Opportunistically identifiable vertebral fractures on routine radiological imaging predict mortality: observational cohort study.

In men and women with opportunistically identifiable vertebral fractures (VFs) on routine CT scans including the chest and/or abdomen, the risk of death is 51% higher than in those with no VF on the CT scan, and 325% higher than an age- and sex-matched general population cohort. PURPOSE: There is little knowledge about the risk of death in patients with VFs present on routine radiological imaging. We evaluated the risk of death in men and women aged 50 years or older with opportunistically identifiable VFs on routine CT scans and not treated with osteoporosis medications. METHODS: Thoracic and lumbar VFs were identified through a blinded, two-step approach on CT scans performed as part of normal clinical care in a Danish hospital in 2010 or later. Subjects with VF were matched on age and sex against those with no VF (1:2-ratio) and a general population cohort (1:3-ratio), respectively, and followed for up to 7 years through the national Danish registers. Subjects treated with an osteoporosis medication in the year prior to baseline were excluded. RESULTS: Subjects with VF had a significantly higher risk of death during follow-up as compared to subjects with no VF on the CT scan (adjusted hazard ratio [HR] 1.51 [95% confidence interval 1.27-1.79; p < 0.001]) and even more so when compared to the general population cohort (HR 4.25 [3.53-5.12; p < 0.001]). In subjects with versus without VF on the CT scan, the risk was higher in those with moderate or severe VF, in those with no malignancy prior to baseline, and in those with a lower Charlson comorbidity index score. CONCLUSION: Subjects with VF available for identification on routine CT scans face a substantially increased risk of death. Opportunistic identification and reporting of VF is important to identify these patients to allow intervention if indicated.

Tip of the iceberg: unveiling the impact on back disorders from cumulative physical job exposure and evaluating bias from the healthy worker effect using a nationwide longitudinal cohort study.

PURPOSE: Longitudinal studies across various sectors with physically demanding jobs are notably absent in back disorder risk research. This study aimed to investigate the relationship between cumulative physical job exposure (PJE) and hospital-diagnosed back disorders among individuals in Denmark. To assess the healthy worker effect, we compared the cumulative risk estimate with results from a naive cross-sectional model ignoring PJE history. METHODS: A nationwide longitudinal cohort study was conducted using Danish registers, encompassing individuals born between 1975 and 1978 and working in 1996. Cumulative PJE was measured with a 10-year look-back period for each year 2006-2017. PJE consisted of lower-body occupational exposures, including the total weight lifted, stand/sit ratio, and the frequency of lifting more than 20 kg per day from a job exposure matrix. Odds ratio for back disorders was estimated for each year and all years combined. RESULTS: The results unveiled a significant 31% increase in the risk of hospital-diagnosed back disorders after 4 years of cumulative PJE. The lowest risk (7%) was observed for incident back disorders with 1 year of exposure, suggesting a healthy worker effect. Nevertheless, this risk is still significantly elevated. This cumulative estimate is fourfold the estimate from the 2006 naive cross section model. CONCLUSION: Our study clearly demonstrates an 31% increase in the risk of hospital-diagnosed back disorders with just 4 years of PJE over a 10-year period. Further, we find that cross-sectional studies strongly underestimate the risk of back disorders due to the healthy worker effect.

Increasing capitation in mixed remuneration schemes: Effects on service provision and process quality of care.

Many health systems apply mixed remuneration schemes for general practitioners, but little is known about the effects on service provision of changing the relative mix of fee for services and capitation. We apply difference-in-differences analyses to evaluate a reform that effectively reversed the mix between fee for services and capitation from 80/20 to 20/80 for patients with type 2 diabetes. Our results show reductions in provision of both the contact services that became capitated and in other non-capitated (still-billable) services. Reduced provision also occurred for guideline-recommended process quality services. We find that the effects are mainly driven by patients with co-morbidities and by general practitioners with high income, relatively many diabetes patients, and solo practitioners. Thus, increasing capitation in a mixed remuneration schemes appears to reduce service provision for patients with type 2 diabetes monitored in general practice with a risk of unwanted quality effects.

Return to work: does cardiac rehabilitation make a difference? Danish nationwide register-based study.

AIM: to assess whether participation in cardiac rehabilitation affects the probability of returning to work after ischaemic heart disease. METHODS: the study population consisted of 24,509 patients (18-70 years of age) discharged from an inpatient admission at a Danish hospital during 2014-2018 and who were working before their admission. Only patients with a percutaneous coronary intervention or coronary artery bypass grafting surgery procedure and ICD-10 codes I20-I25 as their main diagnosis or ICD-10 codes I21, I240, I248 or I249 as secondary diagnosis during an emergency admission were included. Exposure was defined as participation in cardiac rehabilitation (N = 15,742), and binary indicator of being at work in the last week of a given month were used as primary outcomes. Coarsened exact matching (CEM) of exposed and unexposed patients was used to reduce selection bias. Logistic regression models were applied on the matched population (N = 15,762). RESULTS: Less deprived and less comorbid patients were more likely to receive cardiac rehabilitation. CEM succeeded in arriving at a population where this selection was reduced and in this population we found that patients who received cardiac rehabilitation had a lower probability of returning to work after 3 months (OR 0.81, 95%CI: 0.77-0.84), a higher but insignificant probability after 6 (OR 1.02, 95%CI: 0.97-1.08), and a higher probability after 9 (OR 1.08, 95%CI: 1.02-1.15) and 12 months (OR 1.20, 95%CI: 1.13-1.28). CONCLUSIONS: Deprived and comorbid patients have lower use of cardiac rehabilitation. In a matched population where this bias is reduced, cardiac rehabilitation will increase the probability of returning to work.

Effects of screening for anxiety and depression in patients with ischaemic heart disease - a nationwide Danish register study.

AIM: To investigate the effect of screening for anxiety and depression (AD) in patients with ischaemic heart disease (IHD) on the likelihood of receiving treatment for AD. METHODS: We used a nationwide dataset of all Danish patients with an incident IHD diagnosis in the period 2015-2018 (N = 80,701) of which 20,461 (25%) were exposed to screening for AD as part of cardiac rehabilitation. A binary composite indicator for the use of any AD treatment (prescriptions of AD drugs, general practitioner (GP) counselling or referral to a psychologist), was modelled as the dependent variable. The probability of receiving AD treatment was estimated using linear probability and instrumental variable regression models. RESULTS: Exposure to AD screening was lower for patients with low income (change in probability -0.67, 95% CI -0.76; -0.59), low education (change in probability -0.16, 95% CI -0.20; -0.13), and a high comorbidity burden (change in probability -0.09, 95% CI -0.10; -0.07). Screened patients had a lower conditional probability of AD treatment (change in probability -0.0061, p < 0.001) than non-screened patients. The patient's GP also had an impact on the probability of being referred for AD treatment. Using an instrumental variable approach did not affect the results. CONCLUSIONS: Screening for AD was subject to selection at the patient level; patients at lower risk of AD had a higher probability of being screened. Hence, extending systematic screening to cover a larger population may not achieve a noticeable increase in the uptake of AD treatment if it is not supported by appropriate measures to reduce reverse selection into screening.

Use of electronic patient data overview with alerts in primary care increases prescribing of lipid-lowering medications in patients with type 2 diabetes.

