Anna Birna Almarsdóttir

The Nordic countries as a cohort for pharmacoepidemiological research.

The Nordic countries have a long tradition of registry-based epidemiological research. Many population-based health registries were established in the 1960s, with use of unique personal identifiers facilitating linkage between registries. In recent years, each country has established a national database to track prescription drugs dispensed to individuals in ambulatory care. The objectives were to present an overview of the prescription databases established in the Nordic countries, as well as to elaborate on their unique potential for record linkage and cross-national comparison of drug utilization. Five Nordic countries collect drug exposure data based on drugs dispensed at pharmacies and have the potential to link these data to health outcomes. The databases together cover 25 million inhabitants (Denmark: 5.5 million; Finland: 5.3 million; Iceland: 0.3 million; Norway: 4.8 million; and Sweden: 9.2 million). In 2007, the registries encompassed 17 million prescription drug users (68% of the total population). We provide examples of how these databases have been used for descriptive drug utilization studies and analytical pharmacoepidemiological studies linking drug exposure to other health registries. Comparisons are facilitated by many similarities among the databases, including data source, content, coverage and methods used for drug utilization studies and record linkage. There are, however, some differences in coding systems and validity, as well as in some access and technical issues. To perform cross-national pharmacoepidemiological studies, resources, networks and time are needed, as well as methods for pooling data. Interpretation of results needs to account for inter-country heterogeneity and the possibility of spurious relationships. The Nordic countries have a unique potential for collaborative high-quality cross-national pharmacoepidemiological studies with large populations. This research may assist in resolving safety issues of international interest, thus minimizing the risk of either over-reacting on possible signals or underestimating drug safety issues.

Drug‐related problems and pharmacy interventions in community practice

Objectives — (1) To document types and number of drug‐related problems identified by community pharmacy personnel in Sweden; (2) to determine relationships among the types and number of problems identified and the gender, age and number of prescribed drugs in patients; and (3) to document the interventions made by pharmacy personnel with patients and prescribers.

Factors influencing the detection rate of drug‐related problems in community pharmacy

This study analyzes relationships between the number of drug‐related problems detected in community pharmacy practice and the educational level and other characteristics of pharmacy personnel and their work sites. Random samples of pharmacists, prescriptionists and pharmacy technicians were drawn nationwide in Sweden. One hundred and forty‐four (63%) of those meeting the inclusion criteria agreed to take part. The participants documented medication‐related problems, interventions and patient variables on a data collection form. The drug‐related problems were weighted by the number of patients served by each professional. The regression analysis showed the educational level of the professional to have a statistically significant effect on the detection rate, with pharmacists finding on average 2.5 more drug‐related problems per 100 patients than prescriptionists and about 3.6 more than technicians. Previous participation in a study or activity on drug‐related problems and the size of the pharmacy also had statistically significant effects on the problem detection rate. The use of open‐ended questions to create a dialogue with the patient seemed to be a successful means to discover problems. The results of this study indicate the importance of education and training of pharmacy personnel in detection of drug‐related problems. This finding speaks in favor of increasing the pharmacist to other personnel ratio, provided the higher costs will be offset by societal benefits.

Self-reported medicine use among 11- to 15-year-old girls and boys in Denmark 1988-1998

Aims: To describe the self-reported medicine use for common health complaints among 11 - 15-year-olds in Denmark during a ten year period, 1988 - 1998. The paper focuses on medicine for headache, stomach ache, cough, cold, nervousness, and difficulties in getting to sleep. Methods: Four cross-sectional surveys of 11 - 15-year-old students in random samples of schools in Denmark, conducted in 1988 (n=1,671), 1991 (n=1,860), 1994 (n=4,046) and 1998 (n=5,205). The surveys were similar with regard to sampling and data collection. Data were collected by self-administered questionnaires in the classroom. Results: A large proportion of 11 - 15-year-olds reported medicine use during the past month. It was most common to take medicines for headache (used by 55% of 15-year-old girls and 36% of 15-year-old boys in 1998) and stomach ache (33% among 15-year-old girls in 1998). Pain reliever use was higher among girls than boys and this sex difference increased with age. There was an upward trend in reported medicine use from 1988 to 1998, in particular regarding medicine for stomach-ache among 13- and 15-year-old girls. A large proportion of girls were frequent users of medicine for headache, stomach-ache, and sleeping difficulties. Conclusion: A high proportion of 11 - 15-year-old girls and boys reported medicine use in relation to common health complaints. The proportion of users increased during the past decade. It is suggested that more information about medicine be built into health education programs in the future.

Psychotropic Drug Use among Icelandic Children: A Nationwide Population-Based Study

OBJECTIVE The aim of this study was to investigate psychotropic drug use among children in Iceland between 2003 and 2007. METHODS A nationwide population-based drug use study covering the total pediatric population (ages 0-17) in Iceland. Information was obtained from the National Medicines Registry to calculate prevalence of use by year and psychotropic drug group; incidence by year, psychotropic drug group, childs age and sex, and medical specialty of prescriber; the most commonly used psychotropic chemical substances, off-label and unlicensed use and concomitant psychotropic drug use. RESULTS The overall prevalence of psychotropic drug use was 48.7 per 1000 Icelandic children in 2007. Stimulants and antidepressants increased in prevalence from 2003 to 2007 and were the two most prevalent psychotropic drug groups, respectively, 28.4 and 23.4 per 1000 children in 2007. A statistically significant trend of declining prevalence (p = 0.00013) and incidence (p = 0.0018) of antidepressant use occurred during the study period. Out of 21,986 psychotropic drugs dispensed in 2007, 25.4% were used off-label. CONCLUSIONS With reference to reports from other European countries, the results indicate extensive psychotropic drug use among children in Iceland between 2003 and 2007. Further scrutiny is needed to assess the rationale behind this widespread use.

No struggle, no strength: how pharmacists lost their monopoly

Research accounts of the struggle of professions to attain and maintain a monopoly, strategies of exclusion and usurpation, make for interesting and often exciting reading. The purpose of this article is to present a less frequently reported phenomenon--the study of a profession that had a monopoly, and then lost it. The authors attempt to answer the question: under what circumstances will a profession support the state in breaking their own monopoly? The study looked at the pharmacy profession in Iceland in the light of the recent change in drug legislation. Interviews with key actors in the pharmacy profession were conducted to gain an understanding of how they interpreted and experienced this change. Three factors contributed to the break in the professional monopoly: (1) political desire to take advantage of new competition and deregulation policy, (2) desire to cut the health budget and (3) internal divisions within the profession. The results of the study revealed at least four internal divisions within the pharmacy profession: (1) urban/rural, (2) employer/employee, (3) lower/higher education and (4) young/old. The article illustrates how a profession weakened by internal strife became prey to the governments cost cutting activities. This study is an example of how internal conflicts not only weakened the profession, but created a climate conducive to losing its monopoly. Our findings raise fundamental questions about the future of professions in society today.

Cost-Containment as Part of Pharmaceutical Policy

In this article the authors provide insight into the basis for price setting of medicines, the increasing pharmaceutical budgets in the past decades, and the measures governments and insures have taken to curb rising pharmaceutical costs. Four reasons are out lined for the fact that medicines are by some considered expensivey: 1) there are fundamental differences between medicines and other consumer products; 2) medicines are technology requiring an inordinate amount of research and development; 3) medicines are developed, manufactured, and distributed according to strict regulatory requirements; 4) medicines are most often selected by a physician for a specific patient and reimbursed in whole or in party by a third-party insurer or the state. Pharmaceuticals mean share of GDP has been 1.2% in OECD countries in recent decades. Pharmaceuticals accounted for 15.4% of total health expenditure, with public spending about half of this amount. Since 1970, the average share of GDP for pharmaceuticals in most countries has increased 1.5% more per year than GDP growth. Four types of strategies to curb rising Pharmaceuticals costs are described and a taxonomy of strategies provided These are:1)price and profit controls; 2) reimbursement system charges; 3) other fiscal measures; 4) quality measures. Pharmaceuticals policy has suffered from the pervasive misunderstanding that drugs are like any other commodity; resulting in policy makers viewing pharmaceuticals expenditures without thinking about drugs in their proper content of health care. The authors conclude by advocating a balanced approach to policymaking in a environment of rising pharmaceuticals costs.

