A study on the quantity, type, economic value and reasons for pharmaceutical waste returned to pharmacies in Finland.

INTRODUCTION: Some medicines purchased are not used, resulting in pharmaceutical waste. Finland, among many other countries, is seeking to reduce the amount of pharmaceutical waste, but little information on this is currently available. This study aimed to evaluate the quantity, type, economic value, and reasons for returning pharmaceutical waste from households to community pharmacies in Finland. METHODS: Community pharmacies (n = 82) quantified and qualified the amount of pharmaceutical waste returned to them over three days in May 2022. The data was collected using an electronic form. The reasons for returning medicines were asked from customers who returned medicines using a paper questionnaire. The data was analyzed for frequencies and percentages. To estimate the economic value, we used the Finnish medicines prices at the end of June 2022. The annual economic value was calculated by means of a pharmacy size-weighted average. The confidence intervals were estimated using the non-parametric bootstrap method. Sensitivity analyses were conducted to examine the reliability of the results. RESULTS: In total, 5173 medicines were returned to pharmacies, of which 66 % were prescription medicines. The most common medicines group returned were medicines for nervous system (18 %), respiratory system (16 %), and alimentary tract and metabolism (12 %). The estimated annual economic value of the medicines returned was 81 million euros (CI 95 % M€61-M€103), of which the cost to society was 43 million euros (CI 95 % M€30-M€60). 799 customers responded to the questionnaire (Response rate 81.9 %). The limited shelf life of the medicine after opening (36 %), improvement of the medical condition or symptom (25 %), and the unnecessarily large pack size (22 %) were common reasons for returning. CONCLUSION: A considerable amount of pharmaceutical waste is returned to pharmacies, causing unnecessary costs to both individuals and society, indicating the need to reduce waste. The limited shelf life and large pack sizes of medicines account for a large proportion of causes for household pharmaceutical waste. Reducing pharmaceutical waste requires action from all actors in the pharmaceutical chain.

Effectiveness of the Coordinated Return to Work model after orthopaedic surgery for lumbar discectomy and hip and knee arthroplasty: a register-based study.

OBJECTIVES: This study examined the effectiveness of an individualised Coordinated Return to Work (CRtW) model on the length of the return to work (RTW) period compared with a standard prescription of 2-3 months RTW during recovery after lumbar discectomy and hip and knee arthroplasty among Finnish working-age population. METHODS: Cohorts on patients aged 18-65 years old with lumbar discectomy or hip or knee arthroplasty were extracted from the electronic health records of eight Finnish hospital districts in 2015-2021 and compiled with retirement and sickness benefits. The overall effect of the CRtW model on the average RTW period was calculated as a weighted average of area-specific mean differences in RTW periods between 1 year before and 1 year after the implementation. Longer-term effects of the model were examined with an interrupted time series design estimated with a segmented regression model. RESULTS: During the first year of the CRtW model, the average RTW period shortened by 9.1 days (95% CI 4.1 to 14.1) for hip arthroplasty and 14.4 days (95% CI 7.5 to 21.3) for knee arthroplasty. The observed differences were sustained over longer follow-up times. For lumbar discectomy, the first-year decrease was not statistically significant, but the average RTW had shortened by 36.2 days (95% CI 33.8 to 38.5) after 4.5 years. CONCLUSIONS: The CRtW model shortened average RTW periods among working-age people during the recovery period. Further research with larger samples and longer follow-up times is needed to ensure the effectiveness of the model as a part of the Finnish healthcare system.

Agreement between physician- and patient-reported Canadian cardiovascular society scores among patients undergoing elective coronary angiography-The CATS study.

The primary aim of revascularization in stable coronary artery disease (CAD) is symptom relief. The severity of symptoms is usually evaluated by the physician, not by the patient. We examined the agreement between physician- and patient-reported Canadian Cardiovascular Society (CCS) scores among patients scheduled for elective coronary angiography in a cross-sectional study. Patients (n = 650) and cardiologists evaluated the severity of angina symptoms by filling the CCS questionnaire before coronary angiography. Patients were divided into those without CAD (stenosis diameter <50%, n = 445) and those with CAD (stenosis diameter >50%, n = 205). CAD patients were further divided into three groups according to disease severity (single-, double- or triple-vessel disease). The mean age of the patients was 67.6 (9.9) years and 50.6% were women. In 51.8% (95% CI 44.5%-59.0%) of patients with CAD and 51.9% (95% CI 47.0%-56.8%) of those without, physician- and patient reported CCS scores agreed. The physician reported better CCS scores in 33.9% (95% CI 27.6%-40.7%) of patients with CAD and 36.2% (95% CI 31.8%-41.0%) of patients without CAD. The proportions of full or partial agreement between physician- and patient reported CCS scores were similar across the CAD severity groups. To summarize, we observed a significant discrepancy between the physician- and patient-reported symptom severity in patients with or without CAD scheduled for angiography. The physician underestimated the symptoms in third of the cases. Thus, patient-reported symptom severity, rather than physician's evaluation, should be the cornerstone of treatment decisions.

