Economic evaluation of exercise-based cardiac rehabilitation in patients with a recent acute coronary syndrome.

Health care decision-making requires evidence of the cost-effectiveness of medical therapies. We evaluated the cost-effectiveness of exercise-based cardiac rehabilitation (ECR) implemented according to guidelines. All the patients (n = 204) had experienced a recent acute coronary syndrome and were randomized to a 1-year ECR (n = 109) or usual care (UC) group (n = 95). The patients' health-related quality of life was followed using the 15D instrument and health care costs were collected from electronic health registries. The cost-effectiveness of ECR was estimated based on intervention and health care costs and quality-adjusted life years (QALYs) gained. The total average cost per patient was lower in ECR than in UC. The incremental cost was divided by the baseline-adjusted incremental QALYs (0.045), yielding an incremental cost-effectiveness ratio of -€24511/QALYs. A combined endpoint of mortality, recurrent coronary event, or hospitalization for a heart failure occurred for five patients in ECR and 16 patients in UC (HR 3.9, 95% CI 1.4-10.6, P = 0.004, relative risk reduction 73%, number needed to treat eight). ECR is a dominant treatment option and decreases the occurrence of adverse cardiac events. These results are useful for decision-making when planning optimal utilization of resources in Finnish health care.

Systematic review: Factors associated with return to work in burnout.

BACKGROUND: Professional burnout predicts sick leave and even permanent withdrawal from the labour force. However, knowledge of the barriers to and facilitators of return to work (RTW) in such burnout is limited. AIMS: To identify factors associated with RTW of burned-out individuals to inform occupational health care (OHC) RTW policy. METHODS: A systematic search of peer-reviewed quantitative and mixed-method studies published from January 2005 to July 2016 in English and Finnish in ARTO, CINAHL (EBSCO), Medic, PsycINFO (ProQuest), PubMed, Scopus and Web of Science databases, followed by a manual search. We included studies that identify burnout with valid burnout measures and measure the degree of RTW or sick leave as outcomes. We excluded studies with heterogeneous samples without subgroup analyses of RTW in burnout cases. RESULTS: We included 10 studies (three experimental and seven observational) of the initial 1345 identified. The studies reported work-related factors; enhanced communication (positive association) and low control at work (negative association) and individual-related factors; male gender (positive association), covert coping (negative association), high over-commitment to work (positive association) and burnout-related factors; unimpaired sleep (positive association), duration of sick leave over 6 months (negative association) and part-time sick leave (positive association) associated with RTW in burnout. Associations between burnout rehabilitation and RTW, and the level of symptoms and cognitive impairment and RTW remained unclear. CONCLUSIONS: Few quantitative studies, of varied methodological quality, explore factors associated with RTW in burnout. Further research is needed to build an evidence base and develop guidelines for supportive OHC actions.

Primary-care-based episodes of care and their costs in a three-month follow-up in Finland.

OBJECTIVE: To explore patient characteristics, resource use, and costs related to different episodes of care (EOC) in Finnish health care. DESIGN: Data were collected during a three-month prospective, non-randomized follow-up study (Effective Health Centre) using questionnaires and an electronic health record. SETTING: Three primary health care practices in Pirkanmaa, Finland. SUBJECTS: Altogether 622 patients were recruited during a one-week period. Inclusion criteria: the patient had a doctor's or nurse's appointment on the recruiting day and agreed to participate. Exclusion criteria: patients visiting a specialized health guidance clinic for pregnant women, children, and mothers. MAIN OUTCOME MEASURES: Patient characteristics, resource use, and costs based on the ICPC-2 EOC classification. RESULTS: On average, the patients had 1.22 EOCs during the three months. Patient characteristics and resource use differed between the EOC chapters. Chapter L, "Musculoskeletal", had the most episodes (17%). The most common (8%) single EOC was "upper respiratory infection". The mean cost of an episode (COE) was €389.56 (standard error 61.11) and the median COE was €165.00 (interquartile range €118.46-288.56) during the three-month follow-up. The most expensive chapter was K, "Circulatory", with a mean COE of €909.85. The most expensive single COE was in chapter K, €32 545.56. The most expensive 1% of the COEs summed up covered 36% of the total COEs. CONCLUSION: Patient characteristics, resource use, and costs differed between the ICPC-2 chapters, which could be taken into account in service planning and pricing. Future studies should incorporate more specific diagnoses, larger data sets, and longer follow-up times. Key points The most common episodes were under the ICPC-2 "Musculoskeletal" chapter, but the highest mean and single-episode costs were related to the "Circulatory" chapter. The mean (median) cost of episodes that started in primary care was €390 (€165) during the three-month follow-up. Patient characteristics, resource use, and costs differed significantly between the ICPC-2 chapters. The most expensive 1% of the episodes covered 36% of the total costs of all the episodes.

