The Finnish experience to save asthma costs by improving care in 1987-2013.

The Finnish National Asthma Program 1994-2004 markedly improved asthma care in the 1990s. We evaluated the changes in costs during 26 years from 1987 to 2013. Direct and indirect costs were calculated by using data from national registries. Costs from both the societal and patient perspectives were included. The costs were based on patients with persistent, physician-diagnosed asthma verified by lung function measurements. We constructed minimum and maximum scenarios to assess the effect of improved asthma care on total costs. The number of patients with persistent asthma in the national drug reimbursement register increased from 83,000 to 247,583. Improved asthma control reduced health care use and disability, resulting in major cost savings. Despite a 3-fold increase in patients, the total costs decreased by 14%, from €222 million to €191 million. Costs for medication and primary care visits increased, but overall annual costs per patient decreased by 72%, from €2656 to €749. The theoretical total cost savings for 2013, comparing actual with predicted costs, were between €120 and €475 million, depending on the scenario used. The Finnish Asthma Program resulted in significant cost savings at both the societal and patient levels during a 26-year period.

First-year purchases of disease-modifying drugs of incident patients with chronic juvenile arthritis in Finland.

OBJECTIVES: To establish a nationwide overview on drug treatment of juvenile idiopathic arthritis (JIA), which is the most frequent form of chronic arthritis (JA) in children and adolescents. The emphasis is on the first 12 months after diagnosis, and any changes in medication practices during the early years of the present millennium are registered. METHODS: The Social Insurance Institution (SII) in Finland keeps a national register on individuals granted with a special reimbursement for medication of defined chronic diseases. From that register, we identified by the ICD-code of M08 all JA patients aged 16 years or under with an index day from 2000 through 2007. The prescription register of the SII showed the medication purchased for the patients. The register does not cover infused medications given in hospitals. We evaluated the first disease year's medication and the treatment strategy of the very first three months. RESULTS: Within our study period 2000-2007, the proportion of patients using methotrexate during the first year of treatment increased from 54 to 72% (p<0.001). The combination of two or more DMARDs became more popular (increased from 16 to 21%) as the initial treatment strategy. These changes parallel a decrease in per oral glucocorticoids. The proportion of JA patients receiving TNFα-blockers during the first year after diagnose reached the level of about 5% during the years 2004 to 007. CONCLUSIONS: The drug treatment of patients with recent onset JA has become more intensive during the course of the new millennium in Finland, a fact expected to improve the disease outcome.

Validation of the Finnish ISAAC questionnaire on asthma against anti-asthmatic medication reimbursement database in 5-year-old children.

BACKGROUND: Valid identification of childhood asthma at the population level for epidemiological purposes remains a challenge. We aimed at validating the Finnish version of the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire based on parental-reported childhood asthma. MATERIALS AND METHODS: The ISAAC questionnaire has been validated against anti-asthmatic medication reimbursement data of the Finnish Social Insurance Institution, being the gold standard, among 2236 5-year-old consecutively born children (1996-2004) carrying human leukocyte antigen (HLA)-conferred susceptibility to type 1 diabetes. Two combined questionnaire questions (any wheezing symptom or use of asthma medication during the preceding 12 months plus ever asthma; any wheezing symptom or use of asthma medication during the preceding 12 months plus ever doctor-diagnosed asthma) were validated against valid reimbursement with purchase of at least one anti-asthmatic medication during a 12-month period. The validity of the questionnaire was estimated as the sensitivity, specificity, positive predictive value, negative predictive value, and Youden's index. RESULTS: The sensitivity 0.98 [95% confidence interval (CI) = 0.92-0.99]; specificity 0.98 (95% CI = 0.97-0.98); negative predictive value 1.00 (95% CI = 1.00-1.00); and Youden's index 0.96 (95% CI = 0.96-0.96) were the same for each of the two sets of combined questions. The positive predictive value for the first combined question was 0.63 (95% CI = 0.55-0.71), while it was 0.64 (95% CI = 0.57-0.72) for the second combined question. CONCLUSION: The Finnish ISAAC questionnaire was highly valid and is an acceptable instrument for the survey of the prevalence of parental-reported childhood asthma for epidemiological purposes.

