Cost of Illness of Head and Neck Cancer in Sweden.

OBJECTIVES: Head and neck cancer (HNC) is the sixth most common cancer worldwide. The condition and its treatment often lead to marked morbidities and, for some patients, premature death. Inferentially, HNC imposes a significant economic burden on society. This study aims to provide a comprehensive and detailed estimation of the cost of illness of HNC for Sweden in 2019. METHODS: This is a prevalence-based cost of illness study. Resource utilization and related costs are quantified using national registry data. A societal perspective is applied, including (1) direct costs for healthcare utilization, (2) costs for informal care from family and friends, and (3) costs for productivity loss due to morbidity and premature death. The human capital approach is used when estimating productivity losses. RESULTS: The societal cost of HNC for Sweden in 2019 was estimated at €92 million, of which the direct costs, costs for informal care, and costs for productivity loss represented 34%, 2%, and 64%, respectively. Oral cavity cancer was the costliest HNC, followed by oropharyngeal cancer, whereas nasopharyngeal cancer was the costliest per person. The cost of premature mortality comprised 60% of the total cost of productivity loss. Males accounted for 65% of direct costs and 67% of costs for productivity loss. CONCLUSIONS: The societal cost of HNC is substantial and constitutes a considerable burden to Swedish society. The results of the present study may be used by policymakers for planning and allocation of resources. Furthermore, the information may be used for future cost-effectiveness analyses.

Parental decisions to divorce and have additional children among families with children with cerebral palsy: Evidence from Swedish longitudinal and administrative data.

This study analyzes the relationship of having a child with the early-onset disability cerebral palsy (CP) and the parental decision to divorce and to have additional children. We use longitudinal matched case-control data from multiple linked Swedish National Population Registers between 2001 and 2015 and perform Cox proportional hazards regressions with interval-censoring. Although we do not find a general excess parental divorce risk on CP relative to the comparison group without CP, we find that having a child with CP increases the risk of divorce for parents with low education. We also find that having a child with CP reduces the likelihood of having additional children, especially for mothers in the older age range (maternal age at delivery >33 years) and parents with low education. The severity level of the disability, as indicated by gross motor function, is not related to the results. These findings should be understood in the Swedish context, which provides extensive welfare support (e.g., personal assistance). If future studies would find adverse results in countries with less social care and benefits, our results may indicate that it is possible to mitigate negative consequences for the family of a child with disability.

Healthcare costs of dementia diseases before, during and after diagnosis: Longitudinal analysis of 17 years of Swedish register data.

INTRODUCTION: This study examines health-care costs attributed to dementia diseases in the 10 years prior to, during, and 6 years after diagnosis. METHODS: Using administrative register data for people diagnosed with dementia (2010-2016) in southern Sweden (n = 21,184), and a comparison group without dementia, health-care costs over 17 years were examined using longitudinal regression analysis. RESULTS: Average annual health-care costs per person were consistently higher before diagnosis in the dementia group (10 years before: Swedish krona (SEK) 2063, P < .005 and 1 year before: SEK8166, P < .005). At diagnosis, health-care costs were more than twice as high (SEK44,410, P < .005). Four to 6 years after diagnosis, there was no significant different in costs compared to comparators. DISCUSSION: Excess health-care cost arise as early as 10 years before a formal diagnosis of dementia, and while there is a spike in cost after diagnosis, health-care costs are no different 4 years after. These findings question currently accepted assumptions on costs of dementia.

Evaluation of an Alternative Learning System for youths at risk of involvement in urban violence in the Philippines.