Experience of the adequacy and appropriateness of pharmaceuticals-related environmental information and preferred information channels among Finns.

The normal use of medicines is the major environmental source of pharmaceuticals and a significant contributor to the chemicalization of the environment. Despite the key role of medicine users in contributing to this environmental challenge, little research has been conducted into the current state of lay people's pharmaceuticals-related environmental information, namely the information received, the information needed, the topics included in the information received, topics of interest, and previous and preferred information channels. In this study, these aspects were studied among 2,030 Finnish adults by means of an electronic survey. Of the respondents, 84.5% had received information related to pharmaceuticals in the environment (PiE). Female gender, higher age, high education level, general environmental friendliness, and use of prescription medicines were associated with a greater likelihood that information had been received. Furthermore, 39.8% of the respondents considered the amount of information received to be sufficient. Respondents had most commonly received information on 1 to 3 different topics. Proper disposal of medicines and pharmaceutical residues ending up in the environment in general were the most common topics covered by the information received. Medicines disposal and the effects of environmental pharmaceutical residues on people were the most interesting topics among the respondents. PiE-related information was most commonly obtained from traditional media (80.4%) and websites (40.5%), the least common source of PiE-related information being physicians (1.6%). The respondents were eager to receive such information in the future, preferring traditional media and medicine package leaflets as the most convenient information channels. These findings indicate a need for more diverse PiE-related information via easily accessible information channels that can vary based on sociodemographic characteristics.

Reimbursement and use of oral anticoagulants during 2014-2022 - A register-based study.

Background: Vitamin K antagonists, warfarin in particular, have been the mainstay of anticoagulation therapy, but their use has declined in many countries since direct oral anticoagulants (DOACs) have entered the market. Objective: To examine utilization trends of oral anticoagulants (OACs) in Finland considering the reimbursement of DOACs and changes to national treatment guidelines for the treatment of atrial fibrillation (AF). Methods: Both public, aggregated data on reimbursed OAC dispensations and individual-level data on electronic dispensations during 2014-2022 were applied. Data on electronic dispensations during 2015-2016 were used to study OAC initiations. Data on entitlements to reimbursement for DOACs came from public data. Results: In 2014, there were almost 20,000 DOAC users, rising to 214,000 in 2022. The number of warfarin users declined since 2015 from over 181,000 to around 59,000 users in 2022, DOACs exceeding warfarin in the number of users in 2019. The total DOAC costs were higher than warfarin costs each year. Rivaroxaban was the most widely used DOAC during 2014-2018, and apixaban during 2019-2022. In 2015, there were more warfarin (56.7%) than DOAC (43.3%) initiators, but the result was opposite for 2016 (warfarin 39.4%, DOACs 60.6%). The number of individuals entitled to reimbursement for DOACs has increased steadily, and in 2022, there were over 196,000 individuals entitled to this reimbursement due to AF. Conclusions: The uptake of DOACs in Finland appears to have been gradual and slower than in many other countries. During the 2010s, the treatment guidelines for AF were more cautious in recommending DOACs than the European guidelines. The use of DOACs increased as their reimbursement became less restrictive.

The use of isCGM leads to marked reduction in severe hypoglycemia requiring emergency medical service or hospital admission and diabetic ketoacidosis in adult type 1 diabetes patients.

