Medication prescribing for asthma and COPD: a register-based cross-sectional study in Swedish primary care.

BACKGROUND: There is a gap between prescribed asthma medication and diagnosed asthma in children and adolescents. However, few studies have explored this issue among adults, where asthma medication is also used for the treatment of chronic obstructive pulmonary disease (COPD). The aim of this study was to examine the relationship between prescribing of medications indicated for asthma and COPD and the recorded diagnosis for these conditions. METHOD: In a register-based study, individuals prescribed a medication indicated for asthma and COPD during 2004-2005 (Group A; n = 14 101) and patients with diagnoses of asthma or COPD recorded during 2000-2005 (Group B; n = 12 328) were identified from primary health care centers in Skaraborg, Sweden. From a 5% random sample of the medication users (n = 670), the written medical records were accessed. PRIMARY OUTCOMES: prevalence of medication and diagnoses, reasons for prescription. SECONDARY OUTCOMES: type and number of prescribed drugs and performance of peak expiratory flow or spirometry. RESULTS: Medications indicated for asthma and COPD was prescribed to 5.6% of the population in primary care (n = 14 101). Among them, an asthma diagnosis was recorded for 5876 individuals (42%), 1116 (8%) were diagnosed with COPD and 545 (4%) had both diagnoses. The remaining 6564 individuals (46%) were lacking a recorded diagnosis. The gap between diagnosis and medication was present in all age-groups. Medication was used as a diagnostic tool among 30% of the undiagnosed patients and prescribed off-label for 54%. Missed recording of ICD-codes for existing asthma or COPD accounted for 16%. CONCLUSION: There was a large discrepancy between prescribing of medication and the prevalence of diagnosed asthma and COPD. Consequently, the prevalence of prescriptions of medications indicated for asthma and COPD should not be used to estimate the prevalence of these conditions. Medication was used both as a diagnostic tool and in an off-label manner. Therefore, the prescribing of medications for asthma and COPD does not adhere to national clinical guidelines. More efforts should be made to improve the prescribing of medication indicated for asthma and COPD so that they align with current guidelines.

Interaction between participants in focus groups with older patients and general practitioners.

Group interaction is put forward as the principal advantage for focus group research, although rarely reported on. The aim of the article is to contribute to the methodological knowledge regarding focus group research by providing an empirical example of the application of the Lehoux, Poland, and Daudelin template suggested for analysis of the interaction in focus groups. The data source was 18 focus groups' performance in Sweden: 12 with older patients and 6 with general practitioners (GPs). GPs found common ground in belonging to the same profession, whereas the older patients, instead of constituting a group in the word's real sense, started just sharing a common focus. We found the template easy to understand and use, except for identifying participants' explicit and implicit purposes for participating. Furthermore, adding an interaction analysis to the content analysis helped us appreciate and clarify the contexts from which these data were created.

Factors associated with multiple medication use in different age groups.

BACKGROUND: Multiple medicine use among elderly persons is likely to be the result of treatment regimens developed over a long period of time. By learning more about how multiple medication use develops, the quality of prescribing may be improved across the adult lifespan. OBJECTIVE: To describe patterns of multiple medicine use in the general Swedish population and its association with sociodemographic, lifestyle, and health status factors. METHODS: Data from a cross-sectional population health survey collected during 2001-2005 from 2816 randomly selected Swedish residents (age 30-75 y; response rate 76%) were analyzed. Multiple medicine use was restricted to prescription drugs and defined as the 75th percentile; that is, the 25% of the study group using the highest number of drugs per individual. RESULTS: Seventy-one percent of the respondents used some kind of drug, 51.5% used one or more prescription drug, 38.4% used one or more over-the-counter (OTC) medication, and 8.3% used one or more herbal preparation. The cutoff amounts defining multiple medicine use were: 2 or more medications for 30- to 49-year-olds, 3 or more for 50- to 64-year-olds, and 5 or more for 65- to 75-year-olds. No association between use of multiple medicines and use of OTC drugs or herbal preparations was found. When drugs were classified into therapeutic subgroups, 76.3% of those aged 30-49 years, 97.9% of those aged 50-64 years, and 100% of those aged 65-75 years were taking a unique combination of drugs. Multivariate analyses showed that diabetes and poor self-rated health were associated with multiple medicine use in all age cohorts. Female sex and hypertension were associated with multiple medicine use among those aged 30-49 and 50-64 years, current smoking among those aged 50-64 years, and obesity among those aged 65-75 years. CONCLUSIONS: Multiple medicine use was associated with morbidity and poor self-rated health across all age groups. The vast majority of users of multiple drugs are taking a unique combination of medications.

