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1.  Can gender difference in prescription drug use be explained by gender-related morbidity?: a study on a Swedish population during 2006 
BMC Public Health  2014;14:329.
Background
It has been reported that there is a difference in drug prescription between males and females. Even after adjustment for multi-morbidity, females tend to use more prescription drugs compared to males. In this study, we wanted to analyse whether the gender difference in drug treatment could be explained by gender-related morbidity.
Methods
Data was collected on all individuals 20 years and older in the county of Östergötland in Sweden. The Johns Hopkins ACG Case-Mix System was used to calculate individual level of multi-morbidity. A report from the Swedish National Institute of Public Health using the WHO term DALY was the basis for gender-related morbidity. Prescription drugs used to treat diseases that mainly affect females were excluded from the analyses.
Results
The odds of having prescription drugs for males, compared to females, increased from 0.45 (95% confidence interval (CI) 0.44-0.46) to 0.82 (95% CI 0.81-0.83) after exclusion of prescription drugs that are used to treat diseases that mainly affect females.
Conclusion
Gender-related morbidity and the use of anti-conception drugs may explain a large part of the difference in prescription drug use between males and females but still there remains a difference between the genders at 18%. This implicates that it is of importance to take the gender-related morbidity into consideration, and to exclude anti-conception drugs, when performing studies regarding difference in drug use between the genders.
doi:10.1186/1471-2458-14-329
PMCID: PMC3983669  PMID: 24713023
Prescription drugs; Multi-morbidity; Gender difference; Gender-related morbidity
2.  Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care 
BMC Geriatrics  2014;14:40.
Background
Falls are the most common cause of injuries and hospital admissions in the elderly. The Swedish National Board of Health and Welfare has created a list of drugs considered to increase the fall risk (FRIDs) and drugs that might cause/worsen orthostatism (ODs). This cross-sectional study was aimed to assess FRIDs and their correlation with falls in a sample of 369 community-dwelling and nursing home patients aged ≥75 years and who were using a multi-dose drug dispensing system.
Methods
Data were collected from the patients’ electronic medication lists. Retrospective data on reported falls during the previous three months and severe falls during the previous 12 months were collected. Primary outcome measures were incidence of falls as well as numbers of FRIDs and ODs in fallers and non-fallers.
Results
The studied sample had a high incidence of both reported falls (29%) and severe falls (17%). Patients were dispensed a mean of 2.2 (SD 1.5) FRIDs and 2.0 (SD 1.6) ODs. Fallers used on average more FRIDs. Severe falls were more common in nursing homes patients. More women than men experienced severe falls. There were positive associations between number of FRIDs and the total number of drugs (p < 0.01), severe falls (p < 0.01) and female sex (p = 0.03). There were also associations between number of ODs and both total number of drugs (p < 0.01) and being community dwelling (p = 0.02). No association was found between number of ODs and severe falls. Antidepressants and anxiolytics were the most frequently dispensed FRIDs.
Conclusions
Fallers had a higher number of FRIDs. Numbers of FRIDs and ODs were correlated with the total number of drugs dispensed. Interventions to reduce falls in the elderly by focusing on reducing the total number of drugs and withdrawal of psychotropic medications might improve the quality and safety of drug treatment in primary care.
doi:10.1186/1471-2318-14-40
PMCID: PMC3986685  PMID: 24674152
Elderly; Falls; Prevention; Drug therapy; Fall risk-increasing drugs
3.  Case management for frail older people – a qualitative study of receivers’ and providers’ experiences of a complex intervention 
Background
Case management interventions have been widely used in the care of frail older people. Such interventions often contain components that may act both independently of each other and interdependently, which makes them complex and challenging to evaluate. Qualitative research is needed for complex interventions to explore barriers and facilitators, and to understand the intervention’s components. The objective of this study was to explore frail older people's and case managers’ experiences of a complex case management intervention.