Evolution of paediatric off-label use after new significant medicines become available for adults: a study on triptans in Finnish children 1994-2007.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: • Off-label use in children is widespread. New medicines lack marketing authorization for paediatric use, even when they represent significant therapeutic advantages and are intended for treatment of conditions common in children. • Until now no information exists on how off-label use in children develops over time after a significant new medicine is approved for adults and what happens when it is later labelled for one paediatric age group. WHAT THIS STUDY ADDS: • Off-label use of a new significant medicine begins in adolescents and extends to younger children with delay. First marketing authorization to adolescents, providing a more child-friendly formulation, results in increase of off-label use in younger children, and has limited effect on total off-label use. AIM: To investigate the evolution of paediatric off-label use after a therapeutically new group of medicines for a common condition becomes available for adults but is labelled for children with a delay of several years. METHODS: Triptans were used as a model, because migraine is common in children, and is the only indication for triptans. Data on all triptan prescriptions 1994-2007 were extracted from the nationwide Finnish Prescription Register. Prescriptions for children were compared over time. RESULTS: Paediatric patients with triptan prescriptions increased from 204 in 1994 to 2618 in 2007. Sumatriptan accounted for 64% of all paediatric triptan prescriptions. When sumatriptan in a nasal formulation was labelled for children ≥ 12 years in 2003, off-label prescribing to younger children (6-11 years) doubled in 2003-2004. Sumatriptan on-label prescriptions increased to 728 adolescents (45% of sumatriptan in the age group) in 2007, but its off-label use continued also to increase to 1119 (61% of paediatric sumatriptan prescriptions) in 2007. In that year 72% of paediatric triptan use was off-label, 28% on-label. CONCLUSIONS: When a new significant medicine becomes available in adults, off-label use in children starts slowly but continues to extend to younger children reaching a market size which is little influenced by late appearance of a labelled product. Paediatric treatment remains dominated by off-label use despite labelling of a product in an age appropriate formulation to the most relevant age group.

A marked decline in the incidence of renal replacement therapy for amyloidosis associated with inflammatory rheumatic diseases - data from nationwide registries in Finland.

Risk for amyloidosis in rheumatic diseases is associated with a long-lasting inflammation. To assess possible changes in the incidence of terminal uraemia due to amyloidosis associated with rheumatic diseases on a nationwide basis, we scrutinised the files of the Finnish Registry for Kidney Diseases for patients suffering from amyloidosis associated with rheumatoid arthritis (RA), ankylosing spondylitis (AS) or juvenile idiopathic arthritis (JIA) over the period 1995-2008. The registry has an estimated 97-99% coverage of all patients accepted for renal replacement therapy (RRT) in the country. Data on the consumption of antirheumatic drugs were collected from two sources: the Social Insurance Institution's Drug Reimbursement Register, and the Sales Register of the National Agency for Medicines from the above period. Altogether 264 cases were identified. Two hundred twenty-nine of them had RA, 15 AS and 20 JIA. When the total annual number of new admissions to RRT varied between 20 and 37 at the end of 1990s, it was under half of that from 2002 onwards. Over this period, the number of users of low-dose methotrexate (MTX) has increased 3.6-fold, the drug being the most frequently used disease modifying anti-rheumatic drug in Finland. The present nationwide series is the first to show that the incidence of end-stage renal disease due to amyloidosis associated with rheumatic diseases is decreasing. An obvious reason for this is intensive anti-rheumatic drug therapy.

Self-report as an indicator of incident disease.

PURPOSE: Epidemiological studies use self-reports from repeated surveys to ascertain incident disease. However, the accuracy of such measurements remains unknown, as validity studies have typically relied on data from prevalent, rather than incident, disease. This study examined the validity of self-reports in the detection of new-onset disease with measurements at baseline and follow-up conditions. METHODS: We conducted a prospective cohort study of 34,616 Finnish public-sector employees. Data from self-reported, physician-diagnosed diseases from two surveys approximately 4 years apart were compared with corresponding records in comprehensive national health registers used as the validity criterion. RESULTS: There was a considerable degree of misclassification for self-reports as a measure of incident disease. The specificity of self-reports was equally high for the prevalent and incident diseases (range, 93%-99%), but the sensitivity of self-reports was considerably lower for incident than for prevalent diseases: hypertension (55% vs. 86%), diabetes (62% vs. 96%), asthma (63% vs. 91%), coronary heart disease (62% vs. 78%), and rheumatoid arthritis (63% vs. 83%). CONCLUSIONS: This study suggests that the sensitivity of self-reports is substantially worse for incident than for prevalent diseases. Results from studies on self-reported incident chronic conditions should be interpreted with caution.

Maternal and perinatal characteristics and the risk of cow's milk allergy in infants up to 2 years of age: a case-control study nested in the Finnish population.

