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.
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.
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
Comment In: Lancet. 2009 Nov 7;374(9701):1591; author reply 1592-319897117
Comment In: Lancet. 2009 Nov 7;374(9701):1591; author reply 1592-319897118
Comment In: Lancet. 2009 Aug 22;374(9690):590-219595448
Comment In: Lancet. 2009 Nov 7;374(9701):1592; author reply 1592-319897121
Comment In: Lancet. 2009 Nov 7;374(9701):1592; author reply 1592-319897120
BACKGROUND: The Finnish National Asthma Programme was launched in 1994. AIM: A postal self-completion questionnaire study was undertaken to evaluate how the guideline is working in the Finnish healthcare system. METHODS: A postal inquiry was sent to a random sample of 6,000 subjects aged 16+ years who were entitled to special reimbursement for anti-asthmatic medication and 4,657 subjects with self-reported asthma were included. RESULTS: The subjects comprised 38% men (n=1,781) and 62% women (n=2,876). In all, 62% of all the subjects and 78% of those with severe asthma had visited a doctor on account of asthma in the past 12 months. Some 83% of the respondents had a given physician who was responsible for treating their asthma, and 75% of these were under observation by a primary healthcare physician. Visits to asthma nurses were relatively rare. Inhaled glucocorticoids were used by 83% of the subjects, but short-acting beta-2-agonists were still the most commonly used asthma drug in monotherapy regardless of the severity of asthma. Inhaled glucocorticoids and a short-acting beta-2-agonist was the most frequent combination. Every tenth subject used this combination supplemented by a long-acting beta-2-agonist. CONCLUSION: Asthma care in Finland seems to be compatible with the national guidelines in terms of continuity and the common use of inhaled glucocorticoids. The primary care sector has adopted the main responsibility for the treatment of asthma. The common use of short-acting beta-2-agonists is an exception to an otherwise positive trend.
To study the allocation of rehabilitation measures provided by the Finnish Social Insurance Institution in relation to the characteristics and health status of rehabilitants.
A register linkage study.
A total of 67,106 full-time local government employees with a minimum of 10-month job contracts in 10 Finnish towns during the period 1994-2002.
Data on the rehabilitation granted between 1994 and 2002, special medication reimbursements for chronic diseases, and disability retirement, were derived from the registers of the Social Insurance Institution as an indicator of chronic morbidity and linked to the employers' records on demographic characteristics and rates of sickness absence.
In comparison with non-rehabilitants, the rate of sickness absence (> 21 days) was 2.2-2.9-fold (95% confidence interval (CI) 2.0-3.0) higher, the odds ratios of special medication reimbursement 1.5-6.1-fold (95% CI 1.3-6.9) higher and disability retirement 3.1-7.5-fold (95% CI 2.7-9.3) higher among rehabilitants. Older women and employees in manual or lower-grade non-manual jobs predominated in the rehabilitation groups. The proportion of temporary employees receiving rehabilitation was low.
Permanently employed older women with an excess burden of health problems predominate in the receipt of rehabilitation provided by the Social Insurance Institution.
It is unknown if antidepressant treatment is associated with either increased or decreased risk of suicide.
To estimate the risk of suicide, attempted suicide, and overall mortality during antidepressant treatments in a real-life setting with high statistical power.
A cohort study in which all subjects without psychosis, hospitalized because of a suicide attempt from January 1, 1997, to December 31, 2003, in Finland, were followed up through a nationwide computerized database.
A total of 15 390 patients with a mean follow-up of 3.4 years.
The propensity score-adjusted relative risks (RRs) during monotherapy with the most frequently used antidepressants compared with no antidepressant treatment.
In the entire cohort, fluoxetine use was associated with the lowest risk (RR, 0.52; 95% confidence interval [CI], 0.30-0.93), and venlafaxine hydrochloride use with the highest risk (RR, 1.61; 95% CI, 1.01-2.57), of suicide. A substantially lower mortality was observed during selective serotonin reuptake inhibitor use (RR, 0.59; 95% CI, 0.49-0.71; P
Comment In: Evid Based Ment Health. 2007 Aug;10(3):9017652572
A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines.
The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information.
The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P
Comment In: Clin Infect Dis. 2006 May 1;42(9):1231-316586380
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.
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.
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.
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.
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.
To investigate the associations of social support at work and in private life with sleeping problems and use of sleep medication.
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.
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).
Low social support, especially at work, is associated with sleeping-related problems.
