IMPLEMENTING HEALTH TECHNOLOGY ASSESSMENT-BASED RECOMMENDATIONS IN FINLAND: MANAGED UPTAKE OF MEDICAL METHODS.

OBJECTIVES: The Managed Uptake of Medical Methods Program (MUMM) started 10 years ago as a joint venture of the Finnish Office for Health Technology Assessment (Finohta) and the twenty hospital districts in Finland. The aim is to offer information on the effectiveness, safety, organizational effects, and costs of new medical methods to support decisions concerning their uptake in secondary care. In this article, we discuss the successes and challenges of implementing the MUMM program. METHODS: A study of awareness and use of five MUMM recommendations for various medical specialties with short-form web-based surveys to hospitals. RESULTS: The recommendations were noticed and considered relevant. In overall assessment they received a mean rating of 8.4 (range: 4 to 10). Two thirds of the respondents thought MUMM recommendations were useful for practice, but only a third had actually used them in decision making. CONCLUSIONS: HTA-based MUMM recommendations were well received by physicians but in practice they are less used than clinical practice guidelines. Short-form electronic surveys were a useful way of gathering information about awareness and implementation. The surveys also functioned as another method of informing key physicians about the recommendations.

[Pregnancy contraception (Current Care Guideline)]. / KÄYPÄ HOITO -SUOSITUS (Tiivistelmä). Raskauden ehkäisy.

There are no age limits for the start or use of contraception. Prior gynecological examination or cervical smear is not needed. Condom is the only method that protects from sexually transmitted diseases. An increase in the risk of venous thromboembolism (VTE) is associated only with combined contraceptives. However, the risk is remarkably higher with pregnancy, puerperium or with smoking. The most effective reversible methods are intrauterine devices (IUD) and implants, as these do not depend on daily memory. Natural family planning methods are not reliable, and effective contraception should be easily available for all at all times.

[Are programs supporting parenthood skills effective in the prevention and reduction of conduct disorders and problems of childhood?]. / Vaikuttavatko vanhemmuustaitoja tukevat ohjelmat lapsen käytöshäiriöiden ja -ongelmien ehkäisyssä ja vähentämisessä?

In this systematic review it will be evaluated whether parent-targeted programs teaching positive methods of upbringing and interaction are effective in the reduction and prevention of conduct disorders and behavioral problems in children belonging to a risk group. Altogether 29 European studies on parent-targeted programs were selected for the review. Most of the examined methods were based on the social learning theory and the cognitive behavior theory. The majority of the studies proved that long-term programs of 8 to 20 weeks'duration are effective in the reduction of behavioral problems and conduct disorders of childhood.

INFLUENCE OF HEALTH TECHNOLOGY ASSESSMENT AND ITS MEASUREMENT.

OBJECTIVES: The aim of this study was to obtain information on methods used to measure health technology assessment (HTA) influence, decisions that were influenced, and outcomes linked to HTA. METHODS: Electronic databases were used to locate studies in which HTA influence had been demonstrated. Inclusion criteria were studies that reliably reported consideration by decision makers of HTA findings; comparative studies of technology use before and after HTA; and details of changes in policy, health outcomes, or research that could be credibly linked to an HTA. RESULTS: Fifty-one studies were selected for review. Settings were national (24), regional (12), both national and regional (3) hospitals (9), and multinational (3). The most common approach to appraisal of influence was review of policy or administrative decisions following HTA recommendations (51 percent). Eighteen studies (35 percent) reported interview or survey findings, thirteen (26 percent) reviewed administrative data, and six considered the influence of primary studies. Of 142 decisions informed by HTA, the most common types were on routine clinical practice (67 percent of studies), coverage (63 percent), and program operation (37 percent). The most frequent indications of HTA influence were on decisions related to resource allocation (59 percent), change in practice pattern (31 percent), and incorporation of HTA details in reference material (18 percent). Few publications assessed the contribution of HTA to changing patient outcomes. CONCLUSIONS: The literature on HTA influence remains limited, with little on longer term effects on practice and outcomes. The reviewed publications indicated how HTA is being used in different settings and approaches to measuring its influence that might be more widely applied, such as surveys and monitoring administrative data.

