| 1. |
- Gyllensten, Hanna, 1979, et al.
(author)
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Comparing Methods for Estimating Direct Costs of Adverse Drug Events
- 2017
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In: Value in Health. - : Elsevier BV. - 1098-3015 .- 1524-4733. ; 20:10, s. 1299-1310
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Journal article (peer-reviewed)abstract
- Objectives: To estimate how direct health care costs resulting from adverse drug events (ADEs) and cost distribution are affected by methodological decisions regarding identification of ADEs, assigning relevant resource use to ADEs, and estimating costs for the assigned resources. Methods: ADEs were identified from medical records and diagnostic codes for a random sample of 4970 Swedish adults during a 3-month study period in 2008 and were assessed for causality. Results were compared for five cost evaluation methods, including different methods for identifying ADEs, assigning resource use to ADEs, and for estimating costs for the assigned resources (resource use method, proportion of registered cost method, unit cost method, diagnostic code method, and main diagnosis method). Different levels of causality for ADEs and ADEs contribution to health care resource use were considered. Results: Using the five methods, the maximum estimated overall direct health care costs resulting from ADEs ranged from Sk10,000 (Sk = Swedish krona; similar to(sic)1,500 in 2016 values) using the diagnostic code method to more than Sk3,000,000 (similar to(sic)414,000) using the unit cost method in our study population. The most conservative definitions for ADEs contribution to health care resource use and the causality of ADEs resulted in average costs per patient ranging from Sk0 using the diagnostic code method to Sk4066 (similar to(sic)500) using the unit cost method. Conclusions: The estimated costs resulting from ADEs varied considerably depending on the methodological choices. The results indicate that costs for ADEs need to be identified through medical record review and by using detailed unit cost data. Copyright (C) 2017, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc.
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| 2. |
- Kjellgren, Karin I, 1950, et al.
(author)
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Antihypertensive treatment and patient autonomy--the follow-up appointment as a resource for care.
- 2000
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In: Patient education and counseling. - 0738-3991 .- 1873-5134. ; 40:1, s. 39-49
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Journal article (peer-reviewed)abstract
- Since hypertension is a chronic condition which generally requires long-term commitment to pharmacological therapy as well as alterations of patient lifestyle, the patient-physician communication in the clinical setting is an important determinant of the quality of care and health outcome. The aim of the present study was to explore the structure and content of the communication between the patient and the physician, and the process of decision-making at a routine follow-up appointment for hypertension. The study was based on 51 audio-recordings of authentic consultations. Most patients had a passive role in the consultations, and initiated few topics of conversation. The few topics that the patients initiated were usually not about hypertension. Patients' questions about medication mainly referred to unwanted effects of the drugs. Little time was invested in discussing risks related to hypertension. A collaborative shared decision-making was seldom observed in the consultations.
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| 3. |
- Hedenrud, Tove, 1967, et al.
(author)
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"Psychiatry is not a science like others" - a focus group study on psychotropic prescribing in primary care.
- 2013
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In: BMC family practice. - : Springer Science and Business Media LLC. - 1471-2296. ; 14
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Journal article (peer-reviewed)abstract
- Background: Psychotropic drug prescribing is problematic and knowledge of factors affecting the initiation and maintenance of such prescribing is incomplete. Such knowledge could provide a basis for the design of interventions to change prescribing patterns for psychotropics. The aim of this study was to explore the views of general practitioners (GPs), GP interns, and heads of primary care units on factors affecting the prescribing of psychotropic drugs in primary care. Methods: We performed four focus group discussions in Gothenburg, Sweden, with a total of 21 participants (GPs, GP interns, and heads of primary care units). The focus group discussions were transcribed verbatim and analyzed using manifest content analysis. Results: Three different themes emerged from the focus group discussions. The first theme Seeking care for symptoms, reflects the participants’ understanding of why patients approach primary care and comprised categories such as knowledge, attitudes, and society and the media. The second theme, Lacking a framework, resources, and treatment alternatives, which reflects the conditions for the physician-patient interaction, comprised categories such as economy and resources, technology, and organizational aspects. The third theme, Restricting or maintaining prescriptions, with the subthemes Individual factors and External influences, reflects the physicians’ internal decision making and comprised categories such as emotions, knowledge, and pharmaceutical industry. Conclusion: The results of the present study indicate that a variety of factors may affect the prescribing of psychotropic medications in primary care. Many factors were related to characteristics of the patient, the physician or their interaction, rather than the patients’ medical needs per se. The results may be useful for interventions to improve psychotropic prescribing in primary care.
