Non-monotonic health behaviours - implications for individual health-related behaviour in a demand-for-health framework.

A number of behaviours influence health in a non-monotonic way. Physical activity and alcohol consumption, for instance, may be beneficial to one's health in moderate but detrimental in large quantities. We develop a demand-for-health framework that incorporates the feature of a physiologically optimal level. An individual may still choose a physiologically non-optimal level, because of the trade-off in his or her preferences for health versus other utility-affecting commodities. However, any deviation above or below the physiologically optimal level will be punished with respect to health. Distinguishing between two individual types we study (a) the qualitative properties of optimal time-paths of health capital and health-related behaviour, (b) the perturbations of the optimal time-paths that result from changes in exogenous parameters, and (c) steady state properties. Predictions of the model and the implications for empirical analysis are discussed at length. Some comments on potential future extensions conclude the paper.

Cost-effectiveness and cost-utility analyses of hospital-based home care compared to hospital-based care for children diagnosed with type 1 diabetes; a randomised controlled trial; results after two years' follow-up.

BACKGROUND: Practices regarding hospitalisation of children at diagnosis of type 1 diabetes vary both within countries and internationally, and high-quality evidence of best practice is scarce. The objective of this study was to close some of the gaps in evidence by comparing two alternative regimens for children diagnosed with type 1 diabetes: hospital-based care and hospital-based home care (HBHC), referring to specialist care in a home-based setting. METHODS: A randomised controlled trial, including 60 children aged 3-15 years, took place at a university hospital in Sweden. When the children were medically stable, they were randomised to either the traditional, hospital-based care or to HBHC. RESULTS: Two years after diagnosis there were no differences in HbA1c (p = 0.777), in episodes of severe hypoglycaemia (p = 0.167), or in insulin U/kg/24 h (p = 0.269). Over 24 months, there were no statistically significant differences between groups in how parents' reported the impact of paediatric chronic health condition on family (p = 0.138) or in parents' self-reported health-related quality of life (p = 0.067). However, there was a statistically significant difference regarding healthcare satisfaction, favouring HBHC (p = 0.002). In total, healthcare costs (direct costs) were significantly lower in the HBHC group but no statistically significant difference between the two groups in estimated lost production (indirect costs) for the family as a whole. Whereas mothers had a significantly lower value of lost production, when their children were treated within the HBHC regime, fathers had a higher, but not a significantly higher value. The results indicate that HBHC might be a cost-effective strategy in a healthcare sector perspective. When using the wider societal perspective, no difference in cost effectiveness or cost utility was found. CONCLUSIONS: Overall, there are only a few, well-designed and controlled studies that compare hospital care to different models of home care. The results of this study provide empirical support for the safety and feasibility of HBHC when a child is diagnosed with type 1 diabetes. Our results further indicate that the model of care may have an impact on families' daily living, not only during the initial period of care but for a longer period of time. TRIAL REGISTRATION: ClinicalTrials.gov with identity number NCT00804232 , December 2008.

Health investment behaviours and oral/gingival health condition, a cross-sectional study among Swedish 19-year olds.

OBJECTIVES: To test the hypothesis that certain individual, environmental and lifestyle factors are positively associated with beneficial health investment behaviours and oral/periodontal health among adolescents. METHODS: Five hundred and six randomly selected 19-year old subjects living in two different areas (Fyrbodal and Skaraborg) in the county council of Västra Götaland, Sweden participated in a clinical examination and answered questionnaires covering psycho-social and health behavioural issues. Two oral-health models were estimated with gingivitis score as an objective and self-perceived oral health as a subjective indicator. Three health- investment behaviour models were designed with indicators directly related to oral health and two with indicators related to general health as well. The explanatory variables included gender, upper secondary education programme, native country, living area, general self-efficacy and parents' education level. RESULTS: In the objective oral-health model, theoretical studies and living in the Skaraborg area were both positively associated with a lower gingivitis score. For the subjective oral-health indicator, none of the explanatory variables showed statistical significance. In the investment-behaviour model with 'tooth-brushing ≥ 2 times daily' as a health indicator, female gender and theoretical studies showed statistically significant associations. With the indicators 'no/few missed dental appointments', 'no tobacco use' and 'weekly exercise', theoretical studies were statistically significant and positively associated. In the investment model with 'perceived oral health care attention' as an indicator, a high score of general self-efficacy was significantly associated with the feeling of taking good care of the teeth. CONCLUSIONS: Individual, environmental and lifestyle factors are associated with young individuals' oral health investment behaviours and gingival health conditions.

