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 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.

Importance of kidney function, number of chronic conditions and medications for hospitalisation in elderly in Blekinge County, Sweden: a case-control study.

OBJECTIVES: To study the association between risk for hospitalisation in an elderly population related to renal function, number of chronic diseases and number of prescribed drugs. DESIGN: A case-control study. Persons hospitalised were included and their controls were obtained from electronic hospital medical records. If data were lacking on creatinine levels, multiple imputation was used. SETTING: Blekinge County in southwestern Sweden. PARTICIPANTS: Study of individuals aged 75 years or older in 2013. We identified a total of 2,941 patients with a first hospitalisation. Of these, 81 were excluded, 78 due to incomplete data and 3 because of lack of control persons. Controls were matched to the same sex and birth year, which resulted in 5720 persons. PRIMARY AND SECONDARY OUTCOME MEASURES: To analyse the OR for hospitalisation conditional logistic regression was used. RESULTS: A total of 695 persons lacked creatinine value. Using imputation values comparing persons with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 with ≥30 univariate analyses showed an increased OR 2.35 (95% CI 1.83 to 3.03). Adjusted analyses demonstrated an OR of 1.90 (95% CI 1.46 to 2.47). Comparing eGFR<45 mL/min/1.73 m2 against ≥45 univariate analyses showed OR 1.38 (95% CI 1.22 to 1.57). Adjusted analyses OR for the same group were 1.17 (95% CI 1.03 to 1.33). In both models, the OR for five or more chronic conditions and five or more medications showed a statistically increased risk for hospitalisation. CONCLUSIONS: There is a need for systems using data collected in routine care to follow elderly patients to minimise avoidable hospitalisations that can cause adverse effects. Renal function, number of chronic conditions and medications are factors that are of significant importance. This study demonstrates the complexity of this patient group.

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.

Associations of heart failure to prevalence of haematologic- and solid malignancies in southern Sweden: A cross-sectional study.

BACKGROUND: Heart failure (HF) and cancer are common diseases among the elderly population. Many chronic diseases, including diabetes mellitus (DM), share risk factors and increase the incidence of HF and cancer. The aim of this study was to investigate if there was an association between HF and the prevalence of haematologic- and solid malignancies. METHODS: The study population was comprised of almost one million adults living in southern Sweden in 2015. All participants were divided into seven age groups from 20 and onwards, and 10 percentiles according to their socioeconomic status (SES). All data concerning diagnoses from each consultation in both primary- and secondary health care were collected during 18 months. The prevalence of haematologic and solid malignancies was measured separately for men and women, age groups, SES and multimorbidity levels. Multivariable logistic regression was used to determine the associations between HF and the probability of having haematologic- and solid malignancies in more complex models including stratifying variables. RESULTS: People with HF had a higher prevalence of haematologic- and solid malignancies than the general population, but a lower prevalence of solid malignancies than the multimorbid population. The people with HF had an increased OR for haematologic malignancies, 1.69 (95% CI 1.51-1.90), and solid malignancies, OR 1.21 (95% CI 1.16-1.26), when adjusted for gender and age. In more complex multivariate models, multimorbidity explained the increased OR for haematologic- and solid malignancies in people with HF. Increasing socioeconomic deprivation was associated with a decreased risk for solid malignancies, with the lowest risk in the most socioeconomically deprived CNI-percentile. CONCLUSIONS: HF was shown to be associated with malignancies, especially haematologic malignancies. Multimorbidity, however, was an even more important factor for both haematologic- and solid malignancies than HF in our study, but not socioeconomic deprivation. Further research on the interactions between the chronic conditions in people with HF is warranted to examine the strength of association between HF and malignancies.

Familial aggregation of multimorbidity in Sweden: national explorative family study.

