Factors associated with development of retinopathy in patients with type 2 diabetes mellitus at onset and within three years after diagnosis.

OBJECTIVE: To investigate the prevalence of diabetes retinopathy and evaluate the factors influencing its occurrence both at the onset of type 2 diabetes (T2D) and three years into its duration. DESIGN: Retrospective population-based study. SETTING: Data was retrieved from Regional Healthcare Information Platform in Region Halland 2016-2020. SUBJECTS: Patients 35-75 years old in Region Halland receiving first-time diabetes diagnosis according to ICD-code E11-14 in 2016-17. The total cohort consisted of 1659 patients. MAIN OUTCOME MEASURES: The main outcome measure of the study was the occurrence of diabetes retinopathy at onset and within three years from the diabetes diagnosis. Multivariate logistic regression analysis was conducted for diabetes retinopathy at onset and within three years, adjusted for age, gender, comorbidities, levels of HbA1c, cholesterol, kidney functional and blood pressure. RESULTS: At onset, there were 12% with diabetes retinopathy and after three years, 32% of the patients had developed diabetes retinopathy. In the study cohort, 71 of patients who were examined with fundus photography within three years after onset, and 8% had had dietary recommendation without pharmacotherapy. High HbA1c levels, blood pressure values and impaired renal function already at onset were associated with development of diabetes retinopathy at onset and this association persisted after three years. The odds ratio for diabetes retinopathy was increased adjusted for HbA1c elevations, renal impairment, and increased blood pressure at index and when adjusted for these variables three years from index. CONCLUSION: These findings indicate that the risk of developing diabetes retinopathy is present early on at onset and within the first three years of diabetes diagnosis. This highlights the importance of promptly regulating glucose- and blood-pressure levels and follow up kidney dysfunction to mitigate the risk of diabetes retinopathy.

Among patients with type 2 diabetes, 12% had developed diabetes retinopathy already at onset.Among patients with type 2 diabetes, one-third had developed diabetes retinopathy after three years from onset.The presence of diabetes retinopathy already at diabetes onset, was associated with elevated HbA1c levels, renal impairment and elevated blood pressure.Diabetes retinopathy three years after the onset of the disease, was associated with increased HbA1c levels, high blood pressure, and renal dysfunction.

Factors affecting hospitalization and mortality in a retrospective study of elderly patients with heart failure.

BACKGROUND: Heart failure (HF) has a high prevalence in an elderly population and leads to a substantial hospitalization and mortality. The objective of this study was to investigate factors that affect hospitalization and mortality in an elderly population. METHODS: A retrospective observational study was conducted of HF patients aged 76-95 years residing in Region Halland, Sweden. Between 2013 and 2019, a total of 3134 patients received a novel diagnosis of HF and were subsequently monitored for one year using data from a healthcare database. The patients were categorized into HF-phenotypes according to ejection fraction (EF) and those with HF diagnose solely based on clinical criteria with no defined EF. Cox regression analysis for hospital admissions and mortality was evaluated adjusted for pharmacotherapies, healthcare utilization and clinical characteristics. RESULTS: Echocardiogram was performed in 56% of the patients and 51% were treated with recommended HF pharmacotherapy with betablockers combined with renin-angiotensin-aldosterone-system inhibition. The average number of inpatient days was 10.7 while the average number of visits to primary care physician was 5.4 and 8.7 to primary care nurse respectively. A Cox regression analysis for hospital admissions and mortality revealed that an eGFR < 30 ml/min was associated with a hazard ratio (HR) of 1.88 (confidence interval [CI] 1.56-2.28), elevated NT-proBNP with an HR of 2.09 (CI 1.59-2.76), diabetes with an HR of 1.31 (CI 1.13-1.52), and chronic obstructive pulmonary disease with an HR of 1.51 (CI 1.29-1.77). Having a primary care physician visit was associated to an HR of 0.16 (CI 0.14-0.19), and the use of recommended heart failure pharmacotherapy was associated with an HR of 0.52 (CI 0.44-0.61). CONCLUSIONS: In a Swedish elderly population with HF, factors such as advancing age, kidney dysfunction, elevated NT-proBNP levels, diabetes, and COPD were associated with an increased risk of both mortality and hospitalization. Conversely, patients who received recommended heart failure treatment and made regular visits to their primary care physician were associated with a decreased risk. This indicates that elderly patients with HF benefit from recommended HF treatment and highlights that follow-ups in primary care could be advantageous.