Adherence to diagnostic guidelines and quality indicators in asthma and COPD in Swedish primary care.

PURPOSE: To study the clinical evaluation and treatment of patients with asthma and COPD in primary care in Sweden, with a focus on adherence to recommended guidelines and quality indicators. METHODS: All visits at health care centres in Skaraborg, Sweden, are documented in computerized medical records constituting the Skaraborg Primary Care Database (SPCD). In a register-based retrospective observational study, all patients diagnosed with asthma or COPD during 2000-2005 (n = 12,328) were identified. In a 5% random sample (n = 623), information on performed investigations at initial visits and at follow-up during 2004-2005 was collected. Compliance with procedures as recommended by national guidelines was used for quality assessment. RESULTS: Among 499 patients with asthma, 167 (33%) were investigated with spirometry or Peak Expiratory Flow (PEF) during initial visits in agreement with guidelines. Correspondingly, 40 out of 124 patients with COPD (32%) were investigated with spirometry. During follow-up, evaluation in agreement with guidelines was performed in 130 (60%) of patients with asthma and in 35 patients out of 77 (45%) with COPD. Prescribing of ICS reached quality target, still every second patient made an acute visit during follow-up. CONCLUSION: Adherence to recommended guidelines in asthma/COPD was low. Acute visits were common and despite the prescribing of ICS according to recommendations, patients still seem uncontrolled in their disease. There is a need for quality improvement in the clinical evaluation and treatment of patients with asthma and COPD.

"I don't know how many of these [medicines] are necessary.." - a focus group study among elderly users of multiple medicines.

OBJECTIVE: The growing prevalence of multiple medicine use among elderly challenges health care. The aim was to conduct an exploratory study describing multiple medicine use from the elderly patient's perspective. METHODS: Twelve focus groups of 29 men and 30 women 65 years of age or older, using five or more medicines were analysed qualitatively. RESULTS: Initially the participants reported no problems with using multiple medicines; they felt fortunate that medicines existed and kept them alive. However, negative attitudes were also revealed, both similar to those presented in studies on lay experience of medicine-taking and some that appear more specific to users of multiple medicines. The foremost of these was that acceptance of medicines depends on not experiencing adverse effects and worrying whether multiple medicine use is 'good' for the body. Furthermore, participants' perception of their medicines depended on interaction with doctors, i.e. trusting 'good' doctors. CONCLUSION: The participants revealed co-existing accounts of both immediate gratitude and problems with using multiple medicines. Furthermore, the patient-doctor relationship coloured their attitudes towards their medicines. PRACTICE IMPLICATIONS: Importance of the patient-doctor relationship for treatment success is highlighted. Moreover, to be able to capture both accounts of the elderly in this study an appropriate consultation length is needed.

Dispensed volumes of anti-asthmatic drugs related to the prevalence of asthma and COPD in Sweden.

PURPOSE: To explore the possibility of using dispensed volumes asthma/COPD drugs as a proxy for the combined prevalence of asthma plus COPD. METHODS: The proportions of the Swedish population with inhalation drugs for asthma/COPD 2004 were obtained using three different databases. A pharmacy record database gave the volumes of dispensed drugs (defined daily doses, DDDs of R03A + R03B drugs) for each patient, 20 years and older. The X-plain database of Apoteket AB gave drug sales data for Sweden and Swedish population data were obtained from Swedish statistics. RESULTS: The sales volumes of asthma/COPD drugs were much higher for older than for younger people. The volumes increased from 18 DDD/TID for the 20-29 year group up to 124 DDD/TID for patients 70-79 years, or about seven times. The average volumes per patient in the different age groups corresponded to one DDD/day in only three of the age groups (50-79 years). In the youngest group the average drug volume per patient corresponded to one DDD every second day, which may indicate undermedication. The percentages of the Swedish population with asthma/COPD drugs increased from 4.0% for 20-29 years old to 14.5% for 80+ years old, or 3.6 times. When head-to-head comparisons could be made between reported prevalence data of asthma and COPD and our data the two sets of data were in a reasonable agreement. CONCLUSION: The prevalence of drug treatment, i.e. the proportion of the population with dispensed asthma/COPD drugs, could function as a proxy for the disease prevalence of asthma plus COPD.

