The Finnish Interprofessional Medication Assessment (FIMA): baseline findings from home care setting.

PURPOSE: Medication-related problems and declined functional capacity are closely associated factors among older people. The purpose of this study is to describe the procedure of interprofessional medication assessment in home care context and the baseline characteristics of the study population. METHODS: The FIMA study was a randomized, controlled intervention study comparing general practitioner-led interprofessional medication assessment and usual care. Patients' chronic diagnoses and medication use as well as physical and cognitive functions were investigated. Performance in daily activities, use of care services and help from family and relatives, self-rated health and health-related quality of life, and adverse effects commonly related to medication were assessed. RESULTS: The home care patients (n = 512) had significant disease burden and functional limitations. The mean number of all medicines was 15 and that of regularly taken medicines 10. The majority of patients (87%) had excessive polypharmacy. The most commonly used (97%) ATC medicine class was nervous system medicines. Clinically relevant (class C or D SFINX record) drug-drug interactions were seen in 74% of the patients. The most frequent risks of adverse effects were risk of bleeding (66%), constipation (58%) and orthostatism (54%) occurring in over half of the patients. Medicines affecting renal function were used by 85% of the patients. CONCLUSIONS: There is an evident need and justification for medication assessments in home care. In most cases, home care patients fulfill the criteria for regular medication assessments.

Health and medication literacy and the desire to participate in pharmacotherapy decision making - comparison of two countries.

BACKGROUND: Health and medication literacy may be important factors in the outcomes of medical treatment. Similarly, shared decision making or lack of it may influence patient's behavior and adherence to medications. OBJECTIVES: To describe health and medication literacy as well as factors associated with poor medication literacy in two different populations and secondly, to describe desire to participate in decisions concerning medications; and to assess the role of poor medication literacy in decision making. METHODS: A general population based survey in Finland (n = 8003) and in Malta (n = 2000). Health and medication literacy and the desire to participate in decision making was each measured with three statements based on the literature. Medication literacy was operationalized as understanding the instructions on package insert and ability to follow instructions on pharmacy label. RESULTS: Fifteen percent of the Finnish respondents and 16% of Maltese reported always or often having problems understanding package inserts, i.e., poor medication literacy. Males (p = 0.004) and respondents in the age group 65-79 years (p < 0.001) were more prone to report such poor medication literacy. Respondents in Finland (59%) and Malta (65%) reported wanting to discuss different treatment options with the doctor. The respective percentages (42% Finland, 57% Malta) were lower for discussing about the choice of medicine and for deciding about the medicine (36% and 43%, respectively). The desire to participate in deciding about the medicines was higher among females (p < 0.001) and Maltese respondents (p < 0.001). Also those with poor medication literacy more often (p < 0.001) expressed a desire to participate in deciding in the choice of medicine. CONCLUSIONS: Medication literacy was rather low, while desire to participate in pharmacotherapy decision making was high, especially in Malta. Overall, women tended to be more willing to participate in decision making. The desire to participate in decisions was higher among persons with low medication literacy.

Incorporating patient perspectives in health technology assessments and clinical practice guidelines.

BACKGROUND: Ensuring patient involvement in health technology assessments (HTAs) and clinical practice guidelines (CPGs) is important. However, the goals and methods of such involvement are not always clear. OBJECTIVES: The aim of this study was to 1) discover ways to involve patients in HTA and CPG processes, 2) describe challenges, and 3) find ways of informing patients about HTAs and CPGs in Finland. METHODS: As part of a one-day seminar targeted at representatives of patient organizations (POs), 3, 1-h focus group discussions were held (n = 20, with 14 PO representatives). PO representatives included real patients and health care professionals working in the organizations. The discussions were tape-recorded, transcribed, and thematically analyzed. RESULTS: Focus group participants highlighted the importance of gathering patient views from a group of patients, rather than individuals. Surveys through POs were the most frequently mentioned means of gathering patients' views. PO representatives reported interest in cooperating in HTA and CPG processes. The most often mentioned challenges were finding appropriate representatives for the target group and conveying information about HTAs and CPGs to patients. Multichannel communication was seen as essential. Furthermore the information should be readable, comprehensible, tailored, reliable, reusable, complementary, and timely. CONCLUSIONS: Possible strategies to involve patients in HTA and CPG processes were incorporating patient representatives in the CPG and HTA groups, offering timely possibility to participate, and ensuring reporting with clear and unambiguous language. The main identified challenge was finding appropriate representatives of the target group. The role of POs was seen as important particularly when informing the patients.