Pancreatic cancer, healthcare cost, and loss of productivity: a register-based approach.

BACKGROUND: Despite the fact that pancreatic cancer is the fourth leading cause of cancer-related death, there is little empirical evidence on its direct healthcare costs and, especially, its indirect costs due to loss of production. METHODS: The present study is a retrospective analysis of all patients with pancreatic cancer (excluding endocrine cancer) in the primary catchment area of Lund University Hospital, Sweden, during the period 2005-2007. Detailed information on all diagnostic and therapeutic investigations, interventions, and postoperative course and long-term follow-up was collected, as well as absenteeism from work due to the health problem, from which direct costs were calculated. The indirect costs for loss of production due to sickness and premature death were calculated by the human capital method. A total of 83 patients were included, for an incidence rate of 9.9 patients/100,000 inhabitants. RESULTS: Direct treatment cost per pancreatic-cancer patient was estimated at EUR 16,066 for each patient's remaining lifetime. Hospitalization accounted for the major expenditure-60% of the lifetime treatment cost. Patients with resectable tumor had a mean cost of EUR 19,809; locally advanced disease, EUR 14,899; and metastatic disease, 16,179. Younger patients and men had a higher than average lifetime treatment cost. The loss of productivity was estimated at EUR 287,420 per patient younger than 65 years of age, of which premature mortality accounted for 79%. CONCLUSIONS: Adding the cost of palliative care estimated in a previous Swedish study, health-care costs and productivity losses for pancreatic cancer would add up to a substantial economic burden for Sweden at large in 2009 (population 9.1 million), between EUR 86 million and EUR 93 million.

Attained education and self-assessed health later in life when diagnosed with diabetes in childhood: a population-based study.

BACKGROUND: Previous studies have reported conflicting findings on academic achievement in children with type 1 diabetes, and generally lower self-assessed health status among respondents with diabetes. OBJECTIVE: Thus, in this study, using the theoretical framework of the human-capital model, a population-based survey data set for Sweden, and explanatory variables following predictions from theory and previous empirical human-capital studies, individuals diagnosed with diabetes before the age of 19 were examined whether they differ from the general population at the same age concerning (i) educational level attained and (ii) self-assessed health later in life. Special attention was devoted to the association between education and health. SUBJECTS: A set of pooled cross-sectional population survey data complemented with register data, comprising 20 670 individuals (of whom 106 individuals were diagnosed with diabetes), aged 19-38 yr, from 1988 to 2000, was created from the Swedish Biennial Survey of Living Conditions. METHOD: The influence of childhood diabetes was analyzed using multiple regression analysis, controlling for educational level, wage, sex, age, marital status, and parental ethnicity. RESULTS: Childhood diabetes was associated with lower levels of attained education and self-assessed health in comparison with the general population. More educated individuals reported better health, though. CONCLUSIONS: In terms of the rapid increase in the incidence of diabetes in many countries, it is important to bear in mind that investments made both in education and in health, early in life, may facilitate the capability of the individual to experience healthy time later in life.

Insulin-glucose infusion given before hemodialysis increases IGF-I in type 2 diabetes patients with chronic kidney disease.

