Socioeconomic Variations in Use of Prescription Medicines for COPD: A Register-Based Study.

BACKGROUND: The purpose of this study was to examine socioeconomic variations in the use of prescription medicines among elderly subjects with COPD. METHODS: Data from the Danish national administrative registers were used. The study population included 1,365 individuals >60 y old residing in the Municipality of Copenhagen and diagnosed with COPD in a hospital setting in 2007. Logistic regression analysis was applied to examine the associations between the use of all prescription medicines for obstructive pulmonary diseases and the use of long-acting bronchodilators, in subject groups of different socioeconomic position. RESULTS: The study demonstrated that approximately 90% of subjects with COPD purchased at least one prescription medicine for obstructive pulmonary diseases, whereas approximately 50% purchased a long-acting bronchodilator. Medicine use did not vary according to educational status or personal wealth. CONCLUSIONS: There were no systematic socioeconomic differences in the use of relevant prescription medicines in elderly subjects diagnosed with COPD in hospital settings in Copenhagen. However, our findings indicate a gap between guideline recommendations and observed use of long-acting bronchodilators and hence suboptimal quality of treatment in the elderly COPD population.

Empirical relations between sense of coherence and self-efficacy, National Danish Survey.

Salutogenic orientation is a health promotion paradigm focusing on the resources of the individual. This study analyzed the relationship between sense of coherence (SOC) and self-efficacy (SE) based on population data. By conducting an empirical analysis of the two models, we wanted to see whether we could make a valid judgement as to whether both SOC and SE could be utilized in health promotion practice, or whether one is preferable to the other. The study population was randomly selected from the Danish Central Population Register and consisted of five birth-year cohorts (1920, 1930, 1940, 1965 and 1975). The study used the 13-item SOC scale and the general SE scale. The main findings were that SOC score increased by age cohort (p = 0.0004), and there is a positive and graded correlation between SOC and SE (r = 0.39; p < 0.0001) and adjusted OR = 10.3 (CI = 6.7-15.4). We found the strongest association at the lowest level of SOC. For health promotion practice, this finding signifies the importance of focusing on improving SOC in people with a low SOC score, as they are most in need and most likely to increase their SOC level. The finding of higher SOC scores in the older age cohorts indicates that SOC changes over lifetime. Public health work focusing on lifestyle change by increasing SOC can be effective throughout life, however early intervention is important. The finding of a positive correlation between SOC and SE indicates that health promotion altering one of the constructs is paralleled in the other.

Adverse drug reaction labelling for atomoxetine, methylphenidate and modafinil: comparison of product information for oral formulations in Australia, Denmark and the United States.

Medical product information contains information about efficacy and safety for marketed pharmaceuticals. Three studies have compared safety labelling for different therapeutic categories in different countries and detected large variations in a number of reported adverse drug reactions (ADRs). The rapid increase in use of medications for treatment of ADHD symptoms has created concern due to lack of information about effects from long-term use. The aim of this study was to compare ADR information in product information (PI)/summary of product characteristics (SPC) for oral formulations of atomoxetine, methylphenidate and modafinil marketed by the same pharmaceutical companies in Australia, Denmark and the United States. Discrepancies in listed ADRs were defined as types of ADRs (system organ class) not listed in all countries. For ADRs where discrepancies were detected, we extracted information about study design (clinical trials, spontaneous report). Discrepancies in ADR labelling for the medications were found across the three countries. A total of 75 ADR categories were listed for atomoxetine and 80% of these were listed in all three countries. For methylphenidate, totally 101 ADR categories and for modafinil 115 ADR categories were listed. For both substances approximately 60% of listed ADRs were found in all three countries. Discrepancies were primarily detected for ADRs information based on clinical trials. For methylphenidate, many ADRs labelled in Australia and Denmark were not mentioned in PIs issued in the United States. In conclusion, information about possible ADRs associated with the use of a specific product should be made available worldwide, as the prescriber information about medicines' safety profile should not depend on the country in which the medication is licensed.

Inequalities in asthma treatment among children by country of birth and ancestry: a nationwide study in Denmark.

BACKGROUND: Investigations in several Western countries have reported ethnic differences in asthma prevalence and treatment among children and in some countries these differences are increasing. The aim of this study was to analyse whether there are inequalities in asthma treatment by country of birth and ancestry among children residing in Denmark, and whether this potential association may vary between different household income groups. METHODS: Data were obtained by linking the Danish Civil Registration System, the Central Taxpayers' Register and the Danish National Prescription Register. POPULATION: the entire population of children in Denmark from 0 to 17 years of age in 2008 (n=1 209 091). Information on asthma treatment was obtained from the National Prescription Register. The analyses included multiple logistic regression models stratified by household income. RESULTS: Compared with ethnic Danes, immigrant children had the lowest OR for redeeming a prescription for asthma medication, both relief (OR 0.37; 95% CIs, 0.20 to 0.68) and preventive (OR 0.37; (0.22 to 0.59)). Similar associations were found among descendant children (OR for relief treatment 0.82 (0.79 to 0.89) and for preventive treatment 0.68 (0.61 to 0.75)). The pattern of the association remained after stratifying for household income. CONCLUSIONS: We found that, inequalities that cannot be explained by household income alone exist in treatments to prevent asthma as well as to relieve symptoms in children residing in Denmark, by country of birth and ancestry. The difference between immigrants and descendants may indicate that unfamiliarity with the Danish healthcare system is a contributory cause of the inadequate treatment of asthma.

Young adults' medicine use for headache: the combined effect of socioeconomic position and perceived stress, and the contribution of sense of coherence.

BACKGROUND: Over-the-counter analgesic (OTCA) use is increasingly common and may have potential harmful side effects. The primary reason for using analgesics is headache symptoms. Whether OTCA use for headache is sensitive to psychosocial and social circumstances is an understudied topic. OBJECTIVES: The purpose of this study was to examine the combined effect of socioeconomic position (SEP) and perceived stress on OTCA use for headache. An additional objective was to determine whether sense of coherence (SOC) modifies the association. METHODS: Data derived from the cross-sectional "Danish Lifestyle and Medicine Use Study," 2009. The study population consisted of men and women ages 25-44 years (n = 955). The dependent variable was OTCA use for headache within the past 14 days. The independent variables were SEP, perceived stress, and SOC. Gender, headache prevalence, and response method were included as covariates. Associations were examined by means of logistic regression analyses, and reported as odds ratios (ORs) with 95% confidence intervals. RESULTS: The OR for OTCA use was 1.42 (0.94-2.14) (statistically nonsignificant) among participants with low SEP but no perceived stress (reference high SEP, no perceived stress), 2.09 (1.53-2.85) for participants with perceived stress and high SEP, and 2.65 (1.66-4.25) among participants with perceived stress and low SEP. In analysis, stratified by SOC associations were stronger among participants with low SOC than among those with high SOC. CONCLUSIONS: Individuals exposed to both low SEP and high perceived stress have high odds for using OTCA for headache, apparently higher than participants only exposed to 1 of these factors. SOC may act as a buffer against the harmful effects of perceived stress and low SEP on OTCA use. Health care professionals and policymakers need to be aware of the sensitivity of OTCA use to psychosocial and social circumstances.

Prescribing of medicines in the Danish paediatric population outwith the licensed age group: characteristics of adverse drug reactions.

AIM: To identify adverse drug reactions (ADRs) associated with off-label prescribing of medicines in a paediatric population. METHODS: We analysed spontaneous ADR reports for children from ages 0 to 17 years submitted to the Danish national ADR database from 1998 to 2007. We defined off-label prescribing as prescriptions outside the licensed age group. Off-label ADRs were categorized by therapeutic group, age of child, type and severity. The unit of analysis was one ADR. RESULTS: We analysed 4388 ADRs for children reported in the national database. Approximately 17% of reported ADRs were associated with off-label use, 60% of them serious. More than one half of off-label ADRs were reported in adolescents. Serious ADRs due to off-label prescribing are more likely to be reported for hormonal contraceptives (ATC group G), anti-acne preparations (ATC group D) and allergens (ATC group V). CONCLUSION: One-fifth of all ADRs reported over a decade in Danish children was associated with off-label prescribing, and serious ADRs due to off-label prescribing were primarily present in three therapeutic groups: sex hormones, dermatologicals and allergens. There is a need for more research into the prescribing of these medicines in the teenage population, as well as tighter reporting and monitoring of ADRs for medicines prescribed off-label in the paediatric population.

