Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation.

BACKGROUND: Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS: A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION: The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov (identifier: NCT05507177).

Facilitating pharmacy staff's conversations about non-medical medication switches: Development and testing of a communication training.

BACKGROUND: Non-medical medication switches, a change to another medicine or medication label not motivated by medical reasons, occur frequently. Switches often lead to negative patient emotions, such as confusion and anger. Pharmacy staff's communication, i.e. delivering the message and addressing patients' emotions is crucial, but experienced as difficult. OBJECTIVE: To develop and test a communication training for the pharmacy team to facilitate medication switch conversations. METHODS: A communication training was developed based on the 'breaking bad news model' and 'positive message framing' strategies, and incorporating needs and preferences from practice. The training consisted of an e-learning with theory and reflective exercises, a half-day live training session, and an online reflection session. The Kirkpatrick training evaluation model (levels one 'reaction' and two 'learning') was used to evaluate the training. Quantitative data were analyzed using descriptive statistics and interview data was transcribed verbatim and analyzed thematically. RESULTS: Twelve pharmacists and 27 pharmacy technicians from 15 Dutch pharmacies participated in the training. According to Kirkpatrick's model level one, the major learning outcome was to give space to patients to express their emotions and/or concerns (e.g. more silences in the conversations). For level two, most participants valued practicing the conversations, role-playing, and receiving feedback. The majority of the participants indicated that they had sufficient tools and practice during the live training to apply the strategies in daily practice. A few participants still needed time and practice, or missed examples to apply the strategies. CONCLUSION: The communication training based on the two strategies was well-received and participants felt well-equipped post-training. The take-away for participants was to give space to patients to express their emotions. Using these strategies and skills, pharmacy teams can tailor their medication counseling to patients' emotions and concerns during non-medical medication switches to better support patients in proper medication use.

Majority of drug-related problems identified during medication review are not associated with STOPP/START criteria.

PURPOSE: STOPP and START criteria identify potential inappropriate prescribing and potential prescribing omissions. It is unknown whether STOPP/START criteria identify all drug-related problems. This study aims to determine to what extent STOPP/START correspond to drug-related problems (DRPs) identified during a full clinical medication review. METHODS: In 13 Dutch community pharmacies, 457 community-dwelling patients aged ≥65 years and using ≥5 drugs, received a full clinical medication review. Community pharmacists identified potential DRPs and recommendations by implicit criteria. After completion, all identified DRPs and recommendations were compared with STOPP and START criteria by investigators. RESULTS: The total number of potential DRPs identified by community pharmacists was 1656 in 457 patients (mean 3.6 per patient). Eighty-one percent of DRPs were not associated with STOPP/START criteria. The percentage of START criteria present in identified DRPs was higher than the percentage of STOPP criteria (13 vs. 5.7%, p < 0.01). The implementation rate for recommendations associated with STOPP criteria was higher compared to recommendations associated with START criteria (56 vs. 39%, p < 0.01). Both implementation rates of STOPP and START recommendations were lower compared to recommendations not associated with STOPP/START criteria (66%, p = 0.047 and p < 0.001, respectively). CONCLUSIONS: This study shows that the majority of drug-related problems of community-dwelling older patients was not associated with STOPP/START criteria. These findings suggest that application of STOPP/START criteria in full clinical medication review should preferably be combined with implicit criteria.

Pharmacists' and general practitioners' pharmacology knowledge and pharmacotherapy skills.

Understanding differences in the pharmacology knowledge and pharmacotherapy skills of pharmacists and physicians is vital to optimizing interprofessional collaboration and education. This study investigated these differences and the potential influence of work experience. The pharmacology knowledge and pharmacotherapy skills of pharmacists, general practitioners (GPs), and trainees were compared, using a written assessment; 294 participants were included. Overall scores (mean ± SD) ranged from 69.3% ± 6.5% to 76.5% ± 9.5% for basic knowledge, 70.3% ± 10.8% to 79.7% ± 8.4% for applied knowledge, and 66.3% ± 21.1% to 84.7% ± 20.7% for pharmacotherapy skills (analysis of variance all P < .05). The pharmacists had the highest scores for all domains (P < .05), with the exception of pharmacist trainees, who had comparable scores for basic knowledge and pharmacotherapy skills (both P > .05). The GPs scored the lowest for pharmacotherapy skills (P < .05). More work experience was associated with better knowledge of applied pharmacology among pharmacists (by 2% per 10 work-years), but with poorer pharmacotherapy skills among pharmacists and GPs (by 3% and 4% per 10 work-years, respectively). In conclusion, pharmacists and GPs differ in their knowledge and skills, and these differences become more pronounced with more work experience. In general, pharmacists outperform pharmacist trainees, whereas GP trainees outperform GPs. These differences could be important for interdisciplinary collaboration and education.

