Determinants for use of direct-to-consumer telemedicine consultations in primary healthcare-a registry based total population study from Stockholm, Sweden.

BACKGROUND: In recent years, telemedicine consultations have evolved as a new form of providing primary healthcare. Telemedicine options can provide benefits to patients in terms of access, reduced travel time and no risk of disease spreading. However, concerns have been raised that access is not equally distributed in the population, which could lead to increased inequality in health. The aim of this paper is to explore the determinants for use of direct-to-consumer (DTC) telemedicine consultations in a setting where telemedicine is included in the publicly funded healthcare system. METHODS: To investigate factors associated with the use of DTC telemedicine, a database was constructed by linking national and regional registries covering the entire population of Stockholm, Sweden (N = 2.3 million). Logistic regressions were applied to explore the determinants for utilization in 2018. As comparators, face-to-face physician consultations in primary healthcare were included in the study, as well as digi-physical physician consultations, i.e., telemedicine consultations offered by traditional primary healthcare providers also offering face-to-face visits, and telephone consultations by nurses. RESULTS: The determinants for use of DTC telemedicine differed substantially from face-to-face visits but also to some extent from the other telemedicine options. For the DTC telemedicine consultations, the factors associated with higher probability of utilization were younger age, higher educational attainment, higher income and being born in Sweden. In contrast, the main determinants for use of face-to-face visits were higher age, lower educational background and being born outside of Sweden. CONCLUSION: The use of DTC telemedicine is determined by factors that are generally not associated with greater healthcare need and the distribution raises some concerns about the equity implications. Policy makers aiming to increase the level of telemedicine consultations in healthcare should consider measures to promote access for elderly and individuals born outside of Sweden to ensure that all groups have access to healthcare services according to their needs.

Delayed healthcare access among victims of sexual abuse, understood through internal and external gatekeeping mechanisms.

BACKGROUND: Sexual abuse is associated with severe health consequences, and the European Union has, through the Istanbul Convention, urged its member countries to provide specialist care for victims of sexual abuse. AIM: This aim of this study was to investigate patient- and abuse-related characteristics among patients seeking help at a specialist clinic in Sweden, with focus on disclosure, mental health and appropriate healthcare access. METHODS: This is a descriptive study where journal data from 100 consecutive patients January 2017 to February 2018 were analyzed. All adult individuals (women n = 80, men n = 8) who had taken part in the standardized semi-structured intake interview at the clinic were included (n = 88). RESULTS: At admission, mean age was 40.3 (SD 11.9), mean number of psychiatric diagnoses 6.3 (2.6), and 93% of the patients scored above cut-off (≥34) on IES-R for PTSD. A majority of the patients (87%) had been exposed to childhood sexual abuse (CSA), and mean time to first disclosure was 15.9 (SD 15.3) years. In total, 82% of the patients had, despite disclosure, experienced difficulties accessing appropriate healthcare before coming to the specialist clinic. CONCLUSION: Adult victims of sexual abuse have difficulties accessing appropriate healthcare. This constitutes a gender-based equality problem. A model of gatekeeping mechanisms with two dimensions (external and internal) and three categories (Competence related, Organizational and Emotional) is proposed to understand these difficulties.

Parkinson's Disease Among Immigrant Groups and Swedish-Born Individuals: A Cohort Study of All Adults 50 Years of Age and Older in Sweden.

BACKGROUND: There is a lack of studies of Parkinson's disease (PD) in immigrants. OBJECTIVE: To study the association between country of birth and incident PD in immigrants in Sweden versus Swedish-born individuals. METHODS: Study population included all adults aged 50 years and older in Sweden (n = 2775736). PD was defined as having at least one registered diagnosis of PD in the National Patient Register. The incidence of PD in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and co-morbidity. RESULTS: Totally 35833 individuals had an incident diagnosis of PD (20401 men and 15432 women). Incidence rates per 100,000 person-years were for all Swedish-born 95.9 and for all foreign-born 60.1; for all men 112.3 and for all women 73.4, with a male to female ratio of 1.53, with the highest incidence rates for the group 80-84 years of age. After adjusting for potential confounders, the overall relative risk of PD was lower in immigrant men (HR 0.78; 95% CI 0.74-0.82) and women (HR 0.92; 95% CI 0.87-0.98). Among immigrant subgroups, a higher risk of PD was found among women from Finland (HR 1.13; 95% CI 1.05-1.23). CONCLUSION: In general, the risk of PD was lower in first-generation immigrant men and women compared to Swedish-born. The only group with a higher risk of PD was women from Finland.