Objectives: To examine whether multimorbidity aggregates in families in Sweden. Design: National explorative family study. Setting: Swedish Multigeneration Register linked to the National Patient Register, 1997-2015. Multimorbidity was assessed with a modified counting method of 45 chronic non-communicable diseases according to ICD-10 (international classification of diseases, 10th revision) diagnoses. Participants: 2 694 442 Swedish born individuals (48.73% women) who could be linked to their Swedish born first, second, and third degree relatives. Twins were defined as full siblings born on the same date. Main outcome measures: Multimorbidity was defined as two or more non-communicable diseases. Familial associations for one, two, three, four, and five or more non-communicable diseases were assessed to examine risks depending on the number of non-communicable diseases. Familial adjusted odds ratios for multimorbidity were calculated for individuals with a diagnosis of multimorbidity compared with relatives of individuals unaffected by multimorbidity (reference). An initial principal component decomposition followed by a factor analysis with a principal factor method and an oblique promax rotation was used on the correlation matrix of tetrachoric correlations between 45 diagnoses in patients to identify disease clusters. Results: The odds ratios for multimorbidity were 2.89 in twins (95% confidence interval 2.56 to 3.25), 1.81 in full siblings (1.78 to 1.84), 1.26 in half siblings (1.24 to 1.28), and 1.13 in cousins (1.12 to 1.14) of relatives with a diagnosis of multimorbidity. The odds ratios for multimorbidity increased with the number of diseases in relatives. For example, among twins, the odds ratios for multimorbidity were 1.73, 2.84, 4.09, 4.63, and 6.66 for an increasing number of diseases in relatives, from one to five or more, respectively. Odds ratios were highest at younger ages: in twins, the odds ratio was 3.22 for those aged ≤20 years, 3.14 for those aged 21-30 years, and 2.29 for those aged >30 years at the end of follow-up. Nine disease clusters (factor clusters 1-9) were identified, of which seven aggregated in families. The first three disease clusters in the principal component decomposition were cardiometabolic disease (factor 1), mental health disorders (factor 2), and disorders of the digestive system (factor 3). Odds ratios for multimorbidity in twins, siblings, half siblings, and cousins for the factor 1 cluster were 2.79 (95% confidence interval 0.97 to 8.06), 2.62 (2.39 to 2.88), 1.52 (1.34 to 1.73), and 1.31 (1.23 to 1.39), and for the factor 2 cluster, 5.79 (4.48 to 7.48) 3.24 (3.13 to 3.36), 1.51 (1.45 to 1.57), and 1.37 (1.341.40). Conclusions: The results of this explorative family study indicated that multimorbidity aggregated in Swedish families. The findings suggest that map clusters of diseases should be used for the genetic study of common diseases to show new genetic patterns of non-communicable diseases.

A hypothesis - generating Swedish extended national cross-sectional family study of multimorbidity severity and venous thromboembolism.

OBJECTIVES: Venous thromboembolism (VTE) is a common worldwide disease. The burden of multimorbidity, that is, two or more chronic diseases, has increased. Whether multimorbidity is associated with VTE risk remains to be studied. Our aim was to determine any association between multimorbidity and VTE and any possible shared familial susceptibility. DESIGN: A nationwide extended cross-sectional hypothesis - generating family study between 1997 and 2015. SETTING: The Swedish Multigeneration Register, the National Patient Register, the Total Population Register and the Swedish cause of death register were linked. PARTICIPANTS: 2 694 442 unique individuals were analysed for VTE and multimorbidity. MAIN OUTCOMES AND MEASURES: Multimorbidity was determined by a counting method using 45 non-communicable diseases. Multimorbidity was defined by the occurrence of ≥2 diseases. A multimorbidity score was constructed defined by 0, 1, 2, 3, 4 or 5 or more diseases. RESULTS: Sixteen percent (n=440 742) of the study population was multimorbid. Of the multimorbid patients, 58% were females. There was an association between multimorbidity and VTE. The adjusted odds ratio (OR) for VTE in individuals with multimorbidity (2 ≥ diagnoses) was 3.16 (95% CI: 3.06 to 3.27) compared with individuals without multimorbidity. There was an association between number of diseases and VTE. The adjusted OR was 1.94 (95% CI: 1.86 to 2.02) for one disease, 2.93 (95% CI: 2.80 to 3.08) for two diseases, 4.07 (95% CI: 3.85 to 4.31) for three diseases, 5.46 (95% CI: 5.10 to 5.85) for four diseases and 9.08 (95% CI: 8.56 to 9.64) for 5 ≥ diseases. The association between multimorbidity and VTE was stronger in males OR 3.45 (3.29 to 3.62) than in females OR 2.91 (2.77 to 3.04). There were significant but mostly weak familial associations between multimorbidity in relatives and VTE. CONCLUSIONS: Increasing multimorbidity exhibits a strong and increasing association with VTE. Familial associations suggest a weak shared familial susceptibility. The association between multimorbidity and VTE suggests that future cohort studies where multimorbidity is used to predict VTE might be worthwhile.