AIMS: To determine the effect of the use of intermittently scanned continuous glucose monitoring (isCGM) on acute diabetes-related complications in adult type 1 diabetes patients. METHODS: Six hundred and forty-two adult type 1 diabetes patients with isCGM were identified from electronic health records in Siun sote region in Eastern Finland. A retrospective real-world analysis was conducted combining hospital admission and prehospital emergency service data to compare incidences of hypoglycemia requiring emergency medical support (EMS) involvement or hospital admission and diabetic ketoacidosis (DKA) before and after the start of isCGM. Data were collected from January 2015 to April 2020. Primary outcome was the rate of hypoglycemia requiring EMS involvement or hospital admission and DKA events. HbA1c was recorded at the start of isCGM and was compared with the last known HbA1c during the use of isCGM. The isCGM used in the study did not contain alarm functions. RESULTS: Altogether 220 hypoglycemic events were identified during the study period. Incidence rate of hypoglycemic events decreased after the start of isCGM (72 events, incidence rate 50 events/1000 person-years) compared with the time before the start (148 events, incidence rate 76 events/1000 person-years) (p = 0.043). The incidence rate of DKA decreased after the start of isCGM compared with time before isCGM use (4 and 15 events/1000 person-years, respectively; p = 0.002). The change in mean HbA1c was - 0.28% (- 3.1 mmol/mol) between baseline and the last HbA1c measurement (p < 0.001). CONCLUSIONS: In addition to lowering HbA1c in type 1 diabetes patients, isCGM is also effective in preventing acute diabetes-related complications such as hypoglycemia requiring EMS involvement or hospital admission and DKA.

Real-world effectiveness of digital and group-based lifestyle interventions as compared with usual care to reduce type 2 diabetes risk - A stop diabetes pragmatic randomised trial.

Background: No real-world randomised controlled trials (RCTs) have explored the effectiveness of lifestyle interventions based on multiple behaviour change theories and using combined digital and group-based face-to-face delivery to improve risk factors for type 2 diabetes (T2D). Methods: We conducted a one-year, multi-centre, unblinded, pragmatic RCT in primary healthcare using the habit formation, self-determination, and self-regulation theories among 2907 adults aged 18-74 years at increased T2D risk randomised into a digital lifestyle intervention group (DIGI, n = 967), a combined digital and group-based lifestyle intervention group (DIGI+GROUP, n = 971), and a control group receiving usual care (CONTROL, n = 969). We collected data on primary outcomes (diet quality by Healthy Diet Index [HDI], physical activity, body weight, fasting plasma glucose, 2-hour plasma glucose) and secondary outcomes (sedentary time, waist circumference, fasting plasma insulin) using digital questionnaires, clinical examinations, fasting blood tests, and 2-hour oral glucose tolerance tests. Main statistical analyses were performed using linear mixed-effects models adjusted for age, sex, and province. This RCT was registered with ClinicalTrials.gov, NCT03156478. Findings: The 2907 participants assigned were recruited between March 1st, 2017, and February 28th, 2018. Diet quality improved more (3·2 vs. 1·4 HDI points, p<0·001 for difference between groups, p'<0·001 for group*time interaction) and waist circumference tended to decrease more (-1·8 vs. -1·3 cm, p = 0·028, p' = 0·068) in DIGI+GROUP than in CONTROL. Fasting insulin tended to increase in CONTROL but not in DIGI (1·0 vs. 0·0 mU/L, p = 0·033, p' = 0·054) or in DIGI+GROUP (1·0 vs. 0·5 mU/L, p = 0·042, p' = 0·054). Good adherence to DIGI and DIGI+GROUP (≥median of 501 habits/year in DIGI, ≥5 of all 6 sessions in GROUP) was associated with improved diet quality and good adherence to DIGI with increased physical activity and decreased sedentary time. Interpretation: A lifestyle intervention based on multiple behaviour change theories and combined digital and group-based face-to-face delivery improves diet quality and tends to decrease abdominal adiposity and prevent an increase in insulin resistance. Good adherence improves the results of the interventions. Funding: Strategic Research Council at Academy of Finland, Academy of Finland, Novo Nordisk Foundation, and Finnish Diabetes Research foundation.

Data-Driven Identification of Long-Term Glycemia Clusters and Their Individualized Predictors in Finnish Patients with Type 2 Diabetes.

