Potential savings without compromising the quality of care

SUMMARY Aims: This study was designed to analyse the association between adherence to guidelines for rational drug use and surrogate outcome markers for hypertension, diabetes and hypercholesterolaemia. Methods: The study used a cross-sectional ecological design. Data from dispensed prescriptions and medical records were analysed from 24 primary healthcare centres with a combined registered population of 330,000 patients in 2006. Guideline adherence was determined calculating the proportion of the prescribed volume of antidiabetic agents, antihypertensives and lipid-lowering agents representing the 14 different drugs included in the guidelines for these three areas. Patient outcome was assessed using surrogate marker data on HbA1C, blood pressure (BP) and s-cholesterol. The association between the guidelines adherence and outcomes measures was analysed by logistic regression. Results: The proportion of guideline antidiabetic drugs in relation to all antidiabetic drugs prescribed varied between 80% and 97% among the practices, the ratio of angiotensin converting enzyme (ACE)-inhibitors to all renin–angiotensin drugs 40–77% and the ratio of simvastatin to all statins 58–90%. The proportion of patients reaching targets for HbA1C, BP and s-cholesterol varied between 34% and 66%, 36% and 57% and 46% and 71% respectively. No significant associations were found between adherence to the guidelines and outcome. The expenditures for antihypertensives and lipid-lowering drugs could potentially be reduced by 10% and 50% respectively if all practices adhered to the guidelines as the top performing practices. Conclusion: A substantial amount of money can be saved in primary care without compromising the quality of care by using recommended first-line drugs for the treatment diabetes, hypertension and hypercholesterolaemia. What's known • There are substantial price differences between branded and off-patent drugs for the treatment of diabetes, hypertension and hypercholesterolaemia. • There is a wide variation in adherence to prescribe targets in primary healthcare. • There is a limited knowledge on the relation between adherence to prescribing targets or guidelines, patient outcomes and potential savings that could be achieved. What's new • No significant associations were found at a practice level between adherence to the guidelines and outcomes in terms of patients reaching target levels for surrogate markers. • A substantial amount of money can be saved in primary care without compromising the quality of care by using recommended off-patent drugs for the treatment of diabetes, hypertension and hypercholesterolaemia

Quality indicators as a tool in improving the introduction of new medicines

Quality indicators are increasingly used as a tool to achieve safe and quality clinical care, cost-effective therapy, for professional learning, remuneration, accreditation and financial incentives. A substantial number focus on drug therapy but few address the introduction of new medicines even though this is a burning issue. The objective was to describe the issues and challenges in designing and implementing a transparent indicator framework and evaluation protocol for the introduction of new medicines and to provide guidance on how to apply quality indicators in the managed entry of new medicines. Quality indicators need to be developed early to assess whether new medicines are introduced appropriately. A number of key factors need to be addressed when developing, applying and evaluating indicators including dimensions of quality, suggested testing protocols, potential data sources, key implementation factors such as intended and unintended consequences, budget impact and cost-effectiveness, assuring the involvement of the medical professions, patients and the public, and reliable and easy-to-use computerized tools for data collection and management. Transparent approaches include the need for any quality indicators developed to handle conflict of interests to enhance their validity and acceptance. The suggested framework and indicator testing protocol may be useful in assessing the applicability of indicators for new medicines and may be adapted to healthcare settings worldwide. The suggestions build on existing literature to create a field testing methodology that can be used to produce country-specific quality indicators for new medicines as well as a cross international approach to facilitate access to new medicines

Trend of Antihypertensive Medicine Use in the Baltic States between 2008 and 2018: A Retrospective Cross-National Comparison