Disparities in prevalence of heart failure between the genders in relation to age, multimorbidity and socioeconomic status in southern Sweden: a cross-sectional study.

OBJECTIVE: Prior studies have reported that heart failure typically affects elderly, multimorbid and socioeconomically deprived men. Women with heart failure are generally older, have a higher EF (ejection fraction) and have more heart failure-related symptoms than men. This study explored the disparities in the prevalence of heart failure between men and women in relation to age, multimorbidity level and socioeconomic status of the population in southern Sweden. DESIGN: A register-based, cross-sectional cohort study.Setting and subjects: The inhabitants from 20 years of age onwards (N = 981,383) living in southern Sweden in 2015.Main outcome measure: Prevalence and mean probability of having heart failure in both genders. CNI (Care Need Index) percentiles depend on the socioeconomic status of their listed primary healthcare centres. RESULTS: Men had a higher OR for HF - 1.70 (95% CI 1.65-1.75) - than women. The probability of men having heart failure increased significantly compared to women with advancing age and multimorbidity levels. At all CNI levels, the multimorbid patients had a higher prevalence of heart failure in men than in women. The disparity in the mean probability of heart failure between the most affluent and deprived CNI percentile was more apparent in women compared to men, especially from 80 years. CONCLUSIONS: The prevalence of heart failure differs significantly between the genders. Men had an increasing mean probability of heart failure with advancing age and multimorbidity level compared to women. Socioeconomic deprivation was more strongly associated with heart failure in women than in men. The probability of having heart failure differs between the genders in several aspects.Key PointsIndependently of socioeconomic status, men had a higher prevalence of heart failure than women among the multimorbid patients.The mean probability of men having heart failure increased significantly compared to women with advancing age and multimorbidity level.Socioeconomic status was more strongly associated with heart failure in women than in men.

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.

The role of primary care in the cancer care continuum: a qualitative study of cancer survivors' experiences.

OBJECTIVE: To explore how cancer survivors have experienced their contacts with primary care after being diagnosed with cancer, focusing on the integration between cancer specialist and primary care, and participants' views on what could make primary care services better at catering to the needs of cancer survivors. DESIGN: A qualitative study in which data was collected through semi-structured digital focus group interviews and analyzed using a template analysis approach. SETTING AND SUBJECTS: Adult residents of Skåne, Sweden, who had been diagnosed with and initiated treatment for either of five common cancer forms, recruited through patient advocacy groups. MAIN OUTCOME MEASURES: A qualitative description of participants' experiences and perceptions as expressed in focus group interview data. RESULTS: Most participants felt that primary care services had not played a significant role for them, despite patterns of both increased and unmet health needs. Insufficient coordination and communication with specialist cancer care, low availability, lacking personal continuity, low cancer competence and lacking commitment to cancer-related needs were presented as barriers to satisfactory primary care. A strengthened bond between cancer and primary care services, privileged access, and holistic perspectives were all suggested as measures to make primary care more suitable to cancer survivors' needs. CONCLUSION: The study suggests that cancer survivors experience a range of issues that hinders primary care services from playing a productive role in the cancer care process. The results speak for a need for interventions to remove barriers to satisfactory primary care contacts in this group of patients.KEY POINTSThe growing number of cancer survivors highlights the role of primary care services in the cancer care continuum.Despite the presence of unmet needs, few cancer survivors felt that primary care services had been significant to their care.Survivors identified a number of barriers to satisfactory primary care, including lacking coordination and communication between cancer and primary care.Strengthened links between healthcare services, privileged access, and holistic perspectives were suggested to improve primary care delivery for cancer survivors.

