Predicting the health impact of lowering salt consumption in Turkey using the DYNAMO health impact assessment tool

OBJECTIVE

To estimate the impact of three daily salt consumption scenarios on the prevalence and incidence of ischaemic heart disease (IHD) and cerebrovascular disease in 2025 in the Turkish population aged ≥30 years using the DYNAMO Health Impact Assessment tool.

STUDY DESIGN

Statistical disease modelling study.

METHODS

DYNAMO health impact assessment was populated using data from Turkey to estimate the prevalence and incidence of IHD and cerebrovascular disease in 2025. TurkSTAT data were used for demographic data, and national surveys were used for salt consumption and disease-specific burden. Three salt consumption scenarios were modelled: (1) reference scenario: mean salt consumption stays the same from 2012-2013 until 2025; (2) gradual decline: daily salt intake reduces steadily by 0.47 g per year by lowering salt intake from bread by 50% and from table salt by 40% by 2025; and (3) World Health Organization (WHO) advice: daily salt intake of 5 g per day from 2013 until 2025.

RESULTS

The gradual decline scenario would lead to a decrease in the prevalence of IHD and cerebrovascular disease by 0.3% and 0.2%, respectively, and a decrease in the incidence by 0.6 and 0.4 per 1000, respectively. Following WHO's advice would lead to a decrease in the prevalence of IHD and cerebrovascular disease by 0.8% and 0.5%, respectively, and a decrease in the incidence by 1.0 and 0.7 per 1000, respectively.

CONCLUSION

This model indicates that Turkey can lower its future cardiovascular disease burden by following the gradual decline scenario. Following WHO's advice would achieve an even greater benefit.

Potential health gains and health losses in eleven EU countries attainable through feasible prevalences of the life-style related risk factors alcohol, BMI, and smoking: a quantitative health impact assessment

BACKGROUND

Influencing the life-style risk-factors alcohol, body mass index (BMI), and smoking is an European Union (EU) wide objective of public health policy. The population-level health effects of these risk-factors depend on population specific characteristics and are difficult to quantify without dynamic population health models.

METHODS

For eleven countries-approx. 80 % of the EU-27 population-we used evidence from the publicly available DYNAMO-HIA data-set. For each country the age- and sex-specific risk-factor prevalence and the incidence, prevalence, and excess mortality of nine chronic diseases are utilized; including the corresponding relative risks linking risk-factor exposure causally to disease incidence and all-cause mortality. Applying the DYNAMO-HIA tool, we dynamically project the country-wise potential health gains and losses using feasible, i.e. observed elsewhere, risk-factor prevalence rates as benchmarks. The effects of the "worst practice", "best practice", and the currently observed risk-factor prevalence on population health are quantified and expected changes in life expectancy, morbidity-free life years, disease cases, and cumulative mortality are reported.

RESULTS

Applying the best practice smoking prevalence yields the largest gains in life expectancy with 0.4 years for males and 0.3 year for females (approx. 332,950 and 274,200 deaths postponed, respectively) while the worst practice smoking prevalence also leads to the largest losses with 0.7 years for males and 0.9 year for females (approx. 609,400 and 710,550 lives lost, respectively). Comparing morbidity-free life years, the best practice smoking prevalence shows the highest gains for males with 0.4 years (342,800 less disease cases), whereas for females the best practice BMI prevalence yields the largest gains with 0.7 years (1,075,200 less disease cases).

CONCLUSION

Smoking is still the risk-factor with the largest potential health gains. BMI, however, has comparatively large effects on morbidity. Future research should aim to improve knowledge of how policies can influence and shape individual and aggregated life-style-related risk-factor behavior.

De novo post-diagnosis statin use, breast cancer-specific and overall mortality in women with stage I-III breast cancer

Background:

Prior evidence suggests a role for statins in the management of cancer. However, the benefit of statin use in the adjuvant setting remains uncertain. This study investigates associations between statin use initiated after a breast cancer diagnosis and mortality.

Methods:

Women with stage I–III breast cancer were identified from the National Cancer Registry of Ireland (N=4243). Post-diagnostic statin initiators were identified from pharmacy claims data (N=837). Multivariate models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between de novo statin use and mortality.

Results:

The median duration of statin use was 6.7 years. No association was found between post-diagnostic statin use and breast cancer-specific (HR 0.88, 95% CI 0.66, 1.17) or all-cause mortality (HR 1.00, 95% CI 0.82, 1.21).

Conclusions:

The results from our study suggest that initiating statin use after a diagnosis of stage I–III breast cancer is not associated with a reduction in breast cancer-specific mortality.

Use of cardiovascular medicines in newly treated type 2 diabetes patients: A retrospective cohort study in general practice

AIMS

To describe the drug utilisation patterns of aspirin, antihypertensives, vasodilators, and statins in a cohort of newly treated type 2 diabetes subjects previously unexposed to CVD agents.

METHODS

A population-based retrospective cohort study was conducted using a national pharmacy claims database of newly treated type 2 diabetes subjects aged 40 years or older. Data on the use of aspirin, antihypertensives, vasodilators, and statins 1 year after antidiabetic agent initiation were analysed. Poisson regression with a robust error variance was used to estimate adjusted relative risk (RRadj) and 95% CIs between socio-demographic and treatment factors on CVD agent use.

RESULTS

Over a 2-year period (2008-2009), 6093 subjects were identified. One year after antidiabetic agent initiation, 82% of the study population received at least one CVD agent, with 54% receiving aspirin, 64% receiving antihypertensives, 6% vasodilators, and 62% receiving statins. Subjects aged 40-49 years were significantly less likely than those aged 60-69 years to receive CVD agents (RRadj 0.83, 95% CI 0.80-0.87). Over 40% of subjects received antihypertensives without aspirin and statins, while 30% of subjects on statins did not receive aspirin.

CONCLUSIONS

Substantial CVD agent utilisation was noted 1 year after antidiabetic agent initiation. Being aged younger than 60-69 years was associated with decreased utilisation of CVD agents.

Impact of Potentially Inappropriate Prescribing on Adverse Drug Events, Health Related Quality of Life and Emergency Hospital Attendance in Older People Attending General Practice: A Prospective Cohort Study

Background:

Potentially inappropriate prescribing (PIP) describes medications where risk generally outweighs benefit for older people. Cross-sectional studies suggest an association between PIP and poorer health outcomes but there is a paucity of prospective cohort studies. This study investigates the longitudinal association of PIP with adverse drug events (ADEs), health related quality of life, and accident & emergency visits.

Methods:

Study design: Two-year (2010–2012) prospective cohort study (n = 904, ≥70 years, community-dwelling) with linked pharmacy dispensing data. Exposure: Baseline PIP: Screening Tool for Older Persons potentially Inappropriate Prescriptions (STOPP) and Beers 2012 applied 12 months prior. Study outcomes: ADEs (patient interview), health related quality of life (EQ-5D-3L: patient questionnaire), and accident & emergency visits (general practice medical record review). Statistical analysis: Descriptive statistics: Poisson (incidence rate ratio [95% confidence interval [CI]], linear regression models [regression coefficient [95% CI]], and logistic [odds ratio [OR] [95% CI]).

Results:

Of 791 participants eligible for follow-up, 673 (85%) returned a questionnaire and 605 (77%) also completed an ADE interview. Baseline STOPP PIP prevalence was 40% and 445 (74%) patients reported ≥1 ADE at follow-up. In multivariable analysis, ≥2 STOPP PIP was associated with ADEs (adjusted incidence rate ratio: 1.29 [95% CI 1.03, 1.85; p = .03]; poorer health related quality of life [adjusted regression coefficient: −0.11 [95% CI −0.16, −0.06; p < .001]]; and, ≥1 accident & emergency visit [adjusted OR: 1.85 [95% CI 1.06, 3.24; p = .03]]). Baseline Beers 2012 prevalence was 26% and there was no association with adverse health outcomes in multivariable analysis.

Conclusions:

Older community-dwelling people, prescribed ≥2 STOPP PIP are more likely to report ADEs, poorer health related quality of life and attend the accident & emergency department over 2-year follow-up.

Potentially inappropriate prescribing according to STOPP and START and adverse outcomes in community-dwelling older people: a prospective cohort study

AIMS

This study aims to determine if potentially inappropriate prescribing (PIP) is associated with increased healthcare utilization, functional decline and reduced quality of life (QoL) in a community-dwelling older cohort.

METHOD

This prospective cohort study included participants aged ≥65 years from The Irish Longitudinal Study on Ageing (TILDA) with linked administrative pharmacy claims data who were followed up after 2 years. PIP was defined by the Screening Tool for Older Persons Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START). The association with number of emergency department (ED) visits and GP visits reported over 12 months was analyzed using multivariate negative binomial regression adjusting for confounders. Marginal structural models investigated the presence of time-dependent confounding.

RESULTS

Of participants followed up (n = 1753), PIP was detected in 57% by STOPP and 41.8% by START, 21.7% reported an ED visit and 96.1% visited a GP (median 4, IQR 2.5-6). Those with any STOPP criterion had higher rates of ED visits (adjusted incident rate ratio (IRR) 1.30, 95% confidence interval (CI) 1.02, 1.66) and GP visits (IRR 1.15, 95%CI 1.06, 1.24). Patients with two or more START criteria had significantly more ED visits (IRR 1.45, 95%CI 1.03, 2.04) and GP visits (IRR 1.13, 95%CI 1.01, 1.27) than people with no criteria. Adjusting for time-dependent confounding did not affect the findings.

CONCLUSIONS

Both STOPP and START were independently associated with increased healthcare utilization and START was also related to functional decline and QoL. Optimizing prescribing to reduce PIP may provide an improvement in patient outcomes.

Exploring potential mortality reductions in 9 European countries by improving diet and lifestyle: A modelling approach

BACKGROUND

Coronary heart disease (CHD) death rates have fallen across most of Europe in recent decades. However, substantial risk factor reductions have not been achieved across all Europe. Our aim was to quantify the potential impact of future policy scenarios on diet and lifestyle on CHD mortality in 9 European countries.

METHODS

We updated the previously validated IMPACT CHD models in 9 European countries and extended them to 2010-11 (the baseline year) to predict reductions in CHD mortality to 2020(ages 25-74years). We compared three scenarios: conservative, intermediate and optimistic on smoking prevalence (absolute decreases of 5%, 10% and 15%); saturated fat intake (1%, 2% and 3% absolute decreases in % energy intake, replaced by unsaturated fats); salt (relative decreases of 10%, 20% and 30%), and physical inactivity (absolute decreases of 5%, 10% and 15%). Probabilistic sensitivity analyses were conducted.

RESULTS

Under the conservative, intermediate and optimistic scenarios, we estimated 10.8% (95% CI: 7.3-14.0), 20.7% (95% CI: 15.6-25.2) and 29.1% (95% CI: 22.6-35.0) fewer CHD deaths in 2020. For the optimistic scenario, 15% absolute reductions in smoking could decrease CHD deaths by 8.9%-11.6%, Salt intake relative reductions of 30% by approximately 5.9-8.9%; 3% reductions in saturated fat intake by 6.3-7.5%, and 15% absolute increases in physical activity by 3.7-5.3%.

CONCLUSIONS

Modest and feasible policy-based reductions in cardiovascular risk factors (already been achieved in some other countries) could translate into substantial reductions in future CHD deaths across Europe. However, this would require the European Union to more effectively implement powerful evidence-based prevention policies.

The impact of initial antidiabetic agent and use of monitoring agents on prescription costs in newly treated type 2 diabetes: A retrospective cohort analysis

AIMS

To measure the costs associated with the use of antidiabetic agents, monitoring materials and cardiovascular disease (CVD) agents in the management of newly treated type 2 diabetes, and to investigate the factors associated with these costs.

METHODS

A population-based retrospective cohort study was conducted using the Irish national pharmacy claims database. Newly treated patients were identified for 2012 and followed for one year post treatment initiation. Factors associated with costs were assessed using a generalised linear model with gamma family and log-link function. Cost ratios (CR) and 95% CIs were used to determine the contributors of prescription costs. Adjusted odd ratios (OR) and 95% CIs were used to investigate factors associated with high frequency self-monitoring of blood glucose (SMBG).

RESULTS

Mean prescription costs for the 12,941 subjects was €871, while total costs were €11 million. CVD agents accounted for 58% of total costs; 22% of costs were for SMBG; antidiabetic agents accounted for 17% of costs. SMBG resulted in costs that were 80% higher than those without, CR 1.80 (95% CI 1.76-1.84). No significant differences were observed between initiation on metformin or sulphonylureas and high frequency SMBG (OR 1.01 95% CI 0.97-1.04 vs reference). Initiation on newer antidiabetic agents was a significant positive predictors of prescription costs (CR 2.36 95% CI 2.21-2.51 vs metformin).

CONCLUSIONS

Type of initial antidiabetic agent, and SMBG were significant predictors of prescription costs. SMBG represent a major proportion of total costs; however, its use in combination with antidiabetic agents that do not cause hypoglycaemia is questionable.

Initial therapy, persistence and regimen change in a cohort of newly treated type 2 diabetes patients

AIMS

The aim was to describe the utilization of antidiabetic agents, in terms of persistence and regimen change, in the management of a cohort of newly treated type 2 diabetes patients and to investigate associated socio-demographic and treatment factors.

METHODS

A population-based retrospective cohort study was conducted using the national pharmacy claims database in Ireland. Subjects were analyzed for persistence and regimen change. Cox proportional hazards regression examined associations of socio-demographic and treatment factors on treatment patterns. Hazard ratios (HR) and 95% CIs are presented.

RESULTS

A total of 20947 subjects were identified in the study over a 2 year period. Most were initiated on metformin (76%) or sulphonylureas (22%) and 77% were persistent with therapy 12 months after initiation. The likelihood of non-persistence was significantly lower in the youngest (40-49 years) age groups (reference 60-69 years) (HR 1.62, 95% CI 1.42, 1.84) and those on sulphonylureas (HR 1.49, 95% CI 1.36, 1.64). The likelihood of receiving a regimen change was significantly lower in the older (80+ years) age groups (HR 0.63, 95% CI 0.56, 0.71), females (HR 0.91, 95% CI 0.86, 0.95), and those with pre-existing CVD (1 vs. 0 CVD medicines) (HR 0.82, 95% CI 0.74, 0.90), and higher in those on sulphonylureas (HR 1.83, 95% CI 1.73, 1.94).

CONCLUSIONS

Type of treatment, pre-existing CVD and demographic factors are shown to be associated with the observed treatment patterns. Guideline recommended agents were widely used on treatment initiation though a substantial minority were not initiated on the recommended first line agent. Use of guideline recommended agents was not as evident during treatment progression. Further optimization of initial and subsequent antidiabetic agent prescribing may be possible.

Potentially inappropriate prescribing in two populations with differing socio-economic profiles: a cross-sectional database study using the PROMPT criteria

PURPOSE

The purpose of this study is to establish the prevalence of potentially inappropriate prescribing (PIP) in middle-aged adults (45-64 years) in two populations with differing socio-economic profiles, and to investigate factors associated with PIP, using the PROMPT (PRescribing Optimally in Middle-aged People's Treatments) criteria.

METHODS

A retrospective cross-sectional study was conducted using 2012 data from the Enhanced Prescribing Database (EPD), covering the full population in Northern Ireland and the Health Services Executive Primary Care Reimbursement Service (HSE-PCRS) database, covering the most socio-economically deprived third of the population in this age group in the Republic of Ireland. The prevalence for each PROMPT criterion and overall prevalence of PIP were calculated. Logistic regression was used to investigate the association between PIP and gender, age group and polypharmacy.

RESULTS

This study included 441,925 patients from the EPD and 309,748 patients from the HSE-PCRS database. Polypharmacy was common in both datasets (46.7 % in the HSE-PCRS and 20.3 % in the EPD). The prevalence of PIP was 42.9 % (95%CI 42.7, 43.1) in the HSE-PCRS and 21.1 % (95%CI 21.0, 21.2) in the EPD. Age group, female gender and polypharmacy were significantly associated with PIP in both populations (p < 0.05) and polypharmacy had the strongest association.

CONCLUSIONS

PIP is common amongst middle-aged people with the risk of PIP increasing with polypharmacy. Differences in the prevalence of polypharmacy and PIP between the two populations may relate to heterogeneity in healthcare services and different socio-economic profiles, with higher rates of multimorbidity and associated polypharmacy in more deprived groups.

Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections

OBJECTIVES

The aim of this paper is to explore the culture of antibiotic prescribing and consumption in the community for urinary tract infections (UTI) from the perspective of the general practitioners (GPs) and community member.

DESIGN

Indepth interviews were conducted with GPs, and focus groups were held with community members.

SETTING

General practice and community setting.

PARTICIPANTS

15 GPs practising in rural and urban locations in Ireland participated in the indepth interviews. 6 focus groups (n=42) with participants who had direct or indirect experiences with UTI were also undertaken.

RESULTS

The decision to prescribe or consume an antibiotic for a UTI is a set of complex processes including need recognition, information search and evaluation processes governed by the relationship and interactions between the GP and the patient. Different GP and patient decision-making profiles emerged emphasising the diversity and variety of general practice in real-life settings. The GP findings showed a requirement for more microbiological information on antibiotic resistance patterns to inform prescribing decisions. Focus group participants wanted a conversation with the GP about their illness and the treatment options available.

CONCLUSIONS

Collectively, this research identified the consultation as a priority intervention environment for stimulating change in relation to antibiotics. This paper demonstrates how qualitative research can identify the interacting processes which are instrumental to the decision to prescribe or consume an antibiotic for a suspected UTI. Qualitative research empowers researchers to investigate the what, how and why of interventions in real-life setting. Qualitative research can play a critical and instrumental role in designing behavioural change strategies with high impact on practice. The results of this research were used to design a complex intervention informed by social marketing.

TRIAL REGISTRATION NUMBER

NCT01913860; Pre-results.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments

BACKGROUND

Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey.

METHODS

Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model.

RESULTS

Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder.

DISCUSSION

CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa

HIV-infected men and women who choose to conceive risk infecting their partners. To inform safer conception programs we surveyed HIV risk behavior prior to recent pregnancy amongst South African, HIV-infected women (N = 209) and men (N = 82) recruited from antenatal and antiretroviral clinics, respectively, and reporting an uninfected or unknown-HIV-serostatus pregnancy partner. All participants knew their HIV-positive serostatus prior to the referent pregnancy. Only 11 % of women and 5 % of men had planned the pregnancy; 40 % of women and 27 % of men reported serostatus disclosure to their partner before conception. Knowledge of safer conception strategies was low. Around two-thirds reported consistent condom use, 41 % of women and 88 % of men reported antiretroviral therapy, and a third of women reported male partner circumcision prior to the referent pregnancy. Seven women (3 %) and two men (2 %) reported limiting sex without condoms to peak fertility. None reported sperm washing or manual insemination. Safer conception behaviors including HIV-serostatus disclosure, condom use, and ART at the time of conception were not associated with desired pregnancy. In light of low pregnancy planning and HIV-serostatus disclosure, interventions to improve understandings of serodiscordance and motivate mutual HIV-serostatus disclosure and pregnancy planning are necessary first steps before couples or individuals can implement specific safer conception strategies.

Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: a cluster randomized trial

BACKGROUND

Overuse of antimicrobial therapy in the community adds to the global spread of antimicrobial resistance, which is jeopardizing the treatment of common infections.

METHODS

We designed a cluster randomized complex intervention to improve antimicrobial prescribing for urinary tract infection in Irish general practice. During a 3-month baseline period, all practices received a workshop to promote consultation coding for urinary tract infections. Practices in intervention arms A and B received a second workshop with information on antimicrobial prescribing guidelines and a practice audit report (baseline data). Practices in intervention arm B received additional evidence on delayed prescribing of antimicrobials for suspected urinary tract infection. A reminder integrated into the patient management software suggested first-line treatment and, for practices in arm B, delayed prescribing. Over the 6-month intervention, practices in arms A and B received monthly audit reports of antimicrobial prescribing.

RESULTS

The proportion of antimicrobial prescribing according to guidelines for urinary tract infection increased in arms A and B relative to control (adjusted overall odds ratio [OR] 2.3, 95% confidence interval [CI] 1.7 to 3.2; arm A adjusted OR 2.7, 95% CI 1.8 to 4.1; arm B adjusted OR 2.0, 95% CI 1.3 to 3.0). An unintended increase in antimicrobial prescribing was observed in the intervention arms relative to control (arm A adjusted OR 2.2, 95% CI 1.2 to 4.0; arm B adjusted OR 1.4, 95% CI 0.9 to 2.1). Improvements in guideline-based prescribing were sustained at 5 months after the intervention.

INTERPRETATION

A complex intervention, including audit reports and reminders, improved the quality of prescribing for urinary tract infection in Irish general practice.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01913860.

Hormonal contraceptive use in Ireland: trends and co-prescribing practices

Hormonal contraceptives are highly prevalent. Currently, little is known about Irish hormonal contraceptive trends to date since the 1995 British media contraceptive controversy. The aim of this study was to examine recent trends in contraceptive use in Ireland and to determine the frequency of co-prescriptions with important interacting medications. Approximately 40% of the Irish population are prescribed 70% of total medicines under the Irish GMS scheme. Medicines were identified using the WHO Anatomical Therapeutic Chemical (ATC) classification system. Regression analysis was used to examine trends over time. Of all contraceptives dispensed in 2013, oral contraceptives were used the most (74%) and long acting reversible contraceptives (LARCs) the least (7.5%). Fourth generation combined oral contraceptives (COCs) predominated, although a slight significant decline was shown (P < 0.0001). Second and third generation COCs were significantly increasing and decreasing, respectively (P < 0.0001). Progestin-only pills were significantly increasing (P < 0.0001 across age groups). Low rates of contraceptive co-prescribing with important interacting drugs are shown. However, 93.6% of those on enzyme-inducing anti-epileptic medications were co-prescribed ineffective contraception containing <50 μg oestrogen.Irish prescribing trends of second and third generation COCs have remained consistent since 1995. The slow decline in fourth generation COC uptake follows new evidence of an increased risk of venous thromboembolism (VTE) reported in 2011. The low, but increasing, uptake of LARCs is consistent with other countries. Co-prescribing practices involving hormonal contraceptives requires continued vigilance. This study emphasizes the need to optimize co-prescribing practices involving hormonal contraceptives and anti-epileptic medications and highlights the need to address the barriers to the currently low uptake of LARC methods in Ireland.

Modelling Future Coronary Heart Disease Mortality to 2030 in the British Isles

Objective

Despite rapid declines over the last two decades, coronary heart disease (CHD) mortality rates in the British Isles are still amongst the highest in Europe. This study uses a modelling approach to compare the potential impact of future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland.

Methods

CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. Risk factor trends data from recent surveys at baseline were used to model alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; relative decreases in (iii) dietary salt intake of up to 30% by 2030 and (iv) dietary saturated fat of up to 6% by 2030. Probabilistic sensitivity analyses were then conducted.

Results

Projected populations in 2030 were 1.3, 3.4 and 3.9 million in NI, RoI and Scotland respectively (adults aged 25–84). In 2030: assuming recent declining mortality trends continue: 15% absolute reductions in smoking could decrease CHD deaths by 5.8–7.2%. 15% absolute reductions in physical inactivity levels could decrease CHD deaths by 3.1–3.6%. Relative reductions in salt intake of 30% could decrease CHD deaths by 5.2–5.6% and a 6% reduction in saturated fat intake might decrease CHD deaths by some 7.8–9.0%. These projections remained stable under a wide range of sensitivity analyses.

Conclusions

Feasible reductions in four cardiovascular risk factors (already achieved elsewhere) could substantially reduce future coronary deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity.

Trends and interaction of polypharmacy and potentially inappropriate prescribing in primary care over 15 years in Ireland: a repeated cross-sectional study

OBJECTIVES

To examine: (1) changes in polypharmacy in 1997, 2002, 2007 and 2012 and; (2) changes in potentially inappropriate prescribing (PIP) prevalence and the relationship between PIP and polypharmacy in individuals aged ≥65 years over this period in Ireland.

METHODS

This repeated cross-sectional study using pharmacy claims data included all individuals eligible for the General Medical Services scheme in the former Eastern Health Board region of Ireland in 1997, 2002, 2007 and 2012 (range 338,025-539,752 individuals). Outcomes evaluated were prevalence of polypharmacy (being prescribed ≥5 regular medicines) and excessive polypharmacy (≥10 regular medicines) in all individuals and PIP prevalence in those aged ≥65 years determined by 30 criteria from the Screening Tool for Older Persons' Prescriptions.

RESULTS

The prevalence of polypharmacy increased from 1997 to 2012, particularly among older individuals (from 17.8% to 60.4% in those aged ≥65 years). The adjusted incident rate ratio for polypharmacy in 2012 compared to 1997 was 4.16 (95% CI 3.23 to 5.36), and for excessive polypharmacy it was 10.53 (8.58 to 12.91). Prevalence of PIP rose from 32.6% in 1997 to 37.3% in 2012. High-dose aspirin and digoxin prescribing decreased over time, but long-term proton pump inhibitors at maximal dose increased substantially (from 0.8% to 23.8%). The odds of having any PIP in 2012 were lower compared to 1997 after controlling for gender and level of polypharmacy, OR 0.39 (95% CI 0.39 to 0.4).

CONCLUSIONS

Accounting for the marked increase in polypharmacy, prescribing quality appears to have improved with a reduction in the odds of having PIP from 1997 to 2012. With growing numbers of people taking multiple regular medicines, strategies to address the related challenges of polypharmacy and PIP are needed.

Antidepressant prescribing in Irish children: secular trends and international comparison in the context of a safety warning

BACKGROUND

In 2003, the Irish Medicines Board (IMB) warned against the treatment of childhood depression with selective serotonin reuptake inhibitors (SSRIs) due to increased risk of suicide. This study examined the effect of this warning on the prevalence of anti-depressants in Irish children and compared age and gender trends and international comparisons of prescription rates.

METHODS

A retrospective cohort study of the Irish Health Service Executive (HSE) pharmacy claims database for the General Medical Services (GMS) scheme for dispensed medication. Data were obtained for 2002-2011 for those aged ≤ 15 years. Prevalence of anti-depressants per 1000 eligible population, along with 95% confidence intervals, were calculated. A negative binomial regression analysis was used to investigate trends and compare rates across years, sex and age groups (0-4, 5-11, 12-15 years). International prescribing data were retrieved from the literature.

RESULTS

The prevalence of anti-depressants decreased from 4.74/1000 population (95% CI: 4.47-5.01) in 2002 to 2.61/1000 population (95% CI: 2.43-2.80) in 2008. SSRI rates decreased from 2002 to 2008. Prescription rates for contra-indicated SSRIs paroxetine, sertraline and citralopram decreased significantly from 2002 to 2005, and, apart from paroxetine, only small fluctuations were seen from 2005 onwards. Fluoxetine was the most frequently prescribed anti-depressant and rates increased between 2002 and 2011. Anti-depressant rates were higher for younger boys and older girls. The Irish prevalence was lower than the US, similar to the U.K. and higher than Germany and Denmark.

CONCLUSIONS

The direction and timing of these trends suggest that medical practitioners followed the IMB advice.