Bengt Ã…strand

Abstract: Background: The increased application of eServices in health care, in general, and ePrescribing (electronic prescribing) in particular, have brought quality and interoperability to the forefront. The application of standards has been put forward as one important factor in improving interoperability. However, less focus has been placed on other factors, such as stakeholders’ involvement and the measurement of interoperability. An information system (IS) can be regarded to comprise an instrument for technology-mediated work communication. In this study, interoperability refers to the interoperation in the ePrescribing process, involving people, systems, procedures and organizations. We have focused on the quality of the ePrescription message as one component of the interoperation in the ePrescribing process. Objective: The objective was to analyze how combined efforts in improving interoperability with the introduction of the new national ePrescription format (NEF) have impacted interoperability in the ePrescribing process in Sweden, with the focus on the quality of the ePrescription message. Methods: Consecutive sampling of electronic prescriptions in Sweden before and after the introduction of NEF was undertaken in April 2008 (pre-NEF) and April 2009 (post-NEF). Interoperability problems were identified and classified based on message format specifications and prescription rules. Results: The introduction of NEF improved the interoperability of ePrescriptions substantially. In the pre-NEF sample, a total of 98.6% of the prescriptions had errors. In the post-NEF sample, only 0.9% of the prescriptions had errors. The mean number of errors was fewer for the erroneous prescriptions: 4.8 in pre-NEF compared to 1.0 in post-NEF. Conclusions: We conclude that a systematic comprehensive work on interoperability, covering technical, semantical, professional, judicial and process aspects, involving the stakeholders, resulted in an improved interoperability of ePrescriptions

Abstract: Objective  To evaluate Swedish patients' attitudes towards e-prescribing, including the transfer of e-prescriptions, electronic storing of prescriptions and mail-order prescriptions. Methods  This study was a nationwide survey of attitudes among Swedish patients and was conducted as a postal questionnaire. The questionnaire was developed for the purpose of this study and aimed to evaluate respondents' views concerning e-prescribing, electronic storing of e-prescriptions and mail-order prescriptions from aspects including safety, personal benefits and effectiveness. A study population of 1500 individuals meeting the inclusion criteria was randomly selected from a database of individuals in Sweden storing prescriptions electronically (n = 5 840 599).The response rate was 52% (739/1429). Key findings  The vast majority of the respondents had a positive attitude towards e-prescriptions (85%, 628/739) and electronic storing of prescriptions (86%, 633/739), and regarded e-prescriptions to be safe (79%, 584/739), creating benefits for them (78%, 576/739) and promoting faster dispensing (69%, 512/739). Significant differences in attitudes towards e-prescriptions and electronic storing of prescriptions were detected between age groups. Patients storing all their prescriptions electronically had a more positive attitude towards both e-prescriptions and electronic storing of prescriptions compared to patients who stated they had paper prescriptions. The most common suggestion (n = 27) for improvement was to extend the information given about the services. Conclusion  Our nationwide survey showed that a vast majority of Swedish patients had positive attitudes towards e-prescriptions and electronic storing of prescriptions. However, a need for extended information regarding e-prescribing was identified.

Abstract: OBJECTIVES: To analyse the acquisition cost of dispensed prescription drugs for individuals with multiple medications in a national population. METHODS: We collected and analysed individual based data regarding the acquisition cost of dispensed prescription drugs for all individuals with five or more dispensed drugs (DP≥5) in Sweden 2006 (2.2 million). RESULTS: Individuals with DP≥5 (24.5% of the population) accounted for 78.8% of the total acquisition cost, and individuals with DP≥10 (8.6% of the population) and DP≥15 (3.0% of the population) accounted for 46.3% and 23.2%, respectively. The average acquisition cost per defined daily doses (DDD) generally decreased with increasing age. The highest average cost per DDD was observed for individuals with DP≥10. The acquisition cost for women with DP≥5 represented 56.0% of the total acquisition cost. Men with DP≥5 represented 44.0% of the total acquisition cost. CONCLUSIONS: In an entire national population, individuals with multiple medication accounted for four fifths of the total acquisition cost of dispensed drugs. Actions to reduce the number of prescription drugs for the group of patients with a number of different drugs may also result in a substantial reduction of the total acquisition cost.