Disparities in prevalence of heart failure according to age, multimorbidity level and socioeconomic status in southern Sweden: a cross-sectional study.

OBJECTIVE: The aim of this study was to compare the prevalence of heart failure (HF) in relation to age, multimorbidity and socioeconomic status of primary healthcare centres in southern Sweden. DESIGN: A cross-sectional study. SETTING: The data were collected concerning diagnoses at each consultation in all primary healthcare centres and secondary healthcare in the southernmost county of Sweden at the end of 2015. PARTICIPANTS: The individuals living in southern Sweden in 2015 aged 20 years and older. The study population of 981 383 inhabitants was divided into different categories including HF, multimorbidity, different levels of multimorbidity and into 10 CNI (Care Need Index) groups depending on the socioeconomic status of their listed primary healthcare centre. OUTCOMES: Prevalence of HF was presented according to age, multimorbidity level and socioeconomic status. Logistic regression was used to further analyse the associations between HF, age, multimorbidity level and socioeconomic status in more complex models. RESULTS: The total prevalence of HF in the study population was 2.06%. The prevalence of HF increased with advancing age and the multimorbidity level. 99.07% of the patients with HF fulfilled the criteria for multimorbidity. The total prevalence of HF among the multimorbid patients was only 5.30%. HF had a strong correlation with the socioeconomic status of the primary healthcare centres with the most significant disparity between 40 and 80 years of age: the prevalence of HF in primary healthcare centres with the most deprived CNI percentile was approximately twice as high as in the most affluent CNI percentile. CONCLUSION: The patients with HF were strongly associated with having multimorbidity. HF patients was a small group of the multimorbid population associated with socioeconomic deprivation that challenges efficient preventive strategies and health policies.

Advanced Dental Cleaning is Associated with Reduced Risk of COPD Exacerbations - A Randomized Controlled Trial.

PURPOSE: Infections from the oral microbiome may lead to exacerbations of chronic obstructive pulmonary disease (COPD). We investigated whether advanced dental cleaning could reduce exacerbation frequency. Secondary outcomes were disease-specific health status, lung function, and whether the bacterial load and composition of plaque microbiome at baseline were associated with a difference in outcomes. PATIENTS AND METHODS: One-hundred-one primary and secondary care patients with COPD were randomized to intervention with advanced dental cleaning or to dental examination only, repeated after six months. At baseline and at 12 months, data of exacerbations, lung function, COPD Assessment Test (CAT) score, and periodontal status were collected from questionnaires, record review, and periodontal examination. Student's t-test and Mann-Whitney-U (MWU) test compared changes in outcomes. The primary outcome variable was also assessed using multivariable linear regression with adjustment for potential confounders. Microbiome analyses of plaque samples taken at baseline were performed using Wilcoxon signed ranks tests for calculation of alpha diversity, per mutational multivariate analysis of variance for beta diversity, and receiver operating characteristic curves for prediction of outcomes based on machine learning models. RESULTS: In the MWU test, the annual exacerbation frequency was significantly reduced in patients previously experiencing frequent exacerbations (p = 0.020) and in those with repeated advanced dental cleaning (p = 0.039) compared with the non-treated control group, but not in the total population including both patients with a single and repeated visits (p = 0.207). The result was confirmed in multivariable linear regression, where the risk of new exacerbations was significantly lower in patients both in the intention to treat analysis (regression coefficient 0.36 (95% CI 0.25-0.52), p < 0.0001) and in the population with repeated dental cleaning (0.16 (0.10-0.27), p < 0.0001). The composition of microbiome at baseline was moderately predictive of an increased risk of worsened health status at 12 months (AUC = 0.723). CONCLUSION: Advanced dental cleaning is associated with a reduced frequency of COPD exacerbations. Regular periodontal examination and dental cleaning may be of clinical importance to prevent COPD exacerbations.

