The Finnish Interprofessional Medication Assessment (FIMA): baseline findings from home care setting.

PURPOSE: Medication-related problems and declined functional capacity are closely associated factors among older people. The purpose of this study is to describe the procedure of interprofessional medication assessment in home care context and the baseline characteristics of the study population. METHODS: The FIMA study was a randomized, controlled intervention study comparing general practitioner-led interprofessional medication assessment and usual care. Patients' chronic diagnoses and medication use as well as physical and cognitive functions were investigated. Performance in daily activities, use of care services and help from family and relatives, self-rated health and health-related quality of life, and adverse effects commonly related to medication were assessed. RESULTS: The home care patients (n = 512) had significant disease burden and functional limitations. The mean number of all medicines was 15 and that of regularly taken medicines 10. The majority of patients (87%) had excessive polypharmacy. The most commonly used (97%) ATC medicine class was nervous system medicines. Clinically relevant (class C or D SFINX record) drug-drug interactions were seen in 74% of the patients. The most frequent risks of adverse effects were risk of bleeding (66%), constipation (58%) and orthostatism (54%) occurring in over half of the patients. Medicines affecting renal function were used by 85% of the patients. CONCLUSIONS: There is an evident need and justification for medication assessments in home care. In most cases, home care patients fulfill the criteria for regular medication assessments.

Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older.

This cross-sectional analysis of a population-based cohort investigates the postural changes in blood pressure (BP) and heart rate and assesses the prevalence of orthostatic hypotension (OH) and its associations with the medicines used by an elderly population. The study population (n=1000) was a random sample of persons aged 75 years or older in the City of Kuopio, Finland. In 2004, altogether, 781 persons participated in the study. After the exclusion of persons living in institutional care (n=82) and those without orthostatic test (n=46), the final study population comprised 653 home-dwelling elderly persons. OH was defined as a > or =20 mm Hg drop of systolic BP or a > or =10 mm Hg drop of diastolic BP or both 1 or 3 min after standing up from supine position. Systolic BP dropped for more than half of the home-dwelling elderly when they stood up from a supine to a standing position. The total prevalence of OH was 34% (n=220). No significant gender or age differences were seen. The prevalence of OH was related to the total number of medicines in regular use (P<0.05). OH and postural changes in BP are more common among the home-dwelling elderly than reported in previous studies. The prevalence of OH is related to the number of medicines in regular use. There is an obvious need to measure orthostatic BP of elderly persons, as low BP and OH are important risk factors especially among the frail elderly persons.

An intervention to develop repeat prescribing in community pharmacy.

BACKGROUND: Lack of review of patients' medications in repeat prescribing is common. This and other problems in repeat prescribing need to be addressed. Community pharmacists could be more proactive in the review of chronic medications. OBJECTIVE: The purpose of this study was to test the feasibility and effects of pharmacists' interventions in repeat prescribing. METHODS: The normal repeat prescribing process used at Kuopio University Pharmacy and in Kuopio Health Services was developed by an intervention which included a pharmacist's interview and the annual medication data of the patient that were both transferred to the prescribing physician. RESULTS: Physicians in the intervention group identified and solved patients' drug-related problems better than was the case in the comparison group with normal repeat prescribing. Over half the patients receiving repeat prescriptions had at least one drug-related problem. The physicians used more information sources to support repeat prescribing in the intervention system. CONCLUSIONS: Community pharmacists are able to improve the quality of physician's repeat prescribing by providing vital information.

Health and medication literacy and the desire to participate in pharmacotherapy decision making - comparison of two countries.

BACKGROUND: Health and medication literacy may be important factors in the outcomes of medical treatment. Similarly, shared decision making or lack of it may influence patient's behavior and adherence to medications. OBJECTIVES: To describe health and medication literacy as well as factors associated with poor medication literacy in two different populations and secondly, to describe desire to participate in decisions concerning medications; and to assess the role of poor medication literacy in decision making. METHODS: A general population based survey in Finland (n = 8003) and in Malta (n = 2000). Health and medication literacy and the desire to participate in decision making was each measured with three statements based on the literature. Medication literacy was operationalized as understanding the instructions on package insert and ability to follow instructions on pharmacy label. RESULTS: Fifteen percent of the Finnish respondents and 16% of Maltese reported always or often having problems understanding package inserts, i.e., poor medication literacy. Males (p = 0.004) and respondents in the age group 65-79 years (p < 0.001) were more prone to report such poor medication literacy. Respondents in Finland (59%) and Malta (65%) reported wanting to discuss different treatment options with the doctor. The respective percentages (42% Finland, 57% Malta) were lower for discussing about the choice of medicine and for deciding about the medicine (36% and 43%, respectively). The desire to participate in deciding about the medicines was higher among females (p < 0.001) and Maltese respondents (p < 0.001). Also those with poor medication literacy more often (p < 0.001) expressed a desire to participate in deciding in the choice of medicine. CONCLUSIONS: Medication literacy was rather low, while desire to participate in pharmacotherapy decision making was high, especially in Malta. Overall, women tended to be more willing to participate in decision making. The desire to participate in decisions was higher among persons with low medication literacy.

Incorporating patient perspectives in health technology assessments and clinical practice guidelines.

BACKGROUND: Ensuring patient involvement in health technology assessments (HTAs) and clinical practice guidelines (CPGs) is important. However, the goals and methods of such involvement are not always clear. OBJECTIVES: The aim of this study was to 1) discover ways to involve patients in HTA and CPG processes, 2) describe challenges, and 3) find ways of informing patients about HTAs and CPGs in Finland. METHODS: As part of a one-day seminar targeted at representatives of patient organizations (POs), 3, 1-h focus group discussions were held (n = 20, with 14 PO representatives). PO representatives included real patients and health care professionals working in the organizations. The discussions were tape-recorded, transcribed, and thematically analyzed. RESULTS: Focus group participants highlighted the importance of gathering patient views from a group of patients, rather than individuals. Surveys through POs were the most frequently mentioned means of gathering patients' views. PO representatives reported interest in cooperating in HTA and CPG processes. The most often mentioned challenges were finding appropriate representatives for the target group and conveying information about HTAs and CPGs to patients. Multichannel communication was seen as essential. Furthermore the information should be readable, comprehensible, tailored, reliable, reusable, complementary, and timely. CONCLUSIONS: Possible strategies to involve patients in HTA and CPG processes were incorporating patient representatives in the CPG and HTA groups, offering timely possibility to participate, and ensuring reporting with clear and unambiguous language. The main identified challenge was finding appropriate representatives of the target group. The role of POs was seen as important particularly when informing the patients.

Antihypertensive drug treatment in a middle-aged population.

In Finland's North Karelia region a community-based program for control of hypertension was administered for 5 years. Afterward, drug treatment and the impact of such treatment on control of blood pressure were studied in a cross-sectional survey. The study population (n = 10,199) consisted of a 6.6% random sample of people aged 30-64 years in North Karelia (program area) and Kuopio (reference area). Rate of participation was about 90%. The methods included questionnaire, personal interview, and clinical examination. In North Karelia, 24% of the men and 25% of the women were hypertensives (blood pressure greater than or equal to 175 mm Hg systolic and/or 100 mm Hg diastolic, or currently on antihypertensive drug therapy), compared with 33% of the men and 29% of the women in the reference area. In North Karelia, 48% of the male hypertensives and 67% of the female hypertensives were on drug therapy, compared with 32% and 54%, respectively, in the reference area. Of the total population in each area, 14% in North Karelia currently used drugs, compared with 13% in the reference area. Diuretics and beta-blockers were the drugs most commonly prescribed; men used beta-blockers more often than women did. In terms of quantity of medication, type of drugs, and compliance, the differences between the two areas were small. Control of blood pressure, however, was clearly better in North Karelia than in the reference area for hypertensives and drug users and for both men and women. Therefore, compared with the traditional system, organized hypertension care results in more successful treatment.

Change in blood pressure and 5-year risk of coronary heart disease among elderly men: the Finnish cohorts of the Seven Countries Study.

OBJECTIVE: To study the association between blood pressure and change in blood pressure with future coronary risk among elderly men. DESIGN: Cohort study. SETTING: Finnish cohorts of the Seven Countries Study. PARTICIPANTS: Four hundred and seventy-six men aged 65-84 years and free of clinically manifested coronary heart disease at baseline, in 1984. MAIN OUTCOME MEASURES: Fatal myocardial infarction (n = 29), any myocardial infarction (n = 42), and incidence of any new signs and symptoms of coronary heart disease (n = 80) during a 5-year follow-up. RESULTS: In multivariate analysis, a significant inverse U-shaped relationship was observed between baseline diastolic blood pressure and future fatal myocardial infarction, any myocardial infarction and any coronary heart disease. In models predicting the risk of coronary heart disease during 1984-1989, there was a significant interaction between both systolic (SBP) and diastolic blood pressure (DBP) in 1969-1974 and change in blood pressure between 1969-1974 and 1984. In categorical analyses, men (n = 42) who experienced a decline in DBP of > or = 4 mmHg from initial levels of > or = 90 mmHg had a higher risk of any myocardial infarction than men (n = 112) with a change of < 4 mmHg (odds ratio 4.5). For a decline of > or = 10 mmHg or more in SBP from levels of > or = 160 mmHg the corresponding odds ratio was 2.9. Men who experienced a decline in DBP or SBP from normotensive levels or an increase in blood pressure had no excess risk compared with men with stabile (change in DBP < 4 mmHg and change in SBP < 10 mmHg) blood pressure values. CONCLUSION: The present results suggest that among elderly men a decline in DBP or SBP from previously hypertensive levels may be associated with increased coronary risk.

Patients' perceived problems with hypertension and attitudes towards medical treatment.

OBJECTIVE: To study perceived problems and attitudes in hypertension treatment in primary health care. STUDY POPULATION AND METHODS: A cross-sectional survey of 2219 hypertensive patients, identified by general practitioners, in 26 health centres was carried out during 1 week in 1996. A total of 1782 patients (80%) returned two questionnaires and participated in a health examination. The final study population consisted of 1561 patients currently being medically treated for hypertension and 220 patients not currently on medical treatment. The questionnaires contained 82 questions on different aspects of hypertension care and treatment, which were further elaborated using factor analysis. On the basis of reliability and internal validity analyses, 14 problem indices related to medical treatment of hypertension were formed. RESULTS: The most common perceived problem was related to lack of motivation for follow-up of hypertension (72%). Many patients had difficulties to accept being hypertensive (66%). A careless attitude towards hypertension was also common (63%). Lack of information was experienced by 56% of the patients. About 33% felt hopeless about their hypertension, reported adverse effects of hypertension treatment on sexual functions and lack of support by health care personnel. The least frequent problems were reimbursement problems and modification of dosage instructions. The number of problems identified per person varied between zero and 14 with a mean of 4.9 +/- 2.6 (s.d.). CONCLUSION: Perceived problems concerning hypertension, negative attitudes and experiences are very common among hypertensive patients in primary health care.

Physicians' opinions about the management of hypertension: changes in Finland between 1985 and 1992.

The successful management of hypertension requires an active involvement of physicians. We studied trends in Finnish physicians' opinions about the management of hypertension between 1985 and 1992. The response rates in these two random samples of physicians were 68% and 56%, respectively. Physicians who reported regularly treating hypertensive patients were included in our analyses (n1 = 319, n2 = 470). Fifty per cent of physicians used diastolic blood pressure of 100 mm Hg as a criterion for starting drug treatment and a goal blood pressure of 90 mm Hg was reported by 60% of physicians. Both levels decreased from 1985 to 1992. The variation in both of these blood pressure levels as reported by the physicians were wide both in 1985 and 1992. The activity in promoting non-pharmacological measures such as exercise and restriction of fat intake improved during this time period. The choice of drugs for anti-hypertensive therapy changed drastically from 1985 to 1992. For younger patients ACE inhibitors became the drug of choice and for older patients Ca-blockers gained popularity from diuretics. A similar shift can also be seen in the sales statistics. Whether this increased activity in starting drug therapy and using new drugs will improve the outcome of treatment remains to be seen.

Hypertension treatment without labelling effects: the North Karelia Project.

Increases in disability and work loss have been noted following hypertension identification and treatment. To determine if iatrogenic disability is a necessary side-effect of successful treatment, self-reports of days lost from work and days spent in bed because of illness in the year before interview were compared in 1972 and 1977 for three groups in eastern Finland: hypertensives who had been told of their hypertension before 1972, hypertensives newly identified by screening in 1972, and a group of normal controls. The groups were stratified by sex and residence (urban or rural), and analysis of covariance was used to adjust for the effects of age differences among the groups. In 1972, the hypertensives identified before 1972 were significantly older and had significantly higher systolic blood pressure levels than the hypertensives identified in 1972. Hypertensives identified before 1972 had higher work loss and days spent in bed than hypertensives identified in 1972. This association was independent of age, sex, residence, and systolic blood pressure. Upon resurvey in 1977, the group with hypertension newly identified in 1972 had no greater increase in work loss or days spent in bed due to illness than the normal controls. These data support the hypothesis that hypertension identification and treatment can be but does not have to be associated with significant increases in occupational disability and days spent in bed due to illness.

Factors related to non-compliance with antihypertensive drug therapy.

