Reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'-an appraisal of a set of potentially inappropriate medications.

PURPOSE: To analyse the reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'. METHODS: From a previous study that included consecutive primary care patients ≥ 65 years of age, all patients ≥ 75 years of age were analysed. Two physicians independently screened their medication lists and medical records, applying the Swedish indicator which includes potentially inappropriate medications (PIMs): long-acting benzodiazepines, drugs with anticholinergic action, tramadol, propiomazine, codeine, and glibenclamide. The clinical relevance of identified PIMs was independently assessed. Thereafter, the physicians determined in consensus whether some medical action related to the drug treatment was medically justified and prioritised before the next regular visit. If so, the drug treatment was considered inadequate, and if not, adequate. RESULTS: A total of 1,146 drugs were assessed in 149 patients (75‒99 years, 62% female, 0‒20 drugs per patient). In 29 (19%) patients, at least one physician identified ≥ 1 PIM according to the indicator at issue; 24 (16%) patients were concordantly identified with ≥ 1 such PIM (kappa: 0.89). Of 26 PIMs concordantly identified, the physicians concordantly assessed four as clinically relevant and 12 as not clinically relevant (kappa: 0.17). After the consensus discussion, six (4%) patients had ≥ 1 PIM according to the studied indicator that merited action. Using the area under the receiver operating characteristic (ROC) curve, the indicator did not outperform chance in identifying inadequate drug treatment: 0.56 (95% confidence interval: 0.46 to 0.66). CONCLUSION: The Swedish indicator has strong reliability regarding PIM detection but does not validly reflect the adequacy of drug treatment.

¼Läkemedel som bör undvikas till äldre« ur medicinskt perspektiv.

The indicator ¼drugs that should be avoided in older people« from a medical perspective - an analysis with the patient in focus The drug-specific indicator ¼drugs that should be avoided in older people«, defined by the National Board of Health and Welfare of Sweden, is part of a large set of indicators of potentially inappropriate prescribing used for benchmarking in health care and in research. In this study, 149 consecutive primary care patients (75-99 years of age, 62 percent female, 0-20 drugs in the medication list) were included. Their medication lists were screened for potentially inappropriate drugs according to the indicator at issue, including long-acting benzodiazepines, drugs with anticholinergic action, tramadol, propiomazine, codeine, and glibenclamide. Medically justified actions related to these drugs were determined by two specialist physicians in consensus. In all, 29 patients had 32 drugs listed in the indicator, 7 of which, in 6 patients, were deemed relevant to act upon before the next regular physician visit, e.g. the annual control of chronic conditions. For the remaining 25 drugs, in 23 patients, no such related action was medically justified prior to the next regular visit. Using the area under the receiver operating characteristic (ROC) curve, the indicator did not outperform chance to identify inadequately managed drug treatment, defined as the consensus decision by two specialist physicians that some action related to the full medication could be medically justified prior to the next regular visit: 0.56 (95% CI: 0.46-0.66). In conclusion, the indicator ¼drugs that should be avoided in older people« did not warrant action from a medical perspective for four out of five patients, and could not differentiate between adequately and inadequately managed drug treatment.

[What is overdiagnosis?] / Överdiagnostik ­ vad är det?

A considerable amount of spending in health care is deemed wasteful. Overdiagnosis, i.e. the labelling of a person with a diagnosis that lacks net benefit, is an entity within the overarching concept of ¼too much medicine«. Overdiagnosis includes overdetection and overdefinition. Disease mongering is a type of overdefinition with economic drivers. Overtesting and overtreatment are other aspects of ¼too much medicine«, but are not overdiagnosis per se. Medical research tends to focus on benefits of diagnostics and therapy, whereas overdiagnosis and other harms receive less attention, leading to overestimation of benefits. The international network Choosing Wisely has been successful in changing the diagnostic mindset in several countries and a Swedish campaign is under way, yielding new possibilities to counteract ¼too much medicine« and the specific problem of overdiagnosis.