Purpose: To gain an understanding of the heterogeneous group of type 2 diabetes (T2D) patients, we aimed to identify patients with the homogenous long-term HbA1c trajectories and to predict the trajectory membership for each patient using explainable machine learning methods and different clinical-, treatment-, and socio-economic-related predictors. Patients and Methods: Electronic health records data covering primary and specialized healthcare on 9631 patients having T2D diagnosis were extracted from the North Karelia region, Finland. Six-year HbA1c trajectories were examined with growth mixture models. Linear discriminant analysis and neural networks were applied to predict the trajectory membership individually. Results: Three HbA1c trajectories were distinguished over six years: "stable, adequate" (86.5%), "improving, but inadequate" (7.3%), and "fluctuating, inadequate" (6.2%) glycemic control. Prior glucose levels, duration of T2D, use of insulin only, use of insulin together with some oral antidiabetic medications, and use of only metformin were the most important predictors for the long-term treatment balance. The prediction model had a balanced accuracy of 85% and a receiving operating characteristic area under the curve of 91%, indicating high performance. Moreover, the results based on SHAP (Shapley additive explanations) values show that it is possible to explain the outcomes of machine learning methods at the population and individual levels. Conclusion: Heterogeneity in long-term glycemic control can be predicted with confidence by utilizing information from previous HbA1c levels, fasting plasma glucose, duration of T2D, and use of antidiabetic medications. In future, the expected development of HbA1c could be predicted based on the patient's unique risk factors offering a practical tool for clinicians to support treatment planning.

Modelling health and economic impact of nutrition interventions: a systematic review.

Diet related non-communicable diseases (NCDs), as well as micronutrient deficiencies, are of widespread and growing importance to public health. Authorities are developing programs to improve nutrient intakes via foods. To estimate the potential health and economic impact of these programs there is a wide variety of models. The aim of this review is to evaluate existing models to estimate the health and/or economic impact of nutrition interventions with a focus on reducing salt and sugar intake and increasing vitamin D, iron, and folate/folic acid intake. The protocol of this systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016050873). The final search was conducted on PubMed and Scopus electronic databases and search strings were developed for salt/sodium, sugar, vitamin D, iron, and folic acid intake. Predefined criteria related to scientific quality, applicability, and funding/interest were used to evaluate the publications. In total 122 publications were included for a critical appraisal: 45 for salt/sodium, 61 for sugar, 4 for vitamin D, 9 for folic acid, and 3 for iron. The complexity of modelling the health and economic impact of nutrition interventions is dependent on the purpose and data availability. Although most of the models have the potential to provide projections of future impact, the methodological challenges are considerable. There is a substantial need for more guidance and standardization for future modelling, to compare results of different studies and draw conclusions about the health and economic impact of nutrition interventions.

Marked Improvement in A1C Levels After Initiation of Intermittently Scanned Continuous Glucose Monitoring Is Maintained Over 4 Years in Patients With Type 1 Diabetes.

Objective: This study aimed to demonstrate the effectiveness of long-term use of intermittently scanned continuous glucose monitoring (isCGM) in adult patients with type 1 diabetes. Design and methods: In this retrospective real-world study, 689 patients with type 1 diabetes who were >18 years of age and using isCGM were identified from the electronic patient records in North Karelia, Finland. A1C data were collected before and after the initiation of isCGM. The primary outcome was a change in the mean A1C over time after isCGM started. Results: The greatest reductions in the mean A1C levels were observed 6 months (-0.54% [-5.9 mmol/mol], P <0.001) and 12 months (-0.42% [-4.6 mmol/mol], P <0.001) after the initiation of isCGM. Reduction in A1C remained significant for 4 years, although the mean reduction in A1C was -0.18% (-2.05 mmol/mol) (P = 0.009) at 48 months compared with baseline. In a subgroup analysis, patients with a baseline A1C >9% (75 mmol/mol) benefited the most from initiation of isCGM (reduction -0.97% [-10.6 mmol/mol], P <0.001, at 12 months and -0.92% [-10.1 mmol/mol], P <0.001, at 48 months). Neither sex nor age at the start of isCGM were correlated with A1C reduction. Conclusion: Use of isCGM improves A1C levels significantly in adult patients with type 1 diabetes. Significant reduction in A1C persisted over 4 years of use, although the effect diminished over time.

Economic evaluation of infliximab, synthetic triple therapy and methotrexate in the treatment of newly diagnosed juvenile idiopathic arthritis.

