Decline in prolonged hormone replacement therapy in women aged 45 years or more, and impact of a centralised database tool
Authors: Teichert Martina , Baart Fedor , De Smet Peter A G M 
Published: February 2006

Abstract

Objective
Evaluation of discontinuation in prolonged use of menopausal and post-menopausal hormone replacement therapy (HRT) in The Netherlands after the publication of the Million Women Study in The Lancet of August 9, 2003. Furthermore estimation of the contribution of a centralised database tool on this decline, supplying community pharmacists with their patients on prolonged HRT therapy.

Setting
Dispensing data of more than 90% of Dutch community pharmacies were collected in a centralised database. Shortly after the publication of the Million Women Study, this database was used to offer community pharmacists online access to a listing of their patients with prolonged HRT use.

Methods
In August 2003 all women who had used HRT for at least one year were selected as long-term users. This cohort was followed until April 2004. The proportion of patients who had stopped their prolonged HRT in this cohort was calculated. This decline was also measured according to the use of a database tool. For this purpose community pharmacies were divided into pharmacies who had repeatedly consulted the centralised database tool (T pharmacies; n = 343) and control pharmacies who had evidently not consulted the tool (C pharmacies; n =490). The two groups of pharmacies were compared according to characteristics of the pharmacy on which information was available in the centralised database. They were also compared for patient characteristics that were routinely collected in the database. Differences between the two groups for averages of these parameters were tested with a chi square test and with a chi square test for trend for ordinal variables with more categories. The proportion of patients who stopped their prolonged HRT was calculated for each of the two groups of pharmacies. These proportions were compared with a Z test for proportions. The two groups of pharmacies were compared for cessation of HRT treatment and for ceasing treatment earlier by a Kaplan-Meier survival curve. Cox survival analyses was used to estimate the chances for discontinuation of HRT for patients within the two pharmacy groups with the possibility to adjust for possible confounders such as patient's age and type of HRT medication.

Key findings
After publication of the Million Women Study in The Lancet of August 9, 2003, 63% of the women in The Netherlands who had used HRT for more than one year in August 2003 had stopped their prolonged use in April 2004.
A centralised database tool supplying community pharmacists with a list of their patients on prolonged HRT therapy caused a significantly higher proportion of cessation in the T group of pharmacies than in the C group (65% versus 62%; P &lt; 0.05). Furthermore, the time needed for halving the number of patients on prolonged HRT was significantly shorter in T pharmacies than in C pharmacies (187 days versus 202 days; P &lt; 0.05). Patients in T pharmacies had a significantly increased chance of 7.6% (95% confidence interval: 1.05–1.10) of discontinuing their HRT and of doing so earlier.

Conclusions
The results of the Million Women Study had a major impact on prolonged HRT use in The Netherlands. A centralised database tool for prolonged use of HRT could have a modest but significant impact on dispensing patterns.