Medication adherence and knowledge of older patients with and without multidose drug dispensing.

OBJECTIVE: we compared the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD users) with patients receiving manually dispensed drugs (non-MDD users). METHODS: MDD users (≥ 65 years, ≥ 5 oral chronic drugs) were randomly selected from eight Dutch community pharmacies. Non-MDD users (≥ 5 oral chronic drugs) were matched on age and gender. Medication adherence was assessed by using the Medication Adherence Reporting Scale (MARS) and medication knowledge by asking the indication of drugs. Cognitive function was measured with Mini-Mental State Examination (MMSE) for a sub selection of patients. RESULTS: the percentage of patients being adherent to all drugs was higher for MDD users (n = 119, 81%) compared with non-MDD users (n = 96, 58%, P < 0.001).The percentage of patients with adequate knowledge was lower for MDD users (40%) compared with non-MDD users (79%, P < 0.001). The differences in adherence were independent of knowledge and MMSE scores. CONCLUSION: this study shows that older patients receiving their drugs via MDD reported a higher medication adherence compared with patients receiving manually dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving MDD.

The relationship between the extent of collaboration of general practitioners and pharmacists and the implementation of recommendations arising from medication review: a systematic review.

BACKGROUND: Many studies have investigated the effect of medication review on a variety of outcomes, but the elements of the interventions have been quite diverse. Moreover, implementation rates of recommendations also vary widely between studies. OBJECTIVE: The objective of this study was to investigate how the extent of collaboration between the general practitioner (GP) and the pharmacist impacts on the implementation of recommendations arising from medication review. METHODS: MEDLINE, EMBASE and Web of Science were searched for studies published between January 2000 and April 2012. Keywords included medication review, medication therapy management, pharmaceutical services and drug utilization review. Sixteen articles (describing 14 randomized controlled trials [RCTs]) out of 620 titles met the inclusion criteria. Inclusion criteria for the review were medication review, RCT design, involvement of both pharmacist and GP, and home-dwelling patients (mean age >70 years) who had not been recently discharged. After quality assessment of the article, the presence of the following eight key elements reflecting collaboration were scored for each intervention: pharmacist with clinical experience, own pharmacist involved, sharing of medical records, patient interview by pharmacist, invitation of patients by GP, case conference between GP and pharmacist, action plan, follow-up. The primary outcome was the implementation rate of recommendations. Meta-regression analysis was used to assess the association between the implementation rate and the number of key elements present. RESULTS: Twelve RCTs were included after quality assessment. The mean number of key elements within the intervention was 5.2 (range 1-8). The mean implementation rate of recommendations was 50 % (range 17-86). The association between the number of key elements present in the intervention and the implementation rate of recommendations was significant: ß = 0.085 (95 % CI 0.052-0.128; p < 0.0001). CONCLUSION: This systematic review shows a significant association between the number of key elements of the intervention reflecting collaborative aspects in medication review and the implementation rate of recommendations.

Effects of medication review on drug-related problems in patients using automated drug-dispensing systems: a pragmatic randomized controlled study.

