Medical treatments with statins are prescribed to patients with increased risk of cardiovascular events. The benefits from statin treatment are well documented in clinical trials, but long-term adherence in patients is low, indicating that patients have an uncertainty about the necessity and benefits of treatment. The aims of this thesis were to investigate how patients and doctors view different aspects of statin treatment. Further aims were to investigate if the cardiovascular risk level in patients affects their views about different aspects of statin treatment. Yet further aims were to compare health behaviours and views about risk factors in patients using statins to a non-treated population. Data was obtained from patients (n = 829), doctors (n = 330) and a population sample (n = 720) using postal questionnaires. Views about the effect of statin treatment were assessed in different ways for patients and doctors. Patients based their assessments on their own situation, and doctors’ treatment decisions and assessments of anticipated effect of treatment were based on two hypothetical patient cases. The results indicate that patients greatly overestimate the general effect of statins, compared to efficacy results reported from clinical trials. Patients’ previous coronary heart disease or high overall risk were factors not associated with their views and expectations of treatment effect. Statin users with an internally perceived health control and patients satisfied with their doctor’s treatment explanation reported higher beliefs in treatment necessity and benefits. Statin users reported having better health behaviours and generally rated risk factors as more important than the non-treated population. Doctors had suboptimal understanding of the number of patients expected to benefit following five years of statin treatment and had a varying understanding of statins’ ability to prolong life. Overall the results illustrate that patients and doctors have different perspectives and views of the benefits from statin treatment which puts emphasis on how statin treatment is discussed in the clinical setting.

Abstract [en] Title: Discrepancies in medication lists at hospital wards identified by medication reconciliation Authors: Anderberg M. Institute: Uppsala University, Uppsala, Sweden Background and objective: An accurate medication list is essential for a correct assessment of a patient´s condition at hospitals. Previous studies have shown that patients in emergency departments often are affected by discrepancies in medication lists at hospital admission. Less research has been done regarding discrepancies after transferring patients to medical wards. The aim of this study was to identify discrepancies in the electronic medical record in hospital wards for patients admitted via the emergency department. Design: Observational study. Medication reconciliation was performed by a pharmacist shortly after the arrival of patients from the emergency department. This included a patient interview and the investigation of the patient’s medical record. The discrepancies identified at the wards were classified as either omitted drug, wrong dose, additional drug, incorrect frequency or duplicate therapy. Descriptive statistics were used and the proportion of medication lists with at least one discrepancy was presented with 95 % confidence interval. Setting: Three medical wards at Capio S:t Görans Hospital in Stockholm.  Main outcome measures: The proportion of medication lists with at least one discrepancy. The mean value of discrepancies among all patients. Classification and categorization of discrepancies regarding type and ATC index.  Results: In total, 63 patients were included with a mean age of 63 years. At least one discrepancy was identified in 43 % (95 % CI 31-55) of the medication lists. 52 discrepancies were found in total generating a mean value of 0,83 ± 1,17 discrepancies per medication list. The two most common categories were Omitted drug(33%) and Wrong dose(33%). The most frequent drug class associated with medication discrepancies was Drugs for obstructive airway diseases.  Conclusion: 43 % of the patients had at least one discrepancy in the medication list. This indicates the importance of medication reconciliations at medical wards even though the medication list has been updated at the emergency department.