OBJECTIVE: Hemodialysis is associated with catabolism and one contributing factor could be decreased bioavailable IGF-I. The aim of this investigation was to study the response of IGF-I and IGFBP-1 to a euglycemic hyperinsulinemic clamp before hemodialysis in type 2 diabetes (T2D) with chronic kidney disease on hemodialysis (CKD5D). Stage 5 (Stages 0-5 according to renal function) indicates a GFR less than 15 mL/min/1.73 m², D indicates hemodialysis. The response was compared with that in type 1 diabetes (T1D) with normal renal function. DESIGN: Five overnight fasted patients with T2D with CKD5D were subjected to an insulin infusion (1.6 mU/kg/h) for 4 h after which they had lunch followed by a four hour hemodialysis session. The results were compared with results from a previous study in seven T1D patients with normal renal function who had received a similar clamp the same insulin dose with the addition of an initial bolus dose. Blood samples were drawn at 15 to 30 min intervals for analysis of IGFBP-1, IGF-I and insulin and at 5 min intervals to determine blood glucose. RESULTS: There was no significant change between pre- and postdialysis values of IGF-I but there was a significant 29% increase (p<0.05) at the end of hemodialysis compared with the basal levels before insulin infusion in the T2D patients with CKD5D. The fasting mean levels of IGFBP-1 were increased in both T1D with normal renal function (geometric mean: 216 µg/l, range 169-275 µg/l) and in T2D with CKD5D (geometric mean: 112 µg/l , range 78-162 µg/l, p=0.15 compared with T1D patients) in spite of a high mean insulin level (32±5 mU/l). Insulin caused a similar decrease (p<0.05 all groups) in IGFBP-1 mean levels for the first 90 min in the T2D patients with CKD5D (73±7% of basal IGFBP-1 values) and the T1D patients (69±6%) with normal renal function. After 90 min there was a blunted response in the T2D patients with CKD5D whereas IGFBP-1 in the T1D patients with normal renal function continued to decline. After hemodialysis the IGFBP-1 serum levels increased compared with the levels at the end of insulin infusion but the predialysis values remained significantly lower than before the insulin infusion. CONCLUSION: Type 2 diabetes patients with chronic kidney disease requiring hemodialysis (CKD5D) have a high mean basal level of IGFBP-1 in spite of increased insulin levels. The first 90 min response of IGFBP-1 to insulin infusion is similar in T2D patients with CKD5D and T1D patients with normal renal function. After 90 min of insulin infusion a blunted decrease in IGFBP-1 was seen in T2D patients with CKD5D compared with type \1 diabetes with normal renal function. Insulin infusion before hemodialysis reduced the earlier reported increase in IGFBP-1 and increased IGF-I levels. Insulin infusion before dialysis in patients with CKD5D should be further studied since it could contribute to an anabolic effect with more bioavaialable IGF-I thus reducing the catabolic effect of hemodialysis.

Utilisation of physician services in the 50+ population: the relative importance of individual versus institutional factors in 10 European countries.

We analysed the relative importance of individual versus institutional factors in explaining variations in the utilisation of physician services among the 50+ in ten European countries. The importance of the latter was investigated, distinguishing between organisational (explicit) and cultural (implicit) institutional factors, by analysing the influence of supply side factors, such as physician density and physician reimbursement, and demand side factors, such as co-payment and gate-keeping, while controlling for a number of individual characteristics, using cross-national individual-level data from SHARE. Individual differences in health status accounted for about 50% of the between-country variation in physician visits, while the organisational and cultural factors considered each accounted for about 15% of the variation. The organisational variables showed the expected signs, with higher physician density being associated with more visits and higher co-payment, gate-keeping, and salary reimbursement being associated with less visits. When analysing specialist visits separately, however, organisational and cultural factors played a greater role, each accounting for about 30% of the between-country variation, whereas individual health differences only accounted for 11% of the variation.

Varenicline as compared to bupropion in smoking-cessation therapy--cost-utility results for Sweden 2003.