OBJECTIVE: To examine comorbidity and the medication load among asthmatics. Design A self-administered postal inquiry. SETTING: A national register-based random sample of 6000 subjects aged 16 years or older entitled to special reimbursement for anti-asthmatic medication in Finland. SUBJECTS: A total of 4690 subjects with clinically diagnosed asthma. MAIN OUTCOME MEASURES: Reporting of doctor-diagnosed chronic diseases and the number of prescription medicines used by asthmatics. RESULTS: Two-thirds of the subjects (n = 2952, 63%) reported other diseases in addition to other chronic pulmonary diseases and allergies. Musculoskeletal and cardiovascular disorders were the most common, increasing with age. Allergies were most frequent among the young asthmatics. Nearly all the subjects (n = 4444, 95%) took at least one anti-asthmatic medicine, and two out of every three (n = 3051, 65%) received other prescription medicines, most commonly cardiovascular drugs or analgesics. Some 41% (n=1938) of all the asthmatics and as many as 21% of the young adults (n = 269) were taking at least five prescription medicines concomitantly. The total medication load increased with age. CONCLUSION: The load of comorbidity and prescribed medication is heavy in adult asthmatics of all ages. Thus asthmatic patients should best be treated by GPs, while pulmonary specialists work as consultants and take care of the most severe cases.
Hypertension is one of the major causes of disease burden affecting the Finnish population. Over the last decade, evidence-based care has emerged to complement other approaches to antihypertensive care, often without health economic assessment of its costs and effects. This study looks at the extent to which changes proposed by the 2002 Finnish evidence-based Current Care Guidelines concerning the prevention, diagnosis, and treatment of hypertension (the ACCG scenario) can be considered cost-effective when compared to modelled prior clinical practice (the PCP scenario).
A decision analytic model compares the ACCG and PCP scenarios using information synthesised from a set of national registers covering prescription drug reimbursements, morbidity, and mortality with data from two national surveys concerning health and functional capacity. Statistical methods are used to estimate model parameters from Finnish data. We model the potential impact of the different treatment strategies under the ACCG and PCP scenarios, such as lifestyle counselling and drug therapy, for subgroups stratified by age, gender, and blood pressure. The model provides estimates of the differences in major health-related outcomes in the form of life-years and costs as calculated from a 'public health care system' perspective. Cost-effectiveness analysis results are presented for subgroups and for the target population as a whole.
The impact of the use of the ACCG scenario in subgroups (aged 40-80) without concomitant cardiovascular and related diseases is mainly positive. Generally, costs and life-years decrease in unison in the lowest blood pressure group, while in the highest blood pressure group costs and life-years increase together and in the other groups the ACCG scenario is less expensive and produces more life-years. When the costs and effects for subgroups are combined using standard decision analytic aggregation methods, the ACCG scenario is cost-saving and more effective.
The ACCG scenario is likely to reduce costs and increase life-years compared to the PCP scenario in many subgroups. If the estimated trade-offs between the subgroups in terms of outcomes and costs are acceptable to decision-makers, then widespread implementation of the ACCG scenario is expected to reduce overall costs and be accompanied by positive outcomes overall.
Cites: Hum Reprod. 2000 Jan;15(1):95-10610611196
Cites: Arch Intern Med. 2000 May 8;160(9):1277-8310809030
Acute otitis media (AOM) is one of the most common diseases of childhood, representing a major disease burden on the society. New evidence-based guidelines for AOM, focusing on children under 7 years of age, were introduced in Finland in 1999. The aim of this study was to evaluate the cost-effectiveness of implementing those guidelines in Finland.
A 5-year prospective trial was conducted in thirty community primary healthcare centers in Finland. All AOM patients between 0 and 6 years of age visiting the study health centers for the first time, for this episode of illness, during 1 week in November 1998 (n = 579) and November 2002 (n = 369) were included in this study. The outcome measure was the percentage of symptom-free patients.
The mean direct cost of an AOM episode per patient stayed almost the same after implementing the guidelines, euro152 in 1998 and euro150 in 2002. After implementing the guidelines, the percentage of symptom-free patients was 10 percentage points higher than before the guidelines. The treatment after the implementation of the guidelines, thus, was a dominant strategy.
Implementing the guidelines to the treatment of AOM in children was associated with extra health benefits at slightly lower direct costs and, thus, is a dominant strategy. The focus of this study was on the short-term effects of the treatment; including long-term effects in the analysis might affect the results.