High blood pressure is a major risk factor contributing to death and disability rates in the Baltic states. The aim of this study was to compare the utilization of antihypertensive medicines in Estonia, Latvia and Lithuania from 2008 to 2018. In this retrospective cross-national comparison, nationally representative wholesale data from the IQVIA National Retail Audit were analyzed. The utilization of inhibitors of the renin–angiotensin system, beta blockers, calcium channel blockers, diuretics and centrally acting antihypertensives by Defined Daily Doses per 1000 inhabitants and day (DDD/TID) was used to calculate utilization. Time series analysis was used to analyze trends. The utilization increased annually by 10.88, 8.04 and 6.42 DDD/TID in Estonia, Latvia and Lithuania, respectively, from 2008. The utilization of antihypertensive drugs in 2018 was 372, 267 and 379.5 DDD/TID, respectively. Inhibitors of the renin–angiotensin system were the most commonly used class in 2008 and 2018. From 2008, the utilization of beta blockers and fixed-dose combinations including renin–angiotensin system inhibitors increased substantially, while that of calcium channel blockers decreased. Country-specific utilization trends were noted; e.g., the utilization of centrally acting antihypertensives was 30.9 DDD/TID in Lithuania compared to 3.01 DDD/TID in Estonia and 16.17 DDD/TID in Latvia. The use of antihypertensive medicines increased over the study period, but the trends for the different drug classes differed between countries

Differences in utilisation rates between commercial and administrative databases : implications for future health economic and cross national studies

Comparative cross national (CNC) drug utilization studies are challenging. However, there can be concerns with the accuracy and robustness of the data collected with previous studies showing differences in utilisation rates between different databases. In addition, if utilisation rates vary appreciably between countries with no logical explanation. These studies have been carried out for the same class across countries. This has now been extended to compare utilisation rates between different databases among four high volume classes among administrative and commercial databases in one country (Lithuania) between 2004 and 2012 alongside health policies. There were appreciable differences in the utilisation of PPIs (5 to 7 fold) and statins (2 to 6 fold) between the different databases with limited differences for the other two classes. This could be explained by restricted reimbursement for the PPIs and statins, with similar utilisation of renin-angiotensin inhibitors in Lithuania between the databases and with Western European countries in the absence of prescribing restrictions. Low utilisation of anti-depressants in Lithuania versus Western European countries also explained by ongoing policies. Essential to always record the database content in CNC studies alongside health policies otherwise the findings could be misinterpreted. Joint reporting should become standard for future CNC studies

Usage, Risk, and Benefit of Weight-Loss Drugs in Primary Care

Purpose. To investigate the use of the weight-loss drugs rimonabant, sibutramine, and orlistat in primary care and to characterize the patients receiving the drugs. Methods. In this retrospective, descriptive study, 300 randomly selected patients having started weight-loss drug treatment at 15 primary care centres were investigated using the patient's medical records and their complete drug purchase data. Results. Even though 48% of the patients specifically demanded drug treatment, 77% continued treatment less than one year. 28% of rimonabant patients and 32% of sibutramine patients had a history of depression or antidepressant treatment. 41% of sibutramine patients had a history of hypertension and/or cardiovascular disease. 36% had no documented weight after treatment initiation. Conclusions. These results suggest that weight-loss drug treatment was often initiated upon patient request but was of limited clinical benefit as it was managed in a large portion of Swedish primary carecenters

Non-persistence to antihypertensive drug therapy in Lithuania

Purpose: Poor persistence to antihypertensive therapy is an important cause of treatment failure. Investigating persistence is especially important in countries with a high cardiovascular mortality, like Lithuania. The aim of this study was to describe the antihypertensive treatment at initiation, to determine the percentage of patients not being persistent with antihypertensive treatment after 1 year and to explore factors associated with non-persistence. Methods: In this cohort study, data on dispensed prescription medicines from the Lithuanian National Health Insurance Fund (NHIF) were used. All adult patients with a diagnosis of hypertension having first antihypertensive dispensed in 2018 were included. Descriptive statistics was used to determine the number of patients started with monotherapy and combination therapy. Treatment choice by Anatomical Therapeutic Chemical (ATC) and number of active pharmaceutical ingredient (API) was described. Non-persistence was assessed using the anniversary method. Multivariate logistic regression was used to explore factors associated with non-persistence. Results: A total of 72,088 patients were included into the study, 56% started on monotherapy treatment, with 49% being dispensed an angiotensin converting enzyme inhibitor, and 44% started on combination therapy. Overall, 57% of patients were non-persistent after 1 year. Patients’ gender and prescriber qualification showed no association with non-persistence. Younger patients, patients from rural area, patients started with monotherapy, and patients with no medication change had higher odds to become non-persistent. Conclusions: The majority of patients were initiated with treatment following hypertension management guidelines, but it is of concern that over half of the patients were non-persistent to antihypertensive therapy in the first year