Venous thromboembolism 2011-2018 in Stockholm: a demographic study.

Venous thromboembolism (VTE) is an important cause of morbidity and mortality in Western countries. The incidence rate of VTE is estimated at 1-2 cases per 1000 annually. This study was a population-based cohort study of previously treatment naïve patients with a first occurrence of venous thromboembolism (VTE), using data from the administrative health data register of the Stockholm Region 2011-2018. Data on anticoagulant treatment was taken from the Swedish Prescribed Drug Register. We also analyzed all VTE events between 2011 and 2018. Altogether 14,849 naïve incident VTE cases were identified. In 2011 the majority of patients with a first episode of VTE were prescribed warfarin versus non-vitamin K antagonist oral anticoagulants (NOACs), 1144 versus 5. In contrast in 2018, the majority of patients were treated with NOACs, 1049 versus 59 treated with warfarin. Treatment with low molecular weight heparin only decreased from 814 to 683 patients. The frequency of all VTE events in the population increased over time from 1.88/1000 to 1.93/1000 (p = 0.072), and PE diagnoses increased from 0.69/1000 to 0.76/1000 (p = 0.003). In conclusion, during 2011-2018 there has been a shift of prescription of warfarin to a clear predominance of NOACs in the treatment of VTE in the Stockholm Region, in line with current recommendations. In the clinical situation, treatment has been simplified as monitoring of warfarin has decreased substantially. PE events increased during the time period in the population even if the increase was rather modest, while all VTE events did not increase significantly.

End-Stage Kidney Diseases in Immigrant Groups: A Nationwide Cohort Study in Sweden.

BACKGROUND: Our aim was to study the association between the country of birth and incident end-stage kidney disease (ESKD) in several immigrant groups in Sweden, using individuals born in Sweden or with Swedish-born parents as referents. METHODS: A cohort study of first- and second-generation immigrants residing in Sweden between January 1, 1998 and December 31, 2012 was performed. Outcomes were defined as having at least one registered diagnosis of ESKD in the National Patient Register. The incidence of ESKD in different immigrant groups was used in the Cox regression models to estimate hazard ratios (HRs) and 95% CIs. All models were stratified by sex and adjusted for age, geographical residence, educational level, marital status, and neighbourhood socioeconomic status. RESULTS: Compared to their referents, higher incidence rates and HRs of ESKD (HR; 95% CI) were observed in general among foreign-born men (1.10; 1.04-1.16) and women (1.12; 1.04-1.21) but not among second-generation immigrants (persons born in Sweden with foreign-born parents). A particularly high -incidence was noted among men and women from -East-European countries, as well as from non-European regions. A lower incidence of ESKD was noted among men from Finland. CONCLUSIONS: We observed substantial differences in incidence of ESKD between immigrant groups and the Swedish-born population, which may be clinically relevant when monitoring preventive measures in patient subgroups with a higher risk of deteriorating kidney disease, and suggest higher attention to hypertension and diabetes control in immigrants. Mechanisms attributable to the migration process or ethnic differences may lead to an increased risk of ESKD.

The association between relevant comorbidities and dementia in patients with atrial fibrillation.

Risk of dementia is increased in patients with atrial fibrillation (AF). We aimed to study associations between relevant comorbidities and prevalent as well as incident dementia in AF patients. Study population included all adults (n = 12,283) ≥ 45 years diagnosed with AF at 75 primary care centers in Sweden 2001-2007. Logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (95% CI) for associations between comorbidities and prevalent dementia. In a subsample (n = 12,096), (excluding patients with dementia diagnosed before AF onset), Cox regression was used to estimate hazard ratios (HR) with 95% CIs for association between comorbidities, and incident dementia, after adjustment for age, socioeconomic factors and anticoagulant treatment. Totally 937 patients (7.6%), 388 men (5.8%) and 549 women (9.7%), were diagnosed with dementia. After adjustments, prevalent dementia was more common in (ORs, 95% CI) men with congestive heart failure (CHF), stroke, and depression; in women with CHF and depression, and among women > 75 years with stroke, but less common in women with hypertension. During a 5.6-year follow-up (standard deviation 2.5), 750 patients (6.2%; 322 men, 4.9%, and 428 women, 7.8%) were diagnosed with incident dementia. An increased risk of incident dementia was found among men with diabetes and depression; a decreased risk among men and women with CHF, and among women with hypertension, myocardial infarction cerebrovascular diseases. The findings regarding incident dementia need to be interpreted with great caution, as they may have been subject to survival bias.

