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STATIN ADHERENCE, UTILISATION, and PRESCRIBING PATTERNS Improving Effectiveness of Treatment

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STATIN ADHERENCE, UTILISATION, and PRESCRIBING PATTERNS Improving Effectiveness of Treatment STATIN ADHERENCE, UTILISATION, AND PRESCRIBING PATTERNS Improving effectiveness of treatment Heli Halava TURUN YLIOPISTON JULKAISUJA – ANNALES UNIVERSITATIS TURKUENSIS Sarja - ser. D osa - tom. 1231 | Medica - Odontologica | Turku 2016 University of Turku Faculty of Medicine Department of Public Health and Department of Pharmacology, Drug Development and Therapeutics Doctoral Programme of Clinical Investigation, Turku, Finland Supervised by Professor Risto Huupponen, MD, PhD Professor Jussi Vahtera, MD, PhD Department of Pharmacology, Department of Public Health, Drug Development and Therapeutics, University of Turku and University of Turku and Finnish Institute of Occupational Health, and Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland Turku University Hospital, Turku, Finland Reviewed by Professor Reijo Laaksonen, MD, PhD Professor Morten Andersen, MD, PhD School of Medicine, University of Tampere, Centre for Pharmacoepidemiology, Tampere, Karolinska Institutet Finland Karolinska University Hospital, Stockholm, Sweden Opponent Docent, Professor h.c. Mikko Syvänne, MD, PhD, FESC Finnish Heart Association, Helsinki Finland Cover photo: Vili Halava The originality of this thesis has been checked in accordance with the University of Turku quality assurance system using the Turnitin OriginalityCheck service. ISBN 978-951-29-6500-7 (PRINT) ISBN 978-951-29-6501-4 (PDF) ISSN 0355-9483 (Print) ISSN 2343-3213 (Online) Painosalama Oy - Turku, Finland 2016 To my loved ones: Vesa, Vili, Minka, Vilma and Pihla There are things known and things unknown, in between are the doors of perception. Aldous Huxley ABSTRACT Heli Halava Statin adherence, utilisation, and prescribing patterns. Improving effectiveness of treatment. University of Turku, Faculty of Medicine Department of Public Health and Department of Pharmacology, Drug Development and Therapeutics University of Turku Doctoral Programme of Clinical Investigation Annales Universitatis Turkuensis, Medica-Odontologica, Turku, Finland, 2016 Statins are one of the most widely studied and evidence-based medications. Randomised controlled trials have provided convincing evidence on the benefits of statin therapy in preventing cardiovascular events. Despite proven benefits, low costs, and few adverse effects, everyday effectiveness of statins is limited, since adherence to statin therapy is poor. This thesis was conducted as four pharmacoepidemiological studies using register data on statin users in real clinical care. The main purpose of the study was to evaluate prescribing patterns and to discover the lifestyle factors predicting statin nonadherence and discontinuation. This knowledge is essential in order to help physicians to motivate the adherence of their patients to treatment. In Finland, from 1998 to 2004, the number of statin initiators nearly doubled. The discovered channelling of atorvastatin and simvastatin may have affected the treatment outcomes at the public health level. It is possible that money spent on statins in Finland in 1998‒2004 could have been used in a more cost-effective way. In 2015, the percentage of patients receiving reimbursement for statins was 12% of the total population. Thus, it is a major public health and economic challenge to improve statin effectiveness and allocate therapy correctly. Among the participants with cardiovascular comorbidities, risky alcohol use or clustering of lifestyle risks were predictors of nonadherence. In addition, the prevalence of nonadherence to statins increased after retirement among both men and women. This increase in post-retirement nonadherence was highest among those receiving statins for secondary prevention. Discontinuation of statin therapy was predicted by high patient co-payment, and in women, by risky alcohol use. Recognising the predictors of nonadherence to statins is important because nonadherence is associated with an increased risk of adverse cardiovascular outcomes and higher healthcare costs. In conclusion, optimal outcomes in medical therapy require both efficacious medications and adherence to those treatments. When prescribing statins to eligible patients, the physician’s clinical expertise in recognising patients at risk of statin discontinuation and nonadherence, as well as their ability to increase adherence, may have a great effect on public health. Keywords: statins, adherence, nonadherence, discontinuation, prescribing, lifestyle, retirement TIIVISTELMÄ Heli Halava Statiinihoitoon sitoutuminen, lääkekäyttö ja -määräykset. Hoidon vaikuttavuutta parantamassa. Turun yliopisto, lääketieteellinen tiedekunta Kansanterveystieteen oppiaine ja Farmakologian, lääkekehityksen