Association of area-level education with the regional growth trajectories of rates of antibacterial dispensing to patients under 3 years in Norway: a longitudinal retrospective study

Objective To examine the association between area-level education and the local growth trajectories in antibacterial dispensing rates in Norwegian municipalities among children under 3 years old. Design Retrospective, longitudinal study using individual primary care prescription data from the Norwegian Prescription Database for the period 2006–2016. Data were collected on the date of dispensing, the type and amount of antibiotic, the patient’s age, sex and municipality of residence and linked to municipality-level statistics on education available from Statistics Norway. We used multilevel growth curve modelling, with a linear trend variable modelled as a random effect and a cross-level interaction between linear trends and the proportion of the population in the municipality having received a university or college education. Setting The local government level in Norway. The sample includes all municipalities over the study period. Outcome measure Number of dispensed antibacterial prescriptions per 100 children in individual primary care by municipality and year. Results We identified a significant negative linear trend in the square root of the dispensing rate for children under 3 years old during the period. This trend varied between municipalities. A negative cross-level interaction term between population education levels and random trends showed that municipalities with an average level of population education saw a reduction in their square root dispensing rates of −0.053 (95% CI −0.066 to −0.039) prescriptions per 100 children. Each additional percentage point in population education contributed a further −0.0034 (95% CI −0.006 to –0.001) reduction to the square root dispensing rate. Conclusions Municipalities in which a larger proportion of the local population have high educational achievements have been more successful in reducing antibacterial dispensing rates in children under 3 years old. Adopting area-level strategies and addressing local community disadvantages may help to optimise practices and prescribing patterns across local communities

Analgesic use in a Norwegian general population: Change over time and high-risk use - The Tromsø Study

Published version, also available at http://dx.doi.org/10.1186/s40360-015-0016-yBackground: Increased use of analgesics in the population is a cause for concern in terms of drug safety. There is a paucity of population-based studies monitoring the change in use over time of both non-prescription (OTC) analgesics and prescription (Rx) analgesics. Although much is known about the risks associated with analgesic use, we are lacking knowledge on high-risk use at a population level. The purpose of this study was to estimate the prevalence of non-prescription and prescription analgesic use, change over time and the prevalence in the presence of potential contraindications and drug interactions in a general population. Methods: A repeated cross-sectional study with data from participants (30–89 years) of the Tromsø Study in 2001–02 (Tromsø 5; N = 8039) and in 2007–08 (Tromsø 6; N = 12,981). Participants reported use of OTC and Rx analgesics and regular use of all drugs in the preceding four weeks. Change over the time period was analyzed with generalized estimating equations. The prevalence of regular analgesic use in persons with or without a clinically significant contraindication or drug interaction was determined in the Tromsø 6 population, and differences were tested with logistic regression. Results: Analgesic use increased from 54 to 60 % in women (OR = 1.24, 95 % CI 1.15–1.32) and from 29 to 37 % in men (OR = 1.39, 95 % CI 1.27–1.52) in the time period; the increase was due to sporadic use of OTC analgesics. There was substantial regular use of analgesics in several of the contraindication categories examined; the prevalence of non-steroidal anti-inflammatory drugs was more than eight per cent among persons with chronic kidney disease, gastrointestinal ulcers, or high primary cardiovascular risk. About four per cent of the study population demonstrated at least one potential drug interaction with an analgesic drug. Conclusions: The use of analgesics increased in the time period due to an increase in the use of OTC analgesics. Analgesic exposure in the presence of contraindications or drug interactions may put patients at risk. Public and prescriber awareness about clinically relevant contraindications and drug interactions with analgesics need to be increased

Does implementation of the European guidelines based on the SCORE model double the number of Norwegian adults who need cardiovascular drugs for primary prevention? The Tromsø study 2001