This study examined whether maternal background and perinatal factors were associated with the risk of cow's milk allergy (CMA) in infants up to 2 years of age in a nested case-control study. All children born in 1996-2004 in Finland and diagnosed with CMA by 2006 were identified (n = 16,237). For each case, one matched control was selected. Information on maternal and perinatal factors was derived from the Medical Birth Register. The associations were analyzed by conditional logistic regression. Cesarean section (adjusted odds ratio (OR) = 1.18, 95% confidence interval (CI): 1.10, 1.27) and high maternal age (> or =35 years; adjusted OR = 1.23, 95% CI: 1.11, 1.36) were associated with increased risk, whereas low maternal socioeconomic status (adjusted OR = 0.65, 95% CI: 0.59, 0.71), smoking (adjusted OR = 0.72, 95% CI: 0.67, 0.79), high number of previous deliveries (> or =5; adjusted OR = 0.71, 95% CI: 0.59, 0.86), and multiple pregnancy (adjusted OR = 0.70, 95% CI: 0.60, 0.82) were associated with decreased risk of CMA. In conclusion, maternal background and perinatal factors may play a role in the development of CMA, but further research is needed to clarify these associations and the underpinning biologic mechanisms.

Positive change in the utilization of antihypertensive and lipid-lowering drugs among adult CHD patients in Finland: results from a large national database between 2000 and 2006.

AIM: To assess the changes in the utilization of antihypertensive, and lipid-lowering drugs among all adult Finnish coronary heart disease (CHD) patients between 2000 and 2006, and to evaluate the treatment and control of hypertension and dyslipidemia in a population-based sample of CHD patients. METHODS: From the databases of the Social Insurance Institution of Finland, 192,440 CHD patients aged 30 years or more in 2000 and 206,394 in 2006, respectively, were identified. Changes in the utilization of antihypertensive and lipid-lowering drugs were determined. In addition, from the Health 2000 Survey representing the whole Finnish population aged 30 years or more, 527 CHD patients were identified, to assess their characteristics and control of hypertension and dyslipidemia. RESULTS: Between the fall of 2000 and spring of 2001, 75% of the CHD patients were classified as hypertensives and 85% of these used antihypertensive medication. From 2000 to 2006, the utilization of lipid-lowering, and antihypertensive drugs increased from 33 to 52% and from 74 to 78%, respectively. Moreover, combination antihypertensive medication increased from 37 to 48%. Amidst the patients using antihypertensive drugs, the use of renin-angiotensin system blockers increased from 27 to 46% because of more than a three-fold increase in the use of angiotensin receptor blockers. CONCLUSION: Utilization of antihypertensive agents (especially angiotensin receptor blockers) and lipid-lowering drugs has increased remarkably by the end of 2006. However, the treatments are still far from optimal.

Pattern of statin use among 10 cohorts of new users from 1995 to 2004: a register-based nationwide study.

OBJECTIVE: To analyze differences in the pattern of statin use among 10 consecutive yearly cohorts of new users in Finland. STUDY DESIGN: Retrospective cohort study based on administrative claims data. METHODS: New users of statins from January 1, 1995, to December 31, 2004, were captured from a nationwide prescription register, and the pattern of statin use was observed until December 31, 2005. The association between year of statin initiation and persistence with statin therapy during the first year of statin use was modeled using Cox proportional hazards regression analysis with multivariable adjustment. The median adherence (proportion of days covered) was computed among patients who discontinued therapy during each 365-day interval since statin initiation. RESULTS: In total, 490,024 new users of statins were identified. In the multivariable-adjusted model, discontinuation during the first year among initiators of statin use in 1996 and 1997 was similar to that in 1995 (hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.95-1.03 in 1996; and HR, 1.01; 95% CI, 0.98-1.05 in 1997). Compared with the 1995 cohort, the 1998, 1999, 2000, 2001, 2002, 2003, and 2004 cohorts were less likely to discontinue statin use. Hazard ratios of discontinuation for the cohorts ranged from 0.91 (95% CI, 0.88-0.94) in 1998 to 0.80 (95% CI, 0.78-0.83) in 2004. There were no differences in adherence with respect to the duration of therapy among the yearly cohorts. CONCLUSIONS: Compared with the 1995 cohort, 1-year persistence with statin therapy in Finland improved among new users of statins in 1998, and the improvement persisted up to 2004. Adherence to statin therapy remained stable among initiators from 1995 to 2004.

The association of social support at work and in private life with sleeping problems in the Finnish health 2000 study.

OBJECTIVE: To investigate the associations of social support at work and in private life with sleeping problems and use of sleep medication. METHODS: In the nationwide Health 2000 Study, with a cohort of 3430 employees, social support at work and in private life, and sleep-related issues were assessed with self-assessment scales. Purchases of sleep medication over a 3-year period were collected from the nationwide pharmaceutical register of the Social Insurance Institution. RESULTS: Low social support from supervisor was associated with tiredness (odds ratio [OR] 1.68, 95% confidence interval [CI] = 1.26 to 2.23) and sleeping difficulties within the previous month (OR 1.74, 95% CI = 1.41 to 1.92). Low support from coworkers was associated with tiredness (OR 1.55, 95% CI = 1.41 to 1.92), sleeping difficulties within the previous month (OR 1.77, 95% CI = 1.32 to 2.36), and only among women, with short sleep duration (OR 2.06, 95% CI = 1.22 to 3.47). Low private life support was associated with short sleep duration (OR 1.49, 95% CI = 1.13 to 1.98) and among women, with sleeping difficulties (OR 1.46, 95% CI = 1.08 to 1.33). CONCLUSIONS: Low social support, especially at work, is associated with sleeping-related problems.

Incidence of cancer and antidepressant medication: record linkage study.

The consumption of antidepressants, especially selective serotonine reuptake inhibitors (SSRI) has been increasing. Because a large fraction of the population is exposed, even a small excess of risk with respect to cancer should be considered. We carried out a record linkage study in Finland utilizing nationwide databases of reimbursed medication and cancer. The study population included all antidepressant drug (AD) users in Finland who had purchased at least 1 prescription between 1998 and 2005, and who had no cancer diagnosis at the date of first purchase. A control population without AD usage (matched by age and sex) was also included. Data consisted of 418,588 pairs of individuals that cumulated 3.3 million person-years with an average of 4.0 years of follow-up. 19,365 cancer cases were observed. The most frequent cancers were breast, prostate, lung, colon, and brain cancer. In general, only few associations between the utilization of AD and cancer could be detected. Over four years exposure to AD showed a weak association with increased colon and breast cancer incidence, which could have been caused by bias. As conclusion, no clear evidence of neither beneficial nor harmful association between usage of antidepressant and cancer was found.

Incidence of cancer and statin usage--record linkage study.

The consumption of statins (HMG-CoA reductase inhibitors) has been increasing, and a substantial part of the middle-aged and elderly population use them continuously. Because a large fraction of the population is exposed, even a small excess of risk with respect to cancer should be considered. We carried out a record-linkage study in Finland utilizing nationwide databases of reimbursed statin medication and cancer. The study population included all statin users in Finland who had purchased at least 1 prescription between 1996 and 2005 and who had no cancer diagnosis at the date of first purchase. A control population without statin usage was also included. Data consisted of 472,481 pairs of individuals that cumulated 4.2 million person years with an average of 8.8 years of follow-up. Fifty thousand two hundred ninety-four cancer cases were observed. Simvastatin and atorvastatin were the most used substances. The most frequent cancers were prostate, breast, lung, colon, and rectum cancer. In general, no association between the utilization of statins and cancer could be detected. In conclusion, this study adds large-scale, population-based results about the association between statin utilization and the incidence of cancer. We found neither beneficial nor harmful associations between the usage of statins and cancer.

Positive change in the utilization of antihypertensive and lipid-lowering drugs among adult diabetics in Finland. Results from large national database between 2000 and 2006.

OBJECTIVES: To assess changes in the utilization of antihypertensive and lipid-lowering drugs among all adult Finnish diabetics between 2000 and 2006, and to evaluate the treatment and control of hypertension and dyslipidemia in a population-based sample of diabetic patients. METHODS: From the databases of the Social Insurance Institution of Finland, 143 366 diabetic patients aged 30 years or over in 2000-2001 and 187,099 in 2006-2007, respectively, were identified, and changes in the prevalence of antihypertensive and lipid-lowering drugs were determined. In addition, from the Health 2000 Survey representing the whole Finnish population aged 30 years or over, 388 diabetic patients were identified, to assess their characteristics and control of hypertension and dyslipidemia. RESULTS: Between the fall of 2000 and spring of 2001, 83% of the diabetics were classified as hypertensives. Sixty-nine percent of them used antihypertensive medication. From 2000 to 2006, utilization of lipid-lowering drugs increased by 111%, and combination antihypertensive medication, by 31%, for patients with diabetes. Among those using antihypertensive drugs, the use of angiotensin receptor blockers increased by 196%, and the use of either an angiotensin receptor blocker or an angiotensin-converting enzyme inhibitor, by 31%, respectively. Of the treated hypertensive diabetic patients in 2000-2001, only 14% had the blood pressure below 130/80 mmHg, and only 17% of the diabetics using lipid-lowering drugs had the serum low-density lipoprotein-cholesterol value less than 2.5 mmol/l. CONCLUSION: Our findings indicate that the control of hypertension and dyslipidemia among adult diabetics in the beginning of the decade was poor. On the contrary, utilization of antihypertensive agents (especially angiotensin receptor blockers) and lipid-lowering drugs has increased remarkably by the end of 2006. Still, the treatments are far from optimal.

