.8 (in 2000) to 5.3 ± 3.2 (in 2020). The lifetime risk of polypharmacy was substantial, with 89% (n = 409,062 of 461,849) being exposed to ≥5 medications at some point and 47% (n = 217,467 of 461,849) to ≥10 medications. The increases were driven by an expanding group of medications, with analgesics, antihypertensives, proton pump inhibitors, and statins having the largest net increase. Advanced age, male sex, lower socioeconomic status, and Danish ethnicity positively correlated with polypharmacy but could not explain the overall increase in polypharmacy.

CONCLUSIONS

Medication use and polypharmacy have increased among patients with type 2 diabetes. Although the implications and appropriateness of this increased medication use are uncertain, the results stress the increasing need for health care personnel to understand the potential risks associated with polypharmacy, including medication interactions, adverse effects, and over- and underprescribing.

Non-dispensed prescriptions - A nationwide descriptive study

Background

Medication non-adherence is associated with suboptimal health outcomes, higher mortality, and increased healthcare costs.

Objective

The aim of this study was to estimate the number and share of non-dispensed prescriptions at a national level and in specific patient and medicine subgroups.

Methods

The study was a nationwide retrospective register-based study. The data consisted of prescriptions prescribed in Finland in 2020 and dispensed between 2020 and 2022. A prescription was considered non-dispensed if it had not been dispensed within the two-year validity period. For each prescription, information on the patient's birth date, sex, and income as well as details of the prescribed medicine and physician's employment sector (public/private) were collected. Distributions and odds ratios (ORs) with corresponding 95 % confidence intervals (CI) were used in the analyses.

Results

Of the 26 million prescriptions, 13.3 % were never filled. Over 1.7 million people (43.3 % of all people with prescriptions issued in 2020) had at least one non-dispensed prescription. The share of non-dispensed prescriptions was lower in men than women (12.9 % vs. 13.5 %; OR:0.95; CI:0.95-0.95). Compared to the youngest age group, the share of non-dispensed prescriptions was lower in the older age groups. The lowest share of non-dispensed medicines was in antineoplastic and immunomodulating agents (7.8 %) and in cardiovascular system medicines (8.1 %), whereas the highest was in dermatologicals (20.2 %). The proportion of non-dispensed prescriptions varied between medicine groups, from 5 % for thyroid therapy to 38 % for other nervous system drugs. The most frequently non-dispensed medications were paracetamol, ibuprofen, and salbutamol.

Conclusion

The share and number of non-dispensed prescriptions varied across therapeutic areas, medicine groups, active pharmaceutical ingredients, and patient groups. Healthcare professionals should avoid unnecessary prescribing and improve medication adherence to ensure safer and more effective care.

Benzodiazepine use and incident risk of sudden cardiac arrest in patients with cardiovascular diseases

BACKGROUND

Benzodiazepines (BZDs) are commonly prescribed as adjunctive drugs for patients with cardiovascular diseases (CVDs), particularly those who experience anxiety or insomnia. However, the relationship between the use of BZDs and incident risk of sudden cardiac arrest (SCA) has not been well investigated. In this study, we aimed to examine the association between the use of BZDs and the incident risk of SCA among patients with CVD.

METHOD

In this retrospective cohort study, a total of 74,715 eligible patients with new-onset CVD as a primary cause of hospitalization between July 2016 and August 2022 were included from the health information platform in Shenzhen, China. Among them, 61,761 BZD non-initiators were identified and matched to 12,954 BZD initiators by propensity score at a maximum ratio of 5:1. Propensity score-matched Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Over a 12-month follow-up period, 29 (2.24 per 1000 person-years) and 137 (2.22 per 1000 person-years) SCA cases occurred among propensity score-matched BZD initiators and non-initiators, respectively. Patients who initiated BZD treatment were associated with a 101% increased risk of SCA incidence compared with patients without BZD treatment (adjusted HR: 2.01, 95% CI: 1.42, 2.83). Furthermore, compared with the non-use (0 defined daily dose, DDD), the adjusted HR was 1.43 (95% CI: 1.32, 1.56) for the BZD consumption of ≤1 DDD and 2.58 (95% CI: 2.37, 2.81) for the BZD consumption of >1 DDD (P for trend < 0.001) within a 12-month follow-up period.

CONCLUSION

This study provides evidence that BZD initiation may be associated with an increased incident risk of SCA in patients with CVD. Our finding highlights the importance of cautious prescribing BZDs in the health management of patients with CVD.

Methods for pragmatic randomized clinical trials of pain therapies: IMMPACT statement

ABSTRACT

Pragmatic, randomized, controlled trials hold the potential to directly inform clinical decision making and health policy regarding the treatment of people experiencing pain. Pragmatic trials are designed to replicate or are embedded within routine clinical care and are increasingly valued to bridge the gap between trial research and clinical practice, especially in multidimensional conditions, such as pain and in nonpharmacological intervention research. To maximize the potential of pragmatic trials in pain research, the careful consideration of each methodological decision is required. Trials aligned with routine practice pose several challenges, such as determining and enrolling appropriate study participants, deciding on the appropriate level of flexibility in treatment delivery, integrating information on concomitant treatments and adherence, and choosing comparator conditions and outcome measures. Ensuring data quality in real-world clinical settings is another challenging goal. Furthermore, current trials in the field would benefit from analysis methods that allow for a differentiated understanding of effects across patient subgroups and improved reporting of methods and context, which is required to assess the generalizability of findings. At the same time, a range of novel methodological approaches provide opportunities for enhanced efficiency and relevance of pragmatic trials to stakeholders and clinical decision making. In this study, best-practice considerations for these and other concerns in pragmatic trials of pain treatments are offered and a number of promising solutions discussed. The basis of these recommendations was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks.

Continuity of medication information transfer and continuous medication supply during hospital-to-home transitions - nationwide surveys in hospital and community pharmacies after implementing new legal requirements in Germany

BACKGROUND

While successful information transfer and seamless medication supply are fundamental to medication safety during hospital-to-home transitions, disruptions are frequently reported. In Germany, new legal requirements came into force in 2017, strengthening medication lists and discharge summaries as preferred means of information transfer. In addition to previous regulations - such as dispensing medication at discharge by hospital pharmacies - hospital physicians were now allowed to issue discharge prescriptions to be supplied by community pharmacies. The aim of this survey study was to gain first nationwide insights into how these requirements are implemented and how they impact the continuity of medication information transfer and continuous medication supply.

METHODS

Two nationwide self-administered online surveys of all hospital and community pharmacies across Germany were developed and conducted from April 17th to June 30th, 2023.

RESULTS

Overall, 31.0% (n = 111) of all German hospital pharmacies and 4.5% (n = 811) of all community pharmacies participated. The majority of those hospital pharmacies reported that patients who were discharged were typically provided with discharge summaries (89.2%), medication lists (59.5%) and if needed, discharge prescriptions (67.6%) and/or required medication (67.6%). About every second community pharmacy (49.0%) indicated that up to half of the recently discharged patients who came to their pharmacy typically presented medication lists. 34.0% of the community pharmacies stated that they typically received a discharge summary from recently discharged patients at least once per week. About three in four community pharmacies (73.3%) indicated that most discharge prescriptions were dispensed in time. However, one-third (31.0%) estimated that half and more of the patients experienced gaps in medication supply. Community pharmacies reported challenges with the legal requirements - such as patients´ poor comprehensibility of medication lists, medication discrepancies, unmet formal requirements of discharge prescriptions, and poor accessibility of hospital staff in case of queries. In comparison, hospital pharmacies named technical issues, time/personnel resources, and deficits in patient knowledge of medication as difficulties.

CONCLUSION

According to the pharmacies´ perceptions, it can be assumed that discontinuation in medication information transfer and lack of medication supply still occur today during hospital-to-home transitions, despite the new legal requirements. Further research is necessary to supplement these results by the perspectives of other healthcare professionals and patients in order to identify efficient strategies.

Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy

Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.

Any infection among patients with hip fracture: Predictive ability of Charlson, Elixhauser, Rx-Risk, and Nordic comorbidity indices

BACKGROUND

In studies on infection after hip fracture surgery, a common and serious complication, it remains unknown which comorbidity index is best for case-mix confounder adjustment. We evaluated the predictive ability of Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Rx-Risk Index (Rx-Risk), and Nordic Multimorbidity Index (NMI) for any infection up to 1 year from discharge after hip fracture surgery.

METHODS

Using Danish medical registries, we included 92,600 patients (mean age 83 years) surgically treated for hip fracture between 2004 and 2018. Comorbidity-index scores were calculated using prevalence of diagnosis codes, prescription codes, or both. Lookback periods of 1, 5, and 10 years were applied. Logistic regression was used to calculate c-index to assess discrimination of comorbidity indices individually and in combination with a base model of age and sex. Outcome was any infection (not only surgical site infection) in-hospital and 1 year after discharge.

RESULTS

At 10-year lookback period, the c-index for individual comorbidity indices for in-hospital infections varied from 0.53 to 0.56, similar to base model alone (0.56). The predictive ability of comorbidity indices in combination with base model varied from 0.56 to 0.57. Within 1 year after discharge, NMI in combination with base model had best predictive ability for infection (c-index = 0.62), followed by CCI and ECI (c-index = 0.60) and Rx-Risk (c-index = 0.58). Discrimination was similar for all lookback periods.

