[A telephone hotline as an easily accessible service for questions on schizophrenia]

Public relations activities of the German Research Network on Schizophrenia (GRNS) have shown that there is a demand for more information about schizophrenia disorder. This confirms international research findings that relatives of schizophrenia patients are particularly in need of information and support. In response, the GRNS has maintained a telephone hotline since 2001. The hotline is manned by clinical experts, psychiatrists, or psychologists once a week. The telephone calls are documented in a systematic manner. From 2001 to 2003, 3,909 calls were registered. This volume exceeds the limit of the hotline's resources. The telephone hotline is mainly used by relatives of psychotic patients. Most questions relate to the symptoms of schizophrenia and pharmaceutical treatment. The need for emotional support is also a high motivational factor for dialing the hotline number. The telephone hotline seems to be a worthwhile addition to the already existing crisis telephones and should be maintained even after public funding of the network expires.

[School entrance screening: prospects for health data collection for health promotion in the school and community]

The function of school entrance examinations changes over the period of history. Nowadays the early diagnosis of special disease is done by the medical practitioner outside the public health department, while the school health services are confronted with a new task in the field of local surveillance and health promotion. A doctorate thesis focuses on the question of what data should be obtained by the school entrance examination and what are the results for a data-based health promotion in school and community. The thesis concentrates on North Rhine-Westphalia and is based on an expert interview concerning to the "Jugendärztlichen Definitionen" of the Bielefelder Modell.

Utilisation of codeine and propoxyphene: geographic and demographic variations in prescribing, prescriber and recipient categories

OBJECTIVES

To assess (1) whether the utilisation of codeine or propoxyphene differs among the three major Swedish cities (Stockholm, Göteborg and Malmö) and between urban and semirural areas; (2) if so, whether it co-varies with the utilisation of other potentially dependence-promoting drugs, benzodiazepines; (3) what influence age, gender and socioeconomic factors have on the prescribing of the two narcotic analgesics; and (4) whether different codeine-prescriber categories have different prescribing habits.

METHODS

In Sweden, all pharmacies are owned by one corporation, Apoteket AB. This corporation collects, stores and compiles statistics on all drug sales in Sweden, and data are available both on national, regional, county and municipal levels. The employed unit is defined daily dose (DDD) per 1,000 inhabitants per day. Using the pharmacy computer system while dispensing a drug, prescription patterns can be elucidated. This system describes the number of drug items dispensed, drug amounts and age and gender of patients. Furthermore, data from another, ecological study were used to relate codeine and propoxyphene utilisation to that of benzodiazepines and to various socioeconomic data available from records of the city of Malmö.

RESULTS

The utilisation of analgesics in Sweden has increased during a 10-year period. The withdrawal of over-the-counter combinations containing aspirin and low-dose codeine in 1990 resulted only in a transient decrease of codeine use. The utilisation of codeine in Malmö and Göteborg was considerably higher than that in Stockholm and in the rest of Sweden, including the surroundings of Malmö. In Malmö and Göteborg, codeine was most often prescribed by private physicians to middle-aged persons, particularly women. Districts in Malmö with a high utilisation of codeine were associated with unfavourable socioeconomic conditions and a high utilisation of benzodiazepines. The utilisation pattern of propoxyphene showed less or no such deviations.

CONCLUSION

The results suggest an inappropriate use of codeine in two major cities in Sweden.

Comparison of dose standard units for drug utilisation studies

OBJECTIVE

As employment of different dose standards would be impractical and confusing, the aim of this article is to compare the define daily dose (DDD) with some more recently proposed standards, namely, the minimum marketed dose (MMD), the equipotential dose (ED), the average daily dose (ADD), and the non-standard prescribed daily dose (PDD).

METHODS

Literature review, critical comparative analysis.

RESULTS

The DDD, defined by an independent scientific committee assisting the WHO Collaborating Centre for Drugs Statistics Methodology, has been employed in a large number of national and international comparative studies at the population level, usually as number of DDDs per 1000 inhabitants per day. However, the DDD can also be used at the individual level. The PDD, not being a standard unit, can be appropriately used in a second step to explain differences detected by the DDD methodology.

CONCLUSIONS

A globally accepted dose standard unit is important in drug utilisation studies, particularly if different investigations are to be compared. None of the alternatives seemed to offer any advantage over the DDD. Hence there is reason to advocate use of the DDD as the sole standard dose unit in all pharmacoepidemiologic studies.

Pharmaceutical care for patients with skin diseases: a campaign year at Swedish pharmacies

A pharmaceutical care programme for pharmacy customers/patients with skin disorders was carried out at all Swedish pharmacies in 1993 (Skin Year). The objective of the campaign was to increase awareness, compliance and appropriateness of the treatment of skin diseases in patients attending pharmacies. The campaign was carried out primarily at pharmacies and in close contact with other health-care professionals. A variety of promotional material was produced and made available to the pharmacies. The activities were primarily directed towards pharmacy customers but also towards the staff of local health-care centres. To avoid large-scale and costly population surveys in the national evaluation of the Skin Year campaign, evaluation was carried out indirectly by following four disease groups and monitoring the influence that the campaign may have had on the use of medicines by patients with those disorders. The groups chosen were dry skin, eczema, athlete's foot and acne. There was a substantial increase in the use of medication for skin disorders in the campaign year 1993 and in 1994. If it is assumed that the level of drug use is a reflection of the level of treatment it can be concluded that treatment of the four diseases increased substantially, indirectly demonstrating 'increased awareness, compliance and appropriateness of treatment' as stated in the objectives. It is estimated that the campaign may have reduced the number of physician consultations for skin problems and that this has led to a cost reduction of at least SK100 million (equivalent to $15 million) or 5-10% of the health-care costs for skin disorders. Comparable data on patient outcome as a result of the campaign are not available.

General practitioners for rational use of drugs. Examples from Sweden

In the south west region of Stockholm a group of 125 general practitioners (GPs) at 27 health centres asked about the extent to which the drug formulary of the University Hospital was useful in their practices. To answer this question, the GPs asked their local pharmacies for prescribing data. When presented this started a process towards rational prescribing from within the group of GPs, including repeated prescribing surveys, starting with health centres as the unit of analysis and proceeding to individual prescribing analyses on request by the GPs. As the prescribing data revealed major differences between health centres, the GPs arranged two workshops on drug use in primary health care. They developed a list of 167 recommended drugs based on drug statistics and morbidity in general practice. Signs of increased cost cautiousness could be shown. There was a clear trend towards both smaller volumes and cost per prescription item for the health centres in the study area. Compared to the national prescribing pattern, prescribing practice in the study area represented a 20 per cent lower drug cost. Although the GPs decided on a drug list separate from that of the hospital, collaboration between the Drug and Therapeutic Committee at the hospital and the GPs increased as a result of their increased engagement in drug management, thereby also bridging the gap between primary health care and clinical pharmacology.

Age standardisation of drug utilisation: comparisons of different methods using cardiovascular drug data from Sweden and Spain

In drug utilisation studies, the units of defined daily doses (DDD) and DDD/1000 inhabitants per day standardise for differences in dosage and population size, but not for age-related differences in drug utilisation. There is no consensus as to how age standardisation of DDD data should be carried out. Using cardiovascular drug utilisation data from Sweden and Spain, the current study compared the outcome of different methods of age standardisation. Both indirect methods (based on a comparison of observed and expected drug usage) and direct methods (using different weighting for the age categories) were used. The largest impact of standardisation was seen for diuretics. The crude rate for men and women combined was 26 DDD/1000 inhabitants per day in Costa de Ponent and 98 DDD/1000 inhabitants per day in Värmland. The corresponding figures when standardising the Costa de Ponent population were 26 and 58, respectively. Using the equivalent average rate (EAR) method, the rate for Värmland was 129 DDD/1000 inhabitants per day. Lesser but still important differences were found for beta-adrenoceptor and antihypertensives. Thus, the results of standardisation differ depending on which method is used and which drugs are evaluated. EAR is recommended for direct standardisation because of its ease of use and because it does not require the choice of a standard population.

Monitoring of drug prescriptions for children in the county of Jämtland and Sweden as a whole in 1977-1987

One individual-based (Jämtland) and one population-based (Sweden) monitoring system provided information on the prescription sales of drugs for children in ambulatory care. The overall prescription rate decreased between 1977 and 1987 and it was 20-25% lower in Jämtland than in Sweden as a whole. Antibiotics, drugs for ear, nose and throat diseases and respiratory drugs accounted for three out of four prescriptions. Penicillin V dominated among antibiotics and the prescription rate was stable whereas that of other antibiotics increased. During their first year of life one out of ten children in Jämtland had at least one prescription of antibiotics, during their first five years three out of four children. Prescribing of decongestants, especially systemic, decreased during the study period whereas that of anti-asthmatics increased, partly due to the non-approved use of these drugs for common cough. The results from our study underline the need for pharmaco-epidemiological studies linking prescription data to clinical data in order to answer questions on the rational of present drug treatment practices.

On the differences in psychotropic drug use between the three major urban areas in Sweden

Marked differences in the utilisation of psychotropic drugs between the three major urban areas in Sweden were recorded from four sources of information: drug supplies from wholesalers to pharmacies, drug supplies to hospitals for in-patient use, drugs sold on prescription for out-patient use, and out-patient consultation and drug prescribing as recorded by physicians. The total sales of psychotropics in the counties of Gothenburg (110.8 defined daily doses per 1000 inhabitants per day) and Malmö (102.1) were much higher than in the county of Stockholm (73.4), with about 25% of the difference being accounted for by diazepam. Differences in the total sales of psychotropics were not explained by any differences in hospital sales, which amounted to about 10% in all counties. Prescription sales differed due to the higher average number of DDD (defined daily doses) per prescription in Gothenburg and Malmö than in Stockholm (total psychotropics 8 and 15%, respectively), and especially because of the higher number of prescriptions per inhabitant (about 40 and 30-35%, respectively). There was no substantial difference in the pattern of diagnoses between areas, but there was a noticeable difference with regard to prescriber category, as psychiatrists accounted for more of the prescriptions in Stockholm than in Gothenburg and Malmö. The results raise questions about over- and under-treatment of mental disorders and about abuse of drugs. In order to explain the geographical differences in psychotropic drug sales morbidity patterns and prescribing practices should be further explored.

Measurement of drug use in a defined population. Evaluation of the defined daily dose (DDD) methodology

To evaluate the accuracy of the DDD per 1000 inhabitants per unit time as an estimate of the fraction of drug users within a population, DDD figures have been compared with the proportion of apparent drug users, i.e. individuals in the population for who a prescriptions had been dispensed. An individual-based prescription monitoring project provided the necessary data for eight drugs representing continuous long-term medication, short-term medication and medication falling in between those two categories. For digoxin, the long-term drug, the number of DDD/1000 inhabitants/day was about 40% below the proportion of apparent drug users. The DDD figure for antibiotics ranged from 4% below to 28% above the apparent users, and for the remaining drugs it ranged from 17% below (bendroflumethiazide, 1982) to 80% below (naproxen, 1985). The DDD methodology is a valuable first step in overall drug use measurement, but for more precise estimates of drug use it must be supplemented by other techniques.

Prescription monitoring of drug dosages in the county of Jämtland and Sweden as a whole in 1976, 1982 and 1985

Prescribed doses of drugs for which individualisation of dosage is deemed necessary were recorded from one national and one local Swedish prescription monitoring study for the years 1976, 1982 and 1985. Dose patterns were analysed in order to determine whether the practice of individualising drug doses had become more widely adopted by physicians. Amongst drugs eliminated primarily by metabolism, (propranolol and amitriptyline were prescribed in highly variable doses (30-fold or more). The three commonest doses of these agents accounted for about 60% of the prescriptions. In general, doses decreased with increasing patient age. Prescribing practices for piroxicam differed markedly from those of propranolol and amitriptyline, with one fixed dose of piroxicam accounting for about 90% of all prescriptions. For drugs eliminated mainly by renal excretion (digoxin, cimetidine and atenolol) there was an 8-10-fold variation in the prescribed doses. The most frequent dose of these drugs accounted for 40-60% of the prescriptions. Doses of cimetidine and atenolol were lowered only in the oldest patients. The doses of digoxin decreased more evenly with increasing age, and were reduced in elderly patients on long-term maintenance therapy. The difference in digoxin dose between young and old patients increased during the study period. Prescription monitoring as a method for following-up drug usage may be instrumental in evaluating the effect of drug educational efforts.

Over-the-counter sales of drugs in Sweden 1976-1983

The over-the-counter (OTC) sales of drugs were estimated by subtraction of sales on prescription and to hospitals from total drug sales in Sweden during the period 1976-1983. Increased sales of antitussives and decreased sales of expectorants characterized cough remedies. Making topical nasal decongestants available as OTC drugs immediately resulted in a large and increasing volume of OTC sales. Among analgesics, sales of acetaminophen and acetylsalisylic acid + caffeine combinations increased, while those of other groups decreased. Drugs for disorders of the alimentary tract were second to analgesics in the numbers of packs sold; amongst them antacids and laxatives dominated. Laxative sales decreased due to decreased sales of stimulant preparations. Vitamin C and multivitamin preparations dominated OTC vitamin sales. The sales of topical corticosteroids, only available as OTC drugs during the last quarter of 1983, were substantial. The OTC drug sales statistics reflect patterns of self-medication and may be used to monitor this important part of health care.

Continuous recording of drug prescribing in Sweden 1974-1983. Methods and examples of utilization of data

Drug prescribing in Sweden under the National Insurance Act has been continuously recorded since 1974. A random sample of 1 in 288 is drawn from the about 24 million prescriptions issued yearly and the following data are recorded: dispensing pharmacy, type of prescription, year and month of dispensing, year of birth and sex of the patient, trade name, quantity, dosage, and price of the drug. The numbers of prescriptions of drugs free of charge increased by 32% between 1974 and 1983, while that of price deducted drugs decreased by 7%. The national cost of drugs rose sharply during the period. The per capita cost of drugs to persons aged greater than or equal to 75 years was more than eight-fold higher than for persons aged less than or equal to 14 years. A two-fold difference in the number of prescription items was found between women and men, and there were nine- to ten-fold differences between age-groups. Total prescribing varied modestly over time, as did the prescribing to most patient groups and for most groups of drugs. Exceptions to this were prescribing to children, particularly of antiallergic drugs for which a 50% increase was observed between 1974 and 1975, mainly due to increased prescribing of phenylpropanolamine. The recording of prescriptions as described is useful for early identification of new patterns of drug use and for mapping drug utilization and drug dosages in different age groups. The system is particularly powerful as a complement to other methods for recording drug use in Sweden, e.g. wholesale sales statistics and individual prescription monitoring in the county of Jämtland.(ABSTRACT TRUNCATED AT 250 WORDS)

Validation of observed differences in the utilization of antihypertensive and antidiabetic drugs in Northern Ireland, Norway and Sweden

The amount of antihypertensive and antidiabetic drugs based of defined daily doses per 1000 inhabitants per day varies two to three fold between Northern Ireland, Norway, and Sweden. We explored whether variations based on the universally applied defined daily doses might be accounted for by national differences in the actual average prescribed daily doses. Use of prescribed daily doses for antihypertensive drugs resulted in Northern Irish and Norwegian consumption figures which were respectively 40 and 21% lower than the Swedish one, compared to 38 and 25% when defined daily doses were used. The effect of population age-sex differences on the gross defined daily doses per 1000 inhabitants per day figures was determined by applying the Northern Irish or Norwegian age-sex group proportions to Swedish age-sex specific sales data. Taking population differences into account would have resulted in antihypertensive drug use being 21 rather than 38% less in Northern Ireland and 18 rather than 25% less in Norway. Also adjustment for prescribed daily doses left an unexplained difference of 23% between Sweden and Northern Ireland and 14% between Sweden and Norway. For oral antidiabetics use of prescribed daily doses resulted in a Northern Irish - Swedish difference of 62% compared to 67% when defined daily doses were used. Simultaneous adjustment for population differences and prescribed to defined daily dose variations left a 52% difference.

Adverse reactions to nitrofurantoin. Analysis of 921 reports

Reports on adverse reactions to nitrofurantoin today are common in Sweden and constitute 10 to 12 percent of all incoming reports. We present an analysis of 921 reports of adverse reactions received by the Swedish Adverse Drug Reaction Committee during the period 1966--1976. The two largest groups consist of reports of acute pulmonary reactions (43 percent) and allergic reactions (42 percent). The remaining reports fall into any of four smaller groups, chronic pulmonary reactions, liver damage, blood dyscrasias or neuropathy. Acute pulmonary and acute allergic reactions in all aspects are very similar and carry the characteristics of an acute hypersensitivity reaction. The increasing number of reports--even in relation to sales figures--would be best explained by a continuous sensitization. Chronic pulmonary reactions (interstitial pneumonitis) afflict older patients, often after prolonged treatment with relatively small doses. We suggest that these reactions are elicited by a toxic mechanism. Seventy-one percent of all reactions were severe enough to cause the patient's hospitalization; only 1 percent was fatal. The risk of an adverse reaction varies with sex and age, increases with age and is higher in women than in men. The time has come for a re-evaluation of nitrofurantoin and its role in the treatment of urinary tract infections.