BACKGROUND: There are concerns that automated drug dispensing may increase inappropriate drug use. Automated dispensing could lead to perpetual repeating of drug therapies without the necessary re-evaluation. OBJECTIVE: The aim of this study was to examine the effect of a pharmacist-led medication review on drug-related problems (DRPs) in older patients receiving their drugs via automated dispensing. METHODS: This was a pragmatic randomized controlled study conducted in primary care. Patients were recruited from six Dutch community pharmacies. They were eligible if they lived at home, were aged ≥ 65 years, and used five or more different drugs, of which at least one had to be dispensed via an automated system. Patients were randomly allocated to receive a medication review at the start of the study (intervention group) or after 6 months (waiting-list group). Each patient was independently reviewed by two pharmacist reviewers. The results of these medication reviews were sent to the community pharmacist to be discussed with the patient's general practitioner (GP). The primary outcome measure was the number of DRPs leading to a recommendation for drug change. Secondary outcomes were the total number of drug changes and the number of drug changes related to a recommendation. In order to analyse drug changes, medication records were collected 6 months after the medication review or index date in the waiting-list group. Potential DRPs were classified using the DOCUMENT classification. RESULTS: There were no baseline differences between the 63 patients in the intervention group and the 55 patients in the waiting-list group with respect to age, sex, number of drugs per patient and type of drug prescribed. The mean number of DRPs per patient at baseline in the intervention group and waiting list combined was 8.5, with no difference between the groups. At baseline, the mean number of DRPs leading to a recommendation for drug change was 4.5 per patient and did not differ between the two groups. After 6 months, the number of DRPs leading to a recommendation for drug change decreased by 29% in the intervention group versus 5% in the waiting-list group (p < 0.01). Recommendations for cessation of a drug were more frequently accepted than recommendations to add a new drug (82% vs 44%, p = 0.01). CONCLUSIONS: This study shows that patients using automated drug dispensing have a high number of DRPs. Medication review decreases the number of DRPs among these patients. We recommend that all patients with automatic drug dispensing should have a thorough medication review by pharmacists and prescribers.

Co-morbidity and patterns of care in stimulant-treated children with ADHD in the Netherlands.

This study aimed at investigating the use of psychosocial interventions and psychotropic co-medication among stimulant-treated children with attention-deficit hyperactivity disorder (ADHD) in relation to the presence of psychiatric co-morbidity. Stimulant users younger than 16 years were identified in 115 pharmacies and a questionnaire was sent to their stimulant prescribing physician. Of 773 questionnaires sent out, 556 were returned and were suitable for analysis (72%). The results are based on 510 questionnaires concerning stimulant-treated children for whom a diagnosis of ADHD was reported. Of the 510 children diagnosed with ADHD, 31% had also received one or more other psychiatric diagnoses, mainly pervasive developmental disorder or oppositional defiant disorder/conduct disorder. We found an association between the presence of co-morbidity and the use of psychosocial interventions for the child (P < 0.001) and the parents (P < 0.001). In the ADHD-only group, 26% did not receive any form of additional interventions, while psychosocial interventions varied from 8 to 18% in children with ADHD and psychiatric co-morbidity. The presence of diagnostic co-morbidity was also associated with the use of psychotropic co-medication (overall, P = 0.012) and antipsychotics (P < 0.001). Stimulant-treated youths with ADHD and psychiatric co-morbidity received more psychosocial interventions and psychotropic co-medication than children with ADHD-only. The type of psychosocial interventions and psychotropic co-medication received by the children and their parents, depended on the specific co-morbid psychiatric disorder being present.

Current issues around the pharmacotherapy of ADHD in children and adults.

BACKGROUND: New drugs and new formulations enter the growing market for ADHD medication. The growing awareness of possible persistence of ADHD impairment beyond childhood and adolescence resulting in increased pharmacotherapy of ADHD in adults, is also a good reason for making an inventory of the what is generally known about pharmacotherapy in ADHD. AIM: To discuss current issues in the possible pharmacotherapy treatment of ADHD in children, adolescents and adults with respect to the position of pharmacotherapy in ADHD treatment guidelines, the pharmacoepidemiological trends, and current concerns about the drugs used. METHODS: A search of the literature with an emphasis on the position of pharmacotherapy in ADHD treatment guidelines, the pharmacoepidemiological trends, and current concerns about the drugs used in pharmacotherapy. RESULTS: According to the guidelines, the treatment of ADHD in children consists of psychosocial interventions in combination with pharmacotherapy when needed. Stimulants are the first-choice drugs in the pharmacological treatment of ADHD in children despite a number of well known and frequently reported side effects like sleep disorders and loss of appetite. With regard to the treatment of adults, stimulant treatment was recommended as the first-choice pharmacotherapy in the single guideline available. Both in children and adults, there appears to be an additional though limited role for the nonadrenergic drug atomoxetine. The increase of ADHD medication use, in children, adolescents and in adults, can not only be interpreted as a sign of overdiagnosis of ADHD. Despite the frequent use of stimulants, there is still a lack of clarity on the effects of long-term use on growth and nutritional status of children. Cardiovascular effects of both stimulants and atomoxetine are rare but can be severe. The literature suggests that atomoxetine may be associated with suicidal ideation in children. CONCLUSION: Although pharmacotherapy is increasing common in the treatment of ADHD in both children and adults, there are still a lot of questions about side effects and how best to counter them. This suggests an important role for close monitoring of children and adults treated with stimulants or atomoxetine.

