Risk of cancer and serious disease in Danish patients with urgent referral for serious non-specific symptoms and signs of cancer in Funen 2014-2021.

BACKGROUND: In 2011, as the first European country, Denmark introduced the non-organ-specific cancer patient pathway (CPP) for patients presenting with non-specific symptoms and signs of cancer (NSSC). The proportion of patients with cancer over time is unknown. METHODS: A retrospective cohort study of all patients with a NSSC-CPP investigational course in the province of Funen to the Diagnostic Centre in Svendborg from 2014 to 2021 was performed to evaluate the proportion of patients with cancer and serious disease over time. RESULTS: A total of 6698 patients were referred to the NSSC-CPP of which 20.2% had cancer. While the crude referral rate increased from 114 per 100,000 people in 2014 and stabilised to around 214 in 2017-2021, the cancer detection rate of the total yearly new cancers in Funen diagnosed through the NSSC-CPP in DC Svendborg increased from 3 to 6%. CONCLUSIONS: With now high and stable conversion and crude referral rates, the NSSC-CPP is one of the largest CPPs in Denmark as measured by the number of new cancer cases found. Similar urgent referral programmes in other countries might fill an unmet medical need for patients presenting with serious non-specific symptoms and signs of cancer in general practice.

Economic analyses in cardiac electrophysiology: from clinical efficacy to cost utility.

Cardiac electrophysiology is an evolving field that relies heavily on costly device- and catheter-based technologies. An increasing number of patients with heart rhythm disorders are becoming eligible for cardiac interventions, not least due to the rising prevalence of atrial fibrillation and increased longevity in the population. Meanwhile, the expansive costs of healthcare face finite societal resources, and a cost-conscious approach to new technologies is critical. Cost-effectiveness analyses support rational decision-making in healthcare by evaluating the ratio of healthcare costs to health benefits for competing therapies. They may, however, be subject to significant uncertainty and bias. This paper aims to introduce the basic concepts, framework, and limitations of cost-effectiveness analyses to clinicians including recent examples from clinical electrophysiology and device therapy.

Effects of home-based specialized palliative care and dyadic psychological intervention on caregiver burden: results from a randomized controlled trial.

Background The Domus study, a randomized controlled trial (RCT), evaluated the effect of home-based specialized palliative care (SPC) reinforced with a psychological intervention for the patient-caregiver dyad on increasing advanced cancer patients' time spent at home, as opposed to hospitalized, and the number of home deaths. As palliative care extends to include support for patients' families and may thus assist caregivers and decrease demands on them, in this study we evaluated a secondary outcome, caregiver burden.Material and Methods Patients with incurable cancer and their caregivers were randomized (1:1) to care as usual or home-based SPC. Caregiver burden was assessed using the Zarit Burden Interview (ZBI) at baseline and 2, 4, 8 weeks and 6 months after randomization. Intervention effects were assessed in mixed effects models.Results A total of 258 caregivers were enrolled. Eleven per cent of informal caregivers experienced severe caregiver burden at baseline. Caregiver burden increased significantly over time in both groups (p = 0.0003), but no significant effect of the intervention was seen on overall caregiver burden (p = 0.5046) or burden subscales measuring role and personal strain.Conclusion In line with the majority of previous RCTs, the Domus intervention was not able to significantly reduce caregiver burden. Future interventions should consider targeting only caregivers reporting the greatest caregiver burden.

Survival and long-term socioeconomic consequences of childhood and adolescent onset of brain tumours.

AIM: To evaluate survival distributions, long-term socioeconomic consequences, and health care costs in patients with childhood and adolescent onset of brain tumours in a Danish nationwide prospective cohort study. METHOD: A search of national registries identified 2283 patients (1198 males, 1085 females; mean age 9 years 6 months [SD 5 years 7 months]) diagnosed with a brain tumour between 1980 and 2015 and aged no older than 18 years at diagnosis. These were compared with sex-, age-, and residency-matched comparison individuals. Patients with malignant tumours were compared with those with benign tumours. Survival distributions were estimated by the Kaplan-Meier method and hazard ratio by the Cox proportional hazard model. Socioeconomic data at age 20 and 30 years were assessed. RESULTS: The probability of mortality was highest during the first year after tumour diagnosis. In young adulthood, the patients were generally less likely to be married, had lower grade-point averages, educational levels, and income, were less likely to be in employment, and had higher health care costs than comparison individuals. Patients with malignant tumours had worse outcomes with respect to education, employment, and health care costs than those with benign tumours. INTERPRETATION: A diagnosis of brain tumour in childhood and adolescence adversely affects survival and has negative long-term socioeconomic consequences, especially in patients with malignant tumours. These patients require continuous social support.

Direct and indirect costs of heart failure in relation to diabetes status - A nationwide study.

BACKGROUND AND AIM: Heart failure (HF) and diabetes mellitus (DM) are burdensome chronic diseases with high lifetime risks and numerous studies indicate associations between HF and DM. The objective of this study was to investigate the direct and indirect costs of HF patients with and without DM. METHODS AND RESULTS: Patients with a first-time diagnosis of HF from 1998 to 2016 were identified through nationwide Danish registries and stratified according to DM status into HF with or without DM. The economic healthcare cost analysis was based on both direct costs, including hospitalization, procedures, medication and indirect costs including social welfare and lost productivity. The economic burden was investigated prior to, at, and following diagnosis of HF. Patients with concomitant HF and DM were younger (median age 74 vs. 77), had more comorbidities and fewer were female as compared to patients with HF but without DM. The socioeconomic burden of concomitant HF and DM compared to HF alone was substantially higher; 45% in direct costs (€16,237 vs. €11,184), 35% in home care costs (€3123 vs. €2320), 8% in social transfer income (€17,257 vs. €15,994) and they had 27% lower income (€10,136 vs. €13,845). The economic burden peaked at year of diagnosis, but the difference became increasingly pronounced in the years following the HF diagnosis. CONCLUSION: Patients with concomitant HF and DM had a significantly higher economic burden compared to patients with HF but without DM.

Longitudinal analysis of health care costs in patients with childhood onset inherited retinal dystrophies compared to healthy controls.

BACKGROUND: We evaluated health care costs in patients with childhood onset visual impairment caused by inherited retinal dystrophies (IRD). METHODS: The IRD cohort, identified from the Danish Registry of Blind and Partially Sighted Children, was compared to age- and sex-matched controls from the national, Danish population registry. Information on health care expenditures for somatic and psychiatric in- and outpatient services, purchase of prescription medications and paid assistance at home were obtained from national registries for the years 2002-2017. RESULTS: We included 412 in the IRD cohort (6,290 person years) and 1656 (25,088 person years) in the control cohort. Average, annual health care expenditures from age 0-48 years of age were €1,488 (SD 4,711) in the IRD cohort and €1,030 (4,639) in the control cohort. The largest difference was for out-patient eye care (13.26 times greater, 95% confidence interval 12.90-13.64). Psychiatric in-patient expenditures were 1.71 times greater (95% CI 1.66-1.76) in the IRD cohort but psychiatric out-patient health care costs were comparable between groups. CONCLUSIONS: Health care costs were approximately 40% greater in the IRD cohort compared to an age- and sex-matched sample from the general Danish population. This is relevant in the current situation with a number of trials aimed at treating IRDs using genetically based therapies. Although eye care expenditures were many times greater, they made up < 10% of the total health care expenditures even in the IRD cohort. The reduced costs related to injuries in the visually impaired cohort was a surprising finding but may reflect a reduced propensity to seek medical care rather than a reduced risk of injuries.

Welfare consequences of early-onset Borderline Personality Disorder: a nationwide register-based case-control study.

Information regarding welfare consequences of early onset of Borderline Personality Disorder (BPD) is limited. This nationwide study aimed to estimate the educational and employment outcome and health care costs of patients with early-onset BPD compared with matched controls. All patients (< 19 years) with first diagnosis of BPD in the Danish Patient Register (NPR) during the period 1983-2015 were included. Health care costs and socioeconomic variables were extracted from national registers. A total of 171 patients was compared with 677 controls. At the age of 20 years, BPD patients had reached a statistically significantly lower educational level (including lower primary school grades) and employment status compared with the controls. When adjusting for the parents' educational level, BPD patients were nearly 22 times more likely to be unemployed (OR = 21.7, 95% CI 11.9, 39.6), and nearly 15 times more likely to be on disability pension (OR = 14.8, 95% CI 5.0, 43.9) than controls. Furthermore, the total health care costs were more than 8 times higher in the BPD group. Early onset of BPD was associated with lower educational and vocational outcome and increased health care costs as early as at the age of 20 years. Even after controlling for parents' lower socioeconomic status, the patients have poorer outcome than the control group. This underlines that initiatives to support patients in finishing school and secondary education is highly needed. Future prevention and early intervention programs should target patients with early-onset BPD and their families.

Morbidity, Mortality, and Conversion to Neurodegenerative Diseases in Patients with REM Sleep Behavior Disorder and REM Sleep without Atonia.

INTRODUCTION: The underlying pathophysiology of idiopathic REM sleep behavior disorder (iRBD) is not fully understood, although the condition is currently recognized as an early-stage alpha-synuclein disorder. We evaluated the morbidity, mortality, and rate of conversion to a neurodegenerative disorder in a national group of patients. METHODS: All patients in Denmark with a diagnosis of RBD between 2006 and 2013 were identified from the Danish National Patient Registry (NPR) records. We excluded patients who had received a diagnosis of narcolepsy or any of the following neurodegenerative diseases before their diagnosis of RBD: Parkinson's disease, multiple system atrophy, progressive supranuclear paralysis, Alzheimer's, and Lewy body dementia. We used randomly chosen controls matched for age, gender, and municipality. RESULTS: In total, 246 iRBD patients and 982 matched controls were analyzed. The mortality rate was the same in both groups. The morbidity rate was significantly higher in the years before and after an RBD diagnosis, due to a wide variety of disorders in the following major disease groups: mental/behavioral disorders; endocrine/metabolic diseases; diseases of the eye; diseases of the nervous, digestive, musculoskeletal, circulatory, and respiratory systems; abnormal findings not classified elsewhere; external causes; and factors influencing health status. The conversion rate from RBD to a neurodegenerative disease was 13% over the 8 years after a diagnosis of RBD. CONCLUSIONS: A diagnosis of RBD is associated with increased morbidity several years before and after a diagnosis is made. Patients have a higher risk of converting to a neurodegenerative disorder than matched controls. Mortality rates are unchanged.

The impact of changed treatment patterns in multiple myeloma on health-care utilisation and costs, myeloma complications, and survival: A population-based comparison between two time periods in Denmark.

OBJECTIVES: To evaluate health-care utilisation and costs, myeloma complications and survival in Danish patients with multiple myeloma (MM) before and after implementation of new early-line treatments in 2009. METHODS: Based on data from the Danish National Health Registers, 3518 patients diagnosed with MM during 2002-2005 or 2010-2013 and randomly matched control individuals were identified, and health-care utilisation and costs were estimated. RESULTS: Health-care utilisation showed a marked shift from inpatient admissions towards outpatient visits. From early to late period, the mean annual number of outpatient visits increased by 22% and 28% in patients <65 years and ≥65 years, respectively. Additionally, the mean annual outpatient service costs increased correspondingly from 17 001€ to 23 643€ in younger patients and from 11 317€ to 16 144€ in the elderly. Increasing outpatient costs were outbalanced by lower inpatient admission costs and the adjusted total mean annual costs decreased in younger patients, probably partly due to fewer myeloma complications. The five-year survival rates increased markedly in both younger (HR = 0.51) and elderly (HR = 0.69) patients. CONCLUSION: Despite the introduction of new expensive early-line MM treatments in 2009, health-care costs remained stable due to a shift in health-care utilisation towards outpatient clinic care and fewer complications.

Costs of schizotypal disorder: A matched-controlled nationwide register-based study of patients and spouses.

OBJECTIVE: Information on societal cost of patients with schizotypal disorder is limited. The aim was to investigate the societal costs of schizotypal disorder before and after initial diagnosis including both patients and their spouses. METHODS: A register-based cohort study of 762 patients with incident schizotypal disorder (ICD-10; F21) including their spouses and 3048 matched controls, during 2002 to 2016. Total healthcare costs, home care costs, and costs of lost productivity of patients and spouses were included in the analysis. RESULTS: Total costs amounted €47,215 per year for patients with schizotypal disorder, which was fifteen times higher than the matched controls. Of these, 41% were healthcare and home care costs and 59% were costs of lost productivity. Healthcare costs and costs of lost productivity were increased during five years before initial diagnosis of schizotypal disorder. Total costs of spouses to patients were €21,384 compared with € 2519 among spouses of controls. 75% of the total costs of spouses to patients were related to lost productivity. The total costs were higher than the costs of borderline personality disorder, but on the same level as the costs of schizophrenia identified in earlier comparable studies. CONCLUSIONS: The total societal costs of patients with schizotypal disorder drawn from national registers differed substantially from the controls representing the general population. As evidence-based recommendations for diagnoses and treatment of patients with schizotypal disorder do not exist, future research should focus on developing effective treatment for this group of patients to reduce cost of illness.

Long-term employment, education, and healthcare costs of childhood and adolescent onset of epilepsy.

OBJECTIVE: Childhood- and adolescent-onset epilepsy may have a significant impact on long-term educational and vocational status, which in turn has consequences for individuals' socioeconomic status. We estimated the factual long-term socioeconomic consequences and healthcare costs of individuals with diagnosed epilepsy. METHODS: The prospective cohort study included Danish individuals with epilepsy onset before the age of 18 years, diagnosed between 2002 and 2016. Healthcare costs and socioeconomic data were obtained from nationwide administrative and health registers. The prediction was made with a general estimating equation (GEE). A total of 15,329 individuals were found with the diagnosis during this period and were followed until the age of 30 years. These were compared with 31,414 controls. We used 30 years as this represent an age where most has finalized their education, and as such represent the final educational level. Patients and their controls were subdivided into debut age groups of 0-5 and 6-18 years. Individuals were matched for age, gender, and residential location. RESULTS: Compared with control groups, patients with epilepsy at the age of 30 years tended to have the following: 1) parents with lower educational attainment; 2) a significantly lower educational level when controlling for parental education attainment; 3) lower grade-point averages; 4) a lower probability of being in employment and lower income, even when transfer payments were considered; and 5) elevated healthcare costs, including those for psychiatric care. It was also noted that the long-term educational consequences for patients with epilepsy were associated with parental educational level. Differences were more pronounced for those with early (0-5 years) rather than later (6-18 years) onset epilepsy. CONCLUSIONS: Epilepsy is associated with severe long-term socioeconomic consequences: lower educational level, school grades, employment status, and earned income. The presence of epilepsy is associated with parental educational level. LIMITATIONS: SIGNIFICANT OUTCOMES.

Lifetime costs and lifetime net public expenditures of smoking.

BACKGROUND: Current estimates of lifetime costs of smoking are largely based on model analyses using etiologic fractions for a variety of diseases or Markov chain models. Direct estimation studies based on individual data for health costs by smoking status over a lifetime are non-existent. METHODS: We estimated lifetime costs in a societal perspective of 18-year-old daily-smokers (continuing smoking throughout adult life) and never-smokers in Denmark, as well as lifetime public expenditures in the two groups. Main outcomes were lifetime net public expenditures and lifetime health costs according to OECD definitions and lifetime earned incomes. Estimates of these outcomes were based on registries containing individual-level data. Confounder-adjusted differences between daily-smokers and never-smokers were interpreted as smoking-attributable lifetime public expenditures and costs. RESULTS: The net lifetime public expenditure is, on average, €20 520 higher for male 18-year-old daily-smokers than for never-smokers, but €9771 lower, for female daily-smokers compared with never-smokers. In male 18-year-old daily-smokers, average lifetime health costs are €9921 higher and average lifetime earned incomes are €91 159 lower than for never-smokers. The corresponding figures are €5849 higher and €23 928 lower, respectively, for women. CONCLUSION: 18-year-old male daily-smokers are net public spenders over their lifetime compared with never-smokers, while the opposite applies for women. In Denmark, smoking is associated with higher lifetime health costs for society and losses in earned incomes-both for men and women.

Content and validation of the Electronic Patient Medication module (EPM)-the administrative in-hospital drug use database in the Capital Region of Denmark.

Aims: Registries on in-hospital drug use are sparse, especially those that can be linked to nationwide registries. In this study, we present and validate the Electronic Patient Medication module (EPM)-the electronic administrative database on in-hospital drug use covering the Capital Region of Denmark. Methods: The research database (EPM-research) is an adaptation of the database underlying the electronic administrative database for in-hospital drug use (EPM-clinic). The validation study was comprised of two sub-studies. Sub-study 1: Accordance of registration between EPM-clinic and EPM-research was investigated by analyzing randomly chosen retrospective patient records. Sub-study 2: Workflows and real-life registration practices were investigated through visits to three different (two medical and one emergency) departments. An observer followed a nurse while dispensing and administering drugs. This information was compared with EPM-research. The primary endpoint for both sub-studies was accordance of generic name between registrations. Secondary endpoints were exact brand name, dose, and time of each administration. Accordance (proportions) with 95% confidence intervals (CI) using the Clopper-Pearson method were calculated. The study was approved by the Danish Data Protection Agency (BFH-2016-058-04906) and the Danish Patient Safety Authority (3-3013-1884/1/). Results: In sub-study 1 227 retrospective drug administrations were reviewed. Accordance of generic name was 100.0% (CI 98.4%-100.0%). In sub-study 2 176 drug administrations were observed of which 173 were recorded with identical generic name, resulting in 98.3% (CI 95.1%-99.6%) accordance of data. Conclusions: Our validation of the EPM-research showed very high accordance. With detailed information on in-hospital drug use, the EPM-research may be a useful tool in pharmacoepidemiological research.

Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial.

BACKGROUND: While hospitals remain the most common place of death in many western countries, specialised palliative care (SPC) at home is an alternative to improve the quality of life for patients with incurable cancer. We evaluated the cost-effectiveness of a systematic fast-track transition process from oncological treatment to SPC enriched with a psychological intervention at home for patients with incurable cancer and their caregivers. METHODS: A full economic evaluation with a time horizon of six months was performed from a societal perspective within a randomised controlled trial, the DOMUS trial ( Clinicaltrials.gov : NCT01885637). The primary outcome of the health economic analysis was a incremental cost-effectiveness ratio (ICER), which is obtained by comparing costs required per gain in Quality-Adjusted Life Years (QALY). The costs included primary and secondary healthcare costs, cost of intervention and informal care from caregivers. Public transfers were analysed in seperate analysis. QALYs were measured using EORTC QLQ-C30 for patients and SF-36 for caregivers. Bootstrap simulations were performed to obtain the ICER estimate. RESULTS: In total, 321 patients (162 in intervention group, 159 in control group) and 235 caregivers (126 in intervention group, 109 in control group) completed the study. The intervention resulted in significantly higher QALYs for patients when compared to usual care (p-value = 0.026), while being more expensive as well. In the 6 months observation period, the average incremental cost of intervention compared to usual care was €2015 per patient (p value < 0.000). The mean incremental gain was 0.01678 QALY (p-value = 0.026). Thereby, the ICER was €118,292/QALY when adjusting for baseline costs and quality of life. For the caregivers, we found no significant differences in QALYs between the intervention and control group (p-value = 0.630). At a willingness to pay of €80,000 per QALY, the probability that the intervention is cost-effective lies at 15% in the base case scenario. CONCLUSION: This model of fast-track SPC enriched with a psychological intervention yields better QALYs than usual care with a large increase in costs. TRIAL REGISTRATION: The trial was prospectively registered 25.6.2013. Clinicaltrials.gov Identifier: NCT01885637 .

A cost analysis of intensified vs conventional multifactorial therapy in individuals with type 2 diabetes: a post hoc analysis of the Steno-2 study.