Background: Medications are used to treat, cure, or relieve symptoms of diseases, but there is a risk with the use of medications. Drug-related-problems are known to increase morbidity and mortality. Incorrect medical list and discrepancies in these lists can lead to drug-related problems as side effects, hospitalization, non-compliance, drug interactions and overtreated or undertreated patients. Discrepancies can be for example: more prescriptions than necessary, outdated prescriptions, i.e., medicines that will not be used, prescriptions with incorrect dosing and missing prescriptions i.e., medicines used by patients that cannot be seen in the medication list. Purpose:  The aim of this study was to investigate discrepancies in the Swedish prescription list "My saved prescriptions at the pharmacy". The secondary aim was to investigate how common it is to use this prescription list or the dosage label on the medicine packaging to know which medicines to use and which dosage. Methods: The data collection was performed by four pharmacy students at seven pharmacies in Sweden over a period of three weeks during Jan-Feb. 2021 where the prescription list was investigated together with patients to identify any discrepancies. The study included patients who was over 18 years old, spoke Swedish, had three or more prescribed drugs, and agreed to participate.  Results A total of 215 patients were interviewed, where 61% had one or more discrepancies in their medication list. A total of 1717 prescriptions were analyzed, of which 10% were double prescriptions (n = 167), 8% outdated prescriptions (n = 141) and 3% prescriptions with the wrong dosage (n = 42). When analyzing the primary sources of information used by patients to know which medicine to use, the printout of the list "my saved prescriptions at the pharmacy” dominated (n = 72).  Most used information source to know drug dosage was the dosage label on the medicine packaging (n = 112). Conclusions: It is important to have an updated and correct information in the medication list, to prevent drug-related-problems caused by discrepancies. It becomes even more important when we see that the medication list "My saved prescriptions at the pharmacy" and dosage label (containing the same information in the medication list), are the most used primary sources by patients to know which drug to use and in what dosage. Finally, results show a relationship between the number of prescribed drugs and the number of discrepancies that occur, and therefore we see more discrepancies in elderly patients who are usually ill and are being treated for several diseases.  There are opportunities for further research to study e.g., which drug-related-problems are caused by discrepancies in the medication list as well as the degree of danger in these problems. / Användning av läkemedel som avses behandla, lindra eller bota sjukdomar kan i vissa fall utgöra en risk för patientens hälsa. Läkemedelsrelaterade problem p.g.a. felmedicinering står för en stor andel av morbiditeten och mortaliteten bland patienter. En bidragande orsak är ofullständig information i patientens läkemedelslista.   Syftet med studien var att undersöka antalet avvikelser som förekommer i receptlistan ”Mina sparade recept på apoteket”. Studiens sekundära syfte var att undersöka vilka informationskällor som användes av patienter för att veta vilka läkemedel som ska adminstreras och i vilken dos dosering.  Studiens metod var att intervjua patienter som kom till apoteket för att hämta ut läkemedel till sig själva och uppfyllde inklusionskriterierna för att delta i studien. Studien utfördes av fyra farmaceutstudenter på sju olika apotek i fyra olika städer i Sverige som tillsammans med patienter gick igenom receptlistan för att identifiera avvikelser.  Resultatet blev totalt 1717 recept som studerades varav 21% hade avvikelser. Av recepten var 10% dubbla recept (n = 167), 8% inaktuella recept (n = 141) och 3% recept med fel dosering (n = 42). Vid analys av primära informationskällor som används dominerade utskrift av listan ”Mina sparade recept på apoteket” (n = 72) resp. doseringsetiketten på läkemedelsförpackningen (n = 112).  Resultaten visade även ett samband mellan ökade antal läkemedel och antalet avvikelser.  Avvikelser i läkemedelslistan Mina sparade recept är vanligt förekommande därmed är listan inte alltid aktuell. Det är vanligt att denna lista och doseringsetikett på läkemedels-förpackningar används som primära källor av patienter under deras behandlingstid vilket kan innebära en risk för läkemedelsrelaterade problem. En gemensam nationell läkemedelslista är en möjlig lösning till att förebygga läkemedelsrelaterade problem orskade av infromationsbrist i läkemedelslistor. Det är dock nödvändigt med läkemedelsgenomgångar för att bibehålla uppdateringen av listan.