Refill adherence of antihyperglycaemic drugs related to glucose control (HbA1c) in patients with type 2 diabetes.

The aim of this study was to examine a potential association between: (1) refill adherence to antihyperglycaemic drugs and glucose control, and (2) adherence to antihyperglycaemic and cardiovascular drugs for the same patients. Consecutive patients with type 2 diabetes at six Swedish health centres were included. Refill adherence was determined from repeat prescriptions. Satisfactory refill adherence was defined as the percentage of the patients with refills covering > or =80% of the prescribed treatment time. A total of 994 prescriptions were collected from 422 patients, 346 patients had antihyperglycaemic drugs (mean HbA(1c )6.5%) and 76 were on diet and exercise but not on drugs (mean HbA(1c )6.2%) (P = 0.0098). A total of 257 patients (74%) had satisfactory refill adherence. Mean HbA(1c) for the adherent patients was 6.5% and for the non-adherent patients 6.8% (P = 0.025). For patients on insulin only, 69% had satisfactory refill adherence with mean HbA(1c) 6.6% compared to 7.3% (P = 0.005) for the non-adherent patients. Ninety-two percent of the patients with satisfactory refill adherence to antihyperglycaemic agents were also adherent to cardiovascular drugs compared to 62% among those who were non-adherent to antihyperglycaemic drugs (P < 0.001). Patients with satisfactory refill adherence have lower HbA(1c)-levels and higher adherence to cardiovascular drugs than non-adherent patients.

Can drug treatment prevent disease in common practice?

To assess whether drug treatment in common practice can prevent disease, we analysed four preventive cardiovascular randomised clinical trials (RCTs), expressing efficacy by 1-year Number Needed to Treat (NNT) in RCT and common practice effectiveness by the Disease Impact Number (DIN) in all subjects at risk and by the Population impact Number (PIN) in the entire population, based on a Swedish population survey. Adjustments were made for non-adherence. Calculations were made of alternative 1-year drug costs and number of years an average general practitioner (GP) would need to work in order to prevent one event using the actual treatment. Secondary prevention of MI by simvastatin (NNT, DIN and adjusted PIN = 37, 93 and 2657; GP work time 2.7 years; drug costs Euro 1020 - 13505), and prevention of stroke by antihypertensive treatment in high-risk subjects (elderly with systolic blood pressure > 160 mm Hg; NNT, DIN and adjusted PIN = 167, 239 and 11950; GP work time 6 years; drug costs Euro 6095 - 51567) appeared medically and economically effective. Primary prevention of MI by pravastatin (NNT, DIN and adjusted PIN 208, 2080 and 24470; GP work time 12.2 years; drug costs Euro 5736 - 117676) or by antihypertensive drug treatment in low-risk subjects (diastolic blood pressure 90-99 mm Hg) (NNT, DIN and adjusted PIN 1667, 3334 and 116982; GP work time 58.5 years; drug costs Euro 60895 - 511718) seemed ineffective and expensive.

Increased introduction, advertising, and sales of preventive drugs during 1986-2002 in Sweden.

The objective of this study was to survey how introduction of new drugs and promotional activities influence drug sales in Sweden. All drugs on the Swedish market were categorized as curative, symptom-alleviating, substitutive, or preventive. The number of new drugs introduced, drug sales in volume and value, and the number of drug advertisements appearing in the major Swedish medical journal during 1986-2002 were determined for each of the 4 drug categories. Between 1986 and 1998, the relative shares of the 4 drug categories were relatively constant. From 1998 to 2002, the share of new preventive drugs increased from 24% to 30%, their share of advertisements increased from 20% to 35%, and their sales value increased from 25% to 30%. During the same period, the shares of other drugs decreased correspondingly. Pharmaceutical companies have shifted their attention to the introduction, advertising, and sales of preventive drugs in an attempt to exploit preventive medicine. This might lead to waste of resources when expensive preventive drugs are used by numerous patients over many years, as the benefit of preventive drugs for the individual patient cannot be judged easily.

