Associations between outpatient care and later hospital admissions for patients with chronic obstructive pulmonary disease - a registry study from Norway.

BACKGROUND: Although chronic obstructive pulmonary disease (COPD) admissions put a substantial burden on hospitals, most of the patients' contacts with health services are in outpatient care. Traditionally, outpatient care has been difficult to capture in population-based samples. In this study we describe outpatient service use in COPD patients and assess associations between outpatient care (contact frequency and specific factors) and next-year COPD hospital admissions or 90-day readmissions. METHODS: Patients over 40 years of age residing in Oslo or Trondheim at the time of contact in the period 2009-2018 were identified from the Norwegian Patient Registry (in- and outpatient hospital contacts, rehabilitation) and the KUHR registry (contacts with GPs, contract specialists and physiotherapists). These were linked to the Regular General Practitioner registry (characteristics of the GP practice), long-term care data (home and institutional care, need for assistance), socioeconomic and-demographic data from Statistics Norway and the Cause of Death registry. Negative binomial models were applied to study associations between combinations of outpatient care, specific care factors and next-year COPD hospital admissions and 90-day readmissions. The sample consisted of 24,074 individuals. RESULTS: A large variation in the frequency and combination of outpatient service use for respiratory diagnoses (GP, emergency room, physiotherapy, contract specialist and outpatient hospital contacts) was apparent. GP and outpatient hospital contact frequency were strongly associated to an increased number of next-year hospital admissions (1.2-3.2 times higher by increasing GP frequency when no outpatient hospital contacts, 2.4-5 times higher in combination with outpatient hospital contacts). Adjusted for healthcare use, comorbidities and sociodemographics, outpatient care factors associated with lower numbers of next-year hospitalisations were fees indicating interaction between providers (7% reduction), spirometry with GP or specialist (7%), continuity of care with GP (15%), and GP follow-up (8%) or rehabilitation (18%) within 30 days vs. later following any current year hospitalisations. For 90-day readmissions results were less evident, and most variables were non-significant. CONCLUSION: As increased use of outpatient care was strongly associated with future hospitalisations, this further stresses the need for good communication between providers when coordinating care for COPD patients. The results indicated possible benefits of care continuity within and interaction between providers.

Patient experiences and clinical outcomes of admissions to municipal acute wards versus a hospital: a multicentre randomised controlled trial in Norway.

BACKGROUND: In Norway, municipal acute wards (MAWs) were implemented as alternatives to hospitalisation. Evaluations of the quality of MAW services are lacking. The primary objective of this study was to compare patient experiences after admission to a MAW versus to a hospital. The secondary objective was to compare 'readmissions', 'length of stay', 'self-assessed health-related quality of life' as measured by the EuroQol 5 items 5 level (EQ-5D-5L) index, and 'health status' measured by the RAND-12, in patients admitted to a MAW versus a hospital. METHODS: A multicentre randomised controlled trial (RCT), randomising patients to either MAW or hospital. RESULTS: In total, 164 patients were enrolled in the study; 115 were randomised to MAW and 49 to hospital. There were no significant differences between the MAW and hospital groups regarding patient experience, which was rated positively in both groups. Patients in the MAW group reported significantly better physical health status as measured by the RAND-12 four to six weeks after admittance than those randomised to hospital (physical component summary score, 31.7 versus 27.1, p = 0.04). The change in EQ-5D index score from baseline to four to six weeks after admittance was significantly greater among patients randomised to MAWs versus hospitals (0.20 versus 0.02, p = 0.03). There were no other significant differences between the MAW and hospital groups. CONCLUSIONS: In this study, patient experiences and readmissions were similar, whether patients were admitted to a MAW or a hospital. The significant differences in health status and quality of life favouring the MAWs suggest that these healthcare services may be better for elderly patients. However, unfortunately we did not reach the planned sample size due to challenges in the data collection posed by the Covid-19 pandemic.

Municipal acute wards have been implemented in Norway as alternatives to hospitalisation. However, the quality of these wards remains unexplored. Results in this study indicates thatpatient experiences after stays in municipal acute wards are equally positive to experiences after stays in hospitalthere are no significant differences in length-of-stay, readmission rates or mortality between municipal acute wards and hospitalpatients have slightly more positive self-rated health and health status 4­6 weeks after staying in a municipal acute ward.

A lean additive frailty model: With an application to clustering of melanoma in Norwegian families.

Additive frailty models are used to model correlated survival data. However, the complexity of the models increases with cluster size to the extent that practical usage becomes increasingly challenging. We present a modification of the additive genetic gamma frailty (AGGF) model, the lean AGGF (L-AGGF) model, which alleviates some of these challenges by using a leaner additive decomposition of the frailty. The performances of the models were compared and evaluated in a simulation study. The L-AGGF model was used to analyze population-wide data on clustering of melanoma in 2 391 125 two-generational Norwegian families, 1960-2015. Using this model, we could analyze the complete data set, while the original model limited the analysis to a restricted data set (with cluster sizes ≤ 7 $$ \le 7 $$ ). We found a substantial clustering of melanoma in Norwegian families and large heterogeneity in melanoma risk across the population, where 52% of the frailty was attributed to the 10% of the population at highest unobserved risk. Due to the improved scalability, the L-AGGF model enables a wider range of analyses of population-wide data compared to the AGGF model. Moreover, the methods outlined here make it possible to perform these analyses in a computationally efficient manner.

Combination of health care service use and the relation to demographic and socioeconomic factors for patients with musculoskeletal disorders: a descriptive cohort study.

BACKGROUND: Patients with musculoskeletal disorders (MSDs) access health care in different ways. Despite the high prevalence and significant costs, we know little about the different ways patients use health care. We aim to fill this gap by identifying which combinations of health care services patients use for new MSDs, and its relation to clinical characteristics, demographic and socioeconomic factors, long-term use and costs, and discuss what the implications of this variation are. METHODS: The study combines Norwegian registers on health care use, diagnoses, comorbidities, demographic and socioeconomic factors. Patients (≥ 18 years) are included by their first health consultation for MSD in 2013-2015. Latent class analysis (LCA) with count data of first year consultations for General Practitioners (GPs), hospital consultants, physiotherapists and chiropractors are used to identify combinations of health care use. Long-term high-cost patients are defined as total cost year 1-5 above 95th percentile (≥ 3 744€). RESULTS: We identified seven latent classes: 1: GP, low use; 2: GP, high use; 3: GP and hospital; 4: GP and physiotherapy, low use; 5: GP, hospital and physiotherapy, high use; 6: Chiropractor, low use; 7: GP and chiropractor, high use. Median first year health care contacts varied between classes from 1-30 and costs from 20€-838€. Eighty-seven percent belonged to class 1, 4 or 6, characterised by few consultations and treatment in primary care. Classes with high first year use were characterised by higher age, lower education and more comorbidities and were overrepresented among the long-term high-cost users. CONCLUSION: There was a large variation in first year health care service use, and we identified seven latent classes based on frequency of consultations. A small proportion of patients accounted for a high proportion of total resource use. This can indicate the potential for more efficient resource use. However, the effect of demographic and socioeconomic variables for determining combinations of service use can be interpreted as the health care system transforming unobserved patient needs into variations in use. These findings contribute to the understanding of clinical pathways and can help in the planning of future care, reduction in disparities and improvement in health outcomes for patients with MSDs.

Finding good alternatives to hospitalisation: a data register study in five municipal acute wards in Norway.

