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Aim: To identify older patients’ risk factors for drug-related readmissions and assess the preventability of older patients’ drug-related revisits. Methods: Post-hoc analysis of a randomised clinical trial with patients aged ≥ 65 years at eight wards within four hospitals in Sweden. The primary outcome used to identify risk factors was drug-related readmission within 12 months post-discharge. A Cox proportional hazards model was made with sociodemographic and clinical baseline characteristics. Four hundred trial participants were randomly selected and their revisits (admissions and emergency department visits) were assessed to identify potentially preventable drug-related revisits, related diseases and causes. Results: Among 2,637 patients (median age (interquartile range) 81 (74–87) years), 582 (22%) experienced a drug-related readmission within 12 months. Sixteen risk factors (hazard ratio > 1, p < 0.05) related to age, previous hospital visits, medication use, multimorbidity and cardiovascular, liver, lung and peptic ulcer disease were identified. The 400 patients experienced a total of 522 hospital revisits, of which 85 (16%) were potentially preventable drug-related revisits. The two most prevalent diseases and causes related to preventable revisits were heart failure (n=24, 28%) and chronic obstructive pulmonary disease (n=13, 15%), and inadequate treatment (n=23, 27%) and insufficient or no follow-up (n=22, 26%). Conclusion: Risk factors for drug-related readmissions in older hospitalised patients were age, previous hospital visits, medication use and multiple diseases. Potentially preventable drug-related hospital revisits are common and might be prevented through adequate medication use and follow-up in older patients with cardiovascular or lung disease.

Johanna Sulku,1,2 Christer Janson,3 Håkan Melhus,4 Andrei Malinovschi,5 Björn Ställberg,6 Kristina Bröms,2,6 Marieann Högman,3 Karin Lisspers,6 Margareta Hammarlund-Udenaes,1 Elisabet I Nielsen1 1Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden; 2Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden; 3Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden; 4Department of Medical Sciences, Clinical Pharmacogenomics and Osteoporosis, Uppsala University, Uppsala, Sweden; 5Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden; 6Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, SwedenCorrespondence: Johanna SulkuDepartment of Pharmaceutical Biosciences, Faculty of Pharmacy, Uppsala University, Box 591, Uppsala SE-751 24, SwedenTel +46 73 635 7075Fax +46 26 531 237Email johanna.sulku@farmbio.uu.sePurpose: Inhaled corticosteroids (ICS) are often more widely prescribed in the treatment of chronic obstructive pulmonary disease (COPD) than what is recommended in the guidelines. The aim of this study was to evaluate the appropriateness of ICS treatment in COPD patients using the algorithm proposed by the International Primary Care Respiratory Group (IPCRG) and to identify factors associated with ICS treatment.Patients and methods: Appropriateness of ICS therapy was studied with respect to concomitant asthma, history of exacerbations and blood eosinophils (B-Eos) in a Swedish cohort of primary and secondary care patients with COPD. Factors associated with ICS were investigated using multivariable logistic regression.Results: Triple treatment was found to be the most common treatment combination, used by 46% of the 561 included patients, and in total 63% were using ICS. When applying the IPCRG algorithm, there was a possible indication for discontinuation of ICS in 55% of the patients with ICS treatment. Of the patients not using ICS, 18% had an indication for starting such treatment. The strongest factors associated with ICS therapy were frequent exacerbations (aOR 8.61, 95% CI 4.06, 20.67), secondary care contacts (aOR 6.99, 95% CI 2.48, 25.28) and very severe airflow limitation (aOR 5.91, 95% CI 1.53, 26.58).Conclusion: More than half of the COPD patients on ICS met the criteria where withdrawal of the treatment could be tried. There was, however, also a subgroup of patients not using ICS for whom there was an indication for starting ICS treatment. Patients using ICS were characterized by more frequent exacerbations and lower lung function.Keywords: ICS, pharmacological management, inappropriate therapy, chronic obstructive pulmonary disease, IPCRG

Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease characterised by persistent respiratory symptoms and a high risk of exacerbations. Preventive and maintenance pharmacological treatment is primarily administered through handheld inhalers, which are available in several different device-drug combinations. This thesis is about increasing the quality of drug treatment in COPD, where problems related to inhaled drugs are common. The overall aim was to assess and evaluate inhaled pharmacological treatment and critical inhaler technique errors in patients with COPD. The four studies included in this thesis derived from the Tools for Identifying Exacerbations study, which is an observational multicentre study in primary and secondary care in Sweden including 571 patients with COPD. The consequences of a change in the Global Initiative for Obstructive Lung Disease guidelines were investigated (Paper I). The refined COPD assessment of symptoms/risk of exacerbations lead to a high proportion of patients being reclassified to a lower risk group, which in turn had consequences for patients’ pharmacological treatment. The patients’ inhaled pharmacological treatments were assessed (Paper II). A high prevalence of inhaled corticosteroids (ICS) was identified, especially as a triple treatment, i.e., in combination with dual long-acting bronchodilators. Based on a previously developed tool, discontinuation of ICS could be tried in more than half of the patients. Proper inhaler technique is a prerequisite for adequate COPD treatment. Video-recorded demonstrations of inhaler technique were analysed (Paper III). Two-thirds of the patients made at least one critical inhaler technique error. The majority of the patients used a combination of different inhaler device models, which was the only factor associated with critical inhaler technique errors. The changes in inhaled pharmacological COPD treatment and inhaler technique were investigated one year after an initial evaluation and training (Paper IV). A reduction in the proportion of patients making critical inhaler technique errors was found but not in the subgroup of patients who had switched device models during the year. However, no association with COPD symptoms or exacerbations could be detected. The overall results contribute to increased knowledge and understanding of drug treatment in COPD. In order to optimise pharmacological treatment, it is essential to assess disease severity and inhaler technique, particularly in patients who switch device models. Further research is warranted to determine the most optimal educational intervention regarding inhaler technique, which has not yet been settled.