An intervention to develop repeat prescribing in community pharmacy.

BACKGROUND: Lack of review of patients' medications in repeat prescribing is common. This and other problems in repeat prescribing need to be addressed. Community pharmacists could be more proactive in the review of chronic medications. OBJECTIVE: The purpose of this study was to test the feasibility and effects of pharmacists' interventions in repeat prescribing. METHODS: The normal repeat prescribing process used at Kuopio University Pharmacy and in Kuopio Health Services was developed by an intervention which included a pharmacist's interview and the annual medication data of the patient that were both transferred to the prescribing physician. RESULTS: Physicians in the intervention group identified and solved patients' drug-related problems better than was the case in the comparison group with normal repeat prescribing. Over half the patients receiving repeat prescriptions had at least one drug-related problem. The physicians used more information sources to support repeat prescribing in the intervention system. CONCLUSIONS: Community pharmacists are able to improve the quality of physician's repeat prescribing by providing vital information.

Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older.

This cross-sectional analysis of a population-based cohort investigates the postural changes in blood pressure (BP) and heart rate and assesses the prevalence of orthostatic hypotension (OH) and its associations with the medicines used by an elderly population. The study population (n=1000) was a random sample of persons aged 75 years or older in the City of Kuopio, Finland. In 2004, altogether, 781 persons participated in the study. After the exclusion of persons living in institutional care (n=82) and those without orthostatic test (n=46), the final study population comprised 653 home-dwelling elderly persons. OH was defined as a > or =20 mm Hg drop of systolic BP or a > or =10 mm Hg drop of diastolic BP or both 1 or 3 min after standing up from supine position. Systolic BP dropped for more than half of the home-dwelling elderly when they stood up from a supine to a standing position. The total prevalence of OH was 34% (n=220). No significant gender or age differences were seen. The prevalence of OH was related to the total number of medicines in regular use (P<0.05). OH and postural changes in BP are more common among the home-dwelling elderly than reported in previous studies. The prevalence of OH is related to the number of medicines in regular use. There is an obvious need to measure orthostatic BP of elderly persons, as low BP and OH are important risk factors especially among the frail elderly persons.

Availability and choice of antimalarials at medicine outlets in Ghana: the question of access to effective medicines for malaria control.

Although national and international efforts to combat malaria have intensified over the years, problems with availability, distribution, and choice of antimalarials at medicine outlets in Africa continue to exist. This article presents the results of an indicator-based assessment of availability and choice of antimalarials at 130 licensed medicine outlets in Ghana. We also discuss how the choice of an antimalarial to dispense conforms to recommendations of the national policy for malaria therapy. Data were obtained through face-to-face interviews, by reviewing facility records, and by observing the practices of dispensing staff in the medicine outlets. Antimalarials recommended in the policy were not readily available in the most accessible medicine outlets. Few outlets adhered to the policy when choosing antimalarials. Interventions targeting medicine outlets should be initiated to improve availability and access to effective medicines in order to support the national program for malaria control.

Changes in the use of cardiovascular medicines in the elderly aged 75 years or older--a population-based Kuopio 75+ study.

OBJECTIVE: The aim of this population-based cohort study was to examine the changes in the regular use of cardiovascular medication among the elderly aged 75 years or more in Finland in 1998 and 2003. METHODS: The study population (n = 700) was a random sample of all persons aged 75 years or more living in Kuopio, in eastern Finland. Of them, 601 persons participated in 1998. The surviving persons (n = 339) were re-examined in 2003. Of them 85% (n = 289) were home-dwelling and 15% (n = 50) lived in institutional care. Data on their use of medication and their physical and mental health was collected from interviews conducted by trained nurses. RESULTS: From 1998 to 2003 regular use of one or more cardiovascular medicine increased from 80% to 87% among all the survivors (n = 339, P < 0.001). The mean number of regularly used cardiovascular medicines increased from 2.1 (95% CI 1.9-2.3) to 2.7 (95% CI 2.5-2.9, P < 0.001) during the follow-up period. The most commonly used cardiovascular medicines were beta-blocking agents. The proportion of users of beta-blocking agents was in 1998 45% and in 2003 51%. The proportion of users of diuretics increased from 27% to 40% (P < 0.001), users of cardiac therapy from 35% to 43% (P < 0.001), users of ACE inhibitors and AT 1 receptor antagonists from 20% to 30% (P < 0.001) and users of lipid modifying agents from 7% to 12%. CONCLUSIONS: The use of cardiovascular medicines was common among elderly persons. The proportion of users increased with age and over time. A large proportion of elderly persons would need medication monitoring focusing on cardiovascular medication.

