Socioeconomic Variations in Use of Prescription Medicines for COPD: A Register-Based Study.

BACKGROUND: The purpose of this study was to examine socioeconomic variations in the use of prescription medicines among elderly subjects with COPD. METHODS: Data from the Danish national administrative registers were used. The study population included 1,365 individuals >60 y old residing in the Municipality of Copenhagen and diagnosed with COPD in a hospital setting in 2007. Logistic regression analysis was applied to examine the associations between the use of all prescription medicines for obstructive pulmonary diseases and the use of long-acting bronchodilators, in subject groups of different socioeconomic position. RESULTS: The study demonstrated that approximately 90% of subjects with COPD purchased at least one prescription medicine for obstructive pulmonary diseases, whereas approximately 50% purchased a long-acting bronchodilator. Medicine use did not vary according to educational status or personal wealth. CONCLUSIONS: There were no systematic socioeconomic differences in the use of relevant prescription medicines in elderly subjects diagnosed with COPD in hospital settings in Copenhagen. However, our findings indicate a gap between guideline recommendations and observed use of long-acting bronchodilators and hence suboptimal quality of treatment in the elderly COPD population.

Comparison between two assessment methods for exercise-induced laryngeal obstructions.

Exercise-induced laryngeal obstructions (E-ILOs) are important differential diagnoses to exercise-induced asthma and are diagnosed by the continuous laryngoscopy exercise (CLE) test. There are two different methods for evaluating the severity of E-ILOs using recordings from the CLE test; the CLE score and EILOMEA. The aim of this study was to investigate the consistency between these methods. Using their respective method, the developers of each method evaluated 60 laryngoscopic recordings from patients with different subtypes and various levels of severity of E-ILOs. The CLE score evaluates glottic and supraglottic obstructions on a 4-grade scale. EILOMEA uses software to calculate the obstruction severity on continuous scales from a still frame of the larynx during maximal obstruction giving three parameters reflecting glottic and supraglottic obstruction. The means of the EILOMEA measures differed significantly for CLE score 1 vs. 2 and 2 vs. 3, but not for 0 vs. 1 for glottic as well as supraglottic obstructions. The EILOMEA method does not distinguish between CLE score 0 and 1, but otherwise the methods correlate. Since previous studies have suggested that only CLE scores of 2 and 3 reflect a severity of E-ILOs of clinical importance, this lack of the EILOMEA method is not crucial for a correct medical evaluation.

Structured clinical assessment of the ear, nose and throat in patients with granulomatosis with polyangiitis (Wegener's).

The objective of this prospective cross-sectional study is to describe the clinical otorhinolaryngological manifestations of granulomatosis with polyangiitis (Wegener's) (GPA) in a prospective cohort. All patients suffering from GPA seen in a tertiary centre between March 2007 and November 2008 had a detailed clinical assessment by an ENT surgeon of their ear, nose and head and neck complaints. An evaluation of whether there was disease activity and/or infection in each ENT area was made using the European Vasculitis Study Group guidelines. The number of patients assessed was 144. The proportion of female patients was 47 % (n = 69) and the median age was 57.7 years (IQ range 42.5-68.5). The prevalence of ENT involvement was 87 % (125/144). Hearing loss and abnormal tympanic membrane appearance were more common in patients with active disease and no infection (7/8 and 6/8, respectively, in active disease cf. 59/131 and 52/131, respectively, in remission). Nasal crusting was the most common nasal complaint recorded (52/144, 36 %) and bloody rhinorrhoea was the most common symptom in patients with disease activity. Rhinoscopy was highly sensitive in diagnosing disease activity (100 %). Subglottic stenosis was the most common head and neck manifestation (27/121, 22 %) and 74 % were symptomatic. In conclusion, the pattern and frequency of clinical ENT manifestations in GPA have been described in a large patient cohort. The use of tools readily available in the ENT clinic was essential to assess these patients accurately. This dataset will form the basis of an objective scoring system to measure disease activity in the ENT system.

The effect of health, socio-economic position, and mode of data collection on non-response in health interview surveys.

AIMS: To investigate the relationship between potential explanatory factors (socio-economic factors and health) and non-response in two general population health interview surveys (face-to-face and telephone), and to compare the effects of the two interview modes on non-response patterns. METHODS: Data derives from The Danish Health Interview Survey 2000 (face-to-face interview) and The Funen County Health Survey 2000/2001 (telephone interview). Data on all invited individuals were obtained from administrative registers and linked to survey data at individual level. Multiple logistic regression analyses were used to examine associations between potential explanatory factors and non-response. RESULTS: The overall response rate was higher in the face-to-face interview survey (74.5%) than in the telephone survey (69.2%). Refusal was the most common reason for non-response and the same factors were generally associated with non-response in both modes of interview. The non-response rate was high among persons with low socio-economic position. No significant associations between health and non-response were found. CONCLUSIONS: Health status does not play a systematic role for non-response rates in health interview surveys, but the non-response rate is higher in lower socio-economic groups. Analyses of non-response should be performed to understand the implications of survey findings.

[Quality of life more than five years after breast cancer--secondary publication]. / Livskvalitet mere end fem år efter brystkraeft--sekundaerpublikation.

In this national survey, long-term breast cancer survivors (BCS) (n = 1,316) reported quality of life comparable to data from the general Danish female population, but a significantly higher prevalence of chronic pain (42% versus 32%). Paraesthesia, phantom sensation, allodynia, and swelling of arm/shoulder were also reported, and every fifth woman felt that these sequelae limited her daily activities. Health care utilization indicated chronic morbidity. Relatively young age, short education, and former radiotherapy were risk factors for issues such as pain.

Differences in socioeconomic and gender inequalities in tobacco smoking in Denmark and Sweden; a cross sectional comparison of the equity effect of different public health policies.

BACKGROUND: Denmark and Sweden are considered to be countries of rather similar socio-political type, but public health policies and smoking habits differ considerably between the two neighbours. A study comparing mechanisms behind socioeconomic inequalities in tobacco smoking, could yield information regarding the impact of health policy and -promotion in the two countries. METHODS: Cross-sectional comparisons of socioeconomic and gender differences in smoking behaviour among 6 995 Danish and 13 604 Swedish persons aged 18-80 years. RESULTS: The prevalence of smoking was higher in Denmark compared to Sweden. The total attributable fraction (TAF) of low education regarding daily smoking was 36% for Danish men and 35% for Danish women, and 32% and 46%, respectively, for Swedish men and women. TAF of low education regarding continued smoking were 16.2% and 15.8% for Danish men and women, and 11.0% and 18.8% for Swedish men and women, respectively. The main finding of the study was that the socioeconomic patterning of smoking, based on level of education and expressed as the relative contribution to the total burden of smoking exposure, was rather different in Sweden and Denmark. Moreover, these differences were modified by gender and age. As a general pattern, socioeconomic differences in Sweden tended to contribute more to the total burden of this habit among women, especially in the younger age groups. In men, the patterns were much more similar between the two countries. Regarding continued smoking/unsuccessful quitting, the patterns were similar for women, but somewhat different for men. Here we found that socioeconomic differences contributed more to overall continued smoking in Danish men, especially in the middle-age and older age strata. CONCLUSION: The results imply that Swedish anti-smoking policy and/or implemented measures have been less effective in a health equity perspective among the younger generation of women, but more effective among men, compared to Danish policy implementation. The results also raises the more general issue regarding the possible need for a trade-off principle between overall population efficacy versus equity efficacy of anti-tobacco, as well as general public health policies and intervention strategies.

Does job strain mediate the effect of socioeconomic group on smoking behaviour? The impact of different health policies in Denmark and Sweden.

AIMS: The aim was to compare the impact of socioeconomic groups (SEG) on the risk of being a daily smoker or quitter, and to investigate whether the potentially mediating effect of psychosocial working conditions was similar in the Danish and the Swedish populations. METHODS: The study populations consisted of 10,049 employed participants, aged 18-64 years, 51% women, randomly selected from the general populations in the Oresund region, 1999-2000. Odds ratios (OR) for daily-smokers and "non-quitters'' were computed for two age-groups and two SEGs in gender specific models, stratified by country. The association between SEG, current smoking, quitting, and influence at work, job demand and jobstrain, respectively, was tested by means of logistic regression. RESULTS: The contextual determinants defined by country had a different effect on smoking prevalence among men and women and among age groups. Low influence and job strain seemed to have an effect on smoking among Danish women, but not among Swedish women. The OR of being a daily smoker were higher in men than women among younger Danes, but higher in women than men among Swedes. The prevalence of low influence, high demand and job strain was higher and more socially skewed among the Swedes, but did not mediate the effect of SEG on smoking behaviour. CONCLUSIONS: The smoking prevalence was lower and the quit-rates higher among Swedes than Danes. Both countries had social differences in smoking that in absolute terms were rather similar, but in relative terms were higher in Sweden. The mediating effect of psychosocial working conditions was lacking. The determinants of smoking behaviours must be found somewhere else in the social and cultural context.

[Practice staff's participation in preventive measures among adult patients in general practice]. / Personalets deltagelse i forebyggelse blandt voksne patienter i almen laegepraksis.

INTRODUCTION: Prevention of lifestyle-related diseases and related complications represent an increasing part of daily work in general practice. In relation to selected doctor and patient characteristics we analyzed 1) the practice staff's current involvement in preventive measures, and 2) the doctors' wishes for increased involvement. MATERIALS AND METHODS: In total, 378 out of 381 general practitioners from ten counties participating in "Audit on prevention in general practice 2004" filled in a two-page questionnaire. RESULTS: Almost all (377/378) had staff employed. More than half of the doctors stated that the staff performed tasks in connection with weight control, vaccination of adults, blood pressure checks, lung function tests, alcohol abuse treatment and dietary counselling. A total of 72% of the doctors wished for greater staff involvement within one or more areas, especially dietary counselling and smoking cessation support. The staff was more frequently involved in the tasks for doctors who had a nurse employed compared with doctors who did not. Except for skin prick tests no connection was found between the staff's participation and the doctor's sex and age, the type and size of the practice, and the extent of the regional lack of doctors. CONCLUSION: Staff in general practice perform many preventive tasks related to the eight common chronic diseases, but most frequently in practices where there is a nurse employed. Although the participating doctors may have a special interest in the topic, there seems to be a basis for further staff involvement in this type of tasks. Further studies should, however, elucidate whether the participation of the staff substitutes the doctor's work to the extent desired and with sufficient quality.

The effect of non-response on estimates of health care utilisation: linking health surveys and registers.

BACKGROUND: Non-response in health surveys may lead to bias in estimates of health care utilisation. The magnitude, direction and composition of the bias are usually not well known. When data from health surveys are merged with data from registers at the individual level, analyses can reveal non-response bias. Our aim was to estimate the composition, direction and magnitude of non-response bias in the estimation of health care costs in two types of health interview surveys. METHODS: The surveys were (1) a national personal interview survey of 22 484 Danes (2) a telephone interview survey of 5000 Danes living in Funen County. Data were linked with register information on health care utilisation in hospitals and primary care. Health care utilisation was estimated for respondents and non-respondents, and the difference was explained by a decomposition method of bias components. RESULTS: The surveys produced the same pattern of non-response, but with slight differences in non-response bias. Response rates for the interview and telephone surveys were 75 and 69%, respectively. Refusal was the most frequent reason for non-response (22 and 20% of those sampled, respectively), whereas illness, non-contact, and other reasons were less frequent. Respondents used 3-6% less health care than non-respondents at the aggregate level, but the opposite was true for some specific types of health care. Non-response due to illness was the main contributor to non-response bias. CONCLUSIONS: Different types of non-response have different bias effects. However, the magnitude of the bias encourages the continued use of interview health surveys.

Development of comprehensive disease assessment in systemic vasculitis.

The systemic vasculitides are multisystem disorders with considerable mortality and morbidity and frequent relapses. In the absence of reliable serological markers, accurate clinical tools are required to assess disease activity and damage for treatment decisions, and for the performance of clinical trials. This article reviews and summarises the development and use of disease assessment tools for determining activity and damage in systemic vasculitis and reports ongoing initiatives for further development of disease assessment tools. A literature search was conducted using PubMed and reference lists for vasculitis, assessment, clinical trials, outcome and prognosis. The findings indicate that comprehensive disease assessment in vasculitis requires documentation of disease activity, chronic irreversible damage and impairment of function.

Higher smoking prevalence in urban compared to non-urban areas: time trends in six European countries.

We investigated differences in smoking prevalence between urban and non-urban area of residence in six Western European countries (Sweden, Finland, Denmark, Germany, Italy and Spain), and smoking prevalence trends over the period 1985-2000. In most countries, smoking prevalence was highest in urban areas, and increased with urbanization. Urban/non-urban inequalities were most pronounced among individuals with low education levels, and also among females. There were no significant differences in annual rate of change in smoking prevalence between non-urban and urban areas.

Use of natural medicines in the Danish population: a national cross-sectional survey.

BACKGROUND: The use of natural medicines is widespread and increasing. In addition, natural medicine use is based primarily on individual's decisions without counseling from health professionals. Unlike with conventional medicines, it is not possible to evaluate sales statistics and prescription records to determine how much natural medicine is being used and by whom. Self-reporting is the only method available for investigating use of these products. OBJECTIVE: To investigate the use of natural medicines with respect to sociodemographic factors, health status, and conventional drug therapy in a general national population. METHODS: Data were derived from the Danish Health and Morbidity Survey 2000. A representative sample of the Danish population (N = 16 690) was interviewed face-to-face. The association between use of natural medicines within the past 14 days and age, education, health status, and conventional medicine use was analyzed by logistic regression. All analyses were performed separately for each gender. RESULTS: Fourteen percent of the sample population had taken natural medicines within the past 14 days. Use was most prevalent among women and increased with age, but decreased again in the oldest age group (> or = 80 y). Respondents with poor health were the greatest consumers of natural medicines. Use was not associated with educational level and conventional drug therapy. Among conventional medicine users, 14% and 22% of men and women, respectively, used natural medicines. CONCLUSIONS: This study demonstrated that natural medicine use is common and widespread health behavior in all strata of the population and should not be regarded as an alternative to conventional medicine. Clinicians should ask patients about natural medicine use to avoid interactions with conventional drugs.

Health care utilisation among individuals reporting long-term pain: an epidemiological study based on Danish National Health Surveys.

Individuals reporting long-term pain in the 1994 and 2000 Danish Health and Morbidity Surveys, which included random samples of 6000 and 16,684 persons respectively, were investigated concerning their use of the health care systems. A considerably higher use was observed in the pain population in the primary as well as the secondary health care sector, compared with a no pain control group. In 1994, individuals reporting long-term pain had on average 12.8 contacts per year to the primary health care sector compared with 7.3 for the control group. Use of secondary health care sector as estimated by hospital admission frequency and number of in-hospital days was not only significantly higher for the pain group but showed also an increasing tendency during the periods investigated (1991-1997). Women used the health care system significantly more than men, whereas age did not seem to influence. In conclusion, individuals reporting long-term/chronic pain have a significantly higher use of the health care system than individuals without long-term/chronic pain complaints. Reasons may be ascribed to within-patient factors, factors within the health care system (insufficient knowledge on chronic pain resulting in the seeking after a somatic diagnosis, and difficulties in recognizing the endpoint of reasonable treatment attempts), and societal factors (legislation on disability and compensation).

Health-related quality of life associated with chronic conditions in eight countries: results from the International Quality of Life Assessment (IQOLA) Project.

CONTEXT: Few studies and no international comparisons have examined the impact of multiple chronic conditions on populations using a comprehensive health-related quality of life (HRQL) questionnaire. OBJECTIVE: The impact of common chronic conditions on HRQL among the general populations of eight countries was assessed. DESIGN: Cross-sectional mail and interview surveys were conducted. PARTICIPANTS AND SETTING: Sample representatives of the adult general population of eight countries (Denmark, France, Germany, Italy, Japan, The Netherlands, Norway and the United States) were evaluated. Sample sizes ranged from 2031 to 4084. MAIN OUTCOME MEASURES: Self-reported prevalence of chronic conditions (including allergies, arthritis, congestive heart failure, chronic lung disease, hypertension, diabetes, and ischemic heart disease), sociodemographic data and the SF-36 Health Survey were obtained. The SF-36 scale and summary scores were estimated for individuals with and without selected chronic conditions and compared across countries using multivariate linear regression analyses. Adjustments were made for age, gender, marital status, education and the mode of SF-36 administration. RESULTS: More than half (55.1%) of the pooled sample reported at least one chronic condition, and 30.2% had more than one. Hypertension, allergies and arthritis were the most frequently reported conditions. The effect of ischemic heart disease on many of the physical health scales was noteworthy, as was the impact of diabetes on general health, or arthritis on bodily pain scale scores. Arthritis, chronic lung disease and congestive heart failure were the conditions with a higher impact on SF-36 physical summary score, whereas for hypertension and allergies, HRQL impact was low (comparing with a typical person without chronic conditions, deviation scores were around -4 points for the first group and -1 for the second). Differences between chronic conditions in terms of their impact on SF-36 mental summary score were low (deviation scores ranged between -1 and -2). CONCLUSIONS: Arthritis has the highest HRQL impact in the general population of the countries studied due to the combination of a high deviation score on physical scales and a high frequency. Impact of chronic conditions on HRQL was similar roughly across countries, despite important variation in prevalence. The use of HRQL measures such as the SF-36 should be useful to better characterize the global burden of disease.

Social gradient in life expectancy and health expectancy in Denmark.

OBJECTIVES: Health status of a population can be evaluated by health expectancy expressed as average lifetime in various states of health. The purpose of the study was to compare health expectancy in population groups at high, medium and low educational levels. METHODS: Health interview data were combined with life table figures using Sullivan's method. RESULTS: Life expectancy was 4.3 years longer for 30-year-old men with a high educational level than for those with a low level. At age 30, the proportion of expected lifetime in self-rated good health was 67.7%, 76.1% and 82.3% for men with a low, medium and high educational level, respectively. Among women, life expectancy differed by 2.7 years between low and high educational level, and the proportion of expected lifetime in self-rated good health was 62.5% at the low and 80.5% at the high educational level. CONCLUSIONS: Educational level and life expectancy are clearly related. The social gradient in terms of health expectancy is even greater than that in terms of life expectancy.

Prescription and non-prescription medicine use in Denmark: association with socio-economic position.

OBJECTIVE: To analyse the association among different types of medicine use and different measures of socio-economic position (SEP) in one and the same general population. METHODS: Data from The Danish Health and Morbidity Survey 2000 were analysed. The survey was conducted by face-to-face interviews with a representative sample of the adult Danish population (n=16,690). The associations between prescription and over-the-counter (OTC) medicine use and education, occupation and income were assessed by logistic regression analyses. All analyses were adjusted for age, gender and two measures of health status. RESULTS: This cross-sectional analysis of medicine use in a large representative sample of the Danish population found greater use of prescription medicines among disability pensioners and "others" than in salaried employees. Disability pensioners and self-employed individuals used less OTC medicine than salaried employees. Individuals with low income used more prescription medicines but not more OTC medicines, than those with high income. No major differences were found in prescription medicine use with respect to education, but men within the two middle educational groups tended to use prescription medicine less frequently than both lower and higher educated men. A similar trend was not found for women. OTC medicine use was not associated with education for either gender. CONCLUSIONS: The prevalence of prescription medicine use increases with declining SEP, after adjusting for health status. Such an association does not exist for OTC medicine use. The results show that the least affluent have access to prescription medicine. The difference between prescription and OTC medicine use may be explained by a compensation mechanism.

Measuring well-being rather than the absence of distress symptoms: a comparison of the SF-36 Mental Health subscale and the WHO-Five Well-Being Scale.

The health status questionnaire Short-Form 36 (SF-36) includes subscales measuring both physical health and mental health. Psychometrically, the mental health subscale contains a mixture of mental symptoms and psychological well-being items, among other things, to prevent a ceiling effect when used in general population studies. Three of the mental health well-being items are also included in the WHO-Five well-being scale. In a Danish general population study, the mental health subscale was compared psychometrically with the WHO-Five in order to evaluate the ceiling effect. Tests for unidimensionality were used in the psychometric analyses, and the sensitivity of the scales in differentiating between changes in self-reported health over the past year has been tested. The results of the study on 9,542 respondents showed that, although the WHO-Five and the mental health subscale were found to be unidimensional, the WHO-Five had a significantly lower ceiling effect than the mental health subscale. The analysis identified the three depression symptoms in the mental health subscale as responsible for the ceiling effect. The WHO-Five was also found to be significantly superior to the mental health subscale in terms of its sensitivity in differentiating between those persons whose health had deteriorated over the past year and those whose health had not. In conclusion, the WHO-Five, which measures psychological well-being, reflects aspects other than just the absence of depressive symptoms.

The Danish National Cohort Study (DANCOS).

This article gives an overview of a nationally representive public health research database in Denmark, the Danish National Cohort Study (DANCOS). DANCOS combines baseline data from health interview surveys with both pre- and post-baseline data from national health registries with date from a re-interview survey. As part of the national health interview survey programme, three nation-wide surveys were conducted in 1986/1987, 1991 and 1994. The samples in the three cohorts consisted of 23,096 adult Danes ages 16 years and older, and 18,296 (79.2%) were personally interviewed on socio-economic status; living conditions; health behaviour; self-rated health; morbidity; utilization of health services; and the consequences of illness and disability. Each Dane is equipped with a unique identification number that allows highly accurate linkage of data in the health surveys and in the national health and administrative registries. All respondents and non-respondents were followed through 2002, a total of 3,796 had died and 249 had emigrated. The specific cause of death for 2,485 people was recorded in the Danish Register of Causes of Death, updated through 1998. For 1978-1977, the Danish National Hospital Register contained information about 16,503 persons who had been hospitalized for any illness or related health problems, accounting for 70,925 hospital admissions. For 1970-1997, the Danish Psychiatric Central Register comprised information on 1691 persons. For 1990-1997, the Danish National Health Service Register recorded 980,043 contacts with general practitioners and specialist physicians. For 1943-1996, the Danish cancer Registry contained information about one or more cancer diseases among 1,432 people. A total of 4,334 people in the 1994 cohort were re-interview in 2000. DANCOS allows for a wide range of analysis in a historical prospective design of determinants of morbidity and mortality, of health care utilization and of the social effects of ill health. DANCOS also allows studies of methodological issues, including analyzing the characteristics of non-respondents.