BACKGROUND: In Norway, municipal acute wards (MAWs) have been implemented in primary healthcare since 2012. The MAWs were intended to offer decentralised acute medical care 24/7 for patients who otherwise would be admitted to hospital. The aim of this study was to assess whether the MAW represents the alternative to hospitalisation as intended, through 1) describing the characteristics of patients intended as candidates for MAWs by primary care physicians, 2) exploring the need for extended diagnostics prior to admission in MAWs, and 3) exploring factors associated with patients being transferred from the MAWs to hospital. METHODS: The study was based on register data from five MAWs in Norway in the period 2014-2020. RESULTS: In total, 16 786 admissions were included. The median age of the patients was 78 years, 60% were women, and the median length of stay was three days. Receiving oral medication (OR 1.23, 95% CI 1.09-1.40), and the MAW being located nearby the hospital (OR 2.29, 95% CI 1.92-2.72) were factors associated with patients admitted to MAW after extended diagnostics. Patients needing advanced treatment, such as oxygen therapy (OR 2.13, 95% CI 1.81-2.51), intravenous medication (OR 1.60, 95% CI 1.45-1.81), intravenous fluid therapy (OR 1.32, 95% CI 1.19-1.47) and MAWs with long travel distance from the MAW to the hospital (OR 1.46, 95% CI 1.22-1.74) had an increased odds for being transferred to hospital. CONCLUSIONS: Our findings indicate that MAWs do not represent the alternative to hospitalisation as intended. The results show that patients receiving extended diagnostics before admission to MAW got basic treatment, while patients in need of advanced medical treatment were transferred to hospital from a MAW. This indicates that there is still a potential to develop MAWs in order to fulfil the intended health service level.

Does rehabilitation setting influence risk of institutionalization? A register-based study of hip fracture patients in Oslo, Norway.

BACKGROUND: Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients' subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6-12 months from the index admission). METHODS: Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients' age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo's boroughs to control for supply-side and unobserved effects. RESULTS: The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23-0.76) of living in a nursing home at 6-12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF. CONCLUSIONS: The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

A performance comparison of patient pathways in Nordic capital areas - a pilot study for ischaemic stroke patients.

Aims: This article describes and discusses the extension of performance measurement using an episode-based approach so that the measurement includes primary care, and social and long-term-care services. By using data on incident stroke patients from the capital areas of four Nordic countries, this pilot study: (a) extended the disease-based performance analysis to include new indicators that better describe patient care pathways at different levels of care; (b) described and compared the performance of care given in the four areas; (c) evaluated how additional information changed the rankings of performance between the areas; and (d) described the trends in performance in the capital areas. Methods: The construction of data was based on a common protocol that used routinely collected national registers and statistics linked with local municipal registers. We created new variables describing the timing of discharge to home and institutionalisation, as well as describing the use and cost of primary and social hospital services. Risk adjustment was performed with four different sets of confounders. Results: Differences existed in various performance indicators between the four metropolitan areas. The ranking was sensitive to the risk-adjustment method. The study showed that for stroke patients a performance comparison with data that are only from secondary and tertiary care, and without a valid severity measure, is not sufficient for international comparisons. Conclusions: Extending and deepening international performance analysis in order to cover patient pathways, including primary care and social services, is very useful for benchmarking activities when focusing on diseases affecting older people.

Two-view digital breast tomosynthesis versus digital mammography in a population-based breast cancer screening programme (To-Be): a randomised, controlled trial.

BACKGROUND: Digital breast tomosynthesis is an advancement of mammography, and has the potential to overcome limitations of standard digital mammography. This study aimed to compare first-generation digital breast tomo-synthesis including two-dimensional (2D) synthetic mammograms versus digital mammography in a population-based screening programme. METHODS: BreastScreen Norway offers all women aged 50-69 years two-view (craniocaudal and mediolateral oblique) mammographic screening every 2 years and does independent double reading with consensus. We asked all 32 976 women who attended the programme in Bergen in 2016-17, to participate in this randomised, controlled trial with a parallel group design. A study-specific software was developed to allocate women to either digital breast tomosynthesis or digital mammography using a 1:1 simple randomisation method based on participants' unique national identity numbers. The interviewing radiographer did the randomisation by entering the number into the software. Randomisation was done after consent and was therefore concealed from both the women and the radiographer at the time of consent; the algorithm was not disclosed to radiographers during the recruitment period. All data needed for analyses were complete 12 months after the recruitment period ended. The primary outcome measure was screen-detected breast cancer, stratified by screening technique (ie, digital breast tomosynthesis and digital mammography). A log-binomial regression model was used to estimate the efficacy of digital breast tomosynthesis versus digital mammography, defined as the crude risk ratios (RRs) with 95% CIs for screen-detected breast cancer for women screened during the recruitment period. A per-protocol approach was used in the analyses. This trial is registered at ClinicalTrials.gov, number NCT02835625, and is closed to accrual. FINDINGS: Between, Jan 14, 2016, and Dec 31, 2017, 44 266 women were invited to the screening programme in Bergen, and 32 976 (74·5%) attended. After excluding women with breast implants and women who did not consent to participate, 29 453 (89·3%) were eligible for electronic randomisation. 14 734 women were allocated to digital breast tomosynthesis and 14 719 to digital mammography. After randomisation, women with a previous breast cancer were excluded (digital breast tomosynthesis group n=314, digital mammography group n=316), women with metastases from melanoma (digital breast tomosynthesis group n=1), and women who informed the radiographer about breast symptoms after providing consent (digital breast tomosynthesis group n=39, digital mammography group n=34). After exclusions, information from 28 749 women were included in the analyses (digital breast tomosynthesis group n=14 380, digital mammography group n=14 369). The proportion of screen-detected breast cancer among the screened women did not differ between the two groups (95 [0·66%, 0·53-0·79] of 14 380 vs 87 [0·61%, 0·48-0·73] of 14 369; RR 1·09, 95% CI 0·82-1·46; p=0·56). INTERPRETATION: This study indicated that digital breast tomosynthesis including synthetic 2D mammograms was not significantly different from standard digital mammography as a screening tool for the detection of breast cancer in a population-based screening programme. Economic analyses and follow-up studies on interval and consecutive round screen-detected breast cancers are needed to better understand the effect of digital breast tomosynthesis in population-based breast cancer screening. FUNDING: Cancer Registry of Norway, Department of Radiology at Haukeland University Hospital, University of Oslo, and Research Council of Norway.

Comparisons of readmissions and mortality based on post-discharge ambulatory follow-up services received by stroke patients discharged home: a register-based study.

BACKGROUND: Few studies have focused on post-discharge ambulatory care for stroke patients and subsequent differences in readmission and mortality rates. Identifying groups at higher risk according to services received is important when planning post-discharge follow-up in ambulatory care. According to a recent Whitepaper by the Norwegian Government, patients receiving ambulatory care should have follow-up with a general practitioner (GP) within 14 days of hospital discharge. METHODS: All home discharged stroke cases occurring in Oslo from 2009 to 2014 were included. 90- and 365-day all-cause readmissions and mortality were compared separately for patients categorized based on services received (no services, home nursing, ambulatory rehabilitation and home nursing with ambulatory rehabilitation) and early GP follow-up within 14 days following discharge. Variables used to adjust for differences in health status and demographics at admission included inpatient days and comorbidities the year prior to admission, calendar year, sex, age, income, education and functional score. Cox regression reporting hazard ratios (HR) was used. RESULTS: There were no significant differences in readmission rates for early GP follow-up. Patients receiving home nursing and/or rehabilitation had higher unadjusted 90- and 365-day readmission rates than those without services (HR from 1.87 to 2.63 depending on analysis, p < 0.001), but the 90-day differences disappeared after risk adjustment, except for patients receiving only rehabilitation. There were no significant differences in mortality rates according to GP follow-up after risk adjustment. Patients receiving rehabilitation had higher mortality than those without services, even after adjustment (HR from 2.20 to 2.69, p < 0.001), whereas the mortality of patients receiving only home nursing did not differ from those without services. CONCLUSIONS: Our results indicate that the observed differences in unadjusted readmission and mortality rates according to GP follow-up and home nursing were largely due to differences in health status at admission, likely unrelated to the stroke. On the other hand, mortality for patients receiving ambulatory rehabilitation was twice as high compared to those without, even after adjustment and irrespective of also receiving home nursing. Hence, assessing the needs of these patients during discharge planning and providing careful follow-up after discharge seems important.

Early assessment of innovation in a healthcare setting.

