Short-term impact of co-payment level increase on the use of medication and patient-reported outcomes in Finnish patients with type 2 diabetes

A new reimbursement scheme for non-insulin medications used for treatment of hyperglycemia in type 2 diabetes (T2D) was implemented in Finland on January 1, 2017. The aim of the study was to evaluate the impact of this co-payment increase (i.e. + 35 percentage points) on patient-reported satisfaction for diabetes care, diabetes medication use, and financial difficulties. Baseline data were collected in 114 pharmacies, where patients with T2D were asked to fill in a questionnaire in November 2016. Follow-ups were conducted at 6 and 12 months. In total, 955 participants with T2D attended the baseline examination. During the follow-up, satisfaction with diabetes care decreased significantly (p <0.001). Use of insulin increased (OR 1.16, 95 % CI 1.06-1.27) whereas use of metformin and DPP-4 inhibitors decreased (metformin: OR 0.80,95 % CI 0.70-0.90; DPP-4 inhibitors: OR 0.82, 95 % CI 0.73-0.93). Financial difficulties with the purchase of diabetes medications were reported more often both at 6 (OR 2.44,95 % CI 1.96-3.03) and at 12 months (OR 2.70, 95 % CI 2.18-3.35) than at baseline. These negative short-term effects require future studies. If persistent, the long-term effects of lower treatment satisfaction and increased financial difficulties may imply impaired metabolic control and increased diabetes complication risk and health care costs. Patient perspective should be taken into account in future policy making. (C) 2020 The Author(s). Published by Elsevier B.V.Peer reviewe

Socioeconomic Inequalities in Statin Adherence Under Universal Coverage: Does Sex Matter?

BACKGROUND: Previous research shows that low socioeconomic position (SEP; especially low income) is associated with statin nonadherence. We investigated the relationship between SEP and statin adherence in a country with universal coverage using group-based trajectory modeling in addition to the proportion of days covered. METHODS AND RESULTS: Using data from Finnish healthcare registers, we identified 116 846 individuals, aged 45 to 75 years, who initiated statin therapy for primary prevention of cardiovascular disease. We measured adherence as proportion of days covered over an 18-month period since initiation and identified different adherence patterns based on monthly adherence with group-based trajectory modeling. When adjusted for age, marital status, residential area, clinical characteristics, and copayment, low SEP was associated with statin nonadherence (proportion of days covered <80%) among men (eg, lowest versus highest income quintile: odds ratio, 1.41; 95% confidence interval, 1.32-1.50; basic versus higher-degree education: odds ratio, 1.18; 95% confidence interval, 1.13-1.24; unemployment versus employment: odds ratio, 1.17; 95% confidence interval, 1.10-1.25). Among women, the corresponding associations were different (P<0.001 for sex-by-income quintile, sex-by-education level, and sex-by-labor market status interactions) and mainly nonsignificant. Results based on adherence trajectories showed that men in low SEP were likely to belong to trajectories presenting a fast decline in adherence. CONCLUSIONS: Low SEP was associated with overall and rapidly increasing statin nonadherence among men. Conversely, in women, associations between SEP and nonadherence were weak and inconsistent. Group-based trajectory modeling provided insight into the dynamics of statin adherence and its association with SEP

Suomalaisväestön maksuhalukkuus terveyteen liittyvästä elämänlaadusta

Kustannusvaikuttavuusanalyysit tuottavat tietoa interventioiden kustannusvaikuttavuudesta, mitä hyödynnetään päätettäessä resurssien allokoinnista terveydenhuollossa. Koska terveydenhuollon päätöksenteko vaikuttaa koko väestöön sekä veronmaksajina että mahdollisina potilaina, tulisi päätöksenteossa huomioida myös väestön preferenssejä eli arvotuksia. Väestön arvotuksia terveyttä kohtaan tutkitaan maksuhalukkuusmenetelmillä pyrkimyksenä määrittää rahallinen arvo esimerkiksi yhdelle terveyteen liittyvälle laatupainotetulle elinvuodelle (QALY). Uusien hoitojen lisätessä usein elämänlaatua pituuden sijaan olisi tärkeää tietää väestön arvotus tätä parannusta kohtaan. Tässä tutkimuksessa selvitettiin suomalaisväestön maksuhalukkuutta terveyteen liittyvän elämänlaadun paranemisesta, maksuhalukkuuteen yhteydessä olevia tekijöitä ja kyselytavan yhteyttä vastauksiin. Suomalaisten maksuhalukkuutta terveyteen liittyvästä elämänlaadusta ei ole tutkittu aiemmin. Aineistona käytettiin Lääkealan turvallisuus- ja kehittämiskeskus Fimean Lääkebarometri 2015 -väestökyselyä, joka toteutettiin postikyselynä (n=3190) ja internet-paneelikyselynä (n=2235). Maksuhalukkuutta tutkittiin tarjoamalla vastaajille satunnaisesti neljästä mahdollisesta summasta yksi, jonka he pystyivät valitsemaan tai hylkäämään, elämisestä vuoden täydessä terveydentilassa. Aineisto analysoitiin SPSS- ja STATA-ohjelmilla. Vastaajien keskimääräinen maksuhalukkuus QALYsta oli noin 13000 euroa, mikä on samaa tasoa kuin aikaisemmissa eurooppalaisissa tutkimuksissa. Korkeampiin tuloluokkiin kuuluvat, miehet, iäkkäämmät ja huonomman elämänlaadun omaavat hyväksyivät todennäköisemmin tarjotun summan. Myös työmarkkinastatus sekä tarjottu summa olivat yhteydessä maksuhalukkuuteen, mutta eivät pitkäaikaissairaudet tai koulutustaso. Internet-paneelivastaajat hyväksyivät postivastaajia todennäköisemmin tarjotun summan, mutta heidän keskimääräinen maksuhalukkuutensa oli postikyselyyn vastanneita alempi. Havaittuihin tuloksiin vaikuttavat todennäköisesti Suomen verorahoitteinen terveydenhuoltojärjestelmä ja siitä johtuva ostokokemuksen puute