BACKGROUND: Globally, violence disproportionately affects young people, leading to injury, hospitalisation, death, social dysfunction, and poor mental wellbeing. Moreover, it has far-reaching economic consequences for whole nations, due to loss of productivity. Research suggests that attaining a higher level of education promotes factors that insulate youths from poverty and violence. PURPOSE: In this study, we investigated the outcomes, the cost, and the cost-effectiveness of a non-formal education program with an additional psychosocial component. The short-term outcome measure was an increase in educational attainment, a crucial step for youth empowerment. The program analysed was the Alternative Learning System (ALS) offered by the Balay Rehabiliation Centre in Bagong Silang, an urban slum in Manila, which targeted out of school youth. METHODS: The cost-effectiveness analysis of ALS compared to a 'do nothing approach' was performed from the perspective of the service provider. The study sample comprised 239 learners who were enrolled in the ALS during 2015-2018. For the 'do nothing' comparator, a counterfactual scenario was hypothesised. The average cost of the intervention per enrolled learner, and the incremental cost effectiveness ratio (ICER) for passing the Accreditation and Evaluation (A&E) exam at elementary or secondary level, were calculated. RESULTS: The ALS intervention studied resulted in 41% (n = 97) of the learners passing the examination over a period of four years (from 2015-2018). The estimated total cost of the intervention was $371,110, corresponding to $1550 per enrolled learner. The incremental cost-effectiveness ratio for a pass in the exam was found to be $3830. Compared to other, international, alternative learning interventions, the ALS intervention as used in Bagong Silang was found to be more cost-effective. CONCLUSION: From the service provider perspective, the ALS for out-of-school young people was found to be a valuable investment to benefit poor young people living in slums in Manila.

School outcomes of adolescents with cerebral palsy in Sweden.

AIM: To study school outcomes of adolescents with cerebral palsy (CP) compared with a matched comparison group from the general population, and to observe to what extent sociodemographic and disability-specific factors are associated with school outcomes. METHOD: This was a register study of persons with CP in Sweden, born between 1990 and 1999, with a matched comparison group. Logistic regressions were used to estimate the associations between CP and disability-specific factors and school outcomes (receiving final grades, grade scores, fulfilling the requirements for progressing to secondary school/university, and attending secondary school). RESULTS: Children with CP had substantially lower school achievement compared with a general population sample. Much of the difference can be attributed to intellectual disability; however, CP remained strongly negatively associated with school outcomes. Ability to communicate in an effective manner explained most of the variation in children with CP, whereas motor function played a smaller role. INTERPRETATION: The results suggest that school achievements might be improved if the communication barrier could be reduced, for example by ascertaining access to appropriate communication devices and by educators being aware that communicative difficulties do not necessarily imply intellectual disability. This might enhance the school experience and create an environment where children with CP can reach their full potential. WHAT THIS STUDY ADDS: There are reduced educational outcomes associated with cerebral palsy. Negative outcomes are mainly driven by reduced communicative and intellectual ability. Gross motor function is associated with outcomes, but plays a smaller part.

Prevalence of pain and interference with daily activities and sleep in adults with cerebral palsy.

AIM: To analyse the prevalence of pain, pain sites, pain severity, and pain interfering with work or daily activities and sleep in adults with cerebral palsy (CP). METHOD: This was a cross-sectional study based on data from 1591 adults (16-76y, median age 25y; 879 males, 712 females; Communication Function Classification System [CFCS] levels I-V) in the Swedish Cerebral Palsy Follow-up Program. Pain severity was rated for several body sites and pain interference with activities/work and sleep was also evaluated. Logistic regression was used to estimate the odds ratios (ORs) of the factors associated with the prevalence of pain and pain interfering with activities/work or sleep. RESULTS: Pain was reported in 1059 of 1591 adults; a higher proportion self-reported pain (69.9%) compared to proxy-reported pain (62.4%). More adults classified in CFCS level I (72.5%) reported pain compared to those in CFCS levels II to V (56.5-64.9%). Adults with severe/very severe pain had a sixfold risk of pain interfering with activity/work (OR=6.68; 95% CI 4.99-8.96) and sleep (OR=6.60; 95% CI 4.84-8.98). INTERPRETATION: Two-thirds of adults with CP experienced pain, which is likely to be underreported in individuals who do not communicate efficiently or rely on proxy reports. Pain strongly interfered with activities and sleep; thus, it must be assessed and treated more effectively.