AIMS/HYPOTHESIS: We aimed to assess whether general practices (GPs) using an electronic disease management program (DMP) with population overviews, including alerts when patients failed to receive guideline-recommended prescription medications, increased prescriptions of lipid-lowering drugs for patients with type 2 diabetes with no history of lipid-lowering treatment. METHODS: This observational study included 165 GPs that reached a high level of use of the DMP in 2012 and a control group of 135 GPs who reached a high level of use in 2013 and, hence, who were less exposed to the DMP throughout 2012. A binary measure for having been prescribed and filled lipid-lowering drugs at any time within a 12-month exposure period was derived for all patients with type 2 diabetes who did not receive a prescription for lipid-lowering drugs in the baseline year prior to the study period (i.e. 2011). Results were derived using ORs from multivariate logistic regression analyses. Subgroup stratification based on age, sex, diabetes duration, deprivation status and Charlson Comorbidity Index (CCI) score was conducted and assessed. Placebo tests were carried out to assess bias from selection to treatment. RESULTS: Patients who did not receive a prescription of lipid-lowering drugs in the year prior to being listed with GPs that used the DMP had statistically significant greater odds of receiving a prescription of lipid-lowering medications when compared with individuals who attended control GPs (OR 1.23 [95% CI 1.09, 1.38]). When the analysis period was shifted back by 2 years, no significant differences in lipid-lowering drug prescription between the two groups were found to occur, which indicates that these results were not driven by selection bias. Subgroup analyses showed that the increase in lipid-lowering drug prescriptions was primarily driven by changes among male participants (OR 1.32 [95% CI 1.12, 1.54]), patients aged 60-70 years (OR 1.40 [95% CI 1.13, 1.74]), patients with a diabetes duration of ≤5 years (OR 1.33 [95% CI 1.13, 1.56]), non-deprived patients (OR 1.25 [95% CI 1.08, 1.45]) and patients without comorbidities (CCI score = 0; OR 1.27 [95% CI 1.11, 1.45]). CONCLUSIONS/INTERPRETATION: Access to population overviews using a DMP with alerts of clinical performance measures with regard to adhering to guideline-recommended prescription of medications can increase GP prescriptions of lipid-lowering drugs.

Co-payment and adolescents' use of psychologist treatment: Spill over effects on mental health care and on suicide attempts.

The literature around co-payment shows evidence of increasing consumption following reduced co-payment. We apply difference-in-difference methods to assess the effect of abolishing the co-payment on psychologist treatment of anxiety and depression in 18 to 21-year olds. We apply nationwide individual level data with individuals close to this age interval as control group. The population amounts to approximately 1.2 million individuals and a total of 51 million patient months of observations. We show that after removing co-payment, the use of psychologist treatment almost doubles. We find that this increase involves moderately positive spill over effects on outpatient psychiatric care and on prescriptions of antidepressants. In the heterogeneity analysis we find evidence of higher effects on adolescents from families with lower income, indicating that reduced co-payments may increase equality in access. We also see that effects are higher for individuals listed with general practitioners (GPs) with a reluctant referral style; indicating that these GPs' behavior is affected by patient co-payment rates. Interestingly, we find evidence of significant reductions in suicide attempts - primarily among high-income women and low-income men. This indicates that better access to mental health care for adolescents may have a positive impact on their mental health and well-being.

Age, morbidity, or something else? A residual approach using microdata to measure the impact of technological progress on health care expenditure.

This study measures the increment of health care expenditure (HCE) that can be attributed to technological progress and change in medical practice by using a residual approach and microdata. We examine repeated cross-sections of individuals experiencing an initial health shock at different point in time over a 10-year window and capture the impact of unobservable technology and medical practice to which they are exposed after allowing for differences in health and socioeconomic characteristics. We decompose the residual increment in the part that is due to the effect of delaying time to death, that is, individuals surviving longer after a health shock and thus contributing longer to the demand of care, and the part that is due to increasing intensity of resource use, that is, the basket of services becoming more expensive to allow for the cost of innovation. We use data from the Danish National Health System that offers universal coverage and is free of charge at the point of access. We find that technological progress and change in medical practice can explain about 60% of the increment of HCE, in line with macroeconomic studies that traditionally investigate this subject.

Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation [eMindYourHeart trial]: a randomised controlled trial protocol.

BACKGROUND: One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care. METHODS: eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness. DISCUSSION: To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

Back disorder incidence and occupation in Denmark: a cross-sectional register-based study.

PURPOSE: The purpose of the present paper is (1) to describe the occupational distribution of persons with incident back disorders and (2) to determine the incidence rate ratio (RR) for back pain amongst patients working in specific occupation groups. METHODS: Using Danish registries, a total of 20,921 employed persons with incidents back disorders aged 18-64 years were identified in 2016 based on the inclusion criteria from the Danish Back Register. RR was estimated to test for differences in incident back disorder diagnoses across occupations. Pearson's Chi-square test was used to test for homogeneity in back disorder incidence across occupations. RESULTS: The distribution of back disorder incidence for employed is above the distribution of employment in the background population for all age groups above 35 years. For employed women the three occupation groups with the highest RR of back pain incidence are: 'water, sewage and waste'; 'residential institutions and home care'; and 'transport of passengers', while similarly, amongst employed men: 'hairdressers and other personal care'; 'hospitals'; and 'cleaning'. RR of incident back pain disorders is lowest for women employed in 'universities and research' and for men employed in 'IT and telecommunications'. CONCLUSIONS: This study is the first to investigate the occupational status and RR of back disorder incidence across occupation groups in Denmark. The distribution of back pain disorder incidents in the cross-sectional study is weighted to occupation groups involving hard physical activity. This evidence may be useful for considering work environment or pension reforms. These slides can be retrieved under Electronic Supplementary Material.

Resource allocation and the burden of co-morbidities among patients diagnosed with chronic obstructive pulmonary disease: an observational cohort study from Danish general practice.

BACKGROUND: Chronic obstructive pulmonary disease is a leading cause of mortality, and associated with increased healthcare utilization and healthcare expenditure. In several countries, morbidity-based systems have changed the way resources are allocated in general practice. In primary care, fee-for-services tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated expenditures for patients with chronic obstructive pulmonary disease has not previously been examined. The aim of this study is to analyze fee-for-service expenditure of patients diagnosed with chronic obstructive pulmonary disease visiting Danish general practice clinics and further to assess what proportion of fee-for-service expenditure variation was explained by patient morbidity and general practice clinic characteristics, respectively. METHODS: We used patient morbidity characteristics such as diagnostic markers and multi-morbidity adjustment based on adjusted clinical groups (ACGs) and fee-for-service expenditure for a sample of primary care patients for the year 2010. Our sample included 3,973 patients in 59 general practices. We used a multi-level approach. RESULTS: The average annual fee-for-service expenditure of caring for patients diagnosed with chronic obstructive pulmonary disease in general practice was about EUR 400 per patient. Variation in the expenditures was driven by multimorbidity characteristics up to 28% where as characteristics such as age and gender only explained 5%. Expenditures increased progressively with the degree of multimorbidity. In addition, expenditures were higher for patients who had diagnostic markers based on ICPC-2 (body systems and/or components such as infections and symptoms). Nevertheless, 9.8-15.4% of the variation in expenditure was related to the clinic in which the patient was cared for. CONCLUSION: Patient morbidity and general practice clinic characteristics are significant patient-related fee-for-service expenditure drivers in chronic obstructive pulmonary disease care.

Socioeconomic equality in initiation of biologic treatment in Danish patients with inflammatory bowel disease.

BACKGROUND: Low socioeconomic status is associated with disadvantages in health outcomes and delivery of medical care in patients with Inflammatory Bowel Disease (IBD). Inequality in the utilisation of biologic treatment is largely unexplored. AIM: To explore the potential association of socioeconomic status and time to first biologic treatment in a population-based IBD cohort. METHODS: All 37,380 IBD incidences between 2000 and 2017 from the Danish National Patient Register were identified and linked to socioeconomic information including educational level, income and occupational status at diagnosis. Hazard ratios for receiving biologic treatment among socioeconomic groups were estimated using Cox proportional hazard regression. RESULTS: No difference in time between diagnosis and biologic treatment initiation was found comparing patients with upper secondary, vocational, or academic education to those with lower secondary education in patients with IBD. Patients with Crohn's disease in the two highest income quartiles received biologic treatment earlier (HR 1.16; 95% CI: 1.04; 1.30 & HR 1.15; 95% CI: 1.03; 1.30). An elevated treatment rate was found for persons with "other" occupational status (unspecified source of income) compared to employed persons in patients with ulcerative colitis (HR 1.36; 95% CI: 1.11; 1.66), but not in patients with Crohn's disease. CONCLUSION: This study revealed equal initiation of biologic treatment among patients with IBD across different educational background, income and occupational status. However, results are limited to a setting with free universal healthcare coverage and treatment needs should be considered and addressed in future research.

Prediction of the clinical course of chronic obstructive pulmonary disease, using the new GOLD classification: a study of the general population.

RATIONALE: The new Global Initiative for Obstructive Lung Disease (GOLD) stratification of chronic obstructive pulmonary disease (COPD) into categories A, B, C, and D is based on symptoms, level of lung function, and history of exacerbations. OBJECTIVES: To investigate the abilities of this stratification to predict the clinical course of COPD. METHODS: Two similar population studies were performed in an area of Copenhagen including 6,628 individuals with COPD. MEASUREMENTS AND MAIN RESULTS: The patients were monitored for an average period of 4.3 years regarding COPD exacerbations, hospital admissions, and mortality. The percentages of individuals experiencing a COPD exacerbation during the first year of observation were 2.2% in group A, 5.8% in group B, 25.1% in group C, and 28.6% in group D. One- and 3-year mortality rates were 0.6 and 3.8%, respectively, in group A, 3.0 and 10.6% in group B, 0.7 and 8.2% in group C, and 3.4 and 20.1% in group D. Groups B and D, characterized by a higher degree of dyspnea than groups A and C, had five to eight times higher mortality from cardiovascular disease and cancer than did groups A and C. CONCLUSIONS: The new stratification performs well by identifying individuals at risk of exacerbations. Surprisingly, subgroup B, characterized by more severe dyspnea, had significantly poorer survival than group C, in spite of a higher FEV(1) level. This subgroup warrants special attention, as the poor prognosis could be caused by cardiovascular disease or cancer, requiring additional assessment and treatment.

Adherence to COPD guidelines in general practice: impact of an educational programme delivered on location in Danish general practices.

BACKGROUND: The general practitioner (GP) is often the first healthcare contact for patients with chronic obstructive pulmonary disease (COPD). AIMS: To determine whether participating in a standardised educational programme delivered in the GP's own practice is associated with adherence to COPD guidelines. METHODS: A nationwide register-based observational before and after study was undertaken with a control group of propensity-matched practices (follow-up period 6 months). COPD was defined as age 40+ years and at least two prescriptions for inhaled medication. The educational programme consisted of a 3-hr teaching lesson with a respiratory specialist and five visits by a representative from the sponsoring pharmaceutical company focusing on assessment and management of patients including written algorithms. A one-to-one propensity-matched control group of practices was selected. Register data were used to compare the rate of spirometry testing, preventive consultations, and influenza vaccinations provided to COPD patients and the rate of spirometry testing in non-COPD individuals, assumed to reflect diagnostic activity. RESULTS: Data for 102 participating GP practices were analysed. Participating clinics had a significant increase in preventive consultations and influenza vaccinations (p<0.05). For the control group, a significant change was observed only for influenza vaccinations. No significant change was found when comparing participating and control clinics in the difference-in-difference estimator. However, a significant improvement was observed for the subgroup of 48 clinics with the lowest starting point of spirometry testing. CONCLUSIONS: Focused education of GPs and their staff delivered in the GPs' own practices may improve adherence to COPD guidelines, not least for clinics with a high potential for improvement.

Fracture Risk in Men and Women With Vertebral Fractures Identified Opportunistically on Routine Computed Tomography Scans and Not Treated for Osteoporosis: An Observational Cohort Study.

Vertebral fractures (VFs) have been associated with future fractures, yet few studies have evaluated whether this pertains to VFs available for identification on routine radiological imaging. We sought to evaluate the risk of subsequent fractures in subjects with VF identified opportunistically on computed tomography (CT) scans performed as part of routine clinical practice. From the radiology database of Holbæk Hospital we identified the first CT scan including the thorax and/or abdomen of 2000 consecutive men and women aged 50 years or older, performed from January 1, 2010 onward. The scans were assessed in a blinded approach to identify chest and lumbar VF, and these data linked to national Danish registers. Subjects were excluded if treated with an osteoporosis medication (OM) in the year prior to baseline (date of CT), and the remaining subjects with VF matched on age and sex in 1:2 ratio against subjects with no VF. We found that the risk of major osteoporotic fractures (hip, non-cervical vertebral, humerus, and distal forearm fractures) was higher for subjects with VF than without VF: incidence rates (IRs) were 32.88 and 19.59 fractures per 1000 subject-years, respectively, and the adjusted hazard ratio (HRadj) was 1.72 (95% confidence interval [CI], 1.03-2.86). Subsequent hip fracture IRs were 16.75 and 6.60; HRadj 3.02 (95% CI, 1.39-6.55). There were no significant differences in other fracture outcomes (including a pooled estimate of any subsequent fracture, except face, skull, and fingers: IRs 41.52 and 31.38; HRadj 1.31 [95% CI, 0.85-2.03]). Our findings suggest that subjects undergoing routine CT scans including the chest and/or abdomen are a high risk population in terms of fracture risk. Even within this group, subjects with VF are at higher risk of future major osteoporotic fracture (MOF), in particular hip fracture. Hence, systematic opportunistic screening for VF and subsequent fracture risk management is important to reduce the risk of new fractures. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Healthcare costs associated with opportunistically identifiable vertebral fractures.

PURPOSE: Vertebral fractures (VFs) are often available on radiological imaging undertaken during daily clinical work, yet the healthcare cost burden of these opportunistically identifiable fractures has not previously been reported. In this study, we examine the direct healthcare costs of subjects with vertebral fractures available for identification on routine CT scans. METHODS: Thoracolumbar vertebral fractures were identified from 2000 routine CT scans. Subjects with VF on the scan were matched 1:2 against subjects with no VF on the scan, and similarly in a 1:3-ratio against a general population cohort. We excluded those subjects who received treatment with osteoporosis medication(s) in the year prior to baseline. Direct healthcare costs, identified from the national Danish registers, were accrued over up to 6 years of follow-up, and reported per day at risk and per year. RESULTS: In subjects undergoing a CT scan, costs were initially high, yet declined over time. Comparing subjects with prevalent vertebral fracture (n = 321) against those subjects with no vertebral fracture (n = 606), mean total healthcare costs per day at risk was numerically higher in the first three years after baseline, while healthcare costs per year were similar between the cohorts. No differences reached statistical significance. When compared to the general population cohort, costs were significantly higher in the vertebral fracture cohort. CONCLUSION: Subjects with vertebral fractures available for identification on routine CT scans incur substantially higher healthcare costs than matched subjects representing the general population, and numerically, albeit non-significantly, higher healthcare costs per day at risk in the short term, as compared to subjects with no visible VF on the CT scan.

Does participation in preventive child health care at the general practitioner minimise social differences in the use of specialist care outside the hospital system?

INTRODUCTION: The primary purposes of preventive child health care in Denmark are to help ensure a healthy childhood and to create preconditions for a healthy adult life. The aim of this study is to examine whether participation in age-appropriate preventative child health care affects the association between the socioeconomic position of the family and subsequent use of specialised health care outside the hospital system. METHODS: The study population was children born in 1999 and living in Denmark between 1 January 2002 and 31 December 2006 (n=68,366). The study investigated whether the number of contacts with a specialist in 2006 was related to participation in preventive child health care between 2002 and 2005. To control for the potential effect of difference in GP behaviour the data were analysed using a multilevel Poisson model linking each child to the GP with whom he or she was listed. RESULTS: If the children attended any preventive child health care visits, they had the same probability of contact with a specialist regardless of the parents' income. However, children from low-income families not participating in any preventive care had a lower probability of contact with a specialist than children from more affluent families. CONCLUSIONS: Ensuring participation in preventive child health care at the GP may reduce the social gap in utilisation of specialised health care that exists between children from families of different income levels.

Exploring equity in accessing diabetes management treatment: A healthcare gap analysis.

