Epidemiology of myasthenia gravis in Denmark, Finland and Sweden: a population-based observational study.

BACKGROUND: Incidence and prevalence rates of myasthenia gravis (MG) vary considerably across studies, and mortality risk is rarely addressed. We examined the prevalence and incidence rates, mortality and factors associated with mortality with MG. METHOD: This was a registry linkage study based on nationwide health and administrative registries of Denmark, Finland and Sweden (populations of 5.9, 5.6 and 10.5 million, respectively). Patients with MG were identified based on International Classification of Diseases codes from inpatient and outpatient specialised care registries. Yearly prevalence, incidence and mortality rates in relation to the total background population were calculated from 2000 to 2020 (study period). The causes of death and factors associated with mortality were addressed separately. RESULTS: The overall incidence of MG was 1.34 (95% CI 1.27 to 1.41), 1.68 (95% CI 1.60 to 1.75) and 1.62 (95% CI 1.56 to 1.68) per 100 000, and the overall prevalence per 100 000 was 18.56 (95% CI 18.31 to 18.81), 20.89 (95% CI 20.62 to 21.16) and 23.42 (95% CI 23.21 to 23.64) in Denmark, Finland and Sweden, respectively. The overall standardised mortality ratio (SMR) was 1.32 (95% CI 1.23 to 1.42) among patients with MG in Denmark, 1.23 (95% CI 1.15 to 1.33) in Finland, and 1.20 (95% CI 1.14 to 1.26) in Sweden, with higher SMR observed in women than men. Annual incidence and prevalence increased over time, whereas the SMR remained stable. The most common causes of death were MG, chronic ischaemic heart disease and acute myocardial infarction. CONCLUSIONS: This population-based study from three Nordic countries highlights the need for improved care of patients with MG, especially young women.

Economic and societal burden of myasthenia gravis in Denmark, Finland, and Sweden: A population-based registry study.

BACKGROUND AND PURPOSE: Health care resource utilization (HCRU) and the economic burden of myasthenia gravis (MG) are significant, but existing studies rarely include comprehensive nationwide data. We examined HCRU and direct and indirect costs associated with MG overall and by disease severity in Denmark, Finland, and Sweden. METHODS: Data were collected retrospectively from nationwide health and social care registries. All individuals ≥18 years of age with ≥2 International Classification of Diseases diagnoses of MG between 2000 and 2020 were included. HCRU, direct (inpatient and outpatient contacts, medication) and indirect costs (early retirement, sick leave, death), and associated factors were calculated. RESULTS: The full study cohort comprised 8622 people with MG (pwMG). Mean annual numbers of all-cause secondary health care contacts for pwMG were 3.4 (SD = 8.3), 7.0 (SD = 12.3), and 2.9 (SD = 3.9), with mean annual total costs of €12,185, €9036, and €5997 per person in Denmark, Finland, and Sweden, respectively. Inpatient periods, involving 77%-89% of study participants in the three countries, contributed most to direct costs, whereas the majority of indirect costs resulted from early retirement in Denmark and Finland, and sick leave periods in Sweden. Mean annual total costs were highest with very severe MG (€19,570-€33,495 per person across the three countries). Female sex and comorbidities, such as mental and behavioral disorders and severe infections, were also associated with higher total costs. CONCLUSIONS: This population-based study shows a high level of HCRU and a significant direct and indirect economic burden of MG across three Nordic countries, especially for severe forms of MG.

Beyond conventional stroke guidelines: setting priorities.

BACKGROUND AND PURPOSE: Priorities in the care of stroke patients are often intuitive. An open and translucent priority-setting procedure would benefit patients, professionals, and decision-makers. Prioritization is an innovative part of the new Swedish national stroke guidelines. METHODS: Working groups identified diagnostic procedures, interventions and therapies in stroke care, assessed each one according to severity (needs), effect of action, level of scientific evidence and cost-effectiveness. The items were then ranked into priority groups from 1 (highest) to 10 (lowest). Procedures lacking evidence for routine clinical use were also identified (and entered a do-not-do list), as well as procedures in research and development. Resource allocations resulting from the priority-setting process were identified. RESULTS: Of 102 core procedures identified, 50 were assigned to high-priority groups (1-3), 29 to moderate priority groups (4-7) and 23 to low priority groups (8-10). Almost a quarter were graded 8 to 10, indicating that they may not necessarily be applied if resources are scarce. Twenty-eight procedures were assigned to the do-not-do list and 16 to the research and development list. CONCLUSIONS: In stroke services, it is possible to identify not only diagnostic procedures and interventions with high priority, but also a considerable number of items used today that have low priority or should not be used at all. Strict adherence to the guidelines would result in a substantial reallocation of resources from low-priority to high-priority areas.

Asthma treatment preference study: a conjoint analysis of preferred drug treatments.

OBJECTIVE: Assessment of patient preferences for attributes of asthma treatments. METHODS: Two hundred ninety-eight patients (age range, 18 to 60 years) from 15 centers in Sweden completed a questionnaire concerning their asthma, and ranked 18 alternative treatments using conjoint analysis. Patients were receiving treatment with either inhaled corticosteroids (ICS) and short-acting bronchodilator (n = 123) or ICS and long-acting bronchodilator (separate inhalers, n = 87; combination inhaler, n = 88). Attributes analyzed were maintenance treatment, additional reliever, time to onset and duration of reliever, number of symptom-free days (SFDs) per month, and out-of-pocket cost per month. RESULTS: Conjoint analysis showed that the most important aspect of treatment was SFD. Forty percent of the patients had

An economic evaluation of combination treatment with budesonide and formoterol in patients with mild-to-moderate persistent asthma.

Patients with mild asthma may benefit from increasing their inhaled corticosteroid dose, adding a long-acting beta2-agonist, or both. This study assessed the cost-effectiveness of these options. Patients aged > or = 12 years with mild-to-moderate persistent asthma (n = 1272) were randomised to twice-daily, double-blind treatment with budesonide 100 microg, budesonide 100 microg plus formoterol 4.5 microg, budesonide 200 microg, or budesonide 200 microg plus formoterol 4.5 microg for 12 months. Clinical variables included lung function, number of symptom-free days and number of severe exacerbations. Data on medication use, hospitalisation, visits to health professionals and time off work due to asthma were combined with Swedish unit cost data (1999) to estimate the mean annual cost per patient. Budesonide 200 microg plus formoterol 4.5 microg had the greatest efficacy and effectiveness. Budesonide 200 microg plus formoterol 4.5 microg was both more effective and less costly than budesonide 100 microg plus formoterol 4.5 microg, so a cost-effectiveness ratio was not calculated for this comparison. The cost-effectiveness ratio for budesonide 200 microg plus formoterol 4.5 microg compared with budesonide 200 microg alone was SEK 21 per symptom-free days gained. The combination of budesonide and formoterol in mild-to-moderate persistent asthma improved effectiveness at modest additional cost.

Assessing the use of retrospective databases in conducting economic evaluations of drugs: the case of asthma.

When evaluating drug substances, the traditional clinical study setting does not allow scope for observing real-life behaviour since all alternative actions are determined beforehand. However, a study based on prospective or retrospective databases containing real-life data can examine how patients and physicians behave in a real-world setting and can investigate the relationship between the introduction of a drug and the amount of healthcare used in actual practice. We reviewed the quality and potential policy application of published retrospective database studies in which an economic evaluation of the use of drugs in asthma was conducted. A search in literature databases found 16 such studies, which were reviewed and evaluated according to a published checklist. No article fulfilled all the criteria for a 'good' economic evaluation. The results of many of the evaluations may be informative, but not transparent enough to deliver policy conclusions. This may limit the use of the currently published retrospective database studies as a base for policy decision, compared with randomised controlled trials, despite the additional value of these database analyses when well conducted. A greater transparency when presenting material and results is therefore called for, to increase the usefulness of database studies.

Cost effectiveness of nasal budesonide versus surgical treatment for nasal polyps.