CONCLUSIONS

Comorbidity indices have low predictive ability for any infection up to 1 year after hip fracture surgery, similar to that of age and sex alone. For case-mix adjustment, evaluated comorbidity indices are of equal value.

Costs of medications used to treat inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), mainly Crohn's disease (CD) and ulcerative colitis (UC) are chronic diseases causing a lifelong burden and often need sustained treatment throughout a patient's life. Both the incidence and prevalence of IBD has increased in the last decade. Evidence showing the drug costs to IBD patients in Finland is limited. No earlier study has evaluated the drug costs of IBD patients in Finland. Here, we thoroughly assessed these costs.

METHODS

A structured questionnaire, hospital records and national registers were combined to comprehensively assess the actual costs of drug purchases made by IBD patients. The study sample comprised 561 patients.

RESULTS

Total annual mean drug costs were 1428€ per patient. CD patients had higher annual costs than UC patients at 2369€ and 902€, respectively. CD patients also had higher costs in the immunosuppressant, corticosteroid, and biologic subgroup analyses. In addition, C-reactive protein, serum albumin and fecal calprotectin levels had a correlation with costs if the patient had needed corticosteroids. In addition, women reported having a worse quality of life (QoL) but had lower total costs.

CONCLUSIONS

Pharmaceutical drugs are major factors that affect the costs of IBD treatment, and the increased use of biologics has raised these costs.

Real-World Evidence on Clinical Outcomes of Commonly Used Antidepressants in Older Adults Initiating Antidepressants for Depression: A Nationwide Cohort Study in Denmark

OBJECTIVE

The authors investigated the clinical outcomes of commonly used antidepressants among older adults who initiated first-time antidepressants for depression by analyzing the 1-year risk of selected clinically relevant outcomes.

METHODS

This cohort study used nationwide Danish registry data and included all older adults who redeemed a first-time (since 1995) antidepressant prescription with an indication of depression between 2006 and 2017. Only the 10 most frequently redeemed antidepressants were included in the analyses. Outcomes included discontinuation, switching, augmentation, psychiatric hospital contacts, suicide attempt or self-harm, fall-related injuries, cardiovascular events, and all-cause mortality. Incidence rate ratios (IRRs) and 95% confidence intervals were estimated using Poisson regression models, controlling for potential confounders.

RESULTS

The study sample included 93,883 older adults (mean age, 78.0 years, SD=7.5 years; 56% female). The most frequently prescribed antidepressants were selective serotonin reuptake inhibitors (citalopram, 47.04%; escitalopram, 11.81%; fluoxetine, 0.55%; paroxetine, 0.52%; sertraline, 11.17%), serotonin-norepinephrine reuptake inhibitors (duloxetine, 0.71%; venlafaxine, 1.54%), a tricyclic antidepressant (amitriptyline, 1.86%), and two atypical antidepressants (mianserin, 1.93%; mirtazapine, 22.87%). Compared with users of sertraline (the reference drug in this analysis, as Danish guidelines recommend it as the first-choice treatment for depression), users of most of the other nine antidepressants had a significantly higher risk of discontinuation (e.g., mirtazapine: IRR=1.55, 95% CI=1.50-1.61; venlafaxine: IRR=1.22, 95% CI=1.12-1.32), switching (amitriptyline: IRR=1.45, 95% CI=1.15-1.81; venlafaxine: IRR=1.47, 95% CI=1.20-1.80), augmentation, cardiovascular events, and mortality. Overall, mirtazapine and venlafaxine users had the most adverse outcomes compared with sertraline users. These results remained consistent in analyses stratified by sex and age (≤75 years vs. >75 years).

CONCLUSIONS

This real-world evidence suggests that clinical outcomes may vary among initiators of commonly used antidepressants in older adults, which may inform benefit-risk evaluation at treatment initiation, and highlights the importance of careful selection of antidepressant treatment.

Methodological Considerations for Describing Medication Changes in Relation to Clinical Events and Death: An Applied Example in Patients with Type 2 Diabetes and Cancer

INTRODUCTION

Certain clinical events reduce life expectancy and necessitate a reassessment of patient treatment.

OBJECTIVE

To describe medication changes in relation to a cancer diagnosis and the end of life and to highlight challenges and limitations with such descriptions.

METHODS

From a cohort with all Danish patients with type 2 diabetes, we matched patients with incident cancer during 2000-2021 (n = 41,745) with patients without cancer (n = 166,994) using propensity scores. We described their medication usage from cancer diagnosis until death.

RESULTS

The 1- and 5-year mortality were 51% and 86%, respectively, in the cancer group, and 13% and 59% in the non-cancer group. In relation to cancer diagnosis and death, the use of symptomatic medications (e.g., opioids, benzodiazepines) increased (10-60 incident medications per 100 patient-months), and the use of preventive medications (e.g., antihypertensives, statins) decreased (5-30% fewer users). The changes in relation to the diagnosis were driven by patients with short observed lengths of survival (< 2 years). In contrast, changes occurring within a year before death were less dependent on survival strata, and > 60% used preventive medications in their last months.

CONCLUSIONS

Medication changes in relation to a cancer diagnosis were frequent and correlated to the length of survival. The results showcase the challenges and limited clinical utility of anchoring analyses on events or death. While the former diluted the results by averaging changes across patients with vastly different clinical courses, the latter leveraged information unavailable to the treating clinicians. While medication changes were common near death, preventive medications were often used until death.

Use of antipsychotics and antidepressants in first-episode psychotic depression: A nationwide register-based study

BACKGROUND

According to guidelines, psychotic depression should be treated with both antipsychotics and antidepressants, but current practice is largely unknown. We investigated the prevalence of antipsychotic and antidepressant use in first-episode psychotic depression and factors related to antipsychotic use after the diagnosis.

METHODS

We identified individuals aged 16-65 with a first-episode diagnosis of psychotic depression (ICD-10 codes F32.3, F33.3) from nationwide data linkage of Finnish healthcare and population registers during 2000-2018. Point prevalence was measured as 2-week time windows every 3 months, investigating whether the individual had a modeled drug use period ongoing during the window or not, censoring to death and end of data linkage.

RESULTS

The study population included 18,490 individuals (58.0% women; mean age 39.9 years, standard deviation 14.7). The prevalence of use for antidepressants (75.0%), antipsychotics (56.4%), and both (50.0%) were highest at 3 months after the diagnosis. The prevalence declined to 51.8%, 34.1%, and 28.7%, respectively, at 3 years after the diagnosis. In a logistic regression analysis, younger age (adjusted odds ratio < 25 vs. ≥55, 0.82 [95% confidence interval 0.73-0.91]), eating disorders (0.78 [0.66-0.92]), substance use disorders (0.80 [0.73-0.87]), and occupational inactivity (0.80 [0.73-0.87]) were associated with decreased odds of using antipsychotics at 3 months after diagnosis. Increased odds were found for diagnosis from inpatient care (1.74 [1.62-1.86]), and later year of cohort entry (2010-2014 vs. 2000-2004, 1.56 [1.42-1.70]).

CONCLUSION

At most, half of the individuals with newly diagnosed psychotic depression used both antidepressants and antipsychotics. This likely has a negative impact on treatment success.

Melatonin use among children, adolescents, and young adults: a Danish nationwide drug utilization study

We aimed to provide a detailed description of the use of melatonin in Danish children, adolescents, and young adults during 2012-2019. We identified melatonin users 0-24 years of age (n = 43,652; median age 16 years) via the Danish nationwide health registers. Melatonin is a prescription drug in Denmark. The incidence of melatonin use increased from 2.4 to 3.9/1000 person-years during 2012 to 2019. Among 6,557 incident users in 2019, 53% filled only a single prescription within the first 6 months. Long-term use was most common among the younger age groups, with 17% of 5-9-year-olds and 14% of 10-13-year-olds being in continued treatment (no treatment breaks) 12 months after their first melatonin prescription. Disregarding treatment breaks, 3 in 10 were using melatonin 12 months after their first melatonin prescription and this proportion was also highest among 5-9-year-olds (63%) and 10-13-year-olds (51%). Psychopathology was common among melatonin users with 75% registered with either a psychiatric disorder diagnosis (54%), a filled prescription for another psychotropic (58%), or a contact to a private practice psychiatrist (15%) within ± 12 months of treatment initiation. General practitioners authorized melatonin prescriptions to almost half of all new users (48%), while psychiatric specialists authorized 37% of first prescriptions. In conclusion, the incidence of melatonin use increased in Denmark from 2012 to 2019. A substantial proportion of users had concurrent psychopathology most likely explaining their use of melatonin. Long-term melatonin use was more common among the youngest age groups, which should be a focus of interest due to limited safety data.

Methods to assess COPD medications adherence in healthcare databases: a systematic review

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease 2023 report recommends medication adherence assessment in COPD as an action item. Healthcare databases provide opportunities for objective assessments; however, multiple methods exist. We aimed to systematically review the literature to describe existing methods to assess adherence in COPD in healthcare databases and to evaluate the reporting of influencing variables.