Time trends in statin utilization and coronary mortality in western European countries

Objectives. To determine whether there is a relation between statin utilization and coronary heart disease (CHD) mortality in populations with different levels of coronary risk, and whether the relation changes over time. Design. Ecological study using national databases on dispensed medicines and mortality rates. Setting. Western European countries with similar public health systems. Main outcome measures. Population CHD mortality rates (rate/100.000) as a proxy for population coronary risk level, and statin utilization expressed as Defined Daily Dose per one Thousand Inhabitants per Day (DDD/TID), in each country, for each year between 2000 and 2012. Pearson’s correlation coefficients between CHD mortality and statin utilization were calculated. Linear regression analysis was used to assess the relation between changes in CHD mortality and statin utilization over the years. Results. Twelve countries were included in the study. There was a wide range of CHD mortality reduction between the years 2000 and 2012 (from 25.9% in Italy to 57.9% in Denmark) and statin utilization increase (from 121% in Belgium to 1,263% in Denmark). No statistically significant relations were found between CHD mortality rates and statin utilization, nor between changes in CHD and changes in statin utilization in the countries over the years 2000 and 2012. Conclusions. Among the Western European countries studied, the large increase in statin utilization between 2000 and 2012 was not associated with CHD mortality, nor with its rate of change over the years. Factors different from the individual coronary risk, such as population ageing, health authority programs, guidelines, media attention and pharmaceutical industry marketing, may have influenced the large increase in statin utilization. These need to be re-examined with a greater emphasis on prevention strategies

Sibship and dispensing patterns of asthma medication in young children : a population based study

Purpose: Our aim was to study the association between sibship and dispensing patterns of asthma medication in young children, focusing on incidence and persistence, and taking sibship status, asthma diagnoses, and siblings’ medication into account. Methods: A register-based cohort study including all children (n=50,546) born in Stockholm, Sweden 2006–2007, followed up during 2006–2014. Exposure was sibling status; outcome was incidence of dispensed asthma medication and persistence over time. A Cox-model was used to study the association between sibship and asthma medication. Persistence was defined using two different time windows (4- and 18-months) in a refill sequence model including siblings’ and unrelated control children’s medication. Results: After one year of age, the adjusted hazard ratio of dispensed asthma medication was 0.85 (95%CI 0.80–0.90) among children with siblings compared to singletons. The estimated proportion of children with persistent controller medication was 7.2% (4-month model) and 64.5% (18-month model). When including the siblings’ controller medication, the estimated proportion was 8.8% (4-months) and 7.8% for control children (relative risk, RR 0.89, 95%CI 0.81-0.98). The persistence was lower for those with siblings compared to singletons (adj. RR 0.72, 95%CI 0.62-0.85 for 4-months) with similar estimates for older, younger, and full siblings and regardless of asthma diagnoses. Conclusions: Siblings have different dispensing patterns of asthma medications compared to singletons regardless of asthma diagnoses. After including the siblings’ asthma medication and compared with control children, the proportion of children with persistent medication increased which may indicate that siblings share asthma medications.Swedish Research Council for Health, Working Life and WelfareStrategic Research Program in EpidemiologyStockholm County CouncilSwedish Heart Lung FoundationSwedish Research CouncilAccepte

Prevention of hospital infections

Bachelor i sykepleie, 2012Problemstilling: Bacheloroppgaven i sykepleie tar for seg temaer innen sykepleie som forebygger smitte i somatisk sykehus. Ut i fra temaet velger vi å skrive om sykehusinfeksjoner og velger denne problemstillingen: Hvordan kan sykepleier forbygge sykehusinfeksjoner? Oppgavens hensikt er økt kunnskap om sykepleierens rolle i forebygging av sykehusinfeksjoner. Konsekvens av manglende hygiene ved kateterinnleggelse kan påføre pasienten lidelsen urinveisinfeksjon. Med oppgaven ønsker vi å få fram hvordan sykepleiere i praksis skal handle ut i fra lover, retningslinjer og fagkunnskaper for å forebygge denne lidelsen. Avgrensing og presisering av problemstillingen: Oppgaven tar for seg sykepleiers forebyggende rolle i arbeidet med å redusere antall sykehusinfeksjoner, en rolle der sykepleiers moral har betydning. Sykepleieren bør ikke påføre pasienten mer lidelse enn hva han/hun allerede har. Hun får en tydeligere moralsk rolle når hun handler kunnskapsbasert og faglig forsvarlig, i tråd med gjeldende lover og retningslinjer for å fremme helse, forebygge sykdom og lindre lidelse. Sykepleieren har en forebyggende rolle overfor friske mennesker, personer med risiko for helsesvikt og mennesker som utsettes for komplikasjoner. Det forebyggende begrepet kan igjen deles inn i primær-, sekundær- og tertiærforebyggende tiltak. Relevant for denne oppgaven er det tertiærforebyggende tiltaket som skal hindre at nye helseproblemer som at komplikasjoner oppstår ved undersøkelser eller behandling (Kristoffersen, Nortvedt & Skaug, 2005). Fordypning i temaet sykehusinfeksjoner har gjort oss oppmerksomme på at det brukes flere synonyme begreper av det samme ordet. Synonyme ord som nosokomiale infeksjoner, helsetjeneste ervervede infeksjoner og helsetjeneste assosierte infeksjoner. I oppgaven velger vi å bruke begrepet sykehusinfeksjoner, et begrep som faller naturlig når man snakker om infeksjoner ervervet på sykehus. Sykehus infeksjoner [sic] kan defineres som «en infeksjon som oppstår under eller etter og som følge av et opphold på sykehus eller annen helseinstitusjon» (Stordalen, 2009: 55). Sykehusinfeksjoner erverves vanligvis etter 2-3 døgn på somatisk sykehus, og opptil 30 døgn etter utskrivelse fra sykehus. Sykehusinfeksjoner påfører pasienter infeksjoner og ved dette ekstra lidelse. Infeksjonene skyldes ofte slurv, dårlig personlig hygiene eller dårlig generell hygiene blant helsepersonell (Stordalen, 2009). De vanligste sykehusinfeksjonene er urinveisinfeksjoner, nedre luftveisinfeksjoner, postoperative sårinfeksjoner og septikemi (Børøsund, 2010). De tre førstnevnte infeksjonene er de hyppigste og har omtrent lik forekomst (Nasjonalt folkehelseinstitutt, 2011b). Årsaksfaktorene til sykehusinfeksjoner kan være mange og sammensatte. Årsaksfaktorer er blant annet økt instrumentering, effektivisering, rasjonalisering og dårlig hygiene (Stordalen, 2009). Vi velger å avgrense oppgaven til urinveisinfeksjon og hygienens betydning. Dette da vi har bakgrunnskunnskap om at infeksjonsforsvaret i underlivet er ømfintlig overfor mikroorganismer (Bjålie, Haug, Sand & Sjåstad, 2006). Oppgaven begrenses videre til selve kateterinnleggelsen da vi ser det som viktig at sykepleier utfører god hygiene i kontakt med pasientens underliv. Vi har valgt å bruke Florence Nightingale og Joyce Travelbee som sykepleieteoretikere for å få frem sykepleierollen. Vi har valgt Florence Nightingale da hun var en pionèr innenfor sykepleie som tidlig satte fokus på hygienens betydning i forebygging av smitte. Joyce Travelbee valgte vi fordi hun er en sykepleieteoretiker fra nyere år som fokuserer på en profesjonell sykepleie som forebygger sykdom og lidelse. Sykepleieren skal ifølge De basale smittevernrutinene (Nasjonalt Folkehelseinstitutt, 2009) møte pasienter med de samme hygieniske prinsippene ved å følge infeksjonskontrollprogram som finnes i avdelingen. Vi velger derfor ikke å begrense oppgaven til en spesiell avdeling på sykehuset. Den praktiske handlingen i drøftingen tar for seg kateterinnleggelse på voksne kvinner da det er dette vi har mest erfaringer med. I oppgaven benevnes sykepleier som hun/henne