An alpha,beta-unsaturated oxime identified as a strong contact allergen. Indications of antigen formation via several pathways.

The aim of this study was to examine the possible skin sensitizing effect of oximes, employing an alpha,beta-unsaturated oxime as the model compound. Oximes are not frequently used as biologically active compounds. However, they have been shown to possess both anti-inflammatory and anti-allergic activities. Furthermore, in a recent study, a number of oximes and oxime-ethers of hydroxylated benzaldehydes and acetophenones were found to be powerful antioxidants suggested to be used in consumer products such as cosmetics and food. Although there are only few reports on the sensitizing effect of oximes, their ability to be hydrolyzed to the corresponding ketones or aldehydes makes them potential contact allergens. The oxime investigated in this study was demonstrated to be a strong contact allergen in both mice and guinea pigs, capable of sensitize the control animals after only one dermal exposure. In order to elucidate the mechanisms for the formation of the complete antigen, a variety of analogues with different reactivity were tested. The results indicate that alpha,beta-unsaturated oximes can react with proteins via several different pathways. Most likely, a metabolic transformation is involved. Due to the strong allergenic effect of the oxime investigated, we strongly advise against the use of such oximes in consumer products until a better understanding of their interactions with biological macromolecules has been obtained.

Pricing and costs of drugs in the United States and Sweden: a comparison based on drug acquisition costs at the patient outcome level.

Cost consequences of antihypertensive drug pricing were compared in the United States and Sweden. Because of price differences, US drug acquisition costs to prevent one cardiovascular event were 339%, 127%, and 22% higher using the most prescribed calcium channel blocker, angiotensin-converting enzyme inhibitor, and beta blocker, but 65% lower with hydrochlorothiazide. As thiazides are as effective as, but cheaper than, the alternatives, the costs of effective antihypertensive drug treatment may be pronouncedly reduced in both countries. This emphasizes not only the importance of drug pricing but also the cost-increasing influence of commercial marketing. More producer-independent and evidence-based drug information to prescribers is necessary.

GPs' perceptions of multiple-medicine use in older patients.

RATIONALE, AIM AND OBJECTIVE: Multiple-medicine use (polypharmacy) is a growing problem for older patients, prescribers and health policy makers. The general practitioner (GP) is most often the main professional care provider; hence, improvements of treatment can only be carried out in concordance with GPs. The aim of this study was, therefore, to explore GPs' perspectives of treating older users of multiple medicines, using a qualitative approach. METHOD: Six focus groups, with four private GPs and 27 county-employed GPs, were analysed by using the framework method. RESULTS: In contrast to definitions in most epidemiologic studies, the GPs gave a spontaneous definition of polypharmacy as 'the administration of more medicines than are clinically indicated'. They had problems stating both a cut-off number and which medicines should be included. Clinical practice guidelines were thought of as 'medicine generators', having an ambiguous effect on the GPs, who both trust them and find them difficult to apply. There was a perceived lack of communication between GPs and hospital specialists concerning their patients' medicines, which was further perceived to reduce treatment quality. The influence of patient pressure was acknowledged by the GPs as a factor contributing to the development of multiple-medicine use. CONCLUSIONS: The GPs felt insecure although surrounded by clinical practice guidelines. There is a need for policy makers to appreciate this paradox, as the problem is likely to grow in size and proportion. GPs must be empowered to handle the increasing proportion of older users of multiple medicines with individual agendas, receiving care from multiple specialists.

Asthma/COPD drugs reflecting disease prevalence, patient adherence and persistence.

The aim of this review is to discuss the methodological issues involved in using pharmacy-record databases of drug sales in pharmacoepidemiology and to illustrate the usefulness of such data in estimating disease prevalence, patient adherence and persistence to therapy. Recent studies show that asthma/chronic obstructive pulmonary disease (COPD) prevalence increases with age. The volume of acquired asthma/COPD drugs per patient also increases with age and was approximately 2.5-times higher for patients aged 60-69 years compared with patients aged 20-29 years. Despite this, there is a comparatively low interest in asthma/COPD research involving elderly individuals. Published asthma/COPD-prevalence data and drug-treatment-prevalence data correspond reasonably well. Short- as well as long-term studies on drug acquisition indicate that approximately a third of patients have drugs available to cover at least 80% of the prescribed treatment time. Only approximately a tenth of the patients acquired steroids or steroid combinations, corresponding to one daily defined dose per day over a 5-year treatment period. It is probable that asthma/COPD is undertreated in all age groups.