Factors influencing hospitalization or emergency department visits and mortality in type 2 diabetes following the onset of new cardiovascular diagnoses in a population-based study.

BACKGROUND: Individuals with type 2 diabetes (T2D) are at increased risk of developing cardiovascular disease (CVD) which necessitates monitoring of risk factors and appropriate pharmacotherapy. This study aimed to identify factors predicting emergency department visits, hospitalizations, and mortality among T2D patients after being newly diagnosed with CVD. METHODS: In a retrospective observational study conducted in Region Halland, individuals aged > 40 years with T2D diagnosed between 2011 and 2019, and a new diagnosis of CVD between 2016 and 2019, were followed for one year from the date of CVD diagnosis. The first encounter for CVD diagnosis was categorized as inpatient-, outpatient-, primary-, or emergency department care. Follow-up included laboratory tests, blood pressure, pharmacotherapies, and healthcare utilization. Hazard ratios (HR) in two Cox regression analyses determined relative risks for emergency visits/hospitalization and mortality, adjusting for age, sex, glucose regulation, lipid levels, kidney function, blood pressure, pharmacotherapy, and healthcare utilization. RESULTS: The study included a total of 1759 T2D individuals who received a new CVD diagnosis, with 67% diagnosed during inpatient care. The average hospitalization stay was 6.5 days, and primary care follow-up averaged 10.1 visits. Patients with CVD diagnosed in primary care had a HR 0.52 (confidence interval [CI] 0.35-0.77) for emergency department visits/hospitalization, but age had a HR 1.02 (CI 1.00-1.03). Pharmacotherapy with insulin, DPP4-inhibitors, aldosterone antagonists, and beta-blockers had a raised HR. Highest mortality risk was observed when CVD was diagnosed inpatient care, systolic blood pressure < 100 mm Hg and elevated HbA1c. Age had a HR 1.05 (CI 1.03-1.08), eGFR < 30 ml/min HR 1.46 (CI 1.01-2.11), and LDL-Cholesterol > 2,5 h 1.46 (CI 1.01-2.11) and associated with increased mortality risk. Pharmacotherapy with metformin had a HR 0.41 (CI 0.28-0.62), statins a HR 0.39 (CI 0.27-0.57), and a primary care follow-up < 30 days a HR 0.53 (CI 0.37-0.77) and associated with lower mortality risk. CONCLUSIONS: T2D individuals who had a new diagnosis of CVD were predominantly diagnosed when hospitalized, while follow-up typically occurred in primary care. Identifying factors that predict risks of mortality and hospitalization should be a focus of follow-up care, underscoring the critical role of primary care in the effective management of T2D and CVD.

Elderly patients with non-specific complaints at the emergency department have a high risk for admission and 30-days mortality.

BACKGROUND: Older adults have complex medical needs that causes increased use of resources at the emergency department (ED). The prevalence of non-specific complaint (NSC) as a chief-complaint in the ED is common among older adults and is not prioritized even though possibly having worse clinical outcome. The objective was to study hospital admission and mortality for older adults visiting the ED with NSC compared to specific complaints such as dyspnea, chest pain and abdominal pain. METHODS: A retrospective observational study of older adults visiting the ED with NSC and specific complaints; dyspnea, chest pain and abdominal pain was performed. Chief-complaint were collected from electronic medical records. Fatigue, confusion, non-specific complaints, generalized weakness and risk of falling were defined as non-specific complaint (NSC) when registered as chief-complaint at the ED. Admission rate and 30-days mortality were the primary outcomes. RESULTS: A total of 4927 patients were included in the study based on chief-complaint; patients with chest pain 1599 (32%), dyspnea 1343 (27%), abdominal pain 1460 (30%) and NSC 525 (11%). Patients with dyspnea and NSC had the highest hospital admission rate 79% vs 70% compared to patients with chest pain (63%) and abdominal pain (61%) (p = < 0.001). Patients with NSC had a mean LOS 4.7 h at the ED which was significantly higher compared to chest pain, dyspnea and abdominal pain. Mean bed-days for the whole population was 4.2 days compared to patients with NSC who had a mean LOS of 5.6 days. NSC and dyspnea were both associated with the highest 30-day mortality. CONCLUSION: Older patients who present with NSC at the ED are associated with a high risk for admission and 30-days mortality. In addition, patients with NSC have a longer LOS at the ED, a high admission rate and the highest number of bed-days once admitted. This study indicates that ED staff should be more vigilant when an elderly patient presents with NSC at the ED. Further studies and guidelines are needed to improve the management of these individuals.

Comorbidities in heart failure patients that predict cardiovascular readmissions within 100 days-An observational study.

BACKGROUND: Heart failure (HF) commonly arises as a complication to cardiovascular diseases and is closely associated with various comorbidities. The impacts of these comorbidities in patients with HF are diverse. We aimed to analyze the increased risk for cardiovascular-related readmission within 100 days after discharge in patients with HF depending on their different comorbidities. METHODS: A population-based retrospective study was conducted in Region Halland with 5029 patients admitted to hospital with a diagnosis of HF during 2017-2019. The occurrence and number of comorbidities were recorded. Competing risk regression was employed to analyze the hazard ratio (HR) of 10 comorbidities for cardiovascular-related readmission within 100 days after discharge. A composite measure of the 10 common comorbidities was constructed with the comorbidities as dichotomous indicator variables and Rasch analysis. Receiver operating characteristic (ROC) and area under curve (AUC) after logistic regression were used to estimate how well the model explained the probability of death or readmission within 100 days after discharge according to their individual comorbidity level. RESULTS: HF patients with atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, peripheral artery disease or diabetes mellitus as comorbidities had an increased HR for readmission within 100 days after discharge. When these comorbidities were adjusted together, only atrial fibrillation, chronic kidney disease and chronic obstructive pulmonary disease had an increased HR for readmission. ROC analysis after the most complete models using logistic regression with the comorbidities as dichotomous indicator variables or Rasch analysis had a low AUC. CONCLUSIONS: Atrial fibrillation, chronic kidney disease or chronic obstructive pulmonary disease were significantly associated with increased risk for readmission in HF patients, but ROC analysis showed a low AUC, which indicates that other factors are more important for predicting the increased risk of readmission.

Heart failure patients without echocardiography are more commonly diagnosed in hospital care and are associated with higher mortality compared to primary care.

OBJECTIVE: This Swedish study aimed to assess the prevalence, associated clinical factors, and mortality rates of heart failure patients diagnosed without echocardiograms in both hospital and primary care settings. DESIGN: We conducted a retrospective population-based study using data from the Region Halland healthcare database in Sweden covering 330,000 residents. SUBJECTS: From 2013-2019, 3,903 patients received an incidental heart failure diagnosis without an echocardiogram and they were followed for one year. MAIN OUTCOME MEASURES: Using logistic and Cox regression analyses, we evaluated the prevalence, clinical characteristics, and all-cause mortality at intervals of 30, 100, and 365 days post-diagnosis. RESULTS: In this Swedish cohort, the one-year all-cause mortality rate was markedly higher for patients diagnosed in hospitals (42%) compared to those in primary care (20%, p < 0.001). Patients diagnosed in primary care were older and had fewer comorbidities and lower NT-proBNP levels. Hospital-diagnosed patients faced a significantly higher mortality rate in the initial 30 days but saw similar rates to primary care patients thereafter. CONCLUSION: In a Swedish region, heart failure diagnoses without echocardiograms were more common in hospitals, and these patients initially faced worse prognoses. After the first month, however, the prognosis of hospital-diagnosed patients mirrored that of those diagnosed in primary care. These findings emphasize the need for improved diagnostic and treatment approaches in both care settings to enhance outcomes.

In a Swedish study, 58% of heart failure patients diagnosed without an echocardiogram were identified in a hospital setting. Patients diagnosed in primary care were generally older with fewer comorbidities and lower NT-proBNP levels. The first-year post-diagnosis mortality rate was higher for patients diagnosed in hospitals (42%) compared to those diagnosed in primary care (20%).Despite a higher initial mortality for hospital-diagnosed patients, the rates became comparable with primary care diagnoses after the first month.

The Price of Explainability in Machine Learning Models for 100-Day Readmission Prediction in Heart Failure: Retrospective, Comparative, Machine Learning Study.

BACKGROUND: Sensitive and interpretable machine learning (ML) models can provide valuable assistance to clinicians in managing patients with heart failure (HF) at discharge by identifying individual factors associated with a high risk of readmission. In this cohort study, we delve into the factors driving the potential utility of classification models as decision support tools for predicting readmissions in patients with HF. OBJECTIVE: The primary objective of this study is to assess the trade-off between using deep learning (DL) and traditional ML models to identify the risk of 100-day readmissions in patients with HF. Additionally, the study aims to provide explanations for the model predictions by highlighting important features both on a global scale across the patient cohort and on a local level for individual patients. METHODS: The retrospective data for this study were obtained from the Regional Health Care Information Platform in Region Halland, Sweden. The study cohort consisted of patients diagnosed with HF who were over 40 years old and had been hospitalized at least once between 2017 and 2019. Data analysis encompassed the period from January 1, 2017, to December 31, 2019. Two ML models were developed and validated to predict 100-day readmissions, with a focus on the explainability of the model's decisions. These models were built based on decision trees and recurrent neural architecture. Model explainability was obtained using an ML explainer. The predictive performance of these models was compared against 2 risk assessment tools using multiple performance metrics. RESULTS: The retrospective data set included a total of 15,612 admissions, and within these admissions, readmission occurred in 5597 cases, representing a readmission rate of 35.85%. It is noteworthy that a traditional and explainable model, informed by clinical knowledge, exhibited performance comparable to the DL model and surpassed conventional scoring methods in predicting readmission among patients with HF. The evaluation of predictive model performance was based on commonly used metrics, with an area under the precision-recall curve of 66% for the deep model and 68% for the traditional model on the holdout data set. Importantly, the explanations provided by the traditional model offer actionable insights that have the potential to enhance care planning. CONCLUSIONS: This study found that a widely used deep prediction model did not outperform an explainable ML model when predicting readmissions among patients with HF. The results suggest that model transparency does not necessarily compromise performance, which could facilitate the clinical adoption of such models.

Experiences of Heart Failure and the Treatment Journey: A Mixed-Methods Study Among Patients with Heart Failure in Sweden.

Purpose: Qualitative studies that highlight the patient perspective of heart failure (HF) and its impact on the lives of patients are limited. Our study objective was to describe the patient's perspective on HF, including the diagnosis, treatment journey and healthcare interactions, and how HF impacts patients' lives and specifically their health-related quality of life (HRQoL) and work capacity. Patients and Methods: This cross-sectional, non-interventional, mixed-methods patient experience study comprised: (i) a quantitative online survey with study-specific questions and assessments of HRQoL and work impairment among 101 patients with HF in Sweden and (ii) 35 qualitative interviews to gain in-depth understanding of the patients' experiences. Results: Patients were found to experience a highly symptomatic and detrimental impact of HF on their HRQoL and work capacity. Fatigue was the most frequently reported symptom, and it was detrimental to all areas of patients' lives limiting them mentally, socially, and physically. Two-thirds of patients were not aware of the type of HF they had, one-third did not check their body weight regularly, and around half did not increase their physical exercise as recommended by both guidelines and healthcare practitioners. Patients preferred specialist to primary care, desired greater access to healthcare, and continuity in whom they interact with in primary care. Conclusion: Patients with HF experience a highly symptomatic burden that affects them physically, mentally, and socially. Our study highlights a major gap in patients' knowledge about HF and HF-related healthcare. These results demonstrate a challenge for the Swedish healthcare system particularly as regards providing patients with continuity, accessibility, and proximity to primary care.