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Abstract: Background: The eHealth Action Plan required the member states of the European Union (EU) to provide online services such as eprescribing of pharmaceuticals by the end of 2008. So far, implementation activities and efforts of the member states have been uneven. While in Austria pilot projects and feasibility studies have been conducted, Sweden has always been one of the leading countries in the field of eprescribing. Objective: To identify potential success factors for the implementation of eprescribing in Sweden, by comparing the attitudes of Austrian and Swedish physicians. Method: In a web survey, we asked 1824 Austrian and 427 Swedish physicians within primary care and other disciplines to declare to what extent they agreed with ten statements regarding their attitudes towards eprescribing. We deployed the chi-square test for testing the relationship between the country of residence of physicians and their attitudes towards eprescribing. Results: We demonstrated a relationship between the country of residence of physicians and their attitudes towards eprescribing (P<0.001) for all the responses. Of the Swedish physicians, 92% regarded eprescribing as time-saving, 88.1% as being safer and 96.0% as providing a better service for patients. Although less strongly supportive, the attitudes of the Austrian physicians were mainly positive. Conclusion: We found that the major potential success factors for the implementation of eprescribing in Sweden were saving of time for the physician, improved safety and better service for patients. The mainly positive attitudes of the Austrian physicians may enable implementation of eprescribing in due course.

Abstract: PURPOSE: To assess polypharmacy in a population with emphasis on regions. METHODS: We studied the individual-based data of all dispensed prescription drugs (DP) during a 3-month study period in Sweden 2006. As an indicator of polypharmacy, five or more (DP > or = 5) different drugs (substances) dispensed were applied. For analysis, we used comparisons of prevalence, correlation of prevalence of polypharmacy with different socioeconomic variables, and a novel weighted polypharmacy index. RESULTS: The national prevalence of polypharmacy, DP > or = 5, was 10.5% (inter-regional variation 9.1-12.1%). The regional variation in the prevalence of polypharmacy was largest for the age groups > or =90 (45.6-59.1%), 80-89 (46.1-53.4%) and 70-79 years (33.1-38.0%). The national prevalence of excessive polypharmacy, DP > or = 10, was 2.2% (inter-regional variation 1.9-2.6%). The regional variation in prevalence of excessive polypharmacy was largest for the age groups > or =90 (9.8-22.3%), 80-89 (11.4-17.1%) and 70-79 years (7.0-9.4%). We found a fairly strong positive correlation between polypharmacy and the age group > or =70 years (r = 0.84 for men and 0.71 for women). The novel weighted polypharmacy index indicated regional differences in the internal distribution of the prevalence of dispensed drugs for individuals with polypharmacy. CONCLUSION: Our findings indicate that the observed regional differences in the prevalence of polypharmacy partly can be explained by the regional age distribution in Sweden. The use of the novel weighted polypharmacy index indicated regional differences in drug therapy for individuals with polypharmacy.

Abstract: Objective To evaluate Swedish pharmacists’ attitudes towards ePrescribing, including the transfer of ePrescriptions, electronic storing of prescriptions and mail-order prescriptions. Method This study was conducted as a web-based survey among 500 randomly selected Swedish community pharmacists. The questionnaire included open-ended questions, multiple-choice questions and statements to which respondents gave their degree of agreement on a six-point Likert-type rating scale. Free-text answers were categorized into the most commonly mentioned opinions. Differences in respondents’ general characteristics and their level of satisfaction with ePrescribing were tested for significance using χ2 test. The survey had a response rate of 52% (259/500). 96% (248/259) of the respondents were female, and 76% (196/259) were aged 40–64 years. Key findings Swedish community pharmacists were generally satisfied with ePrescribing (98%, 253/259). No significant (P > 0.05) difference in the general satisfaction could be explained by the respondents’ age, gender or years in practice. A majority of the respondents regarded ePrescriptions and electronic storing of prescriptions as being safe for patients (95 and 93% respectively), providing patient benefits (96 and 95% respectively), being cost-effective for the pharmacy (92 and 91% respectively) and contributing to better communication and relationships with both patients and prescribers (62–88%). The positive aspects of ePrescribing most frequently mentioned in free-text answers were being safe (72%, 187/259) and timesaving (55%, 143/259). However, several weaknesses with ePrescribing were also described by the respondents, as well as suggestions for improvement. Conclusion Our nationwide survey of Swedish community pharmacists’ attitudes towards ePrescribing shows that pharmacists are generally satisfied with it, including the transfer of ePrescriptions, electronic storing of prescriptions and to a lower degree mailorder prescriptions.

Abstract: Background An increase in the use of drugs and polypharmacy have been displayed over time in spite of the fact that polypharmacy represents a well known risk factor as regards patients' health due to the adverse drug reactions, drug-drug interactions, and low adherence to drug therapy arising from polypharmacy. For policymakers, as well as for clinicians, it is important to follow the developing trends in drug use and polypharmacy over time. We wanted to study if the prevalence of polypharmacy in an entire national population has changed during a 4-year period. Methods By applying individual-based data on dispensed drugs, we have studied all dispensed prescribed drugs for the entire Swedish population during four 3-month periods 2005-2008. Five or more (DP [greater than or equal to]5) and ten or more (DP [greater than or equal to]10) dispensed drugs during the 3-month period was applied as the cut-offs indicating the existence of polypharmacy and excessive polypharmacy respectively. Results During the period 2005-2008, the prevalence of polypharmacy (DP[greater than or equal to]5) increased by 8.2% (from 0.102 to 0.111), and the prevalence of excessive polypharmacy (DP[greater than or equal to]10) increased by 15.7% (from 0.021 to 0.024). In terms of age groups, the prevalence of polypharmacy and excessive polypharmacy increased as regards all ages with the exception of the age group 0-9 years. However, the prevalence of excessive polypharmacy displayed a clear age trend, with the largest increase for the groups 70 years and above. Furthermore, the increase in the prevalence of polypharmacy was, generally, approximately twice as high for men as for women. Finally, the mean number of dispensed drugs per individual increased by 3.6% (from 3.3 to 3.4) during the study period. Conclusions The prevalence of polypharmacy and excessive polypharmacy, as well as the mean number of dispensed drugs per individual, increased year-by-year in Sweden 2005-2008.