Efficacy of a multicomponent support programme for the caregivers of disabled persons: a randomised controlled study.

AIM: The goal of the present work was to measure the efficacy of a multicomponent programme designed to provide tailored support for the caregivers of disabled persons. SUBJECTS: A total of 135 caregivers-care receiver dyads were randomly divided into an intervention group (n = 66) and a control group (n = 69). One-third of the care receivers were demented, and two-thirds had other diseases. SETTING: Health centres (publicly funded primary health care systems) in 8 rural and urban communities in southeast Finland. INTERVENTION: The multicomponent support programme for the caregivers consisted of a 2-week rehabilitation period. The control group received standard care. OUTCOME MEASUREMENTS: Continuation of the caregiver and care receiver relationship, care receiver mortality at the 2-year follow-up as well as the health-related quality of life (15D scale) and Zung's depression scale of the caregiver at the 1-year follow-up were evaluated. RESULTS: At the 2-year follow-up, the caregiver-care receiver relationship was terminated for any reason in 11 cases (17%) in the intervention group, and in 25 cases (36%) in the control group. After adjusting, the primary outcome (i.e., termination of care giving for any reason) indicated statistical significance (p = 0.04) with a hazard rate of 1.83 (95% confidence interval 1.03-3.29). With a similar adjustment, the difference in mortality and placement to institutional care between the two groups demonstrated a trend towards statistical significance. The caregivers' health, as related to quality of life and depressive symptoms, remained unchanged in both groups at the 1-year follow-up. CONCLUSION: These results indicate that a tailored support programme for caregivers may help the caregiver to continue the caregiver-care receiver relationship and delay institutionalization.

Altered striatal dopamine re-uptake site densities in habitually violent and non-violent alcoholics.

Animal studies suggest that development of substance dependence is associated with dopaminergic activity in striatum and the limbic system. Several genetic studies indicate that allele A1 is associated with both D2 receptor density and alcoholism, although these findings have remained controversial. We studied striatal dopamine (DA) re-uptake site densities in 48 subjects (19 healthy controls, 19 habitually impulsive violent alcoholics, and 10 non-violent alcoholics) with single photon emission computed tomography (SPECT) using iodine-123-labelled 2 beta-carbomethoxy-3 beta(4-iodophenyl)tropane, (beta-CIT) as a tracer. Blind quantitative analysis revealed that the striatal DA transporter density was markedly lower in non-violent alcoholics than in healthy controls (P < 0.001), while violent alcoholics had slightly higher DA transporter densities than controls (P < 0.10). The results indicate that both types of alcoholics have alterations in striatal dopaminergic system, though these occur in opposite directions.

Low diastolic blood pressure and mortality in a population-based cohort of 16913 hypertensive patients in North Karelia, Finland.

OBJECTIVE: To examine the relationship between mortality and diastolic blood pressure during treatment. DESIGN: A prospective follow-up of a population-based dynamic cohort of hypertensive patients. SETTING: Province of North Karelia, eastern Finland. PATIENTS: A cohort of 16 913 North Karelian hypertensive patients in hypertension register of the North Karelia Project, who had been followed up since 1972 until the end of 1985. Most of these patients had been under antihypertensive drug therapy during the follow-up. MAIN OUTCOME MEASURES: Death: all deaths (n = 4490), deaths from cardiovascular disease (n = 2995) and deaths from non-cardiovascular disease (n = 1495). RESULTS: Of all deaths, 17% of those among men and 24% of those among women were of patients with mean diastolic blood pressures less than 90 mmHg. We found a U-shaped relationship between diastolic blood pressure and total, cardiovascular and non-cardiovascular mortalities. We investigated this relationship in more detail using Cox regression model. Low diastolic blood pressure was associated independently with increased mortality for the patients aged 50 years or more at baseline. The occurrence of cardiac failure and other cardiovascular complications of hypertension were more important determinants of mortality than was low diastolic blood pressure alone. CONCLUSIONS: We demonstrated that there is an association between low diastolic blood pressure and mortality for treated hypertensive patients aged 50-69 years. The clinical importance of this relationship for patients without any cardiovascular complications of hypertension seems negligible. For patients with complications, these complications are likely to be primary factors causing greater than normal mortality and low diastolic blood pressure is mostly a secondary phenomenon. Our data do not lend support to speculations that there is overtreatment of hypertension, which would increase mortality through making diastolic blood pressures too low.

Lack of association between the functional variant of the catechol-o-methyltransferase (COMT) gene and early-onset alcoholism associated with severe antisocial behavior.

Addictive drugs, including ethanol, increase the brain's dopaminergic transmission, and catechol-o-methyltransferase (COMT) enzyme has a crucial role in dopamine inactivation. A common functional polymorphism in the COMT gene results in a three- to four-fold variation in enzyme activity. In a previous study, we found an association between type 1 (with late-onset but without prominent antisocial behavior) alcoholism and the low activity allele of the COMT gene. In this work we analyzed whether the COMT polymorphism has any effect on the development of type 2 (with early-onset and habitual impulsive violent behavior) alcoholism. The COMT genotype was determined in 62 impulsive violent recidivist offenders with early-onset (type 2) alcoholism, 123 late-onset nonviolent (type 1) alcoholics, and 267 race and gender-matched controls. The allele and genotype frequencies of these groups were compared with each other and also with previously published data from 3,140 Finnish blood donors. The type 2 alcoholics did not differ from either the blood donors or the controls. The low activity (L) allele frequency was higher among type 1 alcoholics (chi(2) = 4.98, P = 0.026) when compared with type 2 cases. The odds ratio for type 1 alcoholism as compared with type 2 alcoholism for those subjects with the LL genotype versus the HH genotype was 3.0 (95% confidence interval 1.1-8.4, P = 0.017). The results suggest that COMT genotype has no major role in the development of early-onset alcoholism with severe antisocial behavior.

Attitudes to health care prioritisation methods and criteria among nurses, doctors, politicians and the general public.

The aim of this postal questionnaire study was to measure attitudes to health care prioritisation criteria among the Finnish general public (n = 1156), politicians (n = 1096), doctors (n = 803) and nurses (n = 667), altogether 3722 subjects. The questionnaire consisted of questions on background data, a list of seven alternative prioritisation methods and a list of 11 possible criteria for health care prioritisation. The most acceptable prioritisation methods were increased treatment fees and restricting expensive treatments and examinations. Only a few supported administrative prioritisation decisions. One third of the general public indicated that they did not accept any limitations in health care, whereas only 5% of doctors agreed with them. More doctors accepted prioritisation methods than respondents in other groups. Patient is a child, patient is an elderly person, severity of the disease and prognosis of the disease were the most accepted prioritisation criteria. Politicians and the general public also accepted self-induced nature of disease and patient's wealth as prioritisation crieteria. Logistic regression analysis of the general public respondents demonstrated that male gender, higher education and higher personal income were associated with acceptance of most prioritisation criteria. Similarly, older age of the respondent was associated with acceptance of self-induced nature of disease and patient's wealth as prioritisation criteria.

General practitioners' willingness to request plain lumbar spine radiographic examinations.

OBJECTIVES: To examine general practitioners' attitudes to plain lumbar spine radiographic examinations. DESIGN: A postal questionnaire consisting of questions on background data and doctors' opinions about plain lumbar spine radiographic examinations, as well as eight vignettes (imaginary patient cases) presenting indications for lumbar radiography, and five vignettes focusing on the doctors' willingness to request lumbar radiography on the basis of patients' age and duration of symptoms. The data were analysed according to the doctor's age, sex, workplace and the medical school of graduation. SETTING: Finland. SUBJECTS: Six hundred and fifteen randomly selected physicians working in primary health care (64% of original target group). RESULTS: The vignettes revealed that the use of plain lumbar radiographic examination varied between 26 and 88%. Patient's age and radiation protection were the most prominent factors influencing doctors' decisions to request lumbar radiographies. Only slight differences were observed between the attitudes of male and female doctors, as well as between young and older doctors. Doctors' willingness to request lumbar radiographies increased with the patient's age in most vignettes. The duration of patients' symptoms had a dramatic effect on the doctor's decision: in all vignettes, doctors were more likely to request lumbar radiography when patient's symptoms had exceeded 4 weeks. CONCLUSIONS: General practitioners commonly use plain lumbar spine radiographic examinations, despite its limited value in the diagnosis of low back pain. Further consensus and medical education is needed to clarify the indications for plain lumbar radiographic examination.

Risk of homicidal behavior among discharged forensic psychiatric patients.

We studied the risk of homicidal behavior among 281 released male forensic psychiatric patients during the 14-year period 1978-1991. Released patients were about 300 times more likely to commit a homicide than the general male population during the first year outside hospital, and the corresponding risk was 53-fold during a mean follow-up period of 7.8 years. The odds ratio for committing a homicide among all Finnish schizophrenics during the 12-year period 1980-1991 was 9.7, which indicates that previous criminality associated with schizophrenia also increases the risk of homicidal behavior remarkably when compared with schizophrenia per se. We believe that this kind of epidemiological approach is a useful method of identifying and classifying factors associated with very high risk of homicidal behavior and preventing homicidal behavior among high-risk populations.

Comparison of doctors', nurses', politicians' and public attitudes to health care priorities.

OBJECTIVES: The aim of this study was to investigate differences in attitudes concerning prioritisation in health care held by doctors, nurses, local politicians and the general public. METHODS: Four groups were established: a population sample of 2000 subjects, aged 18-70 years; a random sample of 1500 doctors of working age; a random sample of 1000 nurses of working age; and a sample of 2200 politicians involved in health and social care administration, mostly at the municipal level (altogether 6700 subjects). The main questionnaire contained, among other things, a list of 12 statements concerning ethical decisions regarding prioritisation in health care. Respondents were asked to indicate their level of agreement with each statement. RESULTS: Most respondents in all the groups felt able to express an opinion on the statements. Despite considerable professional and cultural differences between groups, the views were generally similar. On the whole, respondents supported liberal policies in which the community took responsibility for subsidising health care. When differences between groups occurred, it was usually the doctors who held discordant views. Doctors were less inclined to consider a patient's economic status as a determinant of priority for treatment than the other three groups. Both doctors and nurses were less punitive towards patients with self-induced diseases. And doctors and politicians were more likely to feel further cuts in health care expenditure were possible than was true for nurses and the public. CONCLUSIONS: While considerable uniformity of opinion exists on ethical issues of prioritisation between the principal interested parties, the views of doctors differ substantially on some matters. If prioritisation was left entirely to doctors, health care provision would not reflect the views of other groups in some important ways.

Economic evaluation comparing From Home To Operation same day admission and preoperative admission one day prior to the surgery process: a randomized, controlled trial of laparoscopic cholecystectomy.

OBJECTIVE: A novel preoperative procedure From Home To Operation (FHTO) seeks to combat increasing operation and infection rates. This is the first prospective randomized controlled trial (RCT) comparing the cost-effectiveness and cost-utility of FHTO and conventional ward procedures for standardized Laparoscopic Cholecystectomy (LC). RESEARCH DESIGN AND METHODS: During 12/2004-7/2005, 47 patients with symptomatic gallstones were randomized to receive LC in the FHTO (28 patients) or in a conventional manner (19 patients) in a Finnish hospital setting. The 15D quality of life tool was administered at the baseline and 1 month after. MAIN OUTCOME MEASURES: A stochastic approach over a month interval for hospital costs, length of postoperative stay, infection rate and Quality-Adjusted Life Years (QALY) was employed. RESULTS: Baseline group characteristics were similar. The mean health care costs with FHTO (1695 EUR) were significantly lower (p < 0.001) than in the conventional arm (2234 EUR). The number of patients discharged on the first postoperative day was 27 (96.4%) and 15 (78.9%) with two (7.1%) infections in the FHTO and four (21.1%) in the conventional arm. A difference in QALYs gained (0.0174; p = 0.030) favouring FHTO was observed. According to a cost-effectiveness acceptability curve, the probability of FHTO being cost-effective was 99%. The results were robust to probabilistic sensitivity analyses. CONCLUSIONS: FHTO can introduce substantial cost savings and have a positive impact on both clinical measures and quality of life. Studies with larger numbers of patients are needed to assess whether conventional ward procedure can be a source of infections, which can be avoided with FHTO. CLINICAL TRIAL REGISTRY: ICJME-qualified registry of the Hospital District of Helsinki and Uusimaa (number 217849).

Health, functional capacity, health behaviour, psychosocial factors and falling in old age.

This study was done to investigate health, functional capacity, health behaviour and psychosocial factors associated with the occurrence of falls leading to medical treatment in elderly Finns (> or = 65 yrs). An unmatched case-control study was performed in the Town of Pori, Western Finland during the 12 months from September 1987 to August 1988. The series consisted of 380 fallers who sought medical treatment and 342 elderly control subjects selected randomly from the population register. Logistic regression analysis showed falls in the home-dwelling men to be associated with high age, high white blood cell count, poor self-perceived health and presence of depressive symptoms. In the home-dwelling women the occurrence of falls was associated with high white blood cell count, low blood haemoglobin level, high age and being afraid of falling. The occurrence of falling in the women showed a tendency to be associated with poor functional capacity, high axillary temperature and poor mental capacity. In the log-linear model in the men occurrence of falling was independently associated with poor self-perceived health and with high white blood cell count. In the women occurrence of falling was associated with high age, poor functional capacity, poor mental capacity, low blood haemoglobin and high white blood cell count. High age was associated with poor functional capacity and with low blood haemoglobin. Poor functional capacity and poor mental capacity were associated with each other. Poor mental and functional capacities, anaemia in women and acute infections are associated with falls leading to medical treatment in the elderly. Elderly subjects with an acute infection should be treated carefully to avoid falling complications.

Times, places, and mechanisms of falls among the elderly.

Elderly persons among the population aged 65 years or over in the town of Pori, Finland, falls leading to medical treatment experiencing during one year, are described by age, sex, month, time of day, place, mechanism, estimated cause, previous falls, symptoms before falling, and activity when falling. Results indicate that the falls can be divided into two main categories: falls due to an extrinsic mechanism such as slipping or stumbling, and falls due to an intrinsic or unknown mechanism. Extrinsic mechanisms are more common in the younger age group (65-74 years), in whom falls are dependent on the time of day and amount of activity, and frequently happen outdoors while walking. Thus, slipping is a common extrinsic mechanism. Intrinsic or unknown mechanisms are more common in the older age group (75 years and above), in which estimated causes, such as orthostatic hypotension, fever, dementia, or joint disorders, can in many cases be detected. These cases are not dependent on time of day or month. Falls due to intrinsic or unknown mechanisms are related to rising from a lying or sitting position and lifting the head or turning the body before the fall. Before falling, some kinds of symptoms are more commonly experienced by persons falling due to an intrinsic or unknown mechanism than by those falling due to an extrinsic mechanism.

The relationship between mental health and drug use.

The aim was to examine the relationship between mental health and use of different kinds of drugs. The study was a cross-sectional survey of a total population aged 45-69 years, conducted in 2 municipalities in southwestern Finland. Altogether 1821 people (80% of those invited), 815 men and 1006 women, took part in the screening. The subjects were examined by a questionnaire mailed beforehand and checked in a personal interview. The questionnaire contained questions about the currently used drugs and Goldberg's questionnaire on mental health. Half of the people examined used prescribed drugs currently, more women used drugs than men, and the use of drugs increased with age. Mental symptoms measured with the Goldberg Index appeared in one fifth of the subjects, showing a slight increase with age. Men with mental symptoms showed a fourfold psychotropic drug use compared with the men without mental symptoms. The women with mental symptoms showed a threefold use of psychotropic drugs compared with the women without mental symptoms. Similar differences were found also in other drug groups, for example cardiac glycosides, other cardiovascular drugs, analgesics and drugs for respiratory and digestive organs. Persons with mental disorders showed a high tendency to drug use, also when those drugs had no direct attachment to the mental problem. Men seemed more liable to somatization of mental problems than women.

Doctors' willingness to refer elderly patients for elective surgery.

OBJECTIVES: We aimed to examine the relationship between doctors' willingness to refer elderly patients for elective surgical operations and patients' age, comorbidity, institutionalization, living habits and signs of dementia. METHOD: A random selection of 837 medical doctors in Finland (response rate 56%) received a postal questionnaire consisting of 18 vignettes, i.e. imaginary patient cases. Respondents were asked whether they would refer the patient on the vignette for elective surgical operation, treat the patient conservatively, or choose some other alternative. In the vignettes, the age of patients was randomly varied between 65 and 85, at 5-year intervals, to provide eight different questionnaires, and each respondent obtained one of them. RESULTS: The proportion of doctors willing to refer the patients for surgery was inversely related to the patients' age: in all the vignettes, doctors said they would refer fewer patients in the oldest age groups. Almost all the doctors claimed they would refer healthy, home-dwelling persons aged 65-70 years for operations. In the oldest age groups of patients, the doctors' willingness to refer was highest for cataract operations (69%) and hip prosthesis operations (63%), but only 18% of doctors would refer such patients for coronary by-pass operations. Comorbidity and institutionalization were associated with fewer doctors referring the patients: the proportion of doctors willing to refer these patients was about half that of those willing to refer otherwise healthy and home-dwelling patients. Smoking by patients also decreased the proportions of doctors willing to refer, but moderate signs of dementia in an elderly patient with cataract were associated with only a slight decrease in referring. CONCLUSIONS: Doctors are less willing to refer old patients for elective surgery, but comorbidity, patients' lifestyle and institutionalization have a greater effect on referrals than age.

Random paired scenarios--a method for investigating attitudes to prioritisation in medicine.

OBJECTIVE: This article describes a method for investigating attitudes towards prioritisation in medicine. SETTING: University of Kuopio, Finland. DESIGN: The method consisted of a set of 24 paired scenarios, which were imaginary patient cases, each containing three different ethical indicators randomly selected from a list of indicators (for example, child, rich patient, severe disease etc.). The scenarios were grouped into 12 random pairs and the procedure was repeated four times, resulting in 12 scenario pairs arranged randomly in five different sets. SURVEY: This method was tested with four groups of subjects (n = 8, n = 47, n = 104 and n = 36). RESULTS: Children and patients with a severe disease were prioritised in all groups. The aged, patients with a mild disease and patients with a self-acquired disease were negatively prioritised in all groups. Poor or rich patients were prioritised in some groups but negatively prioritised in others. CONCLUSIONS: The validity and reliability of this method are good and it is suitable for investigating attitudes towards medical prioritisation.

Overweight, underweight and mortality among the aged.

OBJECTIVE: To clarify the influence of overweight and underweight on the total mortality as well as on different causes of death in an unselected population of old people. DESIGN: The cohort of the aged population was examined in 1971. The survival time of the cohort was followed for ten years. SETTINGS: Rural commune of Hankasalmi in Central Finland. PARTICIPANTS: 721 (80% of total aged population) subjects aged 65 years or over (310 men and 411 women). OUTCOME MEASURES: 10 years survival rate and causes of death by body mass index quartiles and sex. RESULTS: The women in the lowest BMI quartile had the highest mortality in ten-year follow-up (a 26% decrease in survival time). The differences between the total mortality of the other quartiles were small. In the lowest BMI quartile there was overmortality from respiratory diseases and tumours, and undermortality from cardiovascular diseases. In the highest BMI quartile the main groups of causes of death did not differ essentially from those in the whole cohort. CONCLUSION: Underweight was as strong a predictor of mortality, and even stronger, than overweight.

The quantitative risk of violent crime and criminal offending: a case-control study among the offspring of recidivistic Finnish homicide offenders.

OBJECTIVE: To study if later risk of violent offending and criminality among high-risk children can be estimated quantitatively on the basis of parental crimes. METHOD: The criminal and prison records of the offspring (N=11) of homicide recidivists (N=36) were compared with data from controls (N=220) who were matched for sex, domicile of birth and date of birth and death. RESULTS: The risk (odds ratio) was increased up to 24-fold for violent crimes (P=0.01), and up to 17-fold for criminality (P=0.0008) among the offspring of homicide recidivists. CONCLUSION: The quantitative risk of a child for later violent offending and criminality can be estimated on the basis of parental homicide recidivism. This kind of method could be used to choose target groups for early preventive interventions, and to study the effectiveness of prevention.