Recognition of pharmaceutical prescriptions across the European Union: a comparison of five Member States' policies and practices.

BACKGROUND: In 2011, the EU Directive on Patients' Rights in Cross Border Healthcare was approved, including a regulation on mutual recognition of prescriptions. OBJECTIVE: To compare current national policies and practices on prescribing and dispensing, prescription-only medicines (POMs) in European countries in order to identify differences which could, challenge acceptance across borders. METHODS: Semi-structured interviews with 37 national stakeholders were carried out. Furthermore, data on policies for prescribing and dispensing POMs were gathered based on desk research, and, contacts with relevant authorities via a purposely designed questionnaire. RESULTS: Important differences exist regarding: (1) information requirements for prescriptions to be, legally valid, (2) generic and international non-proprietary name (INN) policies and (3) professionals, legally allowed to prescribe POMs. Moreover, there is a lack of EU-wide access to key information for, validating prescriptions, recognizing the equivalence of products or identifying authorised prescribers. CONCLUSION: Differences in legislation and its application across Europe pose important challenges to be, addressed by policy makers with appropriate actions: (1) a prescribed product may not be dispensed, to a patient who needs it, (2) an inappropriate product (or inappropriate instructions) could be, provided and (3) POMs could be dispensed and consumed or sold, based on false prescriptions.

Alcohol-related deaths and social factors in depression mortality: a register-based follow-up of depressed in-patients and antidepressant users in Finland.

BACKGROUND: Excess mortality of depression is established for various causes of death, but evidence is scarce on alcohol-related causes. It also remains unclear whether the magnitude of the excess varies by social factors. This study aimed to quantify the contribution of alcohol-related causes of death and to assess modifying effects of socioeconomic position, employment status, and living arrangements in the excess mortality of depression. METHODS: A 14% sample of community-dwelling Finns aged 40-64 at the end of 1997 was assessed for depression, using register data on psychiatric hospital care and antidepressant use in 1996-1997. Depressed in-patients (n=897), out-patients using antidepressants (n=13,658), and non-depressed individuals (n=217,140) were followed up for cause-specific mortality in 1998-2007, distinguishing between alcohol- and non-alcohol-related deaths, and testing for variation in the excess mortality according to baseline social factors. RESULTS: Depressed in- and out-patients had significant excess mortality for suicide (age-adjusted rate ratios RR=3.77 for men and RR=6.35 for women), all accidental and violent causes (RR=3.47 and RR=4.43), and diseases (RR=1.67 and RR=1.41). Of the excess, alcohol-related causes accounted for 50% among depressed men and 30% among women. Excess mortality varied little by social factors, particularly in non-alcohol-related causes. Where variation was significant, the relative excess was larger among those with higher socioeconomic position and the employed. Absolute excess was, however, larger among those with lower socioeconomic position, the unemployed, and the unpartnered. LIMITATIONS: Depression was measured indirectly by hospital and antidepressant use. CONCLUSIONS: The results highlight the major role of alcohol in depression mortality.

Automated dose dispensing service for primary healthcare patients: a systematic review.

BACKGROUND: An automated dose dispensing (ADD) service has been implemented in primary healthcare in some European countries. In this service, regularly used medicines are machine-packed into unit-dose bags for each time of administration. The aim of this study is to review the evidence for ADD's influence on the appropriateness of medication use, medication safety, and costs in primary healthcare. METHODS: A literature search was performed in April 2012 in the most relevant databases (n = 10), including the Medline, Embase, and Cochrane Library. The reference lists of the studies selected were manually searched. A study was included in the review if the study was conducted in primary healthcare or nursing home settings and medicines were dispensed in unit-dose bags. RESULTS: Out of 328 abstracts, seven studies met the inclusion and reporting quality criteria, but none applied a randomized controlled study design. Of the four controlled studies, one was a national register-based study. It showed that the patient group in the ADD scheme more often used three or more psychotropic drugs and anticholinergics than patients using the standard dispensing procedure, while women in the ADD group used less long-acting benzodiazepines and both genders had fewer drug-drug interactions. In another, regional controlled study, the ADD group consisted of patients with higher risk of inappropriate drug use, according to all indicators applied. The third controlled study indicated that ADD user drug treatments were more likely to remain unchanged than in patients using a standard dispensing procedure. A controlled study from Norway showed that ADD reduced discrepancies in the documentation of patient medication records. Costs were not investigated in any of the studies. CONCLUSIONS: A very limited number of controlled studies have explored ADD in primary healthcare. Consequently, the evidence for ADD's influence on appropriateness and safety of medication use is limited and lacking in information on costs. The findings of this review suggest that patients using the ADD have more inappropriate drugs in their regimens, and that ADD may improve medication safety in terms of reducing the discrepancies in medication records. Further evidence is needed to draw sound conclusions on ADD's outcomes.