Background: Type II diabetes is a common disease worldwide and several drug treatments are available. Some of the more recently approved drugs are DPP4-inhibitors, GLP analogues and SGLT2-inhibitors. Most of the Type II diabetes drugs (T2DMD) are prescribed by primary care physicians. To ensure rational drug use it is important to follow up prescribing patterns to design strategies and interventions that can improve drug treatment, since consequences of inappropriate drug use might be poor health outcomes and increased health costs. Aim: To study differences in the prescribing pattern of T2DMD among primary healthcare centres (PHC) at a macro level in Region Uppsala. Method: A cross-sectional study based on data collected from Region Uppsala’s data register. Data consisted of individuals over 25 years of age with at least one prescription of a diabetes drug from the Anatomic Therapeutic Chemical (ATC) group A10 prescribed within the period of January 2018 to June 2020. Results: There is a moderate difference in the prescribing patterns of T2DMD among different PHCs in Region Uppsala. Overall, a larger proportion of oral antidiabetic drugs (OAD) were prescribed compared to Insulins. Most PHC prescribed a larger proportion of long acting insulins than other Insulins. Among OAD, a larger proportion of Biguanide derivative where prescribed. DPP-4 inhibitors, Sulphonylureas and SGLT2-inhibitors were prescribed to almost the same extent. Conclusion: Overall, there is a minor difference in the prescribing patterns of T2DMD among different PHCs in Region Uppsala during the study period. Lately, prescribing of DPP4-inhibitors, SGLT2-inhibitors and long acting insulins have increased. / I detta fördjupningsprojekt studerades förskrivningsmönstren av typ II diabetesläkemedel i Region Uppsala. Studieresultaten vissa skillnader i hur olika vårdcentraler i Region Uppsala förskriver typ II diabetesläkemedel. Från början var hypotesen att icke-insuliner förskrivs i större utsträckning än insuliner. Vilket visade sig stämma överens med resultaten. I studien jämförs också skillnaden mellan förskrivning av icke-insuliner som funnits längre på marknaden och de nyligen godkända (DPP4-hämmare och SGLT2-inhibitorer). Resultaten visar en tydlig ökning i förskrivning av de nya läkemedlen under studieperioden. En anledning till detta kan vara läkemedels positiva farmakologiska effekter. I studien jämförs också skillnaden i förskrivningen av de olika insuliner i Region Uppsala. Resultaten visar att långverkande insuliner förskrivs i större utsträckning i jämförelse med andra insuliner, vilket är inte enligt rekommendationslistan för förskrivning av typ II diabetesläkemedel Studieresultaten kan användas för att fortsätta följa upp och förbättra kvalitén på diabetesvården i Region Uppsala. Ytterligare studier skulle till exempel kunna utgå ifrån hela populationen med en typ 2 diabetesdiagnos för att studera utfall även för andra interventioner än läkemedel. Dessutom behövs fortfarande kunskap om det är kostnadseffektiv att fler nya typ 2 diabetesläkemedel används. Studien ger kunskap om förskrivningen av typ II diabetesläkemedel i Region Uppsala. Studien kan användas som grund för dialog om förskrivningen av typ II diabetesläkemedel i regionen, så att denna optimeras och fler individer får adekvat behandling. Detta arbete är viktigt eftersom typ II diabetes är en mycket vanlig sjukdom där prevalensen ökar.  Denna studie är en tvärsnittsstudie baserat på sekundärdata från Region Uppsalas elektroniska medicinalt register och primärdata från två enkäter skickade till sjuksköterskor och läkare som jobbar på vårdcentraler med patienter med diabetes. Studien inkluderar data från de 26 offentliga vårdcentraler som hör till förvaltningen Nära, Vård och Hälsa i region Uppsala. Förskrivningsdata baseras på recept för ett diabetesläkemedel från Anatomic Therapeutic Chemical (ATC) gruppen A10, förskrivet mellan januari 2018-juni 2020.