BACKGROUND: Evaluation of costs and short-term cost-effectiveness of infliximab plus methotrexate (IFX + MTX); triple therapy of hydroxychloquine, sulphasalazine, and methotrexate (TRIPLE); or methotrexate monotherapy (MTX) in patients with new-onset polyarticular juvenile idiopathic arthritis (JIA). METHODS: In a prospective multicenter study (ACUTE-JIA), costs and health outcomes of 60 randomized patients with new-onset disease-modifying anti-rheumatic drug (DMARD)-naïve polyarticular JIA were analyzed during the first year. A mapping algorithm was used to obtain utility values from Child Health Assessment Questionnaire (CHAQ). Wallace criteriae were used to assess clinically inactive disease (CID). Linear regression with non-parametric bootstrapping was used to adjust imbalances at baseline. RESULTS: Using prices for IFX biosimilar, adjusted annual mean (SD) costs of treatment (€) were 21,164 (4158), 12,136 (5286), and 18,300 (8635) on IFX + MTX, TRIPLE, and MTX, respectively. Incremental cost-effectiveness ratio (ICER) for IFX + MTX as compared with TRIPLE or MTX were 3442 € or 678 € per additional month spent in CID. Mean (SD) quality-adjusted life years (QALYs) for IFX + MTX, TRIPLE and MTX were 0.755 (0.065), 0.725 (0.062), and 0.686 (0.124). ICER for IFX + MTX vs TRIPLE was 294,433 €, and for IFX + MTX vs MTX 31,435 € per QALY gained. CONCLUSIONS: In short-term, biosimilar IFX + MTX can be considered cost-effective when compared with MTX alone. TRIPLE was cost-effective when compared with MTX and showed cost advantage when compared with IFX + MTX. Cost per time spent in CID showed similar results than ICER evaluations. TRIAL REGISTRATION: This trial was primarily registered with the Ethical Board of Helsinki District University Hospital ( https://www.hus.fi ), clinical trial number 211864, and later with ClinicalTrials.gov, number NCT01015547.

Effects of COVID-19 Pandemic and Lockdown on Monitoring and Treatment Balance of Finnish Coronary Heart Disease and Type 2 Diabetes Patients.

Purpose: We aimed to examine the effect of the COVID-19 pandemic and lockdown on monitoring and treatment balance of Finnish coronary heart disease (CHD) and type 2 diabetes (T2D) patients. Patients and Methods: We used data from the electronic health records on 1604 CHD and 10,136 T2D patients aged 18‒85 years in Eastern Finland. Measurement and levels of low-density lipoprotein cholesterol (LDL) of CHD patients and glycated haemoglobin (HbA1c) of T2D patients were assessed monthly during January 2019-June 2021. Interrupted time-series analysis design was utilized to examine the effect of the lockdown on proportion of patients monitored and treatment balance. Results: Reductions in frequencies of LDL testing of CHD and HbA1c testing of T2D patients were observed during the national lockdown. Downward trend in average LDL was observed from January 2019 until June 2021. Average HbA1c values increased from January 2019 to March 2020 with an additional increase by 2.04 mmol/mol (0.80 to 3.29) in April 2020. However, there was a downward trend in monthly average HbA1c during the lockdown until June 2021 with an additional change in level by 0.61 mmol/mol (95% CI 0.06 to 1.16) in July 2020. Conclusion: The lockdown decreased the frequency of monitoring among both CHD and T2D patients. Meanwhile, monthly average LDL had a steadily improving pattern in CHD patients during the follow-up while temporary worsening in HbA1c in patients with T2D was observed at the time of the lockdown. The lockdown may have introduced selection in patients who had their treatment outcomes monitored. Better self-management of risk factors among patients is also possible.

Economic evaluation of using polygenic risk score to guide risk screening and interventions for the prevention of type 2 diabetes in individuals with high overall baseline risk.

Type 2 diabetes (T2D) with increasing prevalence is a significant global public health challenge. Obesity, unhealthy diet, and low physical activity are one of the major determinants of the rise in T2D prevalence. In addition, family history and genetic risk of diabetes also play a role in the process of developing T2D. Therefore, solutions for the early identification of individuals at high risk for T2D for early targeted detection of T2D, prevention, and intervention are highly preferred. Recently, novel genomic-based polygenic risk scores (PRSs) have been suggested to improve the accuracy of risk prediction supporting the targeting of preventive interventions to those at highest risk for T2D. Therefore, the aim of the present study was to assess the cost-utility of an additional PRS testing information (as a part of overall risk assessment) followed by a lifestyle intervention and an additional medical therapy when estimated 10-year overall risk for T2D exceeded 20% among Finnish individuals screened as at the high-risk category (i.e., 10%-20% 10-year overall risk of T2D) based on traditional risk factors only. For a cost-utility analysis, an individual-level state-transition model with probabilistic sensitivity analysis was constructed. A 1-year cycle length and a lifetime time horizon were applied in the base-case. A 3% discount rate was used for costs and QALYs. Cost-effectiveness acceptability curve (CEAC) and estimates for the expected value of perfect information (EVPI) were calculated to assist decision makers. The use of the targeted PRS strategy reclassified 12.4 percentage points of individuals to be very high-risk individuals who would have been originally classified as high risk using the usual strategy only. Over a lifetime horizon, the targeted PRS was a dominant strategy (i.e., less costly, more effective). One-way and scenario sensitivity analyses showed that results remained dominant in almost all simulations. However, there is uncertainty, since the probability (EVPI) of cost-effectiveness at a WTP of 0€/QALY was 63.0% (243€) indicating the probability that the PRS strategy is a dominant option. In conclusion, the results demonstrated that the PRS provides moderate additional value in Finnish population in risk screening leading to potential cost savings and better quality of life when compared with the current screening methods for T2D risk.

