Sosioekonomisen aseman yhteys muistisairauslääkkeiden käytön aloitukseen kotona-asuvilla 65 vuotta täyttäneillä: väestöpohjainen kohorttitutkimus

Varhaisella diagnoosilla ja lääkehoidolla pystytään hidastamaan muistisairauksien etenemistä ja parantamaan sairastuneiden toimintakykyä sekä elämänlaatua. Tämän tutkimuksen tavoitteena on selvittää, toteutuuko yhdenvertaisuus uuden muistisairauslääkkeen käytön aloituksessa sosioekonomisten ryhmien välillä. Tutkimuksen paneeliaineisto on 10 prosentin satunnaisotos vuonna 2000 65 vuotta täyttäneistä kotona asuvista suomalaisista (n=64 250), joita on seurattu vuosien 2000–2013 ajan. Tässä kansallisiin rekisteritietoihin perustuvassa kohorttitutkimuksessa tarkasteltiin ensiksi AKE-estäjien uusien käyttäjien (n=6 977) uuden muistisairauslääkkeen (memantiini) käytön aloitusta vuosien 2002–2013 aikana. Toisessa analyysissä tarkasteltiin osa-aineistossa sairaalahoitodiagnoosin saaneita muistisairauslääkkeiden uusia käyttäjiä (n=3 475) vuosien 2003–2013 aikana. Coxin suhteellisten riskitiheyksien mallin avulla tarkasteltiin sosioekonomisen aseman yhteyttä 1) memantiinin käytön aloitukseen AKE-estäjän käytön aloittaneilla, ja 2) muistisairauslääkkeen käytön aloitukseen ensimmäisestä kognitiivisiin oireisiin liittyvästä sairaalahoitodiagnoosista. AKE-estäjien käyttäjillä ylempi sosioekonominen asema lisäsi memantiinin käytön aloitusta (suhteellinen riskitiheys (hazard ratio (HR)) 1,43, 95% luottamusväli (LV) 1,23-1,68, p< 0,001). Sairaalahoitodiagnoosin saaneilla sosioekonominen asema ei ollut yhteydessä muistisairauslääkkeen käytön aloitukseen. Lääkehoidon innovaatioiden käyttöönottoon liittyy tämän tutkimuksen mukaan eriarvoisuutta sosioekonomisten ryhmien välillä. Tulevaisuudessa tulisi tutkia, mitkä taustalla olevat tekijät johtavat terveydenhuollon innovaatioihin liittyvään eriarvoisuuteen

Prevalence of potentially inappropriate medication use in older population : comparison of the Finnish Meds75+database with eight published criteria

BackgroundThere are several national and international criteria available for identifying potentially inappropriate medications (PIMs) for older people. The prevalence of PIM use may vary depending on the criteria used. The aim is to examine the prevalence of potentially inappropriate medication use in Finland according to the Meds75+ database, developed to support clinical decision-making in Finland, and to compare it with eight other PIM criteria.MethodsThis nationwide register study consisted of Finnish people aged 75 years or older (n = 497,663) who during 2017-2019 purchased at least one prescribed medicine considered as a PIM, based on any of the included criteria. The data on purchased prescription medicines was collected from the Prescription Centre of Finland.ResultsThe annual prevalence of 10.7-57.0% was observed for PIM use depending on which criteria was used. The highest prevalence was detected with the Beers and lowest with the Laroche criteria. According to the Meds75+ database, annually every third person had used PIMs. Regardless of the applied criteria, the prevalence of PIM use decreased during the follow-up. The differences in the prevalence of medicine classes of PIMs explain the variance of the overall prevalence between the criteria, but they identify the most commonly used PIMs quite similarly.ConclusionPIM use is common among older people in Finland according to the national Meds75+ database, but the prevalence is dependent on the applied criteria. The results indicate that different PIM criteria emphasize different medicine classes, and clinicians should consider this issue when applying PIM criteria in their daily practice.Peer reviewe

Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication

Background Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs). Methods The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants' healthcare service use costs and costs for the intervention were estimated for a 12 month period. Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates. Results The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs -euro1,629, confidence interval (CI) -euro5,489 to euro2,240; incremental effect -0.02, CI -0.06 to 0.02]. The base case ICER was >euro80,000/QALY. Conclusion The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.Peer reviewe

Cost-effectiveness of whole-exome sequencing in progressive neurological disorders of children