Abstract: Objectives  To assess the prevalence and the therapeutic intensity of dispensed drug groups for individuals receiving multiple medications. Methods  The individual-based data of all dispensed outpatient prescriptions in Sweden in 2006 were analysed. Five or more dispensed drugs (DP ≥ 5) during a 12-month period were applied as an indicator of multiple medications. The drugs were categorized according to the second level of the World Health Organization's Anatomic, Therapeutic, Chemical classification. The defined daily dosage per individual during 12 months was applied as an indicator of the therapeutic intensity. Key findings  For the 2.2 million individuals with DP ≥ 5, the drug groups with the highest prevalences were antibacterials (48.2%), analgesics (40.3%), psycholeptics (35.9%), antithrombotic agents (33.4%) and beta-blocking agents (31.7%). As examples, the level of prevalence increased with age for analgesics, psycholeptics, antithrombotic agents and diuretics, and decreased with age for antibacterials, drugs for obstructive airway diseases and antihistamines for systemic use. Substantial differences in the level of prevalence between women and men were observed for several drug groups; for example, thyroid therapy (13.3 vs 3.6%), psychoanaleptics (26.3 vs 18.2%), drugs used in diabetes (9.1 vs 15.7%) and lipid-modifying agents (18.1 vs 30.7%). Generally, the therapeutic intensity increased with the increasing number of dispensed drugs. For a third of the most common drug groups, the therapeutic intensity increased with an increasing age above the 60–69-year age group. Conclusion  The number of drugs taken not only increases the potential risks associated with multiple drug use, but also increases the potential burden of an increased therapeutic intensity, especially for older people. The reported findings may enlighten physicians and healthcare stakeholders concerning the complex patterns of multiple drug use in the entire population and the associated expenses. The findings may also be used as a base for interventions aiming to bring about the most appropriate and balanced prescription of medicines to individuals with multiple diseases.

Abstract: BACKGROUND: The introduction of electronic transfer of prescriptions (ETP) or ePrescriptions in ambulatory health care has been suggested to have a positive impact on the prescribing and dispensing processes. Thereby, implying that ePrescribing can improve safety, quality, efficiency, and cost-effectiveness. In December 2007, 68% of all new prescriptions were transferred electronically in Sweden. The aim of the present study was to assess the quality of ePrescriptions by comparing the proportions of ePrescriptions and non-electronic prescriptions necessitating a clarification contact (correction, completion or change) with the prescriber at the time of dispensing. METHODS: A direct observational study was performed at three Swedish mail-order pharmacies which were known to dispense a large proportion of ePrescriptions (38-75%). Data were gathered on all ePrescriptions dispensed at these pharmacies over a three week period in February 2006. All clarification contacts with prescribers were included in the study and were classified and assessed in comparison with all drug prescriptions dispensed at the same pharmacies over the specified period. RESULTS: Of the 31225 prescriptions dispensed during the study period, clarification contacts were made for 2.0% (147/7532) of new ePrescriptions and 1.2% (79/6833) of new non-electronic prescriptions. This represented a relative risk (RR) of 1.7 (95% CI 1.3-2.2) for new ePrescriptions compared to new non-electronic prescriptions. The increased RR was mainly due to 'Dosage and directions for use', which had an RR of 7.6 (95% CI 2.8-20.4) when compared to other clarification contacts. In all, 89.5% of the suggested pharmacist interventions were accepted by the prescriber, 77.7% (192/247) as suggested and an additional 11.7% (29/247) after a modification during contact with the prescriber. CONCLUSION: The increased proportion of prescriptions necessitating a clarification contact for new ePrescriptions compared to new non-electronic prescriptions indicates the need for an increased focus on quality aspects in ePrescribing deployment. ETP technology should be developed towards a two-way communication between the prescriber and the pharmacist with automated checks of missing, inaccurate, or ambiguous information. This would enhance safety and quality for the patient and also improve efficiency and cost-effectiveness within the health care system.