Methods
The study had a qualitative explorative design and interviews with participants (age 75-95 years), who had received the case management intervention and six case managers who had performed the intervention were conducted. The data were subjected to content analysis.
Results
The analysis gave two content areas: providing/receiving case management as a model and working as, or interacting with, a case manager as a professional. The results constituted four categories: (1 and 2) case management as entering a new professional role and the case manager as a coaching guard, as seen from the provider’s perspective; and (3 and 4) case management as a possible additional resource and the case manager as a helping hand, as seen from the receiver’s perspective.
Conclusions
The new professional role could be experienced as both challenging and as a barrier. Continuous professional support is seemingly needed for implementation. Mutual confidence and the participants experiencing trust, continuity and security were important elements and an important prerequisite for the case manager to perform the intervention. It was obvious that some older persons had unfulfilled needs that the ordinary health system was unable to meet. The case manager was seemingly able to fulfil some of these needs and was experienced as a valuable complement to the existing health system.
doi:10.1186/1472-6963-14-14
PMCID: PMC3897947  PMID: 24410755
Case management; Frail elderly; Intervention studies; Qualitative evaluation
4.  Impact of yoga on blood pressure and quality of life in patients with hypertension – a controlled trial in primary care, matched for systolic blood pressure 
Background
Medical treatment of hypertension is not always sufficient to achieve blood pressure control. Despite this, previous studies on supplementary therapies, such as yoga, are relatively few. We investigated the effects of two yoga interventions on blood pressure and quality of life in patients in primary health care diagnosed with hypertension.
Methods
Adult patients (age 20–80 years) with diagnosed hypertension were identified by an electronic chart search at a primary health care center in southern Sweden. In total, 83 subjects with blood pressure values of 120–179/≤109 mmHg at baseline were enrolled. At baseline, the patients underwent standardized blood pressure measurement at the health care center and they completed a questionnaire on self-rated quality of life (WHOQOL-BREF). There were three groups: 1) yoga class with yoga instructor (n = 28); 2) yoga at home (n = 28); and 3) a control group (n = 27). The participants were matched at the group level for systolic blood pressure. After 12 weeks of intervention, the assessments were performed again. At baseline a majority of the patients (92%) were on antihypertensive medication, and the patients were requested not to change their medication during the study.
Results
The yoga class group showed no improvement in blood pressure or self-rated quality of life, while in the yoga at home group there was a decline in diastolic blood pressure of 4.4 mmHg (p < 0.05) compared to the control group. Moreover, the yoga at home group showed significant improvement in self-rated quality of life compared to the control group (p < 0.05).
Conclusions
A short yoga program for the patient to practice at home seems to have an antihypertensive effect, as well as a positive effect on self-rated quality of life compared to controls. This implies that simple yoga exercises may be useful as a supplementary blood pressure therapy in addition to medical treatment when prescribed by primary care physicians.
Trial registration
ClinicalTrials.gov (NCT01302535)
doi:10.1186/1471-2261-13-111
PMCID: PMC4029555  PMID: 24314119
Hypertension; Yoga; Quality of life; Primary health care; Complementary therapies
5.  Longitudinal age-and cohort trends in body mass index in Sweden – a 24-year follow-up study 
BMC Public Health  2013;13:893.
Background
The aim of this longitudinal study was to analyze whether mean Body Mass Index (BMI), assessed at four occasions, changed within different age groups and birth cohorts over time, i.e., between 1980/81 and 2004/05, after adjustment for possible confounders.
Methods
A sample of 2728 men and 2770 women aged 16–71 years at study start were randomly drawn from the Swedish Total Population Register and followed from 1980/81 to 2004/05. The same sample was assessed on four occasions during the 24-year study period (i.e., every eighth year). The outcome variable, BMI, was based on self-reported height and weight. A mixed model, with random intercept and random slope, was used to estimate annual changes in BMI within the different age groups and birth cohorts.