Data-driven long-term glycaemic control trajectories and their associated health and economic outcomes in Finnish patients with incident type 2 diabetes.

BACKGROUND: Treatments should be customized to patients to improve patients' health outcomes and maximize the treatment benefits. We aimed to identify meaningful data-driven trajectories of incident type 2 diabetes patients with similarities in glycated haemoglobin (HbA1c) patterns since diagnosis and to examine their clinical and economic relevance. MATERIALS AND METHODS: A cohort of 1540 patients diagnosed in 2011-2012 was retrieved from electronic health records covering primary and specialized healthcare in the North Karelia region, Finland. EHRs data were compiled with medication purchase data. Average HbA1c levels, use of medications, and incidence of micro- and macrovascular complications and deaths were measured annually for seven years since T2D diagnosis. Trajectories were identified applying latent class growth models. Differences in 4-year cumulative healthcare costs with 95% confidence intervals (CIs) were estimated with non-parametric bootstrapping. RESULTS: Four distinct trajectories of HbA1c development during 7 years after T2D diagnosis were extracted: patients with "Stable, adequate" (66.1%), "Slowly deteriorating" (24.3%), and "Rapidly deteriorating" glycaemic control (6.2%) as well as "Late diagnosed" patients (3.4%). During the same period, 2.2 (95% CI 1.9-2.6) deaths per 100 person-years occurred in the "Stable, adequate" trajectory increasing to 3.2 (2.4-4.0) in the "Slowly deteriorating", 4.7 (3.1-6.9) in the "Rapidly deteriorating" and 5.2 (2.9-8.7) in the "Late diagnosed" trajectory. Similarly, 3.5 (95% CI 3.0-4.0) micro- and macrovascular complications per 100 person-years occurred in the "Stable, adequate" trajectory increasing to 5.1 (4.1-6.2) in the "Slowly deteriorating", 5.5 (3.6-8.1) in the "Rapidly deteriorating" and 7.3 (4.3-11.8) in the "Late diagnosed" trajectory. Patients in the "Stable, adequate" trajectory had lower accumulated 4-year medication costs than other patients. CONCLUSIONS: Data-driven patient trajectories have clinical and economic relevance and could be utilized as a step towards personalized medicine instead of the common "one-fits-for-all" treatment practices.

Willingness to Pay for Implementation of an Environmentally Friendly Pharmaceutical Policy in Finland-A Discrete Choice Experiment Study.

The use of pharmaceuticals is their main pathway to the environment, making the public a major stakeholder in environmentally friendly pharmaceutical policies, including an environmental classification system for medicines. We studied the Finnish adult population's (n = 2030) preferences and willingness to pay (WTP) for an environmentally friendly pharmaceutical policy by means of an online survey employing a discrete choice experiment (DCE). We also studied the relative importance of the policy attributes, namely, the environmental impact, geographical scope, available information about the environmental impact of a pharmaceutical, and the effect of the respondents' general environmental attitudes on the WTP. The total annual WTP of the Finnish adult population ranges from 37 million to 134 million euros, depending on the attribute levels. Moreover, the environmental attitude of a respondent had a significant impact on the WTP. Generally, the environmental impact of the policy was the most important attribute, the geographical scope of the policy the second, and information about the environmental impact of pharmaceuticals was the third most important attribute. However, the most environmentally friendly respondents preferred information as the second important attribute. This study provides insights into the environmental valuations of the public to be used in preparing new pharmaceutical policy measures.

Correlation of the disease-specific Canadian Cardiovascular Society (CCS) classification and health-related quality of life (15D) in coronary artery disease patients.