ja lääkehoidon oppiaine Turun yliopiston kliininen tohtoriohjelma Annales Universitatis Turkuensis, Medica-Odontologica, Turku, Finland, 2016 Kattavasti tutkittu ja näyttöön perustuva statiinilääkitys on oleellinen osa sydän- ja verisuonitautien ehkäisyä ja hoitoa. Satunnaistetuissa, kontrolloiduissa hoitotutkimuksissa osoitetusta tehosta, matalasta kustannuksesta ja vähäisistä haittavaikutuksista huolimatta statiinien vaikuttavuus arkielämässä jää odotettua heikommaksi, mikäli hoitoon sitoudutaan huonosti. Tämä väitöskirja koostuu neljästä lääke-epidemiologisesta tutkimuksesta, joissa arkielämän statiinikäyttöä tutkittiin rekisteritiedon avulla. Tutkimuksen tavoitteena oli sekä selvittää statiinien käyttöä ja lääkemääräyskäytäntöjä että tunnistaa hoitoon sitoutumiseen vaikuttavia tekijöitä, jotta käytännön lääkärit voisivat lääkehoidon toteutumisen seurannassa paremmin ylläpitää potilaan hoitomotivaatiota. Statiinilääkityksen aloittajien määrä lähes kaksinkertaistui Suomessa vuodesta 1998 vuoteen 2004. Tässä tutkimuksessa havaittu atorva- ja simvastatiinin kanavoituminen viittaa siihen, että statiineihin sijoitettu raha olisi mahdollisesti voitu Suomessa vuosina 1998–2004 käyttää kustannustehokkaammin. Vuonna 2015 statiineista sai sairausvakuutuskorvausta lähes joka kahdeksas suomalainen, minkä vuoksi statiinihoidon oikea kohdentaminen ja vaikuttavuuden parantaminen ovat merkittäviä sekä kansanterveyden että -talouden kannalta. Tämä tutkimus osoittaa, että haitallinen alkoholin käyttö ja elämäntapariskien kasautuminen ennustivat huonoa statiinihoitoon sitoutumista niillä tutkittavilla, joilla oli aiemmin diagnosoitu sydän- ja verisuonitauti tai diabetes. Myös eläköityminen lisäsi huonosti statiinihoitoon sitoutuneiden osuutta sekä miesten että naisten joukossa. Vaikutus tuli selvimmin esiin sekundaaripreventiopotilailla. Statiinihoidon aloittaneista 12 % lopetti lääkityksen ensimmäisen vuoden aikana. Hoidon ennenaikaista lopettamista ennusti korkeampi potilaan maksama osuus lääkekustannuksesta, naisilla myös haitallinen alkoholin käyttö. Edellä mainittujen tekijöiden tunnistaminen on tärkeää, sillä huonon hoitoon sitoutumisen tai hoidon ennenaikaisen lopettamisen tiedetään lisäävän haitallisia valtimosairaustapahtumia ja terveydenhuollon kokonaiskustannuksia. Järkevän ja ihanteellisesti vaikuttavan lääkehoidon edellytyksenä on sopivan käyttöaiheen ja sopivan lääkkeen valinnan lisäksi se, että potilas ymmärtää lääkityksensä merkityksen ja sitoutuu hoitoon. Lääkehoidon lopettamiseen tai hoitoon sitoutumattomuuteen liittyvien riskien tunnistaminen voi merkittävästi edistää kansanterveyttä. Avainsanat: statiinit, hoitoon sitoutuminen ja sitoutumattomuus, lääkehoidon lopettaminen, lääkemääräykset, elämäntapa, eläköityminen Table of contents 7 TABLE OF CONTENTS ABSTRACT ................................................................................................................................ 4 TIIVISTELMÄ ........................................................................................................................... 5 TABLE OF CONTENTS ........................................................................................................... 7 ABBREVIATIONS ..................................................................................................................... 9 LIST OF ORIGINAL PUBLICATIONS ................................................................................ 10 1 INTRODUCTION ................................................................................................................. 11 2 REVIEW OF THE LITERATURE ..................................................................................... 12 2.1 Adherence to medications ............................................................................................... 12 2.1.1 Definition .......................................................................................................... 12 2.1.2 Implementations of adherence .......................................................................... 12 2.1.3 Dimensions affecting adherence ....................................................................... 13 2.1.4 Importance of adherence ................................................................................... 16 2.1.5 Measuring of adherence .................................................................................... 16 2.2 Public health perspective on adherence to cardiovascular medications .......................... 20 2.2.1 Prevention ......................................................................................................... 21 2.2.2 Medical treatment ............................................................................................. 22 2.3 Health behaviour and retirement ..................................................................................... 23
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