The Finnish experience to save asthma costs by improving care in 1987-2013.

The Finnish National Asthma Program 1994-2004 markedly improved asthma care in the 1990s. We evaluated the changes in costs during 26 years from 1987 to 2013. Direct and indirect costs were calculated by using data from national registries. Costs from both the societal and patient perspectives were included. The costs were based on patients with persistent, physician-diagnosed asthma verified by lung function measurements. We constructed minimum and maximum scenarios to assess the effect of improved asthma care on total costs. The number of patients with persistent asthma in the national drug reimbursement register increased from 83,000 to 247,583. Improved asthma control reduced health care use and disability, resulting in major cost savings. Despite a 3-fold increase in patients, the total costs decreased by 14%, from €222 million to €191 million. Costs for medication and primary care visits increased, but overall annual costs per patient decreased by 72%, from €2656 to €749. The theoretical total cost savings for 2013, comparing actual with predicted costs, were between €120 and €475 million, depending on the scenario used. The Finnish Asthma Program resulted in significant cost savings at both the societal and patient levels during a 26-year period.

Evolution of paediatric off-label use after new significant medicines become available for adults: a study on triptans in Finnish children 1994-2007.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: • Off-label use in children is widespread. New medicines lack marketing authorization for paediatric use, even when they represent significant therapeutic advantages and are intended for treatment of conditions common in children. • Until now no information exists on how off-label use in children develops over time after a significant new medicine is approved for adults and what happens when it is later labelled for one paediatric age group. WHAT THIS STUDY ADDS: • Off-label use of a new significant medicine begins in adolescents and extends to younger children with delay. First marketing authorization to adolescents, providing a more child-friendly formulation, results in increase of off-label use in younger children, and has limited effect on total off-label use. AIM: To investigate the evolution of paediatric off-label use after a therapeutically new group of medicines for a common condition becomes available for adults but is labelled for children with a delay of several years. METHODS: Triptans were used as a model, because migraine is common in children, and is the only indication for triptans. Data on all triptan prescriptions 1994-2007 were extracted from the nationwide Finnish Prescription Register. Prescriptions for children were compared over time. RESULTS: Paediatric patients with triptan prescriptions increased from 204 in 1994 to 2618 in 2007. Sumatriptan accounted for 64% of all paediatric triptan prescriptions. When sumatriptan in a nasal formulation was labelled for children ≥ 12 years in 2003, off-label prescribing to younger children (6-11 years) doubled in 2003-2004. Sumatriptan on-label prescriptions increased to 728 adolescents (45% of sumatriptan in the age group) in 2007, but its off-label use continued also to increase to 1119 (61% of paediatric sumatriptan prescriptions) in 2007. In that year 72% of paediatric triptan use was off-label, 28% on-label. CONCLUSIONS: When a new significant medicine becomes available in adults, off-label use in children starts slowly but continues to extend to younger children reaching a market size which is little influenced by late appearance of a labelled product. Paediatric treatment remains dominated by off-label use despite labelling of a product in an age appropriate formulation to the most relevant age group.

First-year purchases of disease-modifying drugs of incident patients with chronic juvenile arthritis in Finland.

OBJECTIVES: To establish a nationwide overview on drug treatment of juvenile idiopathic arthritis (JIA), which is the most frequent form of chronic arthritis (JA) in children and adolescents. The emphasis is on the first 12 months after diagnosis, and any changes in medication practices during the early years of the present millennium are registered. METHODS: The Social Insurance Institution (SII) in Finland keeps a national register on individuals granted with a special reimbursement for medication of defined chronic diseases. From that register, we identified by the ICD-code of M08 all JA patients aged 16 years or under with an index day from 2000 through 2007. The prescription register of the SII showed the medication purchased for the patients. The register does not cover infused medications given in hospitals. We evaluated the first disease year's medication and the treatment strategy of the very first three months. RESULTS: Within our study period 2000-2007, the proportion of patients using methotrexate during the first year of treatment increased from 54 to 72% (p<0.001). The combination of two or more DMARDs became more popular (increased from 16 to 21%) as the initial treatment strategy. These changes parallel a decrease in per oral glucocorticoids. The proportion of JA patients receiving TNFα-blockers during the first year after diagnose reached the level of about 5% during the years 2004 to 007. CONCLUSIONS: The drug treatment of patients with recent onset JA has become more intensive during the course of the new millennium in Finland, a fact expected to improve the disease outcome.