Objectives: To clarify the diagnostic utility and the cost-effectiveness of whole-exome sequencing (WES) as a routine early-diagnostic tool in children with progressive neurological disorders. Methods: Patients with infantile-onset severe neurological diseases or childhood-onset progressive neurological disorders were prospectively recruited to this WES study, in the pediatric neurology clinic at Helsinki University Hospital during 2016-2018. A total of 48 patients underwent a singleton WES. A control group of 49 children underwent traditional diagnostic examinations and were retrospectively collected from the hospital records. Their use of health care services, related to the diagnostic process, was gathered. Incremental cost-effectiveness ratio (ICER) per additional diagnosis was calculated from the health care provider perspective. Bootstrapping methods were used to estimate the uncertainty of cost-effectiveness outcomes. Results: WES provided a better diagnostic yield (38%) than diagnostic pathway that did not prioritize WES in early diagnosis (25%). WES outperformed other diagnostic paths especially when made early, within one year of first admission (44%). Cost-effectiveness in our results are conservative, affected by WES costs during 2016-18. Conclusions: WES is an efficient and cost-effective diagnostic tool that should be prioritized in early diagnostic path of children with progressive neurological disorders. The progressively decreasing price of the test improves cost-effectiveness further. (C) 2021 The Authors. Published by Elsevier Ltd on behalf of European Paediatric Neurology Society.Peer reviewe

Cost-effectiveness of whole-exome sequencing in progressive neurological disorders of children

ObjectivesTo clarify the diagnostic utility and the cost-effectiveness of whole-exome sequencing (WES) as a routine early-diagnostic tool in children with progressive neurological disorders.MethodsPatients with infantile-onset severe neurological diseases or childhood-onset progressive neurological disorders were prospectively recruited to this WES study, in the pediatric neurology clinic at Helsinki University Hospital during 2016–2018. A total of 48 patients underwent a singleton WES. A control group of 49 children underwent traditional diagnostic examinations and were retrospectively collected from the hospital records. Their use of health care services, related to the diagnostic process, was gathered. Incremental cost-effectiveness ratio (ICER) per additional diagnosis was calculated from the health care provider perspective. Bootstrapping methods were used to estimate the uncertainty of cost-effectiveness outcomes.ResultsWES provided a better diagnostic yield (38%) than diagnostic pathway that did not prioritize WES in early diagnosis (25%). WES outperformed other diagnostic paths especially when made early, within one year of first admission (44%). Cost-effectiveness in our results are conservative, affected by WES costs during 2016–18.ConclusionsWES is an efficient and cost-effective diagnostic tool that should be prioritized in early diagnostic path of children with progressive neurological disorders. The progressively decreasing price of the test improves cost-effectiveness further.</div

Effectiveness of clinical exome sequencing in adult patients with difficult-to-diagnose neurological disorders

Objectives Clinical diagnostics in adults with hereditary neurological diseases is complicated by clinical and genetic heterogeneity, as well as lifestyle effects. Here, we evaluate the effectiveness of exome sequencing and clinical costs in our difficult-to-diagnose adult patient cohort. Additionally, we expand the phenotypic and genetic spectrum of hereditary neurological disorders in Finland. Methods We performed clinical exome sequencing (CES) to 100 adult patients from Finland with neurological symptoms of suspected genetic cause. The patients were classified as myopathy (n = 57), peripheral neuropathy (n = 16), ataxia (n = 15), spastic paraplegia (n = 4), Parkinsonism (n = 3), and mixed (n = 5). In addition, we gathered the costs of prior diagnostic work-up to retrospectively assess the cost-effectiveness of CES as a first-line diagnostic tool. Results The overall diagnostic yield of CES was 27%. Pathogenic variants were found for 14 patients (in genes ANO5, CHCHD10, CLCN1, DES, DOK7, FKBP14, POLG, PYROXD1, SCN4A, TUBB3, and TTN) and likely pathogenic previously undescribed variants for 13 patients (in genes ABCD1, AFG3L2, ATL1, CACNA1A, COL6A1, DYSF, IRF2BPL, KCNA1, MT-ATP6, SAMD9L, SGCB, and TPM2). Age of onset below 40 years increased the probability of finding a genetic cause. Our cost evaluation of prior diagnostic work-up suggested that early CES would be cost-effective in this patient group, in which diagnostic costs increase linearly with prolonged investigations. Conclusions Based on our results, CES is a cost-effective, powerful first-line diagnostic tool in establishing the molecular diagnosis in adult neurological patients with variable symptoms. Importantly, CES can markedly shorten the diagnostic odysseys of about one third of patients.Peer reviewe

Attitudes towards genetic testing and information : does parenthood shape the views?

This study examines how parents of pediatric patients might differ in their views and attitudes towards genetic technology and information when compared to adult patients. There is surprisingly little evidence on how parents compare to other parts of population in their attitudes. Previous empirical studies often relate health-related preferences and attitudes to factors such as age, education, and income instead of parental status, thus evading comparison of parents to others as health-related decision makers. Findings related to the parental status can be useful when implementing genetic technology in clinical practice. We conducted a survey of views on genetic technology and information for groups of adult neurology patients (n = 68) and parents of pediatric neurology patients (n = 31) to shed some light on this issue. In addition to our own survey instrument, we conducted other surveys to gain insight on psychosocial factors that might affect these attitudes. The results suggest that parents are more concerned about their children's genetic risk factors when compared to the attitudes of adult patients about their own risk. For both groups, negative emotional state was associated with more concerns towards genetic information. Our study provides insights on how parental views might affect the acceptance of genetic technology and information.Peer reviewe

Effectiveness of clinical exome sequencing in adult patients with difficult-to-diagnose neurological disorders

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