The objectives were to study the associations of perceived health care-related and patient-related factors with self-reported noncompliance with antihypertensive treatment. General practitioners identified all of their hypertensive patients in 26 health centres during 1 week in 1996 (n = 2219). A total of 1782 (80%) patients participated in the study, of whom 1561 were on antihypertensive medication. Based on 82 opinion statements in two questionnaires, 14 problem indices were formed by using factor analysis. Out of these, summary variables concerning problems related to the health care system and the patients were formed. Logistic regression models, including interaction analyses, were used to study the associations with non-compliance. The results were that the majority of patients had at least one perceived health care system-related (88%) and patient-related problem (92%). A high number of both perceived health care system-related problems (adjusted OR 4.77; 95% CI 2.76, 8.26) and patient-related problems (adjusted OR 3.23; 95% CI 1.79, 5.81) were associated with self-reported non-compliance. The experience of adverse drug effects was also associated with non-compliance (adjusted OR 1.41; 95% CI 1.03, 1.94). In conclusion self-reported non-compliance was associated with multiple risks of both perceived health care system-related and patient-related problems.

Drug treatment of high blood pressure in the community--experience in eastern Finland.

The effects of antihypertensive drug therapy were assessed in 8,459 patients (2,801 men and 5,658 women) from the hypertension register of the North Karelia Project in 1978-1979. Fifty-two per cent of the men and 56% of the women were taking one drug only. The most common drugs used were diuretics and beta-blockers. Women were on diuretics more often than men, but beta-blockers were more common in men. The effect of the treatment was assessed in terms of the BP means and percentage of patients whose DBP was below 100 mmHg. BP was controlled better in women than men. The best BP control was obtained in groups of patients who were on a single drug. Adequate BP control was achieved in 71% of men and 83% of women on diuretics, in 75% of men and 83% of women on beta-blockers, in 85% of both sexes on fixed combinations of a diuretic + reserpine + vasodilator, and 79% of men and 89% of women on a diuretic + reserpine. Fixed combinations containing only low doses of each drug are a good alternative for some patients.

The effects of a pharmacy-based intervention on the knowledge and attitudes of asthma patients.

The effects of a pharmacy-based intervention on the knowledge and attitudes of asthma patients was studied with a small convenience sample in four Finnish community pharmacies. The intervention consisted of patient education, counselling and outcomes monitoring according to Therapeutic Outcomes Monitoring (TOM) concept. Twenty-eight patients aged 20-64 years suffering from asthma and having problems in asthma management were involved. Measurements were done at baseline, immediately after the intervention (12 months) and 1 year after the intervention (24 months) using a pre/post-test design, with the patients being their own controls. Both knowledge about and attitudes towards asthma as a disease improved significantly during the intervention. Also knowledge about medication improved significantly during the intervention, though the patients' attitudes towards the medication remained unchanged. The negative correlation between knowledge about and attitudes towards asthma (-0.35) at baseline disappeared after the intervention (0.21). There was a positive correlation between knowledge about and attitudes towards medication at 12 months (0.40, P=0.04) which was still significant 1 year after the intervention (0.40, P=0.04).

A community-based intervention study on the feasibility and effects of the reduction of salt intake in North Karelia, Finland.

A community-based programme to reduce salt consumption to lower general blood pressure levels has been started in North Karelia, a county eastern Finland with high hypertension and CVD rates. The programme is based on the previous activity in the community to control CVD risk factors (the North Karelia Project). Previously, however, salt reduction was not included among the objectives. The aim of the study is to evaluate the feasibility and effects of this new community programme to reduce salt intake. The study period is from spring 1979 to spring 1982. At the outset and at the end cross-sectional random population samples, ages 14 to 65, are examined both in North Karelia and a matched reference community. The surveys include among other measurements 24-hour urine collection (for Na, K and creatinine excretion) and blood pressure. The effect evaluation is concerned whether the programme reduced the general salt intake and whether this was associated with reduction in blood pressure levels among the population. Principles and methods of intervention are presented. Preliminary results from the baseline survey confirmed the high salt intake of the population: the mean 24-hour urinary Na excretion was 215-218 mmol among men and 171-173 mmol among women. The respective K excretion values were 89-91 mmol and 72-72 mmol, and Na/K ratios 2.5-2.6 and 2.4-2.5.

Vitamin A, vitamin E and selenium status in an aged Finnish male population.