Incidence of cancer and antidepressant medication: record linkage study.

The consumption of antidepressants, especially selective serotonine reuptake inhibitors (SSRI) has been increasing. Because a large fraction of the population is exposed, even a small excess of risk with respect to cancer should be considered. We carried out a record linkage study in Finland utilizing nationwide databases of reimbursed medication and cancer. The study population included all antidepressant drug (AD) users in Finland who had purchased at least 1 prescription between 1998 and 2005, and who had no cancer diagnosis at the date of first purchase. A control population without AD usage (matched by age and sex) was also included. Data consisted of 418,588 pairs of individuals that cumulated 3.3 million person-years with an average of 4.0 years of follow-up. 19,365 cancer cases were observed. The most frequent cancers were breast, prostate, lung, colon, and brain cancer. In general, only few associations between the utilization of AD and cancer could be detected. Over four years exposure to AD showed a weak association with increased colon and breast cancer incidence, which could have been caused by bias. As conclusion, no clear evidence of neither beneficial nor harmful association between usage of antidepressant and cancer was found.

Incidence of cancer and statin usage--record linkage study.

The consumption of statins (HMG-CoA reductase inhibitors) has been increasing, and a substantial part of the middle-aged and elderly population use them continuously. Because a large fraction of the population is exposed, even a small excess of risk with respect to cancer should be considered. We carried out a record-linkage study in Finland utilizing nationwide databases of reimbursed statin medication and cancer. The study population included all statin users in Finland who had purchased at least 1 prescription between 1996 and 2005 and who had no cancer diagnosis at the date of first purchase. A control population without statin usage was also included. Data consisted of 472,481 pairs of individuals that cumulated 4.2 million person years with an average of 8.8 years of follow-up. Fifty thousand two hundred ninety-four cancer cases were observed. Simvastatin and atorvastatin were the most used substances. The most frequent cancers were prostate, breast, lung, colon, and rectum cancer. In general, no association between the utilization of statins and cancer could be detected. In conclusion, this study adds large-scale, population-based results about the association between statin utilization and the incidence of cancer. We found neither beneficial nor harmful associations between the usage of statins and cancer.

Maternal and perinatal characteristics and the risk of cow's milk allergy in infants up to 2 years of age: a case-control study nested in the Finnish population.

This study examined whether maternal background and perinatal factors were associated with the risk of cow's milk allergy (CMA) in infants up to 2 years of age in a nested case-control study. All children born in 1996-2004 in Finland and diagnosed with CMA by 2006 were identified (n = 16,237). For each case, one matched control was selected. Information on maternal and perinatal factors was derived from the Medical Birth Register. The associations were analyzed by conditional logistic regression. Cesarean section (adjusted odds ratio (OR) = 1.18, 95% confidence interval (CI): 1.10, 1.27) and high maternal age (> or =35 years; adjusted OR = 1.23, 95% CI: 1.11, 1.36) were associated with increased risk, whereas low maternal socioeconomic status (adjusted OR = 0.65, 95% CI: 0.59, 0.71), smoking (adjusted OR = 0.72, 95% CI: 0.67, 0.79), high number of previous deliveries (> or =5; adjusted OR = 0.71, 95% CI: 0.59, 0.86), and multiple pregnancy (adjusted OR = 0.70, 95% CI: 0.60, 0.82) were associated with decreased risk of CMA. In conclusion, maternal background and perinatal factors may play a role in the development of CMA, but further research is needed to clarify these associations and the underpinning biologic mechanisms.

11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study).