Increase in the duration of antidepressant treatment from 1994 to 2003: a nationwide population-based study from Finland.

OBJECTIVE: We examined the length and continuity of antidepressant treatment and factors associated with long-term of treatment among adults. METHODS: Nationwide data from all reimbursed antidepressant prescriptions in 1994-2003 were linked with patients' data retrieved from Statistics Finland and the Finnish Hospital Discharge Register. Logistic regression models were used to analyse long term use of antidepressants. RESULTS: The annual prevalence of antidepressant use increased from 3.6% in 1994 to 7.3% in 2003. Short-term use (<3 months) decreased from 58% in 1995 to 51% in 2000 and long-term treatment (≥12 months) increased from 18 to 21%. In 2000, 31% of treatment periods lasted ≥6 months and 24% ≥9 months. Long-term treatment correlated to the purchase of other psychotropics, in-patient psychiatric care, and prescription by a psychiatrist. CONCLUSIONS: Treatment periods with antidepressants have become longer over time. Clinical factors related to mental disorder severity predict long-term use. Only a quarter had the treatment duration recommended by clinical guidelines for depression.

Infertility, mental disorders and well-being--a nationwide survey.

OBJECTIVE: Earlier studies suggest that infertility and mental health problems are related and that infertility is a different experience for women and men. The aim of this population-based study is to examine mental disorders, depressivity, psychological distress, perceived health and quality of life among women and men who have experienced infertility. DESIGN: Cross-sectional nationwide Health 2000 Survey. SETTING: Population-based. POPULATION: A representative random sample of Finnish people aged 30-44 years (n = 2291). METHODS: Outcomes were compared between those who had experienced infertility (n = 338) and the rest of the population. Age, marital status, education, income, body mass index, and smoking were controlled for using logistic and linear regressions. MAIN OUTCOME MEASURES: Mental disorders (composite international diagnostic interview, CIDI), depressivity (Beck Depression Inventory, BDI), psychological distress (general health questionnaire, GHQ-12), perceived health, and subjective quality of life. RESULTS: Approximately 20% of women and 9% of men reported having experienced infertility. Childless women with infertility experience had increased adjusted risks for dysthymia (OR 3.41, 95% CI; 1.01-11.5) and anxiety disorders (2.67, 1.00-7.12) compared to women who had not experienced infertility. Women with infertility experience but with a current child had an increased risk for panic disorder (2.58, 1.11-6.01). Childless men with infertility experience had a significantly poorer quality of life compared to men without infertility. CONCLUSIONS: Infertility was associated with mental health, especially dysthymia and anxiety. The results differed by gender and the permanency of infertility. Gender-specific psychosocial support and follow-up for infertile people is warranted.

Attitudes towards biomedical use of tissue sample collections, consent, and biobanks among Finns.

AIMS: To ascertain the attitudes towards the use of existing diagnostic and research samples, the setting up of a national biobank, and different types of informed consent among Finns. METHOD: A population survey of 2,400 randomly selected Finns aged 24-65 was conducted at the beginning of 2007. RESULTS: A total of 1,195 responses (50%) were received after one reminder. Of the respondents, 83% said that they had little or no knowledge of what biobanks were. Despite this, 77% regarded the setting up of a national biobank in a positive light. One third (34%) would not attach any conditions on their consent, while 42% said that it was important to regain consent when the new study contains diverging steps. One third (30%) wanted consent to be regained for every new research project, and 44% would like to decide what type of research their samples would be used for if they were included in a national biobank. One third of both men and women approved of the use of their samples in research involving private enterprises. CONCLUSIONS: In general, Finns were positive toward the setting up of a national biobank, as well as public-private partnerships, even though they considered their knowledge of biobanking to be limited. This, however, did not mean that they were indifferent to the use of their samples, but most wanted the ability to control how their samples are used.

