Yksinasumisen ja tulojen yhteys statiinilääkemääräysten noudattamiseen

Lääkemääräysten noudattamattomuus on vakava kansanterveydellinen ongelma, joka lisää sairastumisen ja kuoleman riskiä. Vaikka pitkäaikainen statiinilääkemääräysten noudattaminen on avainasemassa sydän- ja verisuonisairauksien ennaltaehkäisyssä ja hoidossa, tutkimuksissa on havaittu noudattamisen heikentyvän ensimmäisen puolen vuoden aikana lääkityksen aloittamisesta. Tiedettyjä ennustavia tekijöitä heikolle lääkemääräysten noudattamiselle ovat korkea ikä, oheissairaudet, naimattomuus ja alempi sosioekonominen asema. Asumisjärjestelyiden yhteydestä lääkemääräysten noudattamiseen ja sydänkohtauksen jälkeisestä lääkemääräysten noudattamisesta tiedetään vähemmän. Tässä tutkielmassa tavoitteena on tutkia yksinasumisen yhteyttä statiinilääkemääräysten noudattamiseen sydänkohtauksen saaneilla ja kotitalouden moderoivaa vaikutusta. Tutkielmassa käytetään rekisteriaineistoa, joka koostuu 11 %:n otoksesta Suomen väestöstä ja 80 %:iin asti lisätyllä otoksella vuosina 1988 – 2007 kuolleista. Tutkimusotokseen sisällytettiin kaikki ensimmäisen sydänkohtauksen saaneet potilaat, joilla oli vähintään yksi statiiniosto. Potilaita seurattiin viisi vuotta mutta seuranta lopetettiin, jos potilas muutti maasta, siirtyi laitoshoitoon, sai uuden sydäninfarktin tai kuoli. Analysoinnissa käytettiin GEE-menetelmää (general estimating equations), joka on logistisen regression sovellus pitkittäisaineistolle. Kaikki analyysit tehtiin erikseen naisille ja miehille ja ikä ja lääkkeen ostovuosi vakioitiin malleissa. Lääkemääräysten noudattamattomuus yleistyi ensimmäisen neljän seurantavuoden aikana ja erityisesti ensimmäisen kolmen kuukauden jälkeen. Miehillä yksinasuminen (vetosuhde [OR]=1.24, 95%:n luottamusväli [CI] 1.14–1.36) ja alempiin tuloryhmiin kuuluminen (OR=1.28, 95% CI 1.14-1.42 alimmassa tulokvintiilissä) kasvattivat noudattamattomuuden todennäköisyyttä. Tulojen vakiointi heikensi yksinasumisen yhteyttä, mutta koulutuksen ja työmarkkina-aseman vakioinnilla ei ollut huomattavaa vaikutusta. Yksinasuminen ennusti miehillä lääkemääräysten noudattamattomuutta samalla tavalla kaikissa tuloryhmissä. Naisilla tilastollisesti merkitseviä yhteyksiä ei löytynyt. Johtopäätöksenä yksinasuvilla miehillä on suurempi riski lääkemääräysten noudattamattomuuteen sydänkohtauksen jälkeen verrattuna ei yksin asuviin miehiin. Puolison tuen puuttuminen ja yleisesti huonompi terveyskäyttäytyminen voivat olla selittäviä tekijöitä yhteyden taustalla. Terveydenhuollon työntekijöiden tulisi kiinnittää erityistä huomiota yksinasuvien miesten lääkemääräysten noudattamiseen. Hoitoon sitoutumisen parantamisella voidaan pelastaa henkiä ja säästää terveydenhuoltokuluissa.Non-adherence to drug therapy is a serious public health problem that increases the risk of disease and mortality. Despite long-term adherence to statins is a key element in preventing cardiovascular disease (CVD) and myocardial infarction (MI), previous studies have shown that the level of adherence drops already within the first six months of treatment. Risk factors for non-adherence are older age, comorbidities, being nonmarried and a lower socioeconomic position. Less is known about the role of living arrangements in non-adherence. The aim of this study is to provide new information on the association between living alone and non-adherence to statin drug therapy after MI, and analyze whether household income mediates or moderates the association. The analysis utilizes a register-based dataset consisting of an 11 % sample of the Finnish population with an 80 % oversample of people who died between 1988 and 2007. The study population included patients with first hospitalization for MI and at least one purchase of statins. Individuals are followed for five years after MI and censored at the time of emigration, moving to institutional care, a recurring MI or death. General estimating equations (GEE) method, an application of logistic regression for correlated data, is used to analyze the associations. All analyses are conducted separately for men and women and are adjusted for age and year of medicine purchase. Non-adherence to statin drug therapy increased over the first four years after MI, and a sharp increase occurred after the first three months of follow-up. Among men, the risk of non-adherence was higher for those living alone (odds ratio [OR] =1.24, 95% confidence interval [CI] 1.14–1.36) and those with lower incomes (OR=1.28, 95% CI 1.14-1.42 for lowest quintile). Adjustment for income somewhat attenuated the risk associated with living alone, while adjusting for education and labor market status had a negligible effect. Living alone predicted non-adherence similarly across all income groups among men. No statistically significant associations emerged among women. In conclusion, men living alone have a higher risk of being non-adherent compared to men living with others. Lack of spousal support and generally poorer health behaviors can be mechanisms behind the observed association. Health care professionals should pay special attention to men living alone to identify patients in high risk of non-adherence. By improving medication adherence, lives and unnecessary healthcare costs can be saved