Revisiting the inter-rater reliability of drug treatment assessments according to the STOPP/START criteria.

AIMS: The aim of this study is to revisit the inter-rater reliability of drug treatment assessments according to the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria. METHODS: Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were independently identified by two physicians in two cohorts of older people (I: 200 hip fracture patients, median age 85 years, STOPP/START version 1; II: 302 primary care patients, median age 74 years, STOPP/START version 2). Kappa statistics were used to evaluate inter-rater agreement. RESULTS: In cohort I, a total of 782 PIMs/PPOs, related to 68 (78%) out of 87 criteria, were identified by at least one assessor, 500 (64%) of which were discordantly identified by the assessors, that is, by one assessor but not the other. For four STOPP criteria, all PIMs (n = 9) were concordantly identified. In cohort II, 955 PIMs/PPOs, related to 80 (70%) out of 114 criteria, were identified, 614 (64%) of which were discordantly identified. For three STOPP criteria, all PIMs (n = 3) were concordantly identified. For no START criterion, with ≥1 PPO identified, were all assessments concordant. The kappa value for PIM/PPO identification was 0.52 in both cohorts. In cohort II, the kappa was 0.37 when criteria regarding influenza and pneumococcal vaccines were excluded. Further analysis of discordantly identified PIMs/PPOs revealed methodological aspects of importance, including the data source used and criteria wording. CONCLUSIONS: When the STOPP/START criteria are applied in PIM/PPO research, reliability seems to be an issue not encountered in previous reliability studies.

Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment.

Importance: Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are used in research to reflect the quality of drug treatment in older people and have been suggested for inclusion in core outcome sets for evaluation of interventions for improved prescribing. Their validation so far, however, is primarily restricted to expert opinion-based processes. Objective: To evaluate the performance of 3 explicit PIM/PPO criteria sets as diagnostic tools to identify inadequate drug treatment in older patients. Design, Setting, and Participants: This diagnostic study analyzed patients aged 65 years or older consecutively included from 2 primary health care centers from October to November 2017. Data were analyzed from February to August 2022. Exposures: The PIMs/PPOs were concordantly identified by 2 specialist physicians (2018-2019) retrospectively after a planned physician visit, using 3 European PIM/PPO criteria sets and without knowledge of this diagnostic study. Main Outcomes and Measures: Area under the receiver operating characteristic (ROC) curve, reflecting the ability of PIM/PPO criteria sets to identify the reference standard of inadequate drug treatment, determined by 2 specialist physicians in consensus. Inadequate drug treatment implied that additional action related to the medication could be medically justified before the next regular visit. Results: A total of 302 patients were analyzed (median age, 74 [IQR, 69-81] years; 178 women [59%]; median number of drugs in the medication list, 6 [IQR, 3-9]); 98 patients (32%) had inadequate drug treatment. A total of 0 to 8 PIMs/PPOs per patient were identified using the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, 0 to 6 with the European EU(7)-PIM list, and 0 to 12 with the Swedish set of indicators of prescribing quality. The areas under the ROC curve for the 3 sets to identify the reference standard for inadequate drug treatment were 0.60 (95% CI, 0.53-0.66) for the STOPP/START criteria, 0.69 (95% CI, 0.63-0.75) for the EU(7)-PIM list, and 0.73 (95% CI, 0.67-0.80) for the Swedish set. For comparison, the area under the ROC curve was 0.71 (95% CI, 0.65-0.78) using the number of drugs in the medication list. Conclusions and Relevance: In this diagnostic study, the evaluated PIM/PPO sets had poor to fair performance as diagnostic tools to identify inadequate drug treatment, comparable with a simple count of the number of drugs in the medication list. These findings suggest that use of PIMs/PPOs as indicators of drug treatment quality in core outcome sets for the evaluation of interventions for improved prescribing may need reconsideration.

Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study.

PURPOSE: To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment. METHODS: PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate. RESULTS: In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment. CONCLUSION: One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.

Drug interaction alerts in older primary care patients, and related medically justified actions.

PURPOSE: To describe presented interaction alerts in older patients, and the extent to which these require further medical action for the specific patient or are already being addressed. METHODS: Interaction alerts presented at a physician consultation, for 274 consecutive primary care patients treated with two or more drugs (median age: 75 years; 59% female), were extracted. These alerts are based on Janusmed, a decision support integrated in the medical records that provides recommendations for managing the interactions. One general practitioner (GP) and one GP/clinical pharmacologist determined in retrospect, first independently and then in consensus, whether the alerts justified further medical action, considering each patient's health condition. RESULTS: In all, 405 drug interaction alerts in 151 (55%) patients were triggered. Medical action in response was deemed medically justified for 35 (9%) alerts in 26 (17%) patients. These actions most often involved a switch to a less interacting drug from the same drug class (n = 10), a separate intake (n = 9), or the ordering of a laboratory test (n = 8). Out of 531 actions suggested by the alert system, only 38 (7%) were applicable to the specific patient, as, for instance, laboratory parameters were already being satisfactorily monitored or a separate intake implemented. CONCLUSIONS: More than every other older patient receives drug treatment that triggers drug interaction alerts. Nine in ten alerts were already being addressed or were not relevant in the clinical setting, whereas, for the remaining tenth, some medical action, that for unknown reasons had not been taken, was reasonable. These findings show that interaction alerts are questionable as indicators of problematic prescribing.

[Cervical myelopathy due to nitrous oxide inhalation]. / Omfattande inhalationsbruk av lustgas gav ryggmärgsskada.

A 19 year old male presented to his GP with bilateral numbness and stiffness of hands and lower limbs, as well as muscle weakness and poor balance. The patient admitted recreational use of nitrous oxide (laughing gas) some days earlier. He was hospitalised and underwent a series of plasmapheresis treatments due to an initial suspicion of inflammatory myelitis. Further investigation gave evidence of cervical myelopathy which was deemed secondary to heavy use of nitrous oxide. Substitution therapy with hydroxycobalamine was initiated and the patient gradually recovered, although he was later found to have hyperhomocysteinaemia. The adverse effects of recreational nitrous oxide use are discussed, as well as potential pitfalls in diagnosis.

Association between recorded medication reviews in primary care and adequate drug treatment management - a cross-sectional study.

OBJECTIVE: To investigate the association between a recorded procedure code for a medication review and adequate drug treatment management, and to explore factors associated with this code. DESIGN AND SETTING: Cross-sectional study; two primary health care centres, in Region Västra Götaland, Sweden. SUBJECTS: A total of 302 consecutive patients (≥65 years old, 59% female; median number of drugs: six) requiring a non-urgent consultation with a physician in October-November 2017. MAIN OUTCOME MEASURE: Adequate drug treatment management (treatment that did not require any further action), determined in consensus by two specialists in family medicine blinded to the medication review code. RESULTS: Adequate drug treatment management was, overall, less common in those with a recorded medication review over the last year: 63% versus 73% (p = 0.047). This negative association was evident among patients aged 65-74 years: 49% versus 74% (p = 0.003), but absent in those ≥75 years old: 67% versus 70% (p = 0.77). Recommendations from consensus included the search for additional information to be able to make a decision regarding initiation or withdrawal of a drug (n = 53), withdrawal of a drug (n = 41), or ordering a laboratory test (n = 25). Factors associated with a recorded procedure code included age above the remuneration limit of 75 years (odds ratio: 9.8; 95% confidence interval 5.0-19), type 2 diabetes (3.0 (1.5-6.2)), hypertension (2.4 (1.2-4.8)), and depression (2.5 (1.02-6.0)). CONCLUSIONS: The presence of a recorded medication review was not positively associated with adequate drug treatment management but was associated with the age limit for remuneration, and some chronic diseases.Key pointsTo improve drug treatment in older people in primary care, a remuneration system linked to recorded medication reviews has been introduced.In this study, fewer patients with than without a recorded medication review (63% versus 73%) had adequate drug treatment management.A recorded medication review was ten times more common in those ≥75 years, that is, the age limit for remuneration.Recorded codes for medication reviews were also common in those with type 2 diabetes, hypertension, and depression.