Antidepressant use and mortality in Finland: a register-linkage study from a nationwide cohort.

BACKGROUND: It is generally acknowledged that depressed patients need specific attention during the first weeks after initiation of antidepressant (AD) treatment because of the increased risk of suicide. METHODS: The study population consisted of all individuals residing in Finland from 1999 to 2003 who had purchased a prescribed antidepressant at least once but had no preceding antidepressant prescription. Data sources were the National Prescription Register, the Causes of Death Register, Census Data of Statistics Finland, and the National Care Register. Follow-up started at the first purchase and ended at the end of 2003 or death. Data on prescriptions were used to construct contiguous treatment periods of follow-up time. Life-table analysis with Poisson regression was used to estimate risk ratios (RR) of antidepressant use with respect to all-cause mortality and to deaths from suicide. FINDINGS: Current AD use was associated with a lowered all-cause mortality (RR = 0.18, 95% CI = 0.18-0.19) compared with those who filled one previous prescription only. There was no difference in suicide mortality when any current antidepressant usage was compared to the one-prescription group. Current SSRI usage was associated with lower risk of suicide compared to the one-prescription or other antidepressant groups (RR 0.47, 0.38-0.59). INTERPRETATION: Current AD treatment is associated with decreased all-cause mortality rates in patients who have ever had AD treatment.

Treatment of major depressive disorder in the Finnish general population.

BACKGROUND: Few general population studies of the treatment of major depressive disorder (MDD) have included the whole spectrum of treatments. We estimated the rates of different treatments and the effect of individual and disorder characteristics plus provider type on treatment received. METHODS: In the Health 2000 Study, a representative sample (n=6,005) from the adult Finnish population (> or =30 years) were interviewed (CIDI) in 2000-2001 for the presence of DSM-IV mental disorders during the past 12 months. Logistic regression models were used to examine factors influencing the type of treatment: either pharmacotherapies (antidepressants, anxiolytics, sedatives/hypnotics, antipsychotics) or psychological treatment. RESULTS: Of the individuals with MDD (n=288), currently 24% used antidepressants, 11% anxiolytics, 16% sedatives/hypnotics, 5% antipsychotics, and 17% reported having received psychological treatment. Overall, 31% received antidepressants or psychological treatment or both; 18% received minimally adequate treatment. Of those 33% (n=94) using health care services for mental reasons, 76% received antidepressants or psychological treatment or both; 54% received minimal adequate treatment. In logistic regression models, the use of antidepressants was associated with female sex, being single, severe MDD, perceived disability, and comorbid dysthymic disorder; psychological treatment with being divorced, perceived disability, and comorbid anxiety disorder. CONCLUSIONS: Due to the low use of health services for mental reasons, only one-third of subjects with MDD use antidepressants, and less than one-fifth receives psychological treatment. The treatments provided are determined mostly by clinical factors such as severity and comorbidity, in part by sex and marital status, but not education or income.

Antidepressant utilisation patterns and determinants of short-term and non-psychiatric use in the Finnish general adult population.

BACKGROUND: The aim was to study utilisation patterns and determinants of antidepressant use in the general population >30 years, especially short-term use or use not related to known psychiatric morbidity. METHODS: Participants from a cross-sectional population-based Finnish Health 2000 Study (2000--2001) were linked with the National Prescription Register and National Care Register for Health Care. Within a representative sample (N=7112) of the adult population (>30 years), 12-month DSM-IV depressive, anxiety, and alcohol use disorders were assessed with the M-CIDI. Utilisation patterns of antidepressants were categorised to short-term, intermittent and continuous use. Factors predicting short-term use or use not related to known psychiatric morbidity were investigated. RESULTS: Of Finnish adults 7.1% had used antidepressants in 2000, of which two-thirds reported a physician-diagnosed mental disorder; a third (35%) had major depressive or anxiety disorder during the previous 12 months. In terms of utilisation pattern, 43% were long-term users, 32% intermittent users and 26% short-term users. Short-term use was related to care by a general practitioner and having no known mental disorder. A quarter of all users had no known psychiatric morbidity. This type of user was most common among the older age groups, and inversely related to being single, on disability pension and using mental health services. LIMITATIONS: Not all psychiatric indications for antidepressant use could be explored. CONCLUSIONS: Depression remains the main indication for antidepressant use. About a quarter of users had no known psychiatric indication and the indication remained unclear. Short-term and non-psychiatric use are more commonly prescribed for the elderly.