Refill adherence to oral antihyperglycaemic drugs in Sweden.

Only 49% of the patients with T2D in Sweden that medicate with oral antihyperglycaemic drugs (AHGD) had good blood glucose control (HbA(1C) < 6.0%). The reason can be low medication adherence. The aim of this study was, therefore, to determine the adherence to different oral AHGD. Included were all patients in Sweden, older than 40 years and having at least two expenditures of AHGD between 1 December 2005 and 30 November 2006. After exclusions of inpatients and patients with unspecified daily dosage 171,220 patients (57% men) remained. Medication possession ratio (MPR) was used for estimating adherence and patients were regarded adherent if MPR >or=80%. The overall refill adherence average 90%, with mean MPR (SD) = 107% (30). Eighty-five percent of the patients in their 40s were adherent compared to 91% of the patients in their 80s. About 90.1% of the women were adherent whereas 89.5% of the men were adherent. Patients with an indication for the medicine were more adherent than patients without this information. We conclude that the unsatisfactory blood glucose control showed among many Swedish T2D patients is not the result of non-adherence to prescribed medication.

Medication persistence among patients with asthma/COPD drugs.

OBJECTIVE: To determine medication possession ratio (MPR) of patients with asthma/COPD drugs. METHOD: Individual patient's volumes of asthma/COPD drugs (ATC-code R03) for 2000-2004 were obtained from a pharmacy record database. For each patient the MPR was calculated as the percentage of the treatment time that the patient had drugs available. MAIN OUTCOME MEASURE: Medication possession ratio (MPR). RESULTS: A total of 1,812 patients, 20 years and older, with dispensed asthma/COPD drugs were registered in the database, 928 patients (51%) had acquired drugs less than once per year (68% for 20-29 years old) during the 5-year study. Only 13% of the patients had steroids and steroid combinations available to allow continuous treatment. Eight percent of the patients 20-29 years old had MPR > or = 80% of all the included drugs and 5% when only steroids and steroid combinations were considered. About 25% of the patients had acquired 80% of the total volume of asthma/COPD drugs. CONCLUSION: The majority of the patients, and particularly those in the youngest age group used asthma/COPD drugs only sporadically. This may indicate undermedication which is likely to have a negative impact on patient outcome.

Allergic contact dermatitis--formation, structural requirements, and reactivity of skin sensitizers.

Contact allergy is caused by a wide range of chemicals after skin contact. Its clinical manifestation, allergic contact dermatitis (ACD), is developed upon repeated contact with the allergen. This perspective focuses on two areas that have yielded new useful information during the last 20 years: (i) structure-activity relationship (SAR) studies of contact allergy based on the concept of hapten-protein binding and (ii) mechanistic investigations regarding activation of nonsensitizing compounds to contact allergens by air oxidation or skin metabolism. The second area is more thoroughly reviewed since the full picture has previously not been published. Prediction of the sensitizing capacity of a chemical is important to avoid outbreaks of ACD in the population. Much research has been devoted to the development of in vitro and in silico predictive testing methods. Today, no method exists that is sensitive enough to detect weak allergens and that is robust enough to be used for routine screening. To cause sensitization, a chemical must bind to macromolecules (proteins) in the skin. Expert systems containing information about the relationship between the chemical structure and the ability of chemicals to haptenate proteins are available. However, few designed SAR studies based on mechanistic investigations of prohaptens have been published. Many compounds are not allergenic themselves but are activated in the skin (e.g., metabolically) or before skin contact (e.g., via air oxidation) to form skin sensitizers. Thus, more basic research is needed on the chemical reactions involved in the antigen formation and the immunological mechanisms. The clinical importance of air oxidation to activate nonallergenic compounds has been demonstrated. Oxidized fragrance terpenes, in contrast to the pure terpenes, gave positive patch test reactions in consecutive dermatitis patients as frequently as the most common standard allergens. This shows the importance of using compounds to which people are exposed when screening for ACD in dermatology clinics.