METHOD

We searched MEDLINE, Web of Science and Embase for peer-reviewed articles evaluating adherence to COPD medication in electronic databases, written in English, published up to 11 October 2022 (PROSPERO identifier CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. Methods to assess initiation (dispensing of medication after prescribing), implementation (extent of use over a specific time period) and/or persistence (time from initiation to discontinuation) were listed descriptively. Each included study was evaluated for reporting variables with an impact on adherence assessment: inpatient stays, drug substitution, dose switching and early refills.

RESULTS

160 studies were included, of which four assessed initiation, 135 implementation and 45 persistence. Overall, one method was used to measure initiation, 43 methods for implementation and seven methods for persistence. Most of the included implementation studies reported medication possession ratio, proportion of days covered and/or an alteration of these methods. Only 11% of the included studies mentioned the potential impact of the evaluated variables.

CONCLUSION

Variations in adherence assessment methods are common. Attention to transparency, reporting of variables with an impact on adherence assessment and rationale for choosing an adherence cut-off or treatment gap is recommended.

Ranitidine Use and Incident Cancer in a Multinational Cohort

Importance

Ranitidine, the most widely used histamine-2 receptor antagonist (H2RA), was withdrawn because of N-nitrosodimethylamine impurity in 2020. Given the worldwide exposure to this drug, the potential risk of cancer development associated with the intake of known carcinogens is an important epidemiological concern.

Objective

To examine the comparative risk of cancer associated with the use of ranitidine vs other H2RAs.

Design, Setting, and Participants

This new-user active comparator international network cohort study was conducted using 3 health claims and 9 electronic health record databases from the US, the United Kingdom, Germany, Spain, France, South Korea, and Taiwan. Large-scale propensity score (PS) matching was used to minimize confounding of the observed covariates with negative control outcomes. Empirical calibration was performed to account for unobserved confounding. All databases were mapped to a common data model. Database-specific estimates were combined using random-effects meta-analysis. Participants included individuals aged at least 20 years with no history of cancer who used H2RAs for more than 30 days from January 1986 to December 2020, with a 1-year washout period. Data were analyzed from April to September 2021.

Exposure

The main exposure was use of ranitidine vs other H2RAs (famotidine, lafutidine, nizatidine, and roxatidine).

Main Outcomes and Measures

The primary outcome was incidence of any cancer, except nonmelanoma skin cancer. Secondary outcomes included all cancer except thyroid cancer, 16 cancer subtypes, and all-cause mortality.

Results

Among 1 183 999 individuals in 11 databases, 909 168 individuals (mean age, 56.1 years; 507 316 [55.8%] women) were identified as new users of ranitidine, and 274 831 individuals (mean age, 58.0 years; 145 935 [53.1%] women) were identified as new users of other H2RAs. Crude incidence rates of cancer were 14.30 events per 1000 person-years (PYs) in ranitidine users and 15.03 events per 1000 PYs among other H2RA users. After PS matching, cancer risk was similar in ranitidine compared with other H2RA users (incidence, 15.92 events per 1000 PYs vs 15.65 events per 1000 PYs; calibrated meta-analytic hazard ratio, 1.04; 95% CI, 0.97-1.12). No significant associations were found between ranitidine use and any secondary outcomes after calibration.

Conclusions and Relevance

In this cohort study, ranitidine use was not associated with an increased risk of cancer compared with the use of other H2RAs. Further research is needed on the long-term association of ranitidine with cancer development.

Handling polypharmacy -a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals

BACKGROUND

On average, older patients use five or more medications daily. A consequence is an increased risk of adverse drug reactions, interactions, or medication errors. Therefore, it is important to understand the challenges experienced by the patients, relatives, and healthcare professionals pertinent to the concomitant use of many drugs.

METHODS

We conducted a qualitative study using focus group interviews to collect information from patients, relatives, and healthcare professionals regarding older patients' management of prescribed medicine. We interviewed seven patients using five or more medications daily, three relatives, three general practitioners, nine nurses from different healthcare sectors, one home care assistant, two hospital physicians, and four pharmacists.

RESULTS

The following themes were identified: (1) Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/pill organizers.

CONCLUSION

Medication is the subject of concern among patients and relatives. They become confused and insecure about information from different actors and the package leaflets. Therefore, patients often request a thorough medication review to provide an overview, knowledge of possible side effects and interactions, and a clarification of the medication's timing. In addition, patients, relatives and nurses all request an indication of when medicine should be taken, including allowable deviations from this timing. Therefore, prescribing physicians should prioritize communicating information regarding these matters when prescribing.

Maternal and Early-Life Exposure to Antibiotics and the Risk of Autism and Attention-Deficit Hyperactivity Disorder in Childhood: a Swedish Population-Based Cohort Study

INTRODUCTION

Antibiotics represent the most common type of medication used during pregnancy and infancy. Antibiotics have been proposed as a possible factor in changes in microbiota composition, which may play a role in the aetiology of autism and attention deficit/hyperactivity disorder (ADHD). Our aim was to investigate the association between maternal and early-life antibiotic use and autism and ADHD in childhood.

METHODS

This Swedish nation-wide population-based cohort study included all first live singleton births (N = 483,459) between January 2006 and December 2016. The association of dispensed antibiotics with autism and ADHD in children aged ≤ 11 years was estimated by applying multivariable logistic regression and generalised estimating equations models.

RESULTS

Of the mothers, 25.9% (n = 125,106) were dispensed ≥1 antibiotic during the exposure period (from 3 months pre-conception to delivery), and 41.6% (n = 201,040) of the children received ≥ 1 antibiotic in early life (aged ≤ 2 years). Penicillin was the most prescribed antibiotic class (17.9% of mothers, 38.2% of children). Maternal antibiotic use was associated with an increased risk of autism [odds ratio (OR) = 1.16, 95% confidence interval (CI) 1.09-1.23] and ADHD (OR = 1.29, 95% CI 1.21-1.36) in childhood. Early-life exposure to antibiotics showed an even stronger association [autism (OR = 1.46, 95% CI 1.38-1.55); ADHD (OR = 1.90, 95% CI 1.80-2.00)]. Both maternal and childhood-exposure sub-analyses suggested a dose-response relationship.

CONCLUSION

Maternal and early-life antibiotic use was associated with an increased risk of autism and ADHD in childhood. However, differences were noted by exposure period and antibiotic classes.

Surgical-site infection is associated with increased risk of breast cancer-related lymphedema: A nationwide cohort study

BACKGROUND

Surgical-site infection (SSI) is one of the most common short-term complications following breast cancer treatment and can inhibit lymphatic drainage. It is currently not known whether SSI increases the risk of long-term breast cancer-related lymphedema (BCRL). Thus, the objective of this study was to examine the association between surgical-site infection and the risk of BCRL METHODS: This nationwide study identified all patients treated for unilateral, primary invasive, nonmetastatic breast cancer in Denmark between January 1, 2007, and December 31, 2016 (n = 37,937). A redemption of antibiotics after breast cancer treatment was used as a disease proxy for SSI, included as a time-varying exposure. The risk of BCRL was analyzed up to 3 years after breast cancer treatment using multivariate Cox regression and adjusted for cancer treatment, demographics, comorbidities, and socioeconomic variables.

RESULTS

There were 10,368 (27.33%) patients with a SSI and 27,569 (72.67%) without a SSI (incidence rate per 100 patients, 33.10 (95%CI, 32.47-33.75). The BCRL incidence rate per 100 person-years for patients with SSI was 6.72 (95%CI: 6.41-7.05) and 4.86 (95%CI: 4.70-5.02) for patients without an SSI. There was an overall significant increased risk of BCRL in patients with an SSI (adjusted HR, 1.11; 95%CI: 1.04-1.17), with the highest risk 3 years after breast cancer treatment (adjusted HR, 1.28; 95%CI: 1.08-1.51) CONCLUSION: This large nationwide cohort study showed that SSI was associated with an overall 10% increased risk of BCRL. These findings may be used to identify patients at high risk of BCRL that would benefit from enhanced BCRL surveillance.

Association of anticholinergic drug use with postoperative mortality among patients with hip fracture. A nationwide cohort study

PURPOSE

Anticholinergic (AC) drugs are associated with various determinantal outcomes. Data regarding the effect of AC drugs on mortality among geriatric hip fracture patients are limited and inconsistent.

METHODS

Using Danish health registries, we identified 31,443 patients aged ≥65 years undergoing hip fracture surgery. AC burden was assessed 90 days before surgery by the Anticholinergic Cognitive Burden (ACB) score and number of AC drugs. Logistic and Cox regression producing odds ratios (OR) and hazard ratios (HR) for 30- and 365- day mortality, adjusting for age, sex, and comorbidities were computed.

RESULTS

AC drugs were redeemed by 42% of patients. The 30-day mortality increased from 7% for patients with ACB score of 0 to 16% for patients with ACB score of ≥5, corresponding to an adjusted OR 2.5 (CI: 2.0-3.1). The equivalent adjusted HR for 365-mortality was 1.9 (CI: 1.6-2.1). Using count of AC drugs as exposure we found a stepwise increase in ORs and HRs with increased number of AC drugs; Compared to non-users, adjusted ORs for 30-days mortality were 1.6 (CI: 1.4-1.7), 1.9 (CI: 1.7-2.1), and 2.3 (CI: 1.9-2.7) for users of 1, 2 and 3+ AC drugs. HRs for 365-day mortality were 1.4 (CI: 1.3-1.5), 1.6 (CI: 1.5-1.7) and 1.8 (CI: 1.7-2.0).

