Jørund Straand

The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients: A modified Delphi study

Objective. To establish a clinically relevant list with explicit criteria for pharmacologically inappropriate prescriptions in general practice for elderly people ≥70 years. Design. A three-round Delphi process for validating the clinical relevance of suggested criteria (n = 37) for inappropriate prescriptions to elderly patients. Setting. A postal consensus process undertaken by a panel of specialists in general practice, clinical pharmacology, and geriatrics. Main outcome measures. The Norwegian General Practice (NORGEP) criteria, a relevance-validated list of drugs, drug dosages, and drug combinations to be avoided in the elderly (≤70 years) patients. Results. Of the 140 invited panellists, 57 accepted to participate and 47 completed all three rounds of the Delphi process. The panellists reached consensus that 36 of the 37 suggested criteria were clinically relevant for general practice. Relevance of three of the criteria was rated significantly higher in Round 3 than in Round 1. At the end of the Delphi process, a significant difference between the different specialist groups’ scores was seen for only one of the 36 criteria. Conclusion. The NORGEP criteria may serve as rules of thumb for general practitioners (GPs) related to their prescribing practice for elderly patients, and as a tool for evaluating the quality of GPs’ prescribing in settings where access to clinical information for individual patients is limited, e.g. in prescription databases and quality improvement interventions.

Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study

Aim: Based on a multidisciplinary review of drug use in nursing home residents, this study aimed to identify the most frequent clinically relevant medication problems and to analyse them according to the drugs involved and types of problems. Methods: Cross sectional study auditing drug use by 1354 residents in 23 nursing homes in Bergen, Norway. Data were collected in 1997. A physician/pharmacist panel performed a comprehensive medication review with regard to indications for drug use and active medical conditions. The drug related problems were subsequently classified according to the drugs involved and types of problems (indication, effectiveness, and safety issues). Results: 2445 potential medication problems were identified in 1036 (76%) residents. Psychoactive drugs accounted for 38% of all problems; antipsychotics were the class most often involved. Multiple psychoactive drug use was considered particularly problematic. Potential medication problems were most frequently classified as risk of adverse drug reactions (26%), inappropriate drug choice for indication (20%), and underuse of beneficial treatment (13%). Conclusions: Three of four nursing home residents had clinically relevant medication problems, most of which were accounted for by psychoactive drugs. The most frequent concerns were related to adverse drug reactions, drug choice, and probable undertreatment.

Psychotropic drug use in nursing homes--diagnostic indications and variations between institutions.

Abstract.Objective: Psychotropic drug use among nursing home residents with regard to diagnostic indications and patient- and institution characteristics was analysed. Methods: A cross-sectional study of medication data from 1552 residents at 23 nursing homes in Bergen, Norway, was performed. Psychotropic drug use (neuroleptics, anxiolytics, hypnotics, antidepressants, and two sedative antihistamines) was analysed with regard to prevalence, diagnostic indications, duration of use, and general patient- and institution characteristics. Results: Psychotropic drugs were taken on a daily schedule by 59% of all residents, most commonly as long-term treatment. Antidepressants (in 70% selective serotonin re-uptake inhibitors) were used by 31%, neuroleptics by 23%, and benzodiazepines by 22% of all the residents. Neuroleptics were given for non-psychotic behavioural and psychological symptoms in 66% of the cases. Sleeping disorders were most commonly treated with long-acting benzodiazepine hypnotics. Psychotropic drug use decreased with increasing patient age. Drug use patterns varied greatly between the different nursing homes: the prevalence of neuroleptic use varied from 0 to 61% of the residents, and antidepressant use varied from 10 to 63%. In nursing homes providing relatively more physician staff time, the residents were more likely to use antidepressants. Conclusions: Psychotropic drugs are used by a majority of nursing home residents as long-term symptomatic treatment. The great variations between the institutions can only to a small extent be explained by quantitative differences between the institutions.

Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study)

Objective To assess the effects of a multifaceted educational intervention in Norwegian general practice aiming to reduce antibiotic prescription rates for acute respiratory tract infections and to reduce the use of broad spectrum antibiotics. Design Cluster randomised controlled study. Setting Existing continuing medical education groups were recruited and randomised to intervention or control. Participants 79 groups, comprising 382 general practitioners, completed the interventions and data extractions. Interventions The intervention groups had two visits by peer academic detailers, the first presenting the national clinical guidelines for antibiotic use and recent research evidence on acute respiratory tract infections, the second based on feedback reports on each general practitioner’s antibiotic prescribing profile from the preceding year. Regional one day seminars were arranged as a supplement. The control arm received a different intervention targeting prescribing practice for older patients. Main outcome measures Prescription rates and proportion of non-penicillin V antibiotics prescribed at the group level before and after the intervention, compared with corresponding data from the controls. Results In an adjusted, multilevel model, the effect of the intervention on the 39 intervention groups (183 general practitioners) was a reduction (odds ratio 0.72, 95% confidence interval 0.61 to 0.84) in prescribing of antibiotics for acute respiratory tract infections compared with the controls (40 continuing medical education groups with 199 general practitioners). A corresponding reduction was seen in the odds (0.64, 0.49 to 0.82) for prescribing a non-penicillin V antibiotic when an antibiotic was issued. Prescriptions per 1000 listed patients increased from 80.3 to 84.6 in the intervention arm and from 80.9 to 89.0 in the control arm, but this reflects a greater incidence of infections (particularly pneumonia) that needed treating in the intervention arm. Conclusions The intervention led to improved antibiotic prescribing for respiratory tract infections in a representative sample of Norwegian general practitioners, and the courses were feasible to the general practitioners. Trial registration Clinical trials NCT00272155.

Illness and exposure to negative life experiences in adolescence: two sides of the same coin? A study of 15-year-olds in Oslo, Norway

Aim: To investigate associations between negative life experiences and common illnesses among adolescents. Methods: Cross‐sectional questionnaire study carried out at all lower secondary schools (10 grade) in Oslo, Norway, during 2000 and 2001 (n= 8316 pupils). Different negative life experiences and illnesses were addressed. Results: The participation rate was 88%. Among reported negative life experiences last year were a pressure felt to succeed (62%), death of a close person (26%), exposure to physical violence (22%), bullying at school (15%) and sexual violation (4%). A large number of the pupils had some chronic illness: hay fever (38%), eczema (29%) and asthma (13%). Reported illnesses the previous 12 month were: headache (56%), painful neck or shoulders (35%), sore throat at least three times (15%), lower respiratory tract infection (9%) and mental problems for which help was sought (7%). During the week prior to the survey, 26% of all girls had symptoms of a depressive disorder, while this applied to 10% of all boys. Fifty‐three percent of the boys (29% of the girls) who had depressive symptoms had been exposed to physical violence. Sexually violated boys had a high probability for seeking help for mental problems (OR = 4.9) and for frequent episodes of sore throat (OR = 2.5). Corresponding odds ratios for girls were 1.7 and 2.5, respectively.

Pharmacologically inappropriate prescriptions for elderly patients in general practice: How common? Baseline data from The Prescription Peer Academic Detailing (Rx-PAD) study

Objective. To assess Norwegian general practitioners’ (GPs’) level of potentially harmful drug prescribing for elderly patients. Design. Prescription data for 12 months were retrospectively retrieved from the Norwegian Prescription Database (NorPD). Data were assessed in relation to 13 prescription quality indicators. Setting. General practice. Subjects. A total of 454 GPs attending continuous medical education (CME) groups in Southern Norway, 85 836 patients ≥70 years who received any prescription from the GPs during the study period. Main outcome measures. Number of prescriptions assessed in relation to pharmacological inappropriateness based on a list of 13 explicit prescription quality indicators. Results. Some 18.4% of the patients (66% females with mean age 79.8 years, 34% males with mean age 78.7 years) received one or more inappropriate prescriptions from their GP. An NSAID in a potentially harmful combination with another drug (7%) and a long-acting benzodiazepine (4.6%) were the most frequent inappropriate prescriptions made. Doctor characteristics associated with more inappropriate prescribing practice were old age and working single-handed with many elderly patients. Conclusion. The study reveals areas where GPs’ prescribing practice for elderly patients can be improved and which can be targeted in educational interventions.

Stopping antipsychotic drug therapy in demented nursing home patients: a randomized, placebo-controlled study--the Bergen District Nursing Home Study (BEDNURS).

Despite modest efficacy, unpredictable individual utility, and a high rate of adverse effects, behavioural and psychological symptoms of dementia (BPSD) are common determinants for antipsychotic drug therapy in nursing home patients.

Resin from the mukul myrrh tree, guggul, can it be used for treating hypercholesterolemia? A randomized, controlled study

BACKGROUND Guggul, herbal extract from resin of the Commiphora mukul tree, is widely used in Asia as a cholesterol-lowering agent based on Indian Ayurvedic medicine. Its popularity for this use is increasing in the US and Western Europe. Guggulsterones, the presumed bioactive compounds of guggul, may antagonise two nuclear hormone receptors involved in cholesterol metabolism, which is a possible explanation for hypolipidemic effects of these extracts. However, publications of efficacy data on the use of guggul extracts in Western populations are scarce. OBJECTIVE To study the efficacy of a guggul-based formulation (short: guggul) on blood lipids in healthy adults with moderately increased cholesterol. METHODS Double-blind, randomised, placebo controlled trial in Norwegian general practice. 43 women and men, age 27-70, with moderately increased cholesterol, randomised to use 2160mg guggul (4 capsules) daily, or placebo for 12 weeks. OUTCOME MEASURES Mean change in total cholesterol, low-density lipoprotein cholesterol (LDL-C), triglycerides, high-density lipoprotein cholesterol (HDL-C) and total cholesterol/HDL-C ratio compared with baseline. Lipids were analysed at baseline, and at 6 and 12 weeks. In addition, unexpected events and adverse effects were recorded. RESULTS Two dropouts, one withdrawal, and incomplete lab results for six persons left 34 participants to accomplish the trial (18-guggul, 16-placebo) with complete lab test data. After 12 weeks, mean levels of total cholesterol and HDL-C in the active group were significantly reduced compared with the placebo group. However, the mean levels of LDL-C, triglycerides, and total cholesterol/HDL-C ratio between the two groups did not change significantly. Ten guggul users (vs. four in the placebo group) reported side effects: mild gastrointestinal discomfort (n=7), possible thyroid problems (n=2), and generalized skin rash (n=1). The latter resulted in withdrawal from trial. CONCLUSIONS Even if total cholesterol and HDL-C were significantly reduced, the clinical magnitude of this remains obscure. More and larger studies are needed to establish effects and safety of guggul-based formulations in the treatment for hypercholesterolemia.

