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Purpose: To investigate the eligibility for faricimab in a real-world diabetic macular oedema (DMO) population to the YOSEMITE and RHINE trials, and to compare the eligible DMO populations to the trial populations.

Design, settings and participants: This retrospective cross-sectional analysis used data from the Swedish Macula Registry (SMR) between 1 January 2019 and 31 August 2023. Eligibility criteria mirrored the main criteria of the YOSEMITE and RHINE trials: (1) DMO diagnosis, (2) treatment-naïve, (3) 18 years or older, (4) central retinal thickness (CRT) 325 µm or higher and (5) best-corrected visual acuity (BCVA) ranging from 25 to 73 letters. Individuals with registered proliferative diabetic retinopathy (DR) at the start of treatment were excluded. A secondary selection of eligible individuals was conducted using the same criteria, except for BCVA, which ranged from 25 to 77 letters according to national guidelines (treatment practice).

Main outcome measures: Characteristics at the initial visit of the two eligible SMR populations were compared with baseline data from the clinical trials, respectively.

Results: In total, 3777 individuals with DMO were selected from SMR. Of these, 2357 (62.4%) individuals were treatment-naïve, all were 18 years or older, 1928 (51.0%) exhibited CRT≥325 µm, 1175 (31.1%) had 25-73 letters based on phase III studies, while 1528 (40.5%) had 25-77 letters according to treatment practice. After excluding individuals with registered proliferative DR 1171 (31.0%) individuals in the SMR met all criteria based on phase III studies, while 1522 (40.3%) individuals fulfilled the criteria according to treatment practice. The SMR and treatment practice populations were older (YOSEMITE 67.5±11.6 vs 62.8±10.0 years, p<0.001 and RHINE 67.5±11.6 vs 61.6±10.1 years, p<0.001) than those in the phase III studies and had lower CRT (YOSEMITE 446±96 vs 486±131 µm, p<0.001 and RHINE 446±96 vs 471±127 µm, p=0.001).

Conclusion: Approximately 30% of DMO patients in the SMR met the main trial criteria from YOSEMITE and RHINE, while around 40% met the criteria based on treatment practice. The SMR and treatment practice cohorts were older and had less severe DMO than the trial cohorts. Further research into the safety profile of faricimab in clinical settings is necessary, along with the consideration of additional eligibility criteria when implementing faricimab in ophthalmology practice.

Purpose: To analyse the impact on cost if faricimab is used as the first-line treatment for neovascular age-related macular degeneration (nAMD) compared to standard treatment with bevacizumab.

Methods: Retrospective registry study including real-world data from the Swedish Macula Registry between 2017 and 2022. The observed number of injections and visits for bevacizumab during the first two years of treatment was used (n = 437 patients). Number of faricimab injections was obtained from published clinical trial data and unit costs mostly from publicly available Swedish sources. The provider cost included medication and visit cost and societal cost included additionally patient travel cost. Costs are presented in 2023 EUR.

Results: The incremental societal cost of faricimab was 277 EUR per patient compared to bevacizumab in the base case. Medication cost was higher (1516 EUR) while visit cost (−1183 EUR) and patient travel cost (−56 EUR) were lower due to longer injection intervals. Faricimab was of similar cost as bevacizumab for patients residing far from the clinic. The faricimab injection interval and the number of bevacizumab injections were major drivers of uncertainty in the results.

Conclusion: Faricimab represents a cost-effective alternative to bevacizumab for patients with nAMD in Sweden. Its extended treatment interval is particularly beneficial for patients living far from clinics, and if the real-life faricimab injection interval extends beyond 12 weeks. Our findings emphasize faricimab's potential to free up healthcare staff to treat a larger patient population with existing clinic resources.

Objective: To assess a systematic implementation approach for introducing dapagliflozin to individuals with heart failure and reduced ejection fraction in an outpatient clinical setting.

Methods: Retrospective medical record data were analysed. All individuals diagnosed with heart failure who resided within the hospital catchment area and had visited cardiology or internal medicine department between 2010 and 2019 were screened by using the main inclusion criteria from the DAPA-HF trial. The effectiveness of the previously described seven-step systematic implementation approach was assessed by the proportion receiving information letter, dapagliflozin treatment, follow-ups at 2–12 weeks and 12 months post-dapagliflozin initiation, persistence on dapagliflozin, adverse events, and reasons for discontinuation.

Results: Of the 2433 individuals, 352 met the main DAPA-HF trial criteria in step 2. After exclusions in steps 3 and 4, 191 individuals remained. Of these, 158 were invited for eligibility discussion in step 5, with 107 having received an information letter beforehand. In step 6, dapagliflozin was prescribed to 69 individuals, and in step 7, follow-ups were conducted with 56 individuals at 2–12 weeks and 62 individuals at 12 months. Sixty out of 69 persisted on dapagliflozin after 12 months. Adverse events were reported by nine individuals. Discontinuation was attributed to reasons such as urinary tract infections, genital or abdominal discomfort, and hypotension.

Conclusion: The systematic introduction of dapagliflozin to heart failure patients was effective. Despite this, challenges in uniformly implementing procedures across patients were evident, emphasizing the necessity for a systematic implementation approach.

Purpose: To develop an in-depth understanding of older individuals’ attitudes and perceptions of medication management and care after discharge from hospital-to-home.

Patients and Methods: A qualitative study using semi-structured interviews with selected individuals 75 years and older, discharged from hospital within the last 6–12 months, living at home, and managing their own medications. Face-to-face interviews were audio-recorded, transcribed and analyzed with thematic analysis.

Results: Among the 15 respondents, mean age was 83.5 years (range 75–95 years), 67% were women, and 60% lived alone. The majority (80%) managed their medications with a pill organizer or directly from the pill boxes, while 20% used dose dispensed medications. The analysis of the data led to six themes: Medication adherence, Personal responsibility, Transitions of care, Beliefs about medications, Participation (experience of participation, willingness to participate) and Accessibility (easier to reach hospital than primary care, navigating in the care system, continuity, personal chemistry).

Conclusion: The included respondents who were older individuals, living at home and managing their own medications, expressed that they were medical adherent and self-managing. Two important aspects which were seen were difficulties to reach primary care on their own initiative and the lack of continuity with the same physician over a longer period of time.

Background: Poor medication adherence is prevalent among older people. To optimize therapeutic outcomes, it is crucial to understand the underlying causes and perceptions.

Objective: We aimed to investigate the extent of self-reported medication adherence and associated factors among older people admitted to hospital.

Methods: Individuals living at home aged ≥ 75 years with an emergency admission at a university hospital between September 2018 and September 2021 were included. Participants answered the Medication Adherence Report Scale (MARS-5) questionnaire upon admission regarding their prescribed long-term medications. Participants with a MARS-5 score of 23–25 were defined as adherent and with a score of 5–22 as nonadherent. A multivariable logistic regression analysis was performed to investigate possible factors independently associated with self-reported medication adherence.

Results: A total of 261 individuals were included. The mean age was 84 years (standard deviation 5.7) and the mean MARS-5 score was 23.9 (standard deviation 1.8). Overall, 227 (87%) participants were classified as adherent to their prescribed treatment, while 34 (13%) participants were classified as nonadherent. Participants with cognitive impairment (odds ratio = 0.40, 95% confidence interval 0.18–0.90, p = 0.027) and depression (odds ratio = 0.29, 95% confidence interval 0.10–0.87, p = 0.028) had a lower odds of reporting adherence to their medications.

Conclusions: The majority of individuals aged ≥ 75 years who were recently hospitalized rated themselves as adherent to their prescribed medications according to MARS-5. Future studies would benefit from adding more possible explanatory factors and combining a self-reported assessment with a more objective measurement of medication adherence.

OBJECTIVES: To investigate the eligibility of a real-world neovascular age-related macular degeneration (nAMD) population for the TENAYA and LUCERNE trials (testing faricimab), and to compare the eligible real-world patients to trial participants. DESIGN, SETTINGS AND PARTICIPANTS: In this retrospective cross-sectional study, we used data from the Swedish Macula Registry (SMR) between 1 January 2017 and 31 December 2020. Persons were eligible if they fulfilled the main inclusion criteria in TENAYA and LUCERNE: (1) nAMD diagnosis, (2) treatment naïve, (3) ≥50 years and (4) best-corrected visual acuity (BCVA) of 78-24 letters. MAIN OUTCOME MEASURES: Characteristics at the original visit of the eligible SMR population and baseline data from the clinical trials were compared. RESULTS: In total, 27 962 individuals with nAMD were registered in SMR. A total of 15 399 (55%) individuals were treatment naïve; of these, 15 368 (55%) were ≥50 years and 13 265 (47%) also had BCVA of 78-24 letters and fulfilled eligibility. Among treatment-naïve individuals, 86% were eligible and the BCVA criterion was the most common reason for non-eligibility. The eligible SMR population was significantly older than either TENAYA or LUCERNE. SMR included more women and patients with worse visual acuity than TENAYA, while SMR patients were diagnosed more quickly than LUCERNE. CONCLUSIONS: Almost half of the real-world nAMD population in SMR fulfilled the main inclusion criteria of the TENAYA and LUCERNE trials. Among treatment-naïve individuals, 86% were eligible. Marginally differences were shown between the eligible SMR population and the trial populations. The SMR population were older and more similar to the population in LUCERNE than TENAYA.

Introduction: Mineralocorticoid receptor antagonists (MRAs) reduce mortality and morbidity in patients with heart failure and reduced ejection fraction (HFrEF), but are largely underused. We evaluated the frequency, motives, predictors and outcomes of MRA discontinuation in a real-world heart failure population.

Methods and results: This was a single-centre, retrospective cohort study where medical record-based data were collected on patients with HFrEF between 2010 and 2018. In the final analysis, 572 patients were included that comprised the continued MRA group (n=275) and the discontinued MRA group (n=297). Patients that discontinued MRA were older, had a higher comorbidity index and a lower index estimated glomerular filtration rate (eGFR). Predictors of MRA discontinuations were increased S-potassium, lower eGFR, lower systolic blood pressure, higher frequency of comorbidities and a higher left ventricular ejection fraction. The most common reason for MRA discontinuation was renal dysfunction (n=97, 33%) with 59% of these having an eGFR <30 mL/min/1.73m 2, and elevated S-potassium (n=71, 24%) with 32% of these having an S-potassium >5.5 mmol/L. Discontinuation of MRA increased the adjusted risk of all-cause mortality (HR 1.48; 95% CI 1.07 to 2.05; p=0.019).

Conclusions: Half of all patients with HFrEF initiated on MRA discontinued the treatment. A substantial number of patients discontinued MRA without meeting the guideline-recommended levels of eGFR and S-potassium where mild to moderate hyperkalaemia seems to be the most decisive predictor. Further, MRA discontinuation was associated with increased adjusted risk of all-cause mortality.

Aims: The aim of this study was to investigate a real-world heart failure (HF) cohort regarding (1) prevalence of known diabetes mellitus (DM), undiagnosed DM and pre-diabetes, (2) if hf treatment differs depending on glycaemic status and (3) if treatment of DM differs depending on HF phenotype.

Methods: All patients who had received a diagnosis of HF at Umeå University Hospital between 2010 and 2019 were identified and data were extracted from patient files according to a prespecified protocol containing parameters for clinical characteristics, including echocardiogram results, comorbidities, fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) values. Patients’ HF phenotype was determined using the latest available echocardiogram. The number of patients with previous DM diagnosis was assessed. Patients without a previous diagnosis of DM were classified as non-DM, pre-diabetes or probable DM according to FPG and HbA1c levels using WHO criteria.

Results: In total, 2326 patients (59% male, mean age 76±13 years) with HF and at least one echocardiogram were assessed. Of these, 617 (27%) patients had a previous diagnosis of DM. Of the 1709 patients without a previous diagnosis of DM, 1092 (67%) patients had either an FPG or HbA1c recorded, of which 441 (41%) met criteria for pre-diabetes and 97 (9%) met criteria for probable diabetes, corresponding to 19% and 4% of the entire cohort, respectively. Patients with HF and diabetes were more often treated with diuretics and beta blockers compared with non-DM patients (64% vs 42%, p<0.001 and 88% vs 83%, p<0.001, respectively). There was no difference in DM treatment between HF phenotypes.

Conclusions: DM and pre-diabetes are common in this HF population with 50% of patients having either known DM, probable DM or pre-diabetes. Patients with HF and DM are more often treated with common HF medications. HF phenotype did not affect choice of DM therapy.

Purpose: To describe and compare self-reported medication adherence assessed with the 5-item version of Medication Adherence Report Scale (MARS-5) and pharmacy refill adherence based on data from the Swedish Prescribed Drug Register (SPDR) among persons with ischemic stroke, and to investigate independent predictors associated with respective assessments.

Methods: A study questionnaire was sent to persons with ischemic stroke registered in the Swedish Stroke Register between Dec 2011 and March 2012, and who lived at home 3 months after discharge. The primary outcome was dichotomized to adherent/non-adherent based on MARS-5 and SPDR and analyzed with multivariable logistic regression. Adherence according to MARS-5 was defined as score 23 or higher (out of 25). Adherence according to SPDR was defined as at least one filled statin prescription recorded in SPDR in each 6-month interval during 2 years of follow-up.

Results: Of 420 participants, 367 (87%) and 329 (78%) were adherent according to MARS-5 and SPDR, respectively, and 294 (70%) participants were adherent according to both assessments. A significant association was shown between medication adherence according to the two assessments (p = 0.020). Independent predictors associated with medication adherence according to MARS-5 were female sex, while factors associated with SPDR were male sex and being younger.

Conclusions: The majority of participants were classified as adherent, 87% according to MARS-5 and 78% based on data from SPDR. However, only 70% were adherent according to both MARS-5 and SPDR, and different predictors were associated with the different measurements, suggesting that these assessments are measuring different aspects of adherence.

Purpose: To develop a model for systematic introduction and to test the feasibility in a chronic disease population. We also investigated how the approach was received by the patients.

Methods and results: The systematic introduction approach is a seven-step procedure: step 1, define a few main criteria; step 2, primary scan patients with the one or two main criteria using computerized medical records/databases/clinical registries; step 3, identify patients applying the other predefined criteria; step 4, evaluate if any examinations/laboratory test updates are required; step 5, summon identified patients to the clinic with an information letter; step 6, discuss treatment with the patient and prescribe if appropriate; and step 7, follow up on initiated therapy and evaluate the applied process. The model was tested in a case study during introduction of the new drug sacubitril-valsartan in a heart failure population. In total, 76 out of 1924 patients were identified to be eligible for sacubitril-valsartan and summoned to the clinic to discuss treatment. Patient experiences with the approach were investigated in an interview study with general inductive approach using qualitative content analysis. This resulted in three final categories: a good approach, role of the information letter, and trust in care.

Conclusions: The systematic introduction approach ensures that strict criteria are used in the selection process and that a treatment can be implemented in eligible patients within a specified population with limited resources and time. The model was effective in our case study and maintained the patient's confidence in healthcare.