This is a pre-copy-editing, author-produced PDF of an article accepted for publication in European Heart Journal following peer review. The definitive publisher-authenticated version Hartz, I., Njølstad, I. & Eggen, A.E. (2005). Does implementation of the European guidelines based on the SCORE model double the number of Norwegian adults who need cardiovascular drugs for primary prevention? The Tromsø study 2001. European heart journal. 26(24), 2673 is available online at: dx.doi.org/10.1093/eurheartj/ehi556Aims To study the implications of European guidelines on the use of antihypertensives and/or lipidlowering drugs (LLDs) for primary prevention in a Norwegian population. Methods and results The Tromsø study is a population-based study in the municipality Tromsø, Norway (from 1974 to till now). This analysis includes 45–79-year-old participants in 2001 (n ¼ 6362, attendance rate 86%). From the age of 60 years in men and 70 years in women, almost all participants were defined as high-risk individuals according to the European guidelines, with established cardiovascular disease, diabetes, or a 10-year risk score of 5%. In the primary prevention subgroup of the 45–64-year-olds, recommended antihypertensive and/or LLD use would be higher in men only, 42% compared with 12% on current medication. Among the 65–79-year-olds, .90% would be eligible for antihypertensives and/or LLDs in both sexes when compared with current treatment rates of ,30%. In total, 40% of all participants aged 45–79 would be candidates for primary prevention, compared with 15% on current medication. Conclusion The implementation of the European guidelines could imply a doubling of the numbers of Norwegian adults on cardiovascular medication for primary prevention. Contributors to the increase would be more frequent drug use in men and elderly people, particularly for LLD use

The seventh survey of the Tromsø Study (Tromsø7) 2015–2016: study design, data collection, attendance, and prevalence of risk factors and disease in a multipurpose population-based health survey

Aims: The Tromsø Study is an ongoing population-based health study in Tromsø, Norway, initiated in 1974. The purpose of the seventh survey (Tromsø7) 2015–2016 was to advance the population risk factor surveillance and to collect new types of data. We present the study design, data collection, attendance, and prevalence of risk factors and disease. Methods: All inhabitants in Tromsø municipality, Norway, aged 40 years and older (N=32,591) were invited to a health screening including extensive questionnaires, face-to-face interviews, biological sampling (blood, urine, saliva, nasal/throat swabs, faeces), measurements (anthropometry, blood pressure, pulse, pulse oximetry) and clinical examinations (pain sensitivity, echocardiography, cognitive, physical, and lung function, accelerometer measurements, eye examinations, carotid ultrasound, electrocardiography, dual-energy X-ray absorptiometry, and heart, lung and carotid auscultation). New research areas in this round were dental and oral health examinations, collection of faecal samples for studies of normal bacterial flora and antibiotic resistance, and 24-hour urine samples for examination of sodium and iodine intakes. Results: Attendance was 65% (N=21,083), and was higher in women, age group 50–79 years, previous attenders, and Norwegian-born individuals. Cardiovascular risk factor levels and prevalence of chronic obstructive lung disease decreased since the last survey, while the prevalence of obesity and diabetes increased. Conclusions: Attendance was stable from the sixth survey. Interaction with participants might be key to maintain participation. Favourable trends in risk factors continue, except for a continued increase in obesity. Both new data collection technology and traditional physical examinations will be crucial for the impact of future population studies

Comparing the sociodemographic characteristics of participants and non-participants in the population-based Tromsø Study

Background Diferences in the sociodemographic characteristics of participants and non-participants in populationbased studies may introduce bias and reduce the generalizability of research fndings. This study aimed to compare the sociodemographic characteristics of participants and non-participants of the seventh survey of the Tromsø Study (Tromsø7, 2015–16), a population-based health survey. Methods A total of 32,591 individuals were invited to Tromsø7. We compared the sociodemographic character‑ istics of participants and non-participants by linking the Tromsø7 invitation fle to Statistics Norway, and explored the association between these characteristics and participation using logistic regression. Furthermore, we created a geographical socioeconomic status (area SES) index (low-SES, medium-SES, and high-SES area) based on individual educational level, individual income, total household income, and residential ownership status. We then mapped the relationship between area SES and participation in Tromsø7. Results Men, people aged 40–49 and 80–89 years, those who were unmarried, widowed, separated/divorced, born outside of Norway, had lower education, had lower income, were residential renters, and lived in a low-SES area had a lower probability of participation in Tromsø7. Conclusions Sociodemographic diferences in participation must be considered to avoid biased estimates in research based on population-based studies, especially when the relationship between SES and health is being explored. Particular attention should be paid to the recruitment of groups with lower SES to population-based studies