Abstract: BACKGROUND: Drugs may be prescribed in combinations causing drug-drug interactions (DDI) and adverse drug reactions (ADR), resulting in hospital care. METHODS: To provide prescribers of drug therapy with a better knowledge of individuals' current drug therapy, governments have started to collect prescribing data. RESULTS: The data on individuals' dispensed drugs is available for prescribers, pharmacists, and the registered individuals in Sweden and Denmark. The information has not yet come to an extensive use in healthcare. Pilot projects have been reported positively, but accessibility has to be improved. CONCLUSIONS: To avoid DDIs, reliable information on all drugs used by each single individual needs to be available at the point of care. Knowledge databases about clinically relevant DDIs must be updated and accurate. To tailor the magic bullet for the individual, new genomic- and proteomic-based knowledge about the individual has to be considered in the future.

Abstract: BACKGROUND: The penetration rate of Electronic Health Record (EHR) systems in health care is increasing. However, many different EHR-systems are used with varying ePrescription designs and functionalities. The aim of the present study was to evaluate experienced ePrescribers' attitudes towards ePrescribing for suggesting improvements. METHODS: Physicians (n = 431) from seven out of the 21 Swedish health care regions, using one of the six most widely implemented EHR-systems with integrated electronic prescribing modules, were recruited from primary care centers and hospital clinics of internal medicine, orthopaedics and surgery. The physicians received a web survey that comprised eight questions on background data and 19 items covering attitudes towards ePrescribing. Forty-two percent (n = 199) of the physicians answered the questionnaire; 90% (n = 180) of the respondents met the inclusion criteria and were included in the final analysis. RESULTS: A majority of the respondents regarded their EHR-system easy to use in general (81%), and for the prescribing of drugs (88%). Most respondents believed they were able to provide the patients better service by ePrescribing (92%), and regarded ePrescriptions to be time saving (91%) and to be safer (83%), compared to handwritten prescriptions. Some of the most frequently reported weaknesses were: not clearly displayed price of drugs (43%), complicated drug choice (21%), and the perception that it was possible to handle more than one patient at a time when ePrescribing (13%). Moreover, 62% reported a lack of receipt from the pharmacy after successful transmission of an ePrescription. Although a majority (73%) of the physicians reported that they were always or often checking the ePrescription a last time before transmitting, 25% declared that they were seldom or never doing a last check. The respondents suggested a number of improvements, among others, to simplify the drug choice and the cancellation of ePrescriptions. CONCLUSION: The Swedish physicians in the group studied were generally satisfied with their specific EHR-system and with ePrescribing as such. However, identified weaknesses warrant improvements of the EHR-systems as well as of their implementation in the individual health care organisation.

Abstract: BACKGROUND: Multiple medications is a well-known potential risk factor in terms of patient's health. The aim of the present study was to estimate the prevalence of dispensed drugs and multiple medications in an entire national population, by using individual based data on dispensed drugs. METHODS: Analyses of all dispensed out-patient prescriptions in 2006 from the Swedish prescribed drug register. As a cut-off for multiple medications, we applied five or more different drugs dispensed (DP >or= 5) at Swedish pharmacies for a single individual during a 3-month, a 6-month, and a 12-month study period. For comparison, results were also calculated with certain drug groups excluded. RESULTS: 6.2 million individuals received at least one dispensed drug (DP >or= 1) during 12 months in 2006 corresponding to a prevalence of 67.4%; 75.6% for females and 59.3% for males. Individuals received on average 4.7 dispensed drugs per individual (median 3, Q1-Q3 2-6); females 5.0 (median 3, Q1-Q3 2-7), males 4.3 (median 3, Q1-Q3 1-6).The prevalence of multiple medications (DP >or= 5) was 24.4% for the entire population. The prevalence increased with age. For elderly 70-79, 80-89, and 90-years, the prevalence of DP >or= 5 was 62.4, 75.1, and 77.7% in the respective age groups. 82.8% of all individuals with DP >or= 1 and 64.9% of all individuals with DP >or= 5 were < 70 years. Multiple medications was more frequent for females (29.6%) than for males (19.2%). For individuals 10 to 39 years, DP >or= 5 was twice as common among females compared to males. Sex hormones and modulators of the genital system excluded, reduced the relative risk (RR) for females vs. males for DP >or= 5 from 1.5 to 1.4. The prevalence of DP >or= 1 increased from 45.1 to 56.2 and 67.4%, respectively, when the study period was 3, 6, and 12 respectively months and the corresponding prevalence of DP >or= 5 was 11.3, 17.2, and 24.4% respectively. CONCLUSION: The prevalence of dispensed drugs and multiple medications were extensive in all age groups and were higher for females than for males. Multiple medications should be regarded as a risk in terms of potential drug-drug interactions and adverse drug reactions in all age groups.

