Factors associated with statin discontinuation near end of life in a Danish primary health care cohort.

BACKGROUND: Long-term preventive treatment such as treatment with statins should be reassessed among patients approaching end of life. The aim of the study was to describe the rate of discontinuation of statin treatment and factors associated with discontinuation in the 6 months before death. METHODS: This study is a retrospective cohort study using national registers and blood test results from primary health care patients. Patients in the Copenhagen municipality, Denmark who died between 1997 and 2018 and were statin users during the 10-year period before death were included. We calculated the proportion who remained statin users in the 6-month period before death. Factors associated with discontinuation were tested using logistic regression. RESULTS: A total of 55,591 decedents were included. More patients continued treatment (64%, n = 35,693) than discontinued (36%, n = 19,898) the last 6 months of life. The 70 and 80 age groups had the lowest odds of discontinuing compared to the 90 (OR 1.59, 95% CI 0.93-2.72) and 100 (OR 3.11, 95% CI 2.79-3.47) age groups. Increasing comorbidity score (OR 0.89, 95% CI 0.87; 0.90 per 1-point increase) and use of statins for secondary prevention (OR 0.89, 95% CI 0.85; 0.93) reduced the likelihood of discontinuation as did a diagnosis of dementia, heart failure, or cancer. CONCLUSION: A substantial portion of patients continued statin treatment near end of life. Efforts to promote rational statin use and discontinuation are required among patients with limited life expectancy, including establishing clear, practical recommendations about statin discontinuation, and initiatives to translate recommendations into clinical practice.

Drug-drug interaction between warfarin and statins: A Danish cohort study.

Initiation of statin treatment is suggested to increase the international normalised ratio (INR) among warfarin users. However, available data is limited and conflicting. We conducted a register-based cohort study to evaluate the drug-drug interaction between warfarin and statins. By linking data on INR measurements and filled prescriptions, we identified warfarin users 2000-2015 initiating simvastatin (n = 1363), atorvastatin (n = 165) or rosuvastatin (n = 23). Simvastatin initiation led to an increase in mean INR from 2.40 to 2.71, with INRs peaking after 4 weeks, corresponding to a mean change of 0.32 (95%CI 0.25-0.38). High-dose and low-dose simvastatin led to comparable changes (mean change 0.33 vs 0.29). Initiation of atorvastatin and rosuvastatin lead to INR increases of 0.27 (95%CI 0.12-0.42) and 0.30 (95%CI -0.09-0.69). In conclusion, initiation of simvastatin, atorvastatin or rosuvastatin among warfarin users led to a minor increase in INR. The magnitude of this change is for most patients likely of limited clinical relevance.

Decreased plasma lipid levels in a statin-free Danish primary health care cohort between 2001 and 2018.

BACKGROUND: Lipid levels in blood have decreased considerably during the past decades in the general population partly due to use of statins. This study aims to investigate the trends in lipid levels between 2001 and 2018 in a statin-free population from primary health care, overall and by sex and age. METHODS: In a cohort of 634,119 patients from general practice with no diagnoses or medical treatments that affected lipid levels of total cholesterol (TC; n = 1,574,339) between 2001 and 2018 were identified. Similarly, measurements of low-density lipoprotein cholesterol (LDL-C; n = 1,302,440), high-density lipoprotein cholesterol (HDL-C; n = 1,417,857) and triglycerides (TG; n = 1,329,477) were identified. RESULTS: Mean TC decreased from 5.64 mmol/L (95% CI: 5.63-5.65) in 2001 to 5.17 mmol/L (95% CI: 5.16-5.17) in 2018 while LDL-C decreased from 3.67 mmol/L (95% CI: 3.66-3.68) to 3.04 mmol/L (95% CI: 3.03-3.04). Women aged 70-74 years experienced the largest decreases in TC levels corresponding to a decrease of 0.7 mmol/L. The decrease in LDL-C levels was most pronounced in men ≥85 years with a decrease of 0.9 mmol/L. For both genders, TC and LDL-C levels increased with advancing age until around age 50. After menopause the women had higher TC and LDL-C levels than the men. The median (geometric mean) TG level decreased by 0.4 mmol/L from 2001 to 2008, after which it increased slightly by 0.1 mmol/L until 2018. During life the TG levels of the men were markedly higher than the women's until around age 65-70. HDL-C levels showed no trend during the study period. CONCLUSIONS: The levels of TC and LDL-C decreased considerably in a statin-free population from primary health care from 2001 to 2018. These decreases were most pronounced in the elderly population and this trend is not decelerating. For TG, levels have started to increase, after an initial decrease.

Patterns of complementary and alternative medicine use among Arab immigrants in Denmark: A qualitative study.