Attitudes and behaviour towards psychotropic drug prescribing in Swedish primary care: a questionnaire study.

BACKGROUND: The prescribing of psychotropic drugs, i.e. antidepressants, sedatives (anxiolytics, hypnotics), and antipsychotics is considerable and a large proportion is prescribed by general practitioners (GPs). There are concerns about dependency and medicalisation, and treatment decisions in psychiatry may appear arbitrary. Increased knowledge of GPs' opinions on the prescribing of psychotropics may lead to more rational use of these drugs. We aimed to quantify GPs' attitudes, beliefs and behaviour towards various aspects of psychotropic drug prescribing. METHODS: A questionnaire was distributed to physicians in all 199 GP practices in Region Västra Götaland, Sweden. The questions concerned determinants of psychotropic drug prescribing that had been identified in a previous, qualitative study. RESULTS: Questionnaires from 516 physicians (64% of whom were specialists in family medicine, 21% interns in family medicine, 15% others) at 152 GP practices (59% of which were state owned, 72% in an urban area, with a median of 7808 registered patients) were returned (estimated response rate: 48%). A majority - 62% - of GPs found it easier to start prescribing psychotropic drugs than to stop (95% confidence interval, 57%, 66%) vs. 8% (6%, 10%). Most GPs considered psychotherapy more suitable than psychotropic drugs in cases of mild psychiatric disease: 81% (77%, 84%) vs. 4% (3%, 6%). The problems treated with psychotropic drugs were considered to be mostly socioeconomic, or mostly medical, by similar proportions of physicians: 38% (34%, 42%) vs. 40% (36%, 45%). GPs were on average satisfied with their levels of antidepressant and sedative prescribing in relation to medical needs. More GPs regarded their prescribing of antipsychotics as being too low rather than too high: 33% (28%, 39%) vs. 7% (4%, 10%). CONCLUSIONS: This study illustrates the complexities of psychiatric drug treatment in primary care and identifies potential drivers of increased prescribing of psychotropics. The manifold factors, medical and non-medical, that affect prescribing decisions may explain a sense of arbitrariness surrounding psychotropic drug treatment. This notwithstanding, GPs seem mostly content with their prescribing.

Comparing Methods for Estimating Direct Costs of Adverse Drug Events.

OBJECTIVES: To estimate how direct health care costs resulting from adverse drug events (ADEs) and cost distribution are affected by methodological decisions regarding identification of ADEs, assigning relevant resource use to ADEs, and estimating costs for the assigned resources. METHODS: ADEs were identified from medical records and diagnostic codes for a random sample of 4970 Swedish adults during a 3-month study period in 2008 and were assessed for causality. Results were compared for five cost evaluation methods, including different methods for identifying ADEs, assigning resource use to ADEs, and for estimating costs for the assigned resources (resource use method, proportion of registered cost method, unit cost method, diagnostic code method, and main diagnosis method). Different levels of causality for ADEs and ADEs' contribution to health care resource use were considered. RESULTS: Using the five methods, the maximum estimated overall direct health care costs resulting from ADEs ranged from Sk10,000 (Sk = Swedish krona; ~€1,500 in 2016 values) using the diagnostic code method to more than Sk3,000,000 (~€414,000) using the unit cost method in our study population. The most conservative definitions for ADEs' contribution to health care resource use and the causality of ADEs resulted in average costs per patient ranging from Sk0 using the diagnostic code method to Sk4066 (~€500) using the unit cost method. CONCLUSIONS: The estimated costs resulting from ADEs varied considerably depending on the methodological choices. The results indicate that costs for ADEs need to be identified through medical record review and by using detailed unit cost data.