BACKGROUND: The introduction of second-generation antipsychotic drugs during the 1990s is widely believed to have adversely affected mortality of patients with schizophrenia. Our aim was to establish the long-term contribution of antipsychotic drugs to mortality in such patients. METHODS: Nationwide registers in Finland were used to compare the cause-specific mortality in 66 881 patients versus the total population (5.2 million) between 1996, and 2006, and to link these data with the use of antipsychotic drugs. We measured the all-cause mortality of patients with schizophrenia in outpatient care during current and cumulative exposure to any antipsychotic drug versus no use of these drugs, and exposure to the six most frequently used antipsychotic drugs compared with perphenazine use. FINDINGS: Although the proportional use of second-generation antipsychotic drugs rose from 13% to 64% during follow-up, the gap in life expectancy between patients with schizophrenia and the general population did not widen between 1996 (25 years), and 2006 (22.5 years). Compared with current use of perphenazine, the highest risk for overall mortality was recorded for quetiapine (adjusted hazard ratio [HR] 1.41, 95% CI 1.09-1.82), and the lowest risk for clozapine (0.74, 0.60-0.91; p=0.0045 for the difference between clozapine vs perphenazine, and p<0.0001 for all other antipsychotic drugs). Long-term cumulative exposure (7-11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0.81, 0.77-0.84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0.991; 0.985-0.997). INTERPRETATION: Long-term treatment with antipsychotic drugs is associated with lower mortality compared with no antipsychotic use. Second-generation drugs are a highly heterogeneous group, and clozapine seems to be associated with a substantially lower mortality than any other antipsychotics. Restrictions on the use of clozapine should be reassessed. FUNDING: Annual EVO Financing (Special government subsidies from the Ministry of Health and Welfare, Finland).

Positive change in the utilization of antihypertensive and lipid-lowering drugs among adult CHD patients in Finland: results from a large national database between 2000 and 2006.

AIM: To assess the changes in the utilization of antihypertensive, and lipid-lowering drugs among all adult Finnish coronary heart disease (CHD) patients between 2000 and 2006, and to evaluate the treatment and control of hypertension and dyslipidemia in a population-based sample of CHD patients. METHODS: From the databases of the Social Insurance Institution of Finland, 192,440 CHD patients aged 30 years or more in 2000 and 206,394 in 2006, respectively, were identified. Changes in the utilization of antihypertensive and lipid-lowering drugs were determined. In addition, from the Health 2000 Survey representing the whole Finnish population aged 30 years or more, 527 CHD patients were identified, to assess their characteristics and control of hypertension and dyslipidemia. RESULTS: Between the fall of 2000 and spring of 2001, 75% of the CHD patients were classified as hypertensives and 85% of these used antihypertensive medication. From 2000 to 2006, the utilization of lipid-lowering, and antihypertensive drugs increased from 33 to 52% and from 74 to 78%, respectively. Moreover, combination antihypertensive medication increased from 37 to 48%. Amidst the patients using antihypertensive drugs, the use of renin-angiotensin system blockers increased from 27 to 46% because of more than a three-fold increase in the use of angiotensin receptor blockers. CONCLUSION: Utilization of antihypertensive agents (especially angiotensin receptor blockers) and lipid-lowering drugs has increased remarkably by the end of 2006. However, the treatments are still far from optimal.

Antibiotic use predicts an increased risk of cancer.

Antibiotic use has been hypothesized to be associated with the risk of cancer but the evidence is sparse and inconsistent. The aim of the present study was to determine whether antibiotic use predicts the development of various cancers. This nationwide cohort study included 3,112,624 individuals, aged 30-79 years, with no history of cancer. Information on their antibiotic use between 1995 and 1997 was obtained from the Drug Prescription Registry. During the period 1998-2004, 134,070 cancer cases were ascertained from the Finnish Cancer Registry. Cox proportional hazards regression was used to estimate the relative risks (RRs) with 95% confidence intervals (95% CIs). Antibiotic use was associated with an increased risk of cancer: for categories of increasing antibiotic use (0-1, 2-5 and >/=6 prescriptions), RRs (95% CIs) for cancer were 1.0 (reference), 1.27 (1.26-1.29) and 1.37 (1.34-1.40). RRs (for comparison of lowest and highest exposure group) for the most common primary sites i.e. prostate, breast, lung and colon were 1.39 (1.31-1.48), 1.14 (1.09-1.20), 1.79 (1.67-1.92), and 1.15 (1.04-1.26), respectively. RRs for other primary sites varied between 0.90 (0.76-1.05) for ovary to 2.60 (1.60-4.20) for endocrine gland (excluding thyroid). In conclusion, antibiotic use predicts an increased risk of cancer. Because of the design of our study the possibility of residual confounding cannot be excluded and further studies are required to confirm the results.