Vitamin A (retinol), vitamin E (alpha-tocopherol) and selenium concentrations in serum were studied during the autumn season (October and November) in two Finnish male populations aged 65-84 years and living either in eastern or southwestern Finland. The mean vitamin A concentration was higher in south-western, but the mean selenium concentration was higher in eastern Finland. Mean vitamin A concentrations did not differ between age groups, but in the south-west highest vitamin E and selenium concentrations were found among the youngest population. A severe vitamin A deficiency (below 300 micrograms/l) was found only in 3 (1%) men in the east and 4 (1%) men in the south-west, and a mild deficiency (300-399 micrograms/l) in 11 (4%) men in the east and 16 (4%) men in the south-west. Vitamin E deficiency after the correction by serum total cholesterol (below 2 mg/l/g/l) was found only in 3 (1%) men in the east and 1 (0%) man in the south-west, and low values (2.0-2.9 mg/l/g/l) were found in 13 (4%) men in the east and 34 (9%) men in the south-west. A severe deficiency of selenium (below 46 micrograms/l) was found in 10 (3%) men in the east and 15 (4%) men in the south-west, while a mild deficiency (46-69 micrograms/l) was found in 140 (45%) men in the east and 197 (52%) men in the south-west. The overall vitamin A and vitamin E status of elderly Finnish men was relatively adequate, while severe or mild deficiencies of selenium were common.

Availability and choice of antimalarials at medicine outlets in Ghana: the question of access to effective medicines for malaria control.

Although national and international efforts to combat malaria have intensified over the years, problems with availability, distribution, and choice of antimalarials at medicine outlets in Africa continue to exist. This article presents the results of an indicator-based assessment of availability and choice of antimalarials at 130 licensed medicine outlets in Ghana. We also discuss how the choice of an antimalarial to dispense conforms to recommendations of the national policy for malaria therapy. Data were obtained through face-to-face interviews, by reviewing facility records, and by observing the practices of dispensing staff in the medicine outlets. Antimalarials recommended in the policy were not readily available in the most accessible medicine outlets. Few outlets adhered to the policy when choosing antimalarials. Interventions targeting medicine outlets should be initiated to improve availability and access to effective medicines in order to support the national program for malaria control.

Changes in the use of cardiovascular medicines in the elderly aged 75 years or older--a population-based Kuopio 75+ study.

OBJECTIVE: The aim of this population-based cohort study was to examine the changes in the regular use of cardiovascular medication among the elderly aged 75 years or more in Finland in 1998 and 2003. METHODS: The study population (n = 700) was a random sample of all persons aged 75 years or more living in Kuopio, in eastern Finland. Of them, 601 persons participated in 1998. The surviving persons (n = 339) were re-examined in 2003. Of them 85% (n = 289) were home-dwelling and 15% (n = 50) lived in institutional care. Data on their use of medication and their physical and mental health was collected from interviews conducted by trained nurses. RESULTS: From 1998 to 2003 regular use of one or more cardiovascular medicine increased from 80% to 87% among all the survivors (n = 339, P < 0.001). The mean number of regularly used cardiovascular medicines increased from 2.1 (95% CI 1.9-2.3) to 2.7 (95% CI 2.5-2.9, P < 0.001) during the follow-up period. The most commonly used cardiovascular medicines were beta-blocking agents. The proportion of users of beta-blocking agents was in 1998 45% and in 2003 51%. The proportion of users of diuretics increased from 27% to 40% (P < 0.001), users of cardiac therapy from 35% to 43% (P < 0.001), users of ACE inhibitors and AT 1 receptor antagonists from 20% to 30% (P < 0.001) and users of lipid modifying agents from 7% to 12%. CONCLUSIONS: The use of cardiovascular medicines was common among elderly persons. The proportion of users increased with age and over time. A large proportion of elderly persons would need medication monitoring focusing on cardiovascular medication.

Measuring patient compliance in antihypertensive therapy--some methodological aspects.

The usefulness of prescription refilling patterns in assessing compliance was studied retrospectively in 331 subjects receiving antihypertensive drugs during 1 and 2 year follow-up periods in 1976 and 1977. The compliance distribution was J-shaped for both periods. The number of compliant patients decreased slightly when the follow-up period increased from 1 to 2 years. An arbitrary cutoff point (0.7) yielded 34% noncompliers during the 2 year period. By interviewing patients, an additional 5% of noncompliers so-called early drop-outs, were identified among those who had filled no antihypertensive prescriptions during the 2 year period. The second follow-up year yielded little additional information. Reliability of the results obtained with prescription monitoring was also assessed by interviewing patients concerning eventual hospital stays and physicians' verbal orders that were not recorded on the prescriptions. These factors did not affect the overall compliance distribution, even though some patients might have been classified incorrectly because of them. In research settings and in daily practice prescription monitoring is a useful tool for assessing patient compliance.