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| 4. |
- Kjellgren, Karin I, 1950, et al.
(author)
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Antihypertensive medication in clinical encounters.
- 1998
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In: International journal of cardiology. - 0167-5273. ; 64:2, s. 161-9
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Journal article (peer-reviewed)abstract
- In managing hypertension, patient participation and understanding of the nature and significance of treatment are decisive. We analysed the communication between patient and physician with respect to antihypertensive medication at a follow-up appointment, and assessed patients' knowledge of their medication. The empirical data consist of audio-recordings from 51 hypertensive patients' follow-up appointment with their physicians. Thirty-three of these patients were interviewed in depth immediately after the appointment. The study was performed in primary health care centres and at a specialist clinic for hypertension. When discussing medications, patients mainly talked about experiences of being on medication, whereas physicians generally focused on the pharmacological effect and dosage of the drug. Physicians routinely asked about compliance with drug regimen, but seldom in any depth. Little effort was invested into discussing the effect and goal of therapy. The main finding was that patients had a very fragmentary understanding of the functional nature of their antihypertensive medication. This is unsatisfactory both from the point of view of treatment efficacy and also when considering the legal requirements of involving the patient in the decision making. The follow-up appointments studied gave few possibilities for the patient to learn about their antihypertensive medication.
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| 5. |
- Kjellgren, Karin I, 1950, et al.
(author)
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Hypertensive patients' knowledge of high blood pressure.
- 1997
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In: Scandinavian journal of primary health care. - 0281-3432. ; 15:4, s. 188-92
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To investigate hypertensive patients' understanding of the circulatory system, in particular high blood pressure. DESIGN: Semi-structured audio-taped interviews of patients immediately after a regular follow-up appointment with their physician. SETTING: A primary health care centre and a specialist clinic (hypertension unit) in southern Sweden. PATIENTS: 33 hypertensive patients, consecutively selected. MAIN OUTCOME MEASURE: Focus was set on the exploration of patients' understanding/knowledge. RESULTS: In spite of a long history of hypertensive care, on average ten years, patients had a less than satisfactory understanding of their condition. Most patients knew their blood pressure values, but very few were able to give an account of what high blood pressure implies in functional terms. Knowledge of high blood pressure seems mainly to be derived from sources other than the health care system, in particular from the mass media. Knowledge of the risks associated with hypertension was quite good, as was the insight into how these risks could be managed. CONCLUSION: An assessment of patient knowledge of high blood pressure ought to be a starting point for educational strategies that aim to deepen patients' understanding of their state of health.
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| 6. |
- Kokkinakis, Dimitrios, 1965, et al.
(author)
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Contextualisation of functional symptoms in primary health care
- 2012
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In: The 5th GENEVA Conference on Person-Centered Medicine. Geneva, Switzerland..
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Conference paper (other academic/artistic)abstract
- Background: a number of patients consulting primary health care have physical symptoms that may be labeled “medically unexplained”, i.e. absence of a demonstrable organic etiology. Common functional somatic symptoms (FSS) are irritable bowel, tension headache and chronic fatigue. FSS-patients are generally frustrated with the inability of health care to alleviate their illness. Health care staff often also feel frustration. The communication between patient and care giver is the key for coming to terms with the problem. Objective: to investigate how complex, vague and long-standing symptoms with no identified organic cause are put into context, interpreted and acted upon in primary health-care interactions. Two types of interventions are envisaged (i) methods for early identification of patients at risk of entering a vicious circle of functional symptoms and (ii) methods for re-interpreting symptoms in alternative and more purposeful ways. Methods: the project studies interactions between patients and nurses giving advice over telephone, consultations between patients and physicians, interviews and study patients' medical case notes. Eligible patients (18-65 y.o.) contact their primary health care centre by telephone, have had at least eight physical consultations with nurses or physicians in the last 12 months and if a majority of the symptoms within this time span had no clear organic or psychiatric cause. The project contains a number of subprojects, according to the type of data collected. Several methods of analysis will be used, mainly critical discourse analysis, phenomenologic-hermeneutic and computation linguistic analyses. (Expected) Results: using the collected data, we describe characteristics of the communication that takes place in these settings and the way symptoms and diseases are represented. This will facilitate the development of future interventions aimed at decreasing the morbidity due to FSS and give further insights into the problem.
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| 7. |
- Lidén, Eva, 1955, et al.
(author)
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The meaning of learning to live with medically unexplained symptoms as narrated by patients in primary care: A phenomenological-hermeneutic study
- 2015
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In: International Journal of Qualitative Studies on Health and Well-being. - : Informa UK Limited. - 1748-2623 .- 1748-2631. ; 10
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Journal article (peer-reviewed)abstract
- Background: Although research about medically unexplained symptoms (MUS) is extensive, problems still affect a large group of primary care patients. Most research seems to address the topic from a problem-oriented, medical perspective, and there is a lack of research addressing the topic from a perspective viewing the patient as a capable person with potential and resources to manage daily life. The aim of the present study is to describe and interpret the experiences of learning to live with MUS as narrated by patients in primary health-care settings. Methods: A phenomenological–hermeneutic method was used. Narrative interviews were performed with ten patients suffering from MUS aged 24–61 years. Data were analysed in three steps: naive reading, structural analysis, and comprehensive understanding. Findings: The findings revealed a learning process that is presented in two themes. The first, feeling that the symptoms overwhelm life, involved becoming restricted and dependent in daily life and losing the sense of self. The second, gaining insights and moving on, was based on subthemes describing the patients’ search for explanations, learning to take care of oneself, as well as learning to accept and becoming mindful. The findings were reflected against Antonovsky’s theory of sense of coherence and Kelly’s personal construct theory. Possibilities and obstacles, on an individual as well as a structural level, for promoting patients’ capacity and learning were illuminated. Conclusions: Patients suffering from MUS constantly engage in a reflective process involving reasoning about and interpretation of their symptoms. Their efforts to describe their symptoms to healthcare professionals are part of this reflection and search for meaning. The role of healthcare professionals in the interpretative process should be acknowledged as a conventional and necessary care activity.
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| 8. |
- López, Naldy Parodi, et al.
(author)
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Association between recorded medication reviews in primary care and adequate drug treatment management - a cross-sectional study
- 2021
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In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 39:4, s. 419-428
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Journal article (peer-reviewed)abstract
- Objective To investigate the association between a recorded procedure code for a medication review and adequate drug treatment management, and to explore factors associated with this code. Design and setting Cross-sectional study; two primary health care centres, in Region Vastra Gotaland, Sweden. Subjects A total of 302 consecutive patients (>= 65 years old, 59% female; median number of drugs: six) requiring a non-urgent consultation with a physician in October-November 2017. Main outcome measure Adequate drug treatment management (treatment that did not require any further action), determined in consensus by two specialists in family medicine blinded to the medication review code. Results Adequate drug treatment management was, overall, less common in those with a recorded medication review over the last year: 63% versus 73% (p = 0.047). This negative association was evident among patients aged 65-74 years: 49% versus 74% (p = 0.003), but absent in those >= 75 years old: 67% versus 70% (p = 0.77). Recommendations from consensus included the search for additional information to be able to make a decision regarding initiation or withdrawal of a drug (n = 53), withdrawal of a drug (n = 41), or ordering a laboratory test (n = 25). Factors associated with a recorded procedure code included age above the remuneration limit of 75 years (odds ratio: 9.8; 95% confidence interval 5.0-19), type 2 diabetes (3.0 (1.5-6.2)), hypertension (2.4 (1.2-4.8)), and depression (2.5 (1.02-6.0)). Conclusions The presence of a recorded medication review was not positively associated with adequate drug treatment management but was associated with the age limit for remuneration, and some chronic diseases.
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| 9. |
- Lopez, Naldy Parodi, et al.
(author)
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Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study
- 2022
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In: European Journal of Clinical Pharmacology. - : Springer Science and Business Media LLC. - 0031-6970 .- 1432-1041. ; 78, s. 1331-1339
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Journal article (peer-reviewed)abstract
- Purpose To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment. Methods PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate. Results In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment. Conclusion One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.
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| 10. |
- Lopez, Naldy Parodi, et al.
(author)
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Reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'-an appraisal of a set of potentially inappropriate medications
- 2024
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In: EUROPEAN JOURNAL OF CLINICAL PHARMACOLOGY. - : SPRINGER HEIDELBERG. - 0031-6970 .- 1432-1041.
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Journal article (peer-reviewed)abstract
- Purpose To analyse the reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'.Methods From a previous study that included consecutive primary care patients >= 65 years of age, all patients >= 75 years of age were analysed. Two physicians independently screened their medication lists and medical records, applying the Swedish indicator which includes potentially inappropriate medications (PIMs): long-acting benzodiazepines, drugs with anticholinergic action, tramadol, propiomazine, codeine, and glibenclamide. The clinical relevance of identified PIMs was independently assessed. Thereafter, the physicians determined in consensus whether some medical action related to the drug treatment was medically justified and prioritised before the next regular visit. If so, the drug treatment was considered inadequate, and if not, adequate.Results A total of 1,146 drugs were assessed in 149 patients (75-99 years, 62% female, 0-20 drugs per patient). In 29 (19%) patients, at least one physician identified >= 1 PIM according to the indicator at issue; 24 (16%) patients were concordantly identified with >= 1 such PIM (kappa: 0.89). Of 26 PIMs concordantly identified, the physicians concordantly assessed four as clinically relevant and 12 as not clinically relevant (kappa: 0.17). After the consensus discussion, six (4%) patients had >= 1 PIM according to the studied indicator that merited action. Using the area under the receiver operating characteristic (ROC) curve, the indicator did not outperform chance in identifying inadequate drug treatment: 0.56 (95% confidence interval: 0.46 to 0.66).Conclusion The Swedish indicator has strong reliability regarding PIM detection but does not validly reflect the adequacy of drug treatment.
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| 11. |
- Lopez, Naldy Parodi, et al.
(author)
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Revisiting the inter-rater reliability of drug treatment assessments according to the STOPP/START criteria
- 2023
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In: British Journal of Clinical Pharmacology. - : Wiley. - 0306-5251 .- 1365-2125. ; 89:2, s. 832-842
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Journal article (peer-reviewed)abstract
- Aims The aim of this study is to revisit the inter-rater reliability of drug treatment assessments according to the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria. Methods Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were independently identified by two physicians in two cohorts of older people (I: 200 hip fracture patients, median age 85 years, STOPP/START version 1; II: 302 primary care patients, median age 74 years, STOPP/START version 2). Kappa statistics were used to evaluate inter-rater agreement. Results In cohort I, a total of 782 PIMs/PPOs, related to 68 (78%) out of 87 criteria, were identified by at least one assessor, 500 (64%) of which were discordantly identified by the assessors, that is, by one assessor but not the other. For four STOPP criteria, all PIMs (n = 9) were concordantly identified. In cohort II, 955 PIMs/PPOs, related to 80 (70%) out of 114 criteria, were identified, 614 (64%) of which were discordantly identified. For three STOPP criteria, all PIMs (n = 3) were concordantly identified. For no START criterion, with >= 1 PPO identified, were all assessments concordant. The kappa value for PIM/PPO identification was 0.52 in both cohorts. In cohort II, the kappa was 0.37 when criteria regarding influenza and pneumococcal vaccines were excluded. Further analysis of discordantly identified PIMs/PPOs revealed methodological aspects of importance, including the data source used and criteria wording. Conclusions When the STOPP/START criteria are applied in PIM/PPO research, reliability seems to be an issue not encountered in previous reliability studies.
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| 12. |
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| 13. |
- Rohlin, Anna, et al.
(author)
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GREM1 and POLE variants in hereditary colorectal cancer syndromes
- 2016
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In: Genes, Chromosomes and Cancer. - : Wiley. - 1045-2257 .- 1098-2264. ; 55:1, s. 95-106
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Journal article (peer-reviewed)abstract
- Hereditary factors are thought to play a role in at least one third of patients with colorectal cancer (CRC) but only a limited proportion of these have mutations in known high-penetrant genes. In a relatively large part of patients with a few or multiple colorectal polyps the underlying genetic cause of the disease is still unknown. Using exome sequencing in combination with linkage analyses together with detection of copy-number variations (CNV), we have identified a duplication in the regulatory region of the GREM1 gene in a family with an attenuated/atypical polyposis syndrome. In addition, 107 patients with colorectal cancer and/or polyposis were analyzed for mutations in the candidate genes identified. We also performed screening of the exonuclease domain of the POLE gene in a subset of these patients. The duplication of 16 kb in the regulatory region of GREM1 was found to be disease-causing in the family. Functional analyses revealed a higher expression of the GREM1 gene in colorectal tissue in duplication carriers. Screening of the exonuclease domain of POLE in additional CRC patients identified a probable causative novel variant c.1274A>G, p.Lys425Arg. In conclusion a high penetrant duplication in the regulatory region of GREM1, predisposing to CRC, was identified in a family with attenuated/atypical polyposis. A POLE variant was identified in a patient with early onset CRC and a microsatellite stable (MSS) tumor. Mutations leading to increased expression of genes can constitute disease-causing mutations in hereditary CRC syndromes. © 2015 The Authors. Genes, Chromosomes & Cancer Published by Wiley Periodicals, Inc.
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| 14. |
- Svensson, Staffan, 1972, et al.
(author)
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Adverse events and patients' perceptions of antihypertensive drug effectiveness.
- 2003
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In: Journal of human hypertension. - : Springer Science and Business Media LLC. - 0950-9240 .- 1476-5527. ; 17:10, s. 671-5
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Journal article (peer-reviewed)abstract
- Adverse events that patients attribute to their drug treatment are generally considered to reduce adherence to medication. However, some patients interpret such symptoms as indicating drug effectiveness. If perceivedly effective drugs are more likely to be taken then adverse events may increase adherence. The extent to which patients interpret adverse events as indicating drug effectiveness is not well known. We investigated this in a cross-sectional questionnaire study of 1013 drug-treated hypertensive patients from 55 primary health-care centres and 11 internal medicine clinics in Sweden. We hypothesized that estimates of future risk of complications of hypertension made by hypertensive patients who had adverse events would be lower than estimates made by patients who did not have adverse events, and that these estimates would only differ when patients were estimating their risks in a setting where they continued taking antihypertensive drugs. Patients' risk estimates were measured with visual analogue scales and adverse events were detected by an open question. Contrary to our hypothesis, patients with adverse events (25.7%) gave higher estimates of future risk in the continuing medication setting. This association persisted in a multivariate analysis, where a number of factors related to adverse events and risk were controlled for (OR 1.76 (95% CI, 1.26-2.45), P=0.001 for the most highly correlated risk measure), but risk estimates did not differ between patients with and without adverse events in the setting of not continuing medication. Possible explanations for these findings are pre-existing differences in attitude towards drugs and level of fear of complications.
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| 15. |
- Svensson, Staffan, 1972, et al.
(author)
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Attitudes and behaviour towards psychotropic drug prescribing in Swedish primary care: a questionnaire study
- 2019
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In: Bmc Family Practice. - : Springer Science and Business Media LLC. - 1471-2296. ; 20
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Journal article (peer-reviewed)abstract
- BackgroundThe prescribing of psychotropic drugs, i.e. antidepressants, sedatives (anxiolytics, hypnotics), and antipsychotics is considerable and a large proportion is prescribed by general practitioners (GPs). There are concerns about dependency and medicalisation, and treatment decisions in psychiatry may appear arbitrary. Increased knowledge of GPs' opinions on the prescribing of psychotropics may lead to more rational use of these drugs. We aimed to quantify GPs' attitudes, beliefs and behaviour towards various aspects of psychotropic drug prescribing.MethodsA questionnaire was distributed to physicians in all 199 GP practices in Region Vastra Gotaland, Sweden. The questions concerned determinants of psychotropic drug prescribing that had been identified in a previous, qualitative study.ResultsQuestionnaires from 516 physicians (64% of whom were specialists in family medicine, 21% interns in family medicine, 15% others) at 152 GP practices (59% of which were state owned, 72% in an urban area, with a median of 7808 registered patients) were returned (estimated response rate: 48%). A majority - 62% - of GPs found it easier to start prescribing psychotropic drugs than to stop (95% confidence interval, 57%, 66%) vs. 8% (6%, 10%). Most GPs considered psychotherapy more suitable than psychotropic drugs in cases of mild psychiatric disease: 81% (77%, 84%) vs. 4% (3%, 6%). The problems treated with psychotropic drugs were considered to be mostly socioeconomic, or mostly medical, by similar proportions of physicians: 38% (34%, 42%) vs. 40% (36%, 45%). GPs were on average satisfied with their levels of antidepressant and sedative prescribing in relation to medical needs. More GPs regarded their prescribing of antipsychotics as being too low rather than too high: 33% (28%, 39%) vs. 7% (4%, 10%).ConclusionsThis study illustrates the complexities of psychiatric drug treatment in primary care and identifies potential drivers of increased prescribing of psychotropics. The manifold factors, medical and non-medical, that affect prescribing decisions may explain a sense of arbitrariness surrounding psychotropic drug treatment. This notwithstanding, GPs seem mostly content with their prescribing.