Use of inhaled corticosteroids decreases hospital admissions for asthma in young children.

BACKGROUND: An active use of inhaled corticosteroids for asthma has been associated with less asthma exacerbations and hospital admissions in children aged more than 2 years. The present study aimed to investigate hospital admission rates in young children from two populations in relation to the age-specific use of maintenance medication for asthma. METHODS: Annual data on children aged less than 24 months treated for asthma, including data on the use of maintenance medication based on the purchases of prescribed medications, and annual numbers of admissions to hospital and proportions of readmissions, were collected from 1995 to 1999 in two provinces of Finland. The inclusion criteria, three or more doctor-diagnosed wheezing episodes, were individually checked by the authors in each case. The mean number of children aged less than 24 months during the years of the study was 5490 in Kuopio and 9914 in Oulu area. RESULTS: In the Kuopio area, during the years of the study, 16.5/1000 children aged less than 24 months were on maintenance medication for asthma, and 90% of them were receiving inhaled corticosteroids. In the Oulu area, the respective figures were 13.5/1000 (P<0.001) and 99%. The average admission rate was 7.9/1000 in the Kuopio area and 8.7/1000 in the Oulu area (P<0.05). The readmissions indicated the higher admission rates in the Oulu (40% of all admissions) than in the Kuopio (28%) area (P<0.01). CONCLUSION: Active use of maintenance therapy by inhaled corticosteroids was associated with a decreased need of hospital treatment in young children <24 months old with asthma, mainly because of less readmissions.

11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study).

BACKGROUND: The introduction of second-generation antipsychotic drugs during the 1990s is widely believed to have adversely affected mortality of patients with schizophrenia. Our aim was to establish the long-term contribution of antipsychotic drugs to mortality in such patients. METHODS: Nationwide registers in Finland were used to compare the cause-specific mortality in 66 881 patients versus the total population (5.2 million) between 1996, and 2006, and to link these data with the use of antipsychotic drugs. We measured the all-cause mortality of patients with schizophrenia in outpatient care during current and cumulative exposure to any antipsychotic drug versus no use of these drugs, and exposure to the six most frequently used antipsychotic drugs compared with perphenazine use. FINDINGS: Although the proportional use of second-generation antipsychotic drugs rose from 13% to 64% during follow-up, the gap in life expectancy between patients with schizophrenia and the general population did not widen between 1996 (25 years), and 2006 (22.5 years). Compared with current use of perphenazine, the highest risk for overall mortality was recorded for quetiapine (adjusted hazard ratio [HR] 1.41, 95% CI 1.09-1.82), and the lowest risk for clozapine (0.74, 0.60-0.91; p=0.0045 for the difference between clozapine vs perphenazine, and p<0.0001 for all other antipsychotic drugs). Long-term cumulative exposure (7-11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0.81, 0.77-0.84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0.991; 0.985-0.997). INTERPRETATION: Long-term treatment with antipsychotic drugs is associated with lower mortality compared with no antipsychotic use. Second-generation drugs are a highly heterogeneous group, and clozapine seems to be associated with a substantially lower mortality than any other antipsychotics. Restrictions on the use of clozapine should be reassessed. FUNDING: Annual EVO Financing (Special government subsidies from the Ministry of Health and Welfare, Finland).

A comparison of two multidisciplinary inpatient rehabilitation programmes for fibromyalgia: a register linkage study on work disability.