Abstract: AIMS: Previous studies have indicated the negative effects of socioeconomic deprivation on health status and morbidity. Nevertheless, the economic assignment systems for pharmaceutical benefits in Sweden do not take socioeconomic status (SES) into account. The aim of the study was, therefore, to compare reimbursement for subsidized drugs at primary healthcare centres (HCCs) with differing socioeconomic conditions in relation to real costs. The word reimbursement is used to denote economic compensation to the HCCs from the county council for drug benefit costs. METHODS: The numbers of individuals dispensed drugs, total costs and reimbursement at five HCCs with different socioeconomic conditions were compared. A socioeconomic index was calculated for each HCC on the basis of information from the municipality registries on income (with negative sign), assistance allowance, education, foreign background, and unemployment. Register data on drug benefit costs were retrieved from the National Corporation of Pharmacies (Apoteket AB) and the Swedish Prescribed Drug Register at the National Board of Health and Welfare. Data on listed and unlisted citizens at the Kalmar County Council and on public statistics from registers at the HCC municipalities where the HCCs were situated were retrieved. RESULTS: There was an almost inverse linear relationship between total cost compensation and the socioeconomic index (n = 5; r =-0.99; p = 0.001). The HCCs with the lowest SES received lower cost compensation. CONCLUSIONS: HCCs responsible for citizens with lower SES appeared to be disadvantaged by the prevalent reimbursement system in Sweden, thereby increasing differences in the state of health of the citizens. This, in turn, hampers health preventing programmes and lifestyle interventions. An HCC-specific standardized summary of socioeconomic burden is presented.

Abstract: BACKGROUND: Many patients receive health care in different settings. Thus, a limitation of clinical care may be inaccurate medication lists, since data exchange between settings is often lacking and patients do not regularly self-report on changes in their medication. Health care professionals and patients are both interested in utilizing electronic health information. However, opinion is divided as to who should take responsibility for maintaining personal health records. In Sweden, the government has passed a law to enforce and fund a national register of dispensed medications. The register comprises all individuals with dispensed medications (6.4 million individuals, September 2006) and can be accessed by the individual online via "My dispensed medications". The individual has the right to restrict the accessibility of the information in health care settings. OBJECTIVE: The aim of the present study was to evaluate the users' attitudes towards their access to "My dispensed medications" as part of a new interactive Internet service on prescribed medications. METHOD: A password-protected Web survey was conducted among a first group of users of "My dispensed medications". Data was anonymously collected and analyzed with regard to the usefulness and design of the Web site, the respondents' willingness to discuss their "My dispensed medications" with others, their reasons for access, and their source of information about the service. RESULTS: During the study period (January-March, 2007), all 7860 unique site visitors were invited to answer the survey. Invitations were accepted by 2663 individuals, and 1716 responded to the online survey yielding a view rate of 21.8% (1716/7860) and a completion rate of 64.4% (1716/2663). The completeness rate for each question was in the range of 94.9% (1629/1716) to 99.5% (1707/1716). In general, the respondents' expectations of the usefulness of "My dispensed medications" were high (total median grade 5; Inter Quartile Range [IQR] 3, on a scale 1-6). They were also positive about the design of the Web site (total median grade 5; IQR 1, on a scale 1-6). The high grades were not dependent on age or number of drugs. A majority of the respondents, 60.4% (1037/1716), had learned about "My dispensed medications" from pharmacies. 70.4% (1208/1716) of all respondents said they visited "My dispensed medications" to get control or an overview of their drugs. Getting control was a more common (P < .001) answer for the elderly (age 75 or above), whereas curiosity was more common (P < .001) for the younger age group (18-44 years). CONCLUSION: We found that users of the provider-based personal medication record "My dispensed medications" appreciated the access to their record. Since we found that the respondents liked the design of the Web site and perceived that the information was easy to understand, the study provided no reason for system changes. However, a need for more information about the register, and to extend its use, was recognized.

Abstract: To achieve a safer future prescribing, the Swedish government has introduced a mandatory registration of all drugs dispensed at pharmacies. The medication history in the register may be accessed online by registered individuals, prescribers and pharmacists. After 15 months of action, the prevalence of individuals with dispensed drugs in the Swedish population was 71.0% (6,424,487/9,047,752); women 78.8% and men 63.1%. The incidence rate for individuals with dispensed drugs was estimated as 12.4 (1,000*111,960/9,047,752) per month and 1, 000 inhabitants. The mean number of dispensed prescriptions was 12.1 (median 6, Q1-Q3 2-15) per individual. For the elderly (age group 80-89), the mean number of dispensed prescriptions was 27.8 during the study period (median 24,Q1-Q3 13-38); women 28.8 and men 26.1. When introducing a National Pharmacy Register, containing personal drug information for the majority of the population, issues on security, confidentiality and ethics have to be taken into consideration. The lack of widespread secure digital signatures in health care may delay general availability. To clinically evaluate individual medication history, the relatively high prevalence of dispensed drugs in the population, seems to justify the National Pharmacy Register.