Use of potentially inappropriate medication and polypharmacy in older adults: a repeated cross-sectional study.

BACKGROUND: With age, the number of chronic conditions increases along with the use of medications. For several years, polypharmacy has been found to be on the increase in western societies. Polypharmacy is associated with an increased risk of adverse drug events (ADE). Medications called potentially inappropriate medications (PIM) have also been found to increase the risk of ADEs in an older population. In this study, which we conducted during a national information campaign to reduce PIM, we analysed the prevalence of PIM in an older adult population and in different strata of the variables age, gender, number of chronic conditions and polypharmacy and how that prevalence changed over time. METHODS: This is a registry-based repeated cross-sectional study including two cohorts. Individuals aged 75 or older listed at a primary care centre in Blekinge on the 31st March 2011 (cohort 1, 15,361 individuals) or on the 31st December 2013 (cohort 2, 15,945 individuals) were included in the respective cohorts. Using a chi2 test, the two cohorts were compared on the variables age, gender, number of chronic conditions and polypharmacy. Use of five or more medications at the same time was the definition for polypharmacy. RESULTS: Use of PIM decreased from 10.60 to 7.04% (p-value < 0.001) between 2011 and 2013, while prevalence of five to seven chronic conditions increased from 20.55 to 23.66% (p-value < 0.001). Use of PIM decreased in all strata of the variables age, gender number of chronic conditions and polypharmacy. Except for age 80-84 and males, where it increased, prevalence of polypharmacy was stable in all strata of the variables. CONCLUSIONS: Use of potentially inappropriate medications had decreased in all variables between 2011 and 2013; this shows the possibility to reduce PIM with a focused effort. Polypharmacy does not increase significantly compared to the rest of the population.

Importance of potentially inappropriate medications, number of chronic conditions and medications for the risk of hospitalisation in elderly in Sweden: a case-control study.

OBJECTIVES: This study aimed to investigate the importance of potentially inappropriate medications, number of medications and chronic conditions for the risk of hospitalisation among an elderly population. DESIGN: This is a case-control study. SETTING: Population-based study in 2013 of all individuals aged 75 years and older (17 203) in the county of Blekinge in the southeast of Sweden. PARTICIPANTS: A total of 2941 individuals were included who had at least one hospitalisation to a medical, geriatric and palliative, or orthopaedic ward during 2013. From this total, 81 were excluded because of incomplete data or absence of controls. In total, 5720 patients were included and formed 2860 risk sets matched on age and gender. PRIMARY AND SECONDARY OUTCOME MEASURES: Conditional logistic regression was used to analyse the odds for hospitalisation according to use of potentially inappropriate medication (PIM), number of chronic conditions and medicines using univariate and multivariate models. PIM was defined as long-acting benzodiazepines, tramadol, propiomazine and medicines with anticholinergic effect. RESULTS: The univariate analysis for use of PIM showed a significant association with hospitalisation (OR 1.54, 95% CI 1.30 to 1.83). For the number of chronic conditions, the OR was increased and was significant from two or more chronic conditions, and for the number of medicines from the use of five or more medicines, in the univariate analysis. Use of PIM has no association with hospitalisation in the full model. The number of chronic conditions and medicines in the full models continued to have strong associations for hospitalisation, from five to seven chronic conditions (OR 1.86, 95% CI 1.49 to 2.33) and use of five to nine medicines (OR 1.46, 95% CI 1.21 to 1.77) at the same time. CONCLUSION: The number of chronic conditions and medications are important for the odds of hospitalisation, while the use of PIM, according to the definition used in this study, was no significant in the full model.

Step-wise approach to prevention of chronic diseases in the Danish primary care sector with the use of a personal digital health profile and targeted follow-up - an assessment of attendance.