Perinatal factors and the risk of asthma in childhood--a population-based register study in Finland.

The aim of the study was to assess whether perinatal factors are associated with the risk of asthma in childhood in a register-based, nested case-control study in Finland. All children born between January 1, 1996, and April 30, 2004, who were entitled to a special reimbursement for antiasthmatic drugs (i.e., had diagnosed asthma by 2006 and had purchased inhaled corticosteroids or montelukast at least once), were identified (n = 21,038). For each case, one matched control child was selected. The associations between perinatal factors, derived from the Finnish Medical Birth Register, and the risk of asthma were analyzed by conditional logistic regression. In the final multivariate model, maternal asthma, young age, smoking, previous miscarriages, and a high number of previous deliveries, as well as cesarean section, low gestational age, and low ponderal index, were associated with an increased risk of asthma in children diagnosed before the age of 3 years. Among children diagnosed at the age of 3 years or later, maternal asthma, low gestational age, and low ponderal index were associated with an increased risk, and a high number of previous deliveries was associated with a decreased risk of asthma. In conclusion, perinatal factors play a role in the development of asthma in childhood, but the etiology may differ in early and late-onset asthma.

Do psychological attributes matter for adherence to antihypertensive medication? The Finnish Public Sector Cohort Study.

OBJECTIVE: Psychological factors may be important determinants of adherence to antihypertensive medication, as they have been repeatedly found to be associated with an increased risk of hypertension, coronary heart disease, and health-damaging behaviours. We examined the importance of several psychological attributes (sense of coherence, optimism, pessimism, hostility, anxiety) with regard to antihypertensive medication adherence assessed by pharmacy refill records. METHODS: A total of 1021 hypertensive participants, aged 26-63 years, who were employees in eight towns and 12 hospitals in Finland were included in the analyses. RESULTS: We found 60% of patients to be totally adherent, 36% partially adherent, and 4% totally nonadherent. Multinomial regression analyses revealed high sense of coherence to be associated with lower odds of being totally nonadherent in contrast of being totally adherent (odds ratio=0.55; 95% confidence interval: 0.31-0.96). This association was independent of factors that influenced adherence to antihypertensive medication, such as sociodemographic characteristics, health-related behaviours, self-reported medical history of doctor-diagnosed comorbidity, and anteriority of hypertension status. The association was not specific to certain types of antihypertensive drugs. CONCLUSION: High sense of coherence may influence antihypertensive medication-adherence behaviour. Aspects characterizing this psychological attribute, such as knowledge (comprehensibility), capacity (manageability), and motivation (meaningfulness) may be important determinants of adherence behaviour for asymptomatic illnesses, such as hypertension, in which patients often do not feel or perceive the immediate consequences of skipping medication doses.

Frequency and clinical relevance of drug interactions with lovastatin and simvastatin: an observational database study.

BACKGROUND: Concomitantly used cytochrome P450 (CYP) 3A4 inhibitors and inducers have been shown to alter the plasma concentrations of the HMG-CoA reductase inhibitors ('statins') lovastatin and simvastatin. Myopathy is a serious adverse effect of statins. Concurrent use of statins with fibrates in particular seems to increase the risk of this adverse effect. OBJECTIVE: To evaluate the incidence and clinical consequences of the use of lovastatin or simvastatin with concomitant CYP3A4 inhibitors and inducers, and with fibrates. METHODS: An observational database study of hospitalized patients treated in Turku University Hospital, Turku, Finland, covering the period 1 July 1996 to 30 June 2003, and of nationwide community data from the Finnish Prescription Register over the period 1 April to 30 June 2001 was conducted. In the hospital setting, the study population comprised 71 025 patients (93 467 treatment periods) over 7 years, with a total of 5320 treatment periods of lovastatin or simvastatin. The community-based, nationwide survey included all reimbursed prescriptions of lovastatin and simvastatin (n = 91 656) in Finland during a 3-month period. The frequency of drug-drug interactions involving lovastatin or simvastatin was studied. The efficacy and safety of the various statin/concomitant drug combinations was estimated by evaluating patients' laboratory data. RESULTS: Concomitant use of lovastatin or simvastatin with interacting medication was detected in 13.3% (704) and 6.9% (6338) of patients in hospital and community settings, respectively. Co-administration of lovastatin or simvastatin with CYP3A4 inhibitors or inducers did not have a clinically significant effect on serum lipid values. Plasma creatine kinase (CK) activity was significantly higher in patients receiving a statin and a fibrate compared with a statin only (433 U/L vs 209 U/L, p = 0.053). Co-administration of a statin and a CYP3A4 inhibitor did not increase CK activity. CONCLUSION: Although the pharmacokinetic interactions between lovastatin or simvastatin and CYP3A4 inhibitors and inducers are substantial, their clinical relevance seems to be limited, at least with lower statin doses. However, combining statins with fibrates, especially gemfibrozil, clearly increases the potential for muscular toxicity.

Temporary employment and antidepressant medication: a register linkage study.

Evidence on the association between temporary employment and mental health is mixed. This study examined associations of temporary employment with register-based antidepressant medication by type and length of temporary job contract and socioeconomic position. Antidepressant prescriptions (1998-2002) were linked to register data for 17,071 men and 48,137 women in 10 Finnish municipalities. Repeated measures analyses over time were adjusted for age, socioeconomic position, and calendar year. After adjustments, temporary employment with a job contract more than 6 months was associated with odds ratio (OR) of 1.18 (95% confidence interval CI 1.03-1.37) for antidepressant use in men and 0.99 (0.93-1.06) in women. Among temporary employees with a job contract of 6 months or less the corresponding odds ratio was higher (OR 1.43, 95% CI 1.19-1.73 in men, OR 1.18, 95% CI 1.09-1.28 in women). Long-term unemployed who were in short-term government-subsidised temporary employment had the highest odds of antidepressant use (OR 1.57, 95% CI 1.23-2.02 in men, OR 1.38, 95% CI 1.20-1.59 in women). During the study period, increase in the prevalence of antidepressant medication was more rapid among women in government-subsidised temporary employment than among permanently employed women. Among men, the association between temporary employment and antidepressant use was stronger within lower grade occupations. The results suggest that using antidepressants is more pronounced when temporary employment is unstable.

Shift of statin use towards the elderly in 1995-2005: a nation-wide register study in Finland.

AIM: To describe nation-wide secular trends in statin use. METHODS: Reimbursed prescriptions for lipid lowering drugs between 1995 and 2005 in Finland were retrieved from the nation-wide Prescription Register. The 1 year prevalence and incidence of statin use stratified by gender and age of users were measured for each calendar year. The relative changes (RR) in the incidence and the prevalence were calculated by using the year 1995 as a reference. RESULTS: The 1 year prevalence increased 11-fold (95% confidence interval 11.2, 11.5), i.e. from 7.8 per 1000 inhabitants in 1995 to 88.9 in 2005. The incidence increased five-fold (95% CI 4.9, 5.1) from 355 per 100 000 inhabitants to 1772 during the respective years. The prevalence and incidence were the highest among persons aged 65-74 years. The largest relative increase in incidence was found among those aged >/= 75 years, in both females (RR 14.1, 95% CI 13.0, 15.3) and males (RR 14.0, 95% CI 12.5, 15.7). Since 2002 the prevalence has been higher among females (P < 0.05). CONCLUSIONS: As statin use has increased particularly among the elderly, further studies on the benefits in real life situation are needed in this age group.

Equity in the use of antithrombotic drugs, beta-blockers and statins among Finnish coronary patients.

