The risk of developing a mismatch repair deficient colorectal cancer after undergoing cholecystectomy.

OBJECTIVES: Mismatch repair deficient (dMMR) colorectal cancer (CRC) is caused by inactivation of the MMR DNA repair system, most commonly via epigenetic inactivation of the MLH1 gene, and these tumors occur most frequently in the right colon. The objective was to determine whether cholecystectomy (CCY) increases the risk of a dMMR CRC by comparing CCY incidence in patients with dMMR CRC and proficient MMR (pMMR) CRC to unaffected controls. MATERIALS AND METHODS: All patients diagnosed with CRC in Iceland from 2000 to 2009 (n = 1171) were included. They had previously been screened for dMMR by immunohistochemistry (n = 129 were dMMR). Unaffected age- and sex-matched controls (n = 17,460) were obtained from large Icelandic cohort studies. Subjects were cross-referenced with all pathology databases in Iceland to establish who had undergone CCY. Odds ratios were calculated using unconditional logistic regression. RESULTS: Eighteen (13.7%) dMMR CRC cases and 90 (8.7%) pMMR CRC cases had undergone CCY compared to 1532 (8.8%) controls. CCY-related odds ratios (OR) were 1.06 (95% CI 0.90-1.26, p = .577) for all CRC, 1.16 (95% CI 0.66-2.05 p = .602) for dMMR CRCand 1.04 (95% CI 0.83-1.29, p = .744) for pMMR CRC. Furthermore, OR for dMMR CRC was 0.51 (95% CI 0.16-1.67, p = .266), 2.04 (95% CI 0.92-4.50, p = .080) and 1.08 (95% CI 0.40-2.89, p = .875) <10 years, 10-20 years and >20 years after a CCY, respectively. CONCLUSIONS: There was no evidence of increased risk of developing dMMR CRC after CCY although a borderline significantly increased 2-fold risk was observed 10-20 years after CCY. Larger studies are warranted to examine this further.

[Change in attitude towards antibiotic prescriptions among Icelandic general practitioners]. / Breytt viðhorf til sýklalyfjaávísana hjá íslenskum heimilis- og heilsugæslulæknum.

INTRODUCTION: Antibiotic use is a leading cause of antibiotic resistance and it is therefore important to reduce unnecessary prescribing in Iceland where antibiotic use is relatively high. The purpose of this study was to explore antibiotic prescribing practices among Icelandic physicians and compare the results with results of comparable studies from 1991 and 1995 conducted by the Directorate of Health, Iceland. METHODS: A descriptive cross-sectional study was carried out among all general practitioners registered in Iceland in 1991 and 1995 and all physicians registered in March 2014. Data was collected with questionnaires regarding diagnosis and treatment of simple urinary tract infection, acute otitis media and pharyngitis. A multiple logistic regression analysis was performed and level of significance p≤0.05. RESULTS: Response rates were 85% and 93% in 1991 and 1995 but 31% in 2014. Proportion of physicians who consider themselves prescribing antibiotics more than 10 times per week was 36% in 1991, 32% in 1995 and 21% in 2014. Proportion of trimethoprim-sulfamethoxazole as first choice for simple urinary tract infection reduced from 43% and 45% to 8% in 2014. In 2014, general practitioners considered themselves 87% less likely to prescribe an antibiotic for acute otitis media than in 1991 (p<0.001). They also claimed to use rapid diagnostic tests in pharyngitis five times more often in 2014 than in 1991 (p<0.001). CONCLUSION: Antibiotic prescribing practices have changed significantly in the past two decades in Iceland becoming more in line with clinical guidelines. Improvements are still needed to further reduce inappropriate antibiotic use.

A nationwide study of attention-deficit/hyperactivity disorder drug use among adults in Iceland 2003-2012.