InforMatrix for attention deficit hyperactivity disorder.

The purpose of this review is to facilitate discussion on drug selection for the treatment of ADHD by using only clinically relevant selection criteria and providing an up-to-date overview. The InforMatrix method was used to select drugs to treat attention deficit hyperactivity disorder (ADHD). The following selection criteria were applied: clinical efficacy, safety, tolerability, ease of use, applicability, and cost. The drugs approved for ADHD in the Netherlands were included in the analysis, namely: atomoxetine, immediate-release methylphenidate, and various formulations of slow-release methylphenidate (Concerta, Equasym and Medikinet). Most studies are of limited quality, duration, and size. In one study, Concerta was more effective than atomoxetine. Although no relevant differences were seen in other comparative studies, the clinical experience with atomoxetine is still limited and unexpected toxicity cannot be excluded; few studies have been published with Equasym and Medikinet. No major differences were seen in general tolerability between the drugs. The ease of use of immediate-release methylphenidate is less than for the other drugs. The acquisition cost of immediate-release methylphenidate is considerably lower than that of the slow-release formulations. Atomoxetine is the most expensive drug. The InforMatrix program is available in an interactive format. It enables the user to judge both the importance of the selection criteria and the properties of each therapeutic option per criterion on the basis of his or her own personal expertise and/or the present document.

Long-acting methylphenidate-OROS in youths with attention-deficit hyperactivity disorder suboptimally controlled with immediate-release methylphenidate: a study of cost effectiveness in The Netherlands.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is the most common mental health disorder in youths. Stimulants are the drugs of first choice in the treatment of ADHD. It has been suggested that full costs associated with the treatment of ADHD may be reduced by once-daily administration regimens of stimulants. OBJECTIVES: To estimate the cost effectiveness of treatment with long-acting methylphenidate osmotic release oral system (OROS) [Concerta] for youths with ADHD for whom treatment with immediate-release (IR) methylphenidate is suboptimal. STUDY DESIGN: We developed a Markov model to obtain an incremental cost-effectiveness ratio (ICER). The analysis covered 10 years, with a Markov cycle of 1 day. Costs (in 2005 euros ) included medication, consultations and treatment interventions, and additional costs for attending special education. Quality-adjusted life-years (QALYs) were used as the effectiveness measure. Outcome probabilities were taken from the medical literature and an expert panel of five child psychiatrists and paediatricians. Univariate sensitivity analyses were performed to assess the robustness of the base-case estimate. Multivariate sensitivity analysis was used to estimate a worst- and best-case ICER. RESULTS: The ICER of methylphenidate-OROS treatment in youths with ADHD for whom treatment with IR methylphenidate is suboptimal was euro 2004 per QALY. Total costs after 10 years were euro 15,739 for the IR methylphenidate pathway and euro 16,015 for the methylphenidate-OROS pathway. In the univariate sensitivity analysis, the ICER was sensitive to changes in resource use and the probability of stopping stimulant treatment in favour of IR methylphenidate. An ICER of 0 was reached with a 6.2% price reduction of methylphenidate-OROS. CONCLUSION: Methylphenidate-OROS is a cost-effective treatment for youths with ADHD for whom treatment with IR methylphenidate is suboptimal. Higher medication costs of methylphenidate-OROS were compensated for by savings on resource use, yielding similar 10-year costs compared with treatment with IR methylphenidate. Our analysis is sensitive to both clinical parameters and (differences in) resource utilization and costs between the groups modelled, warranting further research within clinical trials and observational databases, and into the full scope of costs.

Studying co-medication patterns: the impact of definitions.

