New terminology of medication adherence enabling and supporting activities: ENABLE terminology

Introduction: Medication non-adherence negatively affects the effectiveness of evidence-based therapies and sustainability of healthcare systems. Lack of agreed terminology of medication adherence enabling and supporting activities leads to underuse of the available tools. The ENABLE COST Action was aimed at proposing a new terminology for these activities in order to help both scientific research and its clinical application. Methods: Initial discussions within the ENABLE Working Groups allowed for the conceptualization of four interlinked terms related to adherence, i.e., "medication adherence technology", "medication adherence enhancing intervention", "best practice" and "reimbursement". The iterative process of internal discussion was structured around two dedicated international workshops. Moreover, extensive stakeholder consultations have been organised, including an interactive online survey used to assess the level of agreement with, and the clarity of relevant terms and definitions proposed. Results: Detailed analysis of the results of this process allowed for fine-tuning of the items, and finally, for proposing the final set of definitions. Across all the three phases of this process, the definitions were substantially modified to better reflect the concepts, simplify the language, and assure completeness and cohesiveness of terminology. Feedback obtained from the stakeholders helped this process and confirmed that the final terms and definitions were well received by the experts active in the field of medication adherence. Discussion: Covering the gap in the existing terminology, this work proposes a cohesive set of terms and definitions applicable to medication adherence enabling and supporting activities. Promoting evidence-based approach to this field, this terminology may help research, clinical practice and policy.

Reimbursement and use of oral anticoagulants during 2014-2022 - A register-based study

Background

Vitamin K antagonists, warfarin in particular, have been the mainstay of anticoagulation therapy, but their use has declined in many countries since direct oral anticoagulants (DOACs) have entered the market.

Objective

To examine utilization trends of oral anticoagulants (OACs) in Finland considering the reimbursement of DOACs and changes to national treatment guidelines for the treatment of atrial fibrillation (AF).

Methods

Both public, aggregated data on reimbursed OAC dispensations and individual-level data on electronic dispensations during 2014-2022 were applied. Data on electronic dispensations during 2015-2016 were used to study OAC initiations. Data on entitlements to reimbursement for DOACs came from public data.

Results

In 2014, there were almost 20,000 DOAC users, rising to 214,000 in 2022. The number of warfarin users declined since 2015 from over 181,000 to around 59,000 users in 2022, DOACs exceeding warfarin in the number of users in 2019. The total DOAC costs were higher than warfarin costs each year. Rivaroxaban was the most widely used DOAC during 2014-2018, and apixaban during 2019-2022. In 2015, there were more warfarin (56.7%) than DOAC (43.3%) initiators, but the result was opposite for 2016 (warfarin 39.4%, DOACs 60.6%). The number of individuals entitled to reimbursement for DOACs has increased steadily, and in 2022, there were over 196,000 individuals entitled to this reimbursement due to AF.

Conclusions

The uptake of DOACs in Finland appears to have been gradual and slower than in many other countries. During the 2010s, the treatment guidelines for AF were more cautious in recommending DOACs than the European guidelines. The use of DOACs increased as their reimbursement became less restrictive.

Factors associated with non-adherence to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in older patients with peripheral arterial disease

Introduction: As in other chronic conditions, medication adherence is important in the treatment of peripheral arterial disease (PAD). Our study aimed at a) analysing non-adherence to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in groups of older ACEI and ARB users with PAD, and b) identifying characteristics associated with non-adherence. Methods: We focused on the implementation phase of adherence (i.e., after treatment initiation and before possible discontinuation of treatment). The study cohort included ACEI/ARB users aged ≥65 years in whom PAD was newly diagnosed during 2012. Non-adherence was defined as Proportion of Days Covered (PDC) < 80%. Results: Among 7,080 ACEI/ARB users (6,578 ACEI and 502 ARB users), there was no significant difference in the overall proportion of non-adherent patients between ACEI and ARB users (13.9% and 15.3%, respectively). There were differences in factors associated with non-adherence between the groups of persistent and non-persistent (i.e., discontinued treatment at some point during follow-up) ACEI and ARB users. Increasing age, dementia and bronchial asthma were associated with non-adherence in persistent ACEI users. General practitioner as index prescriber was associated with adherence in the groups of non-persistent ACEI users and persistent ARB users. Conclusion: Identified factors associated with non-adherence may help in determining the groups of patients who require increased attention.

Reimbursed Medication Adherence Enhancing Interventions in European Countries: Results of the EUREcA Study

Introduction: Current literature lacks detailed understanding of the reimbursement framework of medication adherence enhancing interventions (MAEIs). As part of the ENABLE COST Action, the EUREcA (“EUropen REimbursement strategies for interventions targeting medication Adherence”) study aimed to provide an in-depth overview of reimbursed MAEIs currently available in European countries at national and regional levels and to pave the way for further MAEIs to be implemented in the future.

Methods: A web-based, cross-sectional survey was performed across 38 European countries and Israel. The survey questionnaire was developed as a result of an iterative process of discussion informed by a desk review. The survey was performed among invited ENABLE collaborators from June to July 2021. Besides descriptive analysis, association between country income and health care expenditure, and the availability of reimbursed MAEIs were also assessed.