Treatment of anxiety disorders in the Finnish general population.

BACKGROUND: Treatments for anxiety disorders in the general population are not widely investigated. We determined the proportion, type and determinants of treatment in the Finnish general population. METHODS: Within the Health 2000 Study, a representative sample (n = 6005) of adults (age > 30 years) were interviewed in 2000-2001 with the Composite International Diagnostic Interview (M-CIDI) to assess the presence of DSM-IV mental disorders during the preceding 12 months. Logistic regression models were used to examine factors influencing the type of treatment (pharmacotherapy and/or psychological treatment) and also the types of pharmacotherapy (antidepressants, anxiolytics, or sedatives and hypnotics) used for anxiety disorders. RESULTS: For individuals with an anxiety disorder, 40% (95/229) currently used psychotropic medication, 23% (55/229) used antidepressants, 19% (44/229) anxiolytics and 17% (41/229) sedatives or hypnotics. Of those using health care services for mental health reasons (34%, 76/229), 80% (61/76) received pharmacotherapy. Only 45% (34/76) reported having psychological treatment, with few having more than 4 visits (27%, 20/76). Living in a semi-urban environment, retirement and high perceived disability increased the likelihood of pharmacotherapy-only treatment; higher education and comorbidity with mood disorders increased the likelihood of psychological treatment. General practitioners more often than psychiatrists provided pharmacotherapy treatment alone (67% vs. 34%, p < 0.05), particularly anxiolytics or sedatives. LIMITATIONS: Use of mental health services and psychological treatment were based on self-reports. No data on duration of pharmacotherapy was available. CONCLUSIONS: Anxiety disorders remain largely untreated in the general population. Among those seeking treatment, pharmacotherapy predominates, whereas even brief psychotherapies are rare. Contrary to clinical guidelines, anxiolytics and sedatives are commonly used instead of antidepressants.

Switching of H(2)-Receptor Antagonists to Over-the-Counter Status in Finland : Implications for Consumption and Adverse Effects.

OBJECTIVE: To evaluate the consumption and safety of H(2)-receptor antagonists after switching ranitidine and famotidine to over-the-counter (OTC) status. METHODS: The Finnish drug consumption data, based on the sales of medicines, and the national register for adverse drug reactions (ADRs) from 1990 to 2003 were used. We studied the consumption of H(2)-receptor antagonists, proton pump inhibitors, sucralfate and antacids (A02BA, A02BC, A02BX02 and A02A, respectively, according to the Anatomical Therapeutic Chemical [ATC] classification). We compared the ADRs of H(2)-receptor antagonists with proton pump inhibitors. RESULTS: The total consumption of medicines for the treatment of peptic ulcer disease and gastro-oesophageal reflux disease increased more than 2-fold from 1990 to 2003 (from 12.8 daily defined doses [DDD]/1000 inhabitants/day to 29.6 DDD/1000 inhabitants/day). Initially, switching ranitidine and famotidine to OTC status in 1996 increased their consumption. Since 1998, proton pump inhibitors have been the most commonly used drug group for the treatment of peptic ulcer and gastro-oesophageal reflux disease in Finland. In 2003, the consumption of proton pump inhibitors was 75% (22.2 DDD/1000 inhabitants/day) of the total consumption of drugs for the treatment of peptic ulcer and gastro-oesophageal reflux disease. Switching ranitidine and famotidine to OTC status did not affect the number of reported adverse reactions to these drugs. CONCLUSIONS: According to information collected from the Finnish consumption and ADR databases, H(2)-receptor antagonists are very often used in self-medication and they do not have serious adverse effects. However, the total number of reports concerning these ATC groups in the national ADR database is not very high, and therefore patient-based surveys are needed to verify this finding.