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| 16. |
- Svensson, Staffan, 1972, et al.
(author)
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[Cervical myelopathy due to nitrous oxide inhalation]. : Omfattande inhalationsbruk av lustgas gav ryggmärgsskada.
- 2022
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In: Lakartidningen. - 1652-7518. ; 119:6-7
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Journal article (peer-reviewed)abstract
- A 19 year old male presented to his GP with bilateral numbness and stiffness of hands and lower limbs, as well as muscle weakness and poor balance. The patient admitted recreational use of nitrous oxide (laughing gas) some days earlier. He was hospitalised and underwent a series of plasmapheresis treatments due to an initial suspicion of inflammatory myelitis. Further investigation gave evidence of cervical myelopathy which was deemed secondary to heavy use of nitrous oxide. Substitution therapy with hydroxycobalamine was initiated and the patient gradually recovered, although he was later found to have hyperhomocysteinaemia. The adverse effects of recreational nitrous oxide use are discussed, as well as potential pitfalls in diagnosis.
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| 17. |
- Svensson, Staffan, 1972, et al.
(author)
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Escitalopram: superior to citalopram or a chiral chimera?
- 2004
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In: Psychother Psychosom. ; 73:1, s. 10-16
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Journal article (peer-reviewed)abstract
- Background: Escitalopram is the active isomer of the antidepressant citalopram. In theory single-isomer drugs may be superior but few have been found to have clinically significant advantages. The manufacturer claims that escitalopram has more efficacy and a faster onset of effect than citalopram. The purpose of this study was to assess how far these claims are justified. Methods: Relevant trial reports were requested from H. Lundbeck A/S and the Swedish drug regulatory authority. The trials consisted of a pooled analysis of 1,321 patients from one unpublished, one partly published and one published eight-week trial, as well as a 24-week trial with 357 patients published as a poster. The studies compared escitalopram with placebo and/or citalopram in outpatients aged 18 years who met specified criteria for depression. The trials' quality was assessed with Moncrieff et al.'s quality assessment instrument and the results compared with the claims from the advertisements. Results: The advertising claims are not justified because they are based on secondary outcomes, non-intention-to-treat analyses and arbitrarily defined subgroups. The subgroup results are inconsistent. Methodological flaws in the trials could account for the differences found. Even if the differences claimed were real they appear too small to justify higher prices. Conclusions: On the evidence available to us the manufacturer's claims of superiority for escitalopram over citalopram are unwarranted. The Swedish and Danish drug regulatory authorities reached similar conclusions. This highlights the need for wider dissemination of national authorities' statements to other countries affected by the European Union's mutual recognition procedure.
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| 18. |
- Svensson, Staffan, 1972, et al.
(author)
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Making sense of blood pressure values in follow-up appointments for hypertension.
- 2008
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In: International Journal of Cardiology. - : Elsevier BV. - 1874-1754 .- 0167-5273. ; 123:2, s. 108-116
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Journal article (peer-reviewed)abstract
- BACKGROUND: Although there are effective ways of treating hypertension, only a minority of all hypertensive people reach target blood pressure levels. This may be a function of how patients and physicians put measured values into context when they decide if the blood pressure is well controlled or too high. METHODOLOGY: Qualitative analysis of audio-taped follow-up appointments for hypertension between 51 outpatients and their 11 physicians. All patients came for routine follow-up appointments for hypertension. The setting was primary and a specialist outpatient care in the south of Sweden. PRINCIPAL FINDINGS: Borderline blood pressure values led to more deliberation. Common ways of contextualising the blood pressure were by comparing it to previous values and by explaining it in terms of stress or lack of rest. The net effect of this was that the representativity and severity of the measured blood pressure value were downplayed by both patients and physicians. In some instances, physicians (but not patients) worked in the opposite direction. Patients were less actively engaged in interpreting the blood pressure values, stated their views about therapy less often, and were careful not to express views that were overly critical of the drug treatment. CONCLUSIONS: Patients and physicians make sense of the blood pressure through a contextualisation process which tends to normalise the face values towards the reference values. The resulting (processed) value is the one acted upon. Discursive handling of the blood pressure therefore makes up an important part of the decision-making.
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| 19. |
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| 20. |
- Svensson, Staffan, 1972
(author)
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Medication adherence, side effects and patient-physician interaction in hypertension
- 2006
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Doctoral thesis (other academic/artistic)abstract
- Hypertension is an important risk factor for cardiovascular disease, the incidence of which it is possible to reduce by prophylactic treatment with antihypertensive drugs. In clinical practice, however, only a minority of patients reach target blood pressure levels. The resulting gap between actual and potential health gains has been attributed to the fact that many patients do not take prescribed treatment as recommended, i.e. ”medication non-adherence”. This phenomenon is, however, insufficiently understood. We investigated the topic of adherence by way of a randomised questionnaire material comprising 1013 patients, and audio-recordings of 51 patient-physician consultations and 33 interviews with the patients made after the consultations. All patients came for regular follow-up appointments with their physicians and were under treatment with antihypertensives. In the questionnaire material, we found that patients who reported side effects of their drugs tended to rate their future risk of cardiovascular complications as being higher. Analysis of the interview data showed that patients had various reasons for sticking to the treatment recommendations: trust in physicians and wanting to avoid sequelae of hypertension were common arguments for doing so, while having side effects and disliking pharmaceuticals in general were reasons against. In the follow-up appointments, we found that the determinants of treatment decisions, i.e. the measured blood pressure values and (suspected) side effects, were defined through negotiation between patients and physicians. On the whole, patients and physicians were more in agreement about the interpretation of blood pressure values than of side effects, and physicians had the last say in the decision-making. We concluded that the antecedents of decisions about using medication are surrounded by uncertainty, and that it is the patient's interpretation of the ”facts” that, ultimately, determines if and how antihypertensive medications will be taken.
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| 21. |
- Svensson, Staffan, 1972, et al.
(author)
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Reasons for adherence with antihypertensive medication.
- 2000
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In: International journal of cardiology. - 0167-5273 .- 1874-1754. ; 76:2-3, s. 157-63
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Journal article (peer-reviewed)abstract
- BACKGROUND: Hypertension is often insufficiently controlled in clinical practice, a prominent reason for this being poor patient adherence with therapy. Little is known about the underlying reasons for poor adherence. We set out to investigate hypertensive patients' self-reported reasons for adhering to or ignoring medical advice regarding antihypertensive medication. METHODS: Qualitative analysis of semi-structured interviews with 33 hypertensive patients in a general-practice centre and a specialist hypertension unit in Southern Sweden. Blood-pressure measurements and laboratory measurements of antihypertensive medication were performed. RESULTS: Nineteen out of 33 patients were classified as adherent. Adherence was a function of faith in the physician, fear of complications of hypertension, and a desire to control blood pressure. Non-adherence was an active decision, partly based on misunderstandings of the condition and general disapproval of medication, but mostly taken in order to facilitate daily life or minimize adverse effects. Adherent patients gave less evidence of involvement in care than non-adherent patients. There was no obvious relation between reported adherence, laboratory markers of adherence and blood-pressure levels. CONCLUSIONS: The interview is a powerful tool for ascertaining patients' concepts and behaviour. To optimize treatment of hypertension, it is important to form a therapeutic alliance in which patients' doubts and difficulties with therapy can be detected and addressed. For this, effective patient-physician communication is of vital importance.
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| 22. |
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| 24. |
- Tukukino, Carina, et al.