Results
Mean BMI increased from 24.1 to 25.5 for men and from 23.1 to 24.3 for women during the 24-year study period. The annual change by age group was highest in the ages of 32–39, 40–47 and 48–55 years among men, and in the ages of 24–31, 32–39, and 40–47 years among women. The highest annual changes were found in the youngest birth cohorts for both men and women, i.e., those born 1958–65, 1966–73, and 1974–81. For each birth cohort, the annual change in BMI increased compared to the previous, i.e., older, birth cohort. In addition, age-by-cohort interaction tests revealed that the increase in BMI by increasing age was higher in the younger birth cohorts (1966–1989) than in the older ones.
Conclusions
Public health policies should target those age groups and birth cohorts with the highest increases in BMI. For example, younger birth cohorts had higher annual increases in BMI than older birth cohorts, which means that younger cohorts increased their BMI more than older ones during the study period.
doi:10.1186/1471-2458-13-893
PMCID: PMC3849274  PMID: 24074433
Age; Birth cohort; Body mass index; Longitudinal data; Mixed models
6.  Frail elderly patients’ experiences of information on medication. A qualitative study 
BMC Geriatrics  2012;12:46.
Background
Older patients generally have only poor knowledge about their medicines. Knowledge is important for good adherence and for participating in decisions about treatment. Patients are entitled to be informed on an individual and adequate level. The aim of the study was to explore frail elderly patients’ experiences of receiving information about their medications and their views on how the information should best be given.
Methods
The study was qualitative in design and was carried out in 2011. Twelve frail elderly (aged 68–88) participants taking cardiovascular medications participated in semi-structured interviews covering issues related to receiving information about prescribed medicines. The interviews were recorded, transcribed and subjected to content analysis, in which the text was analysed in five steps, inspired by Graneheim and Lundman.
Results
The results revealed that the experiences which the elderly participants had regarding the receiving of medical information fell into two main categories: “Comfortable with information” or “Insecure with information”. The elderly felt comfortable when they trusted their physician or their medication, when they received enough information from the prescriber or when they knew how to find out sufficient information by themselves. They felt insecure if they were anxious, if the availability of medical care was poor or if they did not receive enough information.
Conclusions
Factors that frequently caused insecurity about information and anxiety were too short consultations, lack of availability of someone to answer questions or of the opportunity to contact the physician if adverse effects are suspected. These factors could easily be dealt with and there must be improvements in the clinics if the patients´ feelings of security are to be increased.
doi:10.1186/1471-2318-12-46
PMCID: PMC3511244  PMID: 22909093
Elderly; Medication knowledge; Information; Confidence; Qualitative; Content analysis
7.  Lack of adherence to hypertension treatment guidelines among GPs in southern Sweden-A case report-based survey 
BMC Family Practice  2012;13:34.
Background
General practitioners (GPs) often fail to correctly adhere to guidelines for the treatment of hypertension. The reasons for this are unclear, but could be related to lack of knowledge in assessing individual patients' cardiovascular disease risk. Our aim was to investigate how GPs in southern Sweden adhere to clinical guidelines for the treatment of hypertension when major cardiovascular risk factors are taken into consideration.
Method
A questionnaire with five genuine cases of hypertension with different cardiovascular risk profiles was sent to a random sample of GPs in southern Sweden (n = 109) in order to investigate the attitude towards blood pressure (BP) treatment when major cardiovascular risk factors were present.
Results
In general, GPs who responded tended to focus on the absolute target BP rather than assessing the entire cardiovascular risk factor profile. Thus, cases with the highest risk of cardiovascular disease were not treated accordingly. However, there was also a tendency to overtreat the lowest risk individuals. Furthermore, the BP levels for initiating pharmacological treatment varied widely (systolic BP 140-210 mmHg). ACE inhibitors (70%) were the most common first choice of pharmacological treatment.