In this study, we leveraged on complete nationwide prescription data for the total adult population in Iceland (N = 227,000) to examine how attention-deficit/hyperactivity disorder (ADHD) drugs have been used over the past decade. In particular, we aimed to describe the prevalence, incidence and duration of use of stimulants and atomoxetine, among adults (≥19 years) in Iceland, with regard to sex, age, type of drug and specialty of the prescribing physician. Our results indicate that the 1-year period prevalence of ADHD drug use rose, from 2.9 to 12.2 per 1000 adults between 2003 and 2012, with the most pronounced increases among young adults (19-24 years). The annual incidence increased 3 times, similarly among men and women. Extended-release methylphenidate formulations were the most commonly used ADHD drugs. Specialists in psychiatry initiated treatment in 79% of new adult ADHD drug users. The proportion of users still receiving treatment after 1 year varied from 43.0% (19-24 years), 57.2% (25-49 years) to 47.5% (50+ years). After 3 years, the corresponding proportions still on treatment were 12.4%, 24.5% and 24.3%, and after 5 years 7.9%, 15.9% and 16.8%. These results of increasing ADHD drug use and short treatment durations call for further investigation of the quality of treatment regimens for adults with ADHD and better follow-up of patients treated with ADHD drugs.

Primary non-adherence to prescribed medication in general practice: lack of influence of moderate increases in patient copayment.

BACKGROUND: Primary non-adherence refers to the patient not redeeming a prescribed medication at some point during drug therapy. Research has mainly focused on secondary non-adherence. Prior to this study, the overall rate of primary non-adherence in general practice in Iceland was not known. OBJECTIVES: To determine the prevalence of primary non-adherence, test whether it is influenced by a moderate increase in patient copayment implemented in 2010 and examine the difference between copayment groups (general versus concession patients). METHODS: A population-based data linkage study, wherein prescriptions issued electronically by 140 physicians at 16 primary health care centres in the Reykjavik capital area during two periods before and after increases in copayment were matched with those dispensed in pharmacies, the difference constituting primary non-adherence (population: 200 000; patients: 21 571; prescriptions: 22 991). Eight drug classes were selected to reflect symptom relief and degree of copayment. Two-tailed chi-square test and odds ratios for non-adherence by patient copayment groups were calculated. RESULTS: The rate of primary non-adherence was 6.2%. It was lower after the increased copayment, reaching statistical significance for hypertensive agents, non-steroidal anti-inflammatory drugs (NSAIDs) and antipsychotics. Generally, primary non-adherence, except for antibacterials and NSAIDs, was highest in old-age pensioners. CONCLUSIONS: Primary non-adherence in Icelandic general practice was within the range of prior studies undertaken in other countries and was not adversely affected by the moderate increase in patient copayment. Older patients showed a different pattern of primary non-adherence. This may possibly be explained by higher prevalence of medicine use.

Clinical consequences following regulatory changes in respect to reimbursement of statins cost by the Icelandic Social Insurance Administration.

INTRODUCTION: On 1 March 2009, a new reimbursement system was introduced by the Ministry of Health of Iceland regarding drugs to treat hyperlipidaemia. The Social Insurance Administration was only authorised to reimburse 10 and 20 mg simvastatin unless patients were eligible to receive a medical card from the Social Insurance Administration. The purpose of this study was to evaluate the influence of this reimbursement regulation on the clinical outcome. MATERIALS AND METHODS: Patients that received hyperlipidaemia treatment and were admitted to the cardiac ward were enrolled. The criteria were that the patients had been admitted 1 year prior to the regulation change and were using other statins than simvastatin. RESULTS: Out of 233 eligible patients 170 (73%) reached the treatment goal before the switch. After the switch, only 126 (54%) reached their goal (p<0.05). Total cholesterol was found to be increased after the switch by a mean of 0.48 mmol/l (range 3.90-5.53 mmol/l, p<0.001). Low-density lipoprotein cholesterol increased by a mean of 0.48 mmol/l (range 1.62-3.11, p<0.001). The level of triglycerides did not change significantly. Before the introduction of the new regulations, 73% of subjects were well controlled, but after 1 March 2009, this figure dropped to 46% (37% decrease). CONCLUSIONS: In order to lower costs for subsidising drugs, a switch to simvastatin from other cholesterol-lowering drugs was implemented (by the Ministry of Health of Iceland). The result was a significant and unwanted increase in cholesterol levels among patients with heart disease. The reason seems to be inaccurate prescriptions due to lack of competence among physicians and pharmacists. The use of "one drug fits all" does not comply here.

