Impact of the publication of the Finnish Meds75+ database on the use of potentially inappropriate medications in older persons.

AIMS: To evaluate the impact of the updated nationwide Meds75+ database and its linkage to the Finnish health portal on the use of potentially inappropriate medications (PIMs) among older persons. We also aimed to evaluate whether there is regional variation in trend changes of PIM use. METHODS: Meds75+ was implemented at the population level in 2015, so randomization is unfeasible. We used a quasi-experimental interrupted time series analysis to evaluate the changes in levels and trends of PIM use. The data included all Finnish community-dwelling persons aged ≥75 years (N = 920 163) who had medication purchases in the Prescription Register during 2009-2020. Data were linked with the Care Registers for Health and Social Care and the cause of death register. RESULTS: The prevalence of PIMs decreased from 20.2% in 2009 to 11.7% in 2020. The change of level of the monthly PIM users was negative (ß -0.036, 95% confidence interval [CI] -0.202 to 0.131), but not statistically significant (P = .673) after the publication of the database. We found a small decrease (ß -0.018, 95% CI -0.083 to 0.047, P = .593) in the slope of PIM users, but it was not statistically significant. The regional results were similar to the main findings. CONCLUSIONS: Publication of the updated Meds75+ database did not decrease the level or trend of PIM users. In addition, this study did not show any significant regional variation in PIM use trends. Further research should focus on determining barriers and facilitators to the utilization of PIM criteria in clinical practice.

Trends in the use of psychotropics in older people with dementia: interrupted time series of Finnish clinical guidelines of behavioural and psychological symptoms of dementia.

BACKGROUND: Up to 90% of people with dementia experience behavioural and psychological symptoms of dementia (BPSD) as part of their illness. Psychotropics are not recommended as the first-line treatment of BPSD because older people are more prone to adverse reactions. In this study, we evaluate the impact of the Finnish clinical guidelines of BPSD (published in 2017) on psychotropic use in people with dementia. METHODS: This study is based on Finnish Prescription Register data from 2009 to 2020. The data included all community-dwelling Finnish people aged ≥65 and who had anti-dementia medication purchases (n = 217,778). We used three-phased interrupted time series design to evaluate the changes in levels and trends of monthly (n = 144) psychotropic user rates compared with the predicted trends. In addition, we evaluated the changes in levels and trends of monthly new psychotropic user rates. RESULTS: The level of monthly psychotropic user rate decreased non-significantly during the intervention period (ß -0.057, P = 0.853), and during the post-intervention period, there was an increase in the level (ß 0.443, P = 0.091) and slope (ß 0.199, P = 0.198), but not statistically significant. The level of monthly new psychotropic user rate (ß -0.009, P = 0.949) during the intervention period and the level (ß 0.044, P = 0.714) and slope (ß 0.021, P = 0.705) during the post-intervention period were almost unchanged. CONCLUSIONS: Results may indicate possible challenges in deprescribing and better adherence to the guidelines at the beginning of BPSD treatment. Further research into the barriers to implement BPSD guidelines and the availability of non-pharmacological treatments is needed.

Prevalence of potentially inappropriate medication use in older population: comparison of the Finnish Meds75+ database with eight published criteria.

BACKGROUND: There are several national and international criteria available for identifying potentially inappropriate medications (PIMs) for older people. The prevalence of PIM use may vary depending on the criteria used. The aim is to examine the prevalence of potentially inappropriate medication use in Finland according to the Meds75+ database, developed to support clinical decision-making in Finland, and to compare it with eight other PIM criteria. METHODS: This nationwide register study consisted of Finnish people aged 75 years or older (n = 497,663) who during 2017-2019 purchased at least one prescribed medicine considered as a PIM, based on any of the included criteria. The data on purchased prescription medicines was collected from the Prescription Centre of Finland. RESULTS: The annual prevalence of 10.7-57.0% was observed for PIM use depending on which criteria was used. The highest prevalence was detected with the Beers and lowest with the Laroche criteria. According to the Meds75+ database, annually every third person had used PIMs. Regardless of the applied criteria, the prevalence of PIM use decreased during the follow-up. The differences in the prevalence of medicine classes of PIMs explain the variance of the overall prevalence between the criteria, but they identify the most commonly used PIMs quite similarly. CONCLUSION: PIM use is common among older people in Finland according to the national Meds75+ database, but the prevalence is dependent on the applied criteria. The results indicate that different PIM criteria emphasize different medicine classes, and clinicians should consider this issue when applying PIM criteria in their daily practice.

The role of functioning in predicting nursing home placement or death among older home care patients.

OBJECTIVE: There have been few studies predicting institutionalization or death in home care settings. We examined risk factors for nursing home placement (NHP) and death among home care patients. DESIGN: A prospective one-year follow-up study. SETTINGS AND SUBJECTS: Persons aged ≥65 years living in Eastern Finland and receiving regular home care services (n = 293). MAIN OUTCOME MEASURES: Risk factors for NHP or death were investigated using Cox proportional hazards model. Explanatory variables included demographics, health status (Charlson Comorbidity Index, CCI), physical (Timed Up and Go, TUG), and cognitive (Mini-Mental State Examination, MMSE) functioning, Basic and Instrumental Activities of Daily Living (BADL, IADL) and mood (Geriatric Depression Scale, GDS-15). RESULTS: Of the 293 patients (mean age 82.6 years, 70.6% women), 27 (9.2%) moved to a nursing home and 25 (6.9%) died during the follow-up (mean 350 days). The combined outcome of NHP or death was predicted by BADL (HR 0.73, CI 95% 0.62-0.86), IADL (0.75, 0.65-0.87) MMSE (0.92, 0.87-0.96), and TUG (1.02, 1.01-1.03). NHP alone was predicted by BADL (0.62, 0.50-0.78), IADL (0.57, 0.45-0.73), and MMSE (0.88, 0.82-0.94) and mortality by TUG (1.02, 1.01-1.03). CONCLUSION: Basic measures of functioning can be used to identify high-risk patients in home care. Decreasing BADL, IADL and MMSE predict NHP and longer TUG-times death within a year.

Factors associated with institutionalization or death in community-dwelling older populations are studied comprehensively but far less in known about the risks in home care settingsLower BADL, IADL and MMSE scores predict NHP, and a longer TUG time predicted death within a one-year timeframe among home care patients.The basic tests of functioning and mobility can be used to identify high-risk patients in home care.Identification of high-risk patients may also help in targeting of care and rehabilitation.

Effectiveness of clinical exome sequencing in adult patients with difficult-to-diagnose neurological disorders.

OBJECTIVES: Clinical diagnostics in adults with hereditary neurological diseases is complicated by clinical and genetic heterogeneity, as well as lifestyle effects. Here, we evaluate the effectiveness of exome sequencing and clinical costs in our difficult-to-diagnose adult patient cohort. Additionally, we expand the phenotypic and genetic spectrum of hereditary neurological disorders in Finland. METHODS: We performed clinical exome sequencing (CES) to 100 adult patients from Finland with neurological symptoms of suspected genetic cause. The patients were classified as myopathy (n = 57), peripheral neuropathy (n = 16), ataxia (n = 15), spastic paraplegia (n = 4), Parkinsonism (n = 3), and mixed (n = 5). In addition, we gathered the costs of prior diagnostic work-up to retrospectively assess the cost-effectiveness of CES as a first-line diagnostic tool. RESULTS: The overall diagnostic yield of CES was 27%. Pathogenic variants were found for 14 patients (in genes ANO5, CHCHD10, CLCN1, DES, DOK7, FKBP14, POLG, PYROXD1, SCN4A, TUBB3, and TTN) and likely pathogenic previously undescribed variants for 13 patients (in genes ABCD1, AFG3L2, ATL1, CACNA1A, COL6A1, DYSF, IRF2BPL, KCNA1, MT-ATP6, SAMD9L, SGCB, and TPM2). Age of onset below 40 years increased the probability of finding a genetic cause. Our cost evaluation of prior diagnostic work-up suggested that early CES would be cost-effective in this patient group, in which diagnostic costs increase linearly with prolonged investigations. CONCLUSIONS: Based on our results, CES is a cost-effective, powerful first-line diagnostic tool in establishing the molecular diagnosis in adult neurological patients with variable symptoms. Importantly, CES can markedly shorten the diagnostic odysseys of about one third of patients.

Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication.

BACKGROUND: Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs). METHODS: The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants' healthcare service use costs and costs for the intervention were estimated for a 12 month period.Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates. RESULTS: The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs -€1,629, confidence interval (CI) -€5,489 to €2,240; incremental effect -0.02, CI -0.06 to 0.02]. The base case ICER was >€80,000/QALY. CONCLUSION: The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.

Validity of the Finnish Care Register for Social Welfare in a nationwide cohort of people with Alzheimer's disease.

AIMS: To assess the validity and completeness of the Care Register for Social Welfare among community-dwelling people with Alzheimer's disease in Finland. METHODS: The study was carried out in the Medication Use and Alzheimer's disease (MEDALZ) study population, which includes 70,719 people who received a clinically verified diagnosis of Alzheimer's disease between 2005 and 2011 and the people matched with them for comparison (n=282,862). The data were linked to the Care Register for Social Welfare, which contains data on care periods for nursing homes and sheltered housing with 24-h assistance during the time period 1994-2015. The validity of the Care Register for Social Welfare was analysed in relation to the Prescription Register among people with Alzheimer's disease aged >65 years (n=25,640) who fulfilled the definitions of long-term care in certain inpatient care units (nursing homes, institutional care for people with dementia and rehabilitation institutions), although, in Finland, drug purchases should not be recorded in the register during long-term care. RESULTS: The required level of assistance at discharge was recorded for 99.7% of people, diagnoses for 5.1% of the care periods and the discharge date for 100% of the completed care periods. Depending on the definition of long-term care, 6-10% of all long-term care periods included drug purchases during the study period. CONCLUSIONS: The validity of the Care Register for Social Welfare is high, but some limitations should be considered when using the data. Combining health and social care registers provides a potentially more comprehensive database on the utilisation and costs of services.

Incident Use of a Potentially Inappropriate Medication and Hip Fracture in Community-Dwelling Older Persons With Alzheimer's Disease.

BACKGROUND: Potentially inappropriate medications (PIMs) increase the risk of adverse drug reactions and events and have been associated with greater health care service use, such as an increased risk of hospitalization. OBJECTIVE: The aim of this study is to evaluate the association between PIM use and hip fractures in a nationwide cohort of community-dwelling persons ≥65 years old with Alzheimer's disease (AD). METHODS: The study, which is based on the Finnish nationwide MEDALZ cohort, included all persons diagnosed with AD between 2005 and 2011 (n = 70 718). After a 1-year washout period for PIM use and exclusion of persons with previous hip fracture before AD diagnosis or those who had been hospitalized, we included 47 850 persons ≥65 years old with AD. PIM use was identified using Finnish criteria. Associations between PIM use and hip fracture were analyzed with Cox proportional hazards regression. RESULTS: Of the study population, 12.3% (n = 5895) initiated PIMs during the follow-up (maximum follow-up 2921 days and total number of person-years 139 538.7). Of those, 103 (1.7%) persons had hip fractures during the PIM use period. The results suggest that PIM use was only associated with an increased risk of hip fracture with incident PIM use (adjusted hazard ratio = 1.31; 95% CI = 1.06-1.63; P = 0.014). CONCLUSIONS: PIM use is associated with increased risk of hip fracture when a person uses PIMs for the first time. However, the association between PIM use and hip fracture should be investigated more comprehensively in future studies.

A Systematic Review of the Impact of Potentially Inappropriate Medication on Health Care Utilization and Costs Among Older Adults.

BACKGROUND: Potentially inappropriate medications (PIMs) are defined as those medicines having a greater potential risk than benefit for older adults. In this systematic literature review, we evaluate the current evidence on health care service use and health care costs associated with PIMs among older adults. METHODS: A literature search was conducted in August 2015 without publication date restrictions using the databases PubMed and Scopus. Selected articles included in the review of articles were: (1) observational cohort or case-control, or intervention studies; (2) investigating PIM use among older adults aged 65 years or older with outcomes on health care utilization (eg, hospitalization) or health care costs; and (3) use of some published criteria for assessing PIMs. RESULTS: Of 825 abstracts screened, in total 51 articles proceeded to full-text review. Of those full-text articles, 39 articles were included in this review. Most of the articles found that PIMs had a statistically significant effect on health care service use, especially on hospitalization, among older adults. The findings of impact on length of stay or readmissions were inconclusive. Five studies found statistically significant higher medical or total health care costs for PIM users compared those who did not use any PIMs. CONCLUSIONS: PIMs can, in addition to health and quality of life problems, also lead to greater health care service use and, thus, higher health care costs. However, the heterogeneity of the study settings makes the interpretation of the results difficult. Further studies, especially on economic issues with country-specific criteria, are needed.

Regional variation of potentially inappropriate medication use and associated factors among older adults: A nationwide register study.

BACKGROUND: Certain medications should be used with caution in older persons, which challenges rational prescribing. Potentially inappropriate medications (PIMs) are defined as medicines whose potential risk of harm typically outweighs the clinical benefits in geriatric population. Earlier studies have found regional differences in PIM use, but the factors underlying this phenomenon are unclear. OBJECTIVE: To compare prescription PIM prevalence among Finnish hospital districts and determine which population characteristics and factors related to social and health care are associated with regional variation. METHODS: This nationwide register study was based on the Prescription Centre data on all people aged ≥75 years in 2017-2019. Hospital district (n = 20) characteristics were drawn from the Finnish Institute for Health and Welfare's, Finnish Medical Association's, and Finnish Medicines Agency's publicly open data. PIMs were defined according to the Finnish Meds75+ database. A linear mixed-effect model was used to analyze potential associations of regional characteristics with PIM prevalence. RESULTS: Prevalence of PIMs varied between 16.4% and 24.8% across regions. The highest prevalence was observed in the southern regions, while the lowest prevalence was on the west coast. Hospital district characteristics associated with higher PIM prevalence were higher share of population living alone, with excessive polypharmacy, or assessed using the Resident Assessment Instrument, shortage of general practitioners in municipal health centers, and low share of home care personnel. Waiting time in health care or share of population with morbidities were not associated with PIM use. Of the total variance in PIM prevalence, 86% was explained by group-level factors related to hospital districts. The regional variables explained 75% of this hospital-district-level variation. CONCLUSIONS: PIM prevalence varied significantly across hospital districts. Findings suggest that higher PIM prevalence may be related to challenges in the continuity of care rather than differences in health care accessibility or share of the population with morbidities.

Process evaluation of implementation strategies to reduce potentially inappropriate medication prescribing in older population: A scoping review.

OBJECTIVES: Several implementation strategies can reduce potentially inappropriate medication (PIM) prescribing. Although use of PIMs has declined in recent years, it remains prevalent. Various strategies exist to improve the appropriateness of medication use. However, little is known about the processes of these different implementation strategies. This scoping review aims to investigate how the process evaluation of implementation strategies for reducing PIM prescribing in the older population has been studied. METHODS: We searched for process evaluations of implementation strategies for reducing PIM prescribing in PUBMED, SCOPUS and Web of Science published between January 2000 and November 2019 in English. We applied the following inclusion criteria: patients aged ≥65 years, validated PIM criteria, and implementation process evaluated. The review focuses on decision support for health care professionals. We described the findings of the process evaluations, and compared the authors' concepts of process evaluation of the included publications to those of Proctor et al.( 2010). RESULT: Of 9131 publications screened, 29 met our inclusion criteria. Different process evaluation conceptualizations were identified. Most process evaluations took place in the initial stages of the process (acceptability, adoption, appropriateness, and feasibility) and sustainability and implementation costs were seldom evaluated. None of the included publications evaluated fidelity. Multifaceted interventions were the most studied implementation strategies. Medication review was more common in acceptability evaluations, multidisciplinary interventions in adoption evaluations, and computerized systems and educational interventions in feasibility evaluations. Process evaluations were studied from the health care professionals' viewpoint in most of the included publications, but the management viewpoint was missing. DISCUSSION: The conceptualization of process evaluation in the field of PIM prescribing is indeterminate. There is also a current gap in the knowledge of sustainability and implementation costs. Clarifying the conceptualization of implementation process evaluation is essential in order to effectively translate research knowledge into practice.

Cost-effectiveness of whole-exome sequencing in progressive neurological disorders of children.

OBJECTIVES: To clarify the diagnostic utility and the cost-effectiveness of whole-exome sequencing (WES) as a routine early-diagnostic tool in children with progressive neurological disorders. METHODS: Patients with infantile-onset severe neurological diseases or childhood-onset progressive neurological disorders were prospectively recruited to this WES study, in the pediatric neurology clinic at Helsinki University Hospital during 2016-2018. A total of 48 patients underwent a singleton WES. A control group of 49 children underwent traditional diagnostic examinations and were retrospectively collected from the hospital records. Their use of health care services, related to the diagnostic process, was gathered. Incremental cost-effectiveness ratio (ICER) per additional diagnosis was calculated from the health care provider perspective. Bootstrapping methods were used to estimate the uncertainty of cost-effectiveness outcomes. RESULTS: WES provided a better diagnostic yield (38%) than diagnostic pathway that did not prioritize WES in early diagnosis (25%). WES outperformed other diagnostic paths especially when made early, within one year of first admission (44%). Cost-effectiveness in our results are conservative, affected by WES costs during 2016-18. CONCLUSIONS: WES is an efficient and cost-effective diagnostic tool that should be prioritized in early diagnostic path of children with progressive neurological disorders. The progressively decreasing price of the test improves cost-effectiveness further.

Attitudes towards genetic testing and information: does parenthood shape the views?

This study examines how parents of pediatric patients might differ in their views and attitudes towards genetic technology and information when compared to adult patients. There is surprisingly little evidence on how parents compare to other parts of population in their attitudes. Previous empirical studies often relate health-related preferences and attitudes to factors such as age, education, and income instead of parental status, thus evading comparison of parents to others as health-related decision makers. Findings related to the parental status can be useful when implementing genetic technology in clinical practice. We conducted a survey of views on genetic technology and information for groups of adult neurology patients (n = 68) and parents of pediatric neurology patients (n = 31) to shed some light on this issue. In addition to our own survey instrument, we conducted other surveys to gain insight on psychosocial factors that might affect these attitudes. The results suggest that parents are more concerned about their children's genetic risk factors when compared to the attitudes of adult patients about their own risk. For both groups, negative emotional state was associated with more concerns towards genetic information. Our study provides insights on how parental views might affect the acceptance of genetic technology and information.

Patient- and health care-related factors associated with initiation of potentially inappropriate medication in community-dwelling older persons.

Potentially inappropriate medications (PIMs) in older persons are defined as medications of which the potential harms outweigh their benefits. The purpose of this study was to determine how initiation of PIMs accumulate in community-dwelling persons aged 65-74 and ≥75 years, and which patient- and health care-related factors are associated with PIM initiation over time. Data of this study were gathered from population-based registers by a 10% random sample of persons (n = 28 497) aged ≥65 years with no prior PIMs within a 2-year period preceding the index date (1 January 2002), and the study individuals were followed until 2013. The Finnish Prescription Register was linked using a personal identity code to register on inpatient care and causes of deaths and socio-economic data. In this study, 10 698 (37.5%) persons initiated PIMs during the study period. Female gender was associated with PIM initiation in 65-74-year-olds, but not in ≥75-year-olds. In 65-74-year-olds, the risk of PIM initiation increased with the higher income, whereas in ≥75-year-olds, the association between PIM initiation and the high income was not significant. The prescribing physician explained 9%-16% of the variation in the probability of PIM initiation. In conclusion, there were age-related differences in the factors associated with PIM initiation in relation to gender and socio-economic status. Overall, patient-related factors explained a large proportion of variation of PIM initiation, but there were also differences in PIM prescribing among physicians. However, physician-related variance of PIM initiations decreased during the 12-year follow-up.

The association of potentially inappropriate medication use on health outcomes and hospital costs in community-dwelling older persons: a longitudinal 12-year study.

AIMS: To determine (1) whether potentially inappropriate medication (PIM) use defined by the Meds75 + database is associated with fracture-specific hospitalisations and all-cause mortality, and (2) the association between PIM use and all-cause hospitalisation costs in a 12-year follow-up of a nationwide sample of people aged ≥ 65 years in Finland. METHODS: This is a longitudinal study of 20,666 community-dwelling older persons with no prior purchases of PIMs within a 2-year period preceding the index date (1 Jan 2002), who were followed until the end of 2013. Data were obtained from the Finnish Prescription Register, and it was accompanied by information on inpatient care, causes of deaths and socioeconomic status from other national registers. Propensity score matching (PSM) analysis was used to account for potential selection effect in PIM use. Cox proportional hazards regression was used to identify the time to the first fracture or death by comparing PIM-users (n = 10,333) with non-users (n = 10,333). The association between PIM use and hospital costs was analysed with a fixed effects linear model. RESULTS: PIM use was weakly associated with an increased risk of fractures and death. The association was stronger in the first PIM-use periods. Hospitalised PIM-users had 15% higher hospital costs compared to non-users during the 12-year follow-up. CONCLUSION: PIM initiation was associated with an increased risk of fracture-specific hospitalisation and mortality and PIM-users had higher hospital costs than non-users. Health care providers should carefully consider these issues when prescribing PIM for older persons.

Risk Factors for Initiation of Potentially Inappropriate Medications in Community-Dwelling Older Adults with and without Alzheimer's Disease.

BACKGROUND: Various criteria have been created to define potentially inappropriate medications (PIMs) to help improve the quality and safety of medicine use in older patients. Individuals with Alzheimer's disease (AD) may be at higher risk of adverse drug events associated with PIMs (such as falls). OBJECTIVE: Our objective was to determine the risk factors for PIM initiation in a nationwide cohort of community dwellers aged ≥65 years with and without AD. METHODS: The Finnish nationwide MEDALZ cohort includes all patients diagnosed with AD in 2005-2011 (n = 70,718) and two comparison individuals without AD (non-AD) matched for age, sex and region of residence for each person with AD. After a 1-year washout period for PIM use and exclusion of those aged <65 years, we included 50,494 patients with AD and 106,306 comparison subjects. PIM use was defined according to Finnish criteria. RESULTS: Subjects without AD initiated PIMs more frequently than those with AD (16.4 vs. 12.2%, respectively; p < 0.001). The most common PIMs were muscle relaxants and urinary antispasmodics. Older individuals (aged ≥75 years) were less likely to initiate PIMs. In the AD group, women were less likely to initiate PIMs than men. More comorbidities were associated with PIM initiation, especially in the non-AD group. The use of opioids or psychotropic medicines was associated with PIM initiation in both cohorts. Regional differences between university hospital districts were observed. CONCLUSION: PIM initiation was dependent on patient characteristics and possibly also some healthcare system-related factors such as differing regional treatment practices. It is important that medicines prescribed to the older vulnerable population are assessed regularly to avoid adverse effects and ensure safe pharmacotherapy, especially in those with multiple comorbidities.