Naisten tarinoita parisuhdeväkivallasta : aktiivinen toimijuus ja uhriutuminen narratiivisesta näkökulmasta tarkasteltuna

Only abstract. Paper copies of master’s theses are listed in the Helka database (http://www.helsinki.fi/helka). Electronic copies of master’s theses are either available as open access or only on thesis terminals in the Helsinki University Library.Vain tiivistelmä. Sidottujen gradujen saatavuuden voit tarkistaa Helka-tietokannasta (http://www.helsinki.fi/helka). Digitaaliset gradut voivat olla luettavissa avoimesti verkossa tai rajoitetusti kirjaston opinnäytekioskeilla.Endast sammandrag. Inbundna avhandlingar kan sökas i Helka-databasen (http://www.helsinki.fi/helka). Elektroniska kopior av avhandlingar finns antingen öppet på nätet eller endast tillgängliga i bibliotekets avhandlingsterminaler.Tutkimuksen tarkoituksena on analysoida naisten toimijuutta ja naisten uhriutumisen kokemuksia parisuhdeväkivallan kontekstissa. Tämän lisäksi analysoidaan naisten tarinoita parisuhdeväkivallasta. Tarinoiden analyysissa on tarkoitus selvittää, löytyykö tarinoista yhteisiä juonenkulkuja ja ovatko tarinat sijoitettavissa erilaisiin tarinatyyppeihin. Analyysi on tehty narratiivista näkökulmaa käyttäen. Tutkimuksen aineisto on osa Tasa-arvoasiain neuvottelukeskuksen syksyllä 1994 julistaman ”Väkivallasta vapaaksi” -kirjoituskilpailun sadosta. Tarinoissa naiset kirjoittavat kokemuksistaan väkivaltaisen puolison kanssa. Erilaisia narratiivisia sisällönanalyyttisiä menetelmiä yhdistelevän analyysin raportointi jakautuu kahteen osaan. Ensimmäisessä osassa tarkastellaan naisten kirjoittamia tarinoita kokonaisuudessaan ja luodaan niiden pohjalta kolme tyypillistä tarinaa. Toisessa paneudutaan siihen, miten kirjoittajat määrittelevät väkivallan, millaista heidän oma toimijuutensa on ja millaisista uhriutumisen kokemuksista naiset kirjoittavat. Tutkimani tarinat jakautuivat kolmeen erilaiseen tarinatyyppiin. Nimesin tarinat yhteisen tulevaisuuden tarinoiksi, on-off –tarinoiksi, jotka päättyvät eroon sekä erotarinoiksi. Kaikissa tarinoissa on samakaltaisia juonenkäänteitä, mutta tarinoita erottelee kuitenkin se, miten elämää jatketaan yhdessä tai millainen eroprosessi on. Naisten toimijuus ja uhriutuminen näyttäytyivät tutkimuksessani hyvin monimuotoisina. Toisaalta naiset hakivat aktiivisesti apua itselleen, puolisoilleen ja perheelleen. Toisaalta monet kuvasivat myös totaalisia uhriutumisen kokemuksia. Kokemuksia siitä, että mikään ei tunnu enää olevan omassa hallinnassa, koko minuus tuntuu hajoavan. Toimijuus ja uhriutuminen kietoutuivat monessa kohdassa myös tiukasti yhteen. Tarinoiden naiset kertoivat yhtälailla omasta aktiivisesta toimijuudestaan väkivallan kierteen katkaisemiksi sekä kokemuksistaan väkivallan uhreina, joista tuntuu, että mitään ei ole tehtävissä. Tärkeimpiä lähteitä narratiivisen tutkimuksen parista ovat Lielich ym. (1998), Hänninen (1999), Heikkinen (2001) sekä Hyvärinen (2006). Naistutkimuksen, toimijuuden ja uhriutumisen näkökulman tärkempiä lähteitä puolestaan ovat Ronkainen (1999a, 1999b) sekä Husso (2003)