CONCLUSION

Use of AC drugs was associated with increased 30-day and 365-day mortality among older adults with hip fracture. Simply counting the number of AC drugs may be a clinically relevant and easy AC risk assessment tool. Continued effort to reduce AC drug-use is relevant.

Concurrent use of polypharmacy and potentially inappropriate medications with antidepressants in older adults: A nationwide descriptive study in Denmark during 2015-2019

OBJECTIVE

Concurrent polypharmacy and potentially-inappropriate-medication (PIMs) use with antidepressants in older adults is understudied. We investigated the prevalence and associated user characteristics of concurrent polypharmacy (≥5 drugs) and PIMs with antidepressants in all older adults (≥65 years) in Denmark based on prescriptions filled at community pharmacies during 2015-2019.

METHOD

We applied a cross-sectional and cohort study design using socio-demographic and clinical data from Danish registers.

RESULTS

A total of 261,479 older adults (mean age 76 years, females 63%) redeemed at least one prescription of antidepressants during 2015-2019. The prevalence of polypharmacy was 73%, and PIMs was 56%, with over 80% using at least one other nervous system drug or cardiovascular system drug concomitantly with antidepressants. Characteristics associated with higher concurrent use of polypharmacy and PIM with antidepressants were older age, marital status as widow/widower/separated/single, place of residence predominantly in the rural regions, non-western origin, and having somatic diagnoses. Some characteristics showed opposite directions of the associations with the two outcomes, including previous antidepressant use and psychiatric diagnoses being associated with higher use of polypharmacy but lower use of PIM.

CONCLUSION

High polypharmacy and PIM use with antidepressants underline the importance of regularly reviewing pharmacological treatments in older adults with depression.

Electrocardiographic P terminal force in lead V1, its components, and the association with stroke and atrial fibrillation or flutter

BACKGROUND

The electrocardiographic (ECG) marker P terminal force V1 (PTFV1) is generally perceived as a marker of left atrial pathology and has been associated with atrial fibrillation or flutter (AF).

OBJECTIVE

The purpose of this study was to determine the association between PTFV1 components (duration and amplitude) and incident AF and stroke/transient ischemic attack (TIA).

METHODS

The study included patients with an ECG recorded at the Copenhagen General Practitioners Laboratory in 2001 to 2011. PTFV1 ≥4 mV·ms was considered abnormal. Patients with abnormal PTFV1 were stratified into tertiles based on duration (PTDV1) and amplitude (PTAV1) values. Cox regressions adjusted for age, sex, and relevant comorbidities were used to investigate associations between abnormal PTFV1 components and AF and stroke/TIA.

RESULTS

Of 267,636 patients, 5803 had AF and 18,176 had stroke/TIA (follow-up 6.5 years). Abnormal PTFV1 was present in 44,549 subjects (16.7%) and was associated with an increased risk of AF and stroke/TIA. Among patients with abnormal PTFV1, the highest tertile of PTDV1 (78-97 ms) was associated with the highest risk of AF (hazard ratio [HR] 1.37; 95% confidence interval [CI] 1.23-1.52) and highest risk of stroke/TIA (HR 1.13; 95% CI 1.05 -1.20). For PTAV1, the highest tertile (78-126 μV) conferred the highest risk of AF and stroke/TIA (HR 1.20; 95% CI 1.09-1.32; and HR 1.21; 95% CI 1.14-1.25, respectively).

CONCLUSION

Abnormal PTFV1 was associated with an increased risk of AF and stroke/TIA. Increasing PTDV1 showed a dose-response relationship with the development of AF and stroke/TIA, whereas the association between PTAV1 and AF was less apparent.

Utilization of antidepressants, anxiolytics, and hypnotics during the COVID-19 pandemic in Scandinavia

OBJECTIVE

To study patterns of antidepressant, anxiolytic, and hypnotic drug utilization in Denmark, Norway, and Sweden during the first year of the COVID-19 pandemic.

METHODS

The monthly observed number of prescription fills of antidepressants, benzodiazepines and benzodiazepine-related hypnotics (BZ), and other anxiolytics and hypnotics (OAH) per population in 2020 were compared with predicted numbers based on analysis of covariance of prescription fills during 2015-2019.

RESULTS

In March 2020, there was an increased number of prescription fills for antidepressants, anxiolytics, and hypnotics in youths and adults aged 20-59 years in Denmark, Norway, and Sweden. Antidepressant prescription fills increased between 13.5 % and 31.3 % at the end of 2020 in all age groups in Denmark and 17.4 % in youths in Norway. BZ drug prescription fills increased by 20.8 % at the end of 2020 in the 20-59 year age group in Denmark and decreased by 16.7 % in youths in Sweden. A general increase of prescription fills of OAH at the end of 2020 was observed in all countries (range 24.0-80.0 % in Denmark, 11.5-30.8 % in Norway, and 9.1-12.1 % in Sweden). Increases of prescription fills of OAH occurred earlier in Denmark.

LIMITATIONS

Aggregated data with lack of information on indications.

CONCLUSIONS

Peaks of utilization of antidepressants, anxiolytics, and hypnotics observed in March 2020 may reflect medication stock piling. Increased antidepressant drug utilization in Denmark and in Norwegian youths together with the general increase in OAH utilization in the Scandinavian countries in late 2020 may indicate an increase of symptoms of depression and anxiety, as well as disturbed sleep.

Utilization patterns and factors associated with persistence of new users of anti-osteoporosis treatment in Denmark: a population-based cohort study

Persistence with initial treatment was highest after 1 year, decreasing afterwards. Persistence was highest for denosumab followed by alendronate. We identified several factors associated with treatment persistence, some of which were the same irrespective of OTx agent, which could help target subgroups of patients in terms of social and healthcare support.

PURPOSE

To describe patient characteristics, persistence, and factors associated with the persistence of new users of the bisphosphonates (alendronate, risedronate, and ibandronate) and the RANKL inhibitor denosumab in Denmark.

METHODS

A population-based cohort study using health registries (2010-2018). We included alendronate (n = 128,590), risedronate (n = 892), ibandronate (n = 5,855), and denosumab (n = 16,469) users, aged ≥ 50 years.

RESULTS

The 1-year persistence was 68.2% in the alendronate cohort; 39.3% in the risedronate cohort; 56.3% in the ibandronate cohort; and 84.0% in the denosumab cohort. The 2-year persistence was 58.7% in the alendronate cohort; 28.0% in the risedronate cohort; 42.9% in the ibandronate cohort; and 71.9% in the denosumab cohort. The 4-year persistence was 46.3%, 15.4%, 29.6%, and 56.9%, respectively. Later years of treatment initiation were associated with lower persistence for alendronate (adjusted odds ratio (OR) with 95% CI was 0.86 (0.81-0.91) in 2016 compared to 2010), but not for risedronate (OR was 1.56 (0.60-4.06), ibandronate (OR was 0.92 (0.71-1.19) or denosumab (OR was 1.11 (0.87-1.43). Older age was associated with higher persistence for all medications and the same goes for the female sex except for ibandronate. Dementia was associated with higher persistence for alendronate but not denosumab, whereas prior osteoporosis treatment (OT) was the opposite. Several comorbidities were associated with lower persistence for alendronate, but not denosumab.

CONCLUSION

Persistence was highest for denosumab followed by alendronate. We identified several factors associated with treatment persistence, some of which were the same irrespective of OTx agent, which could help target subgroups of patients in terms of social and healthcare support.

Utilization of remote e-prescription (Anat) in Saudi Arabia during COVID-19: Factors associated with primary adherence and antibiotic prescription

Background

The COVID-19 pandemic has affected healthcare systems globally. Various health care technologies have been used to mitigate the risk of disease transmission. Telemedicine is one such technology, and remote consulting and prescribing comprise one of its key aspects. In Saudi Arabia, telephone health services have been widely used through the free Medical Consultation Call Center (937). This platform facilitates medical consultations for all citizens, residents, and visitors. After consultations, healthcare providers are able to issue authenticated e-prescriptions using the Anat platform.

Objectives

To explore the utilization of the Anat remote prescription system in Saudi Arabia during the COVID-19 pandemic and to identify the factors associated with antibiotic prescription and primary medication adherence.

Methods

This retrospective analysis included data from the Anat e‑prescription system using a stratified random sample of 25000 prescriptions issued in Saudi Arabia in 2020. Predictive factors related to the patients, practitioners, and prescriptions were identified through bivariate and multivariate logistic regression analyses.

Results

Out of 25,000 e-prescriptions, 8885 were dispensed, resulting in a 35.5% primary medication adherence rate. The significant predictors of primary adherence were children, respiratory diseases, and antibacterial drugs. In addition, antibiotics made up 32.1% of the e-prescriptions. The prescription of antibiotics was significantly associated with male sex, children, genitourinary system diseases, and being treated by radiologists.

Conclusions

Almost two thirds 62.2% of e-prescriptions were undispensed, with antibiotic eprescriptions at 32.1%. Findings emphasize the need to enhance primary medication adherence and antibiotic prescription interventions. These findings could aid decision-makers in improving patient-centered e-prescribing practices.