Maternal health status and household food security on determining childhood anemia in Bangladesh -a nationwide cross-sectional study.

BACKGROUND: The aim of this study was to examine the effect of household food security on childhood anemia in Bangladesh while controlling for socioeconomic and demographic factors. METHODS: We used nationally representative Bangladesh Demographic Health Survey (BDHS) 2011 data for this study, the only existing survey including anemia information and household food security. The sample included 2171 children aged 6-59 months and their mothers. Differences between socioeconomic and demographic variables were analyzed using Chi-square test. Univariate and multivariate logistic regression analyses were performed to estimate the effects of different socioeconomic and demographic factors on childhood anemia. We also performed mediation analysis to examine the direct and indirect effect of household food security on childhood anemia. RESULTS: In Bangladesh, 53% male (95% CI: 50-56) and 51% female (95% CI: 47-54) children aged 6-59 months were anemic in 2011. The food insecure households have 1.20 times odds (95% CI: 0.97-1.48) of having anemic children comparing to food secure households in the unadjusted model. On the other hand, anemic mothers have 2 times odds (95% CI: 1.67-2.44) of having anemic children comparing to non-anemic mothers. However, household food security is no longer significantly associated with childhood anemia in the adjusted model while mothers' anemia remained a significant factor (OR 1.87: 95% CI: 1.53-2.29). Age of children is the highest associated factor, and the odds are 4.89 (95% CI: 3.21-7.45) for 6-12 months old children comparing to 49-59 months in the adjusted model. Stunting and household wealth are also a significant factor for childhood anemia. Although food security has no significant direct effect on childhood anemia, maternal anemia and childhood stunting mediated that relationship. CONCLUSIONS: Future public health policies need to focus on improving mothers' health with focusing on household food security to eliminate childhood anemia.

Economic evaluation of mindfulness group therapy for patients with depression, anxiety, stress and adjustment disorders compared with treatment as usual.

BACKGROUND: A randomised controlled trial found that a structured mindfulness group therapy (MGT) programme was as effective as treatment as usual (mostly cognitive-behavioural therapy) for patients with a diagnosis of depression, anxiety or stress and adjustment disorders in Sweden (ClinicalTrials.gov: NCT01476371). AIMS: To perform a cost-effectiveness analysis of MGT compared with treatment as usual from both a healthcare and a societal perspective for the trial duration (8 weeks). METHOD: The costs from a healthcare perspective included treatment as usual, medication and costs for providing MGT. The societal perspective included costs from the healthcare perspective plus savings from productivity gains for the trial duration. The effectiveness was measured as quality-adjusted life-years (QALY) using the EQ-5D-5L questionnaire and the UK value set. Uncertainty surrounding the incremental costs and effects were estimated using non-parametric bootstrapping with 5000 replications and presented with 95% confidence intervals and cost-effectiveness acceptability curves. RESULTS: The MGT group had significantly lower healthcare and societal costs (mean differences -€115 (95% CI -193 to -36) and -€112 (95% CI -207 to -17), respectively) compared with the control group. In terms of effectiveness, there was no significant difference in QALY gain (mean difference -0.003, 95% CI -0.0076 to 0.0012) between the two groups. CONCLUSIONS: MGT is a cost-saving alternative to treatment as usual over the trial duration from both a healthcare and a societal perspective for patients with a diagnosis of depression, anxiety or stress and adjustment disorders in Sweden.

Heterogeneity in the associations between common mental disorders and labour outcomes - a population study from southern Sweden.

BACKGROUND: Previous research has shown that Common Mental Disorders (CMD) are unequally distributed between population subgroups, but we know less about how labour outcomes following such disorders are distributed. Our aim is to investigate how the labour outcomes following a CMD diagnosis differ over sex, age, schooling and country of birth. METHODS: We use a population sample from southern Sweden of patients diagnosed with CMD during calendar years 2009-2011, and a matched general population control group, to study labour market outcomes three years following diagnosis. Logistic regression is used to study the associations between a CMD diagnosis and outcomes in employment, sick leave, and disability pension. Interaction analysis is used to study heterogeneity in these associations. RESULTS: CMD diagnosis is associated with reduced employment and increased odds of sick leave and disability pension. Following a CMD diagnosis, men and higher educated individuals have higher odds of non-employment and sick leave compared to women and the lower educated. Foreign-born individuals have higher odds of non-employment and lower odds of sick leave, compared to individuals born in Sweden. Heterogeneity appears to be present also based on age. Younger age is associated with higher odds of non-employment and disability pension and lower odds of sick leave, following a CMD diagnosis. CONCLUSIONS: Heterogeneity in labour outcomes following a CMD diagnosis sometimes contributes to and sometimes mitigates inequalities in employment, sick leave and disability pension between population subgroups. When developing new strategies to tackle mental ill-health in the population, it may therefore be motivated to consider not only inequalities in the prevalence of mental disorders but also heterogeneity in associated adverse labour outcomes.

Effects of a multifaceted intervention QI program to improve ICU performance.

BACKGROUND: To benefit from the increasing clinical evidence, organisational changes have been among the main drivers behind the reduction of ICU mortality during the last decade. Increasing demand, costs and complexity, amplifies the need for optimisation of clinical processes and resource utilisation. Thus, multidisciplinary teamwork and critical care processes needs to be adapted to profit from increased availability of human skill and technical resources in a cost-effective manner. Inadequate clinical performance and outcome data compelled us to design a quality improvement project to address current work processes and competence utilisation. METHODS: During revision period, clinical processes, professional performance and clinical competence were targeted using "scientific production management methodology" approach. As part of the project, an intensivist training program was instituted, and full time intensivist coverage was obtained in the process of creating multi-professional teams, composed of certified intensivists, critical care nurses, assistant nurses, physiotherapists and social counsellors. The use of staff resources and clinical work-processes were optimised in accordance with the outcome of a "value stream mapping". In this process, efforts to enhance the personal dynamics and performance within the teams were paramount. Clinical and economic outcome data were analysed during a seven year follow up period. RESULTS: • Consecutive reduced overall ICU (24%) and long-term (600 days) mortality. The effect on ICU mortality was especially pronounced in the subgroup of patients > 65 years (30%) • Consecutive reduced length of stay (43%, septic patients) and time on ventilator (for septic patients and patients > 65 years of age (23 resp.52%). • Substantial increase in life years gained (13,140 life years) as well as quality-adjusted life-years (9593 QALY: s) over the study period. • High cost-effectiveness as ICU costs were  reduced while patient outcomes were improved. Disregarding the cost reduction in ICU, the intervention is highly cost effective with cost- effectiveness ratios of (75€/QALY) and (55€ / life year) CONCLUSIONS: We have shown favourable results of a QI project aiming to improve the clinical performance and quality through the development of multi-professional interaction, teamwork and systematic revisions of work processes. The economic evaluation shows that the intervention is highly cost-effective and potentially dominating.

Cost-effectiveness of supported employment adapted for people with affective disorders.

OBJECTIVE: The individual enabling and support (IES) model was effective in gaining competitive employment for people with affective disorders compared with traditional vocational rehabilitation (TVR) services in a randomized controlled trial in a Swedish setting. The object of this study is to perform a cost-effectiveness analysis of IES comparing to TVR. METHODS: We considered the costs of intervention and productivity gain due to increased competitive employment. We estimated quality of life using EuroQol 5 Dimension (EQ-5D) and Manchester Short Assessment of Quality of Life (MANSA) scale. EQ-5D was translated into quality-adjusted life-years (QALY), using the UK, Danish, and Swedish tariffs. We performed the analysis from a societal perspective with a one-year timeframe. RESULTS: The cost of IES was €7247 lower per person per year (2014 prices) compared to TVR. There were no significant differences in QALY improvement within or between groups. However, quality of life measured by the MANSA scale significantly improved over the study period in IES. LIMITATIONS: Besides the small sample size, details on the intervention costs for both IES and TVR group were unavailable and had to be obtained from external sources. CONCLUSIONS: Implementation of IES for people with affective disorders is most likely cost-saving and is potentially even dominating TVR, although a larger trial is required to establish this.

What socioeconomic factors are associated with different levels of antenatal care visits in Bangladesh? A behavioral model.

We identify the socioeconomic determinants of three levels of antenatal care (ANC) visits (no, intermediate [1-3], and recommended [≥4]) in Bangladesh using a behavior model framework for health care utilization. Using multinomial logistic regression, we found that different levels of visits had different determinants; for example, media exposure increased the likelihood of intermediate compared with no visits while desire for pregnancy increased the likelihood of recommended compared with intermediate visits. We therefore highlight that ANC policies or interventions should be target-group specific because determinants differ depending on level of ANC visits.

Oral contraceptive use in women with spina bifida in Sweden.

BACKGROUND: Thanks to improved medical care, individuals with spina bifida (SB) live well into adulthood and go through the process of reproductive maturation and the development of sexual desires. However, access to reproductive counselling and contraceptive use has been reported to be lower for women with physical and intellectual disabilities compared to the general population. OBJECTIVE: We investigated oral contraceptive use in women with SB, residing in Sweden and how use varies based on the level of lesion and demographic factors. METHODS: This was a population-based case-control study using annual data from national registers from 2006 to 2015. The sample consisted of 7045 women aged 15-49 years, of which 1173 had a diagnosis of SB. χ2 tests and logistic regression were used to investigate the study objective. RESULTS: The rate of oral contraceptive use in women with SB was 24.6 % compared to 34.5 % among the general population. After adjusting for potential confounders women with SB were found to have a lower probability of using oral contraceptives (OR 0.63 95 % CI 0.56-0.71) compared to women without SB. Among women with SB, those with diagnoses Q05.8 (Sacral SB without hydrocephalus) and Q05.9 (SB unspecified) had a higher likelihood of using oral contraceptives compared to other Q05 diagnoses. CONCLUSION: Women with SB had a lower likelihood of being on oral contraceptives compared to the control group. Further research should investigate if the lower use indicates that oral contraceptives are not an inappropriate method of contraception for women with SB.

Cost-effectiveness analysis of (accelerated) pre-operative versus (conventional) post-operative radiotherapy for patients with oral cavity cancer in Sweden.

BACKGROUND: Treatment for resectable oral cavity cancer (OCC) often includes combinations of surgery and radiotherapy (RT), but there is no conclusive information on the preferred treatment order. The aim of this study was to assess the costs and cost-effectiveness of two alternative treatment regimens for patients with OCC, reflecting pre- and post-operative RT, from a societal perspective. METHODS: The study used data from the ARTSCAN 2 randomised controlled trial, which compares pre-operative accelerated RT with post-operative conventionally fractionated RT. Two-hundred-forty patients were included in the analysis of treatment outcomes. Direct costs were retrieved from the hospital's economic systems, while indirect costs were obtained from national registries. Cost-effectiveness was assessed and a sensitivity analysis was performed. Overall survival (OS) at 5 years, was used as effect measure in the analysis. RESULTS: Two-hundred-nine patients completed the treatments and had retrievable data on costs. Mean direct costs (inpatient and outpatient care) were € 47,377 for pre-operative RT and € 39,841 for post-operative RT (p = 0.001), while corresponding indirect costs were € 19,854 and € 20,531 (p = 0.89). The incremental cost, i.e., the mean difference in total cost between the treatment regimens, was € 6859 paralleled with a 14-percentage point lower OS-rate at 5 years for pre-operative RT (i.e., 58 vs. 72%). Thus, pre-operative RT was dominated by post-operative RT. CONCLUSIONS: From a societal perspective, post-operative RT for patients with resectable OCC is the dominant strategy compared to pre-operative RT.

Time characteristics of the effect of alcohol cessation on the risk of stomach cancer--a meta-analysis.

BACKGROUND: In the Bagnardi et al. (2001) meta-analysis, it was found that alcohol consumption increases the risk of stomach cancer (OR = 1.32 for heavy drinkers). However, it is unknown if drinking cessation reverses this alcohol-elevated risk. METHODS: A systematic literature review was performed to provide the information for a meta-analysis where the dose-risk trend was estimated for years since drinking cessation and the risk of stomach cancer. A random effect generalised least squares model for trend estimation was used, employing study characteristics to control for heterogeneity. RESULTS: Nineteen observational studies were identified in the literature review, of which five studies quantified duration of cessation and risk of stomach cancer, giving a total of 1947 cancer cases. No significant effect of drinking cessation on the risk of stomach cancer could be found (OR = 0.99 CI: 0.97-1.02). CONCLUSIONS: This result should be interpreted with caution due to the limited number of studies in this area. Recent findings suggest a link between heavy drinking and stomach cancer, especially gastric noncardia, but not for moderate drinking. Since all but one of the included studies in this meta-analysis failed to control for consumption level, the current study could not test if the risk decline following drinking cessation differs between moderate and high consumers.

A measure of alcohol affordability for Sweden: Capturing trends among different demographic groups.

The World Health Organization has rated alcohol abuse as one of the leading risk factors for population health worldwide and emphasises the relevance of alcohol affordability (AA) measures as important instruments to monitor alcohol control policy. The present study suggests an AA index that is suitable for measuring AA in Sweden, where off-premises alcohol is exclusively distributed by Systembolaget, the government-owned chain of liquor stores. Sweden provides uniform off-premises prices for alcohol and extensive register data, which profits the accuracy of this index. By allowing for AA comparisons across types of alcoholic beverages (beer, wine, spirits) and price categories, as well as across population groups (age, sex and family composition), and by being transferable to other Nordic countries with uniform off-premises prices, this study will facilitate governmental monitoring and supervision of the alcohol policy in Nordic countries. The suggested AA index is defined as the ratio of the median equivalised disposable income and the price per litre of 100% ethanol for alcohol, scaled to equal 100% in the base year. The income can be measured for the reviewed population or a subgroup, and the price measure can include all sold alcoholic beverages or separate them by beverage type and/or price category. Thereby, the index measures the number of litres of 100% ethanol that are affordable with the median income. Applying the index to the publicly available data for 2011-2019 from Statistics Sweden and Systembolaget reveals that alcohol in Sweden generally became more affordable, with high-priced alcoholic beverages becoming comparably more affordable than low-priced alcohol. However, low-priced beer became less affordable over the last decade. Future studies may validate the AA index against alcohol consumption.

An Overview of Systematic Reviews and Meta-Analyses on the Effect of Medication Interventions Targeting Polypharmacy for Frail Older Adults.

Frailty refers to the lack of resilience and a reduction in a person's ability to recover following a health problem, and it is increasingly becoming a challenging aspect of ageing populations. Many older adults are exposed to polypharmacy; i.e., they continue to be on medications without timely re-evaluation. Medication reviews have proven successful in managing polypharmacy in the general population, but there is uncertainty regarding their effect among frail older adults. This overview of published systematic reviews assesses the impact of medication reviews on polypharmacy in frail older adults. Embase was searched from its inception to January 2021 and 28 systematic reviews were identified, out of which 10 were included in the overview. Medication reviews were the most common intervention in 8 out of 10 systematic reviews. The frailty score was reported as an outcome in one systematic review that found no evidence for fundamental pharmacological effects on frailty. Six systematic reviews reported a statistically significant reduction in the number of inappropriately prescribed medications. Four systematic reviews reported on hospital admissions, with two of them reporting a decrease in hospitalisations. The quality assessment was moderate in six and critically low in four of the systematic reviews. We conclude that medication reviews help in reducing the use of inappropriate medications in frail older adults, but that there is insufficient evidence in terms of frailty score and hospital admissions.

