Anders Carlsten

Evaluation of the quality of drug therapy among elderly patients in nursing homes

Objective. To evaluate drug therapy quality among elderly nursing home residents. Secondary aims were to compare quality in young and old elderly and to determine whether number of prescribers affected quality of drug therapy. Design. A cross-sectional population-based register study. Setting. Nursing home residents in the Gothenburg area using the multi-dose system (e.g. patients who get their drugs machine dispensed into one unit for each dose occasion, a service offered by the National Corporation of Pharmacies). Subjects. All nursing home residents aged 65 years and older. Main outcome measures. The quality of drug therapy assessed using five quality indicators for the elderly recently introduced by the Swedish National Board of Health and Welfare; number of prescribed drugs per resident. Results. Over 70% of residents had one or more potentially inappropriate prescription. Younger nursing home residents (65–79 years) had significantly (p < 0.001) lower quality of drug therapy than older residents (80 + ). The average number of prescribing physicians per resident was high at almost four per resident. An increasing number of prescribers per resident was associated with a higher number of drugs prescribed and a lower quality of drug therapy. Conclusion. Computerized quality assurance systems can provide support for healthcare providers. Quality indicators should be modified to give maximum support for users.

Quality of drug prescribing in elderly people in nursing homes and special care units for dementia: a cross-sectional computerized pharmacy register analysis.

AbstractBackground: Drug prescribing to the elderly is extensive and often inappropriate. Furthermore, the number of drugs used is the most important risk factor for adverse drug reactions. Despite this, drug prescribing in the elderly in Sweden is high and increasing. In 2003 the Swedish National Board of Health and Welfare launched a set of indicators to evaluate the quality of drug therapy in the elderly. Use of this tool in combination with the Swedish computerized national register covering all persons receiving multi-dose drug dispensing (drugs dispensed in one dose unit bag for each dose occasion) would enable detection of inappropriate drug prescribing and could help reduce the risk of drug-related problems among the elderly. Objectives: To assess the extent and quality of drug prescribing in younger and older elderly residents receiving multi-dose drug dispensing in ordinary nursing homes (NHs) and special care units for dementia (NHDs), and to evaluate the relationship between the quality of prescribing and the number of prescribers per resident, in a Swedish county. Methods: The computerized national pharmacy drug register provided the database and a cross-sectional design was used. Selected drug-specific quality indicators proposed by the Swedish National Board of Health and Welfare in 2003 were used to assess the quality of drug prescribing. Results: This study included 3705 residents. Their mean age was 85 years and 72% were women. The mean number of prescribed drugs was 10.3 per resident. The proportion of residents with prescriptions for psychotropic drugs was 80% in NHs and 85% in NHDs. The prevalence of each drug-specific quality indicator was as follows: long-acting benzodiazepines 16.4% (NHs) versus 11.7% (NHDs), anticholinergic drugs 20.7% versus 18.5%, drug duplication 14.6% versus 13.6%, three or more psychotropic drugs 25.6% versus 35.3%, class C interactions (drug combinations that may require dose adjustment) 41.9% versus 38.7% and class D interactions (drug combinations that should be avoided) 8.1% versus 5.6%. Younger elderly residents (age 65–79 years) had a lower quality of drug prescribing. An increasing number of prescribers per resident was associated with a lower quality of drug therapy. Conclusions: We found a lower quality of drug prescribing, e.g. anticholinergic drugs prescribed to approximately 20% of residents of NHs and NHDs, and a higher rate of psychotropic drug use (≥80%) compared with previous studies in NHs. Our results also demonstrated a negative correlation between quality of prescribing and number of prescribers per resident.

Are sedatives and hypnotics associated with increased suicide risk of suicide in the elderly

BackgroundWhile antidepressant-induced suicidality is a concern in younger age groups, there is mounting evidence that these drugs may reduce suicidality in the elderly. Regarding a possible association between other types of psychoactive drugs and suicide, results are inconclusive. Sedatives and hypnotics are widely prescribed to elderly persons with symptoms of depression, anxiety, and sleep disturbance. The aim of this case-control study was to determine whether specific types of psychoactive drugs were associated with suicide risk in late life, after controlling for appropriate indications.MethodsThe study area included the city of Gothenburg and two adjacent counties (total 65+ population 210 703 at the start of the study). A case controlled study of elderly (65+) suicides was performed and close informants for 85 suicide cases (46 men, 39 women mean age 75 years) were interviewed by a psychiatrist. A population based comparison group (n = 153) was created and interviewed face-to-face. Primary care and psychiatric records were reviewed for both suicide cases and comparison subjects. All available information was used to determine past-month mental disorders in accordance with DSM-IV.ResultsAntidepressants, antipsychotics, sedatives and hypnotics were associated with increased suicide risk in the crude analysis. After adjustment for affective and anxiety disorders neither antidepressants in general nor SSRIs showed an association with suicide. Antipsychotics had no association with suicide after adjustment for psychotic disorders. Sedative treatment was associated with an almost fourteen-fold increase of suicide risk in the crude analyses and remained an independent risk factor for suicide even after adjustment for any DSM-IV disorder. Having a current prescription for a hypnotic was associated with a four-fold increase in suicide risk in the adjusted model.ConclusionSedatives and hypnotics were both associated with increased risk for suicide after adjustment for appropriate indications. Given the extremely high prescription rates, a careful evaluation of the suicide risk should always precede prescribing a sedative or hypnotic to an elderly individual.

Suicides by drug poisoning among the elderly in Sweden 1969-1996.

Abstract  Background: Previous studies have shown an association between the rates of suicide employing certain types of medications and the availability of those drugs. During recent years, prescription patterns of psychoactive drugs commonly used in suicides have undergone some major changes. This study examines whether altered prescription patterns are associated with changes in the rates of drug-related suicides in the elderly. Methods: An ecological study was performed, in which rates of suicide by drug poisoning were related to prescription sales of different psychotropic drugs, derived from the National Prescription Survey (1987–1996). Results: Benzodiazepines were the dominant drug type used by elderly persons who committed suicide by drug poisoning. Rates of suicide using benzodiazepines increased despite decreasing prescription sales. Decreasing tricyclic antidepressant sales and increasing SSRI (selective serotonin reuptake inhibitors) sales were paralleled by decreasing rates of suicides employing antidepressants. The fatality ratio (FR) decreased for the antidepressant group, increased for benzodiazepines and remained more or less unchanged for analgesics among the elderly during the study period. Conclusions: Rates of suicide using benzodiazepines increased in the elderly despite decreasing prescription sales. Benzodiazepines should be prescribed restrictively to this age group.

A comparison of two methods for estimating refill adherence to statins in Sweden: the RARE project.

To analyse and compare refill adherence to statins estimated with two different methods with a focus on sensitivity to definitions.

Socioeconomic determinants of psychotropic drug utilisation among elderly: a national population-based cross-sectional study

BackgroundPsychotropic drugs are commonly utilised among the elderly. This study aimed to analyse whether two socioeconomic determinants - income and marital status - are associated with differences in utilisation of psychotropic drugs and potentially inappropriate psychotropic drugs among elderly in Sweden.MethodsAll individuals aged 75 years and older who had purchased a psychotropic drug in Sweden during 2006 were included (68.7% women, n = 384712). Data was collected from national individual-based registers. Outcome measures were utilisation of three or more psychotropic drugs and utilisation of potentially inappropriate psychotropic drugs, as classified by the Swedish National Board of Health and Welfare.ResultsIndividuals with low income were more likely to utilise three or more psychotropic drugs compared to those with high income; adjusted odds ratio (aOR) 1.12 (95% confidence interval [CI] 1.10-1.14). The non-married had a higher probability for utilising three or more psychotropic drugs compared to the married (aOR 1.22; CI 1.20-1.25). The highest probability was observed among the divorced and the never married. Potentially inappropriate psychotropic drugs were more common among individuals with low compared to high income (aOR 1.14; CI 1.13-1.16). Compared to the married, potentially inappropriate psychotropic drug utilisation occurred more commonly among the non-married (aOR 1.08; CI 1.06-1.10). The never married and the divorced had the highest probability.ConclusionsThere was an association between socioeconomic determinants and psychotropic drug utilisation. The probability for utilising potentially inappropriate psychotropics was higher among individuals with low income and among the non-married.

Economic Impact of Adverse Drug Events - A Retrospective Population-Based Cohort Study of 4970 Adults

Background The aim was to estimate the direct costs caused by ADEs, including costs for dispensed drugs, primary care, other outpatient care, and inpatient care, and to relate the direct costs caused by ADEs to the societal COI (direct and indirect costs), for patients with ADEs and for the entire study population. Methods We conducted a population-based observational retrospective cohort study of ADEs identified from medical records. From a random sample of 5025 adults in a Swedish county council, 4970 were included in the analyses. During a three-month study period in 2008, direct and indirect costs were estimated from resource use identified in the medical records and from register data on costs for resource use. Results Among 596 patients with ADEs, the average direct costs per patient caused by ADEs were USD 444.9 [95% CI: 264.4 to 625.3], corresponding to USD 21 million per 100 000 adult inhabitants per year. Inpatient care accounted for 53.9% of all direct costs caused by ADEs. For patients with ADEs, the average societal cost of illness was USD 6235.0 [5442.8 to 7027.2], of which direct costs were USD 2830.1 [2260.7 to 3399.4] (45%), and indirect costs USD 3404.9 [2899.3 to 3910.4] (55%). The societal cost of illness was higher for patients with ADEs compared to other patients. ADEs caused 9.5% of all direct healthcare costs in the study population. Conclusions Healthcare costs for patients with ADEs are substantial across different settings; in primary care, other outpatient care and inpatient care. Hence the economic impact of ADEs will be underestimated in studies focusing on inpatient ADEs alone. Moreover, the high proportion of indirect costs in the societal COI for patients with ADEs suggests that the observed costs caused by ADEs would be even higher if including indirect costs. Additional studies are needed to identify interventions to prevent and manage ADEs.

Cost of illness of patient-reported adverse drug events: a population-based cross-sectional survey.

Objectives To estimate the cost of illness (COI) of individuals with self-reported adverse drug events (ADEs) from a societal perspective and to compare these estimates with the COI for individuals without ADE. Furthermore, to estimate the direct costs resulting from two ADE categories, adverse drug reactions (ADRs) and subtherapeutic effects of medication therapy (STE). Design Cross-sectional study. Setting The adult Swedish general population. Participants The survey was distributed to a random sample of 14 000 Swedish residents aged 18 years and older, of which 7099 responded, 1377 reported at least one ADE and 943 reported an ADR or STE. Main outcome measures Societal COI, including direct and indirect costs, for individuals with at least one self-reported ADE, and the direct costs for prescription drugs and healthcare use resulting from self-reported ADRs and STEs were estimated during 30 days using a bottom-up approach. Results The economic burden for individuals with ADEs were (95% CI) 442.7 to 599.8 international dollars (Int

Physicians' opinions and experiences of the Pharmaceutical Benefits Reform

), of which direct costs were Int

What can we learn from consumer reports on psychiatric adverse drug reactions with antidepressant medication? Experiences from reports to a consumer association

279.6 to 420.0 (67.1%) and indirect costs were Int