Hamid AB. Strategies to improve patient loyalty and medication adherence in Syrian healthcare setting: The mediating role of patient satisfaction

The purpose of this study is to empirically examine the relationships between service quality, patient satisfaction, patient loyalty and medication adherence in the Syrian healthcare setting from a patient's perspective. Based on random sampling technique, data collection was conducted in six hospitals located in the Syrian capital Damascus. The reliability and validity of the theoretical model had been confirmed using quantitative analyses SmartPLS software. The study indicated that our proposed model can significantly explain (35) per cent of patient satisfaction, (55) per cent of patient loyalty and (46) per cent medication adherence in a statistically manner. Our results highlighted that patient satisfaction mediated the relationship between patient loyalty and service quality (assurance, reliability and financial aspect). Besides, patient satisfaction had mediation effect on the relationship between medication adherence and service quality (reliability and financial aspect). Financial aspect had the highest impact on patient satisfaction (β = 0.242) and medication adherence (β = 0.302). In addition, reliability was the only dimension of service quality that had a significant direct impact on patient satisfaction, patient loyalty and medication adherence. To increase patient loyalty in Syrian hospitals, healthcare professionals should place a greater emphasis on the reliability and responsiveness elements of service quality. To the author's knowledge, this is the first study conducted during the COVID pandemic to evaluate the mediating role of patient satisfaction in the relationship between service quality, patient loyalty and medication adherence in the Syrian healthcare sector.

Prevalence and factors associated with polypharmacy: a systematic review and Meta-analysis

Introduction

Polypharmacy is commonly associated with adverse health outcomes. There are currently no meta-analyses of the prevalence of polypharmacy or factors associated with polypharmacy. We aimed to estimate the pooled prevalence of polypharmacy and factors associated with polypharmacy in a systematic review and meta-analysis.

Methods

MEDLINE, EMBASE, and Cochrane databases were searched for studies with no restrictions on date. We included observational studies that reported on the prevalence of polypharmacy among individuals over age 19. Two reviewers extracted study characteristics including polypharmacy definitions, study design, setting, geography, and participant demographics. The risk of bias was assessed using the Newcastle-Ottawa Scales. The main outcome was the prevalence of polypharmacy and factors associated with polypharmacy prevalence. The pooled prevalence estimates of polypharmacy with 95% confidence intervals were determined using random effects meta-analysis. Subgroup analyses were undertaken to evaluate factors associated with polypharmacy such as polypharmacy definitions, study setting, study design and geography. Meta-regression was conducted to assess the associations between polypharmacy prevalence and study year.

Results

106 full-text articles were identified. The pooled estimated prevalence of polypharmacy in the 54 studies reporting on polypharmacy in all medication classes was 37% (95% CI: 31-43%). Differences in polypharmacy prevalence were reported for studies using different numerical thresholds, study setting, and publication year. Sex, study geography, study design and geographical location were not associated with differences in polypharmacy prevalence.

Discussion

Our review highlights that polypharmacy is common particularly among older adults and those in inpatient settings. Clinicians should be aware of populations who have an increased likelihood of experiencing polypharmacy and efforts should be made to review the appropriateness of prescribed medications and occurrence of adverse effects potentially associated with polypharmacy.

Conclusions and implications

Clinicians should be aware of the common occurrence of polypharmacy and undertake efforts to minimize inappropriate polypharmacy whenever possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03279-x.

Associations of Cardiovascular Agents and Metformin with Depression Symptoms: A Cross-Sectional Analysis from the HUNT Study, Norway

BACKGROUND

Cardiovascular agents, including angiotensin-converting enzyme inhibitors, angiotensin II receptor inhibitors, acetylsalicylic acid, statins, and metformin, have demonstrated benefits for depression. However, there is scant evaluation of these drugs' antidepressant properties in large population settings.

OBJECTIVE

This study aimed to examine cross-sectional associations between depression symptoms and the use of cardiovascular agents and metformin in populations with cardiovascular diseases or diabetes mellitus.

METHODS

Participants in the Trøndelag Health Study 2006-08 (HUNT3, n = 40,516) and 2017-19 (HUNT4, n = 42,103) were included and data on their drug use from 2006 to 2019 was retrieved from the Norwegian Prescription Database. The outcome was self-reported depression symptoms defined by the Hospital Anxiety and Depression Scale. Associations between cardiovascular agents or metformin use and self-reported depression were analyzed by multi-level logistic regression in sex-stratified samples.

RESULTS

Among men with cardiovascular diseases, use of acetylsalicylic acid was associated with reduced depression symptoms compared with acetylsalicylic acid non-users (reference) in HUNT3 and HUNT4 [risk ratio = 0.76; 95% confidence interval 0.59-0.94, risk ratio = 0.67; 95% CI 0.52-0.82, respectively]. Similarly, male statin users had a lower likelihood of reporting depression than statin non-users in HUNT3 (risk ratio = 0.70; 95% confidence interval 0.54-0.86) and HUNT4 (risk ratio = 0.67; 95% confidence interval 0.51-0.84). Associations between statins or acetylsalicylic acid use and reduced depression symptoms were detected in women with cardiovascular diseases in HUNT4. We found no statistical support for associations between other cardiovascular agents or metformin use and a reduced or increased depression symptom risk.

CONCLUSIONS

Results suggest negative associations between acetylsalicylic acid or statin use and depression symptoms. However, longitudinal cohort studies and randomized controlled trials are required to confirm the antidepressant effects of these drugs.

Effectiveness and cost-effectiveness of an intervention to improve Initial Medication Adherence to treatments for cardiovascular diseases and diabetes in primary care: study protocol for a pragmatic cluster randomised controlled trial and economic model (the IMA-cRCT study)

BACKGROUND

Between 2 and 43% of patients who receive a new prescription in PC do not initiate their treatments. Non-initiation is associated with poorer clinical outcomes, more sick leave and higher costs to the healthcare system. Existing evidence suggests that shared decision-making positively impacts medication initiation. The IMA-cRCT assesses the effectiveness of the IMA intervention in improving adherence and clinical parameters compared to usual care in patients with a new treatment for cardiovascular disease and diabetes prescribed in PC, and its cost-effectiveness, through a cRCT and economic modelling.

METHODS

The IMA intervention is a shared decision-making intervention based on the Theoretical Model of Non-initiation. A cRCT will be conducted in 24 PC teams in Catalonia (Spain), randomly assigned to the intervention group (1:1), and community pharmacies in the catchment areas of the intervention PC teams. Healthcare professionals in the intervention group will apply the intervention to all patients who receive a new prescription for cardiovascular disease or diabetes treatment (no other prescription from the same pharmacological group in the previous 6 months). All the study variables will be collected from real-world databases for the 12 months before and after receiving a new prescription. Effectiveness analyses will assess impact on initiation, secondary adherence, cardiovascular risk, clinical parameters and cardiovascular events. Cost-effectiveness analyses will be conducted as part of the cRCT from a healthcare and societal perspective in terms of extra cost per cardiovascular risk reduction and improved adherence; all analyses will be clustered. Economic models will be built to assess the long-term cost-effectiveness of the IMA intervention, in terms of extra cost for gains in QALY and life expectancy, using clinical trial data and data from previous studies.

DISCUSSION

The IMA-cRCT represents an innovative approach to the design and evaluation of behavioural interventions that use the principles of complex interventions, pragmatic trials and implementation research. This study will provide evidence on the IMA intervention and on a new methodology for developing and evaluating complex interventions. The results of the study will be disseminated among stakeholders to facilitate its transferability to clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05026775 . Registered 30th August 2021.

Prediction Ability of Charlson, Elixhauser, and Rx-Risk Comorbidity Indices for Mortality in Patients with Hip Fracture. A Danish Population-Based Cohort Study from 2014 – 2018

Objective

Methods

Results

Conclusion

Factors associated with C-reactive protein testing when prescribing antibiotics in general practice: a register-based study

BACKGROUND

The use of C-reactive protein (CRP) tests has been shown to safely reduce antibiotic prescribing for acute respiratory tract infections (RTIs). The aim of this study was to explore patient and clinical factors associated with the use of CRP testing when prescribing antibiotics recommended for RTIs.

METHODS

A nation-wide retrospective cross-sectional register-based study based on first redeemed antibiotic prescriptions issued to adults in Danish general practice between July 2015 and June 2017. Only antibiotics recommended for treatment of RTIs were included in the analysis (penicillin-V, amoxicillin, co-amoxicillin or roxithromycin/clarithromycin). Logistic regression models were used to estimate odds ratios for patient-related and clinical factors on performing a CRP test in relation to antibiotic prescribing.

RESULTS

A total of 984,149 patients redeemed at least one antibiotic prescription during the two-year period. About half of these prescriptions (49.6%) had an RTI stated as the indication, and a CRP test was performed in relation to 45.2% of these scripts. Lower odds of having a CRP test performed in relation to an antibiotic prescription was found for patients aged 75 years and above (OR 0.82, 95CI 0.79-0.86), with a Charlson Comorbidity Index of more than one (OR 0.93, 95CI 0.91-0.95), unemployed or on disability pension (OR 0.84, 95CI 0.83-0.85) and immigrants (OR 0.91, 95CI 0.88-0.95) or descendants of immigrants (OR 0.90, 95CI 0.84-0.96). Living with a partner (OR 1.08, 95CI 1.07-1.10), being followed in practice for a chronic condition (OR 1.22, 95CI 1.18-1.26) and having CRP tests performed in the previous year (OR 1.78, 95CI 1.73-1.84) were associated with higher odds of CRP testing in relation to antibiotic prescribing.

