Tuulikki Vehko

Are statin trials in diabetes representative of real-world diabetes care: a population-based study on statin initiators in Finland

Objective To assess the representativeness of the Heart Protection Study (HPS) and the Collaborative Atorvastatin Diabetes Study (CARDS) for incident statin users. Design A population-based analysis with linked register data. Setting Finland. Population 56 963 patients with diabetes initiating statin use from 2005 to 2008. Main outcome measures We determined the proportions of real-world patients who fulfilled the eligibility criteria for HPS and CARDS trials and assessed the cardiovascular disease (CVD) event rates, assumed to reflect the background CVD risk, for those eligible and ineligible. We used descriptive statistics to identify the patient characteristics, lipid-lowering interventions and adherence to statin therapy. Results Of the real-world patients, 57% (N=32 582) fulfilled the eligibility criteria for HPS (DM) and 49% (N=20 499) of those without CVD for CARDS. The patients ineligible for HPS (DM) had a higher cumulative risk for CVD events than those eligible, whereas regarding CARDS the cumulative risks were of similar magnitude. The overall CVD event rates seemed to be comparable to those in the reviewed trials. Both trials were under-representative of women and users of antihypertensive agents and metformin. 27% and 29% of real-world patients had an initial statin dose corresponding to <20 mg of simvastatin. The proportions of patients who were deemed adherent were 57% in the real world and 85% in both trials. Conclusions Only half of the real-world patients would have qualified for the HPS (DM) and CARDS, limiting their representativeness for clinical practice. Women and users of antihypertensive agents and metformin were under-represented in both trials. These deviations reflect the changes in diabetes treatment over the years and are not expected to modify the average treatment effects of statins on CVD. Prescribing of lower statin doses in clinical practice than used in the trials and lower adherence may, however, attenuate the benefits in the real world.

Changing patterns of secondary preventive medication among newly diagnosed coronary heart disease patients with diabetes in Finland: A register-based study

Aims: Information on medicine use among coronary heart disease (CHD) patients with diabetes in unselected patient populations is scarce. This study examines the use of medication to prevent new cardiac events among newly diagnosed CHD patients with diabetes comparing them to patients without diabetes and examines socioeconomic differences in medicine use in these patient groups. Methods: Data on CHD patients (43,501 men and 31,125 women) with or without diabetes were individually linked from nationwide registers (covering both patients treated in ambulatory and in hospital inpatient care). Age-standardised rates for medication use were calculated and differences between patient groups examined using Poisson regression. Results: β-blocker use was high in all patient groups in 1997—2002, angiotensin-converting enzyme (ACE) inhibitor and angiotensin II antagonist use increased and remained higher among patients with diabetes. More than half of men and women with diabetes used ACE inhibitors and one out of five used angiotensin II antagonists in 2002. Lipid-lowering medication use increased, especially among women. In 1997—98 it was lower in lower socioeconomic groups; among men with diabetes the use remained lower than among others. Conclusions: β-blocker use was constant and ACE inhibitor and angiotensin II antagonist use increased. Lipid-lowering medication use increased considerably after a health insurance reform in 2000, in which elevated reimbursement of drug costs (75%) was extended to include all CHD patients with hyperlipidaemia.Socioeconomic differences in medication use disappeared after the reform. However, lipid-lowering medication use remained at a lower level among men with diabetes, suggesting that their treatment did not follow guidelines.

Increasing resources effected equity in access to revascularizations for patients with diabetes

Abstract Objectives. To examine differences in access to coronary revascularization among a cohort of coronary patients with and without diabetes in 1995–2002 in Finland and to examine how rapidly increasing resources effected socioeconomic equity in access to these operations. Design. An individual level nationwide register-based study of newly diagnosed CHD (coronary heart disease) patients (aged 40–79) in Finland. Rates for revascularizations were calculated per 1 000 person years. Socioeconomic differences were examined using Cox regression. Results. Revascularization rates increased from 354 to 443 per 1 000 person years among men with CHD and from 301 to 366 among patients with diabetes. Among women with CHD the numbers were 224 and 249 and among patients with diabetes 208 and 325. Comparing trends for first revascularization between patient groups with and without diabetes differences increased somewhat among men. Among women, revascularization rates increased more among diabetic patients. Lower revascularization rates among lower socioeconomic groups were found throughout the study period in both patient groups. Conclusions. Simultaneously with large increase in cardiac operation rates, revascularization observed more common among women with diabetes compared to those without. However socioeconomic inequity in access to revascularizations among both genders remained even after increase in resources.

Differences in mortality among women with breast cancer by income – a register-based study in Finland:

Aims: The aim was to assess all-cause and breast cancer mortality by income among women with incident breast cancer and the effect of cancer stage at diagnosis and comorbidity on the differences. Methods: The 43,439 women (age ⩾30) diagnosed with breast cancer in 1998–2008 in Finland were monitored using individual-level Cancer Registry data supplemented with data from Finnish health care registers and sociodemographic data. Results: Overall mortality was greater among breast cancer patients of the lowest income group than in the highest one; the hazard ratio (HR) for age and incidence year adjusted all-cause mortality was 1.9 (95% CI 1.8–2.1) and for breast cancer mortality 2.0 (95% CI 1.8–2.2). The women from the lowest income group were over-represented in the breast cancer stage ‘distant’ (10.1% vs. 3.5% among the highest income group). The presence of comorbidities was more common in patients with the lowest income (at least one comorbidity in 54%) than in the highest (24%). The HR adjusted with stage at presentation and comorbidities was 1.6 (95% CI 1.4–1.7) for all-cause mortality and 1.6 (95% CI 1.4–1.7) for breast cancer mortality. Conclusions: Tumour stage at diagnosis was more severe among lower income groups, and the presence of comorbidities was more common, although this only accounted for a part of the higher breast cancer mortality in these groups. More information is needed about recognition, diagnosis and treatment of breast cancer to examine whether the socioeconomic differences of breast cancer mortality are related to care.

Monitoring the use of lipid-lowering medication among persons with newly diagnosed diabetes: a nationwide register-based study

Objectives To develop a register-based monitoring system to provide information on the use of lipid-lowering medication among persons with diabetes in different patient groups and by socioeconomic position. Design Longitudinal and register-based, before and after diabetes diagnosis. Setting Finnish population. Participants A total of 121 053 persons aged 30–79 years with a new diagnosis of diabetes during 2000–2006. The annual cohorts were divided at the time of diabetes diagnosis by coronary heart disease (CHD) status. Primary and secondary outcome measures Lipid-lowering medication purchases after diabetes diagnosis and prior to the diagnosis. Results According to the health insurance reimbursement data the use of lipid-lowering medication advanced rapidly among people with diabetes in the early 2000s in Finland. Of the patients diagnosed with diabetes in 2000 only one-fourth used lipid-lowering medication in 6–12 months after their diagnosis. For those diagnosed in 2006, the utilization rate was 46%. Among those with a history of CHD the use of medication was markedly higher; 51–58% in 2000 and 77–79% in 2006. Taking into account the increasing trend and measuring the independent effect of the diagnosis of diabetes on lipid-lowering medication, setting the diagnosis increased the use by 10–50%. Despite increasing overall utilisation rates, socioeconomic difference in the use of lipid-lowering medication remained throughout the study period. In particular, the lowest income quintile differed from other income groups and in 2006 its use of lipid-lowering medication remained approximately 10% points lower compared with the overall level. Conclusions The lipid-lowering medication is being applied in an increasing population of new diabetes cases; however, modelling the independent effect of the diagnosis of diabetes on lipid-lowering medication shows that the diagnosis increased use, but did not abolish socioeconomic differences.

Predictors of physicians’ stress related to information systems: a nine-year follow-up survey study

BackgroundAmong the important stress factors for physicians nowadays are poorly functioning, time consuming and inadequate information systems. The present study examined the predictors of physicians’ stress related to information systems (SRIS) among Finnish physicians. The examined predictors were cognitive workload, staffing problems, time pressure, problems in teamwork and job satisfaction, adjusted for baseline levels of SRIS, age, gender and employment sector.MethodsThe study has a follow-up design with two survey data collection waves, one in 2006 and one in 2015, based on a random sample of Finnish physicians was used. The present study used a sample that included 1109 physicians (61.9% women; mean age in 2015 was 54.5; range 34–72) who provided data on the SRIS in both waves. The effects of a) predictor variable levels in 2006 on SRIS in 2015 and b) the change in the predictor variables from 2006 to 2015 on SRIS in 2015 were analysed with linear regression analyses.ResultsRegression analyses showed that the higher level of cognitive workload in 2006 significantly predicted higher level of SRIS in 2015 (β = 0.08). The reciprocity of this association was tested with cross-lagged structural equation model analyses which showed that the direction of the association was from cognitive workload to SRIS, not from SRIS to cognitive workload. Moreover, increases in time pressure (β = 0.16) and problems in teamwork (β = 0.10) were associated with higher levels of SRIS in 2015, whereas job satisfaction increase was associated with lower SRIS (β = − 0.06).ConclusionsAccording to our results, physicians’ cognitive workload may have long-lasting negative ramifications in regard to how stressful physicians experience their health information systems to be. Thus, organisations should pay attention to physicians workload if they wish physicians to master all the systems they need to use. It is also important to provide physicians with enough time and collegial support in their system-related problems, and in learning new systems and system updates.

What patients think about choice in healthcare? A study on primary care services in Finland

Background: The ongoing Finnish health and social service reform will expand choice by opening the market for competition between public and private service providers. This study examined the attitudes of primary care patients towards choice and which patient-related factors are associated with these attitudes. Methods: A sample of attenders during one week in health centres of 12 big cities and municipal consortiums (including seven outsourced local units) and in primary care units of one private company providing outsourced services for municipalities (aged 18−95, n=8128) was used. The questionnaire included questions on choice-related attitudes, sociodemographic factors, health status, use of health services and patient satisfaction. Results: Of the responders, 77% regarded choice to be important, 49% perceived genuine opportunities to make choices and 35% were satisfied with the choice-relevant information. Higher age, low education, having a chronic illness, frequent use of services, having a personal physician and being satisfied with the physician and with waiting times were related to assigning more importance on choice. Younger patients, those with higher education as well as those with chronic illness regarded their opportunities of choosing the service provider and availability of choice-relevant information poorer. Conclusions: The Finnish primary care patients value choice, but they are critical of the availability of choice-relevant information. Choices of patients with complex health care needs should be supported by developing integrated care alternatives and by increasing the availability of information on existing care alternatives to meet their needs.

Predictors of physicians' stress related to information systems: a nine-year follow-up survey study

BackgroundAmong the important stress factors for physicians nowadays are poorly functioning, time consuming and inadequate information systems. The present study examined the predictors of physicians’ stress related to information systems (SRIS) among Finnish physicians. The examined predictors were cognitive workload, staffing problems, time pressure, problems in teamwork and job satisfaction, adjusted for baseline levels of SRIS, age, gender and employment sector.MethodsThe study has a follow-up design with two survey data collection waves, one in 2006 and one in 2015, based on a random sample of Finnish physicians was used. The present study used a sample that included 1109 physicians (61.9% women; mean age in 2015 was 54.5; range 34–72) who provided data on the SRIS in both waves. The effects of a) predictor variable levels in 2006 on SRIS in 2015 and b) the change in the predictor variables from 2006 to 2015 on SRIS in 2015 were analysed with linear regression analyses.ResultsRegression analyses showed that the higher level of cognitive workload in 2006 significantly predicted higher level of SRIS in 2015 (β = 0.08). The reciprocity of this association was tested with cross-lagged structural equation model analyses which showed that the direction of the association was from cognitive workload to SRIS, not from SRIS to cognitive workload. Moreover, increases in time pressure (β = 0.16) and problems in teamwork (β = 0.10) were associated with higher levels of SRIS in 2015, whereas job satisfaction increase was associated with lower SRIS (β = − 0.06).ConclusionsAccording to our results, physicians’ cognitive workload may have long-lasting negative ramifications in regard to how stressful physicians experience their health information systems to be. Thus, organisations should pay attention to physicians workload if they wish physicians to master all the systems they need to use. It is also important to provide physicians with enough time and collegial support in their system-related problems, and in learning new systems and system updates.

Predictors of physicians' stress related to information systems

BackgroundAmong the important stress factors for physicians nowadays are poorly functioning, time consuming and inadequate information systems. The present study examined the predictors of physicians’ stress related to information systems (SRIS) among Finnish physicians. The examined predictors were cognitive workload, staffing problems, time pressure, problems in teamwork and job satisfaction, adjusted for baseline levels of SRIS, age, gender and employment sector.MethodsThe study has a follow-up design with two survey data collection waves, one in 2006 and one in 2015, based on a random sample of Finnish physicians was used. The present study used a sample that included 1109 physicians (61.9% women; mean age in 2015 was 54.5; range 34–72) who provided data on the SRIS in both waves. The effects of a) predictor variable levels in 2006 on SRIS in 2015 and b) the change in the predictor variables from 2006 to 2015 on SRIS in 2015 were analysed with linear regression analyses.ResultsRegression analyses showed that the higher level of cognitive workload in 2006 significantly predicted higher level of SRIS in 2015 (β = 0.08). The reciprocity of this association was tested with cross-lagged structural equation model analyses which showed that the direction of the association was from cognitive workload to SRIS, not from SRIS to cognitive workload. Moreover, increases in time pressure (β = 0.16) and problems in teamwork (β = 0.10) were associated with higher levels of SRIS in 2015, whereas job satisfaction increase was associated with lower SRIS (β = − 0.06).ConclusionsAccording to our results, physicians’ cognitive workload may have long-lasting negative ramifications in regard to how stressful physicians experience their health information systems to be. Thus, organisations should pay attention to physicians workload if they wish physicians to master all the systems they need to use. It is also important to provide physicians with enough time and collegial support in their system-related problems, and in learning new systems and system updates.

How do health care workers manage a patient with multiple care needs from both health and social care services? – A vignette study

Introduction To assess how health care professionals outline the management of care and explore which health or social care professionals were involved in the patients treatment. Methods A survey with a patient vignette for general practitioners (n = 31) and registered nurses (n = 31) working daily in Finnish health centres located in four cities. Respondents answered structural questions and explained in detail the care process that they tailored for the patient. The care process was examined using content analysis. Results A physician–nurse working pair was declared to be in charge of the care process by 27% of respondents, a registered nurse by 9% and a general practitioner by 11%. However, 53% reported that no single person or working pair was in charge of the care process (response rate 72%). The concluding result of the analyses of the presented process was that both treatment practices and the professionals participating in the patients treatment varied. Collaboration with social services was occasional, and few care processes included referrals to social services. Conclusion For the patient who needs both health and social care services, the management of care is a challenge. To improve the chances of patients being actively involved in making treatment plans at least three factors need to be addressed. Firstly, a written treatment plan should explicate the care process. Second, collaboration and interaction between health and social care services should be strengthened, and third, a contact person should be named to avoid care gaps in primary health care. Next-step data from patients need to be collected to get their views on care management and compare these with those from general practitioners and registered nurses.