Abstract: OBJECTIVES: The increased risk of adverse events in patients receiving potentially interacting drugs has long been recognized. The purpose of the present study was to evaluate the change in the risk of receiving potentially interacting drugs during a period covering three decades and to examine the relative risk of actual drug combinations. METHODS: The prescriptions from all individuals (about 8,000) with two or more prescriptions during three periods of 15 months, October to December 1983-1984, 1993-1994 and 2003-2004, were collected from an ongoing cohort study in the county of Jämtland, Sweden. The potential interactions were detected by a computerized system. RESULTS: The relative risk (RR) of receiving potentially interacting drugs increased for type C interactions [RR: 1.177, 95% confidence interval (CI): 1.104-1.256] and decreased for type D interactions (RR: 0.714, 95% CI: 0.587-0.868) from the period 1983-1984 to 2003-2004. Polypharmacy for the participants increased by 61%, from 9.05 filled prescriptions per subject in 1983-1984 to 10.6 in 1993-1994 and 14.6 in 2003-2004. The RR was positively correlated to the pronounced increase in polypharmacy; in addition, an exponential relationship was found for the more severe type D interactions. Few interacting drug combinations were responsible for a large proportion of the risk. CONCLUSION: We conclude that the risk of receiving potentially interacting drugs was strongly correlated to the concomitant use of multiple drugs. The pronounced increase in polypharmacy over time implies a growing reason for prescribers and pharmacists to be aware of drug interactions. Recently established national prescription registers should be evaluated for drug interaction vigilance, both clinically and epidemiologically.

Abstract: OBJECTIVE: The widespread use of pharmaceuticals prescribed by different physicians has caused the Swedish government to propose a new legislation with registration of all prescriptions dispensed at the Swedish pharmacies. In the present study, we wanted to examine the frequency, distribution and determinants of potential drug interactions. METHODS: The prescriptions from all individuals (n=8,214) with two or more prescriptions during October 2003 to December 2004 were collected from the ongoing Jämtland cohort study of a total of about 11,000 individuals. Potential drug-drug interactions were detected with a computerized interaction detection system and classified according to clinical relevance (types A-D). RESULTS: On average each individual filled 14.6 (men 14.3, women 14.8) prescriptions during the study period. 3.6% of the individuals used more than 15 different drugs. The number of detected potential drug interactions type A-D was 4,941 (men 1,949, women 2,992). The risk of receiving a potential interaction type A-D was estimated as the cumulative incidence 0.26 (2,116/8,214) overall, 0.22 (748/3,467) for men and 0.29 (1,368/4,747) for women during the 15-month study period. The age adjusted risk, RR(adj), for women was estimated as 1.30. Excluding sex hormones and modulators of the genital system, the RR(adj) was 0.96, with no elevated risk for women. For potential interactions type D, that might have serious clinical consequences, 167 (cumulative incidence 0.0203) individuals (72 men, cumulative incidence 0.0208, 95 women cumulative incidence 0.0200) were detected. The risk of receiving a combination of potentially interacting drugs was positively correlated to age and polypharmacy. The cumulative incidence for elderly was estimated as 0.36 (65-84 years) and 0.39 (85 years and above). The relative risk for individuals with 15 drugs or more was estimated as 3.67 (95% CI 3.46-3.90). CONCLUSION: In a general population there were relatively few severe potential drug interactions. The new Swedish national pharmacy register will provide health care professionals with a powerful tool to systematically review all prescriptions. An alert system should focus on the more potential drug interactions, type C-D, with close monitoring of elderly and patients with polypharmacy.

Abstract: En stark hemsjukvårdsutveckling har svept över USA. Det som nu kan iakttas är en mer mogen marknad som på olika sätt är under sanering. Vinstnivåerna är lägre och konkurrensen hårdare. Krav ställs nu på redovisning av nyttan för patienterna både kliniskt och humanistiskt och mätning av "kundtillfredsställelsen" är en allt viktigare del.

Abstract: The move away from hospital-based healthcare towards community-based services, led by the USA, makes it important for European countries to examine the implications of such a change before it becomes too extensive. There are already numerous examples of home care services which, either potentially or actually, involve hospital pharmacists. In the UK, for instance, about 180 patients receiving total parenteral nutrition remain in the community; continuous low-dose chemotherapy infusion frequently takes place at home, and self-pumping devices are issued to patients. In Sweden, other services are evolving too, like distribution of continuous peritoneal dialysis and dispensing of solid dose medicines for the elderly. However, some hospital pharmacists must change their attitudes, training needs to encompass the special requirements of these developments, special legislation may need to be enacted and further research must be undertaken before home care becomes a widespread part of European healthcare systems.

Abstract: 1986 gjorde förf. en resa till USA för att studera avancerad hemsjukvård. Under resan besöktes 3 sjukhusapotek som är aktiva inom hemsjukvården samt ett hemsjukvårdsföretag. Avsikten med denna reserapport är att beskriva likheter och skillnader i uppbyggnaden av olika system för en fungerande avancerad hemsjukvård.

