| 11. |
- Lillqvist, Joel, et al.
(författare)
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Are doctors using more preventive medication for cardiovascular disease? : A Swedish cross-sectional study
- 2023
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Ingår i: Scandinavian Journal of Primary Health Care. - : Taylor & Francis. - 0281-3432 .- 1502-7724. ; 41:3, s. 297-305
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Tidskriftsartikel (refereegranskat)abstract
- Background: Despite decreasing mortality from cardiovascular disease (CVD), there are persistent inequities in mortality between socioeconomic groups. Primary preventative medications reduce mortality in CVD; thus, inequitable treatments will contribute to unequal outcomes. Physicians might contribute to inequality by prescribing preventative medication for CVD to themselves in a biased manner.Aim: To determine whether primary medications for preventing CVD were prescribed inequitably between physicians and non-physicians.Design and setting: This retrospective study retrieved registry data on prescribed medications for all physicians in Sweden aged 45–74 years, during 2013, and for reference non-physician individuals, matched by sex, age, residence, and level of education. The outcome was any medication for preventing CVD, received at least once during 2013.Method: Age and the sex-specific prevalence of myocardial infarction (MI) among physicians and non-physicians were used as a proxy for the need for medication. Thereafter, to limit the analysis to preventative medication, we excluded individuals that were diagnosed with CVD or diabetes. To analyse differences in medication usage between physicians and matched non-physicians, we estimated odds ratios (ORs) with conditional logistic regression and adjusted for need and household income.Results: MI prevalences were 5.7% for men and 2.3% for women, among physicians, and 5.4% for men and 1.8% for women, among non-physicians. We included 25,105 physicians and 44,366 non-physicians. The OR for physicians receiving any CVD preventative medication, compared to non-physicians, was 1.65 (95% confidence interval 1.59–1.72).Conclusion: We found an inequity in prescribed preventative CVD medications, which favoured physicians over non-physicians.
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| 12. |
- Lindmark, Anita, 1986-, et al.
(författare)
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Socioeconomic differences in patient reported outcome measures 3 months after stroke : a nationwide Swedish register-based study
- 2024
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Ingår i: Stroke. - : Lippincott Williams & Wilkins. - 0039-2499 .- 1524-4628. ; 55:8, s. 2055-2065
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: There is a well-known association between low socioeconomic status (SES), poor survival, and clinician-reported outcomes after stroke. We aimed to assess socioeconomic differences in Patient Reported Outcome Measures 3 months after stroke.METHODS: This nationwide cohort study included patients registered with acute stroke in the Swedish Stroke Register 2015-2017. Patient Reported Outcome Measures included activities of daily living (mobility, toileting, and dressing), and poststroke symptoms (low mood, fatigue, pain, and poor general health). Information on SES prestroke was retrieved from Statistics Sweden and defined by a composite measure based on education and income tertiles. Associations between SES and Patient Reported Outcome Measures were analyzed using logistic regression adjusting for confounders (sex and age) and additionally for potential mediators (stroke type, severity, cardiovascular disease risk factors, and living alone). Subgroup analyses were performed for stroke type, men and women, and younger and older patients.RESULTS: The study included 44 511 patients. Of these, 31.1% required assistance with mobility, 18% with toileting, and 22.2% with dressing 3 months after stroke. For poststroke symptoms, 12.3% reported low mood, 39.1% fatigue, and 22.7% pain often/constantly, while 21.4% rated their general health as poor/very poor. Adjusted for confounders, the odds of needing assistance with activities of daily living were highest for patients with low income and primary school education, for example, for mobility, odds ratio was 2.06 (95% CI, 1.89-2.24) compared with patients with high income and university education. For poststroke symptoms, odds of poor outcome were highest for patients with low income and university education (eg, odds ratio, 1.79 [95% CI, 1.49-2.15] for low mood). Adjustments for potential mediators attenuated but did not remove associations. The associations were similar in ischemic and hemorrhagic strokes and more pronounced in men and patients <65 years old.CONCLUSIONS: There are substantial SES-related differences in Patient Reported Outcome Measures poststroke. The more severe outcome associated with low SES is more pronounced in men and in patients of working age.
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| 13. |
- Norberg, Helena, 1984-
(författare)
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Bridging the gap between clinical trials and clinical practice : sacubitril-valsartan in heart failure as a model
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- When novel treatments prove more effective than standard therapies, a swift and effective implementation is needed to reach cost-effectiveness and to benefit eligible patients. Meanwhile, women and elderly are often under-represented in clinical trials, which creates a knowledge gap on how to optimize treatment in clinical practice. The arrival of the angiotensin receptor-neprilysin inhibitor sacubitril-valsartan to patients with chronic heart failure and reduced ejection fraction (HFrEF) offered an opportunity to develop and test a new systematic introduction approach, as well as to investigate eligibility and management of sacubitril-valsartan in clinical practice. The aims of this thesis were to investigate obstacles to implement sacubitril-valsartan in a real-world heart failure population, as well as to develop a systematic and effective method to implement novel treatments in patients with chronic disease.With an observational cross-sectional study design, patients were retrospectively included if they had a heart failure diagnosis, living within the Umeå University Hospital catchment area, and had at least one visit at the Heart Centre or Department of internal medicine between January 2010 and March 2016. Eligibility to sacubitril-valsartan was based on the enrollment criteria applied in the landmark trial, PARADIGM-HF. We showed that the primary obstacle to implement sacubitril-valsartan was that only a quarter of the real-world HFrEF population was eligible. The most prominent difference was that real-world patients were significantly older compared with the PARADIGM-HF population. Disproportionally many patients, especially women, were ineligible for sacubitril-valsartan due to intolerance of renin-angiotensin system inhibitors in target doses. With multivariable linear regression analyses, we showed that the lower target doses in women were explained by biological sex differences.Management of heart failure treatment involve many titration steps that risk stressing the resources of both healthcare and patients. We prospectively investigated a direct switch to maximum dose sacubitril-valsartan in patients who tolerated target dose renin-angiotensin system inhibitors (equivalent to enalapril 10 mg twice daily). We showed that the simplified introduction was safe and generally well tolerated during the first year.The systematic introduction approach is a seven-step procedure:1) define a few main criteria2) primary scan patients with the one or two main criteria using computerized medical records/databases/clinical registries3) identify patients applying the other predefined criteria4) evaluate if any examinations/laboratory test updates are required5) summon identified patients with an information letter6) discuss treatment with the patient and prescribe if appropriate7) follow-up on initiated therapy and evaluate the process.We evaluated the approach with a mixed method, including both a case study of the sacubitril-valsartan implementation and an interview study with qualitative content analysis. The new systematic introduction approach effectively implemented sacubitril-valsartan in clinical practice, by identifying eligible patients with limited resources and time. The patients were overall satisfied with the new approach and their confidence in healthcare was maintained.In conclusion, we found that the strict inclusion criteria in the PARADIGM-HF trial would exclude a majority of patients with heart failure if they are implemented and that these criteria have an inherent bias versus the old and the frail, which in turn disproportionately affects women. We further found that patients who are on maximum recommended dose of renin-angiotensin system inhibitors can be safely switched to maximum dose sacubitril-valsartan and that our method of systematic introduction was effective in implementing sacubitril-valsartan to a heart failure population.The approach is a promising example of how to reduce the gap between clinical trials and clinical practice in patients with chronic disease.
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| 14. |
- Norberg, Helena, et al.
(författare)
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Self-reported medication adherence and pharmacy refill adherence among persons with ischemic stroke : a cross-sectional study
- 2022
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Ingår i: European Journal of Clinical Pharmacology. - : Springer Science+Business Media B.V.. - 0031-6970 .- 1432-1041. ; 78, s. 869-877
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: To describe and compare self-reported medication adherence assessed with the 5-item version of Medication Adherence Report Scale (MARS-5) and pharmacy refill adherence based on data from the Swedish Prescribed Drug Register (SPDR) among persons with ischemic stroke, and to investigate independent predictors associated with respective assessments.Methods: A study questionnaire was sent to persons with ischemic stroke registered in the Swedish Stroke Register between Dec 2011 and March 2012, and who lived at home 3 months after discharge. The primary outcome was dichotomized to adherent/non-adherent based on MARS-5 and SPDR and analyzed with multivariable logistic regression. Adherence according to MARS-5 was defined as score 23 or higher (out of 25). Adherence according to SPDR was defined as at least one filled statin prescription recorded in SPDR in each 6-month interval during 2 years of follow-up.Results: Of 420 participants, 367 (87%) and 329 (78%) were adherent according to MARS-5 and SPDR, respectively, and 294 (70%) participants were adherent according to both assessments. A significant association was shown between medication adherence according to the two assessments (p = 0.020). Independent predictors associated with medication adherence according to MARS-5 were female sex, while factors associated with SPDR were male sex and being younger.Conclusions: The majority of participants were classified as adherent, 87% according to MARS-5 and 78% based on data from SPDR. However, only 70% were adherent according to both MARS-5 and SPDR, and different predictors were associated with the different measurements, suggesting that these assessments are measuring different aspects of adherence.
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| 15. |
- Westberg, Annica, et al.
(författare)
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Primary Non-Adherence to Preventive Drugs and Associations with Beliefs About Medicines in Stroke Survivors
- 2022
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Ingår i: Patient Preference and Adherence. - : Dove Medical Press. - 1177-889X. ; 16, s. 343-352
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Tidskriftsartikel (refereegranskat)abstract
- Background: Medication non-adherence is a common problem in clinical practice. Little is known about stroke survivors’ primary non-adherence to preventive drugs, and we hypothesised that their beliefs about medicines are associated with primary non-adherence. The objective was to describe primary non-adherence among stroke survivors and to assess associations between primary non-adherence to preventive drugs and beliefs about medicines.Methods: Questionnaires were sent to 797 individuals 3 months after stroke to assess beliefs about medicines through the Beliefs about Medicines Questionnaire (BMQ). All participants were registered in the Swedish Stroke Register (Riksstroke), and prescriptions for new preventive drugs during the hospital stay were identified through data from Riksstroke. Primary non-adherers were those who failed to fill one or more new prescriptions within 1 month of hospital discharge based on data from the Swedish Prescribed Drug Register. Differences between primary non-adherers and adherers were assessed by X2 tests and associations between the BMQ subscales and primary non-adherence were analysed using independent two-sample t-tests and multivariable logistic regression models.Results: A total of 594 individuals responded to the survey, of which 452 received new prescriptions of preventive drugs. Overall, 53 (12%) participants were classified as primary non-adherent. Primary non-adherers were more often dependent on help or support from next of kin (p=0.032) and had difficulties with memory more often (p=0.002) than the primary adherent individuals. No statistically significant differences in BMQ subscale-scores were found between the two groups (p>0.05).Conclusion: Primary non-adherence to preventive drugs was low, and no associations were found between primary non-adherence and beliefs about medicines. Associations with cognitive impairments such as difficulties with memory and need for help from next of kin suggest that more effort is needed to help stroke survivors to start important preventive drug treatments after discharge from hospital.
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