Income differences in COVID-19 incidence and severity in Finland among people with foreign and native background : A population-based cohort study of individuals nested within households

Background Although intrahousehold transmission is a key source of Coronavirus Disease 2019 (COVID-19) infections, studies to date have not analysed socioeconomic risk factors on the household level or household clustering of severe COVID-19. We quantify household income differences and household clustering of COVID-19 incidence and severity. Methods and findings We used register-based cohort data with individual-level linkage across various administrative registers for the total Finnish population living in working-age private households (N = 4,315,342). Incident COVID-19 cases (N = 38,467) were identified from the National Infectious Diseases Register from 1 July 2020 to 22 February 2021. Severe cases (N = 625) were defined as having at least 3 consecutive days of inpatient care with a COVID-19 diagnosis and identified from the Care Register for Health Care between 1 July 2020 and 31 December 2020. We used 2-level logistic regression with individuals nested within households to estimate COVID-19 incidence and case severity among those infected. Adjusted for age, sex, and regional characteristics, the incidence of COVID-19 was higher (odds ratio [OR] 1.67, 95% CI 1.58 to 1.77, p < 0.001, 28.4% of infections) among individuals in the lowest household income quintile than among those in the highest quintile (18.9%). The difference attenuated (OR 1.23, 1.16 to 1.30, p < 0.001) when controlling for foreign background but not when controlling for other household-level risk factors. In fact, we found a clear income gradient in incidence only among people with foreign background but none among those with native background. The odds of severe illness among those infected were also higher in the lowest income quintile (OR 1.97, 1.52 to 2.56, p < 0.001, 28.0% versus 21.6% in the highest quintile), but this difference was fully attenuated (OR 1.08, 0.77 to 1.52, p = 0.64) when controlling for other individual-level risk factors—comorbidities, occupational status, and foreign background. Both incidence and severity were strongly clustered within households: Around 77% of the variation in incidence and 20% in severity were attributable to differences between households. The main limitation of our study was that the test uptake for COVID-19 may have differed between population subgroups. Conclusions Low household income appears to be a strong risk factor for both COVID-19 incidence and case severity, but the income differences are largely driven by having foreign background. The strong household clustering of incidence and severity highlights the importance of household context in the prevention and mitigation of COVID-19 outcomes.Peer reviewe

Income differences in COVID-19 incidence and severity in Finland among people with foreign and native background : A population-based cohort study of individuals nested within households

Background Although intrahousehold transmission is a key source of Coronavirus Disease 2019 (COVID-19) infections, studies to date have not analysed socioeconomic risk factors on the household level or household clustering of severe COVID-19. We quantify household income differences and household clustering of COVID-19 incidence and severity. Methods and findings We used register-based cohort data with individual-level linkage across various administrative registers for the total Finnish population living in working-age private households (N = 4,315,342). Incident COVID-19 cases (N = 38,467) were identified from the National Infectious Diseases Register from 1 July 2020 to 22 February 2021. Severe cases (N = 625) were defined as having at least 3 consecutive days of inpatient care with a COVID-19 diagnosis and identified from the Care Register for Health Care between 1 July 2020 and 31 December 2020. We used 2-level logistic regression with individuals nested within households to estimate COVID-19 incidence and case severity among those infected. Adjusted for age, sex, and regional characteristics, the incidence of COVID-19 was higher (odds ratio [OR] 1.67, 95% CI 1.58 to 1.77, p < 0.001, 28.4% of infections) among individuals in the lowest household income quintile than among those in the highest quintile (18.9%). The difference attenuated (OR 1.23, 1.16 to 1.30, p < 0.001) when controlling for foreign background but not when controlling for other household-level risk factors. In fact, we found a clear income gradient in incidence only among people with foreign background but none among those with native background. The odds of severe illness among those infected were also higher in the lowest income quintile (OR 1.97, 1.52 to 2.56, p < 0.001, 28.0% versus 21.6% in the highest quintile), but this difference was fully attenuated (OR 1.08, 0.77 to 1.52, p = 0.64) when controlling for other individual-level risk factors—comorbidities, occupational status, and foreign background. Both incidence and severity were strongly clustered within households: Around 77% of the variation in incidence and 20% in severity were attributable to differences between households. The main limitation of our study was that the test uptake for COVID-19 may have differed between population subgroups. Conclusions Low household income appears to be a strong risk factor for both COVID-19 incidence and case severity, but the income differences are largely driven by having foreign background. The strong household clustering of incidence and severity highlights the importance of household context in the prevention and mitigation of COVID-19 outcomes.Peer reviewe