Abstract: Diskussion kring utnyttjandet av ADB-teknik i samarbete mellan apotek och primärvård inom Lerums kommun började under tidigt 80-tal. Augusti 1984 resulterade detta i en överenskommelse mellan Älvsborgs läns landsting och Apoteksbolaget rörande försök med datorstödd läkemedelsinformation för receptförskrivning vid Gråbo vårdcentral. Erfarenheterna redovisas.

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Abstract: Background: It may be favorable to use a combination of drugs, if the combination is well documented, to enhance the effect or to reduce adverse effects. However, in the case of patients visiting several different physicians, who are prescribing less appropriate combination of drugs due to being unaware of each other, the outcome may be negatively influenced. The polypharmacy may even result in serious adverse drug events. Methods: In Sweden, the government has legislated and funded a nationwide mandatory database for all dispensed prescriptions. The information content is available during 15 months for prescribers and dispensing pharmacists, as well as for the registered individual. Prior to the launch of the nationwide database in Sweden, studies were performed to estimate the prevalence of potential drug—drug interactions (DDI) in a general population and to evaluate the historical change in risk over three decades. Results: On average each individual filled 14.6 prescriptions during a 15 month study period (2003-2004). The risk of receiving a potential DDI was estimated as the cumulative incidence 0.26 overall. The relative risk for women was estimated as 1.3. For more severe potential DDIs the cumulative incidence was estimated as 0.02. The risk of receiving a potential DDI was positively correlated to age and polypharmacy. The change in risk over three decades increased for type C (relative risk RR 1.18), but decreased (RR 0.71) for the more severe type D interactions. Polypharmacy increased with more than 60% during the three decade study period. Fifteen months after launch of the new National Pharmacy Register in Sweden, the prevalence of individuals with dispensed drugs was 71% (6,424,487/9,047,752). For elderly (80-89 years) the mean number of dispensed prescriptions was 27.8 during the first 15 months. Conclusions: The new National Pharmacy Register will provide health care professionals with a powerful tool to systematically review all prescriptions. Alert systems integrated in electronic healthcare records may be used to detect potential DDIs. To gain approval among physicians, the alerting should focus on the more severe and clinically relevant DDIs. More individual-oriented information (laboratory, genetic, allergies) may in the future be processed before prescribing of drugs, to better customize the therapy for the single individual.

Abstract: Introduction On a national level the great majority of all medications are dispensed drugs. The drug use and multiple medications have increased successively during the last decades. Multiple medications are commonly associated with irrational excessive use of drugs, and are a well-known risk factor in terms of adverse drug reactions and drug-drug interactions. Multiple medications may also result in unnecessary health expenditure, directly due to redundant drug sales and indirectly due to the increased hospitalization caused by drug-related problems. The aim of the study was to estimate the prevalence of dispensed drugs and multiple medications in an entire national population, by using individual based data on dispensed drugs. Materials and Methods Analysis of dispensed drugs in the entire Swedish population 2006. As a cut-off, we applied five or more different drugs dispensed (DP≥5) for a single individual during a 12-month study period. Results 6.2 million individuals, 67.5% of the entire population, received at least one dispensed drug – 75.6% of all women and 59.3 of all men. The prevalence of DP≥5 was 24.4% for the entire population – 29.6% for women and 19.2% for men. The prevalence increased with age. For elderly 70-79, 80- 89 and 90- years, the prevalence of DP≥5 was 62.4%, 75.2% and 77.8% in the respective age groups. DP≥5 was more common for women than for men, with a RR of 1.5. For individuals between 10 and 39 years, DP≥5 was twice as common among women compared to men. 82.8% of all individuals with DP≥1 and 64.9% of all individuals with DP≥5, were <70 years. Individuals with dispensed drugs received in mean 4.7 drugs per individual (median 3, Q1-Q3 2-6); women 5.0 (median 3, Q1-Q3 2-7), men 4.3 (median 3, Q1-Q3 1-6). Discussion Our study, based on individual data from the Swedish prescribed drug register, demonstrated that the prevalence of dispensed drugs and multiple medications in a national perspective are relevant in all age groups and have a clear gender characteristic. Consequently, rational as well as irrational multiple medications should be regarded as a risk factor in terms of possible adverse drug reactions and drugdrug interactions in all age groups. If all sources of medications are taken into account, the prevalence of multiple medications would probably be even greater. Acknowledgments We wish to thank Andrejs Leimanis, Centre for Epidemiology at The Swedish National Board for Health and Welfare, for assistance with data materials and statistical procedures from the Swedish prescribed drug register. Address for correspondence Bo Hovstadius School of Pure and Applied Natural Sciences, University of Kalmar, 391 82 Kalmar, Sweden e-mail: bo.hovstadius@hik.se

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Abstract: Physicians may inadvertently prescribe improper combinations of drugs. Changes in the epidemiological panorama of potential drug interactions were studied during three decades, from 1983 to 2003. During the study period polypharmacy increased with 61%. Overall, potential drug interactions increased (relative risk 1.177 95% confidence interval 1.104-1.256), although the more severe interactions decreased (relative risk 0.714 95% confidence interval 0.587-0.868). Potential drug interactions and polypharmacy among the elderly should be closely monitored.

