[Epidemiology of polypharmacy in primary healthcare in the Reykjavik metropolitan area 2010-2019].

INTRODUCTION: Taking medicines can induce risks leading to negative health issues that can grow in accordance with the number of medicines used. Many studies on the prevalence of polypharmacy have been carried out in other countries, but such studies are lacking in Iceland. The aim of this study was to analyse the prevalence of polypharmacy in primary care in the Reykjavik metropolitan area. METHODS: The study population consisted of individuals who had been prescribed five or more drugs by physicians in primary care in the Reykjavik metropolitan area during the study period. Data was collected on all drug prescriptions for individuals in the area. Those who had five or more drugs prescribed in the primary healthcare database from 1 January 2010 through 31 December 2019 were included in the study. According to Statistics Iceland, the total number of inhabitants in the area was 200.907 in 2010 and 228.222 in 2019. FINDINGS: The prevalence of polypharmacy increased gradually in 2010-2019, or by 37.9% during this period. Patients with polypharmacy were 9.8% (19.778) at the beginning of the study in 2010 and increased to 13.6% (30.970) in 2019. A clear association was observed between age and polypharmacy, and the study showed polypharmacy to be more common among women. The study findings revealed that the greatest relative increase in polypharmacy was among young people from 20-49 years of age. ATC class analysis showed a sharp increase in the first and third levels of the ATC subgroups. CONCLUSION: The findings suggest polypharmacy to be common in the Reykjavik metropolitan area. Similarly, its prevalence seems to be increasing in younger patients. It is important to gain a better understanding of the reasons for the development of polypharmacy and evaluate the increasing medicalisation in society. The underlying reasons, as well as the effects of polypharmacy, can lead to both positive and negative health outcomes.

[Hypertension Management in Primary Care in the Capital Area of Iceland].

INTRODUCTION: High blood pressure (HT) is one of the main risk factors for cardiovascular diseases which in 2010 caused one third of all mortality in the world. Untreated, HT can cause stroke, myocardial infarction, heart failure, dementia, kidney failure, atherosclerosis and eye diseases. The main aim of this study was to find out how HT is treated in primary care in the capital area of Iceland. MATERIAL AND METHODS: The study is a descriptive retrospective cross-sectional study covering the years 2010, 2014 and 2019. Information about all patients over 18 years old diagnosed with HT were gathered from computerised medical records at every primary care center in the Capital area. RESULTS: The number of individuals diagnosed with HT increased during the study period and the mean age did also increase. The sex ratio changed with more men diagnosed than women. Of 25.873 patients diagnosed with HT in the year 2010, 63.4% received drug treatment. In 2019 this percentage had dropped 60.9% (p<0,001). Of those on antihypertensive drug treatment the proportion receiving one, two or three drugs remained same from 2010-2019. The most common group of drugs used were diuretics (C03), beta-blockers (C07), calcium channel blockers (C08) and renin-angiotensin-aldosteron-system (RAAS) inhibitors (C09). The proportion af these drug groups changed significantly during the study. Fever patients were treated by diuretics (p<0,001) or beta-blockers ((p<0,001) but the number treated by calcium channel blockers (p<0,01) or RAAS inhibitors increased (p<0,001). During the whole stud period 44.1% of the patients reached the target goals. The proportion of patients who reached the target goals in different health care center was specifically for the year 2019. Just over 41% of HT patients reached the targets goals. However, two health care centers achieved notably different results with only one third of the patients attaining the goals. CONCLUSION: As has recently been shown in epidemiologic studies hypertension in Iceland is both underdiagnosed and undertreated although the country ranks high on both counts in international comparison. Furthermore, the fact that under half of hypertensive patients in general practice in the capital area reach the targeted treatment goals, cannot be considered an acceptable. Thus, it is of immense importance to improve both the diagnosis and the treatment of HT.

[Changes in prescriptions on opioids in primary health care during the years 2008-2017].