Factors related to non-compliance with antihypertensive drug therapy.

The objectives were to study the associations of perceived health care-related and patient-related factors with self-reported noncompliance with antihypertensive treatment. General practitioners identified all of their hypertensive patients in 26 health centres during 1 week in 1996 (n = 2219). A total of 1782 (80%) patients participated in the study, of whom 1561 were on antihypertensive medication. Based on 82 opinion statements in two questionnaires, 14 problem indices were formed by using factor analysis. Out of these, summary variables concerning problems related to the health care system and the patients were formed. Logistic regression models, including interaction analyses, were used to study the associations with non-compliance. The results were that the majority of patients had at least one perceived health care system-related (88%) and patient-related problem (92%). A high number of both perceived health care system-related problems (adjusted OR 4.77; 95% CI 2.76, 8.26) and patient-related problems (adjusted OR 3.23; 95% CI 1.79, 5.81) were associated with self-reported non-compliance. The experience of adverse drug effects was also associated with non-compliance (adjusted OR 1.41; 95% CI 1.03, 1.94). In conclusion self-reported non-compliance was associated with multiple risks of both perceived health care system-related and patient-related problems.

Patients' perceived problems with hypertension and attitudes towards medical treatment.

OBJECTIVE: To study perceived problems and attitudes in hypertension treatment in primary health care. STUDY POPULATION AND METHODS: A cross-sectional survey of 2219 hypertensive patients, identified by general practitioners, in 26 health centres was carried out during 1 week in 1996. A total of 1782 patients (80%) returned two questionnaires and participated in a health examination. The final study population consisted of 1561 patients currently being medically treated for hypertension and 220 patients not currently on medical treatment. The questionnaires contained 82 questions on different aspects of hypertension care and treatment, which were further elaborated using factor analysis. On the basis of reliability and internal validity analyses, 14 problem indices related to medical treatment of hypertension were formed. RESULTS: The most common perceived problem was related to lack of motivation for follow-up of hypertension (72%). Many patients had difficulties to accept being hypertensive (66%). A careless attitude towards hypertension was also common (63%). Lack of information was experienced by 56% of the patients. About 33% felt hopeless about their hypertension, reported adverse effects of hypertension treatment on sexual functions and lack of support by health care personnel. The least frequent problems were reimbursement problems and modification of dosage instructions. The number of problems identified per person varied between zero and 14 with a mean of 4.9 +/- 2.6 (s.d.). CONCLUSION: Perceived problems concerning hypertension, negative attitudes and experiences are very common among hypertensive patients in primary health care.

Patient-perceived problems, compliance, and the outcome of hypertension treatment.

OBJECTIVE: To study the associations between the outcome of antihypertensive therapy with both patient-perceived problems and patient initiated modification of dosage instructions. DESIGN AND METHODS: In this cross-sectional survey, all chronic hypertensives aged less than 75 years (n = 971) visiting nine Finnish pharmacies between May and September of 1996 were asked to participate. Of the 866 agreeing to participate, 482 returned the questionnaire (56%). After excluding persons with missing data, the final study population consisted of 428 hypertensive patients. Information on problems with treatment, the modification of dosage instructions, and blood pressure levels was based on patient self-reports. RESULTS: Two-thirds (68%) of the study population reported suffering from one or more problems. The most common problems were symptoms of high blood pressure and adverse drug effects. Thirty-one percent of the male respondents and 21% of the female respondents reported having modified their dosage instructions. Only 36% of the patients had reached the goal blood pressure (< 160/90 mmHg). Patients having problems with hypertension treatment were significantly more likely to have modified their dosage instructions than those without problems (3+ problems, adjusted OR = 4.8). Not reaching goal blood pressure levels was significantly associated with both high number of patient-perceived problems (3+ problems, adjusted OR = 2.1) and modification of dosage instructions (adjusted OR = 1.9). CONCLUSION: The poor outcome in antihypertensive therapy is associated with both patient-perceived problems and patient initiated modification of dosage instructions.