High accuracy calibration of a dynamic vapor sorption instrument and determination of the equilibrium humidities using single salts.

We present a procedure for accurately calibrating a dynamic vapor sorption (DVS) instrument using single salts. The procedure accounts for and tailors distinct calibration tests according to the fundamental properties of each salt. Especially relevant properties influencing the calibration are the heat of solution, heat of condensation, and the kinetics connected to the salt phase transition, as these influence the microclimate surrounding the salts during calibration. All these issues were dealt with to obtain precise calibration results. The DVS instrument comprises two control modes to generate and measure the relative humidity (RH). Both control modes were separately examined and combined to overcome the shortcomings of each of the two control modes and thereby obtain the most accurate results. Repeated calibration testing with the single salts (LiCl, MgCl2, Mg(NO3)2, NaCl, and KNO3) enables five discrete sorption isotherm measurements within the range of 11%-93%RH. The equilibrium RH of the solution for LiCl, MgCl2, Mg(NO3)2, NaCl, and KNO3 was determined with a standard deviation of 0.06%-0.15% (0.45% for KNO3) RH. By comparing the measured calibration values with the well-known equilibrium RH of each salt solution, the presented method's results are both accurate with significant agreement and precise with small variation.

The meaning of learning to live with medically unexplained symptoms as narrated by patients in primary care: a phenomenological-hermeneutic study.

BACKGROUND: Although research about medically unexplained symptoms (MUS) is extensive, problems still affect a large group of primary care patients. Most research seems to address the topic from a problem-oriented, medical perspective, and there is a lack of research addressing the topic from a perspective viewing the patient as a capable person with potential and resources to manage daily life. The aim of the present study is to describe and interpret the experiences of learning to live with MUS as narrated by patients in primary health-care settings. METHODS: A phenomenological-hermeneutic method was used. Narrative interviews were performed with ten patients suffering from MUS aged 24-61 years. Data were analysed in three steps: naive reading, structural analysis, and comprehensive understanding. FINDINGS: The findings revealed a learning process that is presented in two themes. The first, feeling that the symptoms overwhelm life, involved becoming restricted and dependent in daily life and losing the sense of self. The second, gaining insights and moving on, was based on subthemes describing the patients' search for explanations, learning to take care of oneself, as well as learning to accept and becoming mindful. The findings were reflected against Antonovsky's theory of sense of coherence and Kelly's personal construct theory. Possibilities and obstacles, on an individual as well as a structural level, for promoting patients' capacity and learning were illuminated. CONCLUSIONS: Patients suffering from MUS constantly engage in a reflective process involving reasoning about and interpretation of their symptoms. Their efforts to describe their symptoms to healthcare professionals are part of this reflection and search for meaning. The role of healthcare professionals in the interpretative process should be acknowledged as a conventional and necessary care activity.

"Psychiatry is not a science like others" - a focus group study on psychotropic prescribing in primary care.

BACKGROUND: Psychotropic drug prescribing is problematic and knowledge of factors affecting the initiation and maintenance of such prescribing is incomplete. Such knowledge could provide a basis for the design of interventions to change prescribing patterns for psychotropics. The aim of this study was to explore the views of general practitioners (GPs), GP interns, and heads of primary care units on factors affecting the prescribing of psychotropic drugs in primary care. METHODS: We performed four focus group discussions in Gothenburg, Sweden, with a total of 21 participants (GPs, GP interns, and heads of primary care units). The focus group discussions were transcribed verbatim and analyzed using manifest content analysis. RESULTS: Three different themes emerged from the focus group discussions. The first theme Seeking care for symptoms, reflects the participants' understanding of why patients approach primary care and comprised categories such as knowledge, attitudes, and society and the media. The second theme, Lacking a framework, resources, and treatment alternatives, which reflects the conditions for the physician-patient interaction, comprised categories such as economy and resources, technology, and organizational aspects. The third theme, Restricting or maintaining prescriptions, with the subthemes Individual factors and External influences, reflects the physicians' internal decision making and comprised categories such as emotions, knowledge, and pharmaceutical industry. CONCLUSION: The results of the present study indicate that a variety of factors may affect the prescribing of psychotropic medications in primary care. Many factors were related to characteristics of the patient, the physician or their interaction, rather than the patients' medical needs per se. The results may be useful for interventions to improve psychotropic prescribing in primary care.