INTRODUCTION: In recent decades there has been a notable increase in the prescription of opioids in western countries. With this rise in use of opioids the risk of side effects, opioid abuse and deaths linked to opioids have become more apparent. The increase in opioid prescription may partly stem from a change in attitude in relation to pain management. Research has shown that pain is among the most common reasons people seek medical care and chronic pain is prevalent. Iceland is leading the Nordic countries in opioid prescriptions. OBJECTIVE: To examine prescriptions of opioids in primary car in Iceland for all age group from 2008 to 2017. METHODS: The research included all opioid prescription in every health clinic in the capital area in Iceland the between 2008 and 2017. Population in the capital area in this time period was between 201 and 222 thousand people. Data was collected from medical records database of the primary health care and approximatley 68.000 individuals had received a prescription for opioids during the research period. RESULTS: During the research period there was a 17,2% (p<0,01) increase in DDD/1000 inhabitants/day (Defined daily dose) for opioids. About a third of those who got the prescription were men and that ratio did not change during the period. proportionately, the biggest change in DDD/1000 inhabitants/day was in the age group made of people 90 years old and older, about 40,5% ((p<0,01)). The biggest increase in number of people getting a prescription for opioids was in the age group 30-39, about 25,5% ((p<0,01)). Number of prescriptions increased in every category of opioids, measured in DDD/1000 inhabitants/day,15,3% ((p<0,01)) in parkódin, 20,7% ((p<0,01)) in parkódín forte, 4,7% (p<0,01)) in tramadol and 85,6% (p<0,01) in the strongest opioids. DISCUSSION: the evolution of prescriptions for every type of opioid to the clients of the health clinics in the capital area that occured in the years from 2008 to 2017, proportionately highest for the strongest opioids, should encourage a review of pain treatment within the health clinics and development within that field.

[Antidepressants, anxiolytics and hypnotics prescribed to young adults before and after an economic crisis in Iceland - A cross-sectional study at the Primary Health Care of Reykjavik capital area].

BACKGROUND: According to research findings, the financial crisis hitting Iceland in the autumn of 2008 caused both economic and health-related effects on the Icelandic population. It has been well known that the Icelandic population uses more antidepressants, anxiolytics and hypnotics compared to other Nordic countries. The aim of this research was to study the trend in prescription for these drugs by the Primary Health Care of Reykjavik capital area to young adults, during the years prior to and following the crisis. METHOD: In this cross-sectional study, data were gathered on all medical prescriptions of antidepressants, anxiolytics and hypnotics, prescribed by the Primary Health Care of Reykjavik capital area to people aged 18-35, during 2006-2016. While Reykjavík capital residents in the specified age group were approximately 55 thousand during the research period, this study included data on approximately 23 thousand individuals, received from the Icelandic electronical medical record system "Saga" used by the Primary Health Care. RESULTS: Research results demonstrate a significant average annual increase of prescribed defined daily doses (DDD) for all three medication categories during the research period; 3% (p<0,001) for anxiolytics, 1.6% (p<0,001) for hypnotics and 10.5% (p<0,001) for antidepressants. Between 2008-2009, prescribed daily doses of anxiolytics increased by 22.7% (p<0,001), where a 12.9% (p<0,001) increase was seen for women and 39.5% (p<0,001) increase for men. Of those men who were prescribed anxiolytics in 2009, 35% had no history of such prescriptions the previous year. From 2006-2008 an average annual increase of 13.6% (p<0,001) was seen in prescribed daily doses of hypnotics, whereof 24.4% (p<0,001) increase was seen for men and 7.8% (p<0,001) for women. CONCLUSIONS: This study demonstrates a significant increase in prescribed amount of hypnotics and anxiolytics during the years prior and after the economic crisis, with more prominent results amongst men compared to women. This trend was however not observed for antidepressants, which could suggest an overall tendency towards short- and fast acting drug prescriptions as a treatment for challenging difficult personal circumstances during the economic crisis in Iceland.

Co-prescribing of opioids and benzodiazepines/Z-drugs associated with all-cause mortality-A population-based longitudinal study in primary care with weak opioids most commonly prescribed.

Introduction: The risk of mortality associated with the co-prescribing of benzodiazepines and opioids has been explored in a number of papers mainly focusing on strong opioids. The mortality risk associated with the use of weak opioids has not been dealt with to a similar extent. Objective: To assess the mortality risk in primary care patients with consistent 3-year co-prescribing of benzodiazepine/Z-drugs (benzodiazepine receptor modulators) and mainly weak opioids (codeine, tramadol). Methods: Of 221,804 patients contacting the primary healthcare centres, 124,436 were selected for further analysis, 88,832 participants fulfilled the inclusion criteria, aged 10-69 years and were divided into four groups with neither any use of benzodiazepines/Z-drugs nor opioids as Group 1, 3 years' use of opioids and no/minimal benzodiazepines/Z-drugs as Group 2, with benzodiazepines/Z-drugs and no/minimal opioids as Group 3, and finally both benzodiazepines/Z-drugs and opioids as Group 4. Hazard ratios were calculated with the no-drug group as a reference, using Cox proportional hazards regression model adjusted for age, sex, number of chronic conditions and cancer patients excluded (n = 87,314). Results: Hazard ratios for mortality increased both in Group 3 where it was 2.66 (95% CI 2.25-3.09) and in Group 4 where it was 5.12 (95% CI 4.25-6.17), with increased dose and higher number of chronic conditions. In Group 4 an opioid dose-dependent increase in mortality among persons using >1000 DDDs benzodiazepines/Z-drugs was observed when those on less than ≤300 DDDs of opioids with HR 4.94 (95% CI 3.54-6.88) were compared to those on >300 DDDs with HR 7.61/95% CI 6.08-9.55). This increase in mortality was not observed among patients on <1000 DDDs of benzodiazepines/Z-drugs. Conclusion: The study supports evidence suggesting that mortality increases in a dose-dependent manner in patients co-prescribed benzodiazepines/Z-drugs and weak opioids (codeine, tramadol). An association between the number of chronic conditions and a rise in mortality was found. Long-term use of these drugs should preferably be avoided. Non-pharmacological therapy should be seriously considered instead of long-term use of benzodiazepines/Z-drugs, and deprescribing implemented for chronic users of these drugs when possible.