The effect of health, socio-economic position, and mode of data collection on non-response in health interview surveys.

AIMS: To investigate the relationship between potential explanatory factors (socio-economic factors and health) and non-response in two general population health interview surveys (face-to-face and telephone), and to compare the effects of the two interview modes on non-response patterns. METHODS: Data derives from The Danish Health Interview Survey 2000 (face-to-face interview) and The Funen County Health Survey 2000/2001 (telephone interview). Data on all invited individuals were obtained from administrative registers and linked to survey data at individual level. Multiple logistic regression analyses were used to examine associations between potential explanatory factors and non-response. RESULTS: The overall response rate was higher in the face-to-face interview survey (74.5%) than in the telephone survey (69.2%). Refusal was the most common reason for non-response and the same factors were generally associated with non-response in both modes of interview. The non-response rate was high among persons with low socio-economic position. No significant associations between health and non-response were found. CONCLUSIONS: Health status does not play a systematic role for non-response rates in health interview surveys, but the non-response rate is higher in lower socio-economic groups. Analyses of non-response should be performed to understand the implications of survey findings.

Survey of patient and physician assessment of a compliance reminder device in the treatment of hypertension.

Low compliance to therapeutic regimens can have serious impact on patient health. A variety of technologies such as tablet dispensers and reminders has been developed to improve compliance. The aim of this study was to assess the acceptance of patients and physicians with regard to the functions and usefulness of a reminder device. The respondents were participants in a trial evaluating antihypertensive medical treatment. Patients and treating physicians received a self-administered questionnaire to evaluate the device; 1194 patients and their physicians completed the questionnaire. Seventy-three per cent of patients stated that they always or mostly used the device. Overall, 78% of patients and 83% of physicians assessed the device positively. The reminder and feedback functions were assessed similarly. Sixty-four per cent of the patients stated that they would like to continue to use the device, as did 71% of the physicians. The reminder device was well accepted by a majority of patients and physicians in this study. Acceptance is an important factor for such a device to be used in everyday life and a majority of respondents wanted to continue using it. The current device could be a major help for patients on chronic medication therapy in a variety of therapies.

Structures and processes in spontaneous ADR reporting systems: a comparative study of Australia and Denmark.

OBJECTIVE: To explore the organisational structure and processes of the Danish and Australian spontaneous ADR reporting systems with a view to how information is generated about new ADRs. SETTING: The Danish and Australian spontaneous ADR reporting systems. METHOD: Qualitative analyses of documentary material, descriptive interviews with key informants, and observations were made. We analysed the organisational structure of the Danish and Australian ADR reporting systems with respect to structures and processes, including information flow and exchange of ADR data. The analysis was made based on Scott's adapted version of Leavitt's diamond model, with the components: goals/tasks, social structure, technology and participants, within a surrounding environment. RESULTS: The main differences between the systems were: (1) PARTICIPANTS: Outsourcing of ADR assessments to the pharmaceutical companies complicates maintenance of scientific skills within the Danish Medicines Agency (DKMA), as it leaves the handling of spontaneous ADR reports purely administrative within the DKMA, and the knowledge creation process remains with the pharmaceutical companies, while in Australia senior scientific staff work with evaluation of the ADR report; (2) Goals/tasks: In Denmark, resources are targeted at evaluating Periodic Safety Update Reports (PSUR) submitted by the companies, while the resources in Australia are focused on single case assessment resulting in faster and more proactive medicine surveillance; (3) Social structure: Discussions between scientific staff about ADRs take place in Australia, while the Danish system primarily focuses on entering and forwarding ADR data to the relevant pharmaceutical companies; (4) Technology: The Danish system exchanges ADR data electronically with pharmaceutical companies and the other EU countries, while Australia does not have a system for electronic exchange of ADR data; and (5) ENVIRONMENT: The Danish ADR system is embedded in the routines of cooperation within European pharmacovigilance network while the Australian system is acting alone, although they communicate with other systems. CONCLUSION: The two systems differ with regard to reporting requirements, report handling, resources being spent and information exchange with the environment. In Denmark, learning about ADRs primarily takes place in the safety divisions of the pharmaceutical companies and the authorities have no control over the knowledge creation process. In Australia, more learning and control of the knowledge is present than in Denmark.

The effect of non-response on estimates of health care utilisation: linking health surveys and registers.

BACKGROUND: Non-response in health surveys may lead to bias in estimates of health care utilisation. The magnitude, direction and composition of the bias are usually not well known. When data from health surveys are merged with data from registers at the individual level, analyses can reveal non-response bias. Our aim was to estimate the composition, direction and magnitude of non-response bias in the estimation of health care costs in two types of health interview surveys. METHODS: The surveys were (1) a national personal interview survey of 22 484 Danes (2) a telephone interview survey of 5000 Danes living in Funen County. Data were linked with register information on health care utilisation in hospitals and primary care. Health care utilisation was estimated for respondents and non-respondents, and the difference was explained by a decomposition method of bias components. RESULTS: The surveys produced the same pattern of non-response, but with slight differences in non-response bias. Response rates for the interview and telephone surveys were 75 and 69%, respectively. Refusal was the most frequent reason for non-response (22 and 20% of those sampled, respectively), whereas illness, non-contact, and other reasons were less frequent. Respondents used 3-6% less health care than non-respondents at the aggregate level, but the opposite was true for some specific types of health care. Non-response due to illness was the main contributor to non-response bias. CONCLUSIONS: Different types of non-response have different bias effects. However, the magnitude of the bias encourages the continued use of interview health surveys.

Adherence is associated with the quality of professional-patient interaction in Directly Observed Treatment Short-course, DOTS.

OBJECTIVE: To investigate the association between the behaviour of health professionals as reported by patients, the quality of communication, patients' communication about their disease, and non-adherence to Directly Observed Tuberculosis Treatment Short-course, DOTS. METHODS: This study was designed as a case-control study based on 50 cases (non-adherents) and 100 controls (adherents), conducted in a hilly western district in Nepal. The participation rate was 80% for 50 cases and 95% for 100 controls. All covariates with p-value

[Comfort and discomfort: the role of emotions in GPs' prescription practices]. / Behag og ubehag: følelsers betydning i praktiserende laegers laegemiddelordination.

INTRODUCTION: The role of emotions in GPs' prescribing has been ignored. The present article describes 20 GPs' reflections about what precedes comfort and discomfort in prescribing situations. MATERIALS AND METHODS: In-depth interviews were done with 20 GPs who contributed with examples on an open comfort-discomfort scale. Analysis of the data was inspired by grounded theory. RESULTS: The GPs experienced a broad spectrum of emotions when prescribing. In every prescribing situation, conditions could pull towards both comfort and discomfort. Comfort appeared when the indication was correct and the patient's condition was serious, when the patient experienced the problem as serious, when the situation was acute and the medicine effective, and when the GP experienced himself as competent. Medicines were placed between comfort and discomfort when prescribing was perceived as indifferent, unproblematic and easy, when the GP was concerned about inflicting a sick role on the patients, and when patients were not convinced about the appropriateness of the medication. Discomfort appeared when there was a great risk of dependence, when GPs experienced and gave in to pressure, when they had to convince patients, and when they prescribed addictive medicine regularly. The totality of conditions in the situation determined the emotional state in the prescribing situation. DISCUSSION: The GPs' emotions reflected how they evaluated the appropriateness of their prescribing. This should be taken advantage of in rational pharmacotherapy. Future interventions should address both the rationality of GPs and their emotions.

Patient characteristics associated with prescribing of a newly introduced drug: the case of rofecoxib.

OBJECTIVE: To identify socio-demographic characteristics of the first patients receiving a new drug--rofecoxib. OUTCOME MEASUREMENT: Patients starting on rofecoxib or another non-steroidal anti-inflammatory drug (NSAID) and who had not received any NSAIDs the 90 days prior to starting. RESULTS: Starting on rofecoxib was associated with an increasing age (OR in age 80 years and older 8.7; 95% CI 6.7-11.2), a poor self-perceived health (OR=2.4; 95% CI 1.8-3.3), female gender (OR=1.4; 95% CI 1.2-1.6), private insurance (OR=1.3; 1.1-1.5) and previous acetaminophen use (OR=1.3; 1.1-1.7). CONCLUSION: This study noted that specific patient characteristics were associated with getting rofecoxib prescribed shortly after marketing. General practitioners should be aware of selectively prescribing new drugs to specific patients because it may place patients at unintentional and avoidable risk.

