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Høj K, Bekker HL, Bro F, Olesen AE, Kristensen JK, Christensen LD. Person-centred medicine in the care home setting: development of a complex intervention. BMC PRIMARY CARE 2024; 25:189. [PMID: 38802794 PMCID: PMC11131350 DOI: 10.1186/s12875-024-02437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Person-centred medicine is recommended in the care of older patients. Yet, involvement of care home residents and relatives in medication processes remains limited in routine care. Therefore, we aimed to develop a complex intervention focusing on resident and relative involvement and interprofessional communication to support person-centred medicine in the care home setting. METHODS The development took place from October 2021 to March 2022 in the Municipality of Aarhus, Denmark. The study followed the Medical Research Council guidance on complex intervention development using a combination of theoretical, evidence-based, and partnership approaches. The patient involvement tool, the PREparation of Patients for Active Involvement in medication Review (PREPAIR), was included in a preliminary intervention model. Study activities included developing programme theory, engaging stakeholders, and exploring key uncertainties through interviews, co-producing workshops, and testing with end-users to develop the intervention and an implementation strategy. The Consolidated Framework for Implementation Research and the Interprofessional Shared Decision Making Model were used. Data were analysed using a rapid analysis approach. RESULTS Before the workshops, six residents and four relatives were interviewed. Based on their feedback, PREPAIR was modified to the PREPAIR care home to fit the care home population. In total, ten persons participated in the co-producing workshops, including health care professionals and municipal managerial and quality improvement staff. The developed intervention prototype was tested for three residents and subsequently refined to the final intervention, including two fixed components (PREPAIR care home and an interprofessional medication communication template) delivered in a flexible three-stage workflow. Additionally, a multi-component implementation strategy was formed. In line with the developed programme theory, the intervention supported health care professionals´ awareness about resident and relative involvement. It provided a structure for involvement, empowered the residents to speak, and brought new insights through dialogue, thereby supporting involvement in medication-related decisions. The final intervention was perceived to be relevant, acceptable, and feasible in the care home setting. CONCLUSION Our results indicate that the final intervention may be a viable approach to facilitate person-centred medicine through resident and relative involvement. This will be further explored in a planned feasibility study.
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Affiliation(s)
- Kirsten Høj
- Research Unit for General Practice, Aarhus, Denmark.
- Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.
| | - Hilary Louise Bekker
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Research Centre of Patient Involvement, Aarhus University Hospital, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Anne Estrup Olesen
- Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Olesen AE, Vaever TJ, Simonsen M, Simonsen PG, Høj K. Deprescribing in primary care without deterioration of health-related outcomes: A real-life, quality improvement project. Basic Clin Pharmacol Toxicol 2024; 134:72-82. [PMID: 37400998 DOI: 10.1111/bcpt.13925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 07/05/2023]
Abstract
Medication reviews focusing on deprescribing can reduce potentially inappropriate medication; however, evidence regarding effects on health-related outcomes is sparse. In a real-life quality improvement project using a newly developed chronic care model, we investigated how a general practitioner-led medication review intervention focusing on deprescribing affected health-related outcomes. We performed a before-after intervention study including care home residents and community-dwelling patients affiliated with a large Danish general practice. The primary outcomes were changes in self-reported health status, general condition and functional level from baseline to 3-4 months follow-up. Of the 105 included patients, 87 completed the follow-up. From baseline to follow-up, 255 medication changes were made, of which 83% were deprescribing. Mean self-reported health status increased (0.55 [95% CI: 0.22 to 0.87]); the proportion with general condition rated as 'average or above' was stable (0.06 [95% CI: -0.02 to 0.14]); and the proportion with functional level 'without any disability' was stable (-0.05 [95% CI: -0.09 to 0.001]). In conclusion, this general practitioner-led medication review intervention was associated with deprescribing and increased self-reported health status without the deterioration of general condition or functional level in real-life primary care patients. The results should be interpreted carefully given the small sample size and lack of control group.
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Affiliation(s)
- Anne Estrup Olesen
- Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tanja Joest Vaever
- Centre for Health and Care, Municipality of Frederikshavn, Frederikshavn, Denmark
| | - Martin Simonsen
- General practitioner practice 'Laegeklinikken Frederikshavn', Frederikshavn, Denmark
| | | | - Kirsten Høj
- Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
- Research Unit for General Practice, Aarhus, Denmark
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3
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Paust A, Lau SR, Bro F, Prior A, Mygind A. Temporal capital and unaligned times as inequality mechanisms: A case study of chronic care in general practice. Soc Sci Med 2023; 338:116337. [PMID: 37918228 DOI: 10.1016/j.socscimed.2023.116337] [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: 04/27/2023] [Revised: 09/08/2023] [Accepted: 10/11/2023] [Indexed: 11/04/2023]
Abstract
Addressing persistent health inequality is one of the most critical challenges in public health. Structural features of 'time' may provide new perspectives on the link between social inequality and time in a healthcare context. Drawing on the case of chronic care in Danish general practice, we aim to use temporal capital as a theoretical frame to unfold how patients' social positions are interlinked with their medical treatment. We followed patients with multimorbidity and polypharmacy in general practice. Data were collected from interviews, observations, informal conversations, and medical records. We used the concept temporal capital to illuminate the mechanism of inequality in healthcare. We suggest understanding temporal capital as patients' abilities and possibilities to understand, navigate, negotiate, and manage the temporal rhythms of healthcare. Unaligned times, i.e. the mismatch between patients' temporal capital and healthcare organisations and/or professionals' rhythms, are unfolded in five themes: unaligned schedules (scheduling the consultation to fit everyday life and institutional rhythms and attending the consultation), sequences (preparing activities in a specific order to accommodate clinical linearity), agendas (timing the agenda to the clinical workflow), efficiency (ensuring efficiency in the consultation and balancing on-task and off-task content), and pace (conducting the consultation to accommodate fixed durations). Differences in temporal capital and hence abilities and possibilities for aligning with the temporal rhythms of healthcare may be facilitated or restrained by the individual patient's social position, thereby defining and establishing temporal mechanisms of social inequality in medical treatment. In conclusion, social inequality in medical treatment has several temporal references, resulting from pre-existing inequalities and causing new ones. Notions of temporal capital and temporal unalignment provide a useful lens for exploring social inequality in healthcare encounters.
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Affiliation(s)
- Amanda Paust
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000 Aarhus C, Denmark; Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark.
| | - Sofie Rosenlund Lau
- Research Unit for General Medicine, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen K, Denmark.
| | - Flemming Bro
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000 Aarhus C, Denmark; Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark.
| | - Anders Prior
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000 Aarhus C, Denmark.
| | - Anna Mygind
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000 Aarhus C, Denmark.
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4
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Pottegård A, Sørensen AMS, Olesen M, Rasmussen L. Opioid prescriber responsibility: A Danish drug utilization study. Br J Clin Pharmacol 2023; 89:1425-1430. [PMID: 36366867 DOI: 10.1111/bcp.15595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS We describe the distribution of prescribers responsible for opioid initiation and maintenance (general practice, hospital prescribers and other prescribers) in Denmark. METHODS We leveraged data on opioid fills from a 20% sample of all Danes alive during 2000-2021. RESULTS Overall, general practitioners were responsible for most treatment initiation (74% during 2000-2021) and maintenance treatment (92%). However, while hospital prescribers initiated ≈20% of treatments during 2001-2012, this increased to 35% in 2021. Similarly, hospital prescriber's share of maintenance treatment increased from 5.9% during 2000-2012 to 13% in 2021. This change was particularly pronounced for morphine initiation (48% hospital prescribers in 2021 up from 38% during 2000-2010) and oxycodone initiation (78% up from 41%). Regarding choice of opioids, codeine use dropped markedly, in particular among hospital prescribers. Tramadol was consistently the most common first choice opioid in general practice (33% in 2021), whereas its use among hospital prescribers decreased (54% during 2000-2015 to 15% in 2021). Conversely, the proportion of treatment initiation by hospital prescribers composed of morphine and oxycodone increased to 38% and 42% in 2021, respectively. CONCLUSIONS General practice prescribes most opioids; however, hospital prescribers are increasingly responsible for opioid prescribing, in particular initiation of morphine and oxycodone.
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Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anne Mette Skov Sørensen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Morten Olesen
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Lotte Rasmussen
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Ishtiak-Ahmed K, Köhler-Forsberg O, Mortensen EL, Nierenberg AA, Gasse C. Concurrent use of polypharmacy and potentially inappropriate medications with antidepressants in older adults: A nationwide descriptive study in Denmark during 2015-2019. Gen Hosp Psychiatry 2023; 82:66-74. [PMID: 36989765 DOI: 10.1016/j.genhosppsych.2023.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE Concurrent polypharmacy and potentially-inappropriate-medication (PIMs) use with antidepressants in older adults is understudied. We investigated the prevalence and associated user characteristics of concurrent polypharmacy (≥5 drugs) and PIMs with antidepressants in all older adults (≥65 years) in Denmark based on prescriptions filled at community pharmacies during 2015-2019. METHOD We applied a cross-sectional and cohort study design using socio-demographic and clinical data from Danish registers. RESULTS A total of 261,479 older adults (mean age 76 years, females 63%) redeemed at least one prescription of antidepressants during 2015-2019. The prevalence of polypharmacy was 73%, and PIMs was 56%, with over 80% using at least one other nervous system drug or cardiovascular system drug concomitantly with antidepressants. Characteristics associated with higher concurrent use of polypharmacy and PIM with antidepressants were older age, marital status as widow/widower/separated/single, place of residence predominantly in the rural regions, non-western origin, and having somatic diagnoses. Some characteristics showed opposite directions of the associations with the two outcomes, including previous antidepressant use and psychiatric diagnoses being associated with higher use of polypharmacy but lower use of PIM. CONCLUSION High polypharmacy and PIM use with antidepressants underline the importance of regularly reviewing pharmacological treatments in older adults with depression.
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Affiliation(s)
- Kazi Ishtiak-Ahmed
- Department of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, (8200 Aarhus N), Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, (8200 Aarhus, N), Denmark.
| | - Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital - Psychiatry, Aarhus, (8200 Aarhus N), Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, (8200 Aarhus, N), Denmark
| | - Erik Lykke Mortensen
- Department of Public Health, University of Copenhagen, 1353 Copenhagen K, Denmark
| | - Andrew A Nierenberg
- Department of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, (8200 Aarhus N), Denmark; Dauten Family Center for Bipolar Treatment Innovation, MA, General Hospital, Boston, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Christiane Gasse
- Department of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, (8200 Aarhus N), Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, (8200 Aarhus, N), Denmark
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Sandbæk A, Møller MCR, Bro F, Høj K, Due Christensen L, Mygind A. Involving patients in medicines optimisation in general practice: a development study of the “PREparing Patients for Active Involvement in medication Review” (PREPAIR) tool. BMC PRIMARY CARE 2022; 23:122. [PMID: 35596147 PMCID: PMC9121082 DOI: 10.1186/s12875-022-01733-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 05/06/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Many patients have multiple health conditions and take multiple medications (polypharmacy). Active patient involvement may improve treatment outcomes and ensure patient-centred care. Yet, patient involvement remains a challenge in clinical practice. We aimed to develop and pilot test a questionnaire-based preparation and dialogue tool, the PREparing Patients for Active Involvement in medication Review (PREPAIR) tool, to encourage the involvement of patients with polypharmacy in medicines optimisation in general practice.
Methods
We conducted a literature review followed by a co-production process to develop the tool: a workshop with six GPs and pilot testing, including observations and interviews, with 22 patients, three GPs and three practice staff. During this process, we made continuous adaptations to the prototype. We analysed the qualitative data thematically, focusing on the development process and mechanisms of impact.
Findings
The final PREPAIR tool included five items concerning the patient’s experience of 1) adverse drug reactions, 2) excess medication, 3) unnecessary medication, 4) medication satisfaction and 5) medication-related topics to discuss with the GP (open-ended question). The applied workflow during testing was as follows; the patient completed the PREPAIR tool at home, to encourage reflection on the medication, and brought it to the GP consultation. During the consultation, the GP and the patient reviewed the patient’s responses and discussed potential medication-related problems. For some patients, the increased reflection led to worries about the medications. Still, the pilot testing showed that, when using the PREPAIR tool, the patients arrived at the clinic well prepared and empowered to speak. From the PREPAIR-supported dialogue, the GPs obtained a better understanding of patients’ perspectives and provided a more patient-centred consultation. For the patients, the PREPAIR-supported dialogue ultimately promoted an increased sense of security, satisfaction and insight into their medication, despite initial worries for some patients.
Conclusions
We developed a brief tool to support active patient involvement in medication review in general practice. The PREPAIR-tool was well received by both patients and GPs and fitted well into the existing clinical practice. Our findings suggest that the PREPAIR-tool can support patient involvement during consultations and facilitate patient-centred care.
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Baltzer Houlind M, Iversen E, Andersen A, Juul-Larsen HG, Carlson N, Andersen O, Hornum M. Further perspectives on statin use in patients with chronic kidney disease. Basic Clin Pharmacol Toxicol 2022; 131:303-305. [PMID: 36028936 DOI: 10.1111/bcpt.13785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Morten Baltzer Houlind
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,The Capital Region Pharmacy, Herlev, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Esben Iversen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Aino Andersen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Helle Gybel Juul-Larsen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Emergency Department, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Emergency Department, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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Treciokiene I, Bratcikoviene N, Gulbinovic J, Wettermark B, Taxis K. Non-persistence to antihypertensive drug therapy in Lithuania. Eur J Clin Pharmacol 2022; 78:1687-1696. [PMID: 35918539 PMCID: PMC9482566 DOI: 10.1007/s00228-022-03369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Indre Treciokiene
- Department of PharmacoTherapy, -Epidemiology & -Economics, Faculty of Science and Engineering, University of Groningen, -Epidemiology & -Economics, Groningen, Netherlands. .,Pharmacy Center, Institute of Biomedical Science, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Nomeda Bratcikoviene
- Department of Mathematical Statistics, Faculty of Fundamental Sciences, Vilnius Tech, Vilnius, Lithuania.,Department of Human and Medical Genetics, Institute of Biomedical Science, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jolanta Gulbinovic
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bjorn Wettermark
- Pharmacy Center, Institute of Biomedical Science, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Pharmacy, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Katja Taxis
- Department of PharmacoTherapy, -Epidemiology & -Economics, Faculty of Science and Engineering, University of Groningen, -Epidemiology & -Economics, Groningen, Netherlands
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Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core Concepts in Pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf 2022; 31:1015-1026. [PMID: 35819240 PMCID: PMC9545237 DOI: 10.1002/pds.5490] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022]
Abstract
Background Drug utilization studies are essential to facilitate rational drug use in the society. Aim In this review, we provide an overview of drug utilization measures that can be used with individual‐level drug dispensing data, referencing additional reading on the individual analysis. This is intended to serve as a primer for those new to drug utilization research and a shortlist from which researchers can identify useful analytical approaches when designing their drug utilization study. Results and Discussion We provide an overview of: (1) basic measures of drug utilization which are used to describe changes in drug use over time or compare drug use in different populations; (2) treatment adherence measures with specific focus on persistence and implementation; (3) how to measure drug combinations which is useful when assessing drug–drug interactions, concomitant treatment, and polypharmacy; (4) prescribing quality indicators and measures to assess variations in drug use which are useful tools to assess appropriate use of drugs; (5) proxies of prescription drug misuse and skewness in drug use; and (6) considerations when describing the characteristics of drug users or prescribers.
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Affiliation(s)
- Lotte Rasmussen
- Clinical Pharmacology, Pharmacy, and Environmental medicine, department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Björn Wettermark
- Department of Pharmacy, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Douglas Steinke
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Anton Pottegård
- Clinical Pharmacology, Pharmacy, and Environmental medicine, department of Public Health, University of Southern Denmark, Odense, Denmark
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10
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Huibers L, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB. Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study. Scand J Prim Health Care 2022; 40:227-236. [PMID: 35703579 PMCID: PMC9397449 DOI: 10.1080/02813432.2022.2073981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates. DESIGN Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data. SETTING OOH primary care of the Central Denmark Region. SUBJECTS All patient contacts in 2014-2017. MAIN OUTCOME MEASURES GPs' tendency to prescribe antibiotics. Excess variation (not attributable to chance). RESULTS We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including 'activity level' (i.e. number of patients seen in the past hour) for clinic and telephone consultations, 'familiarity with OOH care' (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r2: 0.008-0.025). CONCLUSION Some variation in the GPs' tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs' activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners' activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.
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Affiliation(s)
- Linda Huibers
- Research Unit for General Practice, Aarhus, Denmark
- CONTACT Linda Huibers Research Unit for General Practice, Bartholins Alle 2, Aarhus8000, Denmark
| | | | - Ellen Keizer
- Research Unit for General Practice, Aarhus, Denmark
| | - Bodil Hammer Bech
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
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11
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Thoegersen TW, Saedder EA, Lisby M. Is a High Medication Risk Score Associated With Increased Risk of 30-Day Readmission? A Population-Based Cohort Study From CROSS-TRACKS. J Patient Saf 2022; 18:e714-e721. [PMID: 35617596 DOI: 10.1097/pts.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The primary aim of this study was to evaluate whether a high Medication Risk Score (MERIS) upon admission to an emergency department is associated with increased risk of 30-day readmission in patients discharged directly home. Mortality, visit to general practitioner, and drug changes within 30 days were included as secondary outcomes. METHODS This is a historical cohort study with data from the Danish population-based open-cohort CROSS-TRACKS. Cox regression analyses were used to determine whether a high MERIS score was associated with increased risk of 30-day readmission and mortality. Visit to general practitioner and drug changes were tested with χ2 test and Wilcoxon rank sum test. RESULTS A total of 2106 patients were eligible: 2017 had a MERIS score lower than 14 (low-risk group), and 89 had a score of 14 or higher (high-risk group). The proportion of patients in the high-risk group who were readmitted was 21.3% compared with 16.3% in the low-risk group, resulting in a hazard ratio for readmission of 1.43 (95% confidence interval, 0.9-1.3). The hazard ratio for mortality was 8.3 (95% confidence interval, 3.0-22.8). No statistical significant difference was found in general practitioner visits; however, significantly more drug changes were observed in the high-risk group. CONCLUSIONS A high MERIS score was associated with increased risk of readmissions and can potentially assist healthcare professionals in the prioritizing of patients who may benefit from further exam, for example, additional medication review in acute care setting. Further investigation of MERIS and exploration of causal inferences between medication-related harm and medication-related readmissions are warranted.
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Højlund M, Rasmussen L, Olesen M, Munk-Olsen T, Pottegård A. Who prescribes quetiapine in Denmark? Br J Clin Pharmacol 2022; 88:4224-4229. [PMID: 35535441 PMCID: PMC9545446 DOI: 10.1111/bcp.15388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022] Open
Abstract
The second‐generation antipsychotic quetiapine is commonly used off‐label for its anxiolytic and hypnotic properties. However, quetiapine is associated with problematic side‐effects. We used Danish Medicinal Product Statistics and a 20% random sample of the Danish population's prescription fills (2001–2020) to describe the utilization of quetiapine and proportion of various prescriber types (general practitioner [GP], specialist in private practice, hospital physician and other prescribers) both in connection to first‐time and subsequent prescriptions. In 2020, 92% of all quetiapine was dispensed outside hospitals and the average daily dispensed quantity of quetiapine per user corresponded to 100 mg/user/d. A GP issued 53% of first‐time prescriptions and 75% of subsequent prescriptions for quetiapine in 2020. The proportion of quetiapine prescriptions issued by GPs varied by age group—from 14% among 0–17‐year‐olds to 93% among the ≥80‐year‐olds. Future initiatives on the rational use of quetiapine and related drugs, especially among adults, should target GPs.
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Affiliation(s)
- Mikkel Højlund
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Psychiatry Aabenraa, Mental Health Services in the Region of Southern Denmark, Aabenraa, Denmark
| | - Lotte Rasmussen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Olesen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Trine Munk-Olsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,The National Center for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Anton Pottegård
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
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13
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Kristensen KB, Lund LC, Jensen PB, Broe A, Rotbain E, Damkier P, Pottegård A, Andersen JH, Højlund M, Olesen M, Rasmussen L, Hansen MR, Ernst MT, Wesselhoeft R, Henriksen DP, Reilev M, Bliddal M, Hallas J. Development and Validation of a Nordic Multimorbidity Index Based on Hospital Diagnoses and Filled Prescriptions. Clin Epidemiol 2022; 14:567-579. [PMID: 35509520 PMCID: PMC9058012 DOI: 10.2147/clep.s353398] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/06/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose To develop the Nordic Multimorbidity Index (NMI), a multimorbidity measure specifically suited to the Nordic health and administrative registry data based on current diagnosis, treatment, and coding practices. Methods The NMI was developed to predict 5-year mortality in a population-based cohort of randomly sampled Danish residents aged ≥40 years (n = 425,087) followed from 2013 to 2018. Included predictors were selected from hospital diagnoses and filled drug prescriptions based on a combination of subject matter knowledge and a data-driven approach using backwards elimination. The performance of the NMI was assessed in a temporal validation cohort of Danish residents followed from 2007 to 2012 and in six cohorts of new users of selected drugs. The discriminative performance of the NMI, Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) was assessed using the c-statistic from logistic regression models with 5-year mortality as dependent variable and the multimorbidity index score, age, and sex as independent variables. Results The NMI included 50 predictors. In the temporal validation cohort, the c-statistic of the NMI (0.887, 95% CI 0.883–0.890) exceeded that of the CCI (0.871, 95% CI 0.868–0.874) and ECI (0.866, 95% CI 0.863–0.870). In all new user cohorts, the NMI outperformed the other indices with c-statistics ranging from 0.781 (95% CI 0.779–0.784) to 0.838 (95% CI 0.834–0.842). Conclusion The NMI predicted 5-year mortality in a general Danish population and six cohorts of new users of selected drugs and was superior to the CCI and ECI. The NMI could be preferred over these indices to quantify the level of multimorbidity for, eg, descriptive purposes or confounding control. The NMI should be validated in other patient populations and other Nordic countries.
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Affiliation(s)
- Kasper Bruun Kristensen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Lars Christian Lund
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Peter Bjødstrup Jensen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anne Broe
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emelie Rotbain
- Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Per Damkier
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anton Pottegård
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jacob Harbo Andersen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mikkel Højlund
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Psychiatry Aabenraa, Mental Health Services in the Region of Southern Denmark, Aabenraa, Denmark
| | - Morten Olesen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Lotte Rasmussen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Rix Hansen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Thomsen Ernst
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Rikke Wesselhoeft
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Child and Adolescent Psychiatry Odense, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
| | | | - Mette Reilev
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mette Bliddal
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Correspondence: Jesper Hallas, Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 19, 2, Odense, 5000, Denmark, Tel +4565503010, Email
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14
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Correction. Br J Clin Pharmacol 2022; 88:1398. [PMID: 35088445 PMCID: PMC9050081 DOI: 10.1111/bcp.15146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Høj K, Pedersen HS, Lundberg ASB, Bro F, Nielsen LP, Saedder EA. External validation of the Medication Risk Score in polypharmacy patients in general practice: A tool for prioritizing patients at greatest risk of potential drug-related problems. Basic Clin Pharmacol Toxicol 2021; 129:319-331. [PMID: 34237199 DOI: 10.1111/bcpt.13636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/14/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
Drug-related problems are important causes of patient harm and increased healthcare costs. To assist general practitioners in prioritizing patients in need of a critical medication review, we aimed to assess the ability of the Medication Risk Score (MERIS) to stratify patients with polypharmacy in general practice according to their risk of drug-related problems. We conducted a cross-sectional multi-centre external validation study. Patients receiving more than five concomitant medications (polypharmacy) were eligible. The outcome was potentially serious drug-related problems as evaluated by expert consensus. Performance was assessed in terms of calibration and discrimination indices. Of 497 patients, 489 were included in the main analysis. The median age (interquartile range) was 70.5 years (60-79). In total, 372 potentially serious drug-related problems were observed in 253 patients (52%). The MERIS was well calibrated above a score level of 10. The area under the receiver operating characteristic curve was 0.70 (95% confidence interval: 0.65-0.74). The performance of the MERIS was fair in patients with polypharmacy in general practice. Given the scale of drug-related problems and the lack of efficient prioritization tools in this setting, the MERIS could be a useful risk indicator to complement usual practice.
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Affiliation(s)
- Kirsten Høj
- Research Unit for General Practice, Aarhus, Denmark.,Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Flemming Bro
- Research Unit for General Practice, Aarhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Lars Peter Nielsen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Eva Aggerholm Saedder
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
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16
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Pottegård A, Olesen M, Christensen B, Christensen MB, Hallas J, Rasmussen L. Who prescribes drugs to patients: A Danish register-based study. Br J Clin Pharmacol 2021; 87:2982-2987. [PMID: 33496033 PMCID: PMC8359239 DOI: 10.1111/bcp.14691] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 12/27/2022] Open
Abstract
We describe the distribution of prescriber types responsible for issuing prescriptions in Denmark. Using a 20% random sample of all Danes alive during 2000–2018 (n = 1 515 025) and all their prescriptions filled at community pharmacies (n = 182 143 707), we found that general practitioners issued 88% of all prescriptions, followed by hospital physicians (7.4%) and private practicing specialists (4.2%). These values were stable over the study period. With increasing patient age, general practitioners were responsible for a larger proportion of prescriptions (e.g. 68% for patients aged 0–17 y and 89% for patients ≥51 y). General practitioners were responsible for 84% of all treatment initiation (first prescription) and 90% of all maintenance treatment. Corresponding values for hospital physicians were 9.5 and 6.3%, and for private practicing specialists 5.3 and 3.6%. In conclusion, general practitioners are responsible for the vast majority of prescribing in Denmark, including both treatment initiation and continuation, in particular among the elderly.
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Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Olesen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Bo Christensen
- Department of Public Health, Research Unit for General Practice, Aarhus University, Aarhus, Denmark.,Research Unit for General Practice Aarhus University, Aarhus, Denmark
| | - Morten Bondo Christensen
- Department of Public Health, Research Unit for General Practice, Aarhus University, Aarhus, Denmark.,Research Unit for General Practice Aarhus University, Aarhus, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Lotte Rasmussen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
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