BACKGROUND: Current evidence on chronic disease prevention suggests that interventions targeted at high-risk individuals represents the best way forward. We implemented a step-wise approach in the Danish primary care sector, designed for the systematic and targeted prevention of chronic disease. The intervention centered on a personal digital health profile for all participants, followed by targeted preventive programs for high-risk patients. The present paper examines individual characteristics and health-care usage of patients who took up the targeted preventive programs in response to their personal digital health profile. METHODS: A sample of patients born between 1957 and 1986 was randomly selected from the patient-list system of participating general practitioners in two Danish municipalities. The selected patients received a digital invitation to participate. Consenting patients received a second digital invitation for a personal digital health profile based on questionnaire and electronic patient record data. The personal digital health profile contained individualized information on risk profile and personalized recommendations on further actions. If at-risk or presenting with health-risk behaviour a patient would be advised to contact either their general practitioner or municipal health centre for targeted preventive programs. Attendance at the targeted preventive programs was examined using Poisson regression and chi-squared automatic interaction detection methods. RESULTS: A total of 9400 patients were invited. Of those who participated (30%), 22% were advised to get a health check at their general practitioner. Of these, 19% did so. Another 23% were advised to schedule an appointment for behaviour-change counselling at their municipal health centre. A total of 21% took the advice. Patients who had fair or poor self-rated health, a body mass index above 30, low self-efficacy, were female, non-smokers, or lead a sedentary lifestyle, were most likely to attend the targeted preventive programs. CONCLUSIONS: A personal digital health profile shows some promise in a step-wise approach to prevention in the Danish primary care sector and seems to motivate people with low self-efficacy to attend targeted preventive programs. TRIAL REGISTRATION: Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016 ). Prospectively registered on the 29th of April 2016.

Are perceived barriers to accessing mental healthcare associated with socioeconomic position among individuals with symptoms of depression? Questionnaire-results from the Lolland-Falster Health Study, a rural Danish population study.

OBJECTIVE: To evaluate if perceived barriers to accessing mental healthcare (MHC) among individuals with symptoms of depression are associated with their socio-economic position (SEP). DESIGN: Cross-sectional questionnaire-based population survey from the Lolland-Falster Health Study (LOFUS) 2016-17 of 5076 participants. PARTICIPANTS: The study included 372 individuals, with positive scores for depression according to the Major Depression Inventory (MDI), participating in LOFUS . INTERVENTIONS: A set of five questions on perceived barriers to accessing professional care for mental health problem was posed to individuals with symptoms of depression (MDI score >20). OUTCOMES: The association between SEP (as measured by educational attainment, employment status and financial strain) and five different types of barriers to accessing MHC were analysed in separate multivariable logistic regression models adjusted for gender and age. RESULTS: A total of 314 out of 372 (84%) completed the survey questions and reported experiencing barriers to MHC access. Worry about expenses related to seeking or continuing MHC was a considerable barrier for 30% of the individuals responding and, as such, the greatest problem among the five types of barriers. 22% perceived Stigma as a barrier to accessing MHC, but there was no association between perceived Stigma and SEP. Transportation was not only the barrier of least concern for individuals in general but also the issue with the greatest and most consistent socio-economic disparity (OR 2.99, 95% CI 1.19 to 7.52) for the lowest vs highest educational groups and, likewise, concerning Expenses (OR 2.77, 95% CI 1.34 to 5.76) for the same groups. CONCLUSION: Issues associated with Expenses and Transport were more frequently perceived as barriers to accessing MHC for people in low SEP compared with people in high SEP. Stigma showed no association with SEP.Informed written consent was obtained. Region Zealand's Ethical Committee on Health Research (SJ-421) and the Danish Data Protection Agency (REG-24-2015) approved the study.

Digital Recruitment and Acceptance of a Stepwise Model to Prevent Chronic Disease in the Danish Primary Care Sector: Cross-Sectional Study.