(author)
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Drug interaction alerts in older primary care patients, and related medically justified actions
- 2022
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In: European Journal of Clinical Pharmacology. - : Springer Science and Business Media LLC. - 0031-6970 .- 1432-1041. ; 78, s. 1115-1126
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Journal article (peer-reviewed)abstract
- Purpose To describe presented interaction alerts in older patients, and the extent to which these require further medical action for the specific patient or are already being addressed. Methods Interaction alerts presented at a physician consultation, for 274 consecutive primary care patients treated with two or more drugs (median age: 75 years; 59% female), were extracted. These alerts are based on Janusmed, a decision support integrated in the medical records that provides recommendations for managing the interactions. One general practitioner (GP) and one GP/clinical pharmacologist determined in retrospect, first independently and then in consensus, whether the alerts justified further medical action, considering each patient's health condition. Results In all, 405 drug interaction alerts in 151 (55%) patients were triggered. Medical action in response was deemed medically justified for 35 (9%) alerts in 26 (17%) patients. These actions most often involved a switch to a less interacting drug from the same drug class (n = 10), a separate intake (n = 9), or the ordering of a laboratory test (n = 8). Out of 531 actions suggested by the alert system, only 38 (7%) were applicable to the specific patient, as, for instance, laboratory parameters were already being satisfactorily monitored or a separate intake implemented. Conclusions More than every other older patient receives drug treatment that triggers drug interaction alerts. Nine in ten alerts were already being addressed or were not relevant in the clinical setting, whereas, for the remaining tenth, some medical action, that for unknown reasons had not been taken, was reasonable. These findings show that interaction alerts are questionable as indicators of problematic prescribing.
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| 25. |
- Wallerstedt, Susanna Maria, 1970, et al.
(author)
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Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment
- 2022
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In: JAMA Network Open. - : American Medical Association (AMA). - 2574-3805. ; 5:10
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Journal article (peer-reviewed)abstract
- IMPORTANCE Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are used in research to reflect the quality of drug treatment in older people and have been suggested for inclusion in core outcome sets for evaluation of interventions for improved prescribing. Their validation so far, however, is primarily restricted to expert opinion-based processes. OBJECTIVE To evaluate the performance of 3 explicit PIM/PPO criteria sets as diagnostic tools to identify inadequate drug treatment in older patients. DESIGN, SETTING, AND PARTICIPANTS This diagnostic study analyzed patients aged 65 years or older consecutively included from 2 primary health care centers from October to November 2017. Data were analyzed from February to August 2022. EXPOSURES The PIMs/PPOs were concordantly identified by 2 specialist physicians (2018-2019) retrospectively after a planned physician visit, using 3 European PIM/PPO criteria sets and without knowledge of this diagnostic study. MAIN OUTCOMES AND MEASURES Area under the receiver operating characteristic (ROC) curve, reflecting the ability of PIM/PPO criteria sets to identify the reference standard of inadequate drug treatment, determined by 2 specialist physicians in consensus. Inadequate drug treatment implied that additional action related to the medication could be medically justified before the next regular visit. RESULTS A total of 302 patients were analyzed (median age, 74 [IQR, 69-81] years; 178 women [59%]; median number of drugs in the medication list, 6 [IQR, 3-9]); 98 patients (32%) had inadequate drug treatment. A total of 0 to 8 PIMs/PPOs per patient were identified using the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, 0 to 6 with the European EU(7)-PIM list, and 0 to 12 with the Swedish set of indicators of prescribing quality. The areas under the ROC curve for the 3 sets to identify the reference standard for inadequate drug treatment were 0.60 (95% CI, 0.53-0.66) for the STOPP/ START criteria, 0.69 (95% CI, 0.63-0.75) for the EU(7)-PIM list, and 0.73 (95% CI, 0.67-0.80) for the Swedish set. For comparison, the area under the ROC curve was 0.71 (95% CI, 0.65-0.78) using the number of drugs in the medication list. CONCLUSIONS AND RELEVANCE In this diagnostic study, the evaluated PIM/PPO sets had poor to fair performance as diagnostic tools to identify inadequate drug treatment, comparable with a simple count of the number of drugs in the medication list. These findings suggest that use of PIMs/PPOs as indicators of drug treatment quality in core outcome sets for the evaluation of interventions for improved prescribingmay need reconsideration.
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