BACKGROUND: Earlier studies have mainly reported the use of antithrombotic drugs, beta-blockers and statins among hospital patient populations or MI patients. This study aimed to describe the use of these drugs among middle-aged Finnish coronary patients and to identify patient groups in risk of being prescribed inadequate medication for secondary prevention of coronary heart disease. METHODS: One-year follow-up survey data from a random sample of a cohort of coronary patients were used along with register data linked to the survey. The response rate was 54% (n = 2650). The main outcome measures were use of antithrombotic drugs, beta-blockers and statins and the data were analysed using logistic regression analysis. RESULTS: Among men and women, respectively, 82% and 81% used beta-blockers, 95% and 89% used antithrombotic drugs, and 62% and 59% used statins. Younger men and men from higher socioeconomic groups were more likely to use statins, even after controlling for disease severity and comorbidity. In women, the age trend was reversed and no socioeconomic differences were found. Drug use increased with increased disease severity, but diabetes had only a slight effect. CONCLUSION: The use of antithrombotic drugs and beta-blockers among Finnish coronary patients seemed to be rather appropriate and, to some extent, prescription practices of preventive medication varied according to patients' risk of coronary events. However, statin use was remarkably low among men with low socio-economic status, and there is need to improve preventive drug treatment among diabetic coronary patients.

Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort.

BACKGROUND: It is unknown if antidepressant treatment is associated with either increased or decreased risk of suicide. OBJECTIVE: To estimate the risk of suicide, attempted suicide, and overall mortality during antidepressant treatments in a real-life setting with high statistical power. DESIGN AND SETTING: A cohort study in which all subjects without psychosis, hospitalized because of a suicide attempt from January 1, 1997, to December 31, 2003, in Finland, were followed up through a nationwide computerized database. PARTICIPANTS: A total of 15 390 patients with a mean follow-up of 3.4 years. MAIN OUTCOME MEASURES: The propensity score-adjusted relative risks (RRs) during monotherapy with the most frequently used antidepressants compared with no antidepressant treatment. RESULTS: In the entire cohort, fluoxetine use was associated with the lowest risk (RR, 0.52; 95% confidence interval [CI], 0.30-0.93), and venlafaxine hydrochloride use with the highest risk (RR, 1.61; 95% CI, 1.01-2.57), of suicide. A substantially lower mortality was observed during selective serotonin reuptake inhibitor use (RR, 0.59; 95% CI, 0.49-0.71; P<.001), and this was attributable to a decrease in cardiovascular- and cerebrovascular-related deaths (RR, 0.42; 95% CI, 0.24-0.71; P=.001). Among subjects who had ever used any antidepressant, the current use of medication was associated with a markedly increased risk of attempted suicide (39%, P<.001), but also with a markedly decreased risk of completed suicide (-32%, P=.002) and mortality (-49%, P<.001), when compared with no current use of medication. The results for subjects aged 10 to 19 years were basically the same as those in the total population, except for an increased risk of death with paroxetine hydrochloride use (RR, 5.44; 95% CI, 2.15-13.70; P<.001). CONCLUSIONS: Among suicidal subjects who had ever used antidepressants, the current use of any antidepressant was associated with a markedly increased risk of attempted suicide and, at the same time, with a markedly decreased risk of completed suicide and death. Lower mortality was attributable to a decrease in cardiovascular- and cerebrovascular-related deaths during selective serotonin reuptake inhibitor use.

Organisational downsizing and increased use of psychotropic drugs among employees who remain in employment.