PURPOSE: To show the necessity of distinguishing several patterns of drug prescribing that may lead to co-medication. It is demonstrated how these different patterns can be investigated using large databases containing pharmacy data or reimbursement data. METHODS: Two examples illustrate how the particular pattern of co-medication studied will influence the reported proportion of patients having co-medication, the use of antidepressants among people using anticonvulsants, and the use of antihistamines among people receiving penicillines. RESULTS: Depending on definition and period considered, the percentage of anticonvulsant users co-medicated with antidepressants ranged from 5.8% (95%CI 5.0%, 6.8%) to 14.5% (95%CI 13.2%, 15.9%) in 2000. Comparing 2002 with 2000, the ratio of proportions ranged from 1.3 to 2.1. The percentage of people who received penicillines and were co-medicated with antihistamines ranged from 0.5% (95%CI 0.4%, 0.6%) to 9.7% (95%CI 9.3%, 10.2%) in 2000. Comparing 2002 with 2000, the ratio of proportions ranged from 1.2 to 1.6. CONCLUSION: The co-medication patterns investigated yielded clinical as well as statistically significant different estimates. The estimates differed up to a factor 2.5 for the drugs usually prescribed for long periods, and a factor 12 for drugs prescribed for short periods. Hence, we propose to distinguish the patterns 'co-prescribing', 'concomitant medication,' and 'possibly concurrent medication.' The research question determines the co-medication pattern of interest, and the drug and disease under study determine the time window.

Use of double-blind placebo-controlled N-of-1 trials among stimulant-treated youths in The Netherlands: a descriptive study.

OBJECTIVES: An N-of-1 trial is a double-blind placebo-controlled randomized trial to objectively and systematically evaluate the individual's response. This approach seems extraordinarily suitable for assessing the efficacy of stimulants in the treatment of attention deficit hyperactivity disorder (ADHD). The aim is to examine the use of N-of-1 trials among youths in the Netherlands, the protocols used, and the continuation of stimulant treatment thereafter. METHODS: Physicians requesting N-of-1 trials with stimulants were interviewed about their rationale and protocol. Prevalence and continuation were investigated by extracting N-of-1 trials among youths <20 years of age from a large pharmacy dispensing database for 2000-2004. RESULTS: The main purpose of N-of-1 trials mentioned by physicians was the assessing of individuals' response and dose-finding. Trial length, dosing schedule and efficacy assessment differed per physician. Trials consisted of a maximum of two treatment periods per dose. The annual percentage of youths starting stimulant treatment with an N-of-1 trial fluctuated between 0.6% (3/462) and 3.3% (10/301). No statistical significant difference could be detected between the continuation of stimulant treatment with or without an N-of-1 trial (p = 0.71). CONCLUSIONS: N-of-1 trials with stimulants are infrequently and not optimally used in the Netherlands. The results of N-of-1 protocols described by physicians are of questionable value, due to the small number of treatment periods per dose. More uniformity in the protocols would make it easier to encompass the N-of-1 methodology in physicians' daily practice.

Parents report on stimulant-treated children in the Netherlands: initiation of treatment and follow-up care.

OBJECTIVES: The aim of this study was to describe current practices around initiation and follow-up care of stimulant treatment among stimulant-treated children in a nationwide survey among parents. METHODS: A total of 115 pharmacies detected current stimulant users <16 years old in their pharmacy information system and sent parents a questionnaire regarding their child's stimulant treatment. RESULTS: Parents returned 924 of 1,307 questionnaires (71%). The median age of the stimulant users was 10 years and 85% were boys. In all, 91% were diagnosed with attention-deficit/hyperactivity disorder (ADHD). In 77% of the cases, the child or parents received other therapies besides stimulants-21% received psychotropic co-medication, with melatonin (11%) and antipsychotics (7%) being mentioned most frequently. Stimulant use was primarily initiated by child psychiatrists (51%) and pediatricians (32%), but most children received repeat prescriptions from general practitioners (61%). Of these 924 children, 19% did not receive any follow-up care, and transfer of prescribing responsibility increased the risk of not receiving follow-up care. The 732 children (79%) who were monitored visited a physician approximately twice a year. During follow-up visits, pediatricians performed physical check ups significantly more often. CONCLUSION: Stimulant treatment in The Netherlands is initiated mainly by specialists such as child psychiatrists and pediatricians. In the current study, follow-up care for stimulant-treated children in The Netherlands appeared to be poor, suggesting an urgent need for improvement.