Characteristics, management and outcomes in patients with CKD in a healthcare region in Sweden: a population-based, observational study.

OBJECTIVES: To describe chronic kidney disease (CKD) regarding treatment rates, comorbidities, usage of CKD International Classification of Diseases (ICD) diagnosis, mortality, hospitalisation, evaluate healthcare utilisation and screening for CKD in relation to new nationwide CKD guidelines. DESIGN: Population-based observational study. SETTING: Healthcare registry data of patients in Southwest Sweden. PARTICIPANTS: A total cohort of 65 959 individuals aged >18 years of which 20 488 met the criteria for CKD (cohort 1) and 45 470 at risk of CKD (cohort 2). PRIMARY AND SECONDARY OUTCOME MEASURES: Data were analysed with regards to prevalence, screening rates of blood pressure, glucose, estimated glomerular filtration rate (eGFR), Urinary-albumin-creatinine ratio (UACR) and usage of ICD-codes for CKD. Mortality and hospitalisation were analysed with logistic regression models. RESULTS: Of the CKD cohort, 18% had CKD ICD-diagnosis and were followed annually for blood pressure (79%), glucose testing (76%), eGFR (65%), UACR (24%). UACR follow-up was two times as common in hypertensive and cardiovascular versus diabetes patients with CKD with a similar pattern in those at risk of CKD. Statin and renin-angiotensin-aldosterone inhibitor appeared in 34% and 43%, respectively. Mortality OR at CKD stage 5 was 1.23 (CI 0.68 to 0.87), diabetes 1.20 (CI 1.04 to 1.38), hypertension 1.63 (CI 1.42 to 1.88), atherosclerotic cardiovascular disease (ASCVD) 1.84 (CI 1.62 to 2.09) associated with highest mortality risk. Hospitalisation OR in CKD stage 5 was 1.96 (CI 1.40 to 2.76), diabetes 1.15 (CI 1.06 to 1.25), hypertension 1.23 (CI 1.13 to 1.33) and ASCVD 1.52 (CI 1.41 to 1.64). CONCLUSIONS: The gap between patients with CKD by definition versus those diagnosed as such was large. Compared with recommendations patients with CKD have suboptimal follow-up and treatment with renin-angiotensin-aldosterone system inhibitor and statins. Hypertension, diabetes and ASCVD were associated with increased mortality and hospitalisation. Improved screening and diagnosis of CKD, identification and management of risk factors and kidney protective treatment could affect clinical and economic outcomes.

Prognosis and mortality within 90 days in community-acquired acute kidney injury in the Southwest of Sweden.

BACKGROUND: Community-acquired acute kidney injury (CA-AKI) is common among hospitalized patients and has a poor prognosis. Research is scarce on the impact of a CA-AKI episode among patients without preexisting kidney disease and has not previously been investigated in Sweden. The aim was to describe the outcomes of patients with normal pre-hospitalization kidney function, admitted with community-acquired AKI and to investigate the association between AKI severity with outcomes. METHODS: A retrospective population-based study was applied including patients with CA-AKI according to KDIGO classification, admitted via emergency department (ED) 2017-2019 and with a 90-day follow-up period from the ED-admission, collecting data from the Regional Healthcare Informative Platform. Age, gender and AKI stages, mortality and follow-up regarding recovery and readmission was registered. Hazard ratio (HR) and 95% confidence Interval (CI) for mortality was analyzed using Cox regression adjusted for age, comorbidities, and medication. RESULTS: There were 1646 patients included, mean age was 77.5 years. CA-AKI stage 3 occurred in 51% of patients < 65 years of age and 34% among those > 65 years. In this study, 578 (35%) patients died and 233 (22%) recovered their kidney function. Mortality rate peaked within the first two weeks and among those at AKI stage 3. Nephrology referral post discharge occurred in 3% and 29% were readmitted. HRs for mortality was 1.9 (CI 1.38-2.62) for those who are > 65 years, 1.56 (CI 1.30-1.88) for atherosclerotic-cardiovascular disease. Medication with RAASi related to a decreased HR 0.27 (95% CI 0.22-0.33). CONCLUSIONS: CA-AKI is associated with high mortality within 90 days, increased risk for developing chronic kidney disease (CKD) and only one fifth recover their kidney function after hospitalization with an AKI. Nephrology referral was sparse. Patient follow-up after a hospitalization with AKI should be carefully planned during the first 90 days and focused on identifying those with a higher risk of developing CKD.