Making sense of blood pressure values in follow-up appointments for hypertension.

BACKGROUND: Although there are effective ways of treating hypertension, only a minority of all hypertensive people reach target blood pressure levels. This may be a function of how patients and physicians put measured values into context when they decide if the blood pressure is well controlled or too high. METHODOLOGY: Qualitative analysis of audio-taped follow-up appointments for hypertension between 51 outpatients and their 11 physicians. All patients came for routine follow-up appointments for hypertension. The setting was primary and a specialist outpatient care in the south of Sweden. PRINCIPAL FINDINGS: Borderline blood pressure values led to more deliberation. Common ways of contextualising the blood pressure were by comparing it to previous values and by explaining it in terms of stress or lack of rest. The net effect of this was that the representativity and severity of the measured blood pressure value were downplayed by both patients and physicians. In some instances, physicians (but not patients) worked in the opposite direction. Patients were less actively engaged in interpreting the blood pressure values, stated their views about therapy less often, and were careful not to express views that were overly critical of the drug treatment. CONCLUSIONS: Patients and physicians make sense of the blood pressure through a contextualisation process which tends to normalise the face values towards the reference values. The resulting (processed) value is the one acted upon. Discursive handling of the blood pressure therefore makes up an important part of the decision-making.

Escitalopram: superior to citalopram or a chiral chimera?

BACKGROUND: Escitalopram is the active isomer of the antidepressant citalopram. In theory single-isomer drugs may be superior but few have been found to have clinically significant advantages. The manufacturer claims that escitalopram has more efficacy and a faster onset of effect than citalopram. The purpose of this study was to assess how far these claims are justified. METHODS: Relevant trial reports were requested from H. Lundbeck A/S and the Swedish drug regulatory authority. The trials consisted of a pooled analysis of 1,321 patients from one unpublished, one partly published and one published eight-week trial, as well as a 24-week trial with 357 patients published as a poster. The studies compared escitalopram with placebo and/or citalopram in outpatients aged or=18 years who met specified criteria for depression. The trials' quality was assessed with Moncrieff et al.'s quality assessment instrument and the results compared with the claims from the advertisements. RESULTS: The advertising claims are not justified because they are based on secondary outcomes, non-intention-to-treat analyses and arbitrarily defined subgroups. The subgroup results are inconsistent. Methodological flaws in the trials could account for the differences found. Even if the differences claimed were real they appear too small to justify higher prices. CONCLUSIONS: On the evidence available to us the manufacturer's claims of superiority for escitalopram over citalopram are unwarranted. The Swedish and Danish drug regulatory authorities reached similar conclusions. This highlights the need for wider dissemination of national authorities' statements to other countries affected by the European Union's mutual recognition procedure.

Es el escitalopram superior al citolapram? / Is it the escitalopram higher than the citolapram?

El Escitalopram es un isómero activo del antidepresivo Citalopram. En teoria las drogas isómero simples podrían ser superiores, pero pocos se han encontrado con ventajas clínicamente significativas. El fabricante demanda que el escitalopram tiene mas eficacia y un mas rapido ataque que el citolopram. El proposito de este estudio fue evaluar cuantas de estas declaraciones son justificadas