Åsmund Reikvam

The majority of hospitalised patients have drug-related problems: results from a prospective study in general hospitals

Objective: To describe the frequency and types of drug-related problems (DRPs) in hospitalised patients, and to identify risk factors for DRPs and the drugs most frequently causing them.Methods From May to December 2002, 827 patients from six internal medicine and two rheumatology departments in five hospitals in Norway were included in this study. We recorded demographic data, drugs used, relevant medical history, laboratory data and clinical/pharmacological risk factors, i.e. reduced renal function, reduced liver function, heart failure, diabetes, compliance problems, drugs with a narrow therapeutic index and drug allergy. DRPs were documented after reviewing medical records and participation in multidisciplinary team discussions. An independent quality assessment team retrospectively assessed the DRPs in a randomly selected number of the study population.ResultsOf the patients, 81% had DRPs, and an average of 2.1 clinically relevant DRPs was recorded per patient. The DRPs most frequently recorded were dose-related problems (35.1% of the patients) followed by need for laboratory tests (21.6%), non-optimal drugs (21.4%), need for additional drugs (19.7%), unnecessary drugs (16.7%) and medical chart errors (16.3%). The patients used an average of 4.6 drugs at admission. A multivariate analysis showed that the number of drugs at admission and the number of clinical/pharmacological risk factors were both independent risk factors for the occurrence of DRPs, whereas age and gender were not. The drugs most frequently causing a DRP were warfarin, digitoxin and prednisolone, with calculated risk ratios 0.48, 0.42 and 0.26, respectively. The drug groups causing most DRPs were B01A-antithrombotic agents, M01A-non-steroidal anti-inflammatory agents, N02A-opioids and C09A-angiotensin converting enzyme inhibitors, with risk ratios of 0.22, 0.49, 0.21 and 0.35, respectively.ConclusionsThe majority of hospitalised patients in our study had DRPs. The number of drugs used and the number of clinical/pharmacological risk factors significantly and independently influenced the risk for DRPs. Procedures for identification of, and intervention on, actual and potential DRPs, along with awareness of drugs carrying a high risk for DRPs, are important elements of drug therapy and may contribute to diminishing drug-related morbidity and mortality.

Characteristics of drug-related problems discussed by hospital pharmacists in multidisciplinary teams

ObjectiveTo investigate pharmacist contribution in the therapeutic hospital team by studying drug-related problems (DRPs), pharmacist therapy advice and consequences of the advice.MethodsFrom May to December 2002, 827 patients in five Norwegian hospitals were included in the study. Demographic data, drugs used, relevant medical history, laboratory data and clinical/pharmacological risk factors were recorded prospectively at the wards.Main outcome measureDRPs, patients characteristics, pharmacist advice to physicians, nurses or patients, response to the pharmacist advice, and reasons (stated by the pharmacist) for not discussing an identified DRP, were reported. An independent quality assessment team retrospectively assessed the DRPs for a randomly selected number of the study population.ResultsOn average 2.6 DRPs per patient were found. A total of 2128 DRPs were registered and of these 1583 (74%) DRPs were brought up for discussion. Physician immediate acceptance rates varied from 80% (for extremely important clinically signififcant DRPs) to 50% (for DRPs of minor clinical significance). High age, use of many drugs at admission, existence of many DRPs and many clinical/pharmacological risk factors for DRPs were associated with low immediate acceptance rate. Type of DRP influenced how the DRP was discussed; adverse drug reaction (ADR) and unnecessary drug were discussed with physicians while e.g. medical chart error and need for patient education were discussed with nurses/patients. Reasons for not discussing DRPs in the team were: not given priority (37%), no longer relevant (31%) and others (31%). DRPs of minor clinical significance were most often excluded from discussion (37%) as opposed to 14% and 22% of those of moderate and major clinical significance.ConclusionsThe majority of patients had one or more DRPs. The problems identified as DRPs by the pharmacists were accepted as such by the physicians and to a high degree acted upon. Both clinical significance of the DRP and patient characteristics influenced physician immediate acceptance rate. Some DRPs could be solved by direct contact with nurses or the patients. Awareness of DRPs increases through participation of pharmacists in the multidisciplinary therapeutic hospital team.

Sex-based differences in premature first myocardial infarction caused by smoking: twice as many years lost by women as by men

Background It has been debated whether smoking increases the risk of heart disease relatively more in women than in men. It is not known whether there are sex differences with regard to how many years prematurely smoking causes acute myocardial infarction (AMI) to occur. We aimed to determine how smoking affects the age of onset of first myocardial infarction in both the sexes. Design Clinical data were consecutively entered into a database and were analysed with a multivariate regression technique. Methods In the years 1998-2005, data on 1784 consecutive patients (38.3% women) who were discharged from or died in a district general hospital with a diagnosis of first myocardial infarction were included in the study. Age at first AMI was analysed. Results Unadjusted mean ages were 76.2 years for women and 69.8 years for men, a difference of 6.4 years (P < 0.001). Mean age within the various groups was: women nonsmokers 80.7 years, women smokers 66.2 years, difference 14.4 years (P < 0.001); men nonsmokers 72.2 years, men smokers 63.9 years, difference 8.3 years (P < 0.001). After adjustment for risk factors (hypertension, cholesterol levels, diabetes) and patient characteristics (history of angina, history of stroke) 13.7 years of the age difference in women were attributed to smoking; the corresponding figure in men was 6.2 years (P < 0.001). Conclusion First AMI occurred significantly more prematurely in women than in men smokers, implying that twice as many years were lost by women as by men smokers. Eur J Cardiovasc Prev Rehabil 16:174-179

Identification of drug interactions in hospitals – computerized screening vs. bedside recording

Background and objective:  Managing drug interactions in hospitalized patients is important and challenging. The objective of the study was to compare two methods for identification of drug interactions (DDIs) – computerized screening and prospective bedside recording – with regard to capability of identifying DDIs.

Increased antibiotic use in Norwegian hospitals despite a low antibiotic resistance rate

OBJECTIVES Although antibiotic use and resistance are low in Norway, the situation risks changing for the worse. We investigated trends in antibiotic use and assessed them in relation to antibiotic resistance in Norway. METHODS We drew on hospital pharmacy sales data to record antibiotic use from 2002 to 2007 in eight hospitals serving 36% of the nations population. Antibiotic use was measured using different indices with defined daily doses (DDDs) as the numerator (WHO ATC/DDD classification). RESULTS Total antibiotic use increased from 1.02 to 1.30 DDDs/1000 inhabitants/day (DIDs) and from 61.7 to 72.4 DDDs/100 bed-days (BDs) (17.4%); related to the number of discharges, no significant DDD change was shown. Their use in core units (adult intensive care units, recovery/post-operative wards and departments of internal medicine and surgery with all subspecialties) increased from 64.1 to 80.8 DDDs/100 BDs (26.1%) and by 3.1% related to the number of discharges. The total use of broad-spectrum antibiotics increased by 47.9% when measured as DDDs/100 BDs, and by 19.1% based on the number of discharges; the corresponding figures for core units were 60.5% and 31.2%, respectively. CONCLUSIONS There was a substantial increase in total antibiotic use, and an even more pronounced increase in the use of broad-spectrum antibiotics, which seems unjustified considering the current low antibiotic resistance in Norway.

Markedly Changed Age Distribution among Patients Hospitalized for Acute Myocardial Infarction

Objective : To investigate trends in number of hospital admissions due to acute myocardial infarction (AMI) in different age groups during the last decade. Design : Data on all AMI hospital admissions since 1991 were analysed by gender and by age applying 5-year age groups between ages 60 and 90, and < 60 and S 90 as separate groups. Results : From 1991 to 2000 the number of hospital admissions for AMI was reduced by 18%. In men, AMI rates decreased in all age groups below 80 years and increased in older ages, while in women the corresponding breaking point between decreased and increased rates was 85 years. In the age group < 80 years, men and women included, the number of AMI admissions decreased by 29% (from 11 540 to 8233), while for those S 80 there was an increase of 25% (from 2917 to 3659). Over the decade the ratio of the numbers of AMIs in ages above and below 80 years increased from 0.25 to 0.44. Conclusion : Over the last decade a striking change in age distribution among AMI patients took place, with a marked decrease in age groups below 80 years, as opposed to an equally strong increase in the oldest age groups. The development with regard to trends for AMI morbidity in society has been more favourable than what appears from overall numbers of AMIs.

Use of cardiovascular drugs after acute myocardial infarction: a marked shift towards evidence-based drug therapy.

AbstractObjective. To investigate the prescription pattern for cardiovascular drugs among patients discharged after an acute myocardial infarction (AMI) in hospitals that had participated in a corresponding study seven years earlier, and examine what the indications were for use of the different drugs. Methods. From 16 hospitals we drew a sample of patients who were discharged with a diagnosis of AMI during a three months period in 1999/2000. Physicians in each hospital obtained from the medical records the observed rate of use of cardiovascular drugs at discharge. The drug use was compared with findings from a corresponding sample drawn in 1993. The main indication for use of the different cardiovascular drugs was recorded for the 1999/2000 sample. Results. 399 patients discharged alive were included in the first study and 767 in the second. The use of beta-blockers, ACE inhibitors and statins rose substantially during the period. For patients aged ≤70 drug use in respectively 1993 and 1999/2000 was as follows: beta-blockers 73% vs 89%, ACE inhibitors 14% vs 29%, statins not recorded vs 82%; corresponding figures for patients aged >70 were: beta-blockers 45% vs 74%, ACE inhibitors 19% vs 38%, statins not recorded vs 35%. Aspirin/anticoagulant use was largely unchanged; 93% and 70% of patients aged ≤70 and >70 respectively used these drugs at the second survey. The use of regular nitrates and calcium antagonists had decreased. Nearly half of the >70 group and one-fifth of persons ≤70 used 5–9 cardiovascular drugs. Conclusion. At the end of the 1990s a substantial shift in drug therapy after AMI occurred, with a markedly increased use of drugs proven to be effective in clinical trials and less use of other cardiovascular drugs. The most frequently reported main indication for use of drugs was secondary prevention. The principles of evidence-based drug therapy became increasingly adopted among clinicians during the 1990s.

Changes in myocardial infarction mortality

BACKGROUND The incidence of myocardial infarction (MI) in Norway has decreased substantially over the last two decades, according to recent publications based on data from the Norwegian Patient Registry. To better understand the development of cardiovascular disease over time we have investigated the development of MI mortality in light of the decrease in MI incidence. MATERIAL AND METHODS Data on MI mortality were retrieved from the Cause of Death Registry (Statistics Norway) for the period 1969-2007 and analyzed. Mortality rates (death per 100,000 inhabitants) were calculated for the total population according to sex and the following age groups: 0-39 years, 10-year groups in the range 40-79 years and 80 years and higher. RESULTS Total MI mortality showed a weak increase in the 1970s and the 1980s until 1987. Mortality decreased substantially from 1987 to 2007, 64% for men and 47% for women. The reduction in mortality started first for the youngest age groups. In 2007, the decrease in mortality from the peak years was about 70% for the age groups below 80 years and about 40% in the group above 80 years of age. INTERPRETATION After small changes in the 1970s and 1980s, MI mortality has decreased steadily in the 1990 s in all age groups and has continued to do so after 2000.

Choice of initial antihypertensive drugs and persistence of drug use--a 4-year follow-up of 78,453 incident users.

PurposeTo investigate patterns of initial drug therapy for the treatment of hypertension and to evaluate treatment persistence and change of treatment during a 4-year period in patients receiving thiazides (TZs) and/or angiotensin II-receptor blockers (ARBs) as first-line treatment.MethodsAll initial users of antihypertensive drugs in 2005 and 2009 registered in the Norwegian Prescription Database were included. Treatment on five index dates at 1-year intervals was recorded. A patient was considered to be under treatment on an index date if a drug had been dispensed within the previous 180 days and to have maintained treatment persistence if he/she was on any antihypertensive treatment on the index date and all previous index dates.ResultsAmong 78,453 new users of antihypertensives in 2005, women started more often with TZs than men (30 vs. 25 %) and less often with ARBs (22 vs. 25 %). In men, the hazard of non-persistence with antihypertensive treatment was significantly lower among initial ARB users than among TZ users (hazard ratio 0.87, 95 % confidence interval 0.81–0.94); in women no significant difference was found. After 4 years, 49 % of the men and 51 % of the women who had started with plain TZs were still using TZs, whereas 65 % of the male ARB users and 60 % of the female ARB users were still using ARBs.ConclusionTZs and ARBs were the most widely used first-line antihypertensives. Among the men enrolled in the study, ARB users had a somewhat better persistence with antihypertensive treatment than TZ users. Among both genders, continuation on ARBs was more common than continuation on TZs.

Reduced life expectancy after an incident hospital diagnosis of acute myocardial infarction--effects of smoking in women and men.

BACKGROUND The aim was to investigate possible gender differences in the years of life lost after acute myocardial infarction (MI) and to explore how smoking affects life expectancy in the two genders. METHODS In the years 1998-2005, 2281 patients (36.8% women) who were discharged from or died in hospital following a diagnosis of MI were included. Survivors were followed for a mean of 8 years. The age of death for each patient was subtracted from the average projected age of death for individuals in the general population with a similar age to the patient at the time of their MI. The effects of gender, smoking, and other risk factors on the years of life lost were analysed. RESULTS During follow-up, 55% of the patients died. Non-smokers, ex-smokers and current smokers lost 5.4, 6.4 and 10.3 years of life, respectively. Structural equation modeling showed that currently smoking men lost 4.2 more years more than did non-smoking men (P<0.001), and this was mediated through more prematurely occurring MIs. Female current smokers lost 1.9 years more than male current smokers and female ex-smokers lost 1.8 years more than male ex-smokers (both P<0.001). CONCLUSIONS MI caused a substantial number of years of life lost, with a heavier loss in current smokers than in ex-smokers and non-smokers. The effect was predominantly related to the patients age at the event. More years of life were lost among smoking women than among smoking men, indicating that smoking is most detrimental for the female gender.