OBJECTIVE: Organisational downsizing is common in modern work life, but its effect on employees' mental health is not known. The authors examined whether working in downsizing organisations predicts use of psychotropic drugs among employees who remain in employment. DESIGN, SETTING AND PARTICIPANTS: Prospective cohort study of municipal employees in Finland. 4783 employees worked in downsized units but kept their jobs after downsizing in 1993, 4271 employees lost their jobs during the downsizing, and 17 599 employees did not experience downsizing. The outcome was psychotropic drug prescriptions (antidepressants, anxiolytics and hypnotics) during 1994-2000 extracted from nationwide registers and linked to the data by means of each participant's personal identification number. MAIN RESULTS: After adjustment for predownsizing characteristics, employees who were exposed to downsizing but kept their jobs were at a higher risk of being prescribed psychotropic drugs (rate ratio 1.49, 95% CI 1.10 to 2.02 in men and 1.12, 95% CI 1.00 to 1.27 in women) than those not exposed to downsizing. The association of downsizing was strongest with hypnotics among the men and with anxiolytics among the women. An increased rate of psychotropic prescriptions after downsizing was also seen in male workers who lost their job (rate ratio 1.64, 95% CI 1.19 to 2.25). CONCLUSIONS: The association between organisational downsizing and increased use of psychotropic drugs suggests that this managerial strategy may pose mental health risks among employees.

Allocation of rehabilitation measures provided by the Social Insurance Institution in Finland: a register linkage study.

OBJECTIVE: To study the allocation of rehabilitation measures provided by the Finnish Social Insurance Institution in relation to the characteristics and health status of rehabilitants. DESIGN: A register linkage study. SUBJECTS: A total of 67,106 full-time local government employees with a minimum of 10-month job contracts in 10 Finnish towns during the period 1994-2002. METHODS: Data on the rehabilitation granted between 1994 and 2002, special medication reimbursements for chronic diseases, and disability retirement, were derived from the registers of the Social Insurance Institution as an indicator of chronic morbidity and linked to the employers' records on demographic characteristics and rates of sickness absence. RESULTS: In comparison with non-rehabilitants, the rate of sickness absence (> 21 days) was 2.2-2.9-fold (95% confidence interval (CI) 2.0-3.0) higher, the odds ratios of special medication reimbursement 1.5-6.1-fold (95% CI 1.3-6.9) higher and disability retirement 3.1-7.5-fold (95% CI 2.7-9.3) higher among rehabilitants. Older women and employees in manual or lower-grade non-manual jobs predominated in the rehabilitation groups. The proportion of temporary employees receiving rehabilitation was low. CONCLUSION: Permanently employed older women with an excess burden of health problems predominate in the receipt of rehabilitation provided by the Social Insurance Institution.

Cost-effectiveness analysis of guidelines for antihypertensive care in Finland.

BACKGROUND: Hypertension is one of the major causes of disease burden affecting the Finnish population. Over the last decade, evidence-based care has emerged to complement other approaches to antihypertensive care, often without health economic assessment of its costs and effects. This study looks at the extent to which changes proposed by the 2002 Finnish evidence-based Current Care Guidelines concerning the prevention, diagnosis, and treatment of hypertension (the ACCG scenario) can be considered cost-effective when compared to modelled prior clinical practice (the PCP scenario). METHODS: A decision analytic model compares the ACCG and PCP scenarios using information synthesised from a set of national registers covering prescription drug reimbursements, morbidity, and mortality with data from two national surveys concerning health and functional capacity. Statistical methods are used to estimate model parameters from Finnish data. We model the potential impact of the different treatment strategies under the ACCG and PCP scenarios, such as lifestyle counselling and drug therapy, for subgroups stratified by age, gender, and blood pressure. The model provides estimates of the differences in major health-related outcomes in the form of life-years and costs as calculated from a 'public health care system' perspective. Cost-effectiveness analysis results are presented for subgroups and for the target population as a whole. RESULTS: The impact of the use of the ACCG scenario in subgroups (aged 40-80) without concomitant cardiovascular and related diseases is mainly positive. Generally, costs and life-years decrease in unison in the lowest blood pressure group, while in the highest blood pressure group costs and life-years increase together and in the other groups the ACCG scenario is less expensive and produces more life-years. When the costs and effects for subgroups are combined using standard decision analytic aggregation methods, the ACCG scenario is cost-saving and more effective. CONCLUSION: The ACCG scenario is likely to reduce costs and increase life-years compared to the PCP scenario in many subgroups. If the estimated trade-offs between the subgroups in terms of outcomes and costs are acceptable to decision-makers, then widespread implementation of the ACCG scenario is expected to reduce overall costs and be accompanied by positive outcomes overall.