Aims: The aim of this study was to explore patterns of complementary and alternative medicine use among Arab immigrants in Denmark, in order to increase insight into the hidden practices of this ethnic group. Methods: In this study, 21 Arab immigrants in Denmark were interviewed in Arabic. A purposive strategic sample was recruited from mosques, a healthcare center and by snowballing. Semi-structured interviews were conducted, then audiotaped and transcribed. The analysis was conducted according to Malterud's principles for systematic text condensation and guidelines for qualitative research. Results: Different types of complementary and alternative medicine, referred to as Arabic and Islamic medicine, were used including dietary practices; spiritual healing and cupping therapy, which were mainly used for acute diseases, painful conditions and what so-called jinn-related diseases. Conclusions: Arabic and Islamic medicine is a special form of complementary and alternative medicine, used by some Arab immigrants, which appears to be deeply embedded in their health beliefs within cultural and religious contexts. Healthcare providers should be familiar with diverse health practices and beliefs in order to provide culturally sensitive care and improve the quality of care delivered to ethnic minority patients with different religious backgrounds.

Psychological consequences of screening for cardiovascular risk factors in an un-selected general population: results from the Inter99 randomised intervention study.

BACKGROUND: Concerns that general health checks, including screening for risk factors to ischemic heart disease (IHD), have negative psychological consequences seem widely unfounded; however, previous studies are only based on self-reports from participants. AIM: To investigate if risk factor screening in healthy adults leads to mental distress in the study population, independent of participation. METHODS: The Inter99 study (1999 - 2006) was a randomised intervention in the general population, aiming to prevent IHD by a healthier lifestyle. We included the whole study population, independent of participation (n = 60,915). We merged data with information on the use of psychotropic medication and/or hospitalisation due to psychiatric diagnoses, as retrieved from national registers in Denmark, 4 years before and 5 years after the study began. We conducted analyses using generalised estimating equations. RESULTS: There was no significant difference between the intervention and control groups in their use of antipsychotics, hypnotics/sedatives, antidepressants or anxiolytics. As regards admission to the hospital with mental disorders, no significant difference was seen. These findings were true based on a yearly basis, and when investigating both short-term and a long-term effects of the intervention. There was no interaction with socioeconomic status. Of the 918 persons with a psychiatric diagnosis before the study start, 303 (33%) were re-admitted in the intervention period. Pre-screening of psychological status did not influence the psychological impact of screening. CONCLUSIONS: This large, randomised intervention study supports that screening for risk factors to IHD does not increase mental distress, not even in the mentally or socioeconomically most vulnerable persons. This study included the whole Inter99 study population not only study participants.

Social-, age- and gender differences in testing and positive rates for Chlamydia trachomatis urogenital infection - a register-based study.

BACKGROUND: Chlamydia trachomatis is suspected of causing female infertility. It is the most widespread sexually transmitted infection with an estimated general prevalence of ~5-10% with a peak in younger individuals. C. trachomatis infection is more prevalent among lower social classes. OBJECTIVE: In this study, the association between age, gender, social status and testing and positive rates is investigated in the age group 15-24 years. DESIGN: Case-control study linked to data from Statistics Denmark. METHODS: Data from the Department of Microbiology, Hvidovre University Hospital, Copenhagen were used and included 21887 people tested by general practitioners (GPs) and 3177 people tested at a venereological clinic. The age range was 15-24 years in 2011. These data were linked with the parental educational status delivered by Statistics Denmark, which also delivered a matched control group. The data were analysed using a case-control design. RESULTS: Testing was more frequent in the following groups: age range 20-24 years, females and patients with higher parental educational status. About 87.3% of patient had been tested by GPs. Positive rates were highest among males at the general practice constituting 17.1% versus females 10.6%, younger individuals and patients with lower parental educational status. CONCLUSIONS: The C. trachomatis testing pattern and positive rates highlight a need for a greater focus on males, younger patients and individuals with a lower social status.

Models of care for improving health-related quality of life, mental health, or mortality in persons with multimorbidity: A systematic review of randomized controlled trials.

Objectives: To categorize and examine the effectiveness regarding health-related quality of life (HRQoL), mental health, and mortality of care models for persons with multimorbidity in primary care, community care, and hospitals through a systematic review. Methods: We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials up to May 2020. One author screened titles and abstracts, and to validate, a second author screened 5% of the studies. Two authors independently extracted data and assessed risk of bias using the tool by the Cochrane Effective Practice and Organisation of Care group. Study inclusion criteria were (1) participants aged ≥ 18 years with multimorbidity; (2) referred to multimorbidity or two or more specific chronic conditions in the title or abstract; (3) randomized controlled design; and (4) HRQoL, mental health, or mortality as primary outcome measures. We used the Foundation Framework to categorize the models and the PRISMA-guideline for reporting. Results: In this study, the first to report effectiveness of care models in patients with multimorbidity in hospital settings, we included 30 studies and 9,777 participants with multimorbidity. 12 studies were located in primary care, 9 in community care, and 9 in hospitals. HRQoL was reported as the primary outcome in 12 studies, mental health in 17 studies, and mortality in three studies-with significant improvements in 5, 14, and 2, respectively. The studies are presented according to settings. Conclusions: Although 20 of the care models reported positive effects, the variations in populations, settings, model elements, and outcome measures made it difficult to conclude on which models and model elements were effective.

Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system.

BACKGROUND: Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. METHODS: Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. RESULTS: More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. CONCLUSIONS: More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.