Systemic inflammation and health outcomes in patients receiving treatment for atherosclerotic cardiovascular disease.

BACKGROUND AND AIMS: The burden and outcomes of inflammation in patients with atherosclerotic cardiovascular disease (ASCVD) are not well defined beyond the controlled settings of trials and research cohorts. METHODS: This was an observational study of ASCVD adults undergoing C-reactive protein testing in Stockholm's healthcare (2007-21). After excluding C-reactive protein tests associated with acute illness or medications/conditions that bias C-reactive protein interpretation, systemic inflammation was evaluated over a 3-month ascertainment window. Determinants of C-reactive protein ≥ 2 mg/L were explored with logistic regression. C-reactive protein categories were compared via negative-binomial/Cox regression for subsequent healthcare resource utilization and occurrence of major adverse cardiovascular events, heart failure hