Incidence of ADHD medication use among Finnish children and adolescents in 2008-2019: a need for practice changes?

AIMS: This study examined the incidence of attention-deficit/hyperactivity disorder medication among children and adolescents by sex and age group in Finland during 2008-2019. METHODS: The data on children and adolescents aged 6-18 years receiving reimbursement for any attention-deficit/hyperactivity disorder medication was collected from the nationwide register on reimbursed purchases. The incidence was calculated as a ratio of the number of new users and the number of age and sex-matched population at risk. Negative binomial models were used to calculate rate ratios (RRs). RESULTS: In 2019, the incidence of attention-deficit/hyperactivity disorder medication was 13.4 per 1000 boys and 4.8 per 1000 girls. Among boys, the incidence became 3.7 times greater during the observed years (RR 95% confidence interval (CI) 2.0, 6.5, P<0.0001), whereas in girls it was 7.6 times greater (RR 95% CI 2.1, 27.4, P=0.0019). The boys had 2.8 times the incidence rate compared with the girls (RR 95% CI 2.2, 3.6, P<0.0001). The increase was associated with age only among boys (P=0.0001). The highest incidence rate 23.4 per 1000 individuals (95% CI 22.5, 24.4) was found in 2019 among 6-8-year-old boys. CONCLUSIONS: The incidence of attention-deficit/hyperactivity disorder medication use among children and adolescents increased significantly in Finland during the study period. Incidence was higher among boys, but the increase was greater among girls. The most common group to start attention-deficit/hyperactivity disorder medication was 6-8-year-old boys. These findings warrant critical evaluation of the diagnostic and treatment policies currently available in Finland for the treatment of attention-deficit/hyperactivity disorder and related symptoms.

Outpatient antibiotic prescribing during the first two years of the COVID-19 pandemic: A nationwide register-based time series analysis.

The COVID-19 pandemic has imposed an enormous burden on health care systems around the world. Simultaneously, many countries have reported a decrease in the incidence of other infectious diseases, such as acute respiratory infections, leading to a decline in outpatient antibiotic use. The aim of this study is to assess the impact of the COVID-19 pandemic on outpatient antibiotic prescribing in Finland during the first 2 years of the pandemic. We used nationwide register data, applied descriptive methods, and conducted an interrupted time series analysis (ITSA) using ARIMA modelling. Results from the ARIMA modelling showed that at the baseline, before the pandemic, the level of monthly number of antibiotic prescriptions was 248,560 (95% CI: 224,261 to 272,856; p<0.001) and there was a decreasing trend of 1,202 in monthly number of prescriptions (95% CI: -2,107 to -262; p<0.01). After the COVID-19 pandemic began, there was a statistically significant decline of 48,470 (95% CI: -76,404 to -20,535, p<0.001) prescriptions (-19.5% from the baseline level). The greatest decrease in antibiotic prescribing was observed among children aged 0-17 years. While antibiotic prescribing declined in all antibiotic groups associated with respiratory tract infections, the decrease from 2019 to 2020 was the largest with azithromycin (52.6%), amoxicillin (44.8%), and doxycycline (43.8%). Future studies should continue exploring antibiotic prescribing trends during the COVID-19 pandemic and beyond.

Impact of diabetes diagnosis on dental care utilization: evidence from Finland.

BACKGROUND: Poor oral health is associated with many chronic diseases, including diabetes. As diabetes can worsen oral health and vice versa, care guidelines recommend that patients with diabetes maintain good oral health and have regular dental checkups. We analyzed the impact of receiving an initial type 2 diabetes diagnosis on dental care utilization. METHODS: We used register data on residents aged over 25 in the city of Oulu, Finland, covering the years 2013-2018. We used the difference-in-differences method and individuals with no diabetes diagnosis as control group. As robustness checks, we used propensity score matching and constructed an alternative control group from patients that received the same diagnosis a few years apart. RESULTS: Despite the guideline recommendations, we found that receiving a diabetes diagnosis did not increase the probability for dental care visits in a two-year follow-up. The findings remained similar for both high-income and low-income persons. CONCLUSIONS: The finding is concerning in terms of diabetes management and oral health. Further research is needed on the reasons behind the lack of response to guidelines.

Polypharmacy in children and adolescents initiating antipsychotic drug in 2008-2016: a nationwide register study.

OBJECTIVE: The use of antipsychotics in children and adolescents has increased rapidly. Little is known about psychotropic polypharmacy in children and adolescent initiating an antipsychotic drug. Thus, we investigated the frequency and predictors of polypharmacy during the first year of antipsychotic use in Finnish children and adolescents. METHODS: Between 2008 and 2016, 14 848 individuals aged 1-17 years initiating risperidone, quetiapine, aripiprazole, or olanzapine treatment were identified from Finnish Prescription Registry. Data on psychotropic drug prescriptions prior to and during antipsychotic treatment were collected. Associations between predictors and polypharmacy were analyzed with regression models. RESULTS: During the study period polypharmacy occurred in 44.9% of the new antipsychotic users, being more frequent in girls (55.5%) than in boys (44.5%, p < 0.001). The two most frequent concomitant psychotropic drug classes were antidepressants (66.2%) and psychostimulants/atomoxetine (30.8%). Adolescents aged 13-15 and 16-17 years, and girls showed an increased risk of polypharmacy during antipsychotic treatment (OR 2.37 [95% CI 1.91-2.92], OR 2.39 [95% CI 1.92-2.98], and OR 1.64 [95% CI 1.51-1.78], respectively). The use of psychostimulants/atomoxetine or antidepressants prior to initiation of antipsychotic treatment was strongly associated with polypharmacy during antipsychotic treatment (OR 8.39 [95% CI 7.49-9.41], OR 3.02 [95% CI 2.75-3.31]). CONCLUSIONS: Polypharmacy was common in children and adolescents initiating antipsychotic treatment. Prior use of psychostimulants/atomoxetine and antidepressants increased the risk of polypharmacy. The use of antipsychotics was mainly off-label, thus, the risks of concomitant use of antipsychotics with other psychotropic drugs should be carefully weighed.

Socioeconomic inequalities in insulin initiation among individuals with type 2 diabetes - A quasi-experimental nationwide register study.

Background: Inequalities in access to care can translate to or strengthen existing inequalities in health if people of lower socioeconomic positions do not have equal access to care. I study insulin initiation among individuals with type 2 diabetes and examine whether a reform increasing the co-payment of non-insulin antidiabetics in Finland in 2017 had an inequitable effect on the initiation. In the treatment of type 2 diabetes, insulin is recommended only in later stages and remains covered by the National Health Insurance at a rate of 100%. Data and methods: I evaluated the effect of the reform with Cox proportional hazard modelling using nationwide person-level register data from 2011 to 2019. Exploiting a quasi-experimental design rising from the introduction of the reform allows for consideration of causality. Results: I found that the risk of insulin initiation was lower in the later years of the study period. Additionally, individuals in lower socioeconomic positions had a higher risk of initiation. However, I did not find inequalities in how the reform affected the risk of insulin initiation between income quintiles. Conclusions: Co-payments are unlikely to be the most influential factor behind persisting inequalities in insulin initiation among individuals with type 2 diabetes in Finland. Lower risk in the later years aligns with developing treatment practices of type 2 diabetes.

The impact of a co-payment increase on the consumption of type 2 antidiabetics - A nationwide interrupted time series analysis.

International literature suggests that co-payment increases are associated with decreased medicine use, although the effects depend on context. We examined the impact of a co-payment increase on the consumption of type 2 antidiabetics in Finland, a country with a comprehensive health and social security system including ceiling mechanisms aiming to protect patients from high co-payment expenditures. We used administrative register data on all reimbursed purchases of antidiabetics during 2014-2018. An interrupted time series design with segmented regression was used to examine the mean monthly purchase per person, measured as Defined Daily Doses (DDDs), before and after the co-payment increase. At baseline, the mean monthly purchase per person of type 2 antidiabetics was 105 DDDs (95% CI 103.8; 106.0;p<0.001) and there was a decreasing trend of 0.2 DDDs per month (95% CI -0.23;-0.13;p<0.001). A statistically significant decrease of 5.6 DDDs (95% CI -7.3;-3.8;p<0.001) was detected after the reform; however, no significant change in the trend was observed. No significant increase was detected in the mean monthly per person purchase of insulins. The results suggest that a co-payment increase decreases consumption of necessary medicines despite the presence of a medicine co-payment ceiling mechanism. Whether the decrease was associated with negative health effects remains to be further investigated.

The effect of pharmaceutical co-payment increase on the use of social assistance-A natural experiment study.

Health care out-of-pocket payments can create barriers to access or lead to financial distress. Out-of-pocket expenditure is often driven by outpatient pharmaceuticals. In this nationwide register study, we study the causal relationship between an increase in patients' pharmaceutical expenses and financial difficulties by exploiting a natural experiment design arising from a 2017 reform, which introduced higher co-payments for type 2 diabetes medicines in Finland. With difference-in-differences estimation, we analyze whether the reform increased the use of social assistance, a last-resort financial aid. We found that after the reform the share of social assistance recipients increased more among type 2 diabetes patients than among a patient group not affected by the co-payment increase, suggesting the reform increased the use of social assistance among those subject to it. The results indicate that increases in patients' pharmaceutical expenses can lead to serious financial difficulties even in countries with a comprehensive social security system.