How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic.

OBJECTIVE: To describe how the primary healthcare (PHC) in Iceland changed its strategy to handle the COVID-19 pandemic. DESIGN: Descriptive observational study. SETTING: Reykjavik, the capital of Iceland. POPULATION: The Reykjavik area has a total of 233 000 inhabitants. MAIN OUTCOME MEASURES: The number and the mode of consultations carried out. Drug prescriptions and changes in the 10 most common diagnoses made in PHC. Laboratory tests including COVID-19 tests. Average numbers in March and April 2020 compared with the same months in 2018 and 2019. RESULTS: Pragmatic strategies and new tasks were rapidly applied to the clinical work to meet the foreseen healthcare needs caused by the pandemic. The number of daytime consultations increased by 35% or from 780 to 1051/1000 inhabitants (p<0.001) during the study period. Telephone and web-based consultations increased by 127% (p<0.001). The same tendency was observed in out-of-hours services. The number of consultations in maternity and well-child care decreased only by 4% (p=0.003). Changes were seen in the 10 most common diagnoses. Most noteworthy, apart from a high number of COVID-19 suspected disease, was that immunisation, depression, hypothyroidism and lumbago were not among the top 10 diagnoses during the epidemic period. The number of drug prescriptions increased by 10.3% (from 494 to 545 per 1000 inhabitants, p<0.001). The number of prescriptions from telephone and web-based consultations rose by 55.6%. No changes were observed in antibiotics prescriptions. CONCLUSIONS: As the first point of contact in the COVID-19 pandemic, the PHC in Iceland managed to change its strategy swiftly while preserving traditional maternity and well-child care, indicating a very solid PHC with substantial flexibility in its organisation.

Association between prescription of hypnotics/anxiolytics and mortality in multimorbid and non-multimorbid patients: a longitudinal cohort study in primary care.

OBJECTIVES: To assess the risk of mortality in primary care patients, multimorbid (≥2 chronic conditions) or not, prescribed hypnotics/anxiolytics. DESIGN: A longitudinal cohort study SETTING: Primary healthcare in the Reykjavik area. PARTICIPANTS: 114 084 individuals (aged 10-79 years, average 38.5, SD 18.4) contacting general practitioners during 2009-2012 (mortality follow-up to 31 December 2016). Of those, the reference group comprised 58 560 persons who were neither multimorbid nor had redeemed prescriptions for hypnotics/anxiolytics. Participants (16 108) redeeming prescriptions for hypnotics/anxiolytics on a regular basis for 3 consecutive years were considered as consistent, long-term users. They were subdivided into low-dose (1-300 defined daily doses (DDD)/3 years), medium-dose (301-1095 DDDs/3 years) and high-dose users (>1095 DDDs/3 years). All six groups taking these drugs were compared with the reference group. MAIN OUTCOME MEASURES: All-cause mortality. RESULTS: HRs were calculated with the no multimorbidity-no drug group as a reference, using Cox proportional hazards regression model adjusting for age, sex and the number of chronic conditions (n=111 767), patients with cancer excluded. During follow-up, 516 358 person-years in total, 1926 persons died. Mean follow-up was 1685 days (4.6 years), range 1-1826 days (5.0 years). For all multimorbid patients who took no drugs the HR was 1.14 (95% CI 1.00 to 1.30) compared with those without multimorbidity. HRs in the non-multimorbid participants varied from 1.49 to 3.35 (95% CI ranging from 1.03 to 4.11) with increasing doses of hypnotics/anxiolytics, and correspondingly from 1.55 to 3.52 (1.18 to 4.29) in multimorbid patients. CONCLUSIONS: Mortality increased in a dose-dependent manner among both multimorbid and non-multimorbid patients taking hypnotics/anxiolytics. This increase was clearly associated with prescribing of these drugs. Their use should be limited to the recommended period of 2-4 up to 6 weeks; long-term use may incur increased risk and should be re-examined.