BACKGROUND: Generic health-related quality of life (HRQoL) and disease-specific instruments measure HRQoL from different aspects, although generic instruments often contain dimensions that reflect common symptoms. We evaluated how the change in 15D HRQoL and Canadian Cardiovascular Society (CCS) grading of angina severity correlate among coronary artery disease patients during 12-month follow-up. METHODS: Altogether 1 271 patients scheduled for coronary angiography between June 2015 and February 2017 returned the 15D HRQoL and CCS questionnaires before angiography and after one-year follow-up as a part of routine clinical practice. Spearman correlations between one-year changes in the CCS and the 15D and its dimensions were evaluated. Changes in 15D were classified into 5 categories based on the reported minimal important difference (MID) for the instrument. RESULTS: Change in the CCS grade correlated moderately with the MID-based change in the 15D (r = 0.33, 95% confidence interval 0.27-0.39). Correlations between these instruments were similar in different age groups, between sexes and treatment modalities. Of the individual 15D dimensions, changes in breathing (r = 0.40) and vitality (r = 0.30) had the strongest correlations with CCS change. CONCLUSION: The symptom-based evaluation of the change in the CCS grade may not catch the full benefit or harm of the treatment and vice versa, a generic instrument, such as 15D, likely does not fully capture change in disease-specific symptoms. Thus, generic and disease-specific instruments are complementary and should be used in conjunction.

Hospital treatment costs associated with incident complications in patients with type 2 diabetes-real-world study based on electronic patient information systems.

BACKGROUND: Type 2 diabetes (T2D) and its complications cause a significant public health and economic challenge. To enable the optimal resource allocation across different prevention and treatment policies for the management of T2D-related complications, detailed cost estimates related to the complications of T2D are needed. Therefore, the objective of the study was to provide reliable and sufficiently detailed real-world estimates of costs associated with different T2D complications in a Finnish university hospital setting. METHODS: A cohort of T2D patients living in the catchment area of a university hospital during 2012 and 2016 was identified from the comprehensive national FinDM diabetes database for longitudinal assessment of T2D associated complication treatment costs. Data on patient-level events were extracted from the FinDM data and complemented with all accountable services and related detailed costing data gathered from the university hospital's electronic patient information systems by using unique personal identity codes. Patients were screened for their first diagnoses of complications using the same national quality registry definitions as in the FinDM database. Multivariable gamma regression model with a log link function was applied to study the association between baseline factors and complication costs. In addition, an interactive online tool was developed to create predicted costs for complication costs with selected baseline factors. RESULTS: A total of 27 255 prevalent and incident patients with T2D were identified from the national FinDM register. Finally, a total of 16 148 complication episodes for 7 895 patients were included in the cost analyses. The mean estimated one-year hospital treatment costs of T2D-related complication varied from 6 184 to 24 507 euros per complication. Regression analyses showed that coexisting conditions are significantly associated with initial and recurrent complication costs. CONCLUSIONS: The study shows updated Finnish cost estimates and their main cost drivers for T2D-related complications treated in the university hospital setting. The results of our study highlight the significance of guideline implementation, effective preventive treatments for T2D, as well as the importance of treatment adherence to avoid these costly complications.

Digitally Supported Lifestyle Intervention to Prevent Type 2 Diabetes Through Healthy Habits: Secondary Analysis of Long-Term User Engagement Trajectories in a Randomized Controlled Trial.

BACKGROUND: Digital health interventions may offer a scalable way to prevent type 2 diabetes (T2D) with minimal burden on health care systems by providing early support for healthy behaviors among adults at increased risk for T2D. However, ensuring continued engagement with digital solutions is a challenge impacting the expected effectiveness. OBJECTIVE: We aimed to investigate the longitudinal usage patterns of a digital healthy habit formation intervention, BitHabit, and the associations with changes in T2D risk factors. METHODS: This is a secondary analysis of the StopDia (Stop Diabetes) study, an unblinded parallel 1-year randomized controlled trial evaluating the effectiveness of the BitHabit app alone or together with face-to-face group coaching in comparison with routine care in Finland in 2017-2019 among community-dwelling adults (aged 18 to 74 years) at an increased risk of T2D. We used longitudinal data on usage from 1926 participants randomized to the digital intervention arms. Latent class growth models were applied to identify user engagement trajectories with the app during the study. Predictors for trajectory membership were examined with multinomial logistic regression models. Analysis of covariance was used to investigate the association between trajectories and 12-month changes in T2D risk factors. RESULTS: More than half (1022/1926, 53.1%) of the participants continued to use the app throughout the 12-month intervention. The following 4 user engagement trajectories were identified: terminated usage (904/1926, 46.9%), weekly usage (731/1926, 38.0%), twice weekly usage (208/1926, 10.8%), and daily usage (83/1926, 4.3%). Active app use during the first month, higher net promoter score after the first 1 to 2 months of use, older age, and better quality of diet at baseline increased the odds of belonging to the continued usage trajectories. Compared with other trajectories, daily usage was associated with a higher increase in diet quality and a more pronounced decrease in BMI and waist circumference at 12 months. CONCLUSIONS: Distinct long-term usage trajectories of the BitHabit app were identified, and individual predictors for belonging to different trajectory groups were found. These findings highlight the need for being able to identify individuals likely to disengage from interventions early on, and could be used to inform the development of future adaptive interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT03156478; https://clinicaltrials.gov/ct2/show/NCT03156478. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-6574-y.