Socioeconomic factors and mortality in patients with atrial fibrillation-a cohort study in Swedish primary care.

Background: Preventing ischaemic stroke attracts significant focus in atrial fibrillation (AF) cases. Less is known on the association between socioeconomic factors and mortality and cardiovascular outcomes in patients with AF. Methods: Our study population included adults (n=12 283) ≥45 years diagnosed with AF at 75 primary care centres in Sweden 2001-07. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for the association between the exposures educational level, marital status, neighbourhood socioeconomic status and the outcomes all-cause mortality, after adjustment for age, and comorbid cardiovascular conditions. Results: During a mean of 5.8 years (SD 2.4) of follow-up, 3954 (32.3%) patients had died; 1971 were women (35.0%) and 1983 were men (29.8%). Higher educational level was associated with a reduced mortality in fully adjusted models: HR 0.85 (95% CI 0.77-0.96) for secondary school in men, HR 0.73 (95% CI 0.60-0.88) for college/university in women, and HR 0.82 (95% CI 0.71-0.94) for college/university in men, compared to primary school. Unmarried men and divorced men had an increased risk of death, compared with married men: HR 1.25 (95% CI 1.05-1.50), and HR 1.23 (95% CI 1.07-1.42), respectively. College/university education level was also associated with lower risk of myocardial infarction in men and women, and lower risk of congestive heart failure in women. Conclusion: More attention could be paid to individuals of lower levels of formal education, and unmarried men, in order to provide timely management for AF and prevent its debilitating complications.

Warfarin treatment and risk of stroke among primary care patients with atrial fibrillation.

OBJECTIVE: Our aim was to study the risk of a first ischaemic stroke (IS) in patients with atrial fibrillation (AF) treated in primary healthcare. DESIGN: The study population included all adults (n = 11,517), 45 years and older diagnosed with AF, from 75 primary care centres in Sweden between 2001 and 2007. IS was defined as a hospital care event of stroke between 2001 and 2010. Association between incident stroke and warfarin treatment was explored using Cox regression analysis, with hazard ratios (HRs), and 95% confidence intervals (95%CIs). Adjustment was made for age, socioeconomic factors and co-morbidity. RESULTS: Persistent treatment with warfarin was present among 33.7% of women and 40.0% among men. Persistent warfarin treatment, compared to no persistent treatment, was associated with a stroke preventing effect with fully adjusted HRs of 0.25 (95%CI 0.18-0.36) in women, and 0.25 (95%CI 0.19-0.32) in men. A CHA2DS2-VASc score of at least two among women, and three among men, was associated with a stroke risk exceeding 18% during a mean follow-up of 5.4 years. Risk of haemorrhagic stroke was not increased. CONCLUSIONS: Warfarin is effective in preventing stroke in AF patients in primary healthcare.

Neighbourhood socioeconomic status and coronary heart disease in individuals between 40 and 50†years.

OBJECTIVE: The incidence of myocardial infarction (MI) has decreased in general but not among younger middle-aged adults. We performed a cohort study of the association between neighbourhood socioeconomic status (SES) at the age of 40 and risk of MI before the age of 50 years. METHODS: All individuals in Sweden were included in the year of their 40th birthday, if it occurred between 1998 and 2010. National registers were used to categorise neighbourhood SES into high, middle and low, and to retrieve information on incident MI and coronary heart disease (CHD). Cox regression models, adjusted for marital status, education level, immigrant status and region of residence, provided an estimate of the HRs and 95% CIs for MI or CHD. RESULTS: Out of 587 933 men and 563 719 women, incident MI occurred in 2877 (0.48%) men and 932 (0.17%) women; and CHD occurred in 4400 (0.74%) men and 1756 (0.31%) women during a mean follow-up of 5.5 years. Using individuals living in middle-SES neighbourhoods as referents, living in high-SES neighbourhoods was associated with lower risk of MI in both sexes (HR (95% CI): men: 0.72 (0.64 to 0.82), women: 0.66 (0.53 to 0.81)); living in low-SES neighbourhoods was associated with a higher risk of MI (HR (95% CI): men: 1.31 (1.20 to 1.44), women: 1.28 (1.08 to 1.50)). Similar risk estimates for CHD were found. CONCLUSIONS: The results of our study suggest an increased risk of MI and CHD among residents from low-SES neighbourhoods and a lower risk in those from high-SES neighbourhoods compared with residents in middle-SES neighbourhoods.

Depression or anxiety and all-cause mortality in adults with atrial fibrillation--A cohort study in Swedish primary care.

OBJECTIVE: Our aim was to study depression and anxiety in atrial fibrillation (AF) patients as risk factors for all-cause mortality in a primary care setting. METHODS: The study population included adults (n = 12 283) of 45 years and older diagnosed with AF in 75 primary care centres in Sweden. The association between depression or anxiety and all-cause mortality was explored using Cox regression analysis, with hazard ratios (HRs) and 95% confidence intervals (95% CIs). Analyses were conducted in men and women, adjusted for age, educational level, marital status, neighborhood socio-economic status (SES), change of neighborhood status and anxiety or depression, respectively, and cardiovascular co-morbidities. As a secondary analysis, background factors and their association with depression or anxiety were explored. RESULTS: The risk of all-cause mortality was higher among men with depression compared to their counterparts without depression even after full adjustment (HR = 1.28, 95% CI 1.08-1.53). For anxiety among men and anxiety or depression among women with AF, no associations were found. Cerebrovascular disease was more common among depressed AF patients. CONCLUSIONS: Increased awareness of the higher mortality among men with AF and subsequent depression is called for. We suggest a tight follow-up and treatment of both ailments in clinical practice.

Psychiatric comorbidities in patients with hypertension--a study of registered diagnoses 2009-2013 in the total population in Stockholm County, Sweden.

OBJECTIVE: The objective of this study was to investigate the prevalence of concomitant hypertension and psychiatric disorders in the general population, using administrative healthcare data in Stockholm County. DESIGN AND METHOD: The study population, included all living persons who resided in Stockholm County 1 January 2011 (N = 2 ,058 ,408). Individuals with a diagnosis of hypertension were identified with data from all consultations in primary care, specialized outpatient care, and inpatient care 2009-2013. As outcome, data were obtained on all consultations because of certain psychiatric diagnoses between 2011 and 2013, including specifically depression, anxiety disorders, bipolar disorder, and schizophrenia. Age-adjusted odd ratios (ORs) with 95% confidence intervals (95% CI) were calculated for men and women with and without hypertension, with individuals without hypertension as referents. RESULTS: The age-adjusted ORs for depression in persons with hypertension were 1.293 (95% CI 1.256-1.331,) for men and 1.036 (95% CI 1.013-1.058) for women. The age-adjusted ORs for anxiety in persons with hypertension were 1.279 (95% CI 1.238-1.322) for men and 1.050 (95% CI 1.024-1.076) for women. The OR for bipolar disease were 0.904 (95% CI 0.826-0.990) for men and 0.709 (95% CI 0.656-0.767) for women. For schizophrenia, the ORs were 0.568 (95% CI 0.511-0.632) for men and 0.537 (95% CI 0.478-0.603) for women. CONCLUSION: Increased awareness of the risk of depression and anxiety among hypertensive patients is needed to combat hypertension, its complications, and psychiatric suffering in the population. Hypertension is probably underdiagnosed and neglected in individuals with severe psychiatric disorders. We warrant efforts to integrate psychiatric and hypertensive care.

Neighbourhood socio-economic status and all-cause mortality in adults with atrial fibrillation: A cohort study of patients treated in primary care in Sweden.

OBJECTIVE: Our aim was to study the potential impact of neighbourhood socio-economic status (SES) on all-cause mortality in patients with atrial fibrillation (AF) treated in primary care. METHODS: Study population included adults (n=12,283) of 45 years and older diagnosed with AF in 75 primary care centres in Sweden. Association between neighbourhood SES and all-cause mortality was explored using Cox regression analysis, with hazard ratios (HRs) and 95% confidence intervals (95% CIs), and by Laplace regression where years to death (95% CI) of the first 10% of the participants were used as an outcome. All models were conducted in both men and women and adjusted for age, educational level, marital status, change of neighbourhood status, cardiovascular co-morbidities, anticoagulant treatment and statin treatment. High- and low-neighbourhood SES were compared with middle SES as reference group. RESULTS: After adjustments for potential confounders, higher relative risk of all-cause mortality (HR 1.49, 95% CI 1.13-1.96) was observed in men living in low SES neighbourhoods compared to those from middle SES neighbourhoods. The results were confirmed using Laplace regression; the time until the first 10% of the men in low SES neighbourhoods died was 1.45 (95% CI 0.48-2.42) years shorter than for the men in middle SES neighbourhoods. CONCLUSIONS: Increased rates of heart disease and subsequent mortality among adults in deprived neighbourhoods raise important clinical and public health concerns. These findings could serve as an aid to policy-makers when allocating resources in primary health care settings as well as to clinicians who encounter patients in deprived neighbourhoods.