Observational study of diagnosis and management in adult primary hypothyroidism in southwest of Sweden.

OBJECTIVE: The objective was to explore the management of newly diagnosed hypothyroidism in adults regarding laboratory diagnostics and treatment in Region Halland (RH). In addition, to investigate whether current recommendations were followed regarding diagnostics. DESIGN: Retrospective observational study. SETTING: A population-based study utilizing healthcare registry data from all public primary health care (PHC) clinics in RH during 2014-2019. SUBJECTS: Newly diagnosed patients with hypothyroidism according to ICD-10, aged ≥18 years when diagnosed and living and receiving health care in RH. There were 2494 patients included in the study. MAIN OUTCOME MEASURES: Registrations of thyroid laboratory values, diagnostic codes, and drug treatment was collected. Demographic data were also recorded. Laboratory values were checked also after 12-24 months after initial diagnosis. The main outcome was the proportion with elevated TSH and TPO and how the TSH value had changed at the follow-up. RESULTS: There were 1431 (61%) patients who had elevated TSH at the onset of the disease and TPO was tested in 1133 (46%) of the patients. Elevated TPO was found in 566 (23%) of the patients. After one year, there were 1908 (76%) patients who obtained a prescription for levothyroxine. In 1127 (45%) patients, TSH had normalized within one year. CONCLUSION: There were 39% of the patients diagnosed with hypothyroidism despite normal or subclinical TSH. There was an underuse of TPO in diagnosis and this advocated that the criteria for diagnostics according to current guidelines be followed to avoid unnecessary treatment.

One third were diagnosed with hypothyroidism despite normal thyroid blood tests at onset.Thyroid peroxidase antibodies were used in less than half of the patients diagnosed for hypothyroidism at onset.Less than half of the patients had improved TSH level despite high medication ratio after one year.

Clinical characteristics at hospital discharge that predict cardiovascular readmission within 100 days in heart failure patients - An observational study.

Background: After a heart failure (HF) hospital discharge, the risk of a cardiovascular (CV) related event is highest in the following 100 days. It is important to identify factors associated with increased risk of readmission. Method: This retrospective, population-based study examined HF patients in Region Halland (RH), Sweden, hospitalized with a HF diagnosis between 2017 and 2019. Data regarding patient clinical characteristics were retrieved from the Regional healthcare Information Platform from admission until 100 days post-discharge. Primary outcome was readmission due to a CV related event within 100 days. Results: There were 5029 included patients being admitted for HF and discharged and 1966 (39%) were newly diagnosed. Echocardiography was available for 3034 (60%) patients and 1644 (33%) had their first echocardiography while admitted. The distribution of HF-phenotypes was 33% HF with reduced ejection fraction (EF), 29% HF with mildly reduced EF and 38% HF with preserved EF. Within 100 days, 1586 (33%) patients were readmitted, and 614 (12%) died. A Cox regression model showed that advanced age, longer hospital length of stay, renal impairment, high heart rate and elevated NT-proBNP were associated with an increased risk of readmission regardless of HF-phenotype. Women and increased blood pressure are associated with a reduced risk of readmission. Conclusions: One third had a CV-readmission within 100 days. This study found clinical factors already present at discharge that are associated with increased risk of readmission which should be considered at discharge.

Patterns and Predictors Associated With Long-Term Glycemic Control in Pediatric and Young Adult Patients with Type 1 Diabetes.