CONCLUSIONS

Differences were observed in the use of CRP tests among subgroups of patients indicating that both sociodemographic factors and comorbidity influence the decision to use a CRP test in relation to antibiotic prescriptions in general practice. Potentially, this means that the use of CRP tests could be optimised to increase diagnostic certainty and further promote rational prescribing of antibiotics. The rationale behind the observed differences could be further explored in future qualitative studies.

Pediatric Medication Noninitiation in Spain

OBJECTIVES

To estimate medication noninitiation prevalence in the pediatric population and identify the explanatory factors underlying this behavior.

METHODS

Observational study of patients (<18 years old) receiving at least 1 new prescription (28 pharmaceutical subgroups; July 2017 to June 2018) in Catalonia, Spain. A prescription was considered new when there was no prescription for the same pharmaceutical subgroup in the previous 6 months. Noninitiation occurred when a prescription was not filled within 1 month or 6 months (sensitivity analysis). Prevalence was estimated as the proportion of total prescriptions not initiated. To identify explanatory factors, a multivariable multilevel logistic regression model was used, and adjusted odds ratios were reported.

RESULTS

Overall, 1 539 003 new prescriptions were issued to 715 895 children. The overall prevalence of 1-month noninitiation was 9.0% (ranging from 2.6% [oral antibiotics] to 21.5% [proton pump inhibitors]), and the prevalence of 6-month noninitiation was 8.5%. Noninitiation was higher in the youngest and oldest population groups, in children from families with a 0% copayment rate (vulnerable populations) and those with conditions from external causes. Out-of-pocket costs of drugs increased the odds of noninitiation. The odds of noninitiation were lower when the prescription was issued by a pediatrician (compared with a primary or secondary care clinician).

CONCLUSIONS

The prevalence of noninitiation of medical treatments in pediatrics is high and varies according to patients' ages and medical groups. Results suggest that there are inequities in access to pharmacologic treatments in this population that must be taken into account by health care planners and providers.

Non-initiation of prescribed medication from a Spanish health professionals' perspective: A qualitative exploration based on Grounded Theory

We explore, from the perspective of primary care health professionals, the motivations that lead patients to not initiate prescribed treatments, by developing a qualitative study in Spanish primary care. Six focus groups (N = 46) were conducted with general practitioners, nurse practitioners, social workers and community pharmacists and carried out in primary care (PC) of Barcelona Province, from April to July of 2018. The 46 participants were identified by three general practitioners and two pharmacists. In the interviews, the reasons for non-initiation of PC patients' medication were explored. Triangulated content analysis was performed. Patients' perspective, analysed in a previous study, and professionals' perspective agree on most of the factors that affect non-initiation. New factors were categorized into existent categories, confirming, and supplementing the model developed with patients. Health professionals identified some new factors which were not present in the patients' discourse, such as stigma related to the drug, hidden reasons for consultation, the role of nurses in prescription and support, the role of the pharmacy technician, illiteracy and lack of social support. The professionals confirm and expand on the Theoretical Model of Medication Non-Initiation. Primary care professionals should consider the factors described when prescribing a new medication. Knowledge contributed by the model should guide the design of interventions to improve initiation.

Prescribing antibiotics: the use of diagnostic tests in general practice. A register-based study

OBJECTIVE

To assess (i) the pattern of antibiotic prescribing in Danish general practice, (ii) the use of diagnostic tests [point-of-care (POC) and tests analysed at the hospital laboratory (laboratory tests)], and (iii) the frequency of diagnostic testing in relation to antibiotic prescriptions.

DESIGN

Retrospective cross-sectional register-based study.

SETTING

General practice in a geographical area of Denmark covering 455,956 inhabitants.

SUBJECTS

We studied redeemed antibiotic prescriptions and performed diagnostic tests in general practice from 2013 to 2017 among inhabitants in nine selected municipalities.

MAIN OUTCOME MEASURES

Frequency of antibiotic courses. Frequency and type of diagnostic testing performed in relation to types of antibiotics.

RESULTS

A total of 783,252 antibiotic courses were redeemed from general practice with an overall decrease of 19% during 2013-2017. Diagnostic testing increased by 6% during this period. POC tests comprised the majority of performed diagnostic tests (83%) with C-reactive protein (CRP) as the most frequently used test. A 27% increase in the use of laboratory tests was observed. Tests were performed in relation to 43% of all antibiotic courses; most in relation to prescriptions for sulphonamide and trimethoprim (57%) and rarely when prescribing tetracyclines (10%). Conflicting with national guidelines, Danish GPs prescribed fluoroquinolones without performing any kind of diagnostic testing in 48% of the cases.

CONCLUSIONS

This study provides an overview of the use of diagnostic tests in relation to antibiotics and creates basis for further research into the variability between types of antibiotics. The study indicates that there is room for improvement to use diagnostic tests as an aid to promote prudent antibiotic use.KEY POINTSDiagnostic tests (point-of-care or tests analysed at the hospital laboratory), can increase diagnostic certainty and lead to a reduction in antibiotic use in general practice.A decrease in antibiotic courses in general practice in Denmark was observed during 2013-2017, while the use of diagnostic tests increased.A diagnostic test was performed in relation to 43% of antibiotic courses.Only 52% of prescribed fluoroquinolones was related to a diagnostic test, conflicting with national guidelines.

Prenatal exposure to nitrofurantoin and risk of childhood leukaemia: a registry-based cohort study in four Nordic countries

Background

Studies have suggested increased risks of childhood leukaemia after prenatal exposure to antibiotics, particularly nitrofurantoin. However, these findings may be related to the underlying maternal infection. This multinational study aimed to investigate the association between prenatal nitrofurantoin exposure and childhood leukaemia while accounting for maternal infection.

Methods

In a population-based cohort study of children born in Denmark, Finland, Norway or Sweden from 1997 to 2013, prenatal exposure to nitrofurantoin or pivmecillinam (active comparator) was ascertained from national Prescription Registries. Childhood leukaemia was identified by linkage to national Cancer Registries. Poisson regression was used to estimate incidence rate ratios (IRRs) and incidence rate differences (IRDs) with inverse probability of treatment weights applied to account for confounding.

Results

We included 44 091 children prenatally exposed to nitrofurantoin and 247 306 children prenatally exposed to pivmecillinam. The children were followed for 9.3 years on average (standard deviation 4.1). There were 161 cases of childhood leukaemia. The weighted IRR for prenatal nitrofurantoin exposure when compared with pivmecillinam was 1.34 (95% confidence interval 0.88, 2.06), corresponding to an IRD of 15 per million person-years. Higher point estimates were seen for first- and third-trimester exposure. There was no evidence of a dose–response relationship.

Conclusions

Prenatal exposure to nitrofurantoin was not substantially associated with childhood leukaemia, although a slightly elevated IRR with confidence intervals including the null was observed, corresponding to a small absolute risk. The lack of a dose–response relationship and a clear biological mechanism to explain the findings suggests against a causal association.

How to improve patient satisfaction behavioral compliance and hospital image through nurse caring: Strategizing for healthcare during COVID-19

We investigated the impact of nurse caring on patient satisfaction, behavioral compliance, and organization image from a patient's perspective in the private healthcare sector in the Syrian capital-Damascus. The conceptual model can significantly explain 40, 64, and 49% of satisfaction, compliance, and organization image, respectively in a statistical manner. Responsiveness had more influence on patient satisfaction than communication skills. Friendship behavior had no significant effect on satisfaction, and behavioral compliance. The most important aspect that influenced the organization's image was the nurse's communication skills followed by responsiveness and service friendship behavior.

Drug exposure misclassification in pharmacoepidemiology: Sources and relative impact

BACKGROUND

Drug exposure assessment based on dispensing data can be misclassified when patients do not adhere to their therapy or when information about over-the-counter drugs is not captured in the study database. Previous research has considered hypothetical sensitivity and specificity values, whereas this study aims to assess the impact of literature-based real values of exposure misclassification.

METHODS

A synthetic cohort study was constructed based on the proportion of exposure theoretically captured in a database (range 0.5-1.0) and the level of adherence (0.5-1.0). Three scenarios were explored: nondifferential misclassification, differential misclassification (misclassifications dependent on an unmeasured risk factor doubling the outcome risk), and nondifferential misclassification in a comparative effectiveness study (RR_A and RR_B both 2.0 compared to nonuse, RR_A-B 1.0).

RESULTS

For the scenarios with nondifferential misclassification, 25% nonadherence or 25% uncaptured exposure changed the RR from 2.0 to 1.75, and 1.95, respectively. Applying different proportions of nonadherence or uncaptured use (20% vs. 40%) for subgroups with and without the risk factor, an RR of 0.95 was observed in the absence of a true effect (i.e., true RR = 1). In the comparative effectiveness study, no effect on RR was seen for different proportions of uncaptured exposure; however, different levels of nonadherence for the drugs (20% vs. 40%) led to an underestimation of RR_A-B (0.89).