Symptom prevalence during menopause and factors associated with symptoms and menopausal age. Results from the Norwegian Hordaland Women's Cohort study

OBJECTIVES To describe symptoms during the menopausal transition and age at menopause in a representative Norwegian female cohort over a ten year period, to analyze factors associated with frequency and burden of symptoms and influence on self-rated health. STUDY DESIGN 2229 women aged 40-44 years at inclusion, randomly selected from a national health survey in Hordaland County, Norway, and followed with seven postal questionnaires from 1997 throughout 2009. Data for 2002 women (90%) were eligible for analyses. RESULTS In a longitudinal analysis, 36% of the women reported daily hot flushes in one or more questionnaires, whereas 29% did not experience hot flushes at all. The prevalence of daily hot flushes increased from 2% at age 41-42 to 22% at age 53-54, decreasing to 20% at age 55-57. The odds ratio for reporting daily hot flushes vs. never/seldom for daily smokers was 1.6 (1.24-2.10). Women in the lowest education group had an OR=1.8 (1.21-2.56) for reporting daily hot flushes compared to women with a university degree. There was no relation between the symptom burden and degree of physical exercise, overall feeling of health, BMI, family income, parity or menarche age as recorded at baseline. The mean age for final menstruation period (FMP) in the cohort was 51.1 (50.9-51.3) years. Smokers had a mean age of FMP 0.9 years earlier compared to the non-smokers. CONCLUSIONS Daily smoking and educational level were independent risk factors for experiencing daily menopausal symptoms. Degree of physical exercise, BMI, parity or menarche age did not have significant influence.

Cardiovascular disease by diabetes status in five ethnic minority groups compared to ethnic Norwegians

BackgroundThe population in Norway has become multi-ethnic due to migration from Asia and Africa over the recent decades. The aim of the present study was to explore differences in the self-reported prevalence of cardiovascular disease (CVD) and associated risk factors by diabetes status in five ethnic minority groups compared to ethnic Norwegians.MethodsPooled data from three population-based cross-sectional studies conducted in Oslo between 2000 and 2002 was used. Of 54,473 invited individuals 24,749 (45.4%) participated. The participants self-reported health status, underwent a clinical examination and blood samples were drawn. A total of 17,854 individuals aged 30 to 61 years born in Norway, Sri-Lanka, Pakistan, Iran, Vietnam or Turkey were included in the study. Chi-square tests, one-way ANOVAs, ANCOVAs, multiple and logistic regression were used.ResultsAge- and gender-standardized prevalence of self-reported CVD varied between 5.8% and 8.2% for the ethnic minority groups, compared to 2.9% among ethnic Norwegians (p < 0.001). Prevalence of self-reported diabetes varied from 3.0% to 15.0% for the ethnic minority groups versus 1.8% for ethnic Norwegians (p < 0.001). Among individuals without diabetes, the CVD prevalence was 6.0% versus 2.6% for ethnic minorities and Norwegians, respectively (p < 0.001). Corresponding CVD prevalence rates among individuals with diabetes were 15.3% vs. 12.6% (p = 0.364). For individuals without diabetes, the odds ratio (OR) for CVD in the ethnic minority groups remained significantly higher (range 1.5-2.6) than ethnic Norwegians (p < 0.05), after adjustment for age, gender, education, employment, and body height, except for Turkish individuals. Regardless of diabetes status, obesity and physical inactivity were prevalent in the majority of ethnic minority groups, whereas systolic- and diastolic- blood pressures were higher in Norwegians. In nearly all ethnic groups, individuals with diabetes had higher triglycerides, waist-to-hip ratio (WHR), and body mass index compared to individuals without diabetes. Age, diabetes, hypertension, hypercholesterolemia, and WHR were significant predictors of CVD in both ethnic Norwegians and ethnic minorities, but significant ethnic differences were found for age, diabetes, and hypercholesterolemia.ConclusionsEthnic differences in the prevalence of CVD were prominent for individuals without diabetes. Primary CVD prevention including identification of undiagnosed diabetes should be prioritized for ethnic minorities without known diabetes.