A population-based study of stimulant drug treatment of ADHD and academic progress in children.

OBJECTIVE: We evaluated the hypothesis that later start of stimulant treatment of attention-deficit/hyperactivity disorder adversely affects academic progress in mathematics and language arts among 9- to 12-year-old children. METHODS: We linked nationwide data from the Icelandic Medicines Registry and the Database of National Scholastic Examinations. The study population comprised 11,872 children born in 1994-1996 who took standardized tests in both fourth and seventh grade. We estimated the probability of academic decline (drop of ≥ 5.0 percentile points) according to drug exposure and timing of treatment start between examinations. To limit confounding by indication, we concentrated on children who started treatment either early or later, but at some point between fourth-grade and seventh-grade standardized tests. RESULTS: In contrast with nonmedicated children, children starting stimulant treatment between their fourth- and seventh-grade tests were more likely to decline in test performance. The crude probability of academic decline was 72.9% in mathematics and 42.9% in language arts for children with a treatment start 25 to 36 months after the fourth-grade test. Compared with those starting treatment earlier (≤ 12 months after tests), the multivariable adjusted risk ratio (RR) for decline was 1.7 (95% confidence interval [CI]: 1.2-2.4) in mathematics and 1.1 (95% CI: 0.7-1.8) in language arts. The adjusted RR of mathematics decline with later treatment was higher among girls (RR, 2.7; 95% CI: 1.2-6.0) than boys (RR, 1.4; 95% CI: 0.9-2.0). CONCLUSIONS: Later start of stimulant drug treatment of attention-deficit/hyperactivity disorder is associated with academic decline in mathematics.

Rofecoxib, but not celecoxib, increases the risk of thromboembolic cardiovascular events in young adults-a nationwide registry-based study.

PURPOSE: To examine the risk of thromboembolic cardiovascular events in users of coxibs and NSAIDs in a nationwide cohort. METHODS: Data were synchronised from three nationwide databases, the Icelandic Medicines Registry (IMR), The Icelandic National Patient Registry (INPR) and the Registry for Causes of Death at Statistics Iceland (RCD), for prescriptions for NSAIDs or coxibs with respect to hospitalisation for unstable angina pectoris, myocardial infarction and cerebral infarction over a 3-year period. The Cox proportional hazards model and Poisson regression were used to analyse the data. RESULTS: A total of 108,700 individuals received prescriptions for NSAIDs or coxibs (ATC code M01A), of whom 78,539 received one drug only (163,406 person-years). Among those receiving only one drug 426 individuals were discharged from hospital with endpoint diagnoses. In comparison to diclofenac, the incidence ratios, adjusted for age and gender, were significantly higher for cerebral infarction (2.13; 95% CI 1.54-2.97; P < 0.001), for myocardial infarction (1.77; 95% CI 1.34-2.32; P < 0.001) and for unstable angina pectoris (1.52; 95% CI 1.01-2.30; P = 0.047) for patients who used rofecoxib. For naproxen users, the incidence ratio was 1.46 for myocardial infarction (95% CI 1.03-2.07; P = 0.03), but was reduced in ibuprofen users (0.63; 95% CI 0.40-1.00; P = 0.05). The youngest users of rofecoxib (< or =39 years) had the highest hazard ratio (HR) for cardiovascular events (8.34; P < 0.001), while those > or =60 years had a lower but still significantly elevated HR (1.35; P = 0.001). CONCLUSION: This Icelandic nationwide registry-based study amounting to 163,406 patient-years showed increased risk of cardiovascular events, i.e. cerebral infarction, myocardial infarction and unstable angina pectoris, among rofecoxib and naproxen users in comparison to diclofenac users. The added risk was most pronounced in young adults using rofecoxib.