Conclusion
In this study, GPs in Southern Sweden were suggesting, for different cases, either under- or overtreatment in relation to current guidelines for treatment of hypertension. On reason may be that they failed to correctly assess individual cardiovascular risk factor profiles.
doi:10.1186/1471-2296-13-34
PMCID: PMC3391982  PMID: 22536853
Hypertension; Adherence; Guidelines; Treatment; Primary care
8.  GP's Adherence to Guidelines for Cardiovascular Disease among Elderly: A Quality Development Study 
The Scientific World Journal  2012;2012:767892.
Background. Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs. Objectives. To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement. Method. Data was collected from the medical records of patients aged ≥65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patient's doctor and discussion about regional guidelines. Repeated measurements were performed in 2008. Results and Conclusion. The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS2 score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged.
doi:10.1100/2012/767892
PMCID: PMC3356717  PMID: 22645450
9.  The assessment of renal function in relation to the use of drugs in elderly in nursing homes; a cohort study 
BMC Geriatrics  2011;11:1.
Background
Renal function decreases with age. Dosage adjustment according to renal function is indicated for many drugs, in order to avoid adverse reactions of medications and/or aggravation of renal impairment. There are several ways to assess renal function in the elderly, but no way is ideal. The aim of the study was to explore renal function in elderly subjects in nursing homes and the use of pharmaceuticals that may be harmful to patients with renal impairment.
Methods
243 elderly subjects living in nursing homes were included. S-creatinine and s-cystatin c were analysed. Renal function was estimated using Cockcroft-Gault formula, Modification of Diet in Renal Disease (MDRD) and cystatin C-estimated glomerular filtration rate (GFR). Concomitant medication was registered and four groups of renal risk drugs were identified: metformin, nonsteroidal anti-inflammatory drugs (NSAID), angiotensin-converting enzyme -inhibitors/angiotensin receptor blockers and digoxin. Descriptive statistics and the Kappa test for concordance were used.
Results
Reduced renal function (cystatin C-estimated GFR < 60 ml/min) was seen in 53%. Normal s-creatinine was seen in 41% of those with renal impairment. Renal risk drugs were rather rarely prescribed, with exception for ACE-inhibitors. Poor concordance was seen between the GFR estimates as concluded by other studies.
Conclusions
The physician has to be observant on renal function when prescribing medications to the elderly patient and not only rely on s-creatinine level. GFR has to be estimated before prescribing renal risk drugs, but using different estimates may give divergence in the results.
doi:10.1186/1471-2318-11-1
PMCID: PMC3025849  PMID: 21223578
10.  Barriers to adherence to hypertension guidelines among GPs in southern Sweden: A survey 
Objective
To evaluate barriers to adherence to hypertension guidelines among publicly employed general practitioners (GPs).
Design
Questionnaire-based survey distributed to GPs in 24 randomly selected primary care centres in the Region of Skåne in southern Sweden.
Subjects
A total of 109 GPs received a self-administered questionnaire and 90 of them responded.
Main outcome measures
Use of risk assessment programmes. Reasons to postpone or abstain from pharmacological treatment for the management of hypertension.
Results
Reported managing of high blood pressure (BP) varied. In all, 53% (95% CI 42–64%) of the GPs used risk assessment programmes and nine out of 10 acknowledged blood pressure target levels. Only one in 10 did not inform the patients about these levels. The range for immediate initiating pharmacological treatment was a systolic BP 140–220 (median 170) mmHg and diastolic BP 90–110 (median 100) mmHg. One-third (32%; 95% CI 22–42%) of the GPs postponed or abstained from pharmacological treatment of hypertension due to a patient's advanced age. No statistically significant associations were observed between GPs’ gender, professional experience (i.e. in terms of specialist family medicine and by number of years in practice), and specific reasons to postpone or abstain from pharmacological treatment of hypertension.
Conclusion
These data suggest that GPs accept higher blood pressure levels than recommended in clinical guidelines. Old age of the patient seems to be an important barrier among GPs when considering pharmacological treatment for the management of hypertension.
doi:10.1080/02813430802202111
PMCID: PMC3409603  PMID: 18609250
Barriers; family practice; guidelines; hypertension; primary care; survey

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