BACKGROUND: Patients with fibromyalgia have a high risk of temporary and permanent work disability. Little is known about the effects of fibromyalgia rehabilitation on work disability. OBJECTIVE: To determine whether a specific fibromyalgia rehabilitation programme is superior to a non-specific musculoskeletal rehabilitation of patients with fibromyalgia in terms of work disability. METHODS: A prospective observational study of 215 local government employees with a 6-year post-intervention follow-up to monitor the occurrence of long sick-leave and disability pensions among the participants of two different fibromyalgia rehabilitation programmes. RESULTS: Specific fibromyalgia rehabilitation was not superior to a non-specific musculoskeletal rehabilitation, with the corresponding hazard ratios (95% confidence intervals) after adjustments being 1.02 (0.75-1.40) for long sick-leave, 1.18 (0.75-1.87) for very long sick-leave, and 1.07 (0.63-1.83) for disability pension. CONCLUSION: The results suggest that in reducing work disability among patients with fibromyalgia a specific multidisciplinary fibromyalgia rehabilitation programme practised in Finland provides no benefit compared with non-specific multidisciplinary musculoskeletal rehabilitation. Further research is needed to develop an optimal programme (or several different programmes) to control the burden of work disability related to fibromyalgia.

The association of social support at work and in private life with mental health and antidepressant use: the Health 2000 Study.

BACKGROUND: Social support is assumed to protect mental health, but it is not known whether low social support at work increases the risk of common mental disorders or antidepressant medication. This study, carried out in Finland 2000-2003, examined the associations of low social support at work and in private life with DSM-IV depressive and anxiety disorders and subsequent antidepressant medication. METHODS: Social support was measured with self-assessment scales in a cohort of 3429 employees from a population-based health survey. A 12-month prevalence of depressive or anxiety disorders was examined with the Composite International Diagnostic Interview (CIDI), which encompasses operationalized criteria for DSM-IV diagnoses and allows the estimation of DSM-IV diagnoses for major mental disorders. Purchases of antidepressants in a 3-year follow-up were collected from the nationwide pharmaceutical register of the Social Insurance Institution. RESULTS: Low social support at work and in private life was associated with a 12-month prevalence of depressive or anxiety disorders (adjusted odds ratio 2.02, 95% CI 1.48-2.82 for supervisory support, 1.65, 95% CI 1.05-2.59 for colleague support, and 1.62, 95% CI 1.12-2.36 for private life support). Work-related social support was also associated with subsequent antidepressant use. LIMITATIONS: This study used a cross-sectional analysis of DSM-IV mental disorders. The use of purchases of antidepressant as an indicator of depressive and anxiety disorders can result in an underestimation of the actual mental disorders. CONCLUSIONS: Low social support, both at work and in private life, is associated with DSM-IV mental disorders, and low social support at work is also a risk factor for mental disorders treated with antidepressant medication.

National utilization of transdermal fentanyl among community-dwelling older people in Finland.

BACKGROUND: The use of opioids has increased rapidly in Europe and North America, and older people may be susceptible to opioid-related adverse drug events. The Finnish National Agency for Medicines has recommended that oral opioids be considered the first-line treatment when a strong opioid is required for severe pain. OBJECTIVE: The objective of this study was to investigate and describe the age-, indication-, sex-, and geographic-specific utilization of transdermal fentanyl among older people residing in noninstitutional settings in Finland. METHODS: Reimbursement data for fentanyl, morphine, oxycodone, and hydromorphone were extracted from the Finnish National Prescription Register for 2008. Age-specific population data were used to calculate the annual prevalence of opioid use for malignant and nonmalignant pain for patients aged < or = 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, 85 to 89, 90 to 94, 95 to 99, and >99 years. The annual prevalence of transdermal fentanyl use was also calculated separately for each of the 21 hospital districts in Finland. RESULTS: Reimbursement for transdermal fentanyl was paid to 2746 people for malignant pain and 6223 people for nonmalignant pain. The annual prevalence of transdermal fentanyl use for nonmalignant pain was lowest among men aged < or = 64 years (2.2 users/10,000 men) and highest among women >99 years (539.2 users/10,000 women). The annual prevalence of transdermal fentanyl use was >47 times higher than that of morphine for nonmalignant pain among people aged 85 to 89 years and >97 times higher than that of morphine among people aged 90 to 94 years. A greater than 4-fold variation in the annual prevalence of transdermal fentanyl use was reported among the 21 hospital districts in Finland (range, 9.5-40.6/10,000 inhabitants). CONCLUSIONS: The prevalence of transdermal fentanyl use was higher than that of morphine, oxycodone, and hydromorphone among people aged > or = 80 years residing in noninstitutional settings in Finland. The variation in use between hospital districts suggests that organizational culture may have a strong impact on prescribing practices. Our data highlight the need for further education regarding the appropriate use of opioids among older people.