Whom are we treating with lipid-lowering drugs? Are we following the guidelines? Evidence from a population-based study: the Tromsø study 2001

The original publication is available at: http://dx.doi.org/10.1007/s00228-004-0827-zAbstract Objective: The beneficial effect of lipid-lowering drugs (LLDs) is well documented. Despite increasing sales of LLDs, little is known about what characterizes LLD users. Our objective was to describe LLD users in a general population according to socio-demographic factors, cardiovascular risk factors and coronary heart disease (CHD), and to study the achievement of cholesterol treatment goals according to national guidelines. Methods: The Tromsø study is a population-based study of chronic diseases, risk factors and drug use in the municipality Tromsø, in north Norway. The fifth survey was conducted in 2001 and included 7,973 men and women (attendance rate 78.1%). Self-reported use of LLDs and/or proprietary LLDs was included as LLD use in the analysis. Results: LLD use was reported in 9.6% of all women and 14.0% of all men, of whom 36.5% achieved the nationally recommended lipid goal. Among individuals with CHD, 49.9% of all women and 55.4% of all men were LLD users. The individuals with a risk condition (hypertension and/or diabetes) and total cholesterol level above the target of 5.0 mmol/l and the healthy individuals with total cholesterol level ‡8.0 mmol/l constituted 47.2% of the study population without CHD. In this group, which was eligible for primary prevention, 8.0% of the women and 7.4% of the men reported LLD use. Conclusions: Only half of all subjects with CHD were taking a LLD. The large discrepancy between national recommendations and actual LLD use in primary prevention should be addressed in future revisions of the guidelines

Why do sales of lipid-lowering drugs vary between counties in Norway? Evidence from the OPPHED Health Study 2000 /2001

The original publication is available at: http://dx.doi.org/10.1080/02813430500475365Objective. To study and compare plausible factors that might explain varying sales of lipid-lowering drugs (LLDs) in the two neighbouring counties of Hedmark and Oppland in Norway, with a similar age distribution, socioeconomic structure, and access to healthcare services. Design, setting, subjects. Cross-sectional population study comprising 10 598 attendants aged 40, 45, 60, and 75 years in the OPPHED Health Study, 2000 /2001 (attendance rate 61%). Main outcome measure. Treatment eligibility (cardiovascular morbidity and risk score), treatment frequency in treatment-eligible subgroups and treatment intensity in terms of achievement of total cholesterol (TC) goal. Results. Proportions eligible for LLD treatment in Hedmark and Oppland were similar. There was no difference in prevalence of LLD use among participants with cardiovascular disease or diabetes (secondary prevention subgroup). However, LLD use among men in the primary prevention subgroup was higher in Hedmark compared with Oppland, 6.3% and 4.1%, respectively (pB/0.05). The same tendency was seen among women. In both sexes, more LLD users in the primary prevention subgroup achieved the TC goal in Hedmark compared with Oppland (pB/0.05). Conclusion and implications. The proportion of the population eligible for LLD treatment in the two counties should imply similar treatment rates in both. Higher LLD treatment frequency and intensity in the primary prevention subgroup in Hedmark are probably both contributing factors that explain the higher sales of LLDs in Hedmark compared with Oppland. Feasible intervention thresholds for primary prevention with concurrent reimbursement rules should be defined in guidelines to avoid unintentional variation in LLD use in the future

Self-reported medication use among coronary heart disease patients showed high validity compared with dispensing data