The effects of a pharmacy-based intervention on the knowledge and attitudes of asthma patients.

The effects of a pharmacy-based intervention on the knowledge and attitudes of asthma patients was studied with a small convenience sample in four Finnish community pharmacies. The intervention consisted of patient education, counselling and outcomes monitoring according to Therapeutic Outcomes Monitoring (TOM) concept. Twenty-eight patients aged 20-64 years suffering from asthma and having problems in asthma management were involved. Measurements were done at baseline, immediately after the intervention (12 months) and 1 year after the intervention (24 months) using a pre/post-test design, with the patients being their own controls. Both knowledge about and attitudes towards asthma as a disease improved significantly during the intervention. Also knowledge about medication improved significantly during the intervention, though the patients' attitudes towards the medication remained unchanged. The negative correlation between knowledge about and attitudes towards asthma (-0.35) at baseline disappeared after the intervention (0.21). There was a positive correlation between knowledge about and attitudes towards medication at 12 months (0.40, P=0.04) which was still significant 1 year after the intervention (0.40, P=0.04).

Do asthma patients receive sufficient information to monitor their disease--a nationwide survey in Finland.

OBJECTIVES: The aim of this study was to assess to what extent the principles of asthma monitoring are implemented among Finnish asthma patients and if the patients have received sufficient information to adjust their medication according to asthma symptoms. SETTING: All Finnish asthma patients receiving asthma medication from Finnish community pharmacies during two days in June 1998. MAIN OUTCOME MEASURES: The proportions of asthma patients who monitor their asthma status according to the national guidelines and have received specific instructions on how and when to adjust their asthma medication. RESULTS: Eighty-six per cent of the respondents (86%) monitored their asthma status on a method recommended by the national guidelines. They made Peak Expiratory Flow (PEF) measurements (39% of the respondents), they monitored their symptoms (34%) or both (13%). A smaller proportion of the respondents (58%) were instructed on adjusting their medication according to symptoms. The lowest rates for monitoring the asthma status was found among the elderly (65 years or more) and among those who reported that they had been on medication for longer than 5 years (17% and 13% of the subgroup populations, respectively). The lowest rates for having received specific instructions on adjusting their asthma medication according to symptoms were found among the elderly (36%), among those who reported that they had been on asthma medication less than one year (44%), and among males (54%). CONCLUSIONS: Pharmacists and other health care professionals need to enhance their education activities and their co-operation in training asthma patients to monitor their disease, especially principles of adjusting medication according to symptoms. In this process, especially the training needs of the elderly patients and those who have been using asthma medicines for a long time need to be taken into account.

Counselling patients on psychotropic medication: physicians' opinions on the role of community pharmacists.

OBJECTIVES: To study physicians' opinions on community pharmacists' involvement in counselling patients on use of psychotropic medication. DESIGN: A postal questionnaire with open-ended questions completed by physicians. SUBJECTS: A six per cent random sample (n = 759) of the members of the Finnish Medical Association representing physicians working in hospitals, community health centres, private practices and occupational health services (response rate 64%, n = 487). MAIN MEASURES: Physicians' opinions concerning community pharmacists' involvement in counselling patients about purpose of the medication and adverse effects of benzodiazepines and neuroleptics. RESULTS: When classifying opinions into five categories, majority (72%) of the physicians regarded community pharmacists as a provider of comprehensive or at least general information about adverse effects of benzodiazepines, but only 43% about the purpose of the medication. Correspondingly, 60% of the physicians regarded community pharmacists as a provider of comprehensive or general information about adverse effects of neuroleptics, but only 35% about the purpose of the medication. There was a strong correlation between physicians' opinions concerning pharmacists' involvement in counselling patients about the purpose of the medication of benzodiazepines and neuroleptics (Spearman's coefficient 0.667), and about adverse effects of both type of medication (0.668). Male physicians had more fixed opinions, both positive and negative, than female physicians. CONCLUSIONS: Finnish physicians are still quite critical about community pharmacists involvement in counselling patients on psychotropic medication. Especially with neuroleptics, physicians feel that pharmacists should be cautious when discussing the purpose of the medication if it is excluded from the prescription.