DISCUSSION

All scenarios led to biased estimates, but the magnitude of the bias differed across scenarios. When testing the robustness of findings of pharmacoepidemiologic studies, we recommend using realistic values of nonadherence and uncaptured exposure based on real-world data.

Use of hypnotic drugs among children, adolescents, and young adults in Scandinavia

BACKGROUND

Hypnotic use in children and adolescents is controversial.

OBJECTIVE

To describe the use of hypnotic drugs (melatonin, z-drugs, and sedating antihistamines) among 5- to 24-year-old Scandinavians during 2012 to 2018.

METHODS

Aggregate-level data were obtained from public data sources in Sweden, Norway, and Denmark. We calculated annual prevalence (users/1000 inhabitants) stratified by age group, sex, and country. Quantity of use (Defined Daily Dose (DDD)/user/day) was estimated for Norway and Denmark.

RESULTS

Melatonin was the most commonly used hypnotic, and its use increased markedly from 2012 to 2018, particularly among females and 15- to 24-year-old individuals. Sweden had the highest increase in use (6.5 to 25/1000) compared with Norway (10-20/1000) and Denmark (5.7-12/1000). The annual prevalence of sedating antihistamine use was also highest in Sweden, reaching 13/1000 in 2018 in comparison to 7.5/1000 in Norway and 2.5/1000 in Denmark. Z-drug use decreased in all countries toward 2018, dropping to 3.5/1000 in Sweden, 4.4/1000 in Norway, and 1.7/1000 in Denmark. The quantity of hypnotic use in Norway and Denmark was 0.8-1.0 DDD/user/day for melatonin in 2018, as compared to 0.1-0.3 for z-drugs and antihistamines.

CONCLUSION

The use of melatonin and sedating antihistamines increased among young Scandinavians during 2012-2018, and the increase was twice as high in Sweden compared with Norway and Denmark. In addition, Sweden had the highest use of sedating antihistamines. The Scandinavian variation of hypnotic use could reflect differences in frequency of sleep problems between populations or variation of healthcare access or clinical practice between countries.

Risk of precancerous cervical lesions in women using a hormone-containing intrauterine device and other contraceptives: a register-based cohort study from Denmark

STUDY QUESTION

Is the risk of high-grade precancerous cervical lesions and/or is the risk of lesion progression increased in users of a hormone-containing intrauterine device (HIUD) compared with users of other contraceptive methods.

SUMMARY ANSWER

Women starting use of HIUD had the same subsequent risk of cervical intraepithelial neoplasia 3+ (CIN3+) as copper IUD (CIUD) users, and both groups tended to have lower risks than oral contraceptives (OC) users.

WHAT IS KNOWN ALREADY

HIUDs may cause inflammatory and immunosuppressive changes that may potentially affect the risk of persistent human papillomavirus infection and precancerous cervical lesions.

STUDY DESIGN, SIZE, DURATION

A Danish population-based cohort study was conducted using register data from 2008 to 2011 on 26–50-year-old users of HIUD (n = 60 551), CIUD (n = 30 303), or OC (n = 165 627).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Within each user group, women were divided into two groups; normal cytology or abnormal diagnosis before start of contraceptive use (baseline). Follow-up histology and cytology diagnoses were registered during the 5 years after baseline. Adjusted relative risks (aRR) and 95% CI were calculated for precancerous cervical lesions in HIUD users compared with CIUD and OC users.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with normal cytology at baseline: at follow-up HIUD users had the same risk of CIN3 or higher (3+) as CIUD users; aRR 1.08 (95% CI 0.94–1.22). For the HIUD and CIUD groups compared with OCs, the risks of CIN3+ were lower: aRR 0.63 (95% CI 0.57–0.69) and aRR 0.58 (95% CI 0.52–0.65), respectively. The same was observed for CIN2 risks: aRR 0.86 (95% CI 0.76–0.96) and aRR 0.68 (95% CI 0.58–0.79) for HIUD and CIUD groups, respectively. Women with abnormal diagnosis at baseline: a lower progression risk, except for CIN2+ at baseline, was observed in HIUD users compared with OC users. Similar progression risks were found in HIUD and CIUD users. There were no differences between the three contraceptive groups in persistence or regression of present lesions.

LIMITATIONS, REASONS FOR CAUTION

We adjusted for age, education, and region of residence as a proxy for socio-economic factors. Data on smoking and sexual behavior were not available thus we cannot exclude some differences between the three user groups.

WIDER IMPLICATIONS OF THE FINDINGS

These findings suggest that women may safely use HIUDs.

STUDY FUNDING/COMPETING INTEREST(S)

A.P. Møller Foundation for the Advancement of Medical Science, Else and Mogens Wedell-Wedellborgs Fund, Direktør Emil C. Hertz og Hustru Inger Hertz Fund, and the Fund for Development of Evidence Based Medicine in Private Specialized Practices. EL is principle investigator for a study with HPV-test-kits provided by Roche. The other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Fracture rates in patients discontinuing alendronate treatment in real life: a population-based cohort study

In this nationwide register-based cohort study, we found no difference in the risk of fractures in patients discontinuing versus continuing alendronate (ALN) treatment after 5 years.

INTRODUCTION

Information on fracture risk in patients discontinuing ALN in a real-life setting is sparse. We aimed to examine ALN discontinuation patterns, compare fracture rates in patients discontinuing versus continuing ALN after 5 years of treatment, and define determinants of fractures in ALN discontinuers.

METHODS

A nationwide population-based cohort study using Danish health registry data. Our source population was individuals who had redeemed ≥ 2 ALN prescriptions between January 1, 1995, and September 1, 2017.

RESULTS

We found that 25% of all ALN initiators used ALN for less than 1 year and 43% continued treatment for at least 5 years. We classified n = 1865 as ALN discontinuers and n = 29,619 as ALN continuers. Using Cox proportional hazards regression analysis and an "as-treated" approach, we observed no increased risk of any fracture (incidence rate ratio (IRR) 1.06, 95% CI 0.92-1.23), vertebral fracture (IRR 0.59, 95% CI 0.33-1.05), hip fracture (IRR 1.04, 95% CI 0.75-1.45), or major osteoporotic fracture (IRR 1.05, 95% CI 0.88-1.25) in the ALN discontinuers compared to continuers during a follow-up time of 1.84 ± 1.56 years (mean ± SD) and 2.51 ± 1.60 years, respectively. ALN re-initiation was a major determinant of follow-up among the discontinuers. Old age (> 80 vs. 50-60 years, unadjusted IRR 2.92, 95% CI 1.18-7.24) was the strongest determinant for fractures following ALN discontinuation.

CONCLUSION

In a real-world setting, less than 50% continued ALN treatment for 5 years. We found no difference in the risk of fractures in patients discontinuing versus continuing ALN after 5 years.

Use of antipsychotics in Denmark 1997-2018: a nation-wide drug utilisation study with focus on off-label use and associated diagnoses

AIMS

Antipsychotics are primarily labelled for the treatment of severe mental illness and have documented clinical utility in certain neurological disorders or palliative care. However, off-label use of antipsychotics is common and increasing, and prior studies on antipsychotic utilisation have not specifically assessed users in neurology, palliative care or general practice. We aimed to explore diagnoses associated with antipsychotic use, treatment patterns and characteristics of users without diagnoses relevant to antipsychotic treatment.

METHODS

Population-based study identifiying all users of antipsychotics in Denmark (pop 5.7 mio.) 1997-2018 in the Danish National Prescription Register (DNPR). Possible indications for antipsychotic therapy were evaluated using in- and outpatient contacts from the DNPR. Users were divided hierarchically into six groups: severe mental disorders (schizophrenia, bipolar-spectrum disorders), chronic mental disorders (dementias, mental retardation, autism), other mental disorders (depression-spectrum, anxiety and personality disorders, etc.), selected neurological diseases, cancer and antipsychotic users without any of these diagnoses. This last group was characterised regarding demographics, antipsychotic use, health care utilisation and likely antipsychotic treatment initiator in 2018.

RESULTS

Altogether, 630 307 antipsychotic users were identified, of whom 127 649 had filled prescriptions during 2018. Users without diagnoses relevant to antipsychotic treatment comprised of the largest group (37%), followed by schizophrenia and bipolar-spectrum disorders (34%), other mental disorders (15%), dementia, autism and mental retardation (11%), cancer (2.2%) and neurological diagnoses (2.0%). Of 37 478 incident users in 2018, 39% had no diagnosis relevant to antipsychotic treatment, 7.9% had major depression, 7.7% neurotic/stress-related disorders and 7.5% dementia. Quetiapine was most commonly used, both overall (51%) and among users without diagnoses relevant to antipsychotic treatment (58%). Of 14 474 incident users in 2018 without diagnoses relevant to antipsychotic treatment, treatment was most likely initiated by a general practitioner (65%), with only 17% seeing a psychiatrist during the following year. As many as 18% of patients with adjustment disorders and 14% of those without relevant diagnoses for antipsychotic use, remained on antipsychotic treatment 5 years after their first prescription.