Social class variation in medicine use among adolescents.

BACKGROUND: Little is known about social determinants of adolescents' medicine use. The objective was to analyse the association between the family's social class and adolescents' use of medicine for headache, stomachache, difficulties in getting to sleep, and nervousness. METHODS: Cross-sectional study of 11-, 13- and 15-year-olds, a Danish contribution to the WHO international collaborative study Health Behaviour in School-aged Children (HBSC) 1998. The study population comprised students from a national random sample of schools who answered a standardized questionnaire in the classroom, participation rate 88%, n=5,205. RESULTS: Logistic regression analyses showed that medicine use for all four symptoms increased by decreasing social class, controlled for age and prevalence of the specific symptom for which the medicine was taken. Adjusted OR (95% CI) for medicine use among students from lower social classes were: medicine for headache 1.35 (1.11-1.65), medicine for stomachache 1.41 (1.08-1.84), medicine for difficulties in getting to sleep 2.00 (1.30-3.08), and medicine for nervousness 3.22 (1.87-5.56). CONCLUSION: Symptom-adjusted medicine use in a representative sample of Danish adolescents showed a clear and graded increase with decreasing social class. Policies to reduce social inequality in health should address medicine use as well.

The threatened self: general practitioners' self-perception in relation to prescribing medicine.

Insufficient understanding of the variation in GP's medicine prescribing behaviour and ineffective interventions call for an investigation of the GPs' own perspective. This article describes the GP's self-perception as it emerged in 20 semi-structured interviews that explored the GP's perspective on their own prescribing. Data collection and analysis was largely inspired by grounded theory. The GPs described a constantly active process in which they prescribed, experienced an emotional reaction to their prescribing, evaluated themselves, redefined themselves for the better or worse, defined the new prescribing situation, prescribed and so forth. The GPs felt disappointed with themselves when their prescribing conflicted with their human or scientific ideals, and when they did not live up to their image of themselves, as GPs and as persons. They experienced discomfort when they were exposed to pressure as well as when they gave in to it. These negative emotions demanded a redefinition of the GPs' selves. The GPs applied both preventive and coping strategies to protect themselves from redefining themselves negatively. They strived to live up to their ideals, lowered their ideals, convinced themselves of the appropriateness of their prescribing and sought inspiration and self-development. This study demonstrates that self-perception is fundamental to how GPs prescribe medicines. Future interventions in quality development that aim to improve GPs' prescribing practices should therefore include considerations of the GPs' self-perception and facilitate autonomous self-development.

Prescription and non-prescription medicine use in Denmark: association with socio-economic position.

OBJECTIVE: To analyse the association among different types of medicine use and different measures of socio-economic position (SEP) in one and the same general population. METHODS: Data from The Danish Health and Morbidity Survey 2000 were analysed. The survey was conducted by face-to-face interviews with a representative sample of the adult Danish population (n=16,690). The associations between prescription and over-the-counter (OTC) medicine use and education, occupation and income were assessed by logistic regression analyses. All analyses were adjusted for age, gender and two measures of health status. RESULTS: This cross-sectional analysis of medicine use in a large representative sample of the Danish population found greater use of prescription medicines among disability pensioners and "others" than in salaried employees. Disability pensioners and self-employed individuals used less OTC medicine than salaried employees. Individuals with low income used more prescription medicines but not more OTC medicines, than those with high income. No major differences were found in prescription medicine use with respect to education, but men within the two middle educational groups tended to use prescription medicine less frequently than both lower and higher educated men. A similar trend was not found for women. OTC medicine use was not associated with education for either gender. CONCLUSIONS: The prevalence of prescription medicine use increases with declining SEP, after adjusting for health status. Such an association does not exist for OTC medicine use. The results show that the least affluent have access to prescription medicine. The difference between prescription and OTC medicine use may be explained by a compensation mechanism.

Utilisation of antibiotics in young children: opposite relationships to adult educational levels in Danish and Swedish counties.

