Healthy Aging in Finland: Patients Adhere Well to Chronic Statin Therapy and Their Doctors to the Guidelines

In this issue of Cardiovascular Drugs and Therapy, Upmeier et al. publish a longitudinal study of nine consecutive one-year cohorts (2000–2009) of all initiators of statin therapy, aged 70 years or more in Finland [1]. It is a fine example of the power of epidemiological resources in the Scandinavian countries [2]. In these countries with universal public health insurance, comprehensive drug databases are available that cover all reimbursed drugs for nearly the entire population. Moreover, these data on drug utilisation can be linked on the individual level with other clinical databases from hospitals, mortality registers, etc. Methodological rigor can be applied to build inception cohorts with firsttime users, using data from the preceding 3 years before the first index date. This approach allows to ascertain the absence of drug use prior to an index date to select firsttime users within a credible time-window [3]. In this study the longitudinal perspective spans 12 years (the initial drug-free window and then 9 years of observation). It is an achievement to maintain data integrity and consistency over such long periods on such a scale. Pharmaco-epidemiologists, clinical epidemiologists and public health researchers in other countries can only dream such studies, which require uniquely rich information resources. Finland is a country with a stable population of 5.3 million inhabitants, with a death and birth rate of approximately 1.5/1000inhabitants, and 19.2 % of adults being 65 and older. Over the past decades, the death rate from cardiovascular disease has fallen from a high level, as in many other affluent countries in Europe, and particularly in the North of Europe [4, 5]. The data from this study indicate that the 51.6 % of the statin initiators were persistent after 4 years in Finnish community-dwelling older adults from 70 years old and more (61,7% if a gap of one or more years was allowed). Only 20% were non-persistent in the first year. There is a steady small decline of full persistence over the 4 years, but persistence in the first year seems to predict further long-term persistence. In this study the loss to fol low up (death or institutionalisation) was 17.6 % over 4 years, which is quite low in this age group, and indicative of good health, despite the cardiovascular risk profile in this age group. Statin use in Finland in this age group predominantly occurred in middle and high cardiovascular risk patients, and only in 10 % in low risk patients. Given the limitations of the methodology (insensitive to the risk factors of weight, smoking and lipid levels), this low percentage may even be an overestimation. It means that Finnish GPs follow the guidelines and largely limit the use of statins to middle and high risk patients. As the general practitioners of Finland have established a highly efficient, technologically advanced guideline platform with high penetration, this may not come as a surprise [6]. The rather low discontinuation rates among Finnish older adults are surprising, and contrast with higher rates found in 1 year adherence in ambulatory patients of all ages in several diseases. Vrijens et al. compiled adherence data from electronicmonitoring andUpmeier et al. used pharmacist data [7]. Vrijens et al. found a 1 year persistence rate of 50 %, whereas in the present study by Upmeier et al. this figure was about 80 % in the first year. Upmeier et al.’s adherence measure was restricted to statins, whereas Vrijens et al. compiled data for all R. H. Vander Stichele (*) Heymans Institute of Pharmacology, University of Ghent, Ghent, Belgium e-mail: robert.vanderstichele@ugent.be