Neighborhood deprivation and warfarin, aspirin and statin prescription - A cohort study of men and women treated for atrial fibrillation in Swedish primary care.

BACKGROUND: We aimed to study differences in the prescribing of warfarin, aspirin and statins to patients with atrial fibrillation (AF) in socio-economically diverse neighborhoods. We also aimed to explore the effects of neighborhood deprivation on the relationship between CHADS2 risk score and warfarin prescription. METHODS: Data were obtained from primary health care records that contained individual clinical data that were linked to national data on neighborhood of residence and a deprivation index for different neighborhoods. Logistic regression was used to estimate the potential neighborhood differences in prescribed warfarin, aspirin and statins, and the association between the CHADS2 score and prescribed warfarin treatment, in neighborhoods with high, middle (referent) and low socio-economic (SES). RESULTS: After adjustment for age, socio-economic factors, co-morbidities and moves to neighborhoods with different SES during follow-up, adults with AF living in high SES neighborhoods were more often prescribed warfarin (men odds ratio (OR) (95% confidence interval (CI): 1.44 (1.27-1.62); and women OR (95% CI): 1.19 (1.05-1.36)) and statins (men OR (95% CI): 1.23 (1.07-1.41); women OR (95% CI): 1.23 (1.05-1.44)) compared to their counterparts residing in middle SES. Prescription of aspirin was lower in men from high SES neighborhoods (OR (95% CI): 0.75 (0.65-0.86)) than in those from middle SES neighborhoods. Higher CHADS2 risk scores were associated with higher warfarin prescription which remained after adjustment for neighborhood SES. CONCLUSIONS: The apparent inequalities in pharmacotherapy seen in the present study call for resource allocation to primary care in neighborhoods with low and middle socio-economic status.

Diabetes and psychiatric illness in the total population of Stockholm.

OBJECTIVE: Concomitant psychiatric disorders in people with diabetes affect morbidity and mortality. We aimed to study psychiatric morbidity in people with diabetes and the general population using administrative health care data in Stockholm County. METHODS: The study population included all living persons who resided in Stockholm County, Sweden, on January 1, 2011 (N=2,058,408). Subjects with a diagnosis of diabetes were identified with data from all consultations in primary health care, specialist outpatient care and inpatient care during the time span 2009-2013. As outcome, information was obtained on all consultations due to any psychiatric diagnosis as well as, specifically, schizophrenia, bipolar disorders, depression, and anxiety disorders, in 2011-2013. Analyses were performed by age group and gender. Age-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for women and men with diabetes, using individuals without diabetes as referents, were calculated. RESULTS: Age-adjusted OR for all psychiatric diagnoses among people with diabetes was 1.296 (95% CI 1.267-1.326) for women and 1.399 (95% CI 1.368-1.432) for men. The greatest excess risk was found for schizophrenia, with OR 3.439 (95% CI 3.057-3.868) in women and 2.787 (95% CI 2.514-3.089) in men, with ORs between 1.276 (95% CI 1.227-1.327) and 1.714 (95% CI 1.540-1.905) for the remaining diagnoses. CONCLUSION: The prevalence of psychiatric disorders is elevated in people with diabetes, which calls for preventive action to be taken to minimize suffering and costs to society.

Most common diseases diagnosed in primary care in Stockholm, Sweden, in 2011.

