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PubMed1996

Predicting pregnancy outcome from the degree of maternal serum alpha-fetoprotein elevation.

OBJECTIVE: To determine if a correlation exists between the level of maternal serum alpha-fetoprotein (MSAFP) elevation and the rate of adverse pregnancy outcome, to examine the timing of pregnancies ending in fetal or neonatal death, and to develop a protocol for antepartum surveillance in an effort to prevent these adverse outcomes. STUDY DESIGN: Singleton pregnancies with a single second-trimester elevated MSAFP > or = 2.0 multiples of the median (MoM) were eligible if a targeted ultrasound evaluation (< 24 weeks) was in agreement with the dates and no fetoplacental anomaly was detected. Three groups were established based on the second-trimester MSAFP elevation: 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM. RESULTS: Among the 383 patients enrolled, delivery data were available on 333 infants. Stratified by MSAFP elevations of 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM, the rates of adverse pregnancy outcome were: (1) preterm birth: 14.3%, 15.6%, 20.3%; (2) small for gestational age at birth: 7.4%, 11.1%, 22.2%; and (3) perinatal deaths (neonatal and fetal): 2.6%, 3.3%, 5.6%. Seven pregnancy losses (three neonatal and four fetal deaths) occurred prior to 28 weeks. Of these seven, six fetuses exhibited intrauterine growth retardation by 23-26 weeks' gestation, and five of six were associated with MSAFP levels > or = 2.5 MoM. Four losses (two neonatal and two fetal deaths) occurred after 28 weeks. Of these, three involved structurally normal infants with normal growth who died after 34 weeks. All three of these pregnancies exhibited MSAFP elevations < 2.5 MoM. CONCLUSION: In pregnancies with an unexplained elevated second-trimester MSAFP, the rate of adverse pregnancy outcomes is increased with higher elevations. Any proposed program to improve pregnancy outcome in patients with unexplained MSAFP elevations must include efforts aimed at preventing preterm delivery, repeat ultrasound at 24-26 weeks to rule out early-onset intrauterine growth retardation in pregnancies with elevations > or = 2.5 MoM and fetal biophysical monitoring, even in normally grown fetuses, instituted at 32 weeks to detect fetuses at risk for intrauterine death.

Adolescent↗
PubMed1995

Low-dose versus high-dose oxytocin augmentation of labor--a randomized trial.

OBJECTIVE: Our purpose was to compare the efficacy and safety of low-dose versus high-dose oxytocin regimens in the augmentation of labor. STUDY DESIGN: Three hundred ten term pregnancies requiring augmentation of labor underwent randomization to receive either a low-dose or high-dose oxytocin augmentation regimen. Maternal demographics, labor-delivery data, and neonatal outcome were compared. RESULTS: The high-dose oxytocin group had a significantly lower cesarean section rate, regardless of parity (10.4% vs 25.7%, p < 0.001), with no differences in maternal complications and neonatal outcomes. The time needed to correct the labor abnormality was also significantly decreased (1.24 +/- 1.4 hours vs 3.12 +/- 1.6 hours, p < 0.001) in the high-dose group. CONCLUSIONS: The use of high-dose oxytocin regimen benefits both nulliparous and multiparous women requiring labor augmentation by significantly lowering both the time necessary to correct the labor abnormality and the need for cesarean section.

Adolescent↗
PubMed1996

T and J vertical extensions in low transverse cesarean births.

OBJECTIVE: To determine the frequency of T and J extensions in low transverse cesarean births at a regional perinatal center, identify the indications for these incisions, and evaluate the associated complications. METHODS: We reviewed the medical records of 56 patients delivered between January 1988 and November 1994 by low transverse cesarean birth requiring vertical extension of the incision into-the upper uterine segment. Cases of extension were compared with controls matched for gestational age, presentation, and indication for cesarean delivery. Data collected included demographic information, indications for extension, extension type, estimated blood loss, intraoperative complications, and length of hospital stay. Paired Student t test and McNemar test were used for statistical analysis. RESULTS: Vertical extensions were performed in 1.3% (95% confidence interval 0.42-2.26%) of low transverse incisions over a 7-year period. The most common indications were malpresentation (n = 31), poorly developed lower uterine segment (n = 12), and fetal head deeply arrested in the midpelvis (n = 6). Estimated blood loss was greater for patients requiring an extension (990 +/- 310 mL) compared with controls (790 +/- 150 mL), as were differences in preoperative versus postoperative hemoglobin and hematocrit (P < .05). Surgical complications were observed in 28 of 56 (50%) subjects with a uterine extension, including excessive blood loss (n = 20), broad ligament hematomas or extensions (n = 4), cervical lacerations (n = 4), and uterine artery lacerations (n = 4). Patients with vertical extensions also had longer hospital stays (4.6 +/- 1.6 versus 3.8 +/- 1.1 days) (P < .05). CONCLUSIONS: Low transverse uterine incisions may be inadequate for the safe delivery of a fetus in cases of malpresentation, preterm birth, and poor development of the lower uterine segment. Used to complete these difficult deliveries, T and J extensions are often associated with intraoperative complications and prolonged hospital stays compared with controls.

Adult↗
PubMed2006

Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth.

BACKGROUND: Respiratory distress syndrome (RDS) is a serious complication of preterm birth and the primary cause of early neonatal mortality and disability. OBJECTIVES: To assess the effects on fetal and neonatal morbidity and mortality, on maternal mortality and morbidity, and on the child in later life of administering corticosteroids to the mother before anticipated preterm birth. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 October 2005). SELECTION CRITERIA: Randomised controlled comparisons of antenatal corticosteroid administration (betamethasone, dexamethasone, or hydrocortisone) with placebo or with no treatment given to women with a singleton or multiple pregnancy, expected to deliver preterm as a result of either spontaneous preterm labour, preterm prelabour rupture of the membranes or elective preterm delivery. DATA COLLECTION AND ANALYSIS: Two review authors assessed trial quality and extracted data independently. MAIN RESULTS: Twenty-one studies (3885 women and 4269 infants) are included. Treatment with antenatal corticosteroids does not increase risk to the mother of death, chorioamnionitis or puerperal sepsis. Treatment with antenatal corticosteroids is associated with an overall reduction in neonatal death (relative risk (RR) 0.69, 95% confidence interval (CI) 0.58 to 0.81, 18 studies, 3956 infants), RDS (RR 0.66, 95% CI 0.59 to 0.73, 21 studies, 4038 infants), cerebroventricular haemorrhage (RR 0.54, 95% CI 0.43 to 0.69, 13 studies, 2872 infants), necrotising enterocolitis (RR 0.46, 95% CI 0.29 to 0.74, eight studies, 1675 infants), respiratory support, intensive care admissions (RR 0.80, 95% CI 0.65 to 0.99, two studies, 277 infants) and systemic infections in the first 48 hours of life (RR 0.56, 95% CI 0.38 to 0.85, five studies, 1319 infants). Antenatal corticosteroid use is effective in women with premature rupture of membranes and pregnancy related hypertension syndromes. AUTHORS' CONCLUSIONS: The evidence from this new review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids should be considered routine for preterm delivery with few exceptions. Further information is required concerning optimal dose to delivery interval, optimal corticosteroid to use, effects in multiple pregnancies, and to confirm the long-term effects into adulthood.

Adrenal Cortex Hormones↗
PubMed2002

A hierarchical Poisson mixture regression model to analyse maternity length of hospital stay.

Inpatient length of stay (LOS) is often considered as a proxy of hospital resource consumption. Using statewide obstetrical delivery data, a two-component Poisson mixture model provides a reasonable fit to the heterogeneous LOS distribution. Adopting the generalized linear mixed model (GLMM) approach, random effects are introduced to the two-component Poisson mixture regression model to account for the inherent correlation of patients clustered within hospitals. An EM algorithm is developed for the joint estimation of regression coefficients and variance component parameters. Related diagnostic measures for assessing model adequacy are derived. When applying the method to analyse maternity LOS, appropriate risk factors for the short-stay and long-stay subgroups can be identified from the respective Poisson components. In addition, predicted random hospital effects enable the comparison of relative efficiencies among hospitals after adjustment for patient case-mix and health provision characteristics.

Adult↗
PubMed2002

Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia.

UNLABELLED: Patient-controlled analgesia (PCA) with morphine is a convenient method for providing postoperative analgesia. Despite the fact that it is used after cesarean delivery, data on transfer of morphine and of its active metabolite morphine-6 glucuronide (M6G) into maternal milk are scarce. It is not known whether breast-feeding during PCA with morphine has neonatal implications. We sought to measure morphine and M6G concentrations in colostrum during postpartum IV PCA and evaluate the potential for drug intake by neonates being breast-fed by these mothers. Seven informed and consenting mothers, given IV PCA with morphine, were investigated. Plasma and milk samples were obtained at titration, and at 12, 24, 36, and 48 h. Morphine and M6G were measured by high-performance liquid chromatography. In plasma, morphine concentrations ranged from <1 to 274 ng/mL, M6G ranged from <5 to 974 ng/mL. In milk, opioids were found in only 3 patients in whom morphine concentrations ranged from <1 to 48 ng/mL and M6G from <5 to 1084 ng/mL. The milk-to-plasma ratio was always <1 for morphine. In conclusion, we observed very small morphine and M6G concentrations in colostrum during PCA with morphine. Under these conditions, the amounts of drug likely to be transferred to the breast-fed neonate are negligible. IMPLICATIONS: Colostrum concentrations of morphine and its active metabolite morphine-6 glucuronide were measured in mothers receiving patient-controlled analgesia with morphine after cesarean delivery. The concentrations were found to be very small, thus supporting the safety of breast-feeding in mothers receiving IV patient-controlled analgesia with morphine.

Analgesia, Patient-Controlled↗
PubMed2006

Anal sphincter defects and bowel symptoms in women with and without recognized anal sphincter trauma.

OBJECTIVE: The purpose of this study was to determine the rate of new bowel symptoms and anal sphincter defects in primiparous women with and without recognized anal sphincter (AS) injury. STUDY DESIGN: One hundred seventeen primiparous women classified with increasing degrees of perineal trauma and 21 controls delivered by cesarean section were enrolled immediately postpartum and demographic and delivery data were collected. At 6 weeks' postpartum, subjects completed a bowel function questionnaire and endoanal ultrasonography was performed. Logistic regression, chi-square, and 2-sample t tests were used for statistical analysis. RESULTS: A significant difference in new bowel symptoms was reported in women with (39%) and without (11%) recognized AS injury (P = .002). AS defects were present in 0%, 15%, 23%, 37%, and 67% of women with C/S, first-, second-, third-, and fourth-degree lacerations, respectively. Combined defects of the internal and external AS were associated with the greatest risk of new bowel symptoms (OR 32.1 [95% CI 9.6-107], P < .001). CONCLUSION: In women with and without recognized AS trauma, new bowel symptoms were strongly correlated with the presence of anatomic AS defects postpartum.

Adult↗
PubMed2000

Continuous versus interrupted sutures for perineal repair.

BACKGROUND: Millions of women worldwide undergo perineal repair after childbirth and the type of repair may have an impact on pain and healing. OBJECTIVES: The objective of this review was to assess the effects of continuous subcuticular versus interrupted transcutaneous sutures on women following perineal repair. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: June 1999. SELECTION CRITERIA: Randomised trials comparing continuous subcuticular versus interrupted transcutaneous sutures for the closure of perineal skin after vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. Study authors were contacted for additional information. MAIN RESULTS: Four studies involving 1864 women were included. The trials were heterogeneous with respect to operator skill and training. Compared with interrupted sutures, a continuous subcuticular suture technique of perineal repair was associated with less pain for up to 10 days post partum (odds ratio 0.68, 95% confidence interval 0.53 to 0.86). No differences were seen in the need for analgesia, need for resuturing of the wound or in dyspareunia. Based on one trial only, there was no difference in long-term pain and failure to resume pain-free intercourse within three months of the birth. The continuous technique was associated with less need for the removal of sutures. REVIEWER'S CONCLUSIONS: The continuous subcuticular technique of perineal repair may be associated with less pain in the immediate postpartum period than the interrupted suture technique. The long-term effects are less clear.

Delivery, Obstetric↗
PubMed2000

Absorbable synthetic versus catgut suture material for perineal repair.

BACKGROUND: Approximately 70% of women will experience some degree of perineal trauma following vaginal delivery and will require stitches. This may result in perineal pain and superficial dyspareunia. OBJECTIVES: The objective of this review was to assess the effects of absorbable synthetic suture material as compared with catgut on the amount of short and long term pain experienced by mothers following perineal repair. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials comparing absorbable synthetic (polyglycolic acid and polyglactin) with plain or chromic catgut suture for perineal repair in mothers after vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. MAIN RESULTS: Eight trials were included. Compared with catgut, the polyglycolic acid and polyglactin groups were associated with less pain in first three days (odds ratio 0.62, 95% confidence interval 0.54 to 0.71). There was also less need for analgesia (odds ratio 0.63, 95% confidence interval 0.52 to 0.77) and less suture dehiscence (odds ratio 0.45, 95% confidence interval 0.29 to 0.70). There was no significant difference in long term pain (odds ratio 0.81, 95% confidence interval 0.61 to 1.08). Removal of suture material was significantly more common in the polyglycolic acid and polyglactin groups (odds ratio 2.01, 95% confidence interval 1.56 to 2.58). There was no difference in the amount of dyspareunia experienced by women. REVIEWER'S CONCLUSIONS: Absorbable synthetic suture material (in the form of polyglycolic acid and polyglactin sutures) for perineal repair following childbirth appears to decrease women's experience of short-term pain. The length of time taken for the synthetic material to be absorbed is of concern. A trial addressing the use of polyglactin has recently been completed and this has been included in this updated review.

Catgut↗
PubMed1991

[Fetomaternal transfusion in relation to mode of delivery. Comparison of data from the DFG multicenter study "Rhesus negative" (1965-70) with data from the Freiburg University Gynecologic Clinic (1989)].

Fetomaternal hemorrhage with transfusion of more than 10-25 ml fetal blood into the maternal circulation ("macrotransfusion") is one possible cause of the failure of combined pre- and postpartal anti-D prophylaxis. We analyzed the data from 391 patients who delivered at the UFK Freiburg in 1989. We evaluated the amount of fetomaternal bleeding in different modes of delivery. We observed fetomaternal hemorrhage of clinical relevance in 7.5% of spontaneous delivery, 11.1% of vacuum extraction, 17.7% of cesarean section (p less than 0.05). There was no difference concerning macrotransfusions in the above mentioned modes of delivery. Our data are compared with the data of the DFG multicenter trial "rhesus negative" (1965-79).

Cesarean Section↗
PubMed2006

Clinical characteristics and survival of trisomy 18 in a medical center in Taipei, 1988-2004.

Trisomy 18 is the second most common autosomal trisomy in newborns. The birth prevalence of this disorder is approximately 1 in 3,000 to 1 in 8,000, and the life span of the majority of patients is less than 1 year. As information regarding outcome in trisomy 18 is rather fragmentary in the literature, this study is aimed at investigating the survival and natural history of trisomy 18. We also evaluated the survival age and management of trisomy 18 in two different periods, before and after the implementation of National Health Insurance (NHI) program. Thirty-nine cases of trisomy 18 were collected in Mackay Memorial Hospital in a 17-year period, from 1988 to 2004. Delivery data, survival age, management before and after the implementation of NHI program, structural defects, image findings and cytogenetic results were analyzed by medical and nurse's records. The diagnosis of trisomy 18 was based on the prenatal amniocentesis or postnatal chromosome analysis. Three patients had trisomy 18 mosaicism. Since cardiovascular and central nervous systems are the most common organ systems involved in this disorder, 31 patients received brain ultrasonography and heart ultrasonography for evaluation of their multiple anomalies after admission. All patients except one died in their first year due to severe malformations of the cardiovascular or central nervous systems. The median survival age was 6 days. We found a longer survival with female patients than with male patients (P < 0.05). Implementation of NHI program in the more recent decade of this study period was associated with longer survival of trisomy 18 (P < 0.05). The three most common structural defects were clenched hands (95%), rocker bottom feet (90%), and low set or malformed ears (90%). Low birth weight was present in 90%. By cardiac ultrasonography, the top four heart defects were ventricular septal defect (94%), patent ductus arteriosus (77%) and atrial septal defect (68%). However, ten cases (32%) had complex congenital heart defects. By brain ultrasonography, the most common brain lesion was cerebellar hypoplasia (32%), followed by brain edema (29%), enlarged cisterna magna (26%) and choroid plexus cysts (19%). Although most patients with trisomy 18 die within the first few weeks after birth, it is important to recognize that a small but notable percentage of these patients will survive the first year. When prenatal or postnatal decisions need to be made, the possibility of long-term survival should be included in any discussion to enable families to make the most appropriate decision.

Abnormalities, Multiple↗
PubMed1987

Outpatient clinic therapist attitudes and beliefs relevant to client dropout.

One hundred and seventy-three psychotherapists from 43 Midwestern mental health clinics responded to a survey which addressed therapists' attitudes and beliefs on service delivery topics relevant to client premature therapy termination. Therapists' responses were contrasted with known client and service delivery data. Therapists preferred a treatment duration longer than that expected by clients, overestimated actual treatment length, underestimated actual dropout rates and cited dislike of therapy or the therapist less often than clients did as reasons for premature termination. Causes of therapists' overestimates of treatment length and continuance, and their relevance to the dropout problem, were discussed.

Attitude of Health Personnel↗
PubMed2004

Ecoregions and ecoregionalization: geographical and ecological perspectives.

Ecoregions, i.e., areas exhibiting relative homogeneity of ecosystems, are units of analysis that are increasingly important in environmental assessment and management. Ecoregions provide a holistic framework for flexible, comparative analysis of complex environmental problems. Ecoregions mapping has intellectual foundations in both geography and ecology. However, a hallmark of ecoregions mapping is that it is a truly interdisciplinary endeavor that demands the integration of knowledge from a multitude of sciences. Geographers emphasize the role of place, scale, and both natural and social elements when delineating and characterizing regions. Ecologists tend to focus on environmental processes with special attention given to energy flows and nutrient cycling. Integration of disparate knowledge from the many key sciences has been one of the great challenges of ecoregions mapping, and may lie at the heart of the lack of consensus on the "optimal" approach and methods to use in such work. Through a review of the principal existing US ecoregion maps, issues that should be addressed in order to advance the state of the art are identified. Research related to needs, methods, data sources, data delivery, and validation is needed. It is also important that the academic system foster education so that there is an infusion of new expertise in ecoregion mapping and use.

Ecology↗
PubMed1991

The second stage of labor: factors influencing duration.

Prolonged second stage of labor is associated with increased perinatal mortality. Factors influencing second-stage duration are poorly understood. This study was undertaken to characterize those factors. A population of 473 nulliparous women and 491 multiparous women with spontaneous vaginal deliveries were analyzed extensively with history, physical examination (including clinical pelvimetry), labor and delivery data, and neonatal measurements. On the basis of stepwise multiple linear regression, epidural analgesia (p less than 0.0001), active-phase duration (p less than 0.0001), parity (p less than 0.0001), height (p less than 0.0004), birth weight (p less than 0.0003), and station at complete dilatation (p less than 0.027) predicted second-stage duration. The sum of their effect, however, accounted for less than 25% of the variability in second-stage length (total R2 = 0.233), leaving 75% of the variance unexplained.

Adult↗
PubMed1995

Decrease in perinatal mortality and increase in cesarean section rates.

OBJECTIVES: To investigate the cesarean section (CS) rate in the Riyadh area, its trend and relationship to perinatal mortality (PNM). METHODS: Based on delivery data obtained from the Ministry of Health hospitals, Saudi Arabia, for a total of 12 years, yearly rates of CS, PNM and the ratios of obstetricians and beds per 10,000 population were computed for the Riyadh area and compared with the overall rates for Saudi Arabia. Correlation coefficients were used to investigate the relationship between the CS rate and each of the stated variables. RESULTS: Riyadh had significantly lower rates of CS and PNM than Saudi Arabia as a whole. The CS rate in Riyadh showed a positive trend (increasing from 4.4 to 6.7%) while the PNM rate revealed a significant decreasing trend (decreasing from 21.6/1000 to 16/1000 live births). A negative association existed between the Riyadh rates of PNM and CS (r = -0.2375) and PNM and the availability of obstetricians (r = -0.8693). CONCLUSIONS: From our data it was not possible to establish a cause and effect relationship between the CS and PNM rates.

Cesarean Section↗
PubMed1996

Fetal hyperinsulinism at 14-20 weeks and subsequent gestational diabetes.

OBJECTIVE: To examine the predictive value of amniotic fluid (AF) insulin at 14-20 weeks' gestation for subsequent gestational diabetes and macrosomia in unselected gravidas 35 years or older at time of genetic amniocentesis. METHODS: We identified 296 pregnancies through stored AF samples from genetic amniocenteses (collected March 1987 through August 1992) in women meeting the following criteria: age 35 years or older, amniocentesis at 14-20 weeks, performance of a 50-g glucose challenge test, and adequate delivery data. RESULTS: A modified double-antibody radioimmunoassay reliably measured AF insulin with a detection limit of 0.35 microU/mL. Pregnant women in whom gestational diabetes was later diagnosed had higher median AF insulin levels than women who did not (0.60 versus 0.42 microU/mL, respectively; P = .026). A stepwise logistic regression analysis of gestational age at amniocentesis, maternal second-trimester weight, maternal age, and log AF insulin value on gestational diabetes showed only AF insulin to have a significant association with gestational diabetes (P = .004). Seven of 21 cases of gestational diabetes had AF insulin values exceeding the 95th percentile (1.33 microU/mL) compared with only 14 of 275 women with normal glucose tolerance (P < .001). Amniotic fluid insulin did not predict macrosomia in either nondiabetic or gestational diabetic pregnancies. CONCLUSION: Gestational diabetes is associated with increased AF insulin at 14-20 weeks, suggesting augmentation of fetal insulin production in the early fetal period in at least some cases of gestational diabetes.

Adult↗
PubMedDate not supplied

The Positive and Negative Symptoms Questionnaire: a self-report scale in schizophrenia.

The assessment of various symptoms in schizophrenia has received much interest, although few studies have compared evaluations by clinicians to those of their patients. Self-report tools may improve service delivery, data collection, and possibly also treatment adherence. We constructed the Positive and Negative Symptoms Questionnaire (PNS-Q), a self-report measure, after items from the Scale for Assessment of Positive Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS). The PNS-Q contained 68 items and was administered to 61 schizophrenic inpatients. We examined its psychometric properties and utility as a self-report tool in schizophrenia. The PNS-Q exhibited high internal consistency for both its positive and negative subscales. External validity with the SAPS and SANS was low. The positive symptoms subscale correlated significantly with the SAPS ( r = .341, P < .01), whereas the negative symptoms subscale did not correlate at all with the SANS ( r = -0.086, P > .1). The correlation between patients' insight and scores of the PNS-Q was mixed. A partial correlation analysis failed to confirm a relationship between the rating of the patients' level of insight (measured by the Amador Scale to Assess Unawareness of Mental Disorders [SUMD]) and the disparity between the PNS-Q and the SAPS and SANS. However, the PNS-Q correlated highly with McEvoy's Vignettes, a measure of self-perception of symptoms. The results of this study are discussed in light of current research and methodologic issues. The PNS-Q reflects schizophrenics' self-perception, an important, yet neglected, aspect of schizophrenia. Using this new measure, we believe that clinicians and researchers will be able to gain insight to the inner world of these patients and improve their condition, as well as enhance patients' involvement in treatment planning.

Adult↗
PubMed2006

Do policy changes in the pharmaceutical reimbursement schedule affect drug expenditures? Interrupted time series analysis of cost, volume and cost per volume trends in Sweden 1986-2002.

The last decades increasing pharmaceutical expenditures in Sweden and other western countries have created a need for reforms to reduce the trend. The aim was to analyse if reforms concerning the pharmaceutical reimbursement scheme in Sweden during the years 1986-2002 were associated with changes in cost, volume and cost per volume of pharmaceuticals. Effects of changes in the reimbursement schedule during the study period were evaluated for all registered pharmaceuticals in Sweden and for five indicator drug groups. Five policy changes during the study period were assessed. Three concerned increased patient co-payment (January 1, 1991; January 1, 1995 and June 1, 1999), one the introduction of reference based pricing and increased co-payment (January 1, 1993) and one a new structure of the reimbursement schedule (January 1, 1997). The National Corporation of Swedish Pharmacies provided pharmaceutical delivery data for all Swedish pharmacies. Possible breaks in the trend associated with the investigated reforms were analysed with linear segmented regression analysis. This showed that increased co-payments were not associated with changed level or slope of cost and volume. The new reimbursement schedule was associated with a decreased level of cost and volume, both for all drugs combined and for several of the indicator drug groups. It was also associated with an increased slope for both volume and cost in some indicator drug groups and for all drugs. Introduction of reference based pricing was associated with a reduced slope of cost/defined daily doses (DDD) in all of the indicator drug groups and for all drugs. The analysis showed that major changes in the reimbursement system such as the introduction of a new reimbursement schedule and reference based pricing were associated with reductions in cost and volume for the new reimbursement schedule and cost per volume for reference based pricing.

Drug Costs↗