Results: The survey identified 13 reimbursed MAEIs in nine countries: multi-dose drug dispensing (n = 5), medication review (n = 4), smart device (n = 2), mobile application (n = 1), and patient education (n = 1). The median GDP per capita of countries having ≥1 reimbursed MAEI was significantly higher compared to countries having no reimbursed adherence intervention (33,888 EUR vs 16,620 EUR, respectively; p = 0.05).

Conclusions: Our findings highlight that to date only a small number of MAEIs have been reimbursed in European countries. Comprehensive health technology assessment recommendations and multi-stakeholder collaboration could help removing barriers related to the implementation and reimbursement of MAEIs.

Data-driven long-term glycaemic control trajectories and their associated health and economic outcomes in Finnish patients with incident type 2 diabetes

Background

Treatments should be customized to patients to improve patients’ health outcomes and maximize the treatment benefits. We aimed to identify meaningful data-driven trajectories of incident type 2 diabetes patients with similarities in glycated haemoglobin (HbA1c) patterns since diagnosis and to examine their clinical and economic relevance.

Materials and methods

A cohort of 1540 patients diagnosed in 2011–2012 was retrieved from electronic health records covering primary and specialized healthcare in the North Karelia region, Finland. EHRs data were compiled with medication purchase data. Average HbA1c levels, use of medications, and incidence of micro- and macrovascular complications and deaths were measured annually for seven years since T2D diagnosis. Trajectories were identified applying latent class growth models. Differences in 4-year cumulative healthcare costs with 95% confidence intervals (CIs) were estimated with non-parametric bootstrapping.

Results

Four distinct trajectories of HbA1c development during 7 years after T2D diagnosis were extracted: patients with “Stable, adequate” (66.1%), “Slowly deteriorating” (24.3%), and “Rapidly deteriorating” glycaemic control (6.2%) as well as “Late diagnosed” patients (3.4%). During the same period, 2.2 (95% CI 1.9–2.6) deaths per 100 person-years occurred in the “Stable, adequate” trajectory increasing to 3.2 (2.4–4.0) in the “Slowly deteriorating”, 4.7 (3.1–6.9) in the “Rapidly deteriorating” and 5.2 (2.9–8.7) in the “Late diagnosed” trajectory. Similarly, 3.5 (95% CI 3.0–4.0) micro- and macrovascular complications per 100 person-years occurred in the “Stable, adequate” trajectory increasing to 5.1 (4.1–6.2) in the “Slowly deteriorating”, 5.5 (3.6–8.1) in the “Rapidly deteriorating” and 7.3 (4.3–11.8) in the “Late diagnosed” trajectory. Patients in the “Stable, adequate” trajectory had lower accumulated 4-year medication costs than other patients.

Conclusions

Data-driven patient trajectories have clinical and economic relevance and could be utilized as a step towards personalized medicine instead of the common “one-fits-for-all” treatment practices.

Adherence to Antiplatelet Medications among Persistent and Non-Persistent Older Patients with Peripheral Arterial Disease

Secondary prevention of peripheral arterial disease (PAD) includes administration of antiplatelet agents, and adherence to medication is a requirement for an effective treatment. The aim of this study was to analyse adherence measured using the proportion of days covered (PDC) index separately in persistent and non-persistent patients, and to identify patient- and medication-related characteristics associated with non-adherence in these patient groups. The study cohort of 9178 patients aged ≥ 65 years in whom PAD was diagnosed in 1/–12/2012 included 6146 persistent and 3032 non-persistent patients. Non-adherence was identified as PDC < 80%. Characteristics associated with non-adherence were determined using the binary logistic regression model. In the group of persistent patients, 15.3% of subjects were identified as non-adherent, while among non-persistent patients, 26.9% of subjects were non-adherent to antiplatelet medication. Administration of dual antiplatelet therapy (aspirin and clopidogrel) and a general practitioner as index prescriber were associated with adherence in both patient groups. Our study revealed a relatively high proportion of adherent patients not only in the group of persistent patients but also in the group of non-persistent patients before discontinuation. These results indicate that most non-persistent PAD patients discontinue antiplatelet treatment rapidly after a certain period of adherence.

Reinitiation and Subsequent Discontinuation of Antiplatelet Treatment in Nonpersistent Older Patients with Peripheral Arterial Disease

The successful treatment of peripheral arterial disease (PAD) depends on adequate adherence to medications including antiplatelet agents. The aims of this study were (a) to identify the proportion of nonpersistent patients who reinitiated antiplatelet therapy and how many of them discontinued therapy after reinitiation, and (b) to identify patient- and medication-related characteristics associated with the likelihood of reinitiation and discontinuation among reinitiators. The analysis of reinitiation was conducted on 3032 nonpersistent users of antiplatelet agents aged ≥65 years, with PAD newly diagnosed in 2012. Discontinuation (i.e., a treatment gap of ≥6 months without antiplatelet medication prescription) was analysed in 2006 reinitiating patients. To identify factors associated with the likelihood of reinitiation and discontinuation, Cox regression with time-dependent covariates was used. Reinitiation was recorded in 2006 (66.2%) of 3032 patients who had discontinued antiplatelet medication. Among these 2006 reinitiators, 1078 (53.7%) patients discontinued antiplatelet therapy again. Ischemic stroke and myocardial infarction during nonpersistence and bronchial asthma/chronic obstructive pulmonary disease were associated with an increased likelihood of reinitiation. University education was associated with discontinuation among reinitiators. Factors associated with the probability of reinitiation and discontinuation in reinitiators make it possible to identify older PAD patients in whom "stop-starting" behaviour may be expected.

Comparison of Communication Channels for Large-Scale Type 2 Diabetes Risk Screening and Intervention Recruitment: Empirical Study

Background

Clinical trials have shown that type 2 diabetes (T2D) is preventable through lifestyle interventions targeting high-risk people. Nevertheless, large-scale implementation of risk identification followed by preventive interventions has proven to be challenging. Specifically, recruitment of participants into preventive interventions is an important but often overlooked part of the intervention.

Objective

This study aims to compare the reach and yield of different communication channels to engage people at increased risk of T2D to fill in a digital screening questionnaire, with emphasis on reaching those at most risk. The participants expressing their willingness to participate is the final step in the risk screening test, and we aim to determine which channels had the most participants reach this step.

Methods

We established a stepwise web-based T2D risk screening tool with automated feedback according to the T2D risk level and, for those who were eligible, an invitation to participate in the StopDia prevention intervention study conducted in a primary health care setting. The risk estimate was based on the Finnish Diabetes Risk Score; history of repeatedly measured high blood glucose concentration; or, among women, previous gestational diabetes. We used several channels to invite people to the StopDia web-based screening tool, and respondents were classified into 11 categories based on the channel through which they reported having learned about StopDia. The demographics of respondents reached via different communication channels were compared using variance analysis. Logistic regression was used to study the respondents’ likelihood of progressing through risk screening steps.

Results

A total of 33,399 persons started filling the StopDia screening tool. Of these, 86.13% (28,768/33,399) completed the test and named at least one communication channel as the source of information about StopDia. Altogether, 26,167 persons filled in sufficient information to obtain risk estimates. Of them, 53.22% (13,925/26,167) were at increased risk, 30.06% (7866/26,167) were men, and 39.77% (10,136/25,485) had low or middle education levels. Most frequently mentioned channels were workplace (n=6817), social media or the internet (n=6712), and newspapers (n=4784). The proportion of individuals at increased risk was highest among those reached via community pharmacies (415/608, 68.3%) and health care (1631/2535, 64.33%). The communication channel reaching the largest percentage of interested and eligible men (1353/3979, 34%) was relatives or friends. Health care (578/1069, 54.07%) and radio or television (225/487, 46.2%) accounted for the largest proportion of people with lower education.

Conclusions

Communication channels reaching a large number of people, such as social media and newspapers, were the most effective channels for identifying at-risk people. Personalized approaches increased the engagement of men and less-educated people. Community pharmacies and health care services reached people with a particularly high T2D risk. Thus, communication and recruitment channels should be selected and modified based on the intended target group.

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-6574-y

Pharmacy-based screening to detect persons at elevated risk of type 2 diabetes: a cost-utility analysis

Background

Early identification of people at elevated risk of type 2 diabetes (T2D) is an important step in preventing or delaying its onset. Pharmacies can serve as a significant channel to reach these people. This study aimed to assess the potential health economic impact of screening and recruitment services in pharmacies in referring people to preventive interventions.

Methods

A decision analytic model was constructed to perform a cost-utility analysis of the expected national health economic consequences (in terms of costs and quality-adjusted life years, QALYs) of a hypothetical pharmacy-based service where people screened and recruited through pharmacies would participate in a digital lifestyle program. Cost-effectiveness was considered in terms of net monetary benefit (NMB). In addition, social return on investment (SROI) was calculated as the ratio of the intervention and recruitment costs and the net present value of expected savings. Payback time was the time taken to reach the break-even point in savings. In the base scenario, a 20-year time horizon was applied. Probabilistic and deterministic sensitivity analyses were applied to study robustness of the results.

Results

In the base scenario, the expected savings from the pharmacy-based screening and recruitment among the reached target cohort were 255.3 m€ (95% CI − 185.2 m€ to 717.2 m€) in pharmacy visiting population meaning 1412€ (95% CI − 1024€ to 3967€) expected savings per person. Additionally, 7032 QALYs (95% CI − 1344 to 16,143) were gained on the population level. The intervention had an NMB of 3358€ (95% CI − 1397€ to 8431€) using a cost-effectiveness threshold of 50,000 €/QALY. The initial costs were 122.2 m€ with an SROI of 2.09€ (95% CI − 1.52€ to 5.88€). The expected payback time was 10 and 8 years for women and men, respectively. Results were most sensitive for changes in effectiveness of the intervention and selected discount rate.

Conclusions

T2D screening and recruitment to prevention programs conducted via pharmacies was a dominant option providing both cost savings and QALY gains. The highest savings can be potentially reached by targeting recruitment at men at elevated risk of T2D.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06948-6.

Non-Persistence With Antiplatelet Medications Among Older Patients With Peripheral Arterial Disease

Introduction: Antiplatelet therapy needs to be administered life-long in patients with peripheral arterial disease (PAD). Our study was aimed at 1) the analysis of non-persistence with antiplatelet medication in older PAD patients and 2) identification of patient- and medication-related characteristics associated with non-persistence. Methods: The study data was retrieved from the database of the General Health Insurance Company. The study cohort of 9,178 patients aged ≥ 65 years and treated with antiplatelet medications was selected from 21,433 patients in whom PAD was newly diagnosed between 01/2012 and 12/2012. Patients with a 6 months treatment gap without antiplatelet medication prescription were classified as non-persistent. Characteristics associated with non-persistence were identified using the Cox regression. Results: At the end of the 5 years follow-up, 3,032 (33.0%) patients were non-persistent. Age, history of ischemic stroke or myocardial infarction, clopidogrel or combination of aspirin with clopidogrel used at the index date, higher co-payment, general practitioner as index prescriber and higher overall number of medications were associated with persistence, whereas female sex, atrial fibrillation, anxiety disorders, bronchial asthma/chronic obstructive pulmonary disease, being a new antiplatelet medication user (therapy initiated in association with PAD diagnosis), and use of anticoagulants or antiarrhythmic agents were associated with non-persistence. Conclusion: In patients with an increased probability of non-persistence, an increased attention should be paid to improvement of persistence.

Impact of co-payment level increase of antidiabetic medications on glycaemic control: an interrupted time-series study among Finnish patients with type 2 diabetes

Background

A new special reimbursement scheme (SRS) for non-insulin medications used for treatment of hyperglycaemia in type 2 diabetes (T2D) was implemented in Finland on January 1, 2017. The new SRS affected all community-dwelling Finnish T2D patients as all community-dwelling residents are eligible for reimbursement for prescription medications. The aim of the study was to evaluate the impact of this co-payment increase on glycaemic control among Finnish T2D patients.

Methods

Data on glycaemic control were collected with HbA1c measures from electronic health records from primary health care and specialized care in the North Karelia region, Finland, from patients with a confirmed T2D diagnosis in 2012 who were alive on January 1, 2017 (n = 8436). Average HbA1c levels were measured monthly 36 months before and 33 months after the policy change. Consumption of diabetes medications was measured with defined daily doses (DDDs) based on reimbursed medication purchases. Interrupted time series design analysed with segmented regression model was applied to examine the effect of the policy change on average HbA1c levels.

Results

Eight thousand one hundred forty-three T2D patients had at least one HbA1c measurement within 01/2014–9/2019. Mean age of the patients was 68.1 (SD 11.3) years and 53.0% were women. Average time since T2D diagnosis was 11.5 (SD 6.1) years. An estimated increase of 0.81 (95% confidence interval, CI, 0.04–1.58) mmol/mol in average HbA1c levels was detected at the time of the policy change. In subgroup analyses, strongest effects were detected among patients who used only other diabetes medications than insulin or metformin in 2016 (3.56 mmol/mol, 95% CI 2.50–4.62). Meanwhile, yearly consumption of diabetes medications decreased slightly from 618.9 (SD 487.8) DDDs/patient in 2016 to 602.9 (SD 475.6) DDDs/patient in 2017 (p = 0.048).

Conclusions

Simultaneously with the increase of the co-payment level, the average HbA1c level increased among T2D patients from the North Karelia region, Finland. This may be explained by the decreased consumption of diabetes medications between 2016 and 2017. Special attention should be allocated to glycaemic control of patients utilizing only other antidiabetic medications than metformin or insulin.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05952-6.

Non-Adherence to Statin Treatment in Older Patients with Peripheral Arterial Disease Depending on Persistence Status

The effectiveness of statins in secondary prevention of peripheral arterial disease (PAD) largely depends on patients’ adherence to treatment. The aims of our study were: (a) to analyze non-adherence during the whole follow-up in persistent patients, and only during persistence for non-persistent patients; (b) to identify factors associated with non-adherence separately among persistent and non-persistent patients. A cohort of 8330 statin users aged ≥65 years, in whom PAD was newly diagnosed between January 2012–December 2012, included 5353 patients persistent with statin treatment, and 2977 subjects who became non-persistent during the 5-year follow-up. Non-adherence was defined using the proportion of days covered <80%. Patient- and statin-related characteristics associated with non-adherence were identified with binary logistic regression. A significantly higher proportion of non-adherent patients was found among non-persistent patients compared to persistent subjects (43.6% vs. 29.6%; p < 0.001). Associated with non-adherence in both persistent and non-persistent patients was high intensity statin treatment, while in non-persistent patients, it was employment and increasing number of medications. In patients with a poor adherence during their persistent period, an increased risk for discontinuation may be expected. However, there is also non-adherence among persistent patients. There are differences in factors associated with non-adherence depending on patients’ persistence.

Short-term impact of co-payment level increase on the use of medication and patient-reported outcomes in Finnish patients with type 2 diabetes

A new reimbursement scheme for non-insulin medications used for treatment of hyperglycemia in type 2 diabetes (T2D) was implemented in Finland on January 1, 2017. The aim of the study was to evaluate the impact of this co-payment increase (i.e. + 35 percentage points) on patient-reported satisfaction for diabetes care, diabetes medication use, and financial difficulties. Baseline data were collected in 114 pharmacies, where patients with T2D were asked to fill in a questionnaire in November 2016. Follow-ups were conducted at 6 and 12 months. In total, 955 participants with T2D attended the baseline examination. During the follow-up, satisfaction with diabetes care decreased significantly (p < 0.001). Use of insulin increased (OR 1.16, 95 % CI 1.06-1.27) whereas use of metformin and DPP-4 inhibitors decreased (metformin: OR 0.80, 95 % CI 0.70‒0.90; DPP-4 inhibitors: OR 0.82, 95 % CI 0.73‒0.93). Financial difficulties with the purchase of diabetes medications were reported more often both at 6 (OR 2.44, 95 % CI 1.96-3.03) and at 12 months (OR 2.70, 95 % CI 2.18-3.35) than at baseline. These negative short-term effects require future studies. If persistent, the long-term effects of lower treatment satisfaction and increased financial difficulties may imply impaired metabolic control and increased diabetes complication risk and health care costs. Patient perspective should be taken into account in future policy making.

Use and non-use of a nationwide patient portal – a survey among pharmacy customers

Objectives

A nationwide patient portal (My Kanta) for viewing electronic prescriptions and health data has been phased in since 2010 in Finland. This study aimed to study how commonly Finnish pharmacy customers use My Kanta, the factors related to My Kanta use, the main reasons for non-use and how non-users would like to monitor their medication and health information.

Methods

A survey was conducted among adult pharmacy customers purchasing prescription medicines for themselves or for their child &lt;18 years. Questionnaires (N = 2866) were distributed from 18 pharmacies across Finland. Open-ended questions were analysed qualitatively. Quantitative analyses included frequencies, Chi-square tests, Fisher's exact tests, t-tests and logistic regression analysis.

Key findings

In total, 994 (34.7%) questionnaires were included. Most (82.5%) adult pharmacy customers used My Kanta. Use of the service was associated with use of the internet to search for health-related information (OR: 8.82, 95% CI: 4.65‒16.74), active internet use (OR: 7.30, 95 %: CI 3.54‒15.08), living in Northern (OR: 4.35, 95% CI: 1.75‒10.82) or Eastern (OR: 3.25, 95% CI: 1.41‒7.48) parts of Finland, and the increasing number of currently used regular prescription medicines (OR: 1.16, 95% CI: 1.01‒1.34). The main reasons for non-use were lack of need and tools. Non-users reported physician/health centres and pharmacies as their preferred sources of medication and health information.

Conclusions

Most Finnish pharmacy customers use the My Kanta nationwide patient portal. The strongest predictors for use are factors related to internet use. Some pharmacy customers do not use My Kanta despite having the necessary means. The main reason for non-use is a lack of need. Customers unable to use My Kanta want to monitor their medication and health information via healthcare professionals.

Factors Associated with Reinitiation of Statin Treatment in Older Patients with Peripheral Arterial Disease

BACKGROUND

Long-term persistence represents a basic precondition of successful statin treatment in patients with peripheral arterial disease (PAD).

OBJECTIVES

The aims of our study were evaluation of reinitiation in older PAD patients who were non-persistent with statin treatment, and identification of patient-related characteristics associated with the patient's probability of reinitiation.

METHODS

Our study cohort included 2977 older patients (≥ 65 years) who were non-persistent with statin treatment in whom PAD was newly diagnosed in 2012. Reinitiation was defined as the first statin prescription recorded after discontinuation. To analyze factors associated with the patient´s probability of reinitiation, Cox regression with time-dependent covariates was applied.

RESULTS

After post-discontinuation follow-up of a mean of 27 months, reinitiation of statin treatment was recorded for 1244 (41.8%) patients. Increasing age, Parkinson's disease, being a new statin user (patient in whom statin treatment was initiated in association with PAD diagnosis), general practitioner as the index prescriber who prescribed a statin for the first time after diagnosis of PAD, coadministration of loop diuretics, and longer persistence before discontinuation decreased the patient's likelihood of reinitiation, whereas myocardial infarction during non-persistence, high-intensity statin treatment, and increasing number of medications increased the patient's probability of reinitiation.

CONCLUSIONS

In patients with characteristics associated with a lower probability of reinitiation, more concentrated outreach and further evaluation of these groups to identify interventions that might be helpful to encourage reinitiation are needed.

Patient-Associated Characteristics Influencing the Risk for Non-Persistence with Statins in Older Patients with Peripheral Arterial Disease

BACKGROUND AND OBJECTIVES

Secondary prevention of peripheral arterial disease includes administration of statins regardless of the patient's serum cholesterol level. Our study aimed to identify patient-associated risk factors for statin non-persistence and comparison of the explanatory power of models based on clusters of patient-associated characteristics.

METHODS

Our study cohort (n = 8330) was assembled from the database of the largest health insurance provider in the Slovak Republic. Statin users aged ≥ 65 years in whom peripheral arterial disease was diagnosed during 2012 were included. Patients were followed for 5 years; those with a treatment gap period of at least 6 months without statin prescription were classified as "non-persistent". The risk factors for non-persistence were identified within six models (sociodemographic, cardiovascular events, comorbid conditions, statin-related characteristics, cardiovascular co-medication and full model) using Cox regression. The explanatory power of models was assessed using Harrell's C-index.

RESULTS

At the end of the follow-up, 35.7% of patients were found to be non-persistent. The full model had the highest explanatory power (C = 0.632). Female sex, atorvastatin and rosuvastatin as initially administered statins, being a new statin user and an increasing co-payment were associated with an increased risk for non-persistence. Increasing age, history of ischaemic stroke, diabetes mellitus, general practitioner as index prescriber, increasing overall number of medications and co-administration of certain cardiovascular co-medications were associated with a lower likelihood for non-persistence.

CONCLUSIONS

Patients identified as high risk for non-persistence require special attention aimed at the improvement of their persistence with statin treatment.

The effects of reimbursement reform of antidiabetic medicines from the patients' perspective - a survey among patients with type 2 diabetes in Finland

Background

In Finland, the reimbursement rate for antidiabetic medicines other than insulins was lowered from 100 to 65% at the beginning of 2017. The objective of this study was to examine the effects of this reform experienced by patients with type 2 diabetes. The objective was also to explore if socio-economic status affects this experience.

Methods

The data were collected by conducting a survey among Finnish adults with type 2 diabetes (n = 603). The baseline survey was conducted in November–December 2016. A second follow-up survey was conducted at the end of 2017 where the participants’ experience of the reimbursement reform was surveyed with an open-ended question. Free-form inductive content analysis was used to categorize the answers. The association between the participants’ characteristics and reporting an effect caused by the reimbursement reform was studied with binomial logistic regression.

Results

285 (47.3%) participants reported an effect of some kind caused by the reimbursement reform. The most common reported effects were economic effects (32.7%) and annoyance (12.4%). Having financial difficulties in purchasing antidiabetic medicines (odds ratio (OR) 5.20, 95% confidence interval (Cl) 2.99–9.06) or not having annual deductible exceeded (OR 2.17, 95% CI 1.19–3.95), and use of certain antidiabetic medication groups at baseline were associated with reporting an effect. Socio-economic status was not associated with the likelihood of reporting an effect.

Conclusions

Almost half of the participants with type 2 diabetes reported an effect, most commonly economic effects, such as increased expenditure or difficulty in purchasing medicines, after the reimbursement reform. It is important to study the effects of reimbursement reforms also from the patients’ perspective.

Eight-year trajectories of changes in health-related quality of life in knee osteoarthritis: Data from the Osteoarthritis Initiative (OAI)

Background

Knee osteoarthritis (OA) worsens health-related quality of life (HRQoL) but the symptom pathway varies from person to person. We aimed to identify groups of people with knee OA or at its increased risk whose HRQoL changed similarly. Our secondary aim was to evaluate if patient-related characteristics, incidence of knee replacement (KR) and prevalence of pain medication use differed between the identified HRQoL trajectory groups.

Methods

Eight-year follow-up data of 3053 persons with mild knee OA or at increased risk were obtained from the public Osteoarthritis Initiative (OAI) database. Group-based trajectory modeling was used to identify patterns of experiencing a decrease of ≥10 points (Minimal Important Change, MIC) in the Quality of Life subscale of the Knee injury and Osteoarthritis Outcome Score compared to baseline. Multinomial logistic regression, Cox regression and generalized estimating equation models were used to study secondary aims.

Results

Four HRQoL trajectory groups were identified. Persons in the ‘no change’ group (62.9%) experienced no worsening in HRQoL. ‘Rapidly’ (9.5%) and ‘slowly’ worsening (17.1%) groups displayed an increasing probability of experiencing the MIC in HRQoL. The fourth group (10.4%) had ‘improving’ HRQoL. Female gender, higher body mass index, smoking, knee pain, and lower income at baseline were associated with belonging to the ‘rapidly worsening’ group. People in ‘rapidly’ (hazard ratio (HR) 6.2, 95% confidence interval (CI) 3.6–10.7) and ‘slowly’ worsening (HR 3.4, 95% CI 2.0–5.9) groups had an increased risk of requiring knee replacement. Pain medication was more rarely used in the ‘no change’ than in the other groups.

Conclusions

HRQoL worsening was associated with several risk factors; surgical and pharmacological interventions were more common in the poorer HRQoL trajectory groups indicating that HRQoL does reflect the need for OA treatment. These findings may have implications for targeting interventions to specific knee OA patient groups.