BACKGROUND: Antibiotic utilisation varies profoundly among and within countries, and the extent of antibiotic utilisation correlates with the frequency of bacterial resistance, particularly among children. Hence, it is important to assess which factors may influence prescribing. In addition to variations in morbidity, health-care organisation, drug regulatory and supply systems, prescriber's attitudes, parents' behaviour, attitudes and socio-economic positions seem important. We compared socio-economic position (educational level of adults) and antibiotic utilisation in children in the municipalities within a Danish and a Swedish county which are geographically close, have similar social and economic development, and similar drug regulatory and supply systems. METHODS: Data on antibiotic utilisation (1998), expressed in defined daily doses per 1000 inhabitants per day (DDD/TID), were obtained from the Copenhagen County Health Insurance register and from the National Corporation of Swedish Pharmacies. Data on municipal educational levels were obtained from Statistics Denmark and Statistics Sweden. RESULTS: The utilisation of antibiotics in 0- to 6-year-old children was higher in the Swedish than in the Danish county but varied between the municipalities within both the Swedish (9.6-17.7 DDD/TID) and the Danish (8.0-12.9 DDD/TID) counties. Most notably, utilisation rates correlated negatively with the education levels in the Danish (r=-0.539, P=0.021) but positively in the Swedish (r=+0.390, P=0.025) municipalities. CONCLUSION: The observed variations in antibiotic prescribing may reflect different parental and/or prescriber attitudes towards use of antibiotics and they emphasise that antibiotic prescribing is influenced by factors other than the prevalence of bacterial infections. Relationships between socio-economic position (educational level) and drug utilisation should not be generalised from one area to another.

Pharmaceutical care in Denmark: perceived importance of medicine-related problems and participation in postgraduate training.

OBJECTIVE: To investigate the readiness of Danish community pharmacists to provide pharmaceutical care. Special focus was on information provided to patients on medicine-related problems and participation in postgraduate training. METHOD: National cross-sectional survey distributed to all Danish community pharmacies (N = 288). Response rate 75.7%; non-responders were interviewed by telephone to establish their reasons for not participating. MAIN OUTCOME MEASURES: Prioritization of information to patients regarding medicine-related problems. Postgraduate courses selected by pharmacists during the past three years. RESULTS: In accordance with the profile of Danish community pharmacists, respondents were primarily female and half were below 45 years of age. The main reason given for not responding was lack of time. The prioritization of information to patients regarding medicine-related problems resulted in three clusters of answers. The overall topics of the clusters were: information related to the technical-practical use of medicines; information related to pharmacotherapeutic aspects of medicine use; and information related to the function of the medicine. The clusters accounted for 61.9% of the total variance. The most frequently attended postgraduate courses were on quality assurance and specific diseases. CONCLUSION: The patient information prioritized by Danish community pharmacists is primarily of a technical-practical nature. The postgraduate training pursued is primarily technical without much focus on the philosophy of pharmaceutical care. These factors contribute to the lack of proper readiness of pharmacists to practice pharmaceutical care.

Community participation as an interactive learning process: experiences from a schistosomiasis control project in Zimbabwe.

A schistosomiasis control project was undertaken from 1994 to 1998 in Guruve District, Zimbabwe, based on the active involvement of local communities in the growing and application of the molluscicidal plant Phytolacca dodecandra as a supplement to other control measures such as chemotherapy and health education. The berries of P. dodecandra are highly molluscicidal to the intermediate host snails of schistosomiasis and is rapidly degradable in water. It was observed that plant care fluctuated during the study period. Only a few households participated in snail control activities, although 97% of respondents in a baseline survey had stated a willingness to take part. This invoked an investigation to explore the reality from a user perspective. Focus group discussions, semi-structured interviews and observations were used to solicit information. In spite of a cultural inclination for collective work, many reasons for low-level involvement emerged, inter alia the low perceived value of the project, demands for tangible benefits, inaccessible fields and weak leadership. This study shows that community participation is a complex process upon which a multiplicity of social and cultural determinants have an impact. If community participation is to become successful in development programmes it ought to be viewed as a mutual learning process where obstacles are identified and discussed and solutions shared among community members and project staff.