pharmacoepidemiology and drug safety 2014; 23: 128–139

Published online 30 August 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pds.3488

ORIGINAL REPORT

Selection bias in pharmacy-based patient surveys

P. Frisk1,2, S. Kälvemark-Sporrong1 and B. Wettermark3
1
Department of Pharmacy, Uppsala University, Sweden
2
National Corporation of Swedish Pharmacies (Apoteket AB), Stockholm, Sweden
3
Centre of Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden

ABSTRACT
Purpose To evaluate if there is a selection bias in drug utilization surveys on prescription drugs regularly conducted in Swedish
pharmacies, to describe the direction of this potential bias and discuss the implications for the results.
Methods Age and gender distributions within patient survey samples from drug utilization surveys conducted during 2006–2010 are
compared to the age and gender distribution of all Swedish patients, receiving the same drug or drugs, as given by the Swedish Prescribed
Drug Register. The differences between the proportions of patients within the age and gender segments of each pair of survey/register data
were calculated.
Results In 25 (81%) out of 31 included surveys, patients aged 75 years or older are significantly underrepresented, as they are less likely to
visit the pharmacy to collect their prescription drugs themselves and thus disqualify for the interviews. Data on women show similar results
as overall survey data, whereas the underrepresentation of the oldest age group among men appears in a lower proportion of the surveys,
67%. The general consequence is a selection towards a healthier survey sample, but the consequences in the individual surveys vary,
depending on what drug is being studied.
Conclusion Pharmacy-based patient surveys provide a convenient data collection method for patient self-reported data, but patients aged
75 years or older are consistently underrepresented. In surveys where this may influence the main research question, data should also be
collected with other methods reaching the oldest patients. Copyright © 2013 John Wiley & Sons, Ltd.

key words—patient survey; pharmacy; selection bias; drug utilization; self-report; pharmacoepidemiology

Received 05 November 2012; Revised 29 April 2013; Accepted 27 June 2013

INTRODUCTION newly introduced and existing therapies, post-marketing

Ageing populations, increased disease prevalence,
demands from health-care consumers and the introduc-
tion of new drugs have contributed to increasing expen-
diture within the health sector over the last decades.1,2
This has resulted in a growing interest in drug utilization
studies and outcomes research. The scientific value of
well-designed randomized controlled trials is indisput-
able, but it is also accepted that their findings not
necessarily reflect the effectiveness and safety demon-
strated once a drug has passed regulatory approval and
reached larger, unrestricted patient populations in
routine care.3–6 To study long-term risks and benefits,
rare adverse events, treatment results in vulnerable
patient groups and to make direct comparisons between
*Correspondence to: P. Frisk, Department of Pharmacy, Uppsala University,
P.O. Box 580, SE-751 23 Uppsala, Sweden. E-mail: pia.frisk@farmaci.uu.se
observational studies with data from different sources
are needed.3–6
Large claims databases and prescription registries
are increasingly used in pharmacoepidemiological
studies.6 They are considered to provide data
representative of routine clinical care, at relatively
low cost. Record linkage to other health data registers
and electronical medical records may be conducted to
further study the association between drug exposure
and clinical outcomes.6,7 Nevertheless, these prescrip-
tion databases have some important limitations when
assessing drug exposure. They normally lack informa-
tion on OTC drugs, and the sensitivity may be further
reduced due to drug dispensations abroad, drugs
provided through Internet sites or drugs shared between
relatives. The specificity may be reduced due to poor
compliance, i.e. the registers give valid information on
drug exposure only when dispensed drugs actually are
taken.7,8 Methodological challenges in using register

Copyright © 2013 John Wiley & Sons, Ltd.

 selection bias in pharmacy-based surveys
data also include difficulties defining drug exposure3,9
and estimating prescribed dose from complex dosing
regimen data.9
Prescriber data from medical records normally
contain the clinical information missing in the pharmacy
dispensing databases. However, most health systems
face the challenge of maintaining uniform and complete
records with a quality that allows extraction of reliable
data for epidemiological studies. 10,11 Furthermore, in
some settings, medical records are still not computer-
ized, making data access and extraction very time
consuming.11 Several studies have compared the informa-
tion on prescribed drugs found in medical records with the
corresponding information reported by patients and often
found the medical records to be discrepant.12–14
The rationale behind patient surveys is the assump-
tion that the patient ought to be the primary source of
information in matters regarding his or her health,
especially when it comes to their subjective view and
experiences as users of health care services and drugs.
However, the collection of self-reported data is often
time consuming and logistically complicated. Since
patient surveys are based on samples rather than whole
populations and rely on patient recall, they are subject
to both selection and recall bias, a threat to their
validity.6 Nevertheless, patient self-reported data are
frequently used in drug utilization research, either as
a supplement to data from other sources or when drug
exposure data are validated, often with self-reported
data as the “gold standard”.8,9,12–17
One source for patient self-reported data is to collect
data from patients when they collect their prescriptions
at pharmacies. The National Corporation of Swedish
Pharmacies (Apoteket AB) developed a method where
computer-aided surveys are used to collect drug-
related information from the patient at the pharmacy
counter. The method has mainly been used to collect
data which is more difficult or expensive to collect
from other data sources. Such data include the indica-
tion for use,18 treatment preferences among patients,
attitudes towards co-payment and experiences of
generic substitution.19 So far, no unique identifiers of
any patients have been stored enabling record linkage
to other data to validate the method. Since both patient
selection and survey interviews take place in the phar-
macy with the pharmacists as interviewers, there is a
potential risk of selection bias and recall bias.20
Pharmacies have occasionally been used as a
recruitment or interview setting in drug utilization
surveys, but reports from systematic and nationwide
surveying as described above are scarce.21–24 Conse-
quently, it is important to validate the method, i.e.
recruiting and interviewing survey respondents in
Copyright © 2013 John Wiley & Sons, Ltd.
129
pharmacies. The access to population-based dispensing
data with complete coverage for the entire Swedish
population makes it possible to measure how well the
sample populations selected for pharmacy surveys
represent all patients having the same drug or drugs dis-
pensed during the same time period.
The purpose of this study was to evaluate if there is a
selection bias in patient surveys on prescription drugs
regularly conducted in Swedish pharmacies as part of
the drug dispensing process, to establish the direction
of this potential bias and to discuss the potential implica-
tions for the interpretation of the survey results.
METHODS
The pharmacy-based surveys included in this study
were conducted at 25–71 pharmacies distributed all
over the country, including hospital pharmacies with
dispensing services in ambulatory care, pharmacies
located in primary health care centres and pharmacies
in urban and rural areas. Based on information
provided on the prescription, all patients presenting a
prescription on a drug intended for themselves,
meeting the entry criteria and consenting to participate
were automatically enrolled and asked to participate in
a short, structured questionnaire at the end of the drug-
dispensing process, with the pharmacist as the
interviewer. In surveys including minors, the caregiver
was offered to participate. General entry criteria were
age and gender of the patient, prescribed drug and
dispensing pharmacy. These were checked automatically
when the prescription was registered in the dispensing
system. In addition, criteria such as indication for use,
co-payment willingness and reimbursement status were
sometimes used to select patients. This information was
captured in the questionnaires. The purposes of the
surveys differed but can, so far, be categorized into one
of the following: (i) to study prescribers’ adherence to
prescribing guidelines or reimbursement restrictions for
prescription drugs, (ii) to study patient preferences and
other drug related issues relevant from a patient perspec-
tive and (iii) to study prescribing issues relevant from a
marketing and/or business development perspective.
Data Collection
In this study, all drugs were classified according to the
Anatomical Therapeutic Chemical (ATC) classification
system.25 As part of the review of all pharmacy surveys
of this kind conducted in Sweden between 2006 and
2012, the selection of surveys for this study was based
on the following criteria:
Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
130 p. frisk et al.
(a) The surveys should be completed, i.e. ongoing
surveys were excluded.
(b) For calculation of the relative sample size of
the survey sample, dispensing data from 2010 of
the Swedish population should be available in the
Prescribed Drug Register. To provide survey
samples likely to be representative of all users of
the specific drug in question, the number of
responders in each survey should constitute at
least 0.5% of the period prevalence rate of 2010
for the corresponding drug on the ATC fifth level.
(c) To avoid duplicate registration of patients in each
study, the surveys should only include one pharma-
cological group, ATC fourth level.
(d) Population dispensing data from 2011 in the
Prescribed Drug Register should be available to
assess the potential implications of the study results.
For each included survey, age and gender distribu-
tions of all patients collecting their prescription drugs
themselves and therefore being offered to participate
were calculated. The age categories used were 0–44
years, 45–64 years, 65–74 years and >75 years, one
of the intervals for population statistics recommended
by the WHO also applied in the National Swedish
Drug statistics.26
To measure the overall representativity of the
sample populations selected for surveys, age and
gender distributions of all Swedish patients having
the same drug or drugs dispensed during the same or
approximately the same time period were extracted
from the Swedish Prescribed Drug Register.7
Swedish National Board of Health and Welfare which
is a government agency that, in accordance with
Swedish law, may use population-based registers to
follow and analyse health and social conditions among
the general population. All data were made anonymous
and aggregated for the research team with no possibility
to identify any individual patient.
RESULTS
Out of 49 pharmacy surveys conducted all over Sweden
between 2006 and 2012, 31 surveys were included.
(See Figure 1 and Table 1). The survey samples as
well as their corresponding register populations
included all users, i.e. both prevalent and incident users.
The surveys included belong to the therapeutic areas
diabetes (survey 1–6), asthma/chronic obstructive
pulmonary disease (COPD) (surveys 7–9), oncology/
immunology (surveys 10–18), neurology/psychiatry
(surveys 19–25) and a mixed group with different
therapeutic areas, no 26–31. Children/adolescents were
only included in surveys 2, 26 and 31, where their
caregivers were interviewed.
The most consistent difference between survey and
register samples was an underrepresentation of all
patients aged 75 years or older, seen in 25 surveys
45 surveys 2 surveys
closed/finalised discontinued
surveys 2006-2011 prematurely