Physicians' opinions about the management of hypertension: changes in Finland between 1985 and 1992.

The successful management of hypertension requires an active involvement of physicians. We studied trends in Finnish physicians' opinions about the management of hypertension between 1985 and 1992. The response rates in these two random samples of physicians were 68% and 56%, respectively. Physicians who reported regularly treating hypertensive patients were included in our analyses (n1 = 319, n2 = 470). Fifty per cent of physicians used diastolic blood pressure of 100 mm Hg as a criterion for starting drug treatment and a goal blood pressure of 90 mm Hg was reported by 60% of physicians. Both levels decreased from 1985 to 1992. The variation in both of these blood pressure levels as reported by the physicians were wide both in 1985 and 1992. The activity in promoting non-pharmacological measures such as exercise and restriction of fat intake improved during this time period. The choice of drugs for anti-hypertensive therapy changed drastically from 1985 to 1992. For younger patients ACE inhibitors became the drug of choice and for older patients Ca-blockers gained popularity from diuretics. A similar shift can also be seen in the sales statistics. Whether this increased activity in starting drug therapy and using new drugs will improve the outcome of treatment remains to be seen.

The "questions to ask about your medicines" campaign. An evaluation of pharmacists' and the public's response.

OBJECTIVES: The purpose of this study was to assess the impact of the WHO/EuroPharm Forum "Questions to Ask About Your Medicines" campaign on patient counseling in Finnish community pharmacies. METHODS: The impact of the campaign was assessed by comparing the baseline findings with those at 3 months and 12 months after the implementation. The research methods involved observation of pharmacist-customer interactions, followed by personal interview of the customer. RESULTS: The main positive outcome was the manner in which information was provided, as the counseling became more customized, more empathy was shown toward the customer, and haste was less obvious. The campaign did not increase the number of customers asking questions, with 6% asking at least one pharmacotherapeutic question throughout the campaign. Information was given mostly on the pharmacists' initiative, with approximately 40% receiving at least some oral counseling, mostly regarding how to use the medicine. Approximately 10% of the customers were provided with written information. No change was observed in the pharmacists' spontaneous provision of oral or written information. CONCLUSIONS: The campaign was an attempt to set national and local standards for patient counseling in Finnish pharmacies. Further efforts are needed to change the content and availability of counseling.

Who is using antihypertensive drugs? A prescription analysis from Finland.

OBJECTIVE: To analyse the prescribing of antihypertensives in Finland in 1993. DESIGN: A descriptive three-month follow-up study of reimbursed prescriptions for chronic hypertension dispensed in Finnish pharmacies. SETTING: The nationwide prescription data base of the Social Insurance Institution covering 80% of Finnish pharmacies. Material--The study material consisted of 479 744 antihypertensive prescriptions from ATC-groups hypotensives (C02), diuretics (C03), beta blocking agents (C07), and potassium (A12B) for 279 435 hypertensive patients. RESULTS: Of all the prescriptions (excluding potassium supplements), 30% were for beta blocking agents, 24% for diuretics, 22% for calcium channel blocking agents, 20% for ACE inhibitors or ACE inhibitor + diuretic combinations, and 4% for other hypotensives. Two thirds of the men received a drug from a hypotensive group, nearly half were prescribed a beta blocking agent, and 27% a diuretic. Among women the distribution of the different drug groups was more even: more than half the women (55%) were prescribed hypotensives while beta blocking agents and diuretics were prescribed for 43% and 44%, respectively. Due to the different treatment profile between men and women the expenses of treatment also differed. The cost of prescriptions for female patients was, on average, 17% less than that for male patients. CONCLUSION: The choice of antihypertensive drugs depends on the age and sex of a patient. Prescribing antihypertensive drugs does not fully meet national recommendations. New drugs are gaining ground in the treatment of hypertension. An increase in the cost of treatment will result from this development.