Pharmaceutical policy and the lay public.

Almost every national and supranational health policy document accords high importance to the need to listen to and ‘empower’ patients. The relationship between pharmaceutical policy and the lay public is not direct but mediated by several actors, including health care workers, patient organisations, industry and, most recently, the media. Although the overall aim of health and pharmaceutical policy is to address the needs of all citizens, there are only a few, well organised groups who are actually consulted and involved in the policymaking process, often with the support of the industry. The reasons for this lack of citizen involvement in health and pharmaceutical policymaking are many, for example: there is no consensus about what public involvement means; there is a predominance of special interest groups with narrow, specific agendas; not all decision makers welcome lay participation; patients and professionals have different rationalities with regard to their views on medicine. Because the lay public and medicine users are not one entity, one of the many challenges facing policy makers today is to identify, incorporate and prioritise the many diverse needs. The authors recommend research which includes studies that look at: lay attitudes towards pharmaceutical policy; lay experiences of drug therapy and how it affects their daily lives; the problem of identifying lay representatives; the relationship between industry and the consumers; the effect of the media on medicine users and on pharmaceutical policy itself. The authors acknowledge that although lay involvement in policy is still in its infancy, some patient organisations have been successful and there are developments towards increased lay involvement in pharmaceutical policymaking.

A Population-Based Study of Stimulant Drug Treatment of ADHD and Academic Progress in Children

OBJECTIVE: We evaluated the hypothesis that later start of stimulant treatment of attention-deficit/hyperactivity disorder adversely affects academic progress in mathematics and language arts among 9- to 12-year-old children. METHODS: We linked nationwide data from the Icelandic Medicines Registry and the Database of National Scholastic Examinations. The study population comprised 11 872 children born in 1994–1996 who took standardized tests in both fourth and seventh grade. We estimated the probability of academic decline (drop of ≥5.0 percentile points) according to drug exposure and timing of treatment start between examinations. To limit confounding by indication, we concentrated on children who started treatment either early or later, but at some point between fourth-grade and seventh-grade standardized tests. RESULTS: In contrast with nonmedicated children, children starting stimulant treatment between their fourth- and seventh-grade tests were more likely to decline in test performance. The crude probability of academic decline was 72.9% in mathematics and 42.9% in language arts for children with a treatment start 25 to 36 months after the fourth-grade test. Compared with those starting treatment earlier (≤12 months after tests), the multivariable adjusted risk ratio (RR) for decline was 1.7 (95% confidence interval [CI]: 1.2–2.4) in mathematics and 1.1 (95% CI: 0.7–1.8) in language arts. The adjusted RR of mathematics decline with later treatment was higher among girls (RR, 2.7; 95% CI: 1.2–6.0) than boys (RR, 1.4; 95% CI: 0.9–2.0). CONCLUSIONS: Later start of stimulant drug treatment of attention-deficit/hyperactivity disorder is associated with academic decline in mathematics.

Multimethod research into policy changes in the pharmacy sector—The Nordic case

This article aims to explain the nature of multimethod studies and to illustrate their role in pharmaceutical policy research. In the field of pharmaceutical policy research, methodological and theoretically sound evaluation is the main goal. Reflexive learning is required in order to address and resolve one of the important paradoxes of late modern societies, which is that while the increasing complexity of social systems progressively undermines notions of certainty in social knowledge, it simultaneously raises the stakes in relation to rational guidance of those systems. By reflecting over our own research processes, we identified the strengths and weaknesses of multimethod research. We present our research methods and the experiences of pharmaceutical policy changes from two separate evaluation studies, one from Iceland and the other from Denmark. In addition, examples from a third study in progress are included: a multimethod international comparison of recent changes in pharmaceutical policy in Iceland, Denmark and Norway. Based on our experiences and reflections, we identified four of the most important issues we encountered in carrying them out: The importance of doing research in context; Challenges of comparison and questions of compatibility of data--both qualitative and quantitative; The importance of doing these studies with a multidisciplinary team; Research in pharmaceutical policy is a fluid, ongoing process.