HRT use in 2001 and 2004 in The Netherlands--a world of difference.

OBJECTIVE: Did the publication of the Women Health Initiative (WHI) trial in 2002 and the Million Women Study (MWS) in 2003 lead to changes in prescription rates of hormone replacement therapy (HRT). Therefore, we compare the prescribing of HRT in 2004 (after) with that of 2001 (before the publications) in The Netherlands. METHOD: Community pharmacy dispensing data from a population of approximately 500,000 patients in The Netherlands. Women aged 40-74 years to whom at least one HRT prescription was dispensed in 2001 or 2004 were included. Annual prevalences of HRT in 2001 and 2004 and the percentage change (2004 versus 2001) were calculated for overall HRT (excluding vaginal products) and per HRT category (combined estrogens and progestagens, estrogens only, tibolon and vaginal preparations) and age category. RESULTS: In 2001, 5.64% of the women aged 40-74 used HRT and this percentage declined to 2.39 in 2004. The use of vaginal products among these women did not change, 1.76% in 2001 and 1.65% in 2004. The percentage change was highest in the opposed HRT group (66% decrease) and in women aged 50-54 (64.4% decrease). In 2004, compared with 2001, the proportion of long-term users (>3 year) increased with 12.7%. CONCLUSIONS: In The Netherlands, after publication of the WHI study and the MWS the prescribing of HRT fell dramatically whereas the prescribing of vaginal products did not change. Future patterns of HRT use should be monitored to know whether this decrease will be sustained.

Dramatic change in prescribing of hormone replacement therapy in The Netherlands after publication of the Million Women Study: a follow-up study.

AIMS: To estimate the diffusion of new safety information concerning postmenopausal hormonal replacement therapy (HRT) into prescribing practice in The Netherlands and to assess the impact of revised guidelines on the long-term treatment of HRT. DESIGN: Cross-sectional study. SETTING: Community pharmacy dispensing data from a population of approximately 450,000 patients in the northern and eastern part of The Netherlands. POPULATION: Women aged 45-69 years to whom at least one HRT prescription was dispensed between 1 January 2000 and 1 January 2004. MAIN OUTCOME MEASURES: Annual and quarter prevalences of HRT and the proportion of new HRT users, switchers and continuous HRT users per quarter. RESULTS: The prevalence of HRT prescribing decreased significantly from 107/1000 [95% confidence interval (CI) 104, 110] in 2000 to 87/1000 (95% CI 84, 89) in 2003. The decreasing prevalence was especially evident among the younger age groups and was most pronounced among users of oestrogen/progestagen combinations. The publication of the Women Health Initiative Study (WHI) was followed by a modest decrease in prescribing of HRT, whereas prescribing of HRT declined dramatically after publication of the Million Women Study (MWS) in August 2003. Among the continuous HRT users in the 4th quarter of 2002, 55% used HRT longer than 3 years. This percentage was 53 in the 4th quarter of 2003. CONCLUSIONS: In contrast to the release of the WHI study results, publication of the MWS was followed by a dramatic fall in prescribing of HRT in The Netherlands. Despite the new recommendation that long-term HRT use should be discouraged, the proportion of long-term users did not change after the publication of the MWS.

Psychotropic co-medication among stimulant-treated children in The Netherlands.

OBJECTIVES: The aim of this study was to examine stimulant use from 1998 to 2002 among children in the Dutch pediatric population with emphasis on psychotropic co-medication. METHODS: A drug utilization study was based on community pharmacy-dispensing data from 1998 to 2002 for children aged 0-19 years in the northern and eastern part of The Netherlands. RESULTS: The prevalence of stimulant use increased from 0.6% in 1998 to 1.2% in 2002. Duration of stimulant treatment was longest in children aged 5-14 years. The use of any psychotropic co-medication in stimulant users increased from 12% in 1998 to nearly 15% in 2002. Of those youths who were prescribed stimulant medication in 2002, the most co-prescribed class was the antipsychotics (7.9%). In 1998, none of the stimulant-treated children received antidepressants for co-medication; in 2002, this was 1.8%. CONCLUSION: The prevalence of stimulant use among children in The Netherlands has increased in recent years, mainly as a result of the duration of stimulant treatment. Psychotropic co-medication among stimulant-treated children increased moderately.