BACKGROUND: The development of diabetes technology is rapid and requires education and resources to be successfully implemented in diabetes care management. METHOD: In an observational study, we evaluated the use of advanced diabetes technology, resource utilization, and glycemic control. The study population was 725 individuals with type 1 diabetes (T1D) living in Region Halland, Sweden. The study cohort was followed for 7 years between 2013 and 2019. RESULTS: Children aged 0 to 17 years were associated with significantly better glucose control than young adults aged 18 to 25 years. The mean HbA1c in children and young adults was 53 mmol/mol (7.0%) compared to 61 mmol/mol (7.7%) (P < .0001), respectively. Comorbidities such as attention deficit hyperactivity disorder (ADHD), autism, and coelic disease were associated with higher HbA1c. All groups, regardless of age and comorbidity, showed a positive effect on glucose control after visiting a dietitian or psychologist. Differences were found between the age groups in terms of more use of advanced diabetes technology and more frequent visits to a physician in children compared to young adults. CONCLUSIONS: More frequent visits to physicians, and a visit to dietitians, and psychologists were associated with improved glucose control in individuals with T1D 0 to 25 years. Increased resources, including access to more advanced technologies, may be required in young adults with T1D.

Clinical characteristics and mortality of patients with heart failure in Southern Sweden from 2013 to 2019: a population-based cohort study.

OBJECTIVES: To describe clinical characteristics and prognosis related to heart failure (HF) phenotypes in a community-based population by applying a novel algorithm to obtain ejection fractions (EF) from electronic medical records. DESIGN: Retrospective population-based cohort study. SETTING: Data were collected for all patients with HF in Southwest Sweden. The region consists of three acute care hospitals, 40 inpatient wards, 2 emergency departments, 30 outpatient specialty clinics and 48 primary healthcare. PARTICIPANTS: 8902 patients had an HF diagnosis based on the International Classification of Diseases, Tenth Revision during the study period. Patients <18 years as well as patients declining to participate were excluded resulting in a study population of 8775 patients. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was distribution of HF phenotypes by echocardiography. The secondary outcome measures were 1 year all-cause mortality and HR for all-cause mortality using Cox regression models. RESULTS: Out of 8775 patients with HF, 5023 (57%) had a conclusive echocardiography distributed into HF with reduced EF (35%), HF with mildly reduced EF (27%) and HF with preserved EF (38%). A total of 43% of the cohort did not have a conclusive echocardiography, and therefore no defined phenotype (HF-NDP). One-year all-cause mortality was 42% within the HF-NDP group and 30% among those with a conclusive EF. The HR of all-cause mortality in the HF-NDP group was 1.27 (95% CI 1.17 to 1.37) when compared with the confirmed EF group. There was no significant difference in survival within the HF phenotypes. CONCLUSIONS: This population-based study showed a distribution of HF phenotypes that varies from those in selected HF registries, with fewer patients with HF with reduced EF and more patients with HF with preserved EF. Furthermore, 1-year all-cause mortality was significantly higher among patients with HF who had not undergone a conclusive echocardiography at diagnosis, highlighting the importance of correct diagnostic procedure to improve treatment strategies and outcomes.

Receiving care according to national heart failure guidelines is associated with lower total costs: an observational study in Region Halland, Sweden.

AIMS: Patients with heart failure (HF) have high costs, morbidity, and mortality, but it is not known if appropriate pharmacotherapy (AP), defined as compliance with international evidence-based guidelines, is associated with improved costs and outcomes. The purpose of this study was to evaluate HF patients' health care utilization, cost and outcomes in Region Halland (RH), Sweden, and if AP was associated with lower costs. METHODS AND RESULTS: A total of 5987 residents of RH in 2016 carried HF diagnoses. Costs were assigned to all health care utilization (inpatient, outpatient, emergency department, primary health care, and medications) using a Patient Encounter Costing methodology. Care of HF patients cost €58.6 M, (€9790/patient) representing 8.7% of RH's total visit expenses and 14.9% of inpatient care (IPC) expenses. Inpatient care represented 57.2% of this expenditure, totalling €33.5 M (€5601/patient). Receiving AP was associated with significantly lower costs, by €1130 per patient (P < 0.001, 95% confidence interval 574-1687). Comorbidities such as renal failure, diabetes, chronic obstructive pulmonary disease, and cancer were significantly associated with higher costs. CONCLUSION: Heart failure patients are heavy users of health care, particularly IPC. Receiving AP is associated with lower costs even adjusting for comorbidities, although causality cannot be proven from an observational study. There may be an opportunity to decrease overall costs and improve outcomes by improving prescribing patterns and associated high-quality care.