Mål: Syftet med studien är att beskriva patienternas inställningar till användningen av en QPL, huruvida det är ett möjligt redskap att använda under farmaceutmötet på svenska öppenvårdsapotek. Dessutom att undersöka den rapporterade skillnaden i kunskapsnivå efter användningen av QPL mellan patienterna som valde att använda QPL:en under farmaceutmötet och patienterna som valde att inte göra det. Samt att undersöka om olika bakgrundsfaktorer påverkar användningen av QPL.      Metod: En kvantitativ analys av redan besvarade enkäter genomfördes för att besvara syftet och frågeställningen. Enkäterna analyserades deskriptivt med hjälp av beskrivande mått och genom inferentiell statistik i Microsoft Excel. Delstudien bestod av 179 enkäter.    Resultat: Totalt kodades 179 enkäter utifrån inklusionskriterierna. Patienterna rapporterade att QPL introducerades i 96% (n=172) och användes i 46% (n=83) av farmaceutmöten. Majoriteten av patienterna (n=101) upplevde att QPL inte tog mycket tid att läsa och (n=121) tyckte att frågorna var enkla att förstå. Å andra sidan rapporterade patienterna som hämtade minst ett nytt läkemedel och patienterna som hade svenska som modersmål att de använde QPL mer än andra. Samtidigt upplevde patienterna som använde QPL:en under farmaceutmötet en ökad kunskapsnivå om läkemedel jämfört med patienterna som inte använde QPL:en under mötet.   Slutsats: Patienterna upplevde att QPL:en var ett funktionellt verktyg som fick de att ställa fler frågor och förstå sitt sjukdomstillstånd bättre. QPL:en kan effektiviseras ytterligare genom att förkortas ned och finnas i fler språk. Samtidigt bör farmaceut-patientkommunikation på öppenvårdsapotek effektiviseras ytterligare.

Background: Breast cancer in Sweden is the most common cancer among women affecting over 8000 women each year. Throughout the Covid-19 pandemic multiple studies were conducted about the incidence of Covid-19 in breast cancer patients. However, there were no studies showing the incidence of Covid-19 within pre- and postmenopausal breast cancer patients. Aim: To study the incidence of Covid-19 in different socio-demographic groups of pre- and postmenopausal breast cancer patients as well as the frequency of medications and comorbidities in those patients in Sweden. Methods: A register-based cross-sectional study using SCIFI-PEARL database, which includes multiple connected registers to capture all Covid-19 patients. Using the connected registers to attach socio-demographic characteristics, medication lists, and hospital stays as well as specialist clinic visits from 2015 until 2019 to the patients and calculating the incidence of Covid-19 as well as the frequency of medication use and comorbidities. Results: Covid-19-incidence was 53,4% and 24,3% in pre- and postmenopausal breast cancer patients respectively. Covid-19-incidence was the highest with 35,9% among patients with higher than high school education, 44,2% among working patients, 35,2% among married patients, and 56,7% among patients younger than 30. Paracetamol use was the highest among all breast cancer patients. Osteoarthritis was the most common comorbidity among breast cancer patients with Covid-19.  Conclusion: Breast cancer patients with higher sociodemographic characteristics have higher incidence of Covid-19 in Sweden.

Background and Objective: Comorbidity and especially cardiovascular diseases are common among patients with chronic obstructive pulmonary disease (COPD). The primary purpose of this study was to identify drugs for the treatment of cardiovascular diseases in COPD patients. The secondary purpose was to analyze whether the use of cardiovascular drugs differs between patients with mild and severe COPD symptoms.     Method: The study was a retrospective cross-sectional study of 421 COPD patients whose drug lists were analyzed and cardiovascular drugs were identified. These drugs were then divided into eight drug groups, based on the drug's ATC (Anatomic Therapeutic Chemical classification system) codes. Only patients with reported cardiovascular diseases were included in the analysis. Patients with mild and severe COPD symptoms were identified. Thereafter, the patients were divided into two groups based on the COPD symptoms. Chi-squared test was performed to see if the use of cardiovascular drugs differs between patients with mild and severe COPD symptoms.  Setting: Primary and secondary care patients with COPD in Gävle and Dalarna.  Main outcome measures: Identify and analyze the use of cardiovascular drugs in COPD patients with mild and severe symptoms.  Results: The results of the survey showed that cardiovascular drugs were used by 274 (65%) of the COPD patients. Among them, 66 % with severe COPD symptoms and 34 % with mild symptoms. The use of the eight cardiovascular drug groups were similar between patients with mild and severe COPD symptoms. There wasn’t any statistically significant difference in the use of cardiovascular drugs between patients with mild and severe COPD symptoms (p= 0,893).   Conclusions: There wasn’t any difference in the use of cardiovascular drugs among patients with mild and severe COPD symptoms. However, this result needs to be substantiated with a follow-up study with a larger study population and longer study time to be generalizable.