Self-initiated modification of hypertension treatment in response to perceived problems.

OBJECTIVE: To assess the prevalence of patient-initiated modification of drug instructions and the association between different classes of problems and the modification of hypertension therapy. DESIGN AND METHODS: In this cross-sectional study, all patients (n = 1215) who had been examined at a hypertension clinic during a 1-year period were surveyed. The response rate to the questionnaire was 85%. Of the 1035 respondents, 623 currently taking antihypertensive medication (self-report) were included in the study. RESULTS: Of the patients taking antihypertensive drugs, 36% admitted that they had tried to manage their condition with a lower dosage and/or fewer drugs than prescribed. The percentage of patients who modified their drug regimen decreased with increasing age. One or more problems with the treatment of hypertension were reported by 79% of the respondents. The odds ratio (95% confidence interval) for modification among patients who reported 1 or more problems compared with those not reporting any problem was 3.5 (2.12 to 5.67). The prevalence of modification increased with the number of problems; this was seen in all age groups and among men and women. CONCLUSIONS: Perceived problems in drug taking in the treatment of hypertension have an important impact on the prevalence of modifying drug instructions.

Regular eye examinations of diabetic patients in the Finnish health care system.

A questionnaire about regular eye examinations of diabetic patients was sent to 1,776 physicians in eastern, western and southern provinces of Finland. The study was a part of a larger questionnaire about the medical care of high blood pressure and diabetes. Of the 1,706 doctors working actively, 950 (56%) completed the questionnaire, and 398 (42%) of them treated diabetic patients and gave their opinions of the ophthalmological care in diabetic patients. Regular eye examinations in type I diabetes were carried out annually by 79% of the physicians. In type II diabetic patients, the figure was 55%. In different provinces, these percentages varied from 61% to 81% in type I and from 38% to 74% in type II diabetes. The eye examination was performed in 54% by the physician who also treated diabetes, otherwise the examinations were performed by an ophthalmologist in a hospital, health centre or in private practice. In southern provinces of Finland, regular eye examinations were performed primarily by ophthalmologists in private practice, in western and eastern provinces they were performed by the doctors who also treated diabetes. Most of the regular annual eye examinations were reported by specialists in general practice and physicians working in health centres. The reported current practice in the regular eye examinations of type I diabetic patients is near the current European and American recommendations, but in type II diabetic patients these recommendations are not met adequately.

Change in blood pressure and 5-year risk of coronary heart disease among elderly men: the Finnish cohorts of the Seven Countries Study.

OBJECTIVE: To study the association between blood pressure and change in blood pressure with future coronary risk among elderly men. DESIGN: Cohort study. SETTING: Finnish cohorts of the Seven Countries Study. PARTICIPANTS: Four hundred and seventy-six men aged 65-84 years and free of clinically manifested coronary heart disease at baseline, in 1984. MAIN OUTCOME MEASURES: Fatal myocardial infarction (n = 29), any myocardial infarction (n = 42), and incidence of any new signs and symptoms of coronary heart disease (n = 80) during a 5-year follow-up. RESULTS: In multivariate analysis, a significant inverse U-shaped relationship was observed between baseline diastolic blood pressure and future fatal myocardial infarction, any myocardial infarction and any coronary heart disease. In models predicting the risk of coronary heart disease during 1984-1989, there was a significant interaction between both systolic (SBP) and diastolic blood pressure (DBP) in 1969-1974 and change in blood pressure between 1969-1974 and 1984. In categorical analyses, men (n = 42) who experienced a decline in DBP of > or = 4 mmHg from initial levels of > or = 90 mmHg had a higher risk of any myocardial infarction than men (n = 112) with a change of < 4 mmHg (odds ratio 4.5). For a decline of > or = 10 mmHg or more in SBP from levels of > or = 160 mmHg the corresponding odds ratio was 2.9. Men who experienced a decline in DBP or SBP from normotensive levels or an increase in blood pressure had no excess risk compared with men with stabile (change in DBP < 4 mmHg and change in SBP < 10 mmHg) blood pressure values. CONCLUSION: The present results suggest that among elderly men a decline in DBP or SBP from previously hypertensive levels may be associated with increased coronary risk.