Is the Rule of Halves framework relevant for diabetes care in Copenhagen today? A register-based cross-sectional study.

OBJECTIVE: The study aimed at analysing whether the 'Rule of Halves' framework applies for diabetes care in the Danish healthcare system with high levels of accessibility and equity. The Rule of Halves states that only one-half of people with a particular chronic condition are diagnosed; one-half of those diagnosed get treatment, and one-half of treated achieve desired therapeutic goals. DESIGN: The analysis is cross sectional based on available surveys, register data and clinical databases covering the adult population in Copenhagen. We analysed five levels of prevention and care including behavioural risk factors and biomarkers, prevalence of diagnosed and undiagnosed diabetes as well as how many received care according to guidelines and achieved relevant outcomes. SETTING: The study population is Copenhagen City with a population of 550 000 with 21 500 prevalent cases of diabetes. While the registers used cover the whole population, the surveys include 750 cases and the biobank data 365 cases. OUTCOME MEASURES: Outcome measures are for each level of analysis: the prevalence of high-risk individuals, prevalence of undiagnosed and diagnosed diabetes, proportion receiving treatment and proportion achieving quality and treatment targets. RESULTS: We found that the 'Rule of Halves' framework raises relevant questions on how diabetes care works in a specific population, but the actual proportions found in Copenhagen are far from halves. Our analyses showed that 74% are diagnosed and among those who are 90% are receiving care. 40%-60% have achieved target levels of treatment in terms of HbA1c level and lipid levels. 80% have received eye and foot examinations in the last 2 years. 11% have retinopathy and 25% have macrovascular complications. CONCLUSION: Copenhagen is doing much better than halves, when it comes to diagnosis and providing treatment, whereas the Rule of Halves still prevails when it comes to treatment targets. There is thus still room for improvement.

Job mobility and health in the Danish workforce.

AIMS: The globalized economy has stimulated mobility in the labour market in many countries and Denmark has one of the highest rates of mobility between workplaces among the OECD countries. This raises the question of the potential health effects of mobility and the effect of disease on mobility. METHODS: This study was register-based with a longitudinal design using data on the entire Danish population in 1992-2006. The data included mobility between employers and workplaces and seven different diseases based on admissions to hospital and drug prescriptions. RESULTS: After adjusting for relevant confounders, an exposure-response relationship was seen between mobility and the incidence of ischaemic heart disease, stroke, duodenal ulcer, anxiety/depression and, most strongly, with alcohol-related disorders. The effects were not very strong, however, with odds ratios varying from 1.2 to 1.6. As expected, no effect was seen for colorectal cancer. We also found an effect of both somatic and mental disorders on mobility, but not for the two cancer types. Mobility did not seem to prevent being out of the labour force after diagnosis. CONCLUSIONS: Frequent mobility in the labour market increases the risk of cardiovascular disease, common mental disorders and alcohol-related disorders and these diagnoses also seem to increase the risk of subsequent mobility.

[E-cigarettes also contain detrimental chemicals].

This article reviews studies dealing with the content of electronic (e-) cigarettes. Based on measurements of the e-juice, the inhaled and the exhaled vapour, it is sound to assume that smoking e-cigarettes might have much less detrimental health effects than smoking conventional cigarettes. However, propylene glycol and glycerine are abundant in e-cigarettes and although they are generally perceived as relatively harmless, the long-term effects of heavy exposure to these substances are unknown.

[Health consequences of smoking electronic cigarettes are poorly described].

Despite increasing popularity, health consequences of vaping (smoking electronic cigarettes, e-cigarettes) are poorly described. Few studies suggest that vaping has less deleterious effects on lung function than smoking conventional cigarettes. One large study found that e-cigarettes were as efficient as nicotine patches in smoking cessation. The long-term consequences of vaping are however unknown and while some experts are open towards e-cigarettes as a safer way of satisfying nicotine addiction, others worry that vaping in addition to presenting a health hazard may lead to an increased number of smokers of conventional cigarettes.

Assessment of health impacts of decreased smoking prevalence in Copenhagen: Application of the DYNAMO-HIA model.

AIMS: Tobacco smoking is among the leading risk factors for chronic disease and early death in developed countries, including Denmark, where smoking causes 14% of the disease burden. In Denmark, many public health interventions, including smoking prevention, are undertaken by the municipalities, but models to estimate potential health effects of local interventions are lacking. The aim of the current study was to model the effects of decreased smoking prevalence in Copenhagen, Denmark. METHODS: The DYNAMO-HIA model was applied to the population of Copenhagen, by using health survey data and data from Danish population registers. We modelled the effects of four intervention scenarios aimed at different target groups, compared to a reference scenario. The potential effects of each scenario were modelled until 2040. RESULTS: A combined scenario affecting both initiation rates among youth, and cessation and re-initiation rates among adults, which reduced the smoking prevalence to 4% by 2025, would have large beneficial effects on incidence and prevalence of smoking-related diseases and mortality. Health benefits could also be obtained through interventions targeting only cessation or re-initiation rates, whereas an intervention targeting only initiation among youth had marginal effects on morbidity and mortality within the modelled time frame. CONCLUSIONS: By modifying the DYNAMO-HIA model, we were able to estimate the potential health effects of four interventions to reduce smoking prevalence in the population of Copenhagen. The effect of the interventions on future public health depended on population subgroup(s) targeted, duration of implementation and intervention reach.

Cost-effectiveness of preventive interventions to reduce alcohol consumption in Denmark.

INTRODUCTION: Excessive alcohol consumption increases the risk of many diseases and injuries, and the Global Burden of Disease 2010 study estimated that 6% of the burden of disease in Denmark is due to alcohol consumption. Alcohol consumption thus places a considerable economic burden on society. METHODS: We analysed the cost-effectiveness of six interventions aimed at preventing alcohol abuse in the adult Danish population: 30% increased taxation, increased minimum legal drinking age, advertisement bans, limited hours of retail sales, and brief and longer individual interventions. Potential health effects were evaluated as changes in incidence, prevalence and mortality of alcohol-related diseases and injuries. Net costs were calculated as the sum of intervention costs and cost offsets related to treatment of alcohol-related outcomes, based on health care costs from Danish national registers. Cost-effectiveness was evaluated by calculating incremental cost-effectiveness ratios (ICERs) for each intervention. We also created an intervention pathway to determine the optimal sequence of interventions and their combined effects. RESULTS: Three of the analysed interventions (advertising bans, limited hours of retail sales and taxation) were cost-saving, and the remaining three interventions were all cost-effective. Net costs varied from € -17 million per year for advertisement ban to € 8 million for longer individual intervention. Effectiveness varied from 115 disability-adjusted life years (DALY) per year for minimum legal drinking age to 2,900 DALY for advertisement ban. The total annual effect if all interventions were implemented would be 7,300 DALY, with a net cost of € -30 million. CONCLUSION: Our results show that interventions targeting the whole population were more effective than individual-focused interventions. A ban on alcohol advertising, limited hours of retail sale and increased taxation had the highest probability of being cost-saving and should thus be first priority for implementation.

Cost-effectiveness of changes in alcohol taxation in Denmark: a modelling study.

INTRODUCTION: Excessive alcohol consumption is a public health problem in many countries including Denmark, where 6% of the burden of disease is due to alcohol consumption, according to the new estimates from the Global Burden of Disease 2010 study. Pricing policies, including tax increases, have been shown to effectively decrease the level of alcohol consumption. METHODS: We analysed the cost-effectiveness of three different scenarios of changed taxation of alcoholic beverages in Denmark (20% and 100% increase and 10% decrease). The lifetime health effects are estimated as the difference in disability-adjusted life years between a Danish population that continues to drink alcohol at current rates and an identical population that changes their alcohol consumption due to changes in taxation. Calculation of cost offsets related to treatment of alcohol-related diseases and injuries, was based on health care system costs from Danish national registers. Cost-effectiveness was evaluated by calculating cost-effectiveness ratios (CERs) compared to current practice. RESULTS: The two scenarios of 20% and 100% increased taxation could avert 20,000 DALY and 95,500 DALY respectively, and yield cost savings of -€119 million and -€575 million, over the life time of the Danish population. Both scenarios are thus cost saving. The tax decrease scenario would lead to 10,100 added DALY and an added cost of €60 million. For all three interventions the health effects build up and reach their maximum around 15-20 years after implementation of the tax change. CONCLUSION: Our results show that decreased taxation will lead to an increased burden of disease and related increases in health care costs, whereas both a doubling of the current level of alcohol taxation and a scenario where taxation is only increased by 20% can be cost-saving ways to reduce alcohol related morbidity and mortality. Our results support the growing evidence that population strategies are cost-effective and should be considered for policy making and prevention of alcohol abuse.

Health Impact Assessment of increased cycling to place of work or education in Copenhagen.

OBJECTIVE: To quantify the effects of increased cycling on both mortality and morbidity. DESIGN: Health Impact Assessment. SETTING: Cycling to place of work or education in Copenhagen, Denmark. POPULATION: Effects were calculated based on the working-age population of Copenhagen. MAIN OUTCOME MEASURES: The primary outcome measure was change in burden of disease (measured as disability-adjusted life years (DALY)) due to changed exposure to the health determinants physical inactivity, air pollution (particulate matter <2.5 µm) and traffic accidents. RESULTS: Obtainment of the proposed increase in cycling could reduce the burden of disease in the study population by 19.5 DALY annually. This overall effect comprised a reduction in the burden of disease from health outcomes associated with physical inactivity (76.0 DALY) and an increase in the burden of disease from outcomes associated with air pollution and traffic accidents (5.4 and 51.2 DALY, respectively). CONCLUSION: This study illustrates how quantitative Health Impact Assessment can help clarify potential effects of policies: increased cycling involves opposing effects from different outcomes but with the overall health effect being positive. This result illustrates the importance of designing policies that promote the health benefits and minimise the health risks related to cycling.

[Type 2 diabetes. Social relations and health behaviour]. / Type 2-diabetes. Sociale relationer og sundhedsadfaerd.

INTRODUCTION: Type 2 diabetes is a chronic disease that challenges the Danish health care system and health behaviour is important in connection with rehabilitation. Foreign research shows that social relations are associated with a healthy lifestyle, but this effect has not yet been examined thoroughly based on Danish data. The purpose of this study was to examine the association between social relations and health behaviour among adult Danes with type 2 diabetes. MATERIALS AND METHODS: The study design was cross-sectional and based on data from the report ''Sundheds- og Sygelighedsundersøgelsen 2000'', published by The National Institute of Public Health; 264 respondents with type 2 diabetes were included in the final study population. Social relations were measured in terms of civil status, social contact and functional network. Health behaviour reflects whether the respondents comply with the official Danish recommendations for physical activity, diet, alcohol and smoking. Adjustments were made for sex, age, income, self-rated health, functional ability, stress and Body Mass Index. RESULTS: Social relations measured as civil status and functional network are positively associated with adherence to the recommendations for physical activity and diet. Only the association between functional network and diet remains significant when adjusted for the effects of co-variates. CONCLUSION: The study shows a need for the promotion of health behaviour among adult Danes with type 2 diabetes, and indicates that social relations ought to be part of rehabilitation.