Objective - To validate self-reported use of medications for secondary prevention of coronary heart disease (CHD) in a population-based health study by comparing self-report with pharmacy dispensing data, and explore different methods for defining medication use in prescription databases. Study design and setting - Self-reported medication use among participants with CHD (n = 1483) from the seventh wave of the Tromsø Study was linked with the Norwegian Prescription Database (NorPD). Cohen’s kappa, sensitivity, specificity, and positive and negative predictive values were calculated, using NorPD as the reference standard. Medication use in NorPD was defined in three ways; fixed-time window of 180 days, and legend-time method assuming a daily dose of one dosage unit or one defined daily dose (DDD). Results - Kappa-values for antihypertensive drugs, lipid-lowering drugs and acetylsalicylic acid all showed substantial agreement (kappa ≥0.61). Validity varied depending on the method used for defining medication use in NorPD. Applying a fixed-time window gave higher agreement, positive predictive values and specificity compared with the legend-time methods. Conclusion - Self-reported use of medication for secondary prevention of CHD shows high validity when compared with pharmacy dispensing data. For CHD medications, fixed-time window appears to be the most appropriate method for defining medication use in prescription databases

Undiagnosed diabetes based on HbA 1c by socioeconomic status and healthcare consumption in the Tromsø Study 1994-2016

Introduction - We aimed to investigate whether the proportion of undiagnosed diabetes varies by socioeconomic status and healthcare consumption, in a Norwegian population screened with glycated hemoglobin (HbA1c). Research - design and methods In this cohort study, we studied age-standardized diabetes prevalence using data from men and women aged 40–89 years participating in four surveys of the Tromsø Study with available data on HbA1c and self-reported diabetes: 1994–1995 (n=6720), 2001 (n=5831), 2007–2008 (n=11 987), and 2015–2016 (n=20 170). We defined undiagnosed diabetes as HbA1c ≥6.5% (48 mmol/mol) and no self-reported diabetes. We studied the association of education, income and contact with a general practitioner on undiagnosed diabetes and estimated adjusted prevalence ratio (aPR) from multivariable adjusted (age, sex, body mass index) log-binomial regression. Results - Higher education was associated with lower prevalence of diagnosed and undiagnosed diabetes. Those with secondary and tertiary education had lower prevalence of undiagnosed diabetes (aPR for tertiary vs primary: 0.54, 95% CI: 0.44 to 0.66). Undiagnosed as a proportion of all diabetes was also significantly lower in those with tertiary education (aPR:0.78, 95% CI: 0.65 to 0.93). Household income was also negatively associated with prevalence of undiagnosed diabetes. Across the surveys, approximately 80% of those with undiagnosed diabetes had been in contact with a general practitioner the last year, similar to those without diabetes. Conclusions - Undiagnosed diabetes was lower among participants with higher education. The hypothesis that those with undiagnosed diabetes had been less in contact with a general practitioner was not supported

Is the ongoing obesity epidemic partly explained by concurrent decline in cigarette smoking? Insights from a longitudinal population study. The Tromsø Study 1994–2016

The increase of obesity coincides with a substantial decrease in cigarette smoking. We assessed post-cessation weight change and its contribution to the obesity epidemic in a general population in Norway. A total of 14,453 participants (52.6% women), aged 25–54 years in 1994, who attended at least two of four surveys in the Tromsø Study between 1994 and 2016, were included in the analysis. Hereof 77% participated in both the first and the last survey. Temporal trends in mean body mass index (BMI), prevalence of obesity (BMI ≥ 30 kg/m2) and daily smoking were estimated with generalized estimation equations. We assessed BMI change by smoking status (ex-smoker, quitter, never smoker, daily smoker), and also under a scenario where none quit smoking. In total, the prevalence of daily smoking was reduced over the 21 years between Tromsø 4 (1994–1995) and Tromsø 7 (2015–2016) by 22 percentage points. Prevalence of obesity increased from 5 – 12% in 1994–1995 to 21–26% in 2015–2016, where obesity in the youngest (age 25–44 in 1994) increased more than in the oldest (p < 0.0001). Those who quit smoking had a larger BMI gain compared to the other three smoking subgroups over the 21 years (p < 0.0001). The scenario where none quit smoking would imply a 13% reduction in BMI gain in the population, though substantial age-related differences were noted. We conclude that smoking cessation contributed to the increase in obesity in the population, but was probably not the most important factor. Public health interventions should continue to target smoking cessation, and also target obesity prevention