Antipsychotic Treatment Duration in Children and Adolescents: A Register-Based Nationwide Study.

Objective: Despite the increasing use of antipsychotic drugs in children and adolescents in many countries, little is known about the treatment duration in this vulnerable population. The present nationwide study investigated the duration of antipsychotic treatment and factors associated with treatment discontinuation in Finnish children and adolescents. Methods: All subjects aged 1-17 years who had started a second-generation antipsychotic (SGA) drug (risperidone, quetiapine, aripiprazole, or olanzapine) between January 2008 and December 2016 (n = 20,932) were extracted from the Finnish Prescription Registry and followed up until December 31, 2017. Treatment duration was calculated as the time between the initial purchase of medication and treatment discontinuation. Treatment was considered discontinued if the treatment-free gap was more than 270 days. The associations between explanatory factors and treatment discontinuation were analyzed with the Cox proportional hazards models. Results: The mean and median treatment durations were 509 days (95% confidence interval [95% CI]: 500-517 days) and 317 days (95% CI: 306-325 days), respectively. The duration was shorter in girls than in boys (p < 0.001). Of all SGA users, 35.1% used antipsychotics less than 50 days and 16.0% used more than 600 days. Shorter treatment duration was associated with age groups of 7-12 and 13-15 years compared with 1-6 years (hazard ratio [HR]:1.23 [95% CI: 1.11-1.36]; HR: 1.35 [95% CI: 1.21-1.51], respectively) and initiating treatment with quetiapine or olanzapine compared with risperidone (HR: 1.18 [95% CI: 1.12-1.25]; HR: 1.66 [95% CI 1.46-1.88], respectively). Switching of SGA drug during treatment was associated with longer treatment duration (HR: 0.40 [95% CI: 0.38-0.43]). Conclusions: In children and adolescents, the mean treatment duration of SGAs was relatively long given that the majority of SGA use was off-label. Older age and initiating treatment with quetiapine were associated with earlier treatment discontinuation, whereas switching of antipsychotic drug during therapy increased the possibility of longer SGA use.

New Users of Antipsychotics Among Children and Adolescents in 2008-2017: A Nationwide Register Study.

INTRODUCTION: Recently, prescribing antipsychotics for children and adolescents has been increasing in many countries. These drugs are often prescribed off-label, although antipsychotics have been associated with adverse effects. We determined the recent incidence of antipsychotic use among children and adolescents in Finland. METHODS: Finnish National Prescription Register including all Finnish inhabitants receiving reimbursement for pharmaceuticals was searched for subjects of 1 to 17 years of age who had started an antipsychotic drug between January 1, 2008, and December 31, 2017 (n = 26,353). Between 2008 and 2017, the range of number of Finnish children and adolescents aged 1 to 17 years was 1.01 to 1.03 million/year. The incidence was calculated by dividing the number of new users by all age- and sex-matched Finnish inhabitants in the year. RESULTS: Between 2008 and 2017, the incidence of antipsychotic use among children and adolescents increased from 2.1 to 3.8 per 1000 individuals, respectively. In children aged 7 to 12 years, the incidence of antipsychotic use 1.4-folded (from 1.9 (95% CI: 1.8-2.0) to 2.7 (95% CI: 2.5-2.9) per 1000) with a cumulative increase of 0.2% per year (χ2 = 51.0, p < 0.0001). In adolescents aged 13 to 17 years, the incidence 2.2-folded (from 4.3 (95% CI: 4.1-4.5) to 9.4 (95% CI: 9.1-9.8) per 1000) with a cumulative increase of 0.6% per year (χ2 = 590.3, p < 0.0001). The increase in the incidence of use was steeper in girls (2.3-fold) than in boys (1.4-fold) (χ2 = 85.6, p < 0.0001), especially between 2015 and 2017 (1.6-fold and 1.2-fold, respectively) (χ2 = 151.7, p < 0.0001). The year 2011 was the turning point when the incidence in girls exceeded the incidence in boys, and the incidence of quetiapine use exceeded that of risperidone use. CONCLUSIONS: The incidence of antipsychotic use increased between 2008 and 2017, especially in adolescent girls. The use of quetiapine increased, although it has few official indications in children and adolescents. Future studies should investigate the reasons for increasing use of antipsychotics, especially quetiapine, in children and adolescents.

Costs and Quality at the Hospital Level in the Nordic Countries.