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Abstract: The application of multiple medications has successively increased during a number of years and has thereby increased the potential risks of adverse drug reactions, interactions and non-adherence to drug therapy. This may result in unnecessary health expenditure, directly due to redundant drug sales, and indirectly due to the increased hospitalization caused by drug-related problems. The overall aim of this thesis was to investigate the occurrence and development of drug use, multiple medication, and polypharmacy in an entire national population by using individual-based data on dispensed drugs. The studies (I-V) in the thesis are based on data of dispensed prescription drugs for up to 6.2 million individuals obtained from the Swedish Prescribed Drug Register. The data in the studies cover different periods of time between July 2005-Sept 2008, and the data have been analyzed on the basis of epidemiological measures and statistical methods. The major conclusions of the studies are: the prevalence of dispensed drugs and multiple medications was extensive in all age groups and was higher for females than for males. Multiple medications should be regarded as a risk in terms of potential drug-drug interactions and adverse drug reactions in all age groups (I). Regional differences in the prevalence of polypharmacy were observed and partly explained by the regional age distribution in Sweden. The use of a novel weighted polypharmacy index indicated regional differences in drug therapy for individuals with polypharmacy (II). The number of drugs used by an individual not only increased the potential risks associated with multiple drug use, but also the potential burden of an increased therapeutic intensity, especially for elderly (III). Individuals with ten or more drugs accounted for almost fifty percent of the total acquisition costs of dispensed drugs. Therefore, interventions with a focus on the reduction of the number of prescription drugs for the small group of patients with a large number of different drugs may also result in a substantial reduction in the total drug costs (IV). In spite of national and regional efforts to reduce polypharmacy, the prevalence of polypharmacy and excessive polypharmacy and the mean number of drugs per individual continued to increase in Sweden 2005-2008 (V). The observed year-by-year increase in polypharmacy underlines the importance of monitoring the development of drug use in all ages. Individual-based registers studies of dispensed drugs provide high quality data and could serve as the basis for further research and also in terms of training health care personnel. It can also be used as a base for interventions and the evaluation of drug use. To enable better comparisons on drug use and its consequences, there is a need for standards concerning measurements, classification and criteria which encompass all types of medications. For clinicians, there is a need for information concerning the patient’s actual use of all different types of medications.

Abstract: The thesis aimed to study the developments, in the area of pharmacoinformatics, of the electronic prescribing and dispensing processes of drugs - in medical praxis, follow-up, and research. For hundreds of years, the written prescription has been the method of choice for physicians to communicate decisions on drug therapy and for pharmacists to dispense medication. Successively the prescription has also become a source of information for the patient about how to use the medication to maximize its benefit. Currently, the medical prescription is at a transitional stage between paper and web, and to adapt a traditional process to the new electronic era offers both opportunities and challenges The studies in the thesis have shown that the exposure of prescribed drugs in the general population has increased considerably over three decades. The risk of receiving potentially interacting drugs was also strongly correlated to the concomitant use of multiple drugs, polypharmacy. The pronounced increase in polypharmacy over time constitutes a growing reason for prescribers and pharmacists to be aware of drug interactions. Still, there were relatively few severe potential drug interactions. Recently established national prescription registers should be evaluated for drug interaction vigilance, both clinically and epidemiologically. The Swedish National Pharmacy Register provides prescription dispensing information for the majority of the population. The medication history in the register may be accessed online to improve drug utilization, by registered individuals, prescribers, and pharmacists in a safe and secure way. Lack of widespread secure digital signatures in healthcare may delay general availability. With a relatively high prevalence of dispensed drugs in the population, the National Pharmacy Register seems justified in evaluating individual medication history. With a majority of prescriptions transferred as ePrescriptions, the detected increased risk for prescription errors warrants quality improvement, if the full potential of ePrescriptions is to be fulfilled. The main conclusion of the studies was that ePrescribing with communication of prescribed drug information, storing and retrieving dispensed drug information, offers new opportunities for clinical and scientific

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Abstract: For hundreds of years, the written prescription has been the method of choice for physicians to communicate decisions on drug therapy and for pharmacists to dispense medication, while at the same time being a source of information for the patient about how to use the medication in order to maximise its benefit. Currently, the medical prescription is at the transitional stage between paper and web, and to adapt a traditional process to the new electronic era offers unique challenges.

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