43 surveys 4 surveys including

Statistical Analysis completed > 1 ATC fourth level subgroup
The differences between the proportions in each age and
gender segment of each pair of survey/register data 1 survey lacking
were calculated. Proportions with non-overlapping 39 surveys register data for
confidence intervals on the 95% level of confidence for potential calculation of adequate
were considered statistically significant.27 inclusion sample size

38 surveys 6 surveys with sample

Ethics size < 0,5% of period
for sample
prevalence rate in 2010a
Due to the nature of the individual surveys they were not size analysis
considered to require ethical approval. Nevertheless, 1 survey lacking
each survey was conducted with attention to patient register data for
integrity and data safety issues through all stages of data 32 surveys calculation of current
collection, handling, analysis and presentation. Patients age distribution
participating in the surveys gave their informed consent
prior to the interview, the consent was documented in 31 surveys
included
the questionnaire form and all data were made anony-
mous with no possibility to identify individual patients. a
Figure 1. Inclusion of performed surveys in study. Prevalence data from
The register data analyses were undertaken by the the Swedish Prescribed Drug Register

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
 selection bias in pharmacy-based surveys 131
Table 1. Included surveys
Survey no. ATC code No. of eligible patients* Response rate† Survey duration‡ Age of survey sample (years) Purpose

Insulins and analogues for injection, long acting

∥
1 A10AE 272 93% 10 Jan–28 Feb 2006 18 <
∥
2 A10AE 275 91% 10 Jan–13 May 2006 All ages
††
3 A10AE 663 84% 16 Apr–16 Jun 2007 18 <
††
4 A10AE 400 76% 15 Nov–31 Dec 2007 18 <
††
5 A10AE 427 70% 26 Nov 2008–29 Dec 2008 18 <
††
6 A10AE 375 81% 22 Nov–16 Dec 2010 18 <
Adrenergics and other drugs for obstructive airway diseases
††
7 R03AK 948 89% 23 Nov 2006–28 May 2007 18 <
††
8 R03AK 1192 77% 13 Nov 2008–17 Apr 2009 18 <
††
9 R03AK 1321 76% 28 Dec 2009–26 May 2010 18 <
Antineoplastic and immunomodulating agents
††
10 L01XE 69 86% 31 Aug–1 Dec 2007 18 <
††
11 L01XE 80 83% 1 Oct 2008–11 Feb 2009 18 <
††
12 § L02AE 234 73% 27 Aug–31 Dec 2007 18 <
††
13 ¶ L02BA 142 88% 19 Apr–30 Jun 2007 52 <
††
14 ¶ L02BG 142 91% 19 Apr–30 Jun 2007 52 <
††
15 ¶
L02BG 139 83% 31 Aug–1 Dec 2007 18 <
††
16 ¶ L02BG 152 89% 31 Oct 2008–9 Feb 2009 18 <
††
17 L04AB 287 73% 5 Mar–9 Sep 2007 18 <
††
18 L04AB 280 71% 25 Feb–17 Aug 2008 18 <
Antiepileptics, anti-parkinson drugs and psychoanaleptics
††
19 N03AG 383 74% 18 Oct 2007–31 Jan 2008 18 <
††
20 N03AX 291 69% 24 Apr – 3 Dec 2008 18 <
21 N03AX 515 80% 8 Dec–31 Dec 2009 18 < **
22 N03AX 2571 56% 1 Dec 2010–3 Apr 2011 18 < **
††
23 N04BC 594 87% 11 Dec 2006–7 Mar 2007 18 <
††
24 N06AX 534 75% 1 Aug–3 Oct 2008 18 <
††
25 N06AX 621 64% 14 Apr–19 Jun 2009 18 <

Other drugs
††
26 A01AA 567 89% 12 May–26 Jul 2006 All ages
∥
27 A02BC 598 84% 4–23 Dec 2006 18 <
††
28 B01AC 577 83% 24 May–22 Jul 2007 18 <
29 C10AA 594 91% 19 Jan–25 Feb 2007 18 < **
∥
30 D11AH 39 79% 8 Nov 2006–30 May 2007 All ages
††
31 M01AX 590 86% 8 Dec 2009–13 Jan 2010 18 <

*No of patients presenting a prescription on a drug intended for themselves.

†
No of respondents/No of eligible patients.
‡
Register data were collected from the months corresponding to when each survey was conducted.
§
Only men included.
¶
Only women included.
∥
To study adherence to reimbursement restrictions.
**To study adherence to prescribing guidelines.
††
To study different aspects related to prescribing and/or actual drug use, e.g. daily dose taken by the patient, recommended dosing scheme and indication for use.

(81%) (Table 2). This difference was found across all
therapeutic areas investigated, but it was most
consistent within the therapeutic areas of asthma/COPD
(surveys 7–9) and neurology/psychiatry (surveys 19–25),
where it appeared in all surveys. The underrepresenta-
tion of the oldest age group was accompanied by a
significant overrepresentation of patients in at least
one of the younger age groups in 19 (61%) of the
surveys (Table 2) (Figure 2a).
On the age and gender level, data on women
showed a similar pattern, with a significant
underrepresentation of patients in the oldest age
group in 24 (80%) of the surveys (Table 3)
(Figure 2b) and a significant overrepresentation of
patients in at least one of the younger age groups
in 19 (63%) of these surveys.
Data on men were less consistent, with the oldest
age group being significantly underrepresented in
18 (67%) of the surveys (Table 4) (Figure 2c).
The concomitant overrepresentation of at least one
of the younger age groups was seen in 11(41%)
of the surveys.

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
132 p. frisk et al.
Table 2. Age distributions within each survey and register sample, proportions presented within brackets
Survey no. n (survey) 0–44 yrs 45–64 yrs 65–74 yrs 75+ yrs
n (register)

Diff prop ± C.I.95%

1 272 85 (31.3%) 120 (44.1%) 40 (14.7%) 27 (9.9%)

19 388 5551 (28.6%) 7978 (41.1%) 3328 (17.2%) 2531 (13.1%)
2.6% ±5,5% 3.0% ± 5.9% 2.5% ± 4.2% 3.1% ± 3.6%
2 275 162 (58.9%) 80 (29.1%) 24 (8.7%) 9 (3.3%)
5693 3049 (53.6%) 1817 (31.9%) 555 (9.7%) 272 (4.8%)
5.4% ± 6.0% 2.8% ± 5.5% 1.0% ± 3.4% 1.5% ± 2.2%
3 663 167 (25.2%) 302 (45.6%)* 143 (21.6%)* 51 (7.7%)*
29 755 8477 (28.5%) 11 975 (40.2%) 5296 (17.8%) 4007 (13.5%)
3.3% ± 3.3% 5.3% ± 3.8% 3.8% ± 3.2% 5.8% ± 2.1%
4 491 135 (27.5%) 229 (46.6%)* 94 (19.1%) 33 (6.7%)*
23 091 6222 (26.9%) 9345 (40.5%) 4350 (18.8%) 3174 (13.7%)
0.5% ± 4.0% 6.2% ± 4.5% 0.3% ± 3.5% 7.0% ± 2.3%
5 427 125 (29.3%) 173 (40.5%) 96 (22.5%) 33 (7.7%)*
25 808 6622 (25.7%) 10 155 (39.3%) 5231 (20.3%) 3800 (14.7%)
3.6% ± 4.3% 1.2% ± 4.7% 2.2% ± 4.0% 7.0% ± 2.6%
6 375 120 (32.0%)* 153 (40.8%) 71 (18.9%) 31 (8.3%)*
27 673 6654 (24.0%) 10 392 (37.6%) 6183 (22.3%) 4444 (16.1%)
8.0% ± 4.7% 3.2% ± 5.0% 3.4% ± 4.0 7.8% ± 2.8%
7 948 240 (25.3%) 338 (35.7%) 211 (22.3%) 159 (16.8%)*
45 059 11 882 (26.4%) 14 991 (33.3%) 8943 (19.8%) 9243 (20.5%)
1.1% ± 2.8% 2.4% ± 3.1% 2.4% ± 2.7% 3.7% ± 2.4%
8 1192 178 (14.9%)* 476 (39.9%)* 317 (26.6%)* 221 (18.5%)*
44 756 8467(18.9%) 14 936 (33.4%) 10 477 (23.4%) 10 876 (24.3%)
4.0% ± 2.1% 6.6% ± 2.8% 3.2% ± 2.5% 5.8% ± 2.2%
9 1321 305 (23.1%)* 464 (35.1%)* 331 (25.1%) 221 (16.7%)*
42 941 8250 (19.2%) 13 815 (32.2%) 10 290 (24.0%) 10 586 (24.7%)
3.9% ± 2.3% 3.0% ± 2.6 1.1% ± 2.4% 7.9% ± 2.1%
10 69 10 (14.5%) 27 (39.1%) 21 (30.4%) 11 (15.9%)
685 118 (17.2%) 276 (40.3%) 175 (25.5%) 116 (16.9%)
2.7% ± 8.8% 1.2% ± 12.1% 4.9% ± 11.3% 1.0% ± 9.1%
11 80 17 (21.3%) 31 (38.8%) 19 (23.8%) 13 (16.3%)
750 123 (16.4%) 271 (36.1%) 198 (26.4%) 158 (21.1%)
4.9% ± 9.4% 2.6% ± 11.2% 2.7% ± 9.8% 4.8% ± 8.6%
12 229 0 (0%) 20 (8.7%) 57 (24.9%) 152 (66.4%)*
11 792 6 (0.1%) 719 (6.1%) 2422 (20.5%) 8635 (73.2%)
2.6% ± 3.7% 4.4% ± 5.7% 6.9% ± 6.2%
13 142 NA 59 (41.5%) 46 (32.4%) 37 (26.1%)*
8318 3062(36.8%) 2322 (27.9%) 2934 (35.3%)
4.7% ± 8.2% 4.5% ± 7.8% 9.2% ± 7.3%
14 142 NA 68 (47.9%)* 48 (33.8%) 26 (18.3%)*
6475 2546 (39.3%) 1906 (29.4%) 2023 (31.2%)
8.6% ± 8.3% 4.4% ± 7.9% 12.9% ± 6.5%
15 139 9 (6.5%) 63 (45.3%)* 39 (28.1%) 28 (20.1%)*
2080 69 (3.3%) 761 (36.6%) 490 (23.6%) 760 (36.5%)
3.2% ± 4.2% 8.7% ± 8.5% 4.5% ± 7.7% 16.4% ± 7.0%
16 152 6 (3.9%) 85 (55.9%)* 39 (25.7%) 22 (14.5%)*
2564 57 (2.2%) 874 (34.1%) 670 (26.1%) 963 (37.6%)
1.7% ± 3.1% 21.8% ± 8.1% 0.5% ± 7.2% 23.1% ± 5.9%
17 287 97 (33.8%) 140 (48.8%) 39 (13.6%) 11 (3.8%)
2528 758 (30.0%) 1245 (49.2%) 384 (15.2%) 141 (5.6%)
3.8% ± 5.8% 0.5% ± 6.1% 1.6% ± 4.2% 1.7% ± 2.4%
18 280 114 (40.7%)* 113 (40.4%)* 48 (17.1%) 5 (1.8%)*
3375 1163 (34.5%) 1571 (46.5%) 490 (14.5%) 151 (4.5%)
6.3% ± 6.0% 6.2% ± 6.0% 2.6% ± 4.6% 2.7% ± 1.7%
19 383 161 (42.0%) 153 (39.9%) 50 (13.1%) 19 (5.0%)*
19 075 7641 (40.1%) 6706 (35.2%) 2262 (11.9%) 2466 (12.9%)
2.0% ± 5.0% 4.8% ± 5.0% 1.2% ± 3.4% 8.0% ± 2.2%
20 291 125 (43.0%) 128 (44.0%)* 35 (12.0%) 3 (1.0%)*
5577 2315 (41.5%) 2003 (35.9%) 735 (13.2%) 524 (9.4%)
1.4% ± 5.8% 8.1% ± 5.8% 1.2% ± 3.8% 8.4% ± 1.4%

(Continues)

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
 selection bias in pharmacy-based surveys 133
Table 2. Continued
Survey no. n (survey) 0–44 yrs 45–64 yrs 65–74 yrs 75+ yrs
n (register)

Diff prop ± C.I.95%

21 515 214 (41.6%)* 207 (40.2%) 57 (11.1%) 37 (7.2%)*

19 199 5977 (31.1%) 6897 (35.9%) 2423 (12.6%) 3902 (20.3%)
10.4% ± 4.3% 4.3% ± 4.3% 1.6% ± 2.8% 13.1% ± 2.3%
22 2571 1053 (41.0%)* 1020 (39.7%)* 289 (11.2%)* 209 (8.1%)*
38 663 11 103 (28.7%) 14 478 (37.4%) 5683 (14.7%) 7399 (19.1%)
12.2% ± 2.0% 2.2% ± 2.0% 3.5% ± 1.3% 11.0% ± 1.1%
23 594 51 (8.6%)* 241 (40.6%)* 173 (29.1%) 129 (21.7%)*
14 785 868 (5.9%) 4821 (32.6%) 3832 (25.9%) 5264 (35.6%)
2.7% ± 2.3% 8.0% ± 4.0% 3.2% ± 3.7% 13.9% ± 3.4%
24 534 257 (48.1%)* 225 (42.1%) 38 (7.1%)* 14 (2.6%)*
19 160 6967 (36.4%) 8644 (45.1%) 1939 (10.1%) 1610 (8.4%)
11.8% ± 4.3% 3.0% ± 4.3% 3.0% ± 2.2% 5.8% ± 1.4%
25 621 278 (44.8%)* 289 (46.5%) 39 (6.3%)* 15 (2.4%)*
20 265 7096 (35.0%) 9129 (45.0%) 2299 (11.3%) 1741 (8.6%)
9.8% ± 4.0% 1.5% ± 4.0% 5.1% ± 2.0% 6.2% ± 1.3%
26 567 50 (8.8%)* 209 (36.9%)* 150 (26.5%)* 158 (27.9%)*
21 940 2478 (11.3%) 6105 (27.8%) 4847 (22.1%) 8510 (38.8%)
2.5% ± 2.4% 9.0% ± 4.0% 4.4% ± 3.7% 10.9% ± 3.7%
27 598 93 (15.6%) 299 (50.0%)* 122 (20.4%) 84 (14.0%)*
23 754 3518 (14.8%) 10 048 (42.3%) 4663 (19.6%) 5525 (23.3%)
0.7% ± 2.9% 7.7% ± 4.1% 0.8% ± 3.3% 9.2% ± 2.8%
28 577 6 (1.0%) 201 (34.8%)* 189 (32.8%)* 181 (31.4%)*
29 304 412 (1.4%) 7984 (27.2%) 8262 (28.2%) 12 646 (43.2%)
0.4% ± 0.8% 7.6% ± 3.9% 4.6% ± 3.9% 11.8% ± 3.8%
29 594 18 (3.0%) 259 (43.6%) 204 (34.3%) 113 (19.0%)*
51 048 1303 (2.6%) 20 364 (39.9%) 16 837 (33.0%) 12 544 (24.6%)
0.5% ± 1.4% 3.7% ± 4.0% 1.4% ± 3.8% 5.5% ± 3.2
30 39 30 (76.9%)* 7 (17.9%) 0 (0%) 2 (5.1%)
1033 640 (62.0%) 273 (26.4%) 81 (7.8%) 39 (3.8%)
15.0% ± 13.6% 8.5% ± 12.3% 1.4% ± 7.0%
31 590 7 (1.2%) 190 (32.2%) 238 (40.3%)* 155 (26.3%)*
35 555 674 (1.9%) 10 692 (30.1%) 12 251 (34.5%) 11 938 (33.6%)
0.7% ± 0.9% 2.1% ± 3.8% 5.9% ± 4.0% 7.3% ± 3.6%

*Proportions with non-overlapping confidence intervals on the 95% level of confidence.

DISCUSSION Combining self-reported patient data with data

This study aimed to investigate whether self-reported
patient data collected through interviews performed
in Swedish pharmacies are subject to a selection
bias, and if so, to discuss the potential implications
for the survey results. The overall analysis indicates
that patients aged 75 years or older are underrepre-
sented in more than 80% of the surveys. With
respect to this deviation in age distribution, data on
women show the same results as overall survey data,
whereas data on men are less consistent, with
the underrepresentation of the oldest age group
appearing in a somewhat lower proportion of the
surveys. This selection bias is most likely introduced
by the fact that only patients who appear at the
pharmacy themselves are interviewed. Patients who,
for any reason, are unable to go to the pharmacy
themselves and therefore have a representative to
collect their prescription drugs are excluded.
from other sources may be a suitable method of
studying different aspects of drug prescribing and
utilization, provided the self-reported data are
valid and reliable. The agreement between
interview data regarding drug use and pharmacy
record data has been evaluated in previous studies,
showing a relatively high level of agreement for
chronic or serious conditions,8,15,28,29 but also
indicating differences between therapeutic areas or
drugs/drug classes,8,12,15,28,30 and validation methods
used.8,9,15
Most drugs show an increased prevalence with
increasing age.31–33 reflecting the underlying
association between age and disease. The systematic
exclusion of the oldest patients seen in this study
may thus contribute to a healthy selection effect,
underestimating findings associated with multiple
and/or more severe diseases. When studying cardio-
vascular drugs, this may e.g. have resulted in an

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
134 p. frisk et al.

30 analysing individual surveys and access to

complementary data sources in surveys where the
25
selection bias is expected to have an impact on the
No. of surveys

20 main research question. Conducting home interviews

survey sample
overrepresented
15
survey sample
or interviews in other settings, such as primary care
10
underrepresented centres and hospitals, is an alternative method for
collecting self-reported drug utilization data that
5
potentially provides representative data from all
0
0-44 45-64 65-74 75+
relevant age groups.8,12,35
Age group The design of this study has several limitations. It is
important to distinguish between patients eligible for
a inclusion, i.e. all patients coming to the pharmacy to
30 redeem their own prescription, and respondents,
25
patients who actually agree to participate and complete
No. of surveys

20
the survey interview. In this study, we focus on
survey sample

15
overrepresented patients eligible for inclusion and do not analyse
survey sample
underrepresented
any other factors than age and gender that could
10
influence whether a patient purchased his or her own
5
medication, e.g. other demographic or behavioural
0
0-44 45-64 65-74 75+ characteristics. Nor do we study the reasons why
Age group eligible patients refused to participate in the
b
individual surveys. Hence, the discussion on the
described selection bias and its implications
20 remains simplified since it assumes that the age and
18 gender distributions of all eligible patients are the same
16
No. of surveys

14 as for all respondents. However, a high response rate

12 survey sample
overrepresented
10
survey sample
8
6
underrepresented
4 respondents most likely are minor (Table 1).
2 The results from the analysis on the age and
0
0-44 45-64 65-74 75+
Age group
c
Figure 2. a. Number of surveys with over- and underrepresented age
groups (n = 31). b. Number of surveys with over- and underrepresented
age groups, women (n = 30). c. Number of surveys with over- and under-
represented age groups, men (n = 27)
underestimated prevalence of heart failure.18 Never-
theless, several drugs or drug groups show a different
pattern with varying prevalence rates in different age
groups, depending on their labelled indications,
prescribing guidelines and reimbursement restrictions.
Accordingly, the consequences of a consistent
exclusion of some of the oldest patients may vary
considerably. Based on dispensing data from 2011,
the proportion of patients aged 75 years or older
among prevalent users receiving the drugs included
in this study currently ranges from 4.0 to 73.1%.34 De-
spite the general result presented here, this illustrates
the importance of an unbiased approach when
among those eligible for participation in the included
surveys indicates that the differences in age and
gender distribution between eligible patients and
gender level reveal a less pronounced bias among
men. Recent research has shown that, in patients
aged 75 years or older, women show higher
disability rates than men in the domains of mobility
and activities of daily living, something that is likely
to have an impact on their ability to visit the
pharmacy and purchase their prescription drugs
themselves.36 Whether our results reflect this differ-
ence or are due to the fact that stratification on both
age and gender levels creates too small samples to
detect existing differences among both men and
women, respectively, remains unclear without access
to larger survey samples.
The general results found in the study were
most consistent within the therapeutic areas of
asthma/COPD and neurology/psychiatry, since
the detected selection bias appeared in all surveys
within these areas. These two areas contain some
of the largest surveys in the study; therefore, it
is not clear whether it is the drug group per se
or the large sample sizes that produce the consis-
tent results.

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
 selection bias in pharmacy-based surveys 135
Table 3. Age distributions (women) within each survey and register sample, proportions presented within brackets
Survey no. n (survey) 0–44 yrs 45–64 yrs 65–74 yrs 75+ yrs
n (register)

Diff prop ± C.I.95%

1 113 39 (34.5%) 44 (38.9%) 17 (15.0%) 13 (11.5%)

8552 2365 (27.7%) 3257 (38.1%) 1474 (17.2%) 1456 (17.0%)
6.9% ± 8.8% 0.9% ± 9.1% 2.2% ± 6.6% 5.5% ± 5.9%
2 122 67 (54.9%) 40 (32.8%) 9 (7.4%) 6 (4.9%)
2699 1469 (54.4%) 818 (30.3%) 256 (9.5%) 156 (5.8%)
0.5% ± 9.0% 2.5% ± 8.5% 2.1% ± 4.8% 0.9% ± 3.9%
3 283 71 (25.1%) 128 (45.2%)* 56 (19.8%) 28 (9.9%)*
12 891 3555 (27.6%) 4801 (37.2%) 2292 (17.8%) 2243 (17.4%)
2.5% ± 5.1 8.0% ± 5.9% 2.0% ± 4.7% 7.5% ± 3.5%
4 209 61 (29.2%) 87 (41.6%) 44 (21.1%) 17 (8.1%)*
9860 2556 (25.9%) 3626 (36.8%) 1877 (19.0%) 1801 (18.3%)
3.3% ± 6.2% 4.9% ± 6.8% 2.0% ± 5.6% 10.1% ± 3.8%
5 183 61 (33.3%)* 64 (35.0%) 38 (20.8%) 20 (10.9%)*
10 847 2635 (24.3%) 3941 (36.3%) 2170 (20.0%) 2101 (19.4%)
9.0% ± 6.9% 1.4% ± 7.0% 0.8% ± 5.9% 8.4% ± 4.6%
6 149 54 (36.2%)* 54 (36.2%) 26 (17.4%) 15 (10.1%)*
11 520 2661 (23.1%) 3927 (34.1%) 2552 (22.2%) 2380 (20.7%)
13.1% ± 7.8% 2.2% ± 7.8 4.7% ± 6.1% 10.6% ± 4.9%
7 570 135 (23.7%) 216 (37.9%) 133 (23.3%) 86 (15.1%)*
25 697 6200 (24.1%) 9129 (35.5%) 5248 (20.4%) 5120 (19.9%)
0.4% ± 3.5% 2.4% ± 4.0% 2.9% ± 3.5% 4.8% ± 3.0%
8 723 106 (14.7%)* 313 (43.3%)* 184 (25.4%) 120 (16.6%)*
26 730 4647 (17.4%) 9063 (33.9%) 6418 (24.0%) 6602 (24.7%)
2.7% ± 2.6% 9.4% ± 3.7% 1.4% ± 3.2% 8.1% ± 2.8%
9 820 172 (21.0%)* 297 (36.2%)* 219 (26.7%) 132 (16.1%)*
25 718 4516 (17.6%) 8357 (32.5%) 6328(24.6%) 6517 (25.3%)
3.4% ± 2.8% 3.7% ± 3.3% 2.1% ± 3.1% 9.2% ± 2.6%
10 28 4 (14.3%) 11 (39.3%) 9 (32.1%) 4 (14.3%)
303 48 (15.8%) 122 (40.3%) 80 (26.4%) 53 (17.5%)
1.6% ± 13.6% 1.0% ± 18.9% 5.7% ± 18.0% 3.2% ± 13.7%
11 34 9 (26.5%) 12 (35.3%) 9 (26.5%) 4 (11.8%)
338 53 (15.7%) 121 (35.8%) 90 (26.6%) 74 (21.9%)
10.8% ± 15.3% 0.5% ± 16.9% 0.2% ± 15.6% 10.1% ± 11.7%
13 142 NA 59 (41.5%) 46 (32.4%) 37 (26.1%)*
8318 3062(36.8%) 2322 (27.9%) 2934 (35.3%)
4.7% ± 8.2% 4.5% ± 7.8% 9.2% ± 7.3%
14 142 NA 68 (47.9%)* 48 (33.8%) 26 (18.3%)*
6475 2546 (39.3%) 1906 (29.4%) 2023 (31.2%)
8.6% ± 8.3% 4.4% ± 7.9% 12.9% ± 6.5%
15 139 9 (6.5%) 63 (45.3%)* 39 (28.1%) 28 (20.1%)*
2080 69 (3.3%) 761 (36.6%) 490 (23.6%) 760 (36.5%)
3.2% ± 4.2% 8.7% ± 8.5% 4.5% ± 7.7% 16.4% ± 7.0%
16 152 6 (3.9%) 85 (55.9%)* 39 (25.7%) 22 (14.5%)*
2564 57 (2.2%) 874 (34.1%) 670 (26.1%) 963 (37.6%)
1.7% ± 3.1% 21.8% ± 8.1% 0.5% ± 7.2% 23.1% ± 5.9%
17 193 56 (29.0%) 97 (50.3%) 30 (15.5%) 10 (5.2%)
1688 464 (27.5%) 841 (49.8%) 270 (16.0%) 113 (6.7%)
1.5% ± 6.8% 0.4% ± 7.4% 0.5% ± 5.4% 1.5% ± 3.3%
18 188 73 (38.8%)* 75 (39.9%)* 35 (18.6%) 5 (2.7%)*
2141 654 (30.5%) 1020 (47.6%) 346 (16.2%) 121 (5.7%)
8.3% ± 7.2% 7.7% ± 7.3% 2.5% ± 5.8% 3.0% ± 2.5%
19 196 87 (44.4%) 74 (37.8%) 27 (13.8%) 8 (4.1%)*
9364 3515 (37.5%) 3384 (36.1%) 1093 (11.7%) 1372 (14.7%)
6.9% ± 7.0% 1.6% ± 6.9% 2.1% ± 4.9% 10.6% ± 2.9%
20 150 68 (45.3%) 67 (44.7%)* 14 (9.3%) 1 (0.7%)*
2795 1177 (42.1%) 979 (35.0%) 369 (13.2%) 270 (9.7%)
3.2% ± 8.2% 9.6% ± 8.2% 3.9% ± 4.8% 9.0% ± 1.7%
21 327 130 (39.8%)* 133 (40.7%)* 38 (11.6%) 26 (8.0%)*
11 689 3366 (28.8%) 4106 (35.1%) 1435 (12.3%) 2782 (23.8%)
11.0% ± 5.4% 5.5% ± 5.4% 0.7% ± 3.5% 15.8% ± 3.0%

(Continues)

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
136 p. frisk et al.
Table 3. Continued
Survey no. n (survey) 0–44 yrs 45–64 yrs 65–74 yrs 75+ yrs
n (register)

Diff prop ± C.I.95%

22 1546 603 (39.0%)* 615 (39.8%)* 180 (11.6%)* 148 (9.6%)*

23 103 6116 (26.5%) 8504 (36.8%) 3364 (14.6%) 5119 (22.2%)
12.5% ± 2.5% 3.0% ± 2.5% 2.9% ± 1.7% 12.6% ± 1.6%
23 375 36 (9.6%)* 163 (43.5%)* 103 (27.5%) 73 (19.5%)*
9000 503 (5.6%) 2892 (32.1%) 2221 (24.7%) 3384 (37.6%)
4.0% ± 3.0% 11.3% ± 5.1% 2.8% ± 4.6% 18.1% ± 4.1%
24 391 195 (49.9%)* 160 (40.9%) 24 (6.1%)* 12 (3.1%)*
13 394 4868 (36.3%) 6061 (45.3%) 1258 (9.4%) 1207 (9.0%)
13.5% ± 5.0% 4.3% ± 5.0% 3.3% ± 2.5% 5.9% ± 1.8%
25 454 204 (44.9%)* 210 (46.3%) 27 (5.9%)* 13 (2.9%)*
14 080 4928 (35.0%) 6372 (45.3%) 1473 (10.5%) 1307 (9.3%)
9.9% ± 4.7% 1.0% ± 4.7% 4.5% ± 2.2% 6.4% ± 1.6%
26 423 39 (9.2%) 155 (36.6%)* 110 (26.0%) 119 (28.1%)*
15 768 1538 (9.8%) 4475 (28.4%) 3499 (22.2%) 6266 (39.7%)
0.5% ± 2.8% 8.3% ± 4.6% 3.8% ± 4.2% 11.6% ± 4.4%
27 359 53 (14.8%) 174 (48.5%)* 81 (22.6%) 51 (14.2%)*
13 411 1920 (14.3%) 5458 (40.7%) 2583 (19.3%) 3450 (25.7%)
0.4% ± 3.7% 7.8% ± 5.2% 3.3% ± 4.8% 11.5% ± 3.7%
28 210 2 (1.0%) 62 (29.5%)* 59 (28.1%) 87 (41.4%)*
12 043 122 (1.0%) 2405 (20.0%) 3098 (25.7%) 6418 (53.3%)
0.1% ± 1.3% 9.6% ± 6.2 2.4% ± 6.1% 11.9% ± 6.7%
29 265 6 (2.3%) 98 (37.0%) 99 (37.4%) 62 (23.4%)*
22 724 333 (1.5%) 7518 (33.1%) 7882 (34.7%) 6991 (30.8%)
0.8% ± 1.8% 3.9% ± 5.8% 2.7% ± 5.9% 7.4% ± 5.1%
30 29 21 (72.4%) 7 (24.1%) 0 (0%) 1 (3.4%)
634 375 (59.1%) 181 (28.5%) 56 (8.8%) 22 (3.5%)
13.3% ± 16.7% 4.4% ± 16.0% 0.0% ± 6.8%
31 418 3 (0.7%) 145 (34.7%)* 157 (37.6%) 113 (27.0%)*
24 211 364 (1.5%) 7283 (30.1%) 8222 (34.0%) 8342 (34.5%)
0.8% ± 0.8% 4.6% ± 4.6% 3.6% ± 4.7% 7.4% ± 4.3%

*Proportions with non-overlapping confidence intervals on the 95% level of confidence.

The results are presented with register data as a
reference, representing the whole population of actual
users. The survey is the data source being validated and
hence presented as either deviating from the register
population distribution or not. Register data indeed
represent data collected from the whole population.
Nevertheless, in this study, each set of register data is
limited by a specific time window, which only approxi-
mately corresponds to the data collection period for the
survey and therefore introduces a possible error.
The exact number and location of the pharmacies
involved differ somewhat between the surveys, since
all pharmacies not always participate. This may also
contribute to deviations in the age and gender
distribution of the survey population, especially in
surveys including drugs with regional differences in
prescribing patterns. The surveys were not originally
designed for inclusion in this study. Consequently,
some pharmacologic groups or patient groups are
underrepresented. Data on minors are only included
in three surveys; thus, an analysis of the representativ-
ity of data from minors in pharmacy-based surveys is
not possible. Furthermore, data of the individual
surveys were not stored with unique patient identifiers
to enable linkage between the different surveys
and register data. However, this study represents a large
number of surveys with a variety in therapeutic areas
and patient populations. This allows the results to be
generalized to pharmacy-based surveys in general, with
the limitations mentioned above taken into account.
CONCLUSION
Conducting patient surveys in pharmacies is a convenient
interview method, but the setting per se contributes to the
exclusion of some of the oldest patients, regardless of
what drug group is being studied. In pharmacy
surveys where the selection bias is expected to have
an impact on the main research question, data
should be collected alongside with survey data from
home interviews or other methods reaching the
oldest patients and thus contributing with the data
not captured in pharmacies.

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
 selection bias in pharmacy-based surveys 137
Table 4. Age distributions (men) within each survey and register sample, proportions presented within brackets
Survey no. n (survey) 0–44 yrs 45–64 yrs 65–74 yrs 75+ yrs
n (register)

Diff prop± C.I.95%

1 159 46 (28.9%) 76 (47.8%) 23 (14.5%) 14 (8.8%)

10 836 3186 (29.4%) 4721 (43.6%) 1854 (17.1%) 1075 (9.9%)
0.5% ± 7.1% 4.2% ± 7.8% 2.6% ± 5.5% 1.1% ± 4.4%
2 153 95 (62.1%)* 40 (26.1%)* 15 (9.8%) 3 (2.0%)
2994 1580 (52.8%) 999 (33.4%) 299 (10.0%) 116 (3.9%)
9.3% ± 7.9% 7.2% ± 7.2% 0.2% ± 4.8% 1.9% ± 2.3%
3 380 96 (25.3%) 174 (45.8%) 87 (22.9%)* 23 (6.1%)*
16 864 4922 (29.2%) 7174 (42.5%) 3004 (17.8%) 1764 (10.5%)
3.9% ± 4.4% 3.2% ± 5.1% 5.1% ± 4.3% 4.4% ± 2.4%
4 282 74 (26.2%) 142 (50.4%)* 50 (17.7%) 16 (5.7%)*
13 231 3666 (27.7%) 5719 (43.2%) 2473 (18.7%) 1373 (10.4%)
1.5% ± 5.2% 7.1% ± 5.9% 1.0% ± 4.5% 4.7% ± 2.8%
5 244 64 (26.2%) 109 (44.7%) 58 (23.8%) 13 (5.3%)*
14 961 3987 (26.6%) 6214 (41.5%) 3061 (20.5%) 1699 (11.4%)
0.4% ± 5.6% 3.1% ± 6.3% 3.3% ± 5.4% 6.0% ± 2.9%
6 226 66 (29.2%) 99 (43.8%) 45 (19.9%) 16 (7.1%)*
16 153 3993 (24.7%) 6465 (40.0%) 3631 (22.5%) 2064 (12.8%)
4.5% ± 6.0% 3.8% ± 6.5% 2.6% ± 5.2% 5.7% ± 3.4%
7 378 105 (27.8%) 122 (32.3%) 78 (20.6%) 73 (19.3%)
19 362 5682 (29.3%) 5862 (30.3%) 3695 (19.1%) 4123 (21.3%)
1.6% ± 4.6% 2.0% ± 4.8% 1.6% ± 4.1% 2.0% ± 4.0%
8 469 72 (15.4%)* 163 (34.8%) 133 (28.4%)* 101 (21.5%)
18 026 3820(21.2%) 5873 (32.6%) 4059 (22.5%) 4274 (23.7%)
5.8% ± 3.3% 2.2% ± 4.4% 5.8% ± 4.1% 2.2% ± 3.8%
9 501 133 (26.5%)* 167 (33.3%) 112 (22.4%) 89 (17.8%)*
17 223 3734 (21.7%) 5458 (31.7%) 3962 (23.0%) 4069 (23.6%)
4.9% ± 3.9% 1.6% ± 4.2% 0.6% ± 3.7% 5.9% ± 3.4%
10 41 6 (14.6%) 16 (39.0%) 12 (29.3%) 7 (17.1%)
382 70 (18.3%) 154 (40.3%) 95 (24.9%) 63 (16.5%)
3.7% ± 11.5% 1.3% ± 15.7% 4.4% ± 14.6% 0.6% ± 12.1%
11 46 8 (17.4%) 19 (41.3%) 10 (21.7%) 9 (19.6%)
412 70 (17.0%) 150 (36.4%) 108 (26.2%) 84 (20.4%)
0.4% ± 11.5% 4.9% ± 15.0% 4.5% ± 12.7% 0.8% ± 12.1%
12 229 0 (0%) 20 (8.7%) 57 (24.9%) 152 (66.4%)*
11 792 6 (0.1%) 719 (6.1%) 2422 (20.5%) 8635 (73.2%)
2.6% ± 3.7% 4.4% ± 5.7% 6.9% ± 6.2%
17 94 41 (43.6%) 43 (45.7%) 9 (9.6%) 1 (1.1%)
840 294 (35.0%) 404 (48.1%) 114 (13.6%) 28 (3.3%)
8.6% ± 10.5% 2.4% ± 10.6% 4.0% ± 6.4% 2.3% ± 2.4%
18 92 41 (44.6%) 38 (41.3%) 13 (14.1%) 0 (0%)
1234 509 (41.2%) 551 (44.7%) 144 (11.7%) 20 (2.4%)
3.3% ± 10.5% 3.3% ± 10.4% 2.5% ± 7.3%
19 187 74 (39.6%) 79 (42.2%)* 23 (12.3%) 11 (5.9%)*
9711 4126 (42.5%) 3322 (34.2%) 1169 (12.0%) 1094 (11.3%)
2.9% ± 7.1% 8.0% ± 7.1% 0.3 ± 4.8% 5.4% ± 3.4%
20 141 57 (40.4%) 61 (43.3%) 21 (14.9%) 2 (1.4%)*
2782 1138 (40.9%) 1024 (36.8%) 366 (13.2%) 254 (9.1%)
0.5% ± 8.3% 6.5% ± 8.4% 1.7% ± 6.0% 7.7% ± 2.2%
21 188 84 (44.7%)* 74 (39.4%) 19 (10.1%) 11 (5.9%)*
7510 2611 (34.8%) 2791 (37.2%) 988 (13.2%) 1120 (14.9%)
9.9% ± 7.2% 2.2% ± 7.1% 3.0% ± 4.4% 9.1% ± 3.5%
22 1025 450 (43.9%)* 405 (39.5%) 109 (10.6%)* 61 (6.0%)*
15 560 4987 (32.1%) 5974 (38.4%) 2319 (14.9%) 2280 (14.7%)
11.9% ± 3.1% 1.1% ± 3.1% 4.3% ± 2.0% 8.7% ± 1.6%
23 219 15 (6.8%) 78 (35.6%) 70 (32.0%) 56 (25.6%)*
5787 365 (6.3%) 1929 (33.3%) 1611 (27.8%) 1880 (32.5%)
0.5% ± 3.4% 2.3% ± 6.5% 4.1% ± 6.3% 6.9% ± 5.9%
24 143 62 (43.4%) 65 (45.5%) 14 (9.8%) 2 (1.4%)*
5766 2099 (36.4%) 2583 (44.8%) 681 (11.8%) 403 (7.0%)
7.0% ± 8.2% 0.7% ± 8.3% 2.0% ± 4.9% 5.6% ± 2.0%

(Continues)

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
138 p. frisk et al.
Table 4. Continued
Survey no. n (survey) 0–44 yrs 45–64 yrs 65–74 yrs 75+ yrs
n (register)

Diff prop± C.I.95%

25 167 74 (44.3%)* 79 (47.3%) 12 (7.2%)* 2 (1.2%)*

6185 2168 (35.1%) 2757 (44.6%) 826 (13.4%) 434 (7.0%)
9.3% ± 7.6% 2.7% ± 7.7% 6.2% ± 4.0% 5.8% ± 1.8%
26 144 11 (7.6%)* 54 (37.5%)* 40 (27.8%) 39 (27.1%)*
6172 940 (15.2%) 1630 (26.4%) 1348 (21.8%) 2254 (36.5%)
7.6% ± 4.4% 11.1% ± 8.0% 5.9% ± 7.4% 9.4% ± 7.4%
27 239 40 (16.7%) 125 (52.3%)* 41 (17.2%) 33 (13.8%)*
10 343 1598 (15.5%) 4590 (44.4%) 2080 (20.1%) 2075 (20.1%)
1.3% ± 4.8% 7.9% ± 6.4 % 3.0% ± 4.8% 6.3% ± 4.4%
28 367 4 (1.1%) 139 (37.9%)* 130 (35.4%)* 94 (25.6%)*
17 261 290 (1.7%) 5579 (32.3%) 5164 (29.9%) 6228 (36.1%)
0.6% ± 1.1% 5.6% ± 5.0% 5.5% ± 4.9% 10.5% ± 4.5%
29 329 12 (3.6%) 161 (48.9%) 105 (31.9%) 51 (15.5%)*
28 324 970 (3.4%) 12 846 (45.4%) 8955 (31.6%) 5553 (19.6%)
0.2% ± 2.0% 3.6% ± 5.4% 0.3% ± 5.1% 4.1% ± 3.9%
30 10 9 (90%)* 0 (0%) 0 (0%) 1 (10.0%)
399 265 (66.4%) 92 (23.1%) 25 (6.3%) 17 (4.3%)
23.6% ± 19.2% 5.7% ± 18.7%
31 172 4 (2.3%) 45 (26.2%) 81 (47.1%)* 42 (24.4%)*
11 344 310 (2.7%) 3409 (30.1%) 4029 (35.5%) 3596 (31.7%)
0.4% ± 2.3% 3.9% ± 6.6% 11.6% ± 7.5% 7.3% ± 6.5%

*Proportions with non-overlapping confidence intervals on the 95% level of confidence.

CONFLICT OF INTEREST REFERENCES

The authors declare no conflict of interest.
KEY POINTS
• Pharmacy surveys on prescription drugs,
conducted in pharmacies and enrolling only
those who appear at the pharmacy themselves,
do not provide representative data on patients
aged 75 years or older.
• This selection bias appears, to a varying extent,
in all therapeutic areas studied
• For pharmacy-based surveys to provide valid
data representative of all patients, data should
be collected alongside with data from other
methods reaching the oldest patients.
ACKNOWLEDGEMENTS
We gratefully acknowledge the staff at all the pharmacies
involved in the regular collection of survey data.
This study was funded by the Swedish Academy of
Pharmaceutical Sciences. The individual surveys
included were commissioned and funded by the
pharmaceutical companies holding the marketing li-
cense for each drug and the Dental and Pharmaceutical
Benefits Agency, respectively.
1. Lee TH, Emanuel EJ. Perspective. Tier 4 drugs and the fraying of the social
compact. N Engl J Med 2008; 359: 333–335.
2. Zuvekas SH, Cohen JW. Prescription drugs and the changing concentration of
health care expenditures. Health Aff 2007; 26: 249–257.
3. Schneeweiss S, Avorn J. A review of uses of health care utilization databases for
epidemiologic research on therapeutics. J Clin Epidemiol 2005; 58: 323–337.
4. Eichler, HG, Abadie E, Breckenridge A, et al. Bridging the efficacy-
effectiveness gap: a regulator’s perspective on addressing variability of drug
response. Nat Rev Drug Discov 2011; 10: 495–506.
5. Lu CY. Observational studies: A review of study designs, challenges and
strategies to reduce confounding. Int J Clin Pract 2009; 63: 691–697.
6. Hartzema AG, Tilson HH, Chan KA (eds.). Pharmacoepidemiology and
Therapeutic Risk Management. Harvey Whitney books: Cincinatti, USA, 2008.
7. Wettermark B, Hammar N, MichaelFored C, et al. The new Swedish Prescribed
Drug Register - opportunities for pharmacoepidemiological research and experi-
ence from the first six months. Pharmacoepidemiol Drug Saf 2007; 16: 726–735.
8. Haukka J, Suvisaari J, Tuulio-Henriksson A, Lönnqvist J. High concordance
between self-reported medication and official prescription database information.
Eur J Clin Pharmacol 2007; 63: 1069–1074.
9. Nielsen MW, Søndergaard B, Kjøller M, Hansen EH. Agreement between self-
reported data on medicine use and prescription records vary according to method
of analysis and therapeutic group. J Clin Epidemiol 2008; 61: 919–924.
doi:10.1016/j.jclinepi.2007.10.021
10. Grimsmo A, Hagman E, Faikø E, et al. Patients, diagnoses and processes in
general practice in the Nordic countries. An attempt to make data from
computerised medical records available for comparable statistics. Scand J Prim
Health Care 2001; 19: 76–82.
11. Wettermark B, Vlahovic-Palcevski V, Salvesen Blix H, Rønning M, Vander
Stichele RH. Drug Utilization Research. In Pharmacoepidemiology and
Therapeutic Risk Assessment. Hartzema AG, Tilson HH and Chan KA (eds).
Harvey Whitney books: Cincinatti, USA, 2008: 159–195.
12. Heerdink ER, Leufkens HG, Koppedraaijer C, Bakker A. Information on drug
use in the elderly: a comparison of pharmacy, general-practitioner and patient
data. Pharm World Sci 1995; 17: 20–24.
13. Orrico KB. Sources and types of discrepancies between electronic medical records
and actual outpatient medication use. J Manag Care Pharm 2008; 7: 626–631.
14. Ekedahl A, Brosius H, Jönsson J, et al. Discrepancies between the electronic
medical record, the prescriptions in the Swedish national prescription repos-
itory and the current medication reported by patients. Pharmacoepidemiol
Drug Saf 2011; 11: 1177–1183. doi: 10.1002/pds.2226. Epub 2011 Aug 22.

Copyright © 2013 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds
 selection bias in pharmacy-based surveys
15. Lau HS, de Boer A, Beuning KS, Porsius A. Validation of pharmacy records in
drug exposure assessment. J Clin Epidemiol 1997; 5: 619–625.
16. Monster TB, Janssen WM, de Jong PE, de Jong-van den Berg LT. PREVEND
Study Group Prevention of REnal and Vascular ENT Stage Disease Pharmacy
data in epidemiological studies: an easy to obtain and reliable tool.
Pharmacoepidemiol Drug Saf 2002; 11: 379–384.
17. Noize P, Bazin F, Dufouil C, et al. Comparison of health insurance claims and
patient interviews in assessing drug use: data from the Three-City (3C) Study.
Pharmacoepidemiol Drug Saf 2009; 18: 310–319.
18. Frisk P, Mellgren TO, Hedberg N, et al. Utilisation of angiotensin
receptor blockers in Sweden: combining survey and register data to study
adherence to prescribing guidelines. Eur J Clin Pharmacol 2008;
64: 1223–1229.
19. Frisk P, Rydberg T, Carlsten A, Ekedahl A. Patients´ experiences with
generic substitution – a Swedish pharmacy survey. J Pharm Health Serv Res
2011; 2: 9–15.
20. Bradburn N, Sudman S, Wansink B. Asking Questions: The definitive guide to
questionnaire design. John Wiley & Sons: San Francisco, USA, 2004.
21. Carvajal A, Arias LH, Vega E, et al. Gastroprotection during the administration
of non-steroidal antiinflammatory drugs. A drug utilization-study. Eur J Clin
Pharmacol 2004; 60: 439–444.
22. Motola G, Mazzeo F, Rinaldi B, et al. Self-prescribed laxative use: a drug-
utilization review. Adv Ther 2002; 19: 203–208.
23. Gislason T, Olafson O, Sigvaldason A. Use of antiasthma drugs in Iceland: a
drug utilization study. Eur Respir J 1997; 10: 1230–1234.
24. Mehuys E, Paemeleire K, Van Hees T, et al. Self-medication of regular head-
ache: A community pharmacy-based survey. Eur J Neurol 2012; 19: 1093–1099.
25. World Health Organization (WHO). Guidelines for ATC classification and DDD
assignment. WHO Collaborating Center for Drug Statistics Methodology, Oslo,
2012. www.whocc.no
Copyright © 2013 John Wiley & Sons, Ltd.
139
26. Swedish National Board of Health and Welfare. Läkemedel - statistik för år 2012.
Socialstyrelsen: Stockholm, 2012 [Drug statistics for 2012] Available from: http://
www.socialstyrelsen.se/publikationer2013/2013-3-21 [27 April 2013].
27. Altman DG, Machin D, Bryant NB, Gardner MJ. Statistics with confidence
(2nd ed). BMJ Books, 2000.
28. Caskie GI, Willis SL. Congruence of self-reported medications with pharmacy pre-
scription records in low-income older adults. Gerontologist 2004; 44: 176–185.
29. Klungel OH, de Boer A, Paes AH, et al. Agreement between self-reported anti-
hypertensive drug use and pharmacy records in a population-based study in The
Netherlands. Pharm World Sci 1999; 21: 217–220.
30. Boudreau DM, Daling JR, Malone KE, et al. A validation study of patient
interview data and pharmacy records for antihypertensive, statin, and
antidepressant medication use among older women. Am J Epidemiol 2004;
159: 308–317.
31. Jensen E, Schroll M. A 30-year survey of drug use in the 1914 birth cohort in
Glostrup County, Denmark: 1964–1994. Aging Clin Exp Res 2008; 20: 145–152.
32. Bjerrum L, Sogaard J, Hallas J, Kragstrup J. Polypharmacy: Correlation with sex,
age and drug regimen. Eur J Clin Pharmacol 1998; 54: 197–202.
33. Nobili A, Franchi C, Pasina L, et al. Drug utilization and polypharmacy in an
Italian elderly population: the EPIFARM-Elderly Project. Pharmacoepidemiol
Drug Saf 2011; 20: 488–496.
34. Drug dispensing data from 2011 from the Swedish Prescribed Drug Register.
35. Rikala M, Hartikainen S, Sulkava R, Korhonen MJ. Validity of the Finnish
Prescription Register for measuring psychotropic drug exposures among
elderly finns: a population-based intervention study. Drugs Aging 2010;
27: 337–349.
36. Virués-Ortega J, de Pedro-Cuesta J, Seijo-Martinez M et al. Prevalence of dis-
ability in a composite ≥ 75 year-old population in Spain: A screening survey
based on the International Classification of Functioning. BMC Public Health
2011; 11: 176. http://www.biomedcentral.com/1471-2458/11/176
Pharmacoepidemiology and Drug Safety, 2014; 23: 128–139
DOI: 10.1002/pds