STUDY OBJECTIVES: To calculate incremental cost-utility ratios (cost per QALY gained) for varenicline (Champix; Pfizer), as compared to bupropion, in smoking-cessation programmes for a lifetime follow-up period. DESIGN: The Benefits of Smoking Cessation on Outcomes (BENESCO) simulation model was used for a male and female cohort, respectively, as a point of departure but further extended in order to include the indirect effects of smoking-cessation on production and consumption in the economy. All calculations were performed in 2003 Swedish prices. SETTING: Sweden in 2003. PATIENTS OR PARTICIPANTS: Model cohort consisting of 25% of all smokers among men and women (168,844 males and 208,737 females), distributed by age, 18 and older, as in the Swedish population of 2003. INTERVENTIONS: Varenicline as compared to bupropion, in smoking-cessation programmes for 20-year, 50-year, and lifetime follow-up periods. MEASUREMENTS AND RESULTS: When the indirect effects on production and consumption were included, the incremental costs per QALY gained were euro2056 (euro14,743) for men and euro1193 (euro14,214) for women, in comparison to bupropion and computed for a time horizon of 20 and 50 years (1euro approximately euroSEK9.12). Excluding the indirect effects on production and consumption, varenicline was cost-saving in comparison to bupropion. Sensitivity analysis indicated that the results are robust. Variation of treatment efficiency and intervention costs, respectively, had a larger effect on cost per QALY gained than other variables. CONCLUSIONS: Estimated costs per QALY gained rated smoking-cessation intervention using varenicline among the most cost-effective life-saving medical treatments.

Smoking, healthcare cost, and loss of productivity in Sweden 2001.

AIMS: Objectives were (a) to estimate healthcare cost and productivity losses due to smoking in Sweden 2001 and (b) to compare the results with studies for Sweden 1980, Canada 1991, Germany 1996, and the USA 1998. METHODS: Published estimates on relative risks and Swedish smoking patterns were used to calculate attributable risks for smokers and former smokers. These were applied to cost estimates for smoking-related diseases based on data from public Swedish registers. RESULTS: The estimated total cost for Sweden 2001 was US 804 million dollars; COPD and cancer of the lung accounted for 43%. Healthcare cost accounted for 26% of the total cost. The estimated costs per smoker were US 3,200 dollars in the USA 1998; 1,600 in Canada 1991; 1,100 in Germany 1996; 600 in Sweden 2001; and 300 in Sweden 1980 (all in 2001 US dollar prices). CONCLUSIONS: To reduce the prevalence of smoking is an issue worthwhile pursuing in its own right. In order to reduce the cost of smoking, however, policy-makers should also explore and influence the factors that determine the cost per smoker. Sweden seems to have been more successful than comparable countries in pursuing both these objectives.

Obesity and occupational attainment among the 50+ of Europe.

This paper brings a European perspective to the mainly U.S.-based literature on the relationship between obesity and labour-market outcomes. Using micro-data on workers aged 50 and over from the newly developed SHARE database, the effects of obesity on employment, hours worked, and wages across 10 European countries were analysed. Pooling all countries, the results showed that being obese was associated with a significantly lower probability of being employed for both women and men. Moreover, the results showed that obese European women earned 10% less than their non-obese counterparts. For men, however, the effect was smaller in size and insignificant. Taking health status into account, obese women still earned 9% less. No significant effect of obesity on hours worked was obtained, however. Regressions by country-group revealed that the effects of obesity differed across Europe. For instance, the effect of obesity on employment was greatest for men in southern and central Europe, while women in central Europe faced the greatest wage penalty. The results in this study suggest that the ongoing rise in the prevalence of obesity in Europe may have a non-negligible effect on the European labour market.

Getting ready for the marriage market? The association between divorce risks and investments in attractive body mass among married Europeans.