Lääketietovarannon selvitys

Lääketietovarannolla tarkoitetaan keskitettyä kansallista tietovarantoa, joka sisältäisi keskeiset lääkevalmisteen tiedot. Lääkevalmisteen tiedot ovat mm. lääkevalmisteen perustietoja ja muita valmisteen tietoja kuten hinta- ja korvattavuus, farmakologiset ominaisuudet, valmisteyhteenvedot sekä erilaiset ilmoitukset ja tiedotteet. Lääketietovarannon hyödyt liittyvät laadukkaan ja käyttäjien tarpeita vastaavan tiedon parempaan saatavuuteen ja saavutettavuuteen. Nykytilassa lääkevalmisteen tieto on hajallaan tietovarannoissa, mikä vaikeuttaa tietojen hyödyntämistä eri käyttötarkoituksissa. Monen palvelun ja teknologisen ratkaisun tehokas käyttö on riippuvaista rakenteisen, standardimuotoisen, ajantasaisen, kattavan ja laadukkaan tiedon saatavuudesta. Myös puutteet tiedostojen formaatissa ja tiedon rakenteissa aiheuttavat ongelmia tiedon siirtymisessä eri organisaatioiden ja tietojärjestelmien välillä. Selvitysraportin ensimmäisessä osassa kuvataan lääkevalmisteen tiedonhallinnan ja jakamisen nykytila sekä siihen liittyvät ongelmat sekä keskeiset kansalliset ja kansainväliset hankkeet ja strategiat. Toisessa osassa muodostetaan kokonaiskuva siitä, miten nykytilaan liittyviä haasteita voitaisiin ratkaista kansallisen lääketietovarannon avulla. Kolmannessa osassa esitetään toimenpide-ehdotukset ja alustava toimenpiteiden kehittämispolku

Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS) : introduction and methodology

Funding Information: The Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS) project was conducted by the Clinical Urology and Epidemiology (CLUE) Working Group and supported by the Academy of Finland (309387, 340957), Sigrid Jusélius Foundation and Competitive Research Funding of the Helsinki University Hospital (TYH2019321; TYH2020248). The sponsors had no role in the analysis and interpretation of the data or the manuscript preparation, review, or approval. Funding Information: KMA received a research grant from Astra Zeneca, and is consultant for Gedeon Richter, and received reimbursement for attending a scientific meeting from GSK (Tesaro Bio). RMT received reimbursement for attending a scientific meeting from Olympus. LIL, GHG, YL, RC, ALL, VJS, IEJK, PJK, RJC, RLA, KA, KMA, IB-L, MHB, JLC, SC, PJG, HAG-P, FZG, HAG, LH, MLI-K, KMJ, PKK, NK, TPK, AJK, TK, HL, AKM, BTN, TPN, CN, SMO, SP, NP, CBBR, ARR, TS, RMT, RWMV, YW, YX, LY, JH, and KAOT have no financial conflicts of interest. GHG and RC were panel members of the European Association of Urology (EAU) ad hoc Guideline on Thromboprophylaxis in Urological Surgery. KAOT was chair of the European Association of Urology (EAU) ad hoc Guideline on Thromboprophylaxis in Urological Surgery and panel member of the American Society of Hematology (ASH) Guideline Panel on Prevention of Venous Thromboembolism (VTE) in Surgical Hospitalized Patients. Publisher Copyright: © 2021, The Author(s).Background Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries. Methods We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty. Discussion This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach. Systematic review registration PROSPERO CRD42021234119Peer reviewe

Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS): introduction and methodology

Background: Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries.Methods: We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty.Discussion: This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach.Systematic review registration: PROSPERO CRD42021234119</p

Systematic Reviews and Meta-Analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

Objective: To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery. Background: The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain. Methods: We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty. Results: After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer. Conclusions: VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding