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Lonnberg F, Roos A, Farm M, Heurlin A, Okas M, Gigante B, Siddiqui AJ. Causes of death after first time venous thromboembolism. Thromb J 2024; 22:16. [PMID: 38303070 PMCID: PMC10832181 DOI: 10.1186/s12959-024-00586-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Causes of death after first time community-acquired venous thromboembolism (VTE) diagnosed in unselected patients at the emergency department (ED) was investigated. MATERIALS AND METHODS The study consists of all patients > 18 years of age who had a visit for any medical reason to any of 5 different ED in Stockholm County, Sweden from 1st January 2016 to 31st December 2017. We have identified all patients with a first registered incident VTE; deep vein thrombosis (DVT) and/or pulmonary embolism (PE) during the study period. Cox regression models were used to estimate hazards ratios (HR) with 95% confidence intervals (CIs) for all-cause mortality and cause-specific death in patients with DVT or PE using all other patients as the reference group. RESULTS In total, 359,884 patients had an ED visit during the study period of whom about 2.1% were diagnosed with VTE (DVT = 4,384, PE = 3,212). The patients with VTE were older compared to the control group. During a mean follow up of 2.1 years, 1567 (21%) and 23,741(6.7%) patients died within the VTE and reference group, respectively. The adjusted risk of all-cause mortality was nearly double in patients with DVT (HR 1.7; 95% CI, 1.5-1.8) and more than 3-fold in patients with PE (HR 3.4; 95% CI, 3.1-3.6). While the risk of cancer related death was nearly 3-fold in patient with DVT (HR 2.7; 95% CI, 2.4-3.1), and 5-fold in PE (HR 5.4; 95% CI, 4.9-6.0 respectively). The diagnosis of PE during the ED visit was associated with a significantly higher risk of cardiovascular death (HR 2.2; 95% CI, 1.9-2.6). CONCLUSION Patients with VTE have an elevated risk of all-cause mortality, including cardiovascular death.
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Affiliation(s)
- Frida Lonnberg
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Roos
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Farm
- Karolinska University, Solna, Sweden
- Karolinska University Hospital, Solna, Sweden
| | - André Heurlin
- Acute Medicine, Capio. St. Görans Hospital, Stockholm, Sweden
| | - Mantas Okas
- Acute Medicine, Capio. St. Görans Hospital, Stockholm, Sweden
| | - Bruna Gigante
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Department of Cardiology, Danderyd Hospital, Stockholm, Sweden
| | - Anwar J Siddiqui
- Department of Medicine, Karolinska Institute, Solna, Sweden.
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.
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Sönnerstam E, Harlin F, Gustafsson M. Potentially inappropriate medications among elderly people with neurocognitive disorders - A nationwide register-based study using 3 different explicit criteria. Res Social Adm Pharm 2023; 19:758-763. [PMID: 36717339 DOI: 10.1016/j.sapharm.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/22/2022] [Accepted: 01/22/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND The use of potentially inappropriate medications (PIMs) is a problem since it might contribute significantly to adverse drug reactions and hospital admissions among elderly with major neurocognitive disorder (NCD). To assess the appropriateness of drug treatment, different explicit criteria have been developed. OBJECTIVES To investigate and compare the prevalence of PIM users among elderly with major NCD on a nationwide basis using 3 different explicit criteria. Furthermore, the study aimed to investigate factors associated with the use of PIMs. METHODS This nationwide register-based study included 35,212 people, 65 years or older, diagnosed with major NCD and registered in the Swedish registry for cognitive/dementia disorders up to June 30, 2017 and alive December 31, 2017. PIMs were identified using 3 different explicit criteria; the Swedish quality indicators, the EU(7)-PIM list and the AGS Beers Criteria. PIM use was defined as having collected a minimum of one PIM at least once between July 01 - December 31, 2017. RESULTS The numbers of people using one or more PIMs were 7629 (21.7%) according to the Swedish quality indicators, 11,838 (33.6%) according to the EU(7)-PIM list, and 12,002 (34.1%) according to AGS Beers Criteria. Antipsychotics, antithrombotic agents and anxiolytics were the most frequently used PIM class according to the different assessment tools, respectively. The use of PIMs was positively associated with vascular dementia and Lewy body dementia/Parkinson's disease dementia, regardless of the assessment tool used. However, the association between using at least one PIM and age, sex, MMT-value and frontotemporal dementia, differed depending on the criteria used. CONCLUSIONS The different results and included PIMs indicate the different perspectives on PIMs between criteria, which make it difficult to compare the results. However, psychotropic drug use requires further highlighting, as well as the association between PIM use and different types of major NCD.
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Affiliation(s)
- Eva Sönnerstam
- Department of Integrative Medical Biology, Umeå University, SE-901 87, Umeå, Sweden.
| | - Frida Harlin
- Department of Integrative Medical Biology, Umeå University, SE-901 87, Umeå, Sweden
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, SE-901 87, Umeå, Sweden.
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Parodi López N, Svensson SA, Wallerstedt SM. Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study. Eur J Clin Pharmacol 2022; 78:1331-1339. [PMID: 35648150 PMCID: PMC9283130 DOI: 10.1007/s00228-022-03337-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/12/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment. METHODS PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate. RESULTS In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment. CONCLUSION One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.
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Affiliation(s)
- Naldy Parodi López
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, 405 30, Gothenburg, Sweden. .,Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden.
| | - Staffan A Svensson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, 405 30, Gothenburg, Sweden.,Närhälsan Hjällbo Health Centre, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, 405 30, Gothenburg, Sweden.,HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Sweden
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Parodi López N, Svensson SA, Wallerstedt SM. Association between recorded medication reviews in primary care and adequate drug treatment management - a cross-sectional study. Scand J Prim Health Care 2021; 39:419-428. [PMID: 34549673 PMCID: PMC8725889 DOI: 10.1080/02813432.2021.1973239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To investigate the association between a recorded procedure code for a medication review and adequate drug treatment management, and to explore factors associated with this code. DESIGN AND SETTING Cross-sectional study; two primary health care centres, in Region Västra Götaland, Sweden. SUBJECTS A total of 302 consecutive patients (≥65 years old, 59% female; median number of drugs: six) requiring a non-urgent consultation with a physician in October-November 2017. MAIN OUTCOME MEASURE Adequate drug treatment management (treatment that did not require any further action), determined in consensus by two specialists in family medicine blinded to the medication review code. RESULTS Adequate drug treatment management was, overall, less common in those with a recorded medication review over the last year: 63% versus 73% (p = 0.047). This negative association was evident among patients aged 65-74 years: 49% versus 74% (p = 0.003), but absent in those ≥75 years old: 67% versus 70% (p = 0.77). Recommendations from consensus included the search for additional information to be able to make a decision regarding initiation or withdrawal of a drug (n = 53), withdrawal of a drug (n = 41), or ordering a laboratory test (n = 25). Factors associated with a recorded procedure code included age above the remuneration limit of 75 years (odds ratio: 9.8; 95% confidence interval 5.0-19), type 2 diabetes (3.0 (1.5-6.2)), hypertension (2.4 (1.2-4.8)), and depression (2.5 (1.02-6.0)). CONCLUSIONS The presence of a recorded medication review was not positively associated with adequate drug treatment management but was associated with the age limit for remuneration, and some chronic diseases.Key pointsTo improve drug treatment in older people in primary care, a remuneration system linked to recorded medication reviews has been introduced.In this study, fewer patients with than without a recorded medication review (63% versus 73%) had adequate drug treatment management.A recorded medication review was ten times more common in those ≥75 years, that is, the age limit for remuneration.Recorded codes for medication reviews were also common in those with type 2 diabetes, hypertension, and depression.
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Affiliation(s)
- Naldy Parodi López
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden
- CONTACT Naldy Parodi López Närhälsan Kungshöjd Health Centre, Kaserntorget 11A, 41118, Gothenburg, 44731, Sweden
| | - Staffan A. Svensson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Närhälsan Hjällbo Health Centre, Gothenburg, Sweden
| | - Susanna M. Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Sweden
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Lönnbro J, Holmqvist L, Persson E, Thysell P, Åberg ND, Wallerstedt SM. Inter-rater reliability of assessments regarding the quality of drug treatment, and drug-related hospital admissions. Br J Clin Pharmacol 2021; 87:3825-3834. [PMID: 33609324 DOI: 10.1111/bcp.14790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate inter-rater agreement on the quality of drug treatment, and the relationship between the drug treatment and hospital admission. METHODS Three specialist physicians and two resident physicians determined, independently and in consensus, the quality of drug treatment from an overall medical perspective, and its association with admission, in 30 randomly selected patients (50% female, median age 72 years) admitted to Sahlgrenska University Hospital, Sweden, in April 2018. The inter-rater agreement was evaluated with Gwet's agreement coefficient (AC1 ). RESULTS In all, 200 (95%) out of 210 drugs at admission and 238 (97%) out of 245 drugs at discharge were assessed as reasonable drug treatment by all assessors. Conversely, none of the drugs at admission, and two at discharge, were assessed as unreasonable drug treatment by all assessors (AC1 : 0.88 and 0.94 [all], 0.86 and 0.95 [specialists], 0.92 and 0.92 [residents], respectively). The assessments regarding the association between the drug treatment and the hospital admission (not related or main/contributory reason) were consistent between the assessors for 16 out of 30 patients (AC1 : 0.67 [all], 0.74 [specialists], 0.54 [residents]). In none of the three cases where the hospital admission was considered possibly attributable to a prescribing error did the assessors make consistent assessments. CONCLUSIONS As the inter-rater agreement ranged between weak and almost perfect, the reliability of assessments of drug treatment quality, as well as adverse consequences, appears to be a methodological concern. To yield acceptably reliable results regarding both drug treatment aspects at issue, specialist physicians should be involved.
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Affiliation(s)
- Johan Lönnbro
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lina Holmqvist
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Persson
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Thysell
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - N David Åberg
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,HTA Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
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Toepfer S, Bolbrinker J, König M, Steinhagen-Thiessen E, Kreutz R, Demuth I. Potentially inappropriate medication in older participants of the Berlin Aging Study II (BASE-II) - Sex differences and associations with morbidity and medication use. PLoS One 2019; 14:e0226511. [PMID: 31887163 PMCID: PMC6936809 DOI: 10.1371/journal.pone.0226511] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/27/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction Multimorbidity in advanced age and the need for drug treatment may lead to polypharmacy, while pharmacokinetic and pharmacodynamic changes may increase the risk of adverse drug events (ADEs). Objective The aim of this study was to determine the proportion of subjects using potentially inappropriate medication (PIM) in a cohort of older and predominantly healthy adults in relation to polypharmacy and morbidity. Methods Cross-sectional data were available from 1,382 study participants (median age 69 years, IQR 67–71, 51.3% females) of the Berlin Aging Study II (BASE-II). PIM was classified according to the EU(7)-PIM and German PRISCUS (representing a subset of the former) list. Polypharmacy was defined as the concomitant use of at least five drugs. A morbidity index (MI) largely based on the Charlson Index was applied to evaluate the morbidity burden. Results Overall, 24.1% of the participants were affected by polypharmacy. On average, men used 2 (IQR 1–4) and women 3 drugs (IQR 1–5). According to PRISCUS and EU(7)-PIM, 5.9% and 22.6% of participants received at least one PIM, while use was significantly more prevalent in females (25.5%) compared to males (19.6%) considering EU(7)-PIM (p = 0.01). In addition, morbidity in males receiving PIM according to EU(7)-PIM was higher (median MI 1, IQR 1–3) compared to males without PIM use (median MI 1, IQR 0–2, p<0.001). Conclusion PIM use occurred more frequently in women than in men, while it was associated with higher morbidity in males. As expected, EU(7)-PIM identifies more subjects as PIM users than the PRISCUS list but further studies are needed to investigate the differential impact of both lists on ADEs and outcome. Key points We found PIM use to be associated with a higher number of regular medications and with increased morbidity. Additionally, we detected a higher prevalence of PIM use in females compared to males, suggesting that women and people needing intensive drug treatment are patient groups, who are particularly affected by PIM use.
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Affiliation(s)
- Sarah Toepfer
- Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany
| | - Juliane Bolbrinker
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Maximilian König
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité-Universitätsmedizin, Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany
| | - Reinhold Kreutz
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Ilja Demuth
- Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany
- Berlin Insitute of Health Center for Regenerative Therapies”oder ausführlicher „Charité—Universitätsmedizin Berlin, BCRT—Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
- * E-mail:
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Parodi López N, Wallerstedt SM. Quality of prescribing in older people from a broad family physician perspective: a descriptive pilot study. BMJ Open 2019; 9:e027290. [PMID: 31160274 PMCID: PMC6549657 DOI: 10.1136/bmjopen-2018-027290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the quality of drug treatment in older people from a broad family physician perspective, and to provide evidence for power calculations in full-scale studies on prescribing quality. DESIGN Descriptive, retrospective pilot study. SETTING A primary healthcare centre in Sweden. PARTICIPANTS 123 consecutive patients, ≥65 years, with a non-urgent physician consultation in January 2016. MEASURES The drug treatment was assessed by a physician as either appropriate or suboptimal, taking individual factors like morbidity, life expectancy and concurrent drug treatment into account, and preceded by the application of 493 criteria from three screening tools for Potentially Inappropriate Medications (PIMs) and Potential Prescribing Omissions (PPOs). Suboptimal drug treatment was further categorised regarding priority: (1) immediate change suggested or (2) actions suggested in the longer term. Prevalence of the procedure code 'medication review' and the results thereof were also recorded. RESULTS Median age: 76 years; 48% women. When a family physician perspective was applied, and 593 PIMs/PPOs identified in 117 (95%) patients considered, 45 (37%) patients had suboptimal drug treatment. Immediate handling was suggested in 13 (11%) patients, most often concerning withdrawals of drugs for anxiety and insomnia. Handling in the longer term was suggested in 32 (26%) patients, most often concerning overuse of proton pump inhibitors. Over the last year, the procedure code 'medication review' was recorded for 65 (53%) patients. In medication reviews recorded during January 2016 (n=45), 23 (7%) drugs out of 309 were acted on, most often a dosage adjustment. CONCLUSIONS This pilot study shows that when a broad family physician perspective is applied, taking individual factors and medical priorities in the complex clinical situation into account, drug treatment in primary care is appropriate for the majority of older patients. The results may be useful in sample size considerations for future studies on prescribing practices.
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Affiliation(s)
- Naldy Parodi López
- Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Susanna Maria Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- HTA-centrum, Sahlgrenska universitetssjukhuset, Gothenburg, Sweden
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Use of statins in the elderly according to age and indication-a cross-sectional population-based register study. Eur J Clin Pharmacol 2019; 75:959-967. [PMID: 30826850 DOI: 10.1007/s00228-019-02645-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/04/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To investigate statin use in the elderly by age (≥ 80 vs. 65-79 years) in relation to established indications. METHODS A population-based cohort, including data from four registers, encompassing inhabitants in Region Västra Götaland, Sweden, was used. Statin users were defined as those filling statin prescriptions ≥ 75% of the year 2010. Primary care and hospital diagnoses in 2005-2010 regarding ischemic heart disease, stroke, transient ischemic attacks, and diabetes were considered established indications. RESULTS A total of 278,205 individuals were analyzed. In individuals aged ≥ 80 and 65-79 years (n = 81,885 and n = 196,320, respectively), 17% (95% confidence interval 17%; 18%) and 23% (23%; 23%) respectively, were statin users. Among the statin users, 74% (73%; 74%) of those aged ≥ 80 and 60% (59%; 60%) of those aged 65-79 years had ≥ 1 established indication. Conversely, of those with ≥ 1 established indication, 30% (30%; 31%) and 53% (52%; 53%) were on statins in the respective age groups. Logistic regression revealed that age, nursing home residence, and multi-dose drug dispensing were the most prominent negative predictors for statin use; adjusted odds ratios (95% confidence interval): 0.45 (0.44; 0.46), 0.39 (0.36; 0.42), and 0.47 (0.44; 0.49), respectively. CONCLUSIONS In the oldest old (≥ 80 years), statin users were fewer and had more often an established indication, suggesting that physicians extrapolate scientific evidence for beneficial effects in younger age groups to the oldest, but require a more solid ground for treatment. As the oldest old, nursing home residents, and those with multi-dose drug-dispensing were statin users to a lesser extent, physicians may often refrain from treatment in those with lower life expectancy, either due to age or to severely reduced health status. In both age groups, our results however also indicate some over- as well as undertreatment.
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Lönnbro J, Nylén K, Wallerstedt SM. Developing professional confidence in the art of prescribing-a randomized controlled study on structured collegial discussions during internship. Eur J Clin Pharmacol 2019; 75:687-696. [PMID: 30693366 DOI: 10.1007/s00228-018-02619-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/21/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate whether an educational intervention based on collegial discussions on patient cases could increase interns' professional confidence in prescribing. METHODS In a randomized controlled study at Sahlgrenska University Hospital, Gothenburg, Sweden, 69 interns (median age: 29 years, 54% female) were allocated to an intervention or control group. The intervention consisted of two 3-h seminars based on collegial discussions of patient cases focused on performing medication reviews. This included reconciling the drug treatment and ascertaining that it is reasonable given the patient's current health status, as well as tips on practical handling of the medical records system and integrated decision support. Self-assessed confidence in performing medication reviews was evaluated with questionnaires distributed at baseline and at 6-month follow-up. RESULTS Fifty-seven (83%) interns completed the questionnaires. Although the opposite was found at baseline, intervention interns, in comparison with controls, at follow-up, were more confident in performing medication reviews (4.3 ± 0.9 vs. 3.6 ± 1.3, P = 0.034; 1 = completely disagree to 5 = completely agree). At follow-up, the intervention participants had increased their confidence in prescribing to a greater extent compared with the control participants, including performing medication reviews as well as taking responsibility for the medication list at discharge: + 1.5/+ 1 vs ± 0 on the 5-point agreement scale (all P ≤ 0.01). Among other positive outcomes, the intervention increased the interns' awareness of adverse effects as a potential cause of symptoms and their confidence in withdrawing a medication. CONCLUSION Structured collegial discussions on pharmacotherapy, even of a relatively short duration, can increase junior physicians' professional confidence in prescribing medicines.
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Affiliation(s)
- Johan Lönnbro
- Department of Medicine, Sahlgrenska University Hospital, 413 46, Gothenburg, Sweden
| | - Karin Nylén
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden. .,Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Eriksson AL, Wallerstedt SM. Developing confidence in basic prescribing skills during medical school: a longitudinal questionnaire study investigating the effects of a modified clinical pharmacology course. Eur J Clin Pharmacol 2018; 74:1343-1349. [PMID: 29955909 PMCID: PMC6132548 DOI: 10.1007/s00228-018-2508-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 06/21/2018] [Indexed: 10/29/2022]
Abstract
PURPOSE To investigate if increased focus on pharmacotherapy during medical school can increase students' confidence in basic prescribing skills, that is, performing medication reviews and writing medication discharge summaries. METHODS In 2016, the clinical pharmacology course in medical school in Gothenburg, Sweden, was modified to facilitate the students' acquisition of prescribing skills, with (i) clarified learning outcomes; (ii) supply of a list of common drugs for self-completion; (iii) instructions to practice medication reviews/discharge summaries during the ward-based education; and (iv) a concluding compulsory seminar where the students were to present prescribing-related experiences from their ward-based attendance. Questionnaires were administered to students participating in the course before (2016; n = 101) and after (2017; n = 137) implementation of the modifications. Students were asked to grade their agreement from 1 (totally disagree) to 5 (totally agree) on statements related to their perceived confidence in basic prescribing skills. RESULTS In all, 195 students returned the questionnaire (response rate 82%; median age 24 years; 68% female). Confidence was rated higher after the modifications were implemented, both regarding medication reviews and medication discharge summaries, after vs. before 3.6 ± 1.2 vs. 3.2 ± 1.0 (P = 0.024), and 4.3 ± 0.9 vs. 3.9 ± 1.1 (P = 0.008), respectively. The adjusted odds for being confident in performing these tasks were 1.49/1.36 times greater after the course modifications (P = 0.047/0.019). Perceived confidence in performing medication reviews/summary reports was positively correlated with numbers performed (P < 0.0001). CONCLUSIONS Modifications of the clinical pharmacology course during medical school, focusing on students' training in pharmacotherapy, was associated with increased confidence of this core skill for a physician.
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Affiliation(s)
- Anna L Eriksson
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Susanna M Wallerstedt
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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The associations of geriatric syndromes and other patient characteristics with the current and future use of potentially inappropriate medications in a large cohort study. Eur J Clin Pharmacol 2018; 74:1633-1644. [PMID: 30159676 DOI: 10.1007/s00228-018-2534-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To assess the changes in use of potentially inappropriate medication (PIM) as defined by the 2015 Beers criteria, the EU(7)-PIM, and the PRISCUS list over a 6-year period and to identify determinants for current and future PIM use with a particular focus on geriatric syndromes. METHODS In a German cohort of 2878 community-dwelling adults aged ≥ 60 years, determinants of the use of ≥ 1 PIM were identified in multivariable logistic regression (cross-sectional analysis) and weighted generalized estimating equation models (longitudinal analysis). RESULTS Prevalences for Beers, EU(7), and PRISCUS PIM were 26.4, 37.4, and 13.7% at baseline and decreased to 23.1, 36.5, and 12.3%, respectively, 6 years later. Unadjusted prevalences in participants with any geriatric syndrome (frailty, co-morbidity, functional, or cognitive impairment) were approximately twice as high as in robust older adults. In multivariable analyses, cognitive impairment was statistically significantly associated with the use of PIM of all three criteria in the cross-sectional (odds ratio (OR) point estimates 1.90-2.21) but not in the longitudinal models. In contrast, frailty, co-morbidity, and functional impairment were statistically significantly associated with the use of PIM of at least one of the three criteria in both models. However, the associations varied for the PIM criteria, and in the longitudinal analysis, associations were only statistically significant for Beers PIM (ORs [95% confidence intervals]: frailty (2.23 [1.15, 4.31]), co-morbidity by five total co-morbidity score points (1.21 [1.05, 1.38]), and functional impairment (1.51 [1.00, 2.27]). Other statistically significant determinants of the incidence of PIM (any definition) were female sex, age, coronary heart disease, heart failure, biomarkers of the metabolic syndrome, and history of ulcer, depressive episodes, hip fracture, or any cancer. CONCLUSIONS Older adults with frailty, co-morbidity, cognitive, and functional impairment had higher odds of taking PIM or getting a PIM prescription in the future (exception: cognitive impairment). Physicians should be especially cautious when prescribing drugs for these patients who are particularly susceptible to adverse reactions.
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Rognstad S, Brekke M, Gjelstad S, Straand J, Fetveit A. Potentially Inappropriate Prescribing to Older Patients: Criteria, Prevalence and an Intervention to Reduce It: The Prescription Peer Academic Detailing (Rx-PAD) Study - A Cluster-Randomized, Educational Intervention in Norwegian General Practice. Basic Clin Pharmacol Toxicol 2018; 123:380-391. [PMID: 29753315 DOI: 10.1111/bcpt.13040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 04/29/2018] [Indexed: 12/25/2022]
Abstract
Potentially inappropriate prescriptions (PIP) is drug treatment, which in general, at the group level for a median/mean patient, can be considered unfavourable meaning that the risks commonly may outweigh the benefits. This MiniReview reports and discusses the main findings in a large cluster-randomized educational intervention in Norwegian general practice, aimed at reducing the prevalence of PIPs to patients ≥70 years (The Rx-PAD study). Targets for the intervention were general practitioners (GPs) in continuing medical education (CME) groups receiving educational outreach visits (i.e. peer academic detailing). A Delphi consensus process, with a panel of medical experts, was undertaken to elaborate a list of explicit criteria defining PIPs for patients ≥70 years in general practice. Agreement was achieved for 36 explicit PIP criteria, the so-called Norwegian General Practice (NorGeP) criteria. Using a selection (n = 24) of these criteria during a 1-year baseline period on the prescribing practice of 454 GPs (i.e. those enrolled to participate in the intervention trial), we found a prevalence rate of 24.7 PIPs per 100 patients ≥70 years per year. In the Rx-PAD study, 449 GPs completed an educational intervention (96.6% of the included GPs), 250 in the intervention group and 199 in the control arm. Following the intervention, PIPs were reduced by 13% (95% CI 8.6-17.3), and the number of patients who were no longer exposed to one or more PIPs was reduced by 1173 (8.1%). The GPs who responded most strongly to the educational intervention were the oldest GPs (57-68 years), and these were the GPs with the highest prevalence of PIPs at baseline before the intervention.
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Affiliation(s)
- Sture Rognstad
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Mette Brekke
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Svein Gjelstad
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Jørund Straand
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Arne Fetveit
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Lönnbro J, Wallerstedt SM. Clinical relevance of the STOPP/START criteria in hip fracture patients. Eur J Clin Pharmacol 2017; 73:499-505. [PMID: 28050623 PMCID: PMC5350233 DOI: 10.1007/s00228-016-2188-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/20/2016] [Indexed: 01/08/2023]
Abstract
Purpose The aim of this study was to investigate the clinical relevance of potentially inappropriate medications (PIMs), identified by the STOPP criteria, and potential prescribing omissions (PPOs), identified by the START criteria, and to identify predictors for clinically relevant PIMs and PPOs. Methods The STOPP and START criteria were applied on the medication lists of 200 older hip fracture patients, consecutively recruited to a randomized controlled study in 2009. For each identified PIM and/or PPO, the clinical relevance was assessed at the individual level, using medical records from both hospital and primary care as well as data collected in the original study. Results A total of 555 PIMs/PPOs were identified in 170 (85%) patients (median age: 85 years, 67% female), 298 (54%) of which, in 141 (71%) patients, were assessed as clinically relevant. A greater proportion of PIMs than PPOs were clinically relevant: 71% (95% CI: 66%; 76%) vs. 32% (27%; 38%). A greater proportion of PPOs than PIMs could not be assessed with available information: 38% (32%; 44%) vs. 22% (17%; 27%). Number of drugs and multidose drug dispensing, but not age, sex, cognition, or nursing home residence, were associated with ≥1 clinically relevant PIMs/PPOs. Conclusions The present study illustrates that one in two PIMs/PPOs identified by the STOPP/START criteria is clearly clinically relevant, PIMs being clinically relevant to a greater extent than PPOs. Based on available information, the clinical relevance could not be determined in a non-negligible proportion of PIMs/PPOs. Number of drugs and multidose drug dispensing were associated with ≥1 clinically relevant PIMs/PPOs.
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Affiliation(s)
- Johan Lönnbro
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, SE-413 90, Gothenburg, Sweden.
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Wallerstedt SM, Wettermark B, Hoffmann M. The First Decade with the Swedish Prescribed Drug Register - A Systematic Review of the Output in the Scientific Literature. Basic Clin Pharmacol Toxicol 2016; 119:464-469. [PMID: 27112967 DOI: 10.1111/bcpt.12613] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/18/2016] [Indexed: 01/15/2023]
Abstract
The aim of this study was to quantify and characterize the scientific output from the Swedish Prescribed Drug Register (SPDR) the first decade after its establishment. A systematic literature search was performed in Medline, EMBASE and PubMed (2005-2014). Additional publications were identified by personal knowledge, reference lists, contact with active authors and a citation search in Web of Sciences. Publications using SPDR data were included in the analysis and characterized regarding study type, presence of patient-level record linkage, target population and topic. A total of 719 publications were identified in the literature search and an additional 148 by other strategies. Three hundred and thirty-eight studies fulfilled the inclusion criteria. The majority were analytic (n = 166; 49.1%) or descriptive (n = 100; 29.5%). The remaining studies focused on validation (n = 20; 5.9%), health economics (n = 16; 4.7%) or miscellaneous (n = 36; 10.7%). The analytic studies investigating effects of drug exposure focused mainly on safety (n = 46) and/or effectiveness (n = 24). The first publications appeared in 2007 (n = 6), and in 2014, 90 articles using SPDR were published. Over the years, linkage with other registers using the personal identity number increased (0-88.9% of the publications). The population was often selected by age (49.7%), condition (45.0%) and/or drug (22.8%) and concerned predominantly psychiatric (29.0%) and cardiovascular (20.4%) diseases. In conclusion, this study illustrates that the establishment of a nationwide individual-based register on dispensed prescription drugs facilitates an encouraging development of pharmacoepidemiological research, both regarding the number of publications and the scientific level of the analyses.
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Affiliation(s)
- Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Björn Wettermark
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Department of Healthcare Development, Public Healthcare Services Committee, Stockholm County Council, Stockholm, Sweden
| | - Mikael Hoffmann
- NEPI, Network for Pharmacoepidemiology, Linköping University, Linköping, Sweden
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Wallerstedt SM, Belfrage B, Fastbom J. Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study. Pharmacoepidemiol Drug Saf 2015; 24:906-14. [PMID: 26147790 PMCID: PMC4758385 DOI: 10.1002/pds.3827] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 06/02/2015] [Accepted: 06/08/2015] [Indexed: 11/06/2022]
Abstract
Purpose To evaluate the concurrent validity of three European sets of drug‐specific indicators of prescribing quality Methods In 200 hip fracture patients (≥65 years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug‐specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment). Results According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi‐dose drug dispensing, and number of drugs. Conclusions In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation. Copyright © 2015 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons, Ltd.
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Affiliation(s)
| | | | - Johan Fastbom
- Aging Research Center, Karolinska Institutet and Stockholm University, Sweden
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