Resource use and cost implications of implementing a heart failure program for patients with systolic heart failure in Swedish primary health care.

AIM: Heart failure (HF) is a common but serious condition which involves a significant economic burden on the health care economy. The purpose of this study was to evaluate cost and quality of life (QoL) implications of implementing a HF management program (HFMP) in primary health care (PHC). METHODS AND RESULTS: This was a prospective randomized open-label study including 160 patients with a diagnosis of HF from five PHC centers in south-eastern Sweden. Patients randomized to the intervention group received information about HF from HF nurses and from a validated computer-based awareness program. HF nurses and physicians followed the patients intensely in order to optimize HF treatment according to current guidelines. The patients in the control group were followed by their regular general practitioner (GP) and received standard treatment according to local management routines. No significant changes were observed in NYHA class and quality-adjusted life years (QALY), implying that functional class and QoL were preserved. However, costs for hospital care (HC) and PHC were reduced by EUR 2167, or 33%. The total cost was EUR 4471 in the intervention group and EUR 6638 in the control group. CONCLUSIONS: Introducing HFMP in Swedish PHC in patients with HF entails a significant reduction in resource utilization and costs, and maintains QoL. Based on these results, a broader implementation of HFMP in PHC may be recommended. However, results should be confirmed with extended follow-up to verify long-term effects.

The benefits of using a heart failure management programme in Swedish primary healthcare.

AIM: Heart failure (HF) is a common condition with which high mortality, morbidity, and poor quality of life are associated. It has previously been shown that use of HF management programmes (HFMPs) in HF clinics can be beneficial. The purpose of this study was to evaluate if the use of HFMPs also has beneficial effects on HF patients in primary healthcare (PHC). METHODS AND RESULTS: This is a randomized, prospective, open-label study including 160 patients from five PHC centres with systolic HF and a mean age of 75 years (standard deviation 7.8). In the intervention group, an intensive follow-up was performed by HF nurses and physicians providing information and education about HF and the optimization of HF treatment according to recognized guidelines. There was a significant improvement of composite endpoints in the intervention group. Significantly more patients with reduced N-terminal pro brain natriuretic peptide (P = 0.012), improved cardiac function (P = 0.03), fewer healthcare contacts (P = 0.04), and fewer emergency room visits and admittances (P = 0.0002 and P = 0.03, respectively) could be seen in the intervention group when compared with the control group. CONCLUSIONS: The use of a HFMP in a PHC setting was found to have beneficial effects in terms of reducing the number of healthcare contacts and hospital admissions, and improving cardiac function in patients with systolic HF, even if the result should be interpreted with caution. It can therefore be recommended that HFMPs should be used in PHC.

Cost of heart failure in Swedish primary healthcare.

OBJECTIVES: To calculate the cost for patients with heart failure (HF) in a primary healthcare setting. DESIGN: Retrospective study of all available patient data during a period of one year. SETTING: Two healthcare centers in Linköping in the southeastern region of Sweden, covering a population of 19 400 inhabitants. SUBJECTS: A total of 115 patients with a diagnosis of HF. MAIN OUTCOME MEASURES: The healthcare costs for patients with HF and the healthcare utilization concerning hospital days and visits to doctors and nurses in hospital care and primary healthcare. RESULTS: The mean annual cost for a patient with HF was SEK 37 100. There were no significant differences in cost between gender, age, New York Heart Association functional class, and cardiac function. The distribution of cost was 47% for hospital care, 22% for primary healthcare, 18% for medication, 5% for nursing home, and 6% for examinations. CONCLUSION: Hospital care accounts for the largest cost but the cost in primary healthcare is larger than previously shown. The total annual cost for patients with HF in Sweden is in the range of SEK 5.0-6.7 billion according to this calculation, which is higher than previously known.