This article develops and analyzes patient register-based measures of quality for the major Nordic countries. Previous studies show that Finnish hospitals have significantly higher average productivity than hospitals in Sweden, Denmark, and Norway and also a substantial variation within each country. This paper examines whether quality differences can form part of the explanation and attempts to uncover quality-cost trade-offs. Data on costs and discharges in each diagnosis-related group for 160 acute hospitals in 2008-2009 were collected. Patient register-based measures of quality such as readmissions, mortality (in hospital or outside), and patient safety indices were developed and case-mix adjusted. Productivity is estimated using bootstrapped data envelopment analysis. Results indicate that case-mix adjustment is important, and there are significant differences in the case-mix adjusted performance measures as well as in productivity both at the national and hospital levels. For most quality indicators, the performance measures reveal room for improvement. There is a weak but statistical significant trade-off between productivity and inpatient readmissions within 30 days but a tendency that hospitals with high 30-day mortality also have higher costs. Hence, no clear cost-quality trade-off pattern was discovered. Patient registers can be used and developed to improve future quality and cost comparisons.

Quality, cost, and their trade-off in treating AMI and stroke patients in European hospitals.

OBJECTIVES: This study compared the cost and in-hospital mortality of hospital care for two major diseases, acute myocardial infarction (AMI) and stroke, by pooling patient-level data from five European countries (Finland, France, Germany, Spain, and Sweden). We examined whether a cost-quality trade-off existed in these countries by comparing hospital-level costs and survival rates, and whether hospitals which performed well in terms of cost or quality in treating one patient group (AMI) performed well also in treating the other patient group (stroke). METHODS: A fixed-effect probit regression model for survival and the linear model for log costs were used to calculate indicators for hospital quality and cost, which were plotted against each other. FINDINGS: Both with AMI and stroke there were remarkable differences between hospitals and countries in (both crude and adjusted) rates of patients discharged alive. Swedish and French hospitals had lower mortality than hospitals in Germany, Finland and Spain in the care of AMI patients. However, a longer length of stay in Spanish and German hospitals may bias the results in the two countries. The Finnish hospitals seemed to have lower mortality than the other countries' hospitals in the care of stroke patients. There was no correlation at either the national or hospital level in the quality of treatment of these two diseases. We did not find a clear cost-quality trade-off. The only notable exception was Sweden, where the costs for AMI patients were higher in hospitals with the highest quality of care. CONCLUSIONS: Countries should identify the best performing hospitals both in terms of cost and quality in order to learn from hospitals that demonstrate better practice. It is equally important to better understand the reasons behind the observed differences between hospitals in costs and quality.

Acute myocardial infarction and diagnosis-related groups: patient classification and hospital reimbursement in 11 European countries.

AIMS: As part of the diagnosis related groups in Europe (EuroDRG) project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with patients admitted to hospital for acute myocardial infarction (AMI). The study aims to assist cardiologists and national authorities to optimize their DRG systems. METHODS AND RESULTS: National or regional databases were used to identify hospital cases with a primary diagnosis of AMI. Diagnosis-related group classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify AMI patients according to different sets of variables into diverging numbers of DRGs (between 4 DRGs in Estonia and 16 DRGs in France). The most complex DRG is valued 11 times more resource intensive than an index case in Estonia but only 1.38 times more resource intensive than an index case in England. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only €420 in Poland but to €7930 in Ireland. CONCLUSIONS: Large variation exists in the classification of AMI patients across Europe. Cardiologists and national DRG authorities should consider how other countries' DRG systems classify AMI patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement.

Patient classification and hospital costs of care for acute myocardial infarction in nine European countries.

This study contributes to the literature on the performance of diagnosis-related groups (DRGs) for acute myocardial infarction (AMI) patients by evaluating in nine countries the factors--in addition to DRGs--that affect costs or length of stay and comparing the variation that can be explained with or without DRGs. We evaluate whether the existing DRGs for AMI patients would benefit from additional patient-related and treatment-related factors that are found in administrative data across countries. In most countries, the set of patient and quality variables performed better than the DRG variables. Our results suggest that DRG systems in all countries could be improved by including additional explanatory factors or by refining the existing DRGs. Our results suggest that for AMI and possibly for other related episodes, a refinement of DRGs to include information on patient severity, procedures and levels of complications could improve the ability of DRGs to explain resource use. It seems possible to improve DRG-like hospital payment systems through the inclusion of episode-specific variables.

The interdependence of productivity, cost, and outcome: studies of service delivery in Finnish university hospitals.

The relationship and interdependence between cost and productivity plays a significant role in understanding and assessing service delivery in university hospitals. This article shows some of the elements and factors, highlighting the further need for studies such as EuroHOPE and others. A broad and consistent data comparison in the Nordic region and Finland especially is presented, based on common DRG criteria. Expanding the Nordic data comparisons to other European countries is also discussed, with notice of further work to be published.