BACKGROUND: The most commonly reported diagnoses in primary care are useful to identify and meet health care needs in society. We estimated the rates of the most common diagnoses in primary health care in total and also by gender. METHODS: This was a cross-sectional study including all 2.0 million inhabitants living in Stockholm County, Sweden, on 1 January 2009. Data on all health care appointments made in primary care in 2011 and during 2009-11 were extracted from the Stockholm County Council data warehouse VAL (Vårdanalysdatabasen; Stockholm regional health care data warehouse). Primary care data were analysed by underlying population and age. Appropriate specialist open care and inpatient data were used for comparison. RESULTS: The five most common diagnoses in primary care (in 2011) were acute upper respiratory tract infections (6.0% of the population), essential hypertension (5.6%), coughing (2.6%), dorsalgia (2.6%) and acute tonsillitis (2.4%). Female-to-male ratios were higher for 27 of the 30 most common diagnoses, the exceptions being type 2 diabetes, unspecified types of diabetes and multiple wounds. CONCLUSIONS: The 30 most common diagnoses in primary care reflect the complexity of disorders cared for in the first line of health care. Knowledge of these patterns is important when aiming at using primary health care resources in a proper way.

Utilization and costs of glucose lowering therapies following health technology assessment for the new reimbursement scheme in Sweden.

OBJECTIVES: A new reimbursement scheme (RS) for glucose lowering therapies (GLT) was implemented in Sweden on March 1, 2010. Products on the market were retained, restricted, excluded or excluded for new courses in the new RS. The aim of this study was to compare utilization and costs of GLT for type 2 diabetes Mellitus (T2DM) before and after the implementation of the changed RS. METHODS: This was a quasi-experimental study using data on dispensed GLT and costs from a database on dispensed individual based prescriptions in Sweden. Segmented regression analyses were used to assess utilization and costs. RESULTS: Following the changed reimbursement status, there was an accelerated increasing trend in number of patients treated with restricted (P=0.0007) or retained (P=0.0021) insulins, as well as in costs for insulin based GLT (P=0.0014). No impact was detected in the total number of patients treated with oral GLT, but a slightly negative trend in total costs for oral GLT was detected following the intervention (P=0.0177). CONCLUSIONS: The new reimbursement scheme had a minor impact on utilization and costs of oral GLT. Despite restricted reimbursement for patients with T2DM, the utilization of insulin based GLT and related costs increased faster following the intervention.

Utilization and costs of lipid modifying therapies following health technology assessment for the new reimbursement scheme in Sweden.

INTRODUCTION: A new reimbursement scheme (RS) for lipid modifying therapies (LMT) was implemented in Sweden in June 2009. Products on the market were continued, restricted or excluded in the new RS. The aim of this study was to compare utilization, costs and switching behavior in patients treated with LMT before and after the new RS. MATERIALS AND METHODS: This is a quasi-experimental study using data on dispensed LMT and costs from a database on dispensed individual prescriptions in Sweden. Segmented regression analyses were used to assess utilization and costs of LMT. RESULTS: Number of patients treated with products with restricted reimbursement increased in level (P=0.0336) following the changes in the scheme, while decreased in level (P<0.0001) for products excluded from the RS. Patients initially treated with products excluded from the RS discontinued to a greater extent, and switched to higher doses of the same substance or to generic simvastatin. The total annual costs decreased moderately. CONCLUSIONS: The decreasing trend in utilization of low-dose atorvastatin and rosuvastatin was accelerated and so was the increasing trend in utilization of generic simvastatin following the new RS. Switching to higher doses and discontinuation increased and expected savings were overestimated.

Health factors and longevity in men and women: a 26-year follow-up study.

Health factors have the power to prevent and postpone diseases and death; however, studies using the same methodology in both men and women are sparse. We aimed to study the ability of health factors to prevent mortality in a population-based, 26-year follow-up of Swedish men and women. During 1969-70, a health-screening programme was offered to a stratified sample of 3,064 individuals aged 18-64 years to estimate health-care needs. Missing data (largely according to protocol) for physical fitness, BMI, and smoking habits left 935 subjects, 463 men and 472 women. Alcohol consumption in grams per week and BMI was calculated. Tobacco smoking was recorded as yes/no. Multivariate analysis was performed by Cox regression with age adjusted hazard ratios (HR) and 95% confidence interval (CI). Moderate alcohol consumption did not lead to any decrease in mortality. Having two health factors halved the mortality risk in men and women (hazard ratio (HR) 0.52, confidence interval (CI) 0.39-0.70). A further risk reduction was seen in men with three health factors (HR 0.17, CI 0.074-0.41). Men had about 70 per cent higher risk of mortality compared with women after adjustments for all health factors (HR 1.67, CI 1.26-2.23). Men compared to women had greater benefit of all three health factors. This in combination with the overall higher mortality risk in men makes a healthy lifestyle more important for them. The benefit of moderate alcohol consumption could not be detected in this study, and may be explained by an unhealthy drinking pattern in Sweden.