OBJECTIVE: To conduct a cost-effectiveness study of nasal budesonide versus surgical treatment in the management of nasal polyps. DESIGN AND METHODS: A decision-tree model reflecting two different treatment strategies for nasal polyps in Sweden was developed. The first strategy was initial polypectomy, performed under three different sets of circumstances: inpatient functional endoscopic surgery, outpatient evulsion with sedation, or outpatient evulsion with local anaesthesia; all treatments were followed by intranasal treatment with budesonide (Rhinocort) 128 microg twice daily. The second strategy was initial intranasal treatment with budesonide 128 microg twice daily. PERSPECTIVE: Healthcare provider perspective. OUTCOME MEASURES AND RESULTS: After 1 month, treatment with nasal budesonide was classified as a success (82.5%) or a failure (17.5%) based on clinical study data. In cases of success, the treatment was continued, and in cases of failure, polypectomy was undertaken, followed by budesonide 128 microg twice daily. Treatments were evaluated after 4 months using prices from the Central Hospital in Skövde, Sweden. The expected reduction in cost from using initial nasal budesonide treatment compared with the different alternatives of polypectomy were 9760 Swedish kronors (SEK) for inpatient functional endoscopic surgery, SEK2747 for outpatient evulsion with sedation, and SEK672 for outpatient evulsion with anaesthesia (1998 values). Nasal budesonide 128 microg twice daily treatment for nasal polyps revealed a potential reduction in costs of 53% compared with the primary surgery approach. CONCLUSION: Initial treatment of nasal polyps with nasal budesonide provides lower costs than treatment with initial polypectomy with maintained effectiveness.

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.

Epilepsy in Sweden: health care costs and loss of productivity--a register-based approach.

PURPOSE: The objective was to estimate health care costs and productivity losses due to epilepsy in Sweden and to compare these estimates to previously published estimates. METHODS: Register data on health care utilisation, pharmaceutical sales, permanent disability and mortality were used to calculate health care costs and costs that accrue due to productivity losses. By linkage of register information, we were able to distinguish pharmaceuticals prescribed against epilepsy from prescriptions that were prompted by other indications. RESULTS: The estimated total cost of epilepsy in Sweden in 2009 was 441 million, which corresponds to an annual per-patient cost of 8,275. Health care accounted for about 16% of the estimated total cost, and drug costs accounted for about 7% of the total cost. The estimated health care cost corresponded to about 0.2% of the total health care cost in Sweden in 2009. Indirect costs were estimated at 370 million, 84% of which was due to sickness absenteeism. Costs resulting from epilepsy-attributable premature deaths or permanent disability to work accounted for about 1% of the total indirect cost in Sweden in 2009. DISCUSSION: The per-patient cost of epilepsy is substantial. Thus, even though the prevalence of the illness is relatively small, the aggregated cost that epilepsy incurs on society is significant.

Changes in alcohol consumption: an analysis of self-reported use of alcohol in a Swedish national sample 1988-89 and 1996-97.

AIM: To analyse factors associated with alcohol consumption, and how these changed over the period 1988-97, a period during which Sweden entered the European Union. METHODS: Data were used from two waves (1988-89 and 1996-97) of the representative longitudinal micro-level ULF survey in Sweden to estimate a two-part model of consumption. RESULTS: Experiencing financial stress, monthly salary, and not being married were all correlated with alcohol consumption, especially for males in 1988-89. In 1996-97 these correlations were much weaker, revealing a levelling-out trend towards conformity. The pattern was less clear for females. Further, the youngest age group (16-29 years) increased its consumption significantly more than the older age groups. CONCLUSION: There were significant changes in alcohol behaviour, especially for males, coinciding with Sweden joining the EU and preceding the very substantial general increase in consumption levels since 1998. This underlying process should be kept in mind when analysing the more recent trends. The results support the contention that alcohol policy should be a combination of measures targeting the whole population (e.g. via public health campaigns) with specific measures directed towards more vulnerable groups (e.g. young people).