AIMS/HYPOTHESIS: Long-term follow-up of the Steno-2 study demonstrated that intensified multifactorial intervention increased median lifespan by 7.9 years and delayed incident cardiovascular disease by a median of 8.1 years compared with conventional multifactorial intervention during 21.2 years of follow-up. In this post hoc analysis of data from the Steno-2 study, we aimed to study the difference in direct medical costs associated with conventional vs intensified treatment. METHODS: In 1993, 160 Danish individuals with type 2 diabetes and microalbuminuria were randomised to conventional or intensified multifactorial target-driven intervention for 7.8 years. Information on direct healthcare costs was retrieved from health registries, and the costs in the two groups of participants were compared by bootstrap t test analysis. RESULTS: Over 21.2 years of follow-up, there was no difference in total direct medical costs between the intensified treatment group, €12,126,900, and the conventional treatment group, €11,181,700 (p = 0.48). The mean cost per person-year during 1996-2014 was significantly lower in the intensified treatment group (€8725 in the intensive group and €10,091 in the conventional group, p = 0.045). The main driver of this difference was reduced costs associated with inpatient admissions related to cardiovascular disease (p = 0.0024). CONCLUSIONS/INTERPRETATION: Over a follow-up period of 21.2 years, we found no difference in total costs and reduced cost per person-year associated with intensified multifactorial treatment for 7.8 years compared with conventional multifactorial treatment. Considering the substantial gain in life-years and health benefits achieved with intensified treatment, we conclude that intensified multifaceted intervention in high-risk individuals with type 2 diabetes seems to be highly feasible when balancing healthcare costs and treatment benefits in a Danish healthcare setting.

Dyadic coping in specialized palliative care intervention for patients with advanced cancer and their caregivers: Effects and mediation in a randomized controlled trial.

OBJECTIVE: Specialized palliative care (SPC) interventions increasingly include patient-caregiver dyads, but their effects on dyadic coping are unknown. We investigated whether an SPC and dyadic psychological intervention increased aspects of dyadic coping in patients with advanced cancer and their caregivers, whether dyad characteristics moderated effects and whether aspects of dyadic coping mediated significant intervention effects on caregivers' anxiety and depression. METHODS: We randomized 258 patients with incurable cancer and their caregivers to care as usual or accelerated transition from oncological treatment to home-based SPC and dyadic psychological support. In secondary outcome analyses, using mixed-effects models, we estimated intervention effects and 95% confidence intervals (CIs) for communication of stress and common coping, and moderation by dyad type and demographics. In path analyses, we investigated whether stress communication and common coping mediated intervention effects on caregivers' symptoms of anxiety and depression. (Clinicaltrials.gov NCT01885637). RESULTS: The intervention significantly increased common coping in patients and caregivers in couples (estimated difference, 0.68; 95% CI, 0.11 to 1.24) and stress communication by partner caregivers (0.97; 0.24 to 1.24). We found some support for different intervention effects for spouses and other dyads, but no evidence of mediation. CONCLUSIONS: Specialized palliative care and dyadic psychological intervention may affect aspects of dyadic coping. Common coping and stress communication did not mediate the previously found significant intervention effects on caregiver anxiety and depression, indicating that other mechanisms may have been central in the intervention.

Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark.

OBJECTIVE: We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures. METHODS: From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics. RESULTS: A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners. SIGNIFICANCE: Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.

Morbidity and mortality of nonepileptic seizures (NES): A controlled national study.

Nonepileptic seizures (NES, psychogenic NES-PNES) are associated with significant morbidities. We evaluated the morbidities and mortality in a national group of children, adolescent, and adult patients before and after a first diagnosis of PNES. METHODS: From the Danish National Patient Registry (1998-2013), we identified 1057 people of all ages with a diagnosis of NES and matched them with 2113 control individuals by age, gender, and geography. Comorbidities were calculated three years before and after diagnoses. RESULTS: Patients with PNES showed increased comorbidities 3 years before and after diagnosis in almost all the diagnostic domains. The strongest associations were identified with other neurological diseases (after diagnosis, Hazard Ratio (HR): 38.63; 95% Confidence Interval (CI): 21.58-69.13; P < 0.001), abnormal clinical and laboratory findings (HR: 46.59; 95 CI: 27.30-79.52; P < 0.001), other health-related factors (HR: 12.83; 95%CI: 8.45-19.46; P < 0.001), and psychiatric comorbidities (HR: 15.45; 95% CI: 9.81-24.33). Epilepsy was identified in 8% of the patients with PNES. We found especially frequent comorbidity involving overweight, depression, anxiety, dissociative somatoform condition, other convulsions, lipothymias, reports of pain and other symptoms in several organ systems, and several reports of minimal traumas to the head, trunk, and extremities. Mortality was higher in patients with NES than in controls (HR: 3.21; 95% CI: 1.92-5.34; P < 0.001). CONCLUSION: Morbidity is more frequent in several domains, including neurological, psychiatric, and other diseases, before and after a diagnosis of NES. Mortality is significantly higher in patients with PNES as compared to controls.

Socioeconomic Costs and Health Inequalities from Psoriasis: A Cohort Study.

BACKGROUND: To date, there are no nationwide studies of the social and economic burden of psoriasis to patients in Denmark. Incentives for health care management based on patient-related outcomes and value (IMPROVE) in psoriasis and psoriatic arthritis is a project aimed at assisting movement from activity-based to outcome-based health care management. One of the key objectives in IMPROVE is to describe the disease-associated socioeconomic burden of psoriasis. METHODS: A case-matched study of the impact of psoriasis on patients' income, employment and health care costs in Denmark was performed. The IMPROVE study was a retrospective analysis of patients with a hospital diagnosis of psoriasis identified from the Danish National Patient Registry (NPR). In total, 13,025 psoriasis patients and 25,629 matched controls were identified from the NPR. Data from psoriasis patients and matched controls were compared for social and economic factors including income, employment, health care costs and risk of comorbidities. RESULTS: Psoriasis was associated with increased health care costs (mean annual costs +116% compared to control, p < 0.001), peaking in the year of referral to hospital for psoriasis and sustained thereafter. Both direct and indirect costs were significantly higher for patients with psoriasis than controls (p < 0.001). In the years before and immediately following hospital diagnosis, the rates of employment were lower in psoriasis patients than controls. Comorbidities, including cardiovascular (odds ratio 1.93 [95% CI 1.77-2.09]) and psychiatric conditions (odds ratio 2.61 [95% CI 2.30-2.97]), were more prevalent in patients with psoriasis than controls. CONCLUSION: In Denmark, psoriasis has a significant impact on health care costs, income and employment, and is associated with a range of comorbidities.

Effect of home-based specialised palliative care and dyadic psychological intervention on caregiver anxiety and depression: a randomised controlled trial.

BACKGROUND: Specialised palliative care trials often fail to address intervention effects on caregiver anxiety and depression, particularly in bereavement. We evaluate effects of specialised palliative care and dyadic psychological intervention on caregiver anxiety and depression in a randomised controlled trial (RCT). METHODS: Patients with incurable cancer and limited antineoplastic treatment options and their caregivers, recruited from a university hospital oncology department, were randomised (1:1) to care as usual or accelerated transition from oncological treatment to home-based specialised palliative care. We assessed caregivers' symptoms of anxiety and depression with the Symptom Checklist-92 up to six months after randomisation and 19 months into bereavement, and estimated intervention effects in mixed effects models. RESULTS: The 'Domus' trial enrolled 258 caregivers. The intervention significantly attenuated increases in caregivers' symptoms of anxiety overall (estimated difference, -0.12; 95% confidence interval, -0.22 to -0.01, p = 0.0266), and symptoms of depression at eight weeks (-0.17; -0.33 to -0.02; p = 0.0314), six months (-0.27; -0.49 to -0.05; p = 0.0165), and in bereavement at two weeks (-0.28; -0.52 to -0.03; p = 0.0295) and two months (-0.24; -0.48 to -0.01; p = 0.0448). CONCLUSIONS: This first RCT evaluating specialised palliative care with dyadic psychological support significantly attenuated caregiver anxiety and depression before and during bereavement. (Clinicaltrials.gov: NCT01885637).