Healthcare inequities are often investigated empirically as associations between socio-economic characteristics and differences between observed healthcare utilisation and estimates of needs-based utilisation. However, the concept of 'need' is tricky to operationalise and utilisation may be contingent on inequities arising at an earlier stage. In this study, we apply a unique combination of register and survey data collected in 2019 to assess equity in opportunities to access treatment for patients with recently diagnosed type 2 diabetes. In the study of this population (N = 1864) we escape the challenge of estimating needs by arguing that need can be approximated from treatment guidelines within a nationwide framework of disease management programmes. Furthermore, instead of observed utilisation we use patient reports on whether they have been offered treatment as a measure of opportunities to access multiple components of care, that is, we focus on possible inequalities arising prior to possible utilisation inequalities. 'Healthcare gaps' are computed as the discrepancy between an index of guideline recommended treatments and patients' perceived offers of treatments, thus providing a novel take on the 'healthcare deprivation profiles' approach to the study of healthcare inequalities. Using this method, we explore and document inequalities along multiple dimensions of familiar socio-economic factors (income, education, occupation) as well as self-reported barriers to access. We also provide supporting evidence that healthcare gaps, as measured in our study, are associated with poorer quality of care, and that those who experience large gaps are more likely to be disadvantaged in terms of self-reported difficulties in relation to key self-care aspects. We conclude that even in a health system with comprehensive universal coverage, healthcare inequity can arise already at the stage of offering access to preventive treatment. The results warrant further research into the causes, consequences and remedies of such inequities.

The potential of smoking cessation programmes and a smoking ban in public places: comparing gain in life expectancy and cost effectiveness.

BACKGROUND: Interventions aimed at reducing the number of smokers are generally believed to be cost effective. However as the cost of the interventions should be paid up front whereas the gains in life years only appear in the future--the budgetary consequences might be a barrier to implementing such interventions. AIMS: The aim of the present paper was to assess the long-term cost effectiveness as well as the short-term (10 years) budget consequences of cessation programmes and a smoking ban in enclosed public places. METHODS: We develop a population-based Markov model capable of analyzing both interventions and assess long-term costs effectiveness as well as short-term budgetary consequences and outcome gains. The smoking cessation programme model was based on data from the Danish National Smoking Cessation Database (SCDB), while the model of the smoking ban was based on effect estimates found in the literature. RESULTS: On a population level the effect of a smoking ban has the largest potential compared with the effect of smoking cessation programmes. Our results suggest that smoking cessation programmes are cost saving and generate life-years, whereas the costs per life-year gained by a smoking ban are 40,645 to 64,462 DKK (100 DKK = €13.4). These results are conservative as they do not include the healthcare cost saving related to reduced passive smoking. CONCLUSIONS: Our results indicate that smoking cessation programmes and a smoking ban in enclosed public places both in the short term and the long term are cost-effective strategies compared with the status quo.

Cost and quality impacts of treatment setting for type 2 diabetes patients with moderate disease severity: Hospital- vs. GP-based monitoring.

OBJECTIVES: This study investigates cost and quality implications of moving regular monitoring of patients with moderate severity type 2 diabetes (T2D) away from specialized hospital clinics into general practice (GP). METHODS: A 2016 cross-section of patients with moderate disease severity T2D were algorithmically identified using Danish administrative databases. 152,632 GP- and 21,359 hospital-monitored patients with T2D were identified. Total annual healthcare cost is decomposed into GP, medication, nonhospital-specialist, hospital outpatient and inpatient costs. Hospitalizations are used to proxy for quality of care. Cost and quality impacts of treatment setting are assessed using an instrumental variable (IV) analysis. A wide range of patient confounders are used to reduce selection bias, with the difference in patients' travel-time between nearest specialist outpatient clinic and GP used as an instrument to control for remaining endogeneity of treatment setting. Two-part models are used for zero-inflated outcomes. RESULTS: Average total annual healthcare cost were 14,056 DKK greater amongst hospital-monitored patients. IV analysis accounting for endogeneity of treatment setting indicates hospital-based monitoring is causally linked to higher total annual healthcare costs. The estimated local average treatment effect of hospital-based monitoring on total annual healthcare costs was higher (117.2%, 95% CI: 23.3%, 211.1%) than GP-based monitoring. No difference of treatment settings' quality based on evidence of hospitalizations was found. CONCLUSION: For patients with moderate disease severity T2D, IV analysis accounting for treatment setting endogeneity bias identifies an expected efficiency improvement (average cost reduction without reduction of quality) of moving regular disease management from hospital-based setting to the GP setting.