Background: Pressurized metered dose inhalers (pMDI) use propellants for pulmonary drug delivery. The propellants used in pMDI:s are strong greenhouse gases. The Powder dose inhaler (PDI) doesn’t use any propellants and contributes less to the carbon footprint. Aim: The purpose of this project is to present data on inhaler use in the Uppsala County Council in Sweden. This project aims to answer questions regarding pressurized metered dose inhalers (pMDI) carbon footprint, how prescriptions of inhaler types with lower carbon footprint compare with pMDI and how the Uppsala County Council compares with other county councils in Sweden. Methods: This cross-sectional study uses prescription data for collected inhalers in Uppsala County Council and similar county councils in Sweden. Calculations of carbon footprint of the propellants in pMDI:s and for the lifecycle of pMDI and PDI. Results: The study showed that the climate load from the greenhouse gases norflurane and apaflurane in pMDIs are 981 477kg CO2e in Uppsala County Council year 2020. Of all the county councils studied, the county council with the highest percentage of pMDIs use was Stockholm County Council, the Uppsala County Council was close second.  Conclusion: Uppsala County Council might need to review if there is a way to lower the amount of pMDI prescriptions to reduce its carbon footprint deviating from the rest of County Councils in Sweden. This project ties into Uppsala County Council goal of reducing the climate impact of medical anesthesia greenhouse gases with 10% by 2022 from 2018.

In order for a medication treatment to be considered successful, several roles and functions along the pharmacological treatment chain must function and cooperate effectively. The chain can most easily be described as five transitions; diagnosis, prescription treatment, dispensing, drug use and finally results and follow-up. Unfortunately, there are many problems and inefficiencies in the pharmacological drug chain. Unfortunately, those who study medication errors and their solutions have focused on individual parts of the pharmacological treatment system. However, for this reason, this study aims to develop a general framework for system analysis of inefficiencies along the pharmacological treatment chain. Due to the size of the problem, this project focused on medication adherence. Adherence can be defined as to what extent the patient follows the medication treatment plan. Adherence has many known problems and difficulties, among other things, it has major financial consequences. It can also be difficult to measure compliance, and there is no recognized perfect method. A system dynamic model is a theoretical image of a real system or object, which is a model used to understand the nonlinear behavior of complex systems. These models are useful when considering interventions and their effects when there are complex relationships. The project started with a literature study, and then went into data collection. Here, a search design and refinements were designed to find relevant articles. Once the articles were selected, the data was compiled from the articles and the analysis began. Here, factors and effects on adherence were identified as well as other interesting information from the articles. When the information was compiled and analyzed, the system dynamic model was created. The model was then sent via email to experts in the field to validation and revise the model. During the data collection, 23 relevant articles were found, compiled into 38 factors associated with compliance. In addition to these factors, 8 were excluded because they were too disease-specific or too ambiguous in their effect of adherence. The various articles studied many different chronic diseases, but hypertension was the most common. How adherence was measured in the articles also varied greatly, however, some form of self-report or questionnaire was most common method used. Three out of seven experts responded to the sent-out model and provided valuable comments. Although these are not sufficient to validate the model, their views showed that a validation can be designed in this way. The model would have to be sent to a larger set of experts and stakeholders, but because these experts are recognized in their fields, it gave weight to the results even though they were few reviewers. With the support of the literature and the experts’ statement, it was concluded that this model provides a good foundation and structure to continue to build upon. In addition, the model has proven to have many key relationships and cornerstones with important and relevant factors. It is also concluded that it is possible to translate the model into quantitative patterns, which is based on the fact that the factor itself can be translated quantitatively. Overall, it is also finally concluded that the model created in this project could be of great use in future projects when working towards a framework for system analysis of inefficiencies along the pharmacological treatment chain.