CONCLUSIONS

Over one-third of antipsychotic users in Denmark did not have psychiatric, neurological or cancer diagnoses as possible indications for antipsychotic therapy. Many antipsychotics are initiated or prescribed in general practice, and a concerningly large subgroup without documented diagnoses relevant for antipsychotics continued to receive them. Rational prescribing, adequate side effect monitoring and further research into reasons for the observed antipsychotic use patterns and their risk-benefit ratio are needed.

Is Prescription Nonredemption a Source of Poor Health Among the Roma? Cross-Sectional Analysis of Drug Consumption Data From the National Health Insurance Fund of Hungary

Background: The health status of the Roma is inferior to that of the general population. The causes of poor health among this population are still ambiguous, but they include low utilization of healthcare services. Our study aimed to investigate prescription redemptions in segregated Roma colonies (SRC) where the most disadvantaged quartile of Roma people are living.

Methods: A cross-sectional study was carried out with data obtained from the National Institute of Health Insurance Fund Management in the settlements belonging to the study area of the “Public Health-Focused Model Program for Organizing Primary Care Services.” The study included 4,943 residents of SRC and 62,074 residents of the complementary area (CA) of the settlements where SRC were located. Crude and age- and sex-standardized redemption ratios for SRC and CA were calculated for each Anatomic Therapeutic Chemical (ATC) group and for the total practice by ATC group. Standardized relative redemptions (RR) with 95% confidence intervals were calculated for SRC, with CA as a reference.

Results: The crude redemption ratios were 73.13% in the SRC and 71.15% in the CA. RRs were higher in the SRC than in the CA for cardiovascular, musculoskeletal system, and alimentary tract and metabolism drugs (11.5, 3.7, and 3.5%, respectively). In contrast, RRs were lower in the SRC than in the CA for anti-infective agents (22.9%) due to the poor redemption of medicines prescribed for children or young adults. Despite the overall modest differences in redemption ratios, some ATC groups showed remarkable differences. Those include cardiovascular, alimentary and musculoskeletal drugs.

Conclusion: Redemption of prescriptions was significantly higher among Roma people living in SRC than among those living in CA. The better redemption of cardiovascular and alimentary tract drugs was mainly responsible for this effect. These findings contradict the stereotype that the Roma do not use health services properly and that prescription non-redemption is responsible for their poor health.

Primary non-adherence to inhaled medications measured with e-prescription data from Poland

BACKGROUND

Treatment adherence greatly influences the clinical outcomes in various fields of medicine, including management of asthma and COPD. With the recent implementation of a nationwide e-Health solutions in Poland, new and unique opportunities for studying primary non-adherence in asthma and COPD emerged. The aim was to study primary non-adherence to inhaled medications available in Poland indicated in asthma and/or COPD and analyse the impact of patients' demographics and inhalers' characteristics (dry powder inhalers (DPIs) vs metered dose inhalers (MDIs) and presence of a dosage counter) on primary non-adherence.

METHODS

A retrospective analysis of all e-prescriptions issued in Poland in 2018 (n = 119,880) from the national e-prescription pilot framework.

RESULTS

Primary non-adherence for inhalable medications reached 15.3%. It significantly differed among age groups-the lowest (10.8%) was in 75 + years-old patients, highest (18%) in 65-74 years-old patients. No gender differences in primary non-adherence were found. The highest non-adherence was observed for ICS + LABA combinations (18.86%). A significant difference was found between MDI and DPI inhalers and between inhalers with/without a dosage counter.

CONCLUSIONS

Out of e-prescriptions for inhaled medications issued in 2018 in Poland, 15.3% were not redeemed. The degree of primary non-adherence was influenced by age, but not gender. Significant differences between MDIs and DPIs and between inhalers with/without a dosage counter were observed.

The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach

OBJECTIVE

To estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care.

DESIGN

Non-controlled before-and-after study.

SETTING

Bidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain.

PARTICIPANTS

The service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking.

OUTCOMES

The primary outcomes were the number of medicines, the type of discrepancy, and GPs' decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs.

RESULTS

The MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n=152). The main GPs' decision was to withdraw the treatment (54.8%, n=125), which meant that the number of medicines per patient was reduced by 0.92 (9.12±3.82 vs. 8.20±3.81; p<.0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61±.13 vs 0.52±0.91; p=.405 and 0.17 (0.33±0.66 vs. 0.16±0.42; p=.007), respectively. The cost per patient was reduced by €444.9 (€1003.3±2165.3 vs. €558.4±1273.0; p=.018).

CONCLUSION

The MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios.

Prescription of antimicrobials in primary health care as a marker to identify people living with undiagnosed HIV infection, Denmark, 1998 to 2016

Background

Development of additional diagnostic strategies for earlier HIV diagnosis are needed as approximately 50% of newly diagnosed HIV-infected individuals continue to present late for HIV care.

Aim

We aimed to analyse antimicrobial consumption in the 3 years preceding HIV diagnosis, assess whether there was a higher consumption in those diagnosed with HIV compared with matched controls and whether the level of consumption was associated with the risk of HIV infection.

Methods

We conducted a nested case–control study, identifying all individuals (n = 2,784 cases) diagnosed with HIV in Denmark from 1998 to 2016 and 13 age-and sex-matched population controls per case (n = 36,192 controls) from national registers. Antimicrobial drug consumption was estimated as defined daily doses per person-year. We used conditional logistic regression to compute odds ratios and 95% confidence intervals.

Results

In the 3 years preceding an HIV diagnosis, we observed more frequent and higher consumption of antimicrobial drugs in cases compared with controls, with 72.4% vs 46.3% having had at least one prescription (p < 0.001). For all antimicrobial classes, the association between consumption and risk of subsequent HIV diagnosis was statistically significant (p < 0.01). The association was stronger with higher consumption and with shorter time to HIV diagnosis.

Conclusion

HIV-infected individuals have a significantly higher use of antimicrobial drugs in the 3 years preceding HIV diagnosis than controls. Prescription of antimicrobial drugs in primary healthcare could be an opportunity to consider proactive HIV testing. Further studies need to identify optimal prescription cut-offs that could endorse its inclusion in public health policies.

Prevalence trends and individual patterns of antiepileptic drug use in pregnancy 2006-2016: A study in the five Nordic countries, United States, and Australia

PURPOSE

To describe recent international trends in antiepileptic drug (AED) use during pregnancy and individual patterns of use including discontinuation and switching.

METHODS

We studied pregnancies from 2006 to 2016 within linked population-based registers for births and dispensed prescription drugs from Denmark, Finland, Iceland, Norway, Sweden, and New South Wales, Australia and claims data for public and private insurance enrollees in the United States. We examined the prevalence of AED use: the proportion of pregnancies with ≥1 prescription filled from 3 months before pregnancy until birth, and individual patterns of use by trimester.

RESULTS

Prevalence of AED use in almost five million pregnancies was 15.3 per 1000 (n = 75 249) and varied from 6.4 in Sweden to 34.5 per 1000 in the publicly-insured US population. AED use increased in all countries in 2006-2012 ranging from an increase of 22% in Australia to 104% in Sweden, and continued to rise or stabilized in the countries in which more recent data were available. Lamotrigine, clonazepam, and valproate were the most commonly used AEDs in the Nordic countries, United States, and Australia, respectively. Among AED users, 31% only filled a prescription in the 3 months before pregnancy. Most filled a prescription in the first trimester (59%) but few filled prescriptions in every trimester (22%).

CONCLUSIONS

Use of AEDs in pregnancy rose from 2006 to 2016. Trends and patterns of use of valproate and lamotrigine reflected the safety data available during this period. Many women discontinued AEDs during pregnancy while some switched to another AED.

Primary Non-Adherence to Antihistamines-Conclusions From E-Prescription Pilot Data in Poland

Background

In allergic conditions such as allergic rhinitis and urticaria, orally administered H₁-antihistamines belong to first-line therapy and therefore, are widely prescribed. Due to the frequent, and often chronic, course of allergic diseases, adherence is of great importance. In 2018 a novel, nationwide e-prescription system was piloted in Poland, which allowed to analyze primary non-adherence to orally administered H₁ antihistamines.

Objectives

To assess the primary non-adherence to orally administered H₁-antihistamines in Poland, defined as not redeeming the drug issued on a particular e-prescription within its validity period.

Methods

The study was based on all e-prescriptions issued in Poland in 2018, issued for 119.880 drugs. The analysis included nine major orally administered H₁ antihistamines available in Poland.

Results

Out of 2280 analyzed e-prescriptions on orally administered antihistamines, 1803 (79.1%) of them were redeemed. Therefore, the level of primary non-adherence reached 21%. Among women it reached 19.9%, but it was not significantly lower than among men (23.4%, p=0.064). The highest non-adherence (31.3%) was observed in the age group 19-39, whilst the highest adherence rate (84.6%) was observed in those 75 years or older. The most frequently prescribed second-generation antihistamine was bilastine—596 e-prescriptions with 23.7% primary non-adherence.

Conclusions

More than 1 out of 5 e-prescriptions on orally administered H₁-antihistamines were not redeemed in Poland in 2018. Age, but not gender, significantly influenced the degree of primary non-adherence to these drugs. To authors knowledge, this is the first real-life study on primary non-adherence to H₁-antihistamines in Poland and one of the very few on this subject worldwide.