Does subsidized orthodontic treatment reduce inequalities in access? Evidence from Norway based on population register data.

OBJECTIVE: An important part of Norwegian welfare policy is to provide subsidized orthodontic treatment for children and adolescents. The objective of this policy is that dental services should be allocated according to children's need for treatment, and not according to parents' ability to pay. The probability of receiving orthodontic treatment independent of parent's household income was examined. METHODS: The study population encompassed children and adolescents aged 10-18 years in 2019 (n = 354 439). Information about whether they had started orthodontic treatment was obtained from the Norwegian Health Economics Administration. The key independent variable was net equalized household income. Inequalities were measured using concentration indices, which were estimated according to the severity of the malocclusion (very great need, great need, obvious need and no need). Two indices were used to measure relative inequality: the unstandardized concentration index and the partial concentration index. Absolute inequality was measured using the corrected concentration index. Relevant control variables were included in some of the analyses. RESULTS: The unstandardized indices were in the range 0.04 (very great need) to 0.05 (obvious need). For all three groups of severity, the 95% confidence intervals overlapped. The values of the partial indices were significantly lower than the values of the unstandardized indices. The partial indices were in the range 0.008 (very great need) to 0.03 (obvious need). The 95% confidence intervals for the partial indices did not overlap with the 95% confidence intervals of the unstandardized indices. For all three groups of severity, the indices that measured absolute inequality were close to zero. CONCLUSIONS: It is possible to achieve the egalitarian aim of equality in service provision by subsidizing orthodontic treatment. This is possible within a system where the cost of orthodontic treatment is reimbursed according to the criteria of need. These criteria function in such a way that patients with the greatest need for orthodontic treatment are given the highest priority.

Production losses from morbidity and mortality by disease, age and sex in Norway.

AIM: The inclusion of production losses in health care priority setting is extensively debated. However, few studies allow for a comparison of these losses across relevant clinical and demographic categories. Our objective was to provide comprehensive estimates of Norwegian production losses from morbidity and mortality by age, sex and disease category. METHODS: National registries, tax records, labour force surveys, household and population statistics and data from the Global Burden of Disease were combined to estimate production losses for 12 disease categories, 38 age and sex groups and four causes of production loss. The production losses were estimated via lost wages in accordance with a human capital approach for 2019. RESULTS: The main causes of production losses in 2019 were mental and substance use disorders, totalling NOK121.6bn (32.7% of total production losses). This was followed by musculoskeletal disorders, neurological disorders, injuries, and neoplasms, which accounted for 25.2%, 7.4%, 7.4% and 6.5% of total production losses, respectively. Production losses due to sick leave, disability insurance and work assessment allowance were higher for females than for males, whereas production losses due to premature mortality were higher for males. The latter was related to neoplasms, cardiovascular disease and injuries. Across age categories, non-fatal conditions with a high prevalence among working populations caused the largest production losses. CONCLUSIONS: The inclusion of production losses in health care priority debates in Norway could result in an emphasis on chronic diseases that occur among younger populations at the expense of fatal diseases among older age groups.

Disease-specific health spending by age, sex, and type of care in Norway: a national health registry study.