Health-related quality of life in relation to shark symptomatic and radiographic definitions of knee osteoarthritis : data from Osteoarthritis Initiative (OAI) 4-year follow- up study

Background: The purpose was to quantify the decrement in health utility (referred as disutility) associated with knee osteoarthritis (OA) and different symptomatic and radiographic uni- and bilateral definitions of knee OA in a repeated measures design of persons with knee OA or at increased risk of developing knee OA. Methods: Data were obtained from the Osteoarthritis Initiative database. SF-12 health-related quality of life was converted into SF-6D utilities, and were then handled as the health utility loss by subtracting 1.000 from the utility score, yielding a negative value (disutility). Symptomatic OA was defined by radiographic findings (Kellgren-Lawrence, K-L, grade >= 2) and frequent knee pain in the same knee. Radiographic OA was defined by five different definitions (K-L >= 2 unilaterally / bilaterally, or the highest / mean / combination of K-L grades of both knees). Repeated measures generalized estimating equation (GEE) models were used to investigate disutility in relation to these different definitions. Results: Utility decreased with worsening of symptomatic or radiographic status of knee OA. The participants with bilateral and unilateral symptomatic knee OA had 0.03 (p <0.001) and 0.02 (p <0.001) points lower utility scores, respectively, compared with the reference group. The radiographic K-L grade 4 defined as the mean or the highest grade of both knees was related to a decrease of 0.04 (p <0.001) and 0.03 (p <0.001) points in utility scores, respectively, compared to the reference group. Conclusions: Knee OA is associated with diminished health-related quality of life. Health utility can be quantified in relation to both symptomatic and radiographic uni- and bilateral definitions of knee OA, and these definitions are associated with differing disutilities. The performance of symptomatic definition was better, indicating that pain experience is an important factor in knee OA related quality of life.Peer reviewe

Impact of type 2 diabetes treated with non-insulin medication and number of diabetes-coexisting diseases on EQ-5D-5L index scores in the Finnish population

Background: Type 2 diabetes (T2D) causes significant health and economic burden. In addition to comorbidities there are also coexisting diseases linked to obesity, lifestyle and T2D. The aim of this study was to examine the effect of T2D and T2D-coexisting diseases on health-related quality of life (HRQoL) in the Finnish population and whether it is T2D or the coexisting diseases that have the largest impact on HRQoL.Methods: The study was based on a national cross-sectional population survey (n=5305). Respondents' HRQoL was measured using the EQ-5D-5L instrument. Our study included diabetic respondents treated with non-insulin medications (NI-T2D) with or without insulin and non-diabetic respondents, whereas diabetic respondents not taking any anti-diabetic medications or treated with insulin alone were excluded. A crosswalk algorithm was used to convert EQ-5D-5L index scores into EQ-5D-3L index scores as a sensitivity analysis. A two-part model was used to examine the association between T2D and coexisting diseases and HRQoL.Results: The unadjusted mean (SD) EQ-5D-5L index scores for non-diabetics (n=4856) was 0.90 (0.13) and 0.85 (0.16) for respondents with NI-T2D (n=449). With adjustment for demographic factors, the difference in EQ-5D-5L index scores was 0.036 (95% CI 0.023-0.050). After adjusting for the number of coexisting diseases, the EQ-5D-5L index scores among respondents with NI-T2D and three or more coexisting diseases were lower when compared to all non-diabetics but not when compared to non-diabetics with similar number of coexisting diseases. The number of T2D-coexisting diseases had a larger effect on EQ-5D-5L index scores in younger age groups (20 and 40years old).Conclusions: Lower EQ-5D-5L index score is associated with NI-T2D when compared to non-diabetic respondents. When compared to non-diabetics, the disutility associated with NI-T2D increases as more coexisting diseases appear. The disutility effect of coexisting diseases was equally large in non-diabetics and respondents with NI-T2D. Thus, public health interventions targeting the prevention of both T2D and its coexisting diseases have potential to have significant benefits also in terms of HRQoL.</p