Impact of type 2 diabetes treated with non-insulin medication and number of diabetes-coexisting diseases on EQ-5D-5 L index scores in the Finnish population

BACKGROUND

Type 2 diabetes (T2D) causes significant health and economic burden. In addition to comorbidities there are also coexisting diseases linked to obesity, lifestyle and T2D. The aim of this study was to examine the effect of T2D and T2D-coexisting diseases on health-related quality of life (HRQoL) in the Finnish population and whether it is T2D or the coexisting diseases that have the largest impact on HRQoL.

METHODS

The study was based on a national cross-sectional population survey (n = 5305). Respondents' HRQoL was measured using the EQ-5D-5 L instrument. Our study included diabetic respondents treated with non-insulin medications (NI-T2D) with or without insulin and non-diabetic respondents, whereas diabetic respondents not taking any anti-diabetic medications or treated with insulin alone were excluded. A crosswalk algorithm was used to convert EQ-5D-5 L index scores into EQ-5D-3 L index scores as a sensitivity analysis. A two-part model was used to examine the association between T2D and coexisting diseases and HRQoL.

RESULTS

The unadjusted mean (SD) EQ-5D-5 L index scores for non-diabetics (n = 4856) was 0.90 (0.13) and 0.85 (0.16) for respondents with NI-T2D (n = 449). With adjustment for demographic factors, the difference in EQ-5D-5 L index scores was 0.036 (95% CI 0.023-0.050). After adjusting for the number of coexisting diseases, the EQ-5D-5 L index scores among respondents with NI-T2D and three or more coexisting diseases were lower when compared to all non-diabetics but not when compared to non-diabetics with similar number of coexisting diseases. The number of T2D-coexisting diseases had a larger effect on EQ-5D-5 L index scores in younger age groups (20 and 40 years old).

CONCLUSIONS

Lower EQ-5D-5 L index score is associated with NI-T2D when compared to non-diabetic respondents. When compared to non-diabetics, the disutility associated with NI-T2D increases as more coexisting diseases appear. The disutility effect of coexisting diseases was equally large in non-diabetics and respondents with NI-T2D. Thus, public health interventions targeting the prevention of both T2D and its coexisting diseases have potential to have significant benefits also in terms of HRQoL.

Physicians' views on patient participation in choice of oral anticoagulants in atrial fibrillation-a qualitative study

Direct oral anticoagulants provide an alternative to vitamin K antagonists for the anticoagulation therapy in atrial fibrillation (AF). The availability of several treatment options with different attributes makes shared decision-making appropriate for the choice of anticoagulation therapy. The aim of this study was to understand how physicians choose an oral anticoagulant (OAC) for patients with AF and how physicians view patients' participation in this decision. Semi-structured interviews with 17 Finnish physicians (eight general practitioners and nine specialists) working in the public sector were conducted. An interview guide on experience, prescribing and opinions about oral anticoagulants was developed based on previous literature. The data were thematically analysed using deductive and inductive approaches. Based on the interviews, patient's opinion was the most influential factor in decision-making when there were no clinical factors limiting the choice between OACs. Of patient's preferences, the most important was the attitude towards co-payments of OACs. Patients' opinions on monitoring of treatment, dosing and antidote availability were also mentioned by the interviewees. The choice of an OAC in AF was patient-centred as all interviewees expressed that patient's opinion affects the choice.

Health-related quality of life in relation to symptomatic and radiographic definitions of knee osteoarthritis: data from Osteoarthritis Initiative (OAI) 4-year follow-up study

Background

The purpose was to quantify the decrement in health utility (referred as disutility) associated with knee osteoarthritis (OA) and different symptomatic and radiographic uni- and bilateral definitions of knee OA in a repeated measures design of persons with knee OA or at increased risk of developing knee OA.

Methods

Data were obtained from the Osteoarthritis Initiative database. SF-12 health-related quality of life was converted into SF-6D utilities, and were then handled as the health utility loss by subtracting 1.000 from the utility score, yielding a negative value (disutility). Symptomatic OA was defined by radiographic findings (Kellgren-Lawrence, K-L, grade ≥ 2) and frequent knee pain in the same knee. Radiographic OA was defined by five different definitions (K-L ≥ 2 unilaterally / bilaterally, or the highest / mean / combination of K-L grades of both knees). Repeated measures generalized estimating equation (GEE) models were used to investigate disutility in relation to these different definitions.

Results

Utility decreased with worsening of symptomatic or radiographic status of knee OA. The participants with bilateral and unilateral symptomatic knee OA had 0.03 (p < 0.001) and 0.02 (p < 0.001) points lower utility scores, respectively, compared with the reference group. The radiographic K-L grade 4 defined as the mean or the highest grade of both knees was related to a decrease of 0.04 (p < 0.001) and 0.03 (p < 0.001) points in utility scores, respectively, compared to the reference group.

Conclusions

Knee OA is associated with diminished health-related quality of life. Health utility can be quantified in relation to both symptomatic and radiographic uni- and bilateral definitions of knee OA, and these definitions are associated with differing disutilities. The performance of symptomatic definition was better, indicating that pain experience is an important factor in knee OA related quality of life.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0979-7) contains supplementary material, which is available to authorized users.

