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Use of secondary preventive drugs after stroke
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Stroke is a serious condition that can have significant impact on an individual’s health and is a significant burden on public health and public finances. Secondary preventive drug treatment after stroke is important for decreasing the risk of recurrent strokes. Non-adherence to drug treatment hampers the treatment effect, especially in long-term preventive treatments. The aim of this thesis was to study the use of secondary preventive drugs after stroke among Swedish stroke patients in terms of inequalities in implementation in clinical practice and patient adherence to treatment over time.

Methods Riks-Stroke, the Swedish stroke register, was used to sample stroke patients and as a source of information on background characteristics and medical and health care-related information including information on prescribed preventive drugs. The patients that were included had a stroke between 2004 and 2012. Individual patient data on prescriptions filled in Swedish pharmacies were retrieved from the Swedish Prescribed Drug Register and used to estimate patient adherence to drug treatment. Data on education, income, and country of birth were included from the LISA database at Statistics Sweden. A questionnaire survey was used to collect information about patients’ perceptions about stroke, beliefs about medicines, and self-reported adherence.

Results Results showed that a larger proportion of men than women were prescribed statins and warfarin after stroke. There was also a social stratification in the prescribing of statins. Patients with higher income and a higher level of education were more likely to be prescribed a statin compared to patients with low income and low level of education. Statins were also more often prescribed to patients born in Nordic countries, Europe, or outside of Europe compared to patients born in Sweden. Primary non-adherence (not continuing treatment at all within 4 months of discharge from hospital) was low for preventive drug treatment after stroke. Data on filled prescriptions, however, indicated that the proportion of patients who continued to use the drugs declined during the first 2 years after stroke. For most drugs, refill adherence in drug treatment was associated with female sex, good self-rated health, and living in institutions and (for antihypertensive drugs and statins) having used the drug before the stroke. For statins and warfarin, a first-ever stroke was also associated with continuous drug use. Self-reported adherence 3 months after stroke also showed associations with patients’ personal beliefs about medicines; non-adherent patients scored higher on negative beliefs and lower on positive beliefs about medicines.

Conclusion Inequalities between men and women and between different socioeconomic groups were found in the prescribing of secondary preventive drugs after stroke. Only a small proportion of Swedish stroke patients did not continue treatment after discharge from hospital, but the proportion of non-adherent patients increased over time. Poor adherence to preventive drug treatment after stroke is a public health problem, and improving adherence to drug treatment requires consideration of patients’ personal beliefs and perceptions about drugs.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2013. , 66 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1603
Keyword [en]
stroke, secondary prevention, drug use, equality, medication adherence, medication beliefs
National Category
Other Clinical Medicine Social and Clinical Pharmacy
Research subject
Medicine; Clinical Pharmacology; Social Pharmacy
Identifiers
URN: urn:nbn:se:umu:diva-82472ISBN: 978-91-7459-736-3 (print)OAI: oai:DiVA.org:umu-82472DiVA: diva2:661492
Public defence
2013-11-29, Sal E04, byggnad 6E, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-11-08 Created: 2013-11-01 Last updated: 2013-11-08Bibliographically approved
List of papers
1. Persistent use of secondary preventive drugs declines rapidly during the first 2 years after stroke.
Open this publication in new window or tab >>Persistent use of secondary preventive drugs declines rapidly during the first 2 years after stroke.
2010 (English)In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 2, 397-401 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND PURPOSE: To prevent new cardiovascular events after stroke, prescribed preventive drugs should be used continuously. This study measures persistent use of preventive drugs after stroke and identifies factors associated with persistence.

METHODS: A 1-year cohort (21,077 survivors) from Riks-Stroke, the Swedish Stroke Register, was linked to the Swedish Prescribed Drug Register.

RESULTS: The proportion of patients who were persistent users of drugs prescribed at discharge from hospital declined progressively over the first 2 years to reach 74.2% for antihypertensive drugs, 56.1% for statins, 63.7% for antiplatelet drugs, and 45.0% for warfarin. For most drugs, advanced age, comorbidity, good self-perceived health, absence of low mood, acute treatment in a stroke unit, and institutional living at follow-up were independently associated with persistent medication use.

CONCLUSIONS: Persistent secondary prevention treatment declines rapidly during the first 2 years after stroke, particularly for statins and warfarin. Effective interventions to improve persistent secondary prevention after stroke need to be developed.

Place, publisher, year, edition, pages
American Heart Association, 2010
Keyword
medication persistence, secondary prevention, stroke
National Category
Social and Clinical Pharmacy
Identifiers
urn:nbn:se:umu:diva-35680 (URN)10.1161/STROKEAHA.109.566950 (DOI)20075360 (PubMedID)
Available from: 2010-08-31 Created: 2010-08-31 Last updated: 2017-12-12Bibliographically approved
2. Few sex differences in the use of drugs for secondary prevention after stroke: a nationwide observational study
Open this publication in new window or tab >>Few sex differences in the use of drugs for secondary prevention after stroke: a nationwide observational study
2012 (English)In: Pharmacoepidemiology and Drug Safety, ISSN 1053-8569, E-ISSN 1099-1557, Vol. 21, no 9, 911-919 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: This observational study describes the sex differences in the use of secondary preventive drugs after ischemic stroke in terms of prescribing and persistence. Also, sex differences in patient- and treatment-related factors associated with drug use were investigated.

METHODS: In this nationwide register-based study, the Swedish Stroke Register was linked to the Swedish Prescribed Drug Register for information on drugs prescribed for, and bought by, stroke patients. Background factors were included from the Swedish Stroke Register.

RESULTS: Included in the database were 9331 men and 9018 women. Men were more often prescribed statins, 48.8% versus 38.1% [age-adjusted prevalence ratio (PR) = 0.86, 95%CI = 0.82-0.91], and warfarin, 38.4% versus 26.4% after stroke (age-adjusted PR = 0.88, 95%CI = 0.79-0.97). There were no differences in prescribing of antihypertensive or antiplatelet drugs. No sex differences were seen regarding not continuing drug treatment after discharge (primary non-adherence). Women had slightly higher persistence to antihypertensive treatment 2 years after discharge, 76.3% versus 71.9% for men (age-adjusted PR = 1.05, 95%CI = 1.00-1.09), but there were no differences in persistence to antiplatelet, warfarin or statin treatments. Similar factors were related to statin and warfarin prescribing for both men and women. Only antihypertensive treatment before stroke was associated to persistence to antihypertensive treatment, and this increased persistence for both men and women.

CONCLUSIONS: This study showed few differences between men and women after stroke. Patients' use of secondary preventive drugs needs to be improved, and from a public health perspective, poor persistence is probably a greater problem than differences between the sexes. Copyright © 2011 John Wiley & Sons, Ltd.

Place, publisher, year, edition, pages
San Francisco: John Wiley & Sons, 2012
Keyword
fat mass, fat distribution, abdominal fat, gynoid fat, stroke cox proportional hazard model
National Category
Pharmacology and Toxicology
Identifiers
urn:nbn:se:umu:diva-50193 (URN)10.1002/pds.2268 (DOI)000308295000001 ()22069216 (PubMedID)
Available from: 2011-11-28 Created: 2011-11-28 Last updated: 2017-12-08Bibliographically approved
3. Social stratification in the dissemination of statins after stroke in Sweden
Open this publication in new window or tab >>Social stratification in the dissemination of statins after stroke in Sweden
2013 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 69, no 5, 1173-1180 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Since 2005, statins have been recommended to patients with ischaemic stroke. The objective of this study was to analyse how statin treatment has been disseminated in different patient groups (age, sex, socioeconomic status and country of birth) in Sweden between 2004 and 2009.

METHODS: The Swedish Stroke Register (Riks-Stroke) has been linked to the Longitudinal Integration Database for Health Insurance and Labour Market Studies. Approximately 85 % of stroke patients in Sweden are included in Riks-Stroke. Odds ratios for statin prescribing were calculated using a multivariable logistic regression model including age, sex, socioeconomic status and risk factors.

RESULTS: During the study period, 108,950 ischaemic stroke patients were discharged alive from hospital. The proportion with statins at discharge increased from 32.9 % in 2004 to 60.1 % in 2009. Patients with secondary school or university education had slightly higher odds [odds ratio (OR) 1.07, 95 % confidence interval (CI) 1.04-1.11 and OR 1.05, 95 % CI 1.01-1.10 respectively] than patients with primary school education. Patients on a high income were prescribed more statins than those on a low income (OR 1.24, 95 % CI 1.19-1.28). Compared with patients born in Sweden, patients born in other countries were prescribed more statins (Nordic countries excepting Sweden: OR 1.07, 95 % CI 1.01-1.14; Europe: OR 1.31, 95 % CI 1.22-1.40; Outside Europe: OR 1.20, 95 % CI 1.08-1.34).

CONCLUSIONS: Statin prescribing after ischaemic stroke has increased from 2004 to 2009. Our results also show a social stratification in the dissemination of statins, with patients having a higher income and patients with higher education receiving statins more often than those with a lower income and education, and patients born in Sweden receiving statins less often than those born outside of Sweden.

Keyword
brain infarction, secondary prevention, statins, socioeconomic status, ethnic groups
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-61918 (URN)10.1007/s00228-012-1454-8 (DOI)23187964 (PubMedID)
Available from: 2012-11-30 Created: 2012-11-30 Last updated: 2017-12-07Bibliographically approved
4. The association between patients' beliefs about medicines and adherence to drug treatment after stroke: a cross-sectional questionnaire survey
Open this publication in new window or tab >>The association between patients' beliefs about medicines and adherence to drug treatment after stroke: a cross-sectional questionnaire survey
2013 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 9, e003551- p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Adherence to preventive drug treatment is a clinical problem and we hypothesised that patients' beliefs about medicines and stroke are associated with adherence. The objective was to examine associations between beliefs of patients with stroke about stroke and drug treatment and their adherence to drug treatment.

DESIGN: Cross-sectional questionnaire survey.

SETTING: Patients with stroke from 25 Swedish hospitals were included.

MEASUREMENTS: Questionnaires were sent to 989 patients to assess their perceptions about stroke (Brief Illness Perception Questionnaire, Brief IPQ), beliefs about medicines (Beliefs about Medicines Questionnaires, BMQ) and adherence to treatment (Medication Adherence Report Scale, MARS) 3 months after stroke onset. Only patients living at home were included in the analysis. The primary outcome was self-reported adherence as measured on MARS. MARS scores were dichotomised into adherent/non-adherent. Background and clinical data from the Swedish Stroke register were included.

RESULTS: 811 patients were still living at home and 595 answered the questionnaire. Complete MARS data were available for 578 patients and 72 (12.5%) of these were classified as non-adherent. Non-adherent patients scored lower on positive beliefs as measured on BMQ-necessity (OR = 0.90, 95% CI 0.83 to 0.98) and BMQ-benefit (OR=0.77, 95% CI 0.68 to 0.87), and higher on negative beliefs as measured on BMQ-concern (OR=1.12, 95% CI 1.05 to 1.21), BMQ-overuse (OR=1.29, 95% CI 1.14 to 1.45), and BMQ-harm (OR=1.12, 95% CI 1.01 to 1.24). The Brief IPQ showed that non-adherent patients believed their current treatment to be less useful (p=0.001).

CONCLUSIONS: This study showed associations between beliefs of Swedish patients with stroke about medicines and adherence. Positive beliefs were less common and negative more common among non-adherent. To improve adherence, patients' beliefs about medicines should be considered.

National Category
Social and Clinical Pharmacy
Identifiers
urn:nbn:se:umu:diva-82446 (URN)10.1136/bmjopen-2013-003551 (DOI)24068768 (PubMedID)
Available from: 2013-11-01 Created: 2013-11-01 Last updated: 2017-12-06Bibliographically approved

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