BACKGROUND: During recent years, stepwise approaches to health checks have been advanced as an alternative to general health checks. In 2013, we set up the Early Detection and Prevention project (Tidlig Opsporing og Forebyggelse, TOF) to develop a stepwise approach aimed at patients at high or moderate risk of a chronic disease. A novel feature was the use of a personal digital mailbox for recruiting participants. A personal digital mailbox is a secure digital mailbox provided by the Danish public authorities. Apart from being both safe and secure, it is a low-cost, quick, and easy way to reach Danish residents. OBJECTIVE: In this study we analyze the association between the rates of acceptance of 2 digital invitations sent to a personal digital mailbox and the sociodemographic determinants, medical treatment, and health care usage in a stepwise primary care model for the prevention of chronic diseases. METHODS: We conducted a cross-sectional analysis of the rates of acceptance of 2 digital invitations sent to randomly selected residents born between 1957 and 1986 and residing in 2 Danish municipalities. The outcome was acceptance of the 2 digital invitations. Statistical associations were determined by Poisson regression. Data-driven chi-square automatic interaction detection method was used to generate a decision tree analysis, predicting acceptance of the digital invitations. RESULTS: A total of 8814 patients received an invitation in their digital mailbox from 47 general practitioners. A total of 40.22% (3545/8814) accepted the first digital invitation, and 30.19 % (2661/8814) accepted both digital invitations. The rates of acceptance of both digital invitations were higher among women, older patients, patients of higher socioeconomic status, and patients not diagnosed with or being treated for diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular disease. CONCLUSIONS: To our knowledge, this is the first study to report on the rates of acceptance of digital invitations to participate in a stepwise model for prevention of chronic diseases. More studies of digital invitations are needed to determine if the acceptance rates seen in this study should be expected from future studies as well. Similarly, more research is needed to determine whether a multimodal recruitment approach, including digital invitations to personal digital mailboxes will reach hard-to-reach subpopulations more effectively than digital invitations only.

Impact of heart failure and other comorbidities on mortality in patients with chronic obstructive pulmonary disease: a register-based, prospective cohort study.

BACKGROUND: Multimorbidity has already become common in primary care and will be a challenge in the future. Primary care in Sweden participates to a great extent in the care of patients with two severe, chronic conditions: chronic obstructive pulmonary disease (COPD) and heart failure. Both conditions are characterized by high mortality and often coexist. Age, sex, heart failure and other comorbidities are considered to be the major predictors of mortality in patients with COPD. We aimed to study the impact of heart failure, other comorbidities, age and sex on mortality in patients with COPD. METHODS: A register-based, prospective cohort study conducted in Blekinge County in Sweden with about 150,000 inhabitants. The study population was comprised of people aged ≥35 years. The data about diagnoses of COPD and heart failure came from the 2007 health care register, in which we found 984 individuals with a diagnosis of COPD. Date of death was collected from January 1st, 2008 -August 31st, 2015. The diagnosis-based Adjusted Clinical Groups (ACG) Case-Mix System 7.1 was used to describe comorbidity. Each individual was assigned one of six comorbidity levels called resource utilization bands (RUB) graded from 0 to 5. RESULTS: Estimated eight year mortality in patients with COPD and coexisting heart failure was seven times higher than in patients with COPD alone - odds ratio 7.06 (95% CI 3.88-12.84). Adjusting for age and male sex resulted in odds ratio 3.75 (95% CI 1.97-7.15). Further adjusting for other comorbidities resulted in odds ratio 3.26 (95% CI 1.70-6.25). The mortality was strongly associated with the highest comorbidity level - RUB 5 where the odds ratio was 5.19 (95% CI 2.59-10.38). CONCLUSION: Heart failure has an important impact on mortality in patients with COPD. The mortality in patients with COPD and coexisting heart failure was strongly associated with age, male sex and other comorbidities. Of those three predictors, only other comorbidities can be influenced. Heart failure and other comorbidities should be recognized early and properly treated in order to improve survival in patients with coexisting COPD and heart failure.