Socioeconomic Inequalities in Statin Adherence Under Universal Coverage: Does Sex Matter?

BACKGROUND

Previous research shows that low socioeconomic position (SEP; especially low income) is associated with statin nonadherence. We investigated the relationship between SEP and statin adherence in a country with universal coverage using group-based trajectory modeling in addition to the proportion of days covered.

METHODS AND RESULTS

Using data from Finnish healthcare registers, we identified 116 846 individuals, aged 45 to 75 years, who initiated statin therapy for primary prevention of cardiovascular disease. We measured adherence as proportion of days covered over an 18-month period since initiation and identified different adherence patterns based on monthly adherence with group-based trajectory modeling. When adjusted for age, marital status, residential area, clinical characteristics, and copayment, low SEP was associated with statin nonadherence (proportion of days covered <80%) among men (eg, lowest versus highest income quintile: odds ratio, 1.41; 95% confidence interval, 1.32-1.50; basic versus higher-degree education: odds ratio, 1.18; 95% confidence interval, 1.13-1.24; unemployment versus employment: odds ratio, 1.17; 95% confidence interval, 1.10-1.25). Among women, the corresponding associations were different (P<0.001 for sex-by-income quintile, sex-by-education level, and sex-by-labor market status interactions) and mainly nonsignificant. Results based on adherence trajectories showed that men in low SEP were likely to belong to trajectories presenting a fast decline in adherence.

CONCLUSIONS

Low SEP was associated with overall and rapidly increasing statin nonadherence among men. Conversely, in women, associations between SEP and nonadherence were weak and inconsistent. Group-based trajectory modeling provided insight into the dynamics of statin adherence and its association with SEP.

Cost-effectiveness of statin treatment for primary prevention in conditions of real-world adherence--estimates from the Finnish prescription register

OBJECTIVE

To estimate the cost-effectiveness of statin therapy for primary prevention of coronary heart disease (CHD) events under real-world adherence.

METHODS

A cost-effectiveness model was applied to estimate the expected 10-year costs and health outcomes (in terms of quality-adjusted life-years, QALYs) associated with and without statin treatment (at defined adherence levels) among hypothetical cohorts of Finnish men and women who were initially without established CHD. Treatment efficacy, cost, and quality of life estimates were obtained from published sources. Long-term treatment adherence was measured based on data from the national prescription register.

RESULTS

At an assumed willingness-to-pay threshold of €20,000 per QALY gained, statin treatment with real-world adherence was cost-effective among the older patient groups when the patients' 10-year CHD risk was as high as 20% and did not seem cost-effective in the youngest age groups. Conversely, statin treatment with full adherence was cost-effective for almost all patient groups with a 10-year CHD risk of at least 15%.

CONCLUSIONS

Even though generic statins are now low-cost drugs, treatment adherence seems to have a major impact on the cost-effectiveness of statin treatment in primary prevention. This finding stresses the importance of making a concerted effort for improving adherence among patients on statin therapy to obtain full benefit of the investment in statins. Therefore, novel cost-effective approaches to improve treatment adherence are warranted.

Sequential cohort design applying propensity score matching to analyze the comparative effectiveness of atorvastatin and simvastatin in preventing cardiovascular events

Background

Sequential cohort design (SCD) applying matching for propensity scores (PS) in accrual periods has been proposed to mitigate bias caused by channeling when calendar time is a proxy for strong confounders. We studied the channeling of patients according to atorvastatin and simvastatin initiation in Finland, starting from the market introduction of atorvastatin in 1998, and explored the SCD PS approach to analyzing the comparative effectiveness of atorvastatin versus simvastatin in the prevention of cardiovascular events (CVE).

Methods

Initiators of atorvastatin or simvastatin use in the 45–75-year age range in 1998–2006 were characterized by their propensity of receiving atorvastatin over simvastatin, as estimated for 17 six-month periods. Atorvastatin (10 mg) and simvastatin (20 mg) initiators were matched 1∶1 on the PS, as estimated for the whole cohort and within each period. Cox regression models were fitted conventionally, and also for the PS matched cohort and the periodically PS matched cohort, to estimate the hazard ratios (HR) for CVEs.

Findings

Atorvastatin (10 mg) was associated with a 11%–12% lower incidence of CVE in comparison with simvastatin (20 mg). The HR estimates were the same for a conventional Cox model (0.88, 95% confidence interval 0.85–0.91), for the analysis in which the PS was used to match across all periods and the Cox model was adjusted for strong confounders (0.89, 0.85–0.92), and for the analysis in which PS matching was applied within sequential periods (0.88, 0.84–0.92). The HR from a traditional PS matched analysis was 0.80 (0.77–0.83).

Conclusions

The SCD PS approach produced effect estimates similar to those obtained in matching for PS within the whole cohort and adjusting the outcome model for strong confounders, but at the cost of efficiency. A traditional PS matched analysis without further adjustment in the outcome model produced estimates further away from unity.