Healthcare costs after kidney transplantation compared to dialysis based on propensity score methods and real world longitudinal register data from Sweden.

This study aimed to estimate the healthcare costs of kidney transplantation compared with dialysis using a propensity score approach to handle potential treatment selection bias. We included 693 adult wait-listed patients who started renal replacement therapy between 1998 and 2012 in Region Skåne and Stockholm County Council in Sweden. Healthcare costs were measured as annual and monthly healthcare expenditures. In order to match the data structure of the kidney transplantation group, a hypothetical kidney transplant date of persons with dialysis were generated for each dialysis patient using the one-to-one nearest-neighbour propensity score matching method. Applying propensity score matching and inverse probability-weighted regression adjustment models, the potential outcome means and average treatment effect were estimated. The estimated healthcare costs in the first year after kidney transplantation were €57,278 (95% confidence interval (CI) €54,467-60,088) and €47,775 (95% CI €44,313-51,238) for kidney transplantation and dialysis, respectively. Thus, kidney transplantation leads to higher healthcare costs in the first year by €9,502 (p = 0.066) compared to dialysis. In the following two years, kidney transplantation is cost saving [€36,342 (p < 0.001) and €44,882 (p < 0.001)]. For patients with end-stage renal disease, kidney transplantation reduces healthcare costs compared with dialysis over three years after kidney transplantation, even though the healthcare costs are somewhat higher in the first year. Relating the results of existing estimates of costs and health benefits of kidney transplantation shows that kidney transplantation is clearly cost-effective compared to dialysis in Sweden.

Survival and causes of death in adults with spina bifida in Sweden: a population-based case-control study.

OBJECTIVE: To analyse survival rates and causes of death in adults with spina bifida in Sweden compared with a matched control group. DESIGN AND METHODS: This population-based study included 11,900 adults born between 1950 and 1997. Three national Swedish registers were used to identify individuals with a diagnosis of spina bifida and a matched control group without spina bifida in the period 1990-2015. International Classification of Diseases codes were used to identify causes of death. Survival analysis was conducted and causes of death in the 2 groups were compared. RESULTS: There was a lower probability of survival for people with spina bifida in all age groups (p < 0.001) compared with the control group. The most prevalent causes of death in people with spina bifida were congenital, respiratory, nervous, cardiovascular, genitourinary, and injuries. People with spina bifida had a higher probability of dying from congenital (p < 0.001), respiratory (p = 0.002), genitourinary (p < 0.002), and nervous-related (p < 0.001) and lower probability of injury-related deaths (p < 0.001). CONCLUSION: Adults with spina bifida in Sweden have a lower survival rate compared with the general population, with the frequency of certain causes of death differing between the two groups. In order to reduce excess premature mortality, prevention and careful management of potentially fatal conditions are essential throughout a patient's lifespan.

Pain and labor outcomes: A longitudinal study of adults with cerebral palsy in Sweden.

BACKGROUND: Pain is a global health concern with substantial societal costs and limits the activity participation of individuals. The prevalence of pain is estimated to be high among individuals with cerebral palsy (CP). OBJECTIVES: To estimate the association between pain and labor outcomes for adults with CP in Sweden. METHODS: A longitudinal cohort study based on data from Swedish population-based administrative registers of 6899 individuals (53,657 person-years) with CP aged 20-64 years. Individual fixed effects regression models were used to analyze the association between pain and labor outcomes (employment and earnings from employment), as well as potential pathways through which pain might affect employment and earnings. RESULTS: Pain was associated with adverse outcomes varying across severity, corresponding to a reduction of 7-12% in employment and 2-8% in earnings if employed. Pain might affect employment and earnings through increased likelihood of both sickness leave and early retirement. CONCLUSION: Pain management could potentially be important to improve labor outcomes for adults with CP, in addition to improving the quality of life.