BACKGROUND: Norway is a high-income nation with universal tax-financed health care and among the highest per person health spending in the world. This study estimates Norwegian health expenditures by health condition, age, and sex, and compares it with disability-adjusted life-years (DALYs). METHODS: Government budgets, reimbursement databases, patient registries, and prescription databases were combined to estimate spending for 144 health conditions, 38 age and sex groups, and eight types of care (GPs; physiotherapists & chiropractors; specialized outpatient; day patient; inpatient; prescription drugs; home-based care; and nursing homes) totaling 174,157,766 encounters. Diagnoses were in accordance with the Global Burden of Disease study (GBD). The spending estimates were adjusted, by redistributing excess spending associated with each comorbidity. Disease-specific DALYs were gathered from GBD 2019. RESULTS: The top five aggregate causes of Norwegian health spending in 2019 were mental and substance use disorders (20.7%), neurological disorders (15.4%), cardiovascular diseases (10.1%), diabetes, kidney, and urinary diseases (9.0%), and neoplasms (7.2%). Spending increased sharply with age. Among 144 health conditions, dementias had the highest health spending, with 10.2% of total spending, and 78% of this spending was incurred at nursing homes. The second largest was falls estimated at 4.6% of total spending. Spending in those aged 15-49 was dominated by mental and substance use disorders, with 46.0% of total spending. Accounting for longevity, spending per female was greater than spending per male, particularly for musculoskeletal disorders, dementias, and falls. Spending correlated well with DALYs (Correlation r = 0.77, 95% CI 0.67-0.87), and the correlation of spending with non-fatal disease burden (r = 0.83, 0.76-0.90) was more pronounced than with mortality (r = 0.58, 0.43-0.72). CONCLUSIONS: Health spending was high for long-term disabilities in older age groups. Research and development into more effective interventions for the disabling high-cost diseases is urgently needed.

Inequality in quality-adjusted life expectancy by educational attainment in Norway: an observational study.

BACKGROUND: Health inequalities are often assessed in terms of life expectancy or health-related quality of life (HRQoL). Few studies combine both aspects into quality-adjusted life expectancy (QALE) to derive comprehensive estimates of lifetime health inequality. Furthermore, little is known about the sensitivity of estimated inequalities in QALE to different sources of HRQoL information. This study assesses inequalities in QALE by educational attainment in Norway using two different measures of HRQoL. METHODS: We combine full population life tables from Statistics Norway with survey data from the Tromsø study, a representative sample of the Norwegian population aged ≥ 40. HRQoL is measured using the EQ-5D-5L and EQ-VAS instruments. Life expectancy and QALE at 40 years of age are calculated using the Sullivan-Chiang method and are stratified by educational attainment. Inequality is measured as the absolute and relative gap between individuals with lowest (i.e. primary school) and highest (university degree 4 + years) educational attainment. RESULTS: People with the highest educational attainment can expect to live longer lives (men: + 17.9% (95%CI: 16.4 to 19.5%), women: + 13.0% (95%CI: 10.6 to 15.5%)) and have higher QALE (men: + 22.4% (95%CI: 20.4 to 24.4%), women: + 18.3% (95%CI: 15.2 to 21.6%); measured using EQ-5D-5L) than individuals with primary school education. Relative inequality is larger when HRQoL is measured using EQ-VAS. CONCLUSION: Health inequalities by educational attainment become wider when measured in QALE rather than LE, and the degree of this widening is larger when measuring HRQoL by EQ-VAS than by EQ-5D-5L. We find a sizable educational gradient in lifetime health in Norway, one of the most developed and egalitarian societies in the world. Our estimates provide a benchmark against which other countries can be compared.

Third dose mRNA vaccination against SARS-CoV-2 reduces medical complaints seen in primary care: a matched cohort study.

BACKGROUND: SARS-CoV-2 mRNA vaccination has been associated with both side effects and a reduction in COVID-related complaints due to the decrease in COVID-19 incidence. We aimed to investigate if individuals who received three doses of SARS-CoV-2 mRNA vaccines had a lower incidence of (a) medical complaints and (b) COVID-19-related medical complaints, both as seen in primary care, when compared to individuals who received two doses. METHODS: We conducted a daily longitudinal exact one-to-one matching study based on a set of covariates. We obtained a matched sample of 315,650 individuals aged 18-70 years who received the 3rd dose at 20-30 weeks after the 2nd dose and an equally large control group who did not. Outcome variables were diagnostic codes as reported by general practitioners or emergency wards, both alone and in combination with diagnostic codes of confirmed COVID-19. For each outcome, we estimated cumulative incidence functions with hospitalization and death as competing events. RESULTS: We found that the number of medical complaints was lower in individuals aged 18-44 years who received three doses compared to those who received two doses. The differences in estimates per 100,000 vaccinated were as follows: fatigue 458 less (95% confidence interval: 355-539), musculoskeletal pain 171 less (48-292), cough 118 less (65-173), heart palpitations 57 less (22-98), shortness of breath 118 less (81-149), and brain fog 31 less (8-55). We also found a lower number of COVID-19-related medical complaints: per 100,000 individuals aged 18-44 years vaccinated with three doses, there were 102 (76-125) fewer individuals with fatigue, 32 (18-45) fewer with musculoskeletal pain, 30 (14-45) fewer with cough, and 36 (22-48) fewer with shortness of breath. There were no or fewer differences in heart palpitations (8 (1-16)) or brain fog (0 (- 1-8)). We observed similar results, though more uncertain, for individuals aged 45-70 years, both for medical complaints and for medical complaints that were COVID-19 related. CONCLUSIONS: Our findings suggest that a 3rd dose of SARS-CoV-2 mRNA vaccine administered 20-30 weeks after the 2nd dose may reduce the incidence of medical complaints. It may also reduce the COVID-19-related burden on primary healthcare services.

Post-covid medical complaints following infection with SARS-CoV-2 Omicron vs Delta variants.

The SARS-CoV-2 Omicron (B.1.1.529) variant has been associated with less severe acute disease, however, concerns remain as to whether long-term complaints persist to a similar extent as for earlier variants. Studying 1 323 145 persons aged 18-70 years living in Norway with and without SARS-CoV-2 infection in a prospective cohort study, we found that individuals infected with Omicron had a similar risk of post-covid complaints (fatigue, cough, heart palpitations, shortness of breath and anxiety/depression) as individuals infected with Delta (B.1.617.2), from 14 to up to 126 days after testing positive, both in the acute (14 to 29 days), sub-acute (30 to 89 days) and chronic post-covid (≥90 days) phases. However, at ≥90 days after testing positive, individuals infected with Omicron had a lower risk of having any complaint (43 (95%CI = 14 to 72) fewer per 10,000), as well as a lower risk of musculoskeletal pain (23 (95%CI = 2-43) fewer per 10,000) than individuals infected with Delta. Our findings suggest that the acute and sub-acute burden of post-covid complaints on health services is similar for Omicron and Delta. The chronic burden may be lower for Omicron vs Delta when considering musculoskeletal pain, but not when considering other typical post-covid complaints.

Impact of COVID-19 on pregnancy-related healthcare utilisation: a prospective nationwide registry study.

OBJECTIVE: To assess the impact of COVID-19 on pregnancy-related healthcare utilisation and differences across social groups. DESIGN: Nationwide longitudinal prospective registry-based study. SETTING: Norway. PARTICIPANTS: Female residents aged 15-50 years (n=1 244 560). MAIN OUTCOME MEASURES: Pregnancy-related inpatient, outpatient and primary care healthcare utilisation before the COVID-19 pandemic (prepandemic: 1 January to 11 March 2020), during the initial lockdown (first wave: 12 March to 3 April 2020), during the summer months of low restrictions (summer period: 4 April to 31 August 2020) and during the second wave to the end of the year (second wave: 1 September to 31 December 2020). Rates were compared with the same time periods in 2019. RESULTS: There were 130 924 inpatient specialist care admissions, 266 015 outpatient specialist care consultations and 2 309 047 primary care consultations with pregnancy-related diagnostic codes during 2019 and 2020. After adjusting for time trends and cofactors, inpatient admissions were reduced by 9% (adjusted incidence rate ratio (aIRR)=0.91, 95% CI 0.87 to 0.95), outpatient consultations by 17% (aIRR=0.83, 95% CI 0.71 to 0.86) and primary care consultations by 10% (aIRR=0.90, 95% CI 0.89 to 0.91) during the first wave. Inpatient care remained 3%-4% below prepandemic levels throughout 2020. Reductions according to education, income and immigrant background were also observed. Notably, women born in Asia, Africa or Latin America had a greater reduction in inpatient (aIRR=0.87, 95% CI 0.77 to 0.97) and outpatient (aIRR 0.90, 95% CI 0.86 to 0.95) care during the first wave, compared with Norwegian-born women. We also observed that women with low education had a greater reduction in inpatient care during summer period (aIRR=0.88, 95% CI 0.83 to 0.92), compared with women with high educational attainment. CONCLUSION: Following the introduction of COVID-19 mitigation measures in Norway in March 2020, there were substantial reductions in pregnancy-related healthcare utilisation, especially during the initial lockdown and among women with an immigrant background.

General practitioner visits after SARS-CoV-2 omicron compared with the delta variant in children in Norway: a prospective nationwide registry study.

BACKGROUND: SARS-CoV-2 infection in children is followed by an immediate increase in primary care utilisation. The difference in utilisation following infection with the delta and omicron virus variants is unknown. OBJECTIVES: To study whether general practitioner (GP) contacts were different in children infected with the omicron versus delta variant for up to 4 weeks after the week testing positive. SETTING: Primary care. PARTICIPANTS: All residents in Norway aged 0-10. After excluding 47 683 children with a positive test where the virus variant was not identified as delta or omicron and 474 children who were vaccinated, the primary study population consisted of 613 448 children. MAIN OUTCOME MEASURES: GP visits. METHODS: We estimated the difference in the weekly share visiting the GP after being infected with the delta or omicron variant to those in the study population who were either not tested or who tested negative using an event study design, controlling for calendar week of consultation, municipality fixed effects and sociodemographic factors in multivariate logistic regressions. RESULTS: Compared with preinfection, increased GP utilisation was found for children 1 and 2 weeks after testing positive for the omicron variant, with an OR of 6.7 (SE: 0.69) in the first week and 5.5 (0.72) in the second week. This increase was more pronounced for children with the delta variant, with an OR of 8.2 (0.52) in the first week and 7.1 (0.93) in the second week. After 2 weeks, the GP utilisation returned to preinfection levels. CONCLUSION: The omicron variant appears to have resulted in less primary healthcare interactions per infected child compared with the delta variant.

Association of COVID-19 Vaccination During Pregnancy With Incidence of SARS-CoV-2 Infection in Infants.

Importance: Pregnant women are recommended to receive COVID-19 vaccination to reduce risk of severe COVID-19. Whether vaccination during pregnancy also provides passive protection to infants after birth remains unclear. Objective: To determine whether COVID-19 vaccination in pregnancy was associated with reduced risk of COVID-19 in infants up to age 4 months during COVID-19 pandemic periods dominated by Delta and Omicron variants. Design, Setting, and Participants: This nationwide, register-based cohort study included all live-born infants born in Norway between September 1, 2021, and February 28, 2022. Exposures: Maternal messenger RNA COVID-19 vaccination during second or third trimester compared with no vaccination before or during pregnancy. Main Outcomes and Measures: The risk of a positive polymerase chain reaction test result for SARS-CoV-2 during an infant's first 4 months of life by maternal vaccination status during pregnancy with either dose 2 or 3 was estimated, as stratified by periods dominated by the Delta variant (between September 1 and December 31, 2021) or Omicron variant (after January 1, 2022, to the end of follow-up on April 4, 2022). A Cox proportional hazard regression was used, adjusting for maternal age, parity, education, maternal country of birth, and county of residence. Results: Of 21 643 live-born infants, 9739 (45.0%) were born to women who received a second or third dose of a COVID-19 vaccine during pregnancy. The first 4 months of life incidence rate of a positive test for SARS-CoV-2 was 5.8 per 10 000 follow-up days. Infants of mothers vaccinated during pregnancy had a lower risk of a positive test compared with infants of unvaccinated mothers and lower risk during the Delta variant-dominated period (incidence rate, 1.2 vs 3.0 per 10 000 follow-up days; adjusted hazard ratio, 0.29; 95% CI, 0.19-0.46) compared with the Omicron period (incidence rate, 7.0 vs 10.9 per 10 000 follow-up days; adjusted hazard ratio, 0.67; 95% CI, 0.57-0.79). Conclusions and Relevance: The results of this Norwegian population-based cohort study suggested a lower risk of a positive test for SARS-CoV-2 during the first 4 months of life among infants born to mothers who were vaccinated during pregnancy. Maternal COVID-19 vaccination may provide passive protection to young infants, for whom COVID-19 vaccines are currently not available.

The educational burden of disease: a cohort study.

BACKGROUND: Students with health disorders might be at risk of disengaging from education, which can reinforce socioeconomic inequalities in health. We aimed to evaluate the associations between 176 diseases and injuries and later school performance in Norwegian adolescents and to estimate the importance of each disorder using a novel measure for the educational burden of disease (EBoD). METHODS: We used diagnostic information from government-funded health services for all Norwegian inhabitants who were born between Jan 1, 1995, and Dec 31, 2002, were registered as living in Norway at age 11-16 years, and were participating in compulsory education. School performance was assessed as grade point average at the end of compulsory education at age 16 years. We used a linear regression of school performance on disease in a fixed-effects sibling comparison model (113 411 families). The association (regression coefficients) between disease and school performance was multiplied by disease prevalence to estimate the proportional EBoD among 467 412 individuals participating in compulsory education. FINDINGS: Overall, although most diseases were not meaningfully associated with grade point average (regression coefficients close to 0), some were strongly associated (eg, intellectual disability regression coefficients -1·2 for boys and -1·3 for girls). The total educational disease burden was slightly higher for girls (53·5%) than for boys (46·5%). Mental health disorders were associated with the largest educational burden among adolescents in Norway (total burden 44·6%; boys 24·6% vs girls 20·0%), of which hyperkinetic disorder contributed to 22·1% of the total burden (boys 14·6% vs girls 7·5%). Among somatic diseases, those with unknown causes and possibly mental causes were associated with the largest educational burden. INTERPRETATION: The EBoD concept could provide a simple metric to guide researchers and policy makers. Because mental health disorders form a large component of the educational burden, investment in mental health might be particularly important for improving educational outcomes in adolescents. FUNDING: The Research Council of Norway.

Body mass index and healthcare costs: using genetic variants from the HUNT study as instrumental variables.

BACKGROUND: Past studies have found associations between obesity and healthcare costs, however, these studies have suffered from bias due to omitted variables, reverse causality, and measurement error. METHODS: We used genetic variants related to body mass index (BMI) as instruments for BMI; thereby exploiting the natural randomization of genetic variants that occurs at conception. We used data on measured height and weight, genetic information, and sociodemographic factors from the Nord-Trøndelag Health Studies (HUNT), and individual-level registry data on healthcare costs, educational level, registration status, and biological relatives. We studied associations between BMI and general practitioner (GP)-, specialist-, and total healthcare costs in the Norwegian setting using instrumental variable (IV) regressions, and compared our findings with effect estimates from ordinary least squares (OLS) regressions. The sensitivity of our findings to underlying IV-assumptions was explored using two-sample Mendelian randomization methods, non-linear analyses, sex-, healthcare provider-, and age-specific analyses, within-family analyses, and outlier removal. We also conducted power calculations to assess the likelihood of detecting an effect given our sample 60,786 individuals. RESULTS: We found that increased BMI resulted in significantly higher GP costs; however, the IV-based effect estimate was smaller than the OLS-based estimate. We found no evidence of an association between BMI and specialist or total healthcare costs. CONCLUSIONS: Elevated BMI leads to higher GP costs, and more studies are needed to understand the causal mechanisms between BMI and specialist costs.

Inequality in access to dental services in a market-based dental care system: A population study from Norway 1975-2018.

OBJECTIVE: To examine income-related inequalities in access to dental services from 1975 to 2018. In Norway, dental care services for adults are privately financed. This may lead to income-related inequalities in access. In the early 1970s, that is, at the beginning of the study period, there were marked inequalities in access to dental services according to personal income. However, from the beginning of the 1970s, there has been a large increase in gross national income per capita in Norway as a result of the growth of the oil and gas industry. This increase in income also meant that people with a low income in 1975 had a rise in their level of income. According to the law of diminishing utility, an increase in income leads to higher consumption of dental services for people with a low level of income compared to people with a high level of income. The study hypothesis is that the inequalities in access to dental services that existed in 1975 became less over time. METHODS: Statistics Norway collected samples of cross-sectional health survey data for the following years: 1975, 1985, 1995, 2002, 2008, 2012 and 2018. For each sample, individuals 21 years and older were drawn randomly from the non-institutionalized adult population using a two-stage stratified cluster sample technique. Inequalities were measured using the concentration index. The dependent variable was the use of dental services during the last year, and the key independent variable was equivalized household income. RESULTS: The concentration index for inequalities in use of dental services according to income decreased from 0.10 (95% CI = 0.09, 0.11) in 1975 to 0.04 (95% CI = 0.03, 0.05) in 2018. The decrease was particularly large from 2002 to 2012. This was a period with a large growth in gross national income. CONCLUSION: People with a low income had a marked increase in their purchasing power from 1975 to 2018. This coincided with an increase in demand for dental care for this low-income group.

The impact of primary care physician density on perinatal health: Evidence from a natural experiment.

We examined the impact of primary care physician density on perinatal health outcomes in Norway. From 1992 and onwards, primary care physicians who chose to work in selected remote municipalities were given an annual reduction in their student loan. This reduction, combined with increased supply of physicians, led to an increase in the density of primary care physicians in these selected municipalities. Our register-based population study showed that this increase in physician density significantly improved perinatal health in terms of fewer fetal deaths and increased birth weight. The richness of the data allowed us to perform several robustness tests.

Parental income gradients in adult health: a national cohort study.

BACKGROUND: Disparities in health by adult income are well documented, but we know less about the childhood origins of health inequalities, and it remains unclear how the shape of the gradient varies across health conditions. This study examined the association between parental income in childhood and several measures of morbidity in adulthood. METHODS: We used administrative data on seven complete Norwegian birth cohorts born in 1967-1973 (N = 429,886) to estimate the association between parental income from birth to age 18, obtained from tax records available from 1967, linked with administrative registries on health. Health measures, observed between ages 39 and 43, were taken from registry data on consultations at primary health care services based on diagnostic codes from the International Classification of Primary Care (ICPC-2) and hospitalizations and outpatient specialist consultations registered in the National Patient Registry (ICD-10). RESULTS: Low parental income during childhood was associated with a higher risk of being diagnosed with several chronic and pain-related disorders, as well as hospitalization, but not overall primary health care use. Absolute differences were largest for disorders related to musculoskeletal pain, injuries, and depression (7-9 percentage point difference). There were also differences for chronic disorders such as hypertension (8%, CI 7.9-8.5 versus 4%, CI 4.1-4.7) and diabetes (3.2%, CI 3.0-3.4 versus 1.4%, CI 1.2-1.6). There was no difference in consultations related to respiratory disorders (20.9%, CI 20.4-21.5 versus 19.7%, CI 19.2-20.3). Childhood characteristics (parental education, low birth weight, and parental marital status) and own adult characteristics (education and income) explained a large share of the association. CONCLUSIONS: Children growing up at the bottom of the parental income distribution, compared to children in the top of the income distribution, had a two- to threefold increase in somatic and psychological disorders measured in adulthood. This shows that health inequalities by socioeconomic family background persist in a Scandinavian welfare-state context with universal access to health care.

Parental income and mental disorders in children and adolescents: prospective register-based study.

BACKGROUND: Children with low-income parents have a higher risk of mental disorders, although it is unclear whether other parental characteristics or genetic confounding explain these associations and whether it is true for all mental disorders. METHODS: In this registry-based study of all children in Norway (n = 1 354 393) aged 5-17 years from 2008 to 2016, we examined whether parental income was associated with childhood diagnoses of mental disorders identified through national registries from primary healthcare, hospitalizations and specialist outpatient services. RESULTS: There were substantial differences in mental disorders by parental income, except for eating disorders in girls. In the bottom 1% of parental income, 16.9% [95% confidence interval (CI): 15.6, 18.3] of boys had a mental disorder compared with 4.1% (95% CI: 3.3, 4.8) in the top 1%. Among girls, there were 14.2% (95% CI: 12.9, 15.5) in the lowest, compared with 3.2% (95% CI: 2.5, 3.9) in the highest parental-income percentile. Differences were mainly attributable to attention-deficit hyperactivity disorder in boys and anxiety and depression in girls. There were more mental disorders in children whose parents had mental disorders or low education, or lived in separate households. Still, parental income remained associated with children's mental disorders after accounting for parents' mental disorders and other factors, and associations were also present among adopted children. CONCLUSIONS: Mental disorders were 3- to 4-fold more prevalent in children with parents in the lowest compared with the highest income percentiles. Parents' own mental disorders, other socio-demographic factors and genetic confounding did not fully explain these associations.

Alcohol-attributed disease burden in four Nordic countries between 2000 and 2017: Are the gender gaps narrowing? A comparison using the Global Burden of Disease, Injury and Risk Factor 2017 study.

INTRODUCTION AND AIMS: The gender difference in alcohol use seems to have narrowed in the Nordic countries, but it is not clear to what extent this may have affected differences in levels of harm. We compared gender differences in all-cause and cause-specific alcohol-attributed disease burden, as measured by disability-adjusted life-years (DALY), in four Nordic countries in 2000-2017, to find out if gender gaps in DALYs had narrowed. DESIGN AND METHODS: Alcohol-attributed disease burden by DALYs per 100 000 population with 95% uncertainty intervals were extracted from the Global Burden of Disease database. RESULTS: In 2017, all-cause DALYs in males varied between 2531 in Finland and 976 in Norway, and in females between 620 in Denmark and 270 in Norway. Finland had the largest gender differences and Norway the smallest, closely followed by Sweden. During 2000-2017, absolute gender differences in all-cause DALYs declined by 31% in Denmark, 26% in Finland, 19% in Sweden and 18% in Norway. In Finland, this was driven by a larger relative decline in males than females; in Norway, it was due to increased burden in females. In Denmark, the burden in females declined slightly more than in males, in relative terms, while in Sweden the relative decline was similar in males and females. DISCUSSION AND CONCLUSIONS: The gender gaps in harm narrowed to a different extent in the Nordic countries, with the differences driven by different conditions. Findings are informative about how inequality, policy and sociocultural differences affect levels of harm by gender.

Socioeconomic Gradients in Mortality Following HF Hospitalization in a Country With Universal Health Care Coverage.

OBJECTIVES: This study explored the association between socioeconomic position (SEP) and long-term mortality following first heart failure (HF) hospitalization. BACKGROUND: It is not clear to what extent education and income-individually or combined-influence mortality among patients with HF. METHODS: This study included 49,895 patients, age 35+ years, with a first HF hospitalization in Norway during 2000 to 2014 and followed them until death or December 31, 2014. The association between education, income, and mortality was explored using Cox regression models, stratified by sex and age group (35 to 69 years and 70+ years). RESULTS: Compared with patients with primary education, those with tertiary education had lower mortality (adjusted hazard ratio [HR]: 0.89; 95% confidence interval [CI]: 0.78 to 0.99 in younger men; HR: 0.57; 95% CI: 0.43 to 0.75 in younger women; HR: 0.90; 95% CI: 0.84 to 0.97 in older men, and HR: 0.87; 95% CI: 0.81 to 0.93 in older women). After adjusting for educational differences, younger and older men and younger women in the highest income quintile had lower mortality compared with those in the lowest income quintile (HR: 0.63; 95% CI: 0.55 to 0.72; HR: 0.78; 95% CI: 0.63 to 0.96, and HR: 0.91; 95% CI: 0.86 to 0.97, respectively). The association between income and mortality was almost linear. No association between income and mortality was observed in older women. CONCLUSIONS: Despite the well-organized universal health care system in Norway, education and income were independently associated with mortality in patients with HF in a clear sex- and age group-specific pattern.

Body mass index and lifetime healthcare utilization.

BACKGROUND: Overweight and obesity is a major global public health challenge, and understanding the implications for healthcare systems is essential for policy planning. Past studies have typically found positive associations between obesity and healthcare utilization, but these studies have not taken into consideration that obesity is also associated with early mortality. We examined associations between body mass index (BMI, reported as kg/m2) and healthcare utilization with and without taking BMI-specific survival into consideration. METHODS: We used nationally representative data on 33 882 adults collected between 2002 and 2015. We computed BMI- and age-specific primary and secondary care utilization and multiplied the estimated values with gender-, age-, and BMI-specific probabilities of surviving to each age. Then, we summed the average BMI-specific utilization between 18 and 85 years. RESULTS: During a survival-adjusted lifetime, males with normal weight (BMI: 18.5-24.9) had, on average, 167 primary care, and 77 secondary care contacts. In comparison, males with overweight (BMI: 25.0-29.9), category I obesity (BMI: 30.0-34.9), and category II/III obesity (BMI ≥35.0) had 11%, 41%, and 102% more primary care, and 14%, 29%, and 78% more secondary care contacts, respectively. Females with normal weight had, on average, 210 primary care contacts and 91 secondary care contacts. Females with overweight, category I obesity, and category II/III obesity had 20%, 34%, and 81% more primary care contacts, and 26%, 16%, and 16% more secondary care contacts, respectively. CONCLUSION: The positive association between BMI and healthcare utilization was reduced, but not offset, when BMI-specific survival was taken into consideration. Our findings underpin previous research and suggest that interventions to offset the increasing prevalence of overweight, and especially obesity, are warranted.

Association of Household Income With Life Expectancy and Cause-Specific Mortality in Norway, 2005-2015.

Importance: Examining causes of death and making comparisons across countries may increase understanding of the income-related differences in life expectancy. Objectives: To describe income-related differences in life expectancy and causes of death in Norway and to compare those differences with US estimates. Design and Setting: A registry-based study including all Norwegian residents aged at least 40 years from 2005 to 2015. Exposures: Household income adjusted for household size. Main Outcomes and Measures: Life expectancy at 40 years of age and cause-specific mortality. Results: In total, 3 041 828 persons contributed 25 805 277 person-years and 441 768 deaths during the study period (mean [SD] age, 59.3 years [13.6]; mean [SD] number of household members per person, 2.5 [1.3]). Life expectancy was highest for women with income in the top 1% (86.4 years [95% CI, 85.7-87.1]) which was 8.4 years (95% CI, 7.2-9.6) longer than women with income in the lowest 1%. Men with the lowest 1% income had the lowest life expectancy (70.6 years [95% CI, 69.6-71.6]), which was 13.8 years (95% CI, 12.3-15.2) less than men with the top 1% income. From 2005 to 2015, the differences in life expectancy by income increased, largely attributable to deaths from cardiovascular disease, cancers, chronic obstructive pulmonary disease, and dementia in older age groups and substance use deaths and suicides in younger age groups. Over the same period, life expectancy for women in the highest income quartile increased 3.2 years (95% CI, 2.7-3.7), while life expectancy for women in the lowest income quartile decreased 0.4 years (95% CI, -1.0 to 0.2). For men, life expectancy increased 3.1 years (95% CI, 2.5-3.7) in the highest income quartile and 0.9 years (95% CI, 0.2-1.6) in the lowest income quartile. Differences in life expectancy by income levels in Norway were similar to differences observed in the United States, except that life expectancy was higher in Norway in the lower to middle part of the income distribution in both men and women. Conclusions and Relevance: In Norway, there were substantial and increasing gaps in life expectancy by income level from 2005 to 2015. The largest differences in life expectancy between Norway and United States were for individuals in the lower to middle part of the income distribution.