Physicians' views on patient participation in choice of oral anticoagulants in atrial fibrillation-a qualitative study

Direct oral anticoagulants provide an alternative to vitamin K antagonists for the anticoagulation therapy in atrial fibrillation (AF). The availability of several treatment options with different attributes makes shared decision-making appropriate for the choice of anticoagulation therapy. The aim of this study was to understand how physicians choose an oral anticoagulant (OAC) for patients with AF and how physicians view patients' participation in this decision. Semi-structured interviews with 17 Finnish physicians (eight general practitioners and nine specialists) working in the public sector were conducted. An interview guide on experience, prescribing and opinions about oral anticoagulants was developed based on previous literature. The data were thematically analysed using deductive and inductive approaches. Based on the interviews, patient's opinion was the most influential factor in decision-making when there were no clinical factors limiting the choice between OACs. Of patient's preferences, the most important was the attitude towards co-payments of OACs. Patients' opinions on monitoring of treatment, dosing and antidote availability were also mentioned by the interviewees. The choice of an OAC in AF was patient-centred as all interviewees expressed that patient's opinion affects the choice.Peer reviewe

Eight-year trajectories of changes in health-related quality of life in knee osteoarthritis : Data from the Osteoarthritis Initiative (OAI)

Background Knee osteoarthritis (OA) worsens health-related quality of life (HRQoL) but the symptom pathway varies from person to person. We aimed to identify groups of people with knee OA or at its increased risk whose HRQoL changed similarly. Our secondary aim was to evaluate if patient-related characteristics, incidence of knee replacement (KR) and prevalence of pain medication use differed between the identified HRQoL trajectory groups. Methods Eight-year follow-up data of 3053 persons with mild knee OA or at increased risk were obtained from the public Osteoarthritis Initiative (OAI) database. Group-based trajectory modeling was used to identify patterns of experiencing a decrease of >= 10 points (Minimal Important Change, MIC) in the Quality of Life subscale of the Knee injury and Osteoarthritis Outcome Score compared to baseline. Multinomial logistic regression, Cox regression and generalized estimating equation models were used to study secondary aims. Results Four HRQoL trajectory groups were identified. Persons in the 'no change' group (62.9%) experienced no worsening in HRQoL. 'Rapidly' (9.5%) and 'slowly' worsening (17.1%) groups displayed an increasing probability of experiencing the MIC in HRQoL. The fourth group (10.4%) had 'improving' HRQoL. Female gender, higher body mass index, smoking, knee pain, and lower income at baseline were associated with belonging to the 'rapidly worsening' group. People in 'rapidly' (hazard ratio (HR) 6.2, 95% confidence interval (CI) 3.6-10.7) and 'slowly' worsening (HR 3.4, 95% CI 2.0-5.9) groups had an increased risk of requiring knee replacement. Pain medication was more rarely used in the 'no change' than in the other groups. Conclusions HRQoL worsening was associated with several risk factors; surgical and pharmacological interventions were more common in the poorer HRQoL trajectory groups indicating that HRQoL does reflect the need for OA treatment. These findings may have implications for targeting interventions to specific knee OA patient groups.Peer reviewe

Reinitiation and Subsequent Discontinuation of Antiplatelet Treatment in Nonpersistent Older Patients with Peripheral Arterial Disease

The successful treatment of peripheral arterial disease (PAD) depends on adequate adherence to medications including antiplatelet agents. The aims of this study were (a) to identify the proportion of nonpersistent patients who reinitiated antiplatelet therapy and how many of them discontinued therapy after reinitiation, and (b) to identify patient- and medication-related characteristics associated with the likelihood of reinitiation and discontinuation among reinitiators. The analysis of reinitiation was conducted on 3032 nonpersistent users of antiplatelet agents aged >= 65 years, with PAD newly diagnosed in 2012. Discontinuation (i.e., a treatment gap of >= 6 months without antiplatelet medication prescription) was analysed in 2006 reinitiating patients. To identify factors associated with the likelihood of reinitiation and discontinuation, Cox regression with time-dependent covariates was used. Reinitiation was recorded in 2006 (66.2%) of 3032 patients who had discontinued antiplatelet medication. Among these 2006 reinitiators, 1078 (53.7%) patients discontinued antiplatelet therapy again. Ischemic stroke and myocardial infarction during non-persistence and bronchial asthma/chronic obstructive pulmonary disease were associated with an increased likelihood of reinitiation. University education was associated with discontinuation among reinitiators. Factors associated with the probability of reinitiation and discontinuation in reinitiators make it possible to identify older PAD patients in whom "stop-starting" behaviour may be expected