OBJECTIVES: Early assessment can assist in allocating resources for innovation effectively and produce the most beneficial technology for an institution. The aim of the present study was to identify methods and discuss the analytical approaches applied for the early assessment of innovation in a healthcare setting. METHODS: Knowledge synthesis based on a structured search (using the MEDLINE, Embase, and Cochrane databases) and thematic analysis was conducted. An analytical framework based on the stage of innovation (developmental, introduction, or early diffusion) was applied to assess whether methods vary according to stage. Themes (type of innovation, study, analysis, study design, method, and main target audience) were then decided among the authors. Identified methods and analysis were discussed according to the innovation stage. RESULTS: A total of 1,064 articles matched the search strategy. Overall, thirty-nine articles matched the inclusion criteria. The use of methods has a tendency to change according to the stage of innovation. Stakeholder analysis was a prominent method in the innovation stages and particularly in the developmental stage, as the introduction and early diffusion stage has more availability of data and may apply more complex methods. Barriers to the identified methods were also discussed as all of the innovation stages suffered from lack of data and substantial uncertainty. CONCLUSIONS: Although this review has identified applicable approaches for early assessment in different innovation stages, research is required regarding the value of the available data and methods and tools to enhance interactions between different parties at different stages of innovation.

Retrospective cohort study of breast cancer incidence, health service use and outcomes in Europe: a study of feasibility.

Background: Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries. Methods: Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24 years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region. Results: In total, 24 576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.2-98.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix. Conclusion: Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy.

Prostate-specific antigen testing for prostate cancer: Depleting a limited pool of susceptible individuals?

After the introduction of the prostate specific antigen (PSA) test in the 1980s, a sharp increase in the incidence rate of prostate cancer was seen in the United States. The age-specific incidence patterns exhibited remarkable shifts to younger ages, and declining rates were observed at old ages. Similar trends were seen in Norway. We investigate whether these features could, in combination with PSA testing, be explained by a varying degree of susceptibility to prostate cancer in the populations. We analyzed incidence data from the United States' Surveillance, Epidemiology, and End Results program for 1973-2010, comprising 511,027 prostate cancers in men ≥40 years old, and Norwegian national incidence data for 1953-2011, comprising 113,837 prostate cancers in men ≥50 years old. We developed a frailty model where only a proportion of the population could develop prostate cancer, and where the increased risk of diagnosis due to the massive use of PSA testing was modelled by encompassing this heterogeneity in risk. The frailty model fits the observed data well, and captures the changing age-specific incidence patterns across birth cohorts. The susceptible proportion of men is [Formula: see text] in the United States and [Formula: see text] in Norway. Cumulative incidence rates at old age are unchanged across birth cohort exposed to PSA testing at younger and younger ages. The peaking cohort-specific age-incidence curves of prostate cancer may be explained by the underlying heterogeneity in prostate cancer risk. The introduction of the PSA test has led to a larger number of diagnosed men. However, no more cases are being diagnosed in total in birth cohorts exposed to the PSA era at younger and younger ages, even though they are diagnosed at younger ages. Together with the earlier peak in the age-incidence curves for younger cohorts, and the strong familial association of the cancer, this constitutes convincing evidence that the PSA test has led to a higher proportion, and an earlier timing, of diagnoses in a limited pool of susceptible individuals.

Ethnic differences in the incidence of type 1 diabetes in Norway: a register-based study using data from the period 2002-2009.

BACKGROUND: Few studies have looked at variation in type 1 diabetes incidence between immigrant groups within a country. OBJECTIVE: To investigate differences in incidence rates of childhood-onset type 1 diabetes between immigrant groups and ethnic Norwegians, and their contribution to the number of incident cases of type 1 diabetes in Norway. SUBJECTS: The study includes 2221 individuals with newly onset type 1 diabetes diagnosed during 2002-2009 in children of 0-14 yr in Norway registered in the nationwide and population-based Norwegian Childhood Diabetes Registry. METHODS: Incident cases were classified in seven groups based on country of maternal birth and three age groups. Statistics Norway provided the corresponding population sizes. Incidence rates were compared by Poisson regression. RESULTS: The overall incidence rate was 34.0 cases per 100,000 person-years (95% CI: 32.6, 35.5). There were large variations in incidence across the immigrant groups (p < 0.001), ranging from 6.8 per 100,000 person-years (95% CI: 1.9-17.5) for South/East Asians to 26.0 cases per 100,000 person-years (95% CI: 11.9-49.3) for sub-Saharan Africans. The differences remained significant after adjusting for age and gender. CONCLUSIONS: There are large variations in the rate of incidence of type 1 diabetes across the ethnic groups, and several immigrant groups have significantly lower incidence than ethnic Norwegians. Immigrant groups contributed ca. 5% of the total cases of type 1 diabetes and influence the overall incidence in Norway only to a small extent.

Risk adjustment in measurements of predicted mortality after myocardial infarction.

BACKGROUND: In 2014, the government introduced elements of quality-based funding (pay-for-performance) for the hospital sector. Survival is included as a quality indicator. If such quality indicators are to be used for funding purposes, it must be established that the observed variations are caused by conditions that the hospital trusts are able to influence, and not by any underlying variables. The objective of this study was to investigate how the predicted mortality after myocardial infarction was influenced by various forms of risk adjustment. MATERIAL AND METHOD: Data from the Norwegian Patient Register on 10,717 patients who had been discharged with the diagnosis of myocardial infarction in 2009 were linked to data on socioeconomic status, comorbidity, travel distances and mortality. The predicted 30-day mortality after myocardial infarction was analysed at the hospital-trust level, using three different models for risk adjustment. RESULTS: Unadjusted 30-day mortality was highest in the catchment area of Førde Hospital Trust (12.5%) and lowest in Asker og Bærum (5.2%). Risk adjustment changed the estimates of mortality for many of the hospital trusts. In the model involving the most comprehensive risk adjustment, mortality was highest in the catchment area of Akershus University Hospital (10.9%) and lowest in the catchment areas of Sunnmøre Hospital Trust (5.2%) and Nordmøre og Romsdal Hospital Trust (5.2%). INTERPRETATION: The variation in treatment quality between the hospital trusts, as measured by predicted mortality after myocardial infarction, is influenced by the methods used for risk adjustment. If the quality-based funding scheme is to continue, well-documented models for risk adjustment of the quality indicators need to be established.

Cost-effectiveness of TNF inhibitors vs synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: a Markov model study based on two longitudinal observational studies.

OBJECTIVE: The objective of this study was to estimate the additional costs and health benefits of adding a TNF inhibitor (TNFi) (adalimumab, certolizumab, etanercept, golimumab, infliximab) to a synthetic DMARD (sDMARD), e.g. MTX, in patients with RA. METHODS: We developed the Norwegian RA model as a Markov model simulating 10 years of treatment with either TNFi plus sDMARDs (TNFi strategy) or sDMARDs alone (synthetic strategy). Patients in both strategies started in one of seven health states, based on the Short Form-6 Dimensions (SF-6D). The patients could move to better or worse health states according to transition probabilities. In the TNFi strategy, patients could stay on TNFi (including switch of TNFi), or switch to non-TNFi-biologics (abatacept, rituximab, tocilizumab), sDMARDs or no DMARD. In the synthetic strategy, patients remained on sDMARDs. Data from two observational studies were used for the assessment of resource use and utilities in the health states. Health benefits were evaluated using the EuroQol-5 Dimensions (EQ-5D) and SF-6D. RESULTS: The Norwegian RA model predicted that 10-year discounted health care costs totalled €124,942 (€475,266 including production losses) for the TNFi strategy and €65,584 (€436,517) for the synthetic strategy. The cost per additionally gained quality-adjusted life-year of adding a TNFi was €92,557 (€60,227 including production losses) using SF-6D and €61,285 (€39,841) using EQ-5D. Including health care costs only, the probability that TNFi treatment was cost-effective was 90% when using EQ-5D, assuming a Norwegian willingness-to-pay level of €67,300. CONCLUSION: TNFi treatment for RA is cost-effective when accounting for production losses. Excluding production losses, TNFi treatment is cost-effective using EQ-5D, but not SF-6D.

Socio-economic Inequality in the Use of Procedures and Mortality Among AMI Patients: Quantifying the Effects Along Different Paths.

It is not known whether inequality in access to cardiac procedures translates into inequality in mortality. In this paper, we use a path analysis model to quantify both the direct effect of socio-economic status on mortality and the indirect effect of socio-economic status on mortality as mediated by the provision of cardiac procedures. The study links microdata from the Finnish and Norwegian national patient registers describing treatment episodes with data from prescription registers, causes-of-death registers and registers covering education and income. We show that socio-economic variables affect access to percutaneous coronary intervention in both countries, but that these effects are only moderate and that the indirect effects of the socio-economic factors on mortality through access to percutaneous coronary intervention are minor. The direct effects of income and education on mortality are significantly larger. We conclude that the socio-economic gradient in the use of percutaneous coronary intervention adds to socio-economic differences in mortality to little or no extent.

Parameter Heterogeneity In Breast Cancer Cost Regressions - Evidence From Five European Countries.

We investigate parameter heterogeneity in breast cancer 1-year cumulative hospital costs across five European countries as part of the EuroHOPE project. The paper aims to explore whether conditional mean effects provide a suitable representation of the national variation in hospital costs. A cohort of patients with a primary diagnosis of invasive breast cancer (ICD-9 codes 174 and ICD-10 C50 codes) is derived using routinely collected individual breast cancer data from Finland, the metropolitan area of Turin (Italy), Norway, Scotland and Sweden. Conditional mean effects are estimated by ordinary least squares for each country, and quantile regressions are used to explore heterogeneity across the conditional quantile distribution. Point estimates based on conditional mean effects provide a good approximation of treatment response for some key demographic and diagnostic specific variables (e.g. age and ICD-10 diagnosis) across the conditional quantile distribution. For many policy variables of interest, however, there is considerable evidence of parameter heterogeneity that is concealed if decisions are based solely on conditional mean results. The use of quantile regression methods reinforce the need to consider beyond an average effect given the greater recognition that breast cancer is a complex disease reflecting patient heterogeneity.

Spatial navigation measured by the Floor Maze Test in patients with subjective cognitive impairment, mild cognitive impairment, and mild Alzheimer's disease.

BACKGROUND: Impaired spatial navigation is an early sign of Alzheimer's disease (AD), but this can be difficult to assess in clinical practice. We examined how the performance on the Floor Maze Test (FMT), which combines navigation with walking, differed between patients with subjective cognitive impairment (SCI), mild cognitive impairment (MCI), and mild AD. We also explored if there was a significant relationship between the FMT and the cognitive tests or sociodemographic factors. METHODS: The study included 128 patients from a memory clinic classified as having SCI (n = 19), MCI (n = 20), and mild AD (n = 89). Spatial navigation was assessed by having the patients walk through the FMT, a two-dimensional maze. Both timed measures and number of errors were recorded. Cognitive function was assessed by the Word List Memory test, the Clock Drawing test, the Trail Making tests (TMT) A and B, and the Mini Mental Status Examination (MMSE). RESULTS: The patients with MCI were slower than those with SCI, while the patients with mild AD more frequently completed the FMT with errors or gave up than the patients with MCI. Performance on the FMT was significantly associated with executive function (measured by TMT-B). CONCLUSIONS: The performances on the FMT worsened with increasing severity of cognitive impairment, and the FMT was primarily associated with executive function. The explained variance was relatively low, which may indicate that the standard cognitive test battery does not capture impairments of spatial navigation.

A hierarchical frailty model for familial testicular germ-cell tumors.

Using a 2-level hierarchical frailty model, we analyzed population-wide data on testicular germ-cell tumor (TGCT) status in 1,135,320 two-generational Norwegian families to examine the risk of TGCT in family members of patients. Follow-up extended from 1954 (cases) or 1960 (unaffected persons) to 2008. The first-level frailty variable was compound Poisson-distributed. The underlying Poisson parameter was randomized to model the frailty variation between families and was decomposed additively to characterize the correlation structure within a family. The frailty relative risk (FRR) for a son, given a diseased father, was 4.03 (95% confidence interval (CI): 3.12, 5.19), with a borderline significantly higher FRR for nonseminoma than for seminoma (P = 0.06). Given 1 affected brother, the lifetime FRR was 5.88 (95% CI: 4.70, 7.36), with no difference between subtypes. Given 2 affected brothers, the FRR was 21.71 (95% CI: 8.93, 52.76). These estimates decreased with the number of additional healthy brothers. The estimated FRRs support previous findings. However, the present hierarchical frailty approach allows for a very precise definition of familial risk. These FRRs, estimated according to numbers of affected/nonaffected family members, provide new insight into familial TGCT. Furthermore, new light is shed on the different familial risks of seminoma and nonseminoma.