Psychotropic drug use among Icelandic children: a nationwide population-based study.

OBJECTIVE: The aim of this study was to investigate psychotropic drug use among children in Iceland between 2003 and 2007. METHODS: A nationwide population-based drug use study covering the total pediatric population (ages 0-17) in Iceland. Information was obtained from the National Medicines Registry to calculate prevalence of use by year and psychotropic drug group; incidence by year, psychotropic drug group, child's age and sex, and medical specialty of prescriber; the most commonly used psychotropic chemical substances, off-label and unlicensed use and concomitant psychotropic drug use. RESULTS: The overall prevalence of psychotropic drug use was 48.7 per 1000 Icelandic children in 2007. Stimulants and antidepressants increased in prevalence from 2003 to 2007 and were the two most prevalent psychotropic drug groups, respectively, 28.4 and 23.4 per 1000 children in 2007. A statistically significant trend of declining prevalence (p = 0.00013) and incidence (p = 0.0018) of antidepressant use occurred during the study period. Out of 21,986 psychotropic drugs dispensed in 2007, 25.4% were used off-label. CONCLUSIONS: With reference to reports from other European countries, the results indicate extensive psychotropic drug use among children in Iceland between 2003 and 2007. Further scrutiny is needed to assess the rationale behind this widespread use.

[Prevalence of psychotropic drug use among elderly Icelanders living at home]. / Algengi gedlyfjanotkunar eldri Islendinga utan stofnana.

OBJECTIVE: To evaluate the prevalence of psychotropic drug use among home-dwelling elderly Icelanders in the year 2006. MATERIALS AND METHODS: A population-based drug utilization study using the Icelandic Medicines Registry. The study group consisted of Icelanders, seventy years and older living at home (8% of total population). Prevalence of antidepressant, neuroleptic, anxiolytic and hypnotic use (ATC-groups N06A, N05A, N05B, N05C) was defined as the dispension per 100 individuals of one or more prescriptions for these drugs within the year 2006. For cross-national comparison we used data for 70-74 year olds in the Danish Registry of Medicinal Product Statistics. RESULTS: One third of all dispensed prescriptions in Iceland in 2006 were for people aged 70 years and older, and one fourth were for psychotropics. Elderly women were more likely than men to use psychotropics (RR=1.40 95% CI: 1.37-1.43). The prevalence of psychotropic use was 65.5% for women and 46.8% for men. Anxiolytics and hypnotics (N05B or N05C) were the most frequently used psychotropics, with a prevalence of 58.5% for women and 40.3% for men. Antidepressants were used by 28.8 % of women and 18.4 % of men. Neuroleptics were used by 5%. By comparing 70-74 years old Icelanders and Danes, the Icelanders were 1.5 to 2.5 times more likely to receive any psychotropics drug in 2006. CONCLUSION: Use of psychotropics, especially anxiolytics and hypnotics, is common among elderly Icelanders. Comparing information for 70 to 74 year olds with Danes of same age, the prescribing of psychotropics is more frequent in Iceland.

[Use of methylphenidate among children in Iceland 1989-2006]. / Notkun metýlfenídats medal barna á Islandi 1989-2006.

STUDY OBJECTIVE: To determine the prevalence of methylphenidate use among children in Iceland and show utilization trends from 1989 to 2006. Patterns of use were analyzed by sex, age and region of habitation, short-acting vs. long-acting formulations and presciber's specialty. MATERIALS AND METHODS: A descriptive observational study. Data was retrieved from the nationwide Register on Prescribed Drugs in Iceland and the Icelandic Directorate of Health surveillance system on prescribed methylphenidate. The study population encompassed the total pediatric population (0-18 year-olds) in Iceland during the study period. Total, sex-, age, and region-specific yearly prevalence rates were computed. Specific prevalence rates of short-acting and long-acting methylphenidate use were compared. Prescribed volume and number of prescriptions were analyzed in relation to specialty of prescriber. Prevalence ( per thousand) was defined as the number of children per 1,000 children in the population who received at least one methylphenidate prescription in the given year. RESULTS: The total prevalence of methylphenidate use among children (0-18) in Iceland was 0.2 per thousand in 1989 and 25.1 per thousand in 2006. Overall use was three times more common among boys than girls. Prevalence was highest at age 10, 77.4 per thousand among boys and 24.3 per thousand among girls. A variance in use between regions was detected. Prevalence of short-acting methylphenidate use decreased from 2003 (18.7 per thousand) to 2006 (6.8 per thousand), while prevalence of long-acting medication increased from 14.4 per thousand to 24.6 per thousand. In 2006 pediatricians were the most common prescribers of methylphenidate to children in Iceland, accounting for 41% of prescriptions. CONCLUSION: Use of methylphenidate among children in Iceland increased considerably from 1989 to 2004, when a plateau seems to have been reached. In accordance with the trend in many Western countries, a rise in use of long-acting drugs was detected concurrently with a steep decrease in use of short-acting drugs. Compared to utilization rates in Europe, prevalence of methylphenidate use among children in Iceland is high.

Health care systems in transition: Iceland

The Health Systems in Transition (HiT) series provide detailed descriptions of health systems in the countries of the WHO European Region as well as some additional OECD countries. An individual health system review (HiT) examines the specific approach to the organization, financing and delivery of health services in a particular country and the role of the main actors in the health system. It describes the institutional framework, process, content, and implementation of health and health care policies. HiTs also look at reforms in progress or under development and make an assessment of the health system based on stated objectives and outcomes with respect to various dimensions (health status, equity, quality, efficiency, accountability).

[Gender and age differences in waiting time on hospital waiting list.].

OBJECTIVE: The size of waiting lists has traditionally been viewed as a fairly good measure of the quality of health care services. No statistical analysis exists in Iceland of the length of waiting times and the potential variation between groups of patients. This study was conducted within the office of the Directorate of Health in Iceland. This location was convenient since standardized information on waiting lists is collected by the office three times a year. Variations in waiting times were studied based on gender on the one hand and on age on the other. MATERIAL AND METHOD: Data from the largest waiting lists, those amounting to 400 or more patients, were included in the study. The most frequently awaited operations were identified and the groups of people waiting for them analyzed. The departments and prospective operations included in the study were: Dept. of General Surgery at the University Hospital (UH) (laparoscopic gastro-oesophageal antireflux operation), Opthalmology at UH (phakoemulsification with implantation of artificial lens in posterior chamber), Orthopedic Surgery at UH (primary total prosthetic replacement of hip joint using sement), The Rehabilitation Center at Reykjalundur (rehabilitation, not specified), Ear, Nose and Throat (ENT) at UH (tonsillectomy), and Reconstructive Surgery at UH (reduction mammoplasty with transposition of areola). The lists were sorted by gender and age, with the latter consisting of two categories, older and younger patients. Every attempt was made as to ensure similar sample sizes for both age groups within each department. Finally, the median waiting time was determined and a Mann-Whitney test conducted in order to test for significance. RESULTS: The median waiting time for males at the General Surgery Dept. was 73 weeks as compared to 60 weeks for females. This was the only department where the median waiting time was significantly longer for males than for females (p<0.05). At three of the departments the older group had a longer median waiting time than the younger group, 18 weeks compared to 14 at Opthalmology (p<0.001), 26 versus 17 weeks at Reykjalundur (p<0.025) and 33 versus 21 weeks at ENT (p<0.01). Waiting times for females was significantly longer than for males at two departments, Reykjalundur (21 vs. 17 weeks, p<0.05) and ENT (33 vs. 29 weeks, p<0.05). CONCLUSION: This study revealed age and gender differences in median waiting times at Icelandic hospitals. These differences were in many cases marked and statistically significant. Various explanations have been put forward, however, further research is needed in order to determine if it these differences are due to actual clinical needs assessments or to age or gender discrimination.