This article explores to what extent married middle-aged individuals in Europe are governed by the risk of experiencing divorce, when shaping their physical appearance. The main result is that divorce risks, proxied by national divorce rates, are negatively connected to body mass index (BMI) among married individuals but unrelated to BMI among singles. Hence, it seems that married people in societies where divorce risks are high are more inclined to invest in their outer appearance. One interpretation is that high divorce rates make married people prepare for a potential divorce and future return to the marriage market.

The significance of overweight and obesity for individual health behaviour: an economic analysis based on the Swedish surveys of living conditions 1980-81, 1988-89, and 1996-97.

AIMS: The aim of the study was to examine whether being overweight (25or=30) affect subsequent individual health behaviour, applying the framework of the individual-as-producer-of-health model. METHODS: A set of panel data for 3,693 individuals interviewed repeatedly in 1980-81, 1988-89, and 1996-97 was created from the Swedish population-based biannual survey of living conditions. Self-assessed health was chosen as indicator of individual health capital and physical exercise as indicator of individual health investment. RESULTS: (a) Men and women who suffered from obesity invested significantly less in their health in terms of physical exercise and reported significantly lower self-assessed health than the general male and female population, respectively. (b) Men who suffered from overweight invested less in their health and reported significantly lower self-assessed health than the general population, whereas women who were overweight--but not obese--did not differ from the general population. (c) Men and women who went from being obese to being overweight reported self-assessed health levels that did not differ from the general male and female population, respectively, but exercised less than men and women in general. CONCLUSIONS: The results imply (a) that the individual weight history must be taken into account in studies of the effect of obesity and overweight on health and health-related behaviour and (b) that men and women differ concerning the impact of obesity and overweight on health and health investments.

A community action programme for reducing harmful drinking behaviour among adolescents: the Trelleborg Project.

AIMS: To evaluate a 3-year community intervention programme by measuring changes in drinking patterns in a 15-16-year-old population. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: The action programme included five demand-reducing and one supply-reducing interventions. Cross-sectional, non-repeated data were collected from a questionnaire distributed in classrooms from 1999 to 2001 and 2003 (n = 1376, 724 boys and 652 girls; response rate = 92.3%). Stepwise logistic regression analyses were used to determine the relationship between different risk factors and excessive drinking, heavy episodic drinking, purchaser of alcohol and alcohol provided by parents. The results from the intervention community were also compared with similar Swedish cross-sectional data sets. FINDINGS: The results of our analyses indicated a decrease in harmful drinking behaviour in Trelleborg when comparing baseline with postintervention measurements. The comparison with other studies showed that the changes in these indicators were more rapid and consistent in Trelleborg. Finally, the multivariable logistic regression analyses showed that the outcomes were not likely to be attributed to changes in environmental factors. CONCLUSIONS: We concluded that a community action programme based on the systems approach reduced hazardous alcohol consumption effectively among adolescents in Trelleborg.

The cost utility of bupropion in smoking cessation health programs: simulation model results for Sweden.

STUDY OBJECTIVES: To calculate incremental cost-utility ratios (cost per quality-adjusted life-year [QALY] gained) for bupropion (Zyban; GlaxoSmithKline; Gothenburg, Sweden), as compared to nicotine replacement therapy (NRT) in smoking cessation programs for a follow-up period of 20 years. DESIGN: The Global Health Outcomes simulation model was used for a male cohort and for a female cohort as a point of departure but was further extended in order to include the following: (1) the indirect effects of smoking cessation on production and consumption in the economy, and (2) morbidity-specific QALYs gained. SETTING: Sweden in 2001. PATIENTS OR PARTICIPANTS: Model cohort consisting of 612,851 male and 780,970 female smokers, distributed by age, > or = 35 years old, as in the Swedish population of 2001. INTERVENTIONS: Bupropion, as compared to NRT (nicotine patches and nicotine gums), in smoking cessation programs for a follow-up period of 20 years. MEASUREMENTS AND RESULTS: When the indirect effects on production and consumption were taken into account, bupropion was cost saving in comparison to both NRTs. When only the direct costs were included, bupropion was still cost saving in comparison to nicotine gum. The incremental costs per QALY gained were relatively low for bupropion in comparison to nicotine patches, 6,600 Swedish kronas (SEK) (approximately 725 euro) per QALY gained for men and 4,900 SEK (approximately 535 euro) for women, all calculations in 2001 Swedish prices. The comprehensive sensitivity analysis showed robust results; results were, however, more sensitive to quit rates and intervention costs than to other variables. CONCLUSIONS: Bupropion is a cost-effective therapy in smoking cessation programs. Furthermore, recent studies report even higher effectiveness in terms of quit rates than was assumed here, indicating that our estimated cost-utility ratio should be even more favorable to bupropion.

Growth hormone treatment in hemodialysis patients--a randomized, double-blind, placebo-controlled study.

OBJECTIVE: Renal failure and hemodialysis (HD) affect the anabolic growth hormone (GH)-insulin-like growth factor (IGF) axis. A positive correlation between serum IGF-I and normalized protein catabolic rate (PCRn) in HD patients has been reported, and the aim of this study was to assess the metabolic impact of recombinant human (rh)GH in these patients. MATERIAL AND METHODS: In a randomized, double-blind, placebo-controlled study, rhGH was given to 35 HD patients for 8 weeks: 0.025 IU/kg/day for 1 week, increasing to 0.05 IU/kg/day. Patients with diabetes, malignancy or clinical signs of infection and those receiving steroid treatment were excluded. RESULTS: All patients completed the study. Side-effects were rare and equally distributed between the two groups. Post-treatment, serum IGF-I and IGF-I standard deviation score (IGF-I SD) increased in the rhGH group compared to the placebo group: 283+/-33 vs 151+/-16 mg/l (p = 0.001) and 1.8+/-0.6 vs -0.2+/-0.6 (p = 0.002), respectively. IGF binding protein-3 was higher in the rhGH group compared to the placebo group: 5859+/-285 vs 4369+/-321 mg/l (p = 0.002). PCRn was significantly higher in the rhGH group compared to the placebo group: 1.09+/-0.06 vs 0.90+/-0.06 g/kg/day (p = 0.029). No differences were found in body weight, serum albumin or leptin between the two groups. There was no change in C-reactive protein (CRP) in the rhGH group compared to the placebo group: 17.4+/-9.0 vs 12.3+/-4.6 mg/l (p = NS). When the patients were subgrouped according to the CRP level (< or > 10 mg/1), the effect on PCRn persisted only in rhGH-treated subjects with a normal CRP level: 1.10+/-0.08 vs 0.81+/-0.09 g/kg/day (p = 0.025). CONCLUSION: Treatment of HD patients with rhGH at a moderate dose causes augmentation of PCRn which is considered to indicate a higher dietary protein intake. The anabolic effect of rhGH seems to be abolished by subclinical inflammation.

The quality of drugs in private pharmacies in Lao PDR: a repeat study in 1997 and 1999.

OBJECTIVE: To present a repeated test of the quality of ampicillin, tetracycline, chloroquine and ASA from private pharmacies in Laos in 1997 and 1999, and to discuss the quality in relation to the National Drug Policy Programme. METHOD: A total of 115 of 214 licensed private pharmacies were selected in Savannakhet province, a pilot province in the Lao National Drug Policy Programme. The four drugs, if available, were collected at each pharmacy. Thirty tablets of each drug were taken from a selected container. In 1997, 366 samples were analysed and three hundred in 1999. Identity, assay (content of active component) and measurement of weight variation tests were performed. Drug quality was compared mainly according to the standards of the British and United States' pharmacopoeias. RESULTS: The percentage of substandard drugs decreased significantly from 46% to 22% between 1997 and 1999 (P< 0.001). Substandard ampicillin and tetracycline were reduced significantly from 67% to 9% and from 38% to 12%, respectively (P < 0.001). In total, 3% vs 1% contained no active ingredient, 12% vs 4% had too little or too much active ingredient, and 35% vs 14% had weight variation outside pharmacopoeial limits. CONCLUSION: Drug quality was improved. However, the prevalence of substandard drugs was still unacceptably high, which may result in adverse clinical effect or treatment failure for individual patients.

Social participation, social capital and daily tobacco smoking: a population-based multilevel analysis in Malmö, Sweden.

AIMS: The aim of this study was to investigate the influence of contextual and individual factors on daily tobacco smoking. METHODS: The public-health survey in Malmö 1994 is a cross-sectional study. A total of 5600 individuals aged 20-80 years were invited to answer a postal questionnaire. The participation rate was 71%. A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second, was performed. We analysed the effect (intra-area correlation, cross-level modification and odds ratios) of individual and neighbourhood factors on smoking after adjustment for individual factors. RESULTS: Neighbourhood factors accounted for 2.5% of the crude total variance in daily tobacco smoking. This effect was significantly reduced when the individual factors such as education were included in the model. However, individual social capital, measured by social participation, only marginally affected the total neighbourhood variance in daily tobacco smoking. In fact, no significant variance in daily tobacco smoking remained after the introduction of the individual factors other than individual social capital in the model. CONCLUSION: In Malmö, the neighbourhood variance in daily tobacco smoking is mainly affected by individual factors other than individual social capital, especially socioeconomic status measured as level of education.

Investments in social capital--implications of social interactions for the production of health.

This paper develops a theoretical model of the family as producer of health- and social capital. There are both direct and indirect returns on the production and accumulation of health- and social capital. Direct returns (the consumption motives) result since health and social capital both enhance individual welfare per se. Indirect returns (the investment motives) result since health capital increases the amount of productive time, and social capital improves the efficiency of the production technology used for producing health capital. The main prediction of the theoretical model is that the amount of social capital is positively related to the level of health; individuals with high levels of social capital are healthier than individuals with lower levels of social capital, ceteris paribus. An empirical model is estimated, using a set of individual panel data from three different time periods in Sweden. We find that social capital is positively related to the level of health capital, which supports the theoretical model. Further, we find that the level of social capital (1) declines with age, (2) is lower for those married or cohabiting, and (3) is lower for men than for women.

Differences in health care utilisation and workdays lost between individuals with and without asthma.

The study aims to compare health care utilisation and workdays lost for individuals with and without asthma in Sweden. Individual data on self-perceived asthma problems, self-reported utilisation of outpatient care and official data on inpatient care, and official data on workdays lost was obtained from the HILDA database (health and individuals: longitudinal data and analysis). The study covered 13,000 individuals. Independent t-tests were performed to compare average differences in primary care visits, emergency room visits, days in hospital and workdays lost. Individuals with severe asthma, as compared with the general population, were found to utilise primary care visits, emergency room visits and hospitalisation according to the following ratios: 1.9(:1), 4.9 and 4.3 per year, respectively. For workdays lost the ratio was 1.9. All differences were statistically significant. For individuals reporting mild asthma, no significant differences were found compared with the general population. This finding may be due to the success of asthma management in this population. Both the official data and the self-reported data provided evidence of the burden of asthma to individuals and society. Briefly, self-reported severe asthmatics utilised 2-5 times more resources than the general population, while there were no differences in resource utilisation between self-reported mild asthmatics and the general population.

Employer investments in employee health implications for the family as health producer.

The model presented in this paper further extends the demand-for-health model in which the family is the producer of health investments, to consider the case in which an employer has incentives for investing in the health of a family member. The household and the employer are assumed to interact strategically in the production of health. The general insight provided is that the conditions which determine the nature of the relationship between the employer and the employee, for instance market conditions, production technologies, taxes, and government regulation, will also affect the allocation of health investments and health capital within the family.