Bakgrund: Globalt drabbas 300 miljoner av depression och sjukdomen kan idag behandlas med både antidepressiva läkemedel och psykoterapi. Depression diagnosticeras utifrån klassificeringssystemen ICD-10 och DSM-5 och självskattats utifrån MADRS-skala. Sjukdomen kan delas in i följande svårighetsgrader: lätt/lindrig depression, medelsvår/måttlig depression och svår/djup depression. Vid val av antidepressiva läkemedel är det viktigt att ta hänsyn till svårighetsgrad, biverkningar och interaktioner.  Syfte: Syftet med denna studie är att kartlägga läkemedelslistor framtagna av Sveriges olika läkemedelskommittéer och beskriva val av läkemedelsbehandling vid depression för vuxna och äldre.  Metod: En dokumentanalys utfördes som lämpar sig till att kunna jämföra aktuell offentlig information. Datainsamlingen utfördes hösten 2022 med hjälp av Sveriges 21 olika regioners behandlingsrekommendationer för vuxna och äldre. En egen bedömningsskala med maximalt tre poäng utfördes för att lyckas bedöma regionernas läkemedelsrekommendationer.  Resultat: För vuxna rekommenderar 19 regioner vid lindrig-medelsvår depression sertralin, vid medelsvår-svår rekommenderar 13 regioner venlafaxin och vid svår rekommenderar sex regioner TCA där amitriptylin/klomipramin är mest förekomna. För äldre rekommenderar 13 regioner sertralin/mirtazapin/escitalopram vid lindrig-medelsvår depression, vid medelsvår-svår rekommenderar 13 regioner duloxetin/venlafaxin och vid svår rekommenderar två regioner duloxetin. Enligt den egna bedömningsskalan uppnås varierande antal poäng där totalt sju regioner uppnår maximal poäng.  Slutsats: SSRI var den vanligaste preparatgruppen som rekommenderades av regionerna vid medelsvår depression hos både vuxna- och äldre. Vid svår depression var den vanligaste preparatgruppen SNRI för äldre och TCA för vuxna. Enligt den egna bedömningsskalan var Läkemedelverkets och Socialstyrelsens rekommendationer mest vanligt förekomna källorna hos regionerna. / Background: Globally, 300 millions of people suffer from depression and the disease can today be treated with both antidepressants and psychotherapy. Depression is diagnosed from the classification system ICD-10 and DSM-5 and is self-assessed based on the MADRS-scale. The disease can be divided into the following difficulty level: light/mild depression, medium/moderate depression, and severe/deep depression. It is very important to consider difficulty level, side effects and interactions when choosing an antidepressant.  Aim: The aim of this study is to identify drug lists produced by Sweden’s different pharmaceutical committees and describe the choice of drug treatment for depression for adults and the elderly.  Materials and methods: A document analysis was performed which is suitable to be able to compare public information. The collection of data was performed autumn 2022 with the help of Sweden’s 21 different regions treatment recommendations for adults and the elderly. An own assessment scale was accomplished to judge the regions drug treatment recommendations. Results: For the adults, 19 regions primarily recommend sertraline for mild-moderate depression, for moderate-deep depression 13 regions recommend venlafaxine and for deep depression six regions recommend TCA where amitriptyline/clomipramine are most common. For the elderly, 13 regions primarily recommend sertraline/mirtazapine/escitalopram for mild-moderate depression, for moderate-deep depression 13 regions recommend duloxetine/venlafaxin and for deep depression two regions recommend duloxetine. According to the own assessment scale a varying number of points were achieved, were a total of seven regions achieved maximum points.  Conclusions: SSRIs were the most common drug group recommended by the regions for moderate depression for both adults and the elderly. In deep depression the most common drug group was SNRIs for the elderly and TCAs for adults. According to the own assessment scale the Swedish- Medicines Agency and Social Welfare Board are most common sources in the regions.