Type 2 Diabetes-Related Health Economic Impact Associated with Increased Whole Grains Consumption among Adults in Finland.

The prevalence of type 2 diabetes (T2D) is increasing rapidly worldwide. A healthy diet supporting the control of energy intake and body weight has major importance in the prevention of T2D. For example, a high intake of whole grain foods (WGF) has been shown to be inversely associated with risk for T2D. The objective of the study was to estimate the expected health economic impacts of increased WGF consumption to decrease the incidence of T2D in the Finnish adult population. A health economic model utilizing data from multiple national databases and published scientific literature was constructed to estimate these population-level health economic consequences. Among the adult Finnish population, increased WGF consumption could reduce T2D-related costs between 286€ and 989€ million during the next 10-year time horizon depending on the applied scenario (i.e., a 10%-unit increase in a proportion of daily WGF users, an increased number (i.e., two or more) of WGF servings a day, or alternatively a combination of these scenarios). Over the next 20-30 years, a population-wide increase in WGF consumption could lead to much higher benefits. Furthermore, depending on the applied scenario, between 1323 and 154,094 quality-adjusted life years (QALYs) could be gained at the population level due to decreased T2D-related morbidity and mortality during the next 10 to 30 years. The results indicate that even when the current level of daily WGF consumption is already at a relatively high-level in a global context, increased WGF consumption could lead to important health gains and savings in the Finnish adult population.

Pharmacy-based screening to detect persons at elevated risk of type 2 diabetes: a cost-utility analysis.

BACKGROUND: Early identification of people at elevated risk of type 2 diabetes (T2D) is an important step in preventing or delaying its onset. Pharmacies can serve as a significant channel to reach these people. This study aimed to assess the potential health economic impact of screening and recruitment services in pharmacies in referring people to preventive interventions. METHODS: A decision analytic model was constructed to perform a cost-utility analysis of the expected national health economic consequences (in terms of costs and quality-adjusted life years, QALYs) of a hypothetical pharmacy-based service where people screened and recruited through pharmacies would participate in a digital lifestyle program. Cost-effectiveness was considered in terms of net monetary benefit (NMB). In addition, social return on investment (SROI) was calculated as the ratio of the intervention and recruitment costs and the net present value of expected savings. Payback time was the time taken to reach the break-even point in savings. In the base scenario, a 20-year time horizon was applied. Probabilistic and deterministic sensitivity analyses were applied to study robustness of the results. RESULTS: In the base scenario, the expected savings from the pharmacy-based screening and recruitment among the reached target cohort were 255.3 m€ (95% CI - 185.2 m€ to 717.2 m€) in pharmacy visiting population meaning 1412€ (95% CI - 1024€ to 3967€) expected savings per person. Additionally, 7032 QALYs (95% CI - 1344 to 16,143) were gained on the population level. The intervention had an NMB of 3358€ (95% CI - 1397€ to 8431€) using a cost-effectiveness threshold of 50,000 €/QALY. The initial costs were 122.2 m€ with an SROI of 2.09€ (95% CI - 1.52€ to 5.88€). The expected payback time was 10 and 8 years for women and men, respectively. Results were most sensitive for changes in effectiveness of the intervention and selected discount rate. CONCLUSIONS: T2D screening and recruitment to prevention programs conducted via pharmacies was a dominant option providing both cost savings and QALY gains. The highest savings can be potentially reached by targeting recruitment at men at elevated risk of T2D.