Impact of changes to reimbursement of fixed combinations of inhaled corticosteroids and long-acting ß2 -agonists in obstructive lung diseases: a population-based, observational study.

BACKGROUND: In 2010, the Icelandic government introduced a new cost-saving policy that limited reimbursement of fixed inhaled corticosteroid/long-acting ß2 -agonist (ICS/LABA) combinations. METHODS: This population-based, retrospective, observational study assessed the effects of this policy change by linking specialist/primary care medical records with data from the Icelandic Pharmaceutical Database. The policy change took effect on 1 January 2010 (index date); data for the year preceding and following this date were analysed in 8241 patients with controlled/partly controlled asthma and/or chronic obstructive pulmonary disease (COPD) who had been dispensed an ICS/LABA during 2009. Oral corticosteroid (OCS) and short-acting ß2 -agonist (SABA) use, and healthcare visits, were assessed pre- and post-index. RESULTS: The ICS/LABA reimbursement policy change led to 47.8% fewer fixed ICS/LABA combinations being dispensed during the post-index period among patients whose asthma and/or COPD was controlled/partly controlled during the pre-index period. Fewer ICS monocomponents were also dispensed. A total of 48.6% of patients were no longer receiving any respiratory medications after the policy change. This was associated with reduced disease control, as demonstrated by more healthcare visits (44.0%), and more OCS (76.3%) and SABA (51.2%) dispensations. CONCLUSIONS: Overall, these findings demonstrate that changes in healthcare policy and medication reimbursement can directly impact medication use and, consequently, clinical outcomes and should, therefore, be made cautiously.

Adverse reactions to food and food allergy in young children in Iceland and Sweden.

OBJECTIVE: To investigate the prevalence of adverse reactions to food and food allergy in Icelandic and Swedish 18-month-old children. DESIGN: Prospective multicentre comparative study. SETTING: Primary health care centres in Sweden and Iceland. SUBJECTS: A total of 324 children in Iceland and 328 in Sweden who attended for regular 18-month check-up. MAIN OUTCOME MEASURES: Adverse reaction to food according to questionnaire, and food allergy according to skin prick tests and double blind food challenge tests. RESULTS: Adverse reactions to food were reported in 27% of children in Iceland and 28% in Sweden. Food allergy was confirmed in 2.0% in both countries. Allergy among other family members was reported in 45% of the Icelandic children and 62% in the Swedish (p < 0.001). Indoor smoking was reported by 30% of the Icelandic families and 3% of the Swedish. Respiratory infections were reported significantly more often in Icelandic children than Swedish. CONCLUSION: Adverse reactions to food and food allergy were similar in Icelandic and Swedish children. At the age of 18 months one can expect to confirm food allergy in approximately one out of 15 children with reported adverse reactions to food.

[Medical treatment of coronary heart disease in Iceland.].

OBJECTIVE: During the last decades the knowledge of prevention of coronary heart disease (CHD) has increased dramatically. RESULTS from large clinical trials on drug treatment of patients with CHD with various groups of drugs has given new possibilities to improve the prognosis of our patients. However, results from several studies have shown that this knowledge has not yet been put into practice. The main aim of our study, which is a part of a larger enquiry into the actual practice of secondary prevention of CHD in Iceland, was to evaluate the medical treatment of CHD, other than lipid lowering therapy. MATERIAL AND METHODS: All patients with residence in Hafnarfjörethur, Garethabaer and Bessastaethahreppur who have been diagnosed as having CHD were sent a letter with an invitation to participate in the study and a request for an informed consent. Those who choose to participate responded to a questionnaire and gave a permission for a review of their records with respect to a specific diagnosis and lipid values. The patients were divided into four groups on the basis of their history: I. myocardial infarction (MI), II. coronary artery bypass surgery (CABG), III. percutaneous transiluminal coronary angioplasty (PTCA) and IV. angina pectoris (AP). If a patient fulfilled the critera for more than one diagnostic group the CABG group had the highest priority followed by PTCA, MI and finally AP. RESULTS: A total of 533 patients with CHD were living in the study area and of those 402 (75%) participated in the study. Aspirin was used by 284 patients (71%), 75% among men and 65% among women (p=0.018). The highest proportion (91%) being among those who had undergone CABG, and the lowest among those with angina pectoris (56%). Half of the patients (52%) used beta blockers and 119 (30%) diuretics. A total of 172 patients received treatment with nitrates (43%), 57% of the women and 27% of the men (p=0.006). Calcium blockers were used by 145 patients (36%) and ACE inhibitors by 81 (20%). Among women in the age group 40 to 80 years, 16% were receiving hormone replacement therapy. CONCLUSIONS: These results indicate that in Iceland, as in many other countries, secondary prevention of CHD is not beeing fully implemented and the scientific evidence that has been obtained from large clinical trials, has not yet been put into practice. There is obviously a great potential to improve the medical treatment and prognosis of our patients with CHD.

[Medical surveilance and secondary prevention of coronary heart disease in general practice.].

OBJECTIVE: Prevention, both primary and secondary, is an important part in the daily work of most doc-tors. Family physicians (FP) carry the responsibility of implementing both stages of prevention. Coronary heart disease (CHD) is an example of chronic disease where FP have a responsibility both in treatment and prevention. Recent large double blind clinical trials have confirmed the efficacy of various methods of secondary prevention. However, it seems that these tools are used insufficiently, and there may be opportunities for improvement. The aim of this study, which is a part of a larger inquiry about CHD patients, was to evaluate what kind of surveillance these patients receive by their FP and how secondary prevention is organized and implemented in general. MATERIAL AND METHODS: All CHD patients with residence in Hafnarfjörethur, Garethabaer and Bessastaethahreppur (urban communities with 25,000 inhabitants), were invitated to participate in the study. They received an invitation letter and a request for an informed consent. If they chose to participate they answered a questionnaire about CHD risk factors and their medical treatment. Information about their CHD status was gathered by a review of their records at the respective health center. The patients were divided into four groups on the basis of their history: I. Myocardial infarction (MI), II. coronary artery bypass surgery (CABG), III. percutaneous transiluminal coronary angioplasty (PTCA), IV. angina pectoris (AP). If a patient fulfilled the critera for more than one diagnostic group the CABG group had the highest priority followed by PTCA, MI and finally AP. RESULTS: Of 533 patients with CHD 402 (75%) participated in the study. Electrocardiogram had been recorded for 225 (56%) of these patients. Information about blood pressure was found for 369 (92%) and the mean systolic blood pressure was 143 mraHg (SD 19.8) and diastolic 82 mmHg (SD 9.5). Of CHD patients 15% were followed solely by their FP, 31% were exclusively followed by other specialists (car-diologists), 23% were followed both by FP and other specialists and 11% were without any medical surveillance. About 15% of the participants smoked, 12% were daily smokers and 56% were ex-smokers. Consultation report from a cardiologist had been sent to the respective FP for 43% of the patients. CONCLUSIONS: These results indicate that there is a number of opportunities to improve medical treat-ment and secondary prevention of CHD in Iceland. Improved organization of medical surveillance with clear definiton of treatment goals and full utilisation of those possibilities that are in the Icelandic health care system for secondary prevention, including improvement in the exchange of informations between those involved in treating CHD.

[How is cholesterol lowering therapy implemented among patients with coronary heart disease in Iceland?].

OBJECTIVE: High serum cholesterol is one of the major risk factors for coronary heart disease (CHD). RESULTS from large clinical trials have convincingly shown the importance of cholesterol lowering therapy among patients with established CHD. Revised guidelines for cholesterol lowering therapy were published in Iceland in 1996 recommending reduction of total cholesterol below 5.0 mmol/L in the face of established coronary heart disease. We have today very limited knowledge about whether we are implementing these recommendations or not and the aim of this study was to evaluate this question. This study is a part of a larger enquiry into the actual practice of secondary prevention of CHD in Iceland. MATERIAL AND METHODS: All patients with residence in Hafnarfjörethur, Garethabaer and Bessastaethahreppur who have been diagnosed as having CHD were sent a letter with an invitation to participate in the study and a request for an informed consent. Those who chose to participate responded to a questionnaire and gave a permission for a review of their records with respect to a specific diagnosis and lipid values. The patients were divided into four groups on the basis of their history: I. myocardial infarction (MI), II. coro notnary artery bypass surgery (CABG), III. percuta notneous transiluminal coronary angioplasty (PTCA), IV. angina pectoris (AP). If a patient fulfilled a cri notterion for more than one diagnostic group the CABG group had the highest priority followed by PTCA, MI and finally AP. RESULTS: Of 533 patients with CHD 402 (75%) chose to participate. Average cholesterol in the total group was 6.2 mmol/L (95% C.I. 6.07-6.34). In the four subgroups the respective cholesterol values were: I 6.3, II 5.9, III 5.9, IV 6.5 mmol/L. Only 25% of the patients knew their cholesterol values, 20% in group I, 43% in group II, 30% and 15% in groups III and IV respectively. A total of 113 patients (28%) were receiving cholesterol lowering drug therapy at the time of the study. Respective treatment ratios in the four subgroups were 25% in group I, 47% in II, 42% in III and 13% in group IV. CONCLUSIONS: In spite of overwhelming evidence of the benefit associated with lipid lowering therapy for CHD patients this study has shown marked underuse of this therapeutic modality. Quality control study as this one is a valuable method to evaluate how practising physicians are implementing recommendations, based on scientific evidence, given by health authorities.

Acute bronchitis in adults. How close do we come to its aetiology in general practice?

OBJECTIVE: To investigate how close we can come to the aetiology of acute bronchitis in adults in a primary care setting. DESIGN: Prospective study. SETTING: General practice population in Gardabaer district, south-western Iceland. SUBJECTS: 140 patients > or = 16 years old who were diagnosed as having acute bronchitis during a two-year period (1992-1993). MAIN OUTCOME MEASURES: Laboratory investigations (twice with a minimum four-week interval), used in general practice to analyse respiratory tract infections. They included serology for Chlamydia pneumoniae, Mycoplasma pneumoniae, respiratory tract viruses, and the level of C-reactive protein. RESULTS: Of a total of 140 patients, two blood samples were taken on scheduled time in 113 patients. Serology confirmed recent infection in 18 (16%) of these patients. Only two (2%) had a bacterial infection (one C. pneumoniae, one M. pneumoniae). The others (84%) did not have a significant increase in antibody titres. Only four (4%) had C-reactive protein levels higher than 48 mg/l. CONCLUSIONS: The study indicates that it is difficult to come close to a precise aetiology with respect to infectious agents of acute bronchitis in general practice. We conclude that the disease is rarely caused by atypical bacteria such as C. pneumoniae and M. pneumoniae, and rarely caused by bacterial infections severe enough significantly to increase the level of C-reactive protein.

[Prognosis in patients having irritable bowel syndrome.].

Irritable bowel syndrome (IBS) is among the most common gastrointestinal disorders. In this survey, the prognosis of patients diagnosed with IBS was examined. In 1982, 81 (2.9%) of the inhabitants in Egilsstaethir health care district had diagnosed IBS on their medical records (ICCH 558). Twelve years later, in 1994, the health records of those patients were examined. Information was gathered through a questionnaire, which 76% answered. Of those who answered 28% had no longer any symptoms, but 38% experienced symptoms once a month or more frequently. The medical records of 11 patients who died were checked, revealing that two had had a confirmed gastrointestinal disease, but not in the colon.

Proctosigmoidoscopy in primary health care.

Of 282 patients who underwent rigid proctosigmoidoscopy (PSS) in primary care in the city of Västerås during 1985, 5.7% had polyps or tumours in the rectum. Barium examination of the large bowel was performed on 194 of these 282 patients and showed polyps or tumours in 6.2%. Use of these two methods led to diagnosis of polyps or tumour in the large bowel in 9.6% (27/282). Polyps were found by both methods in only one patient. Of four patients with tumours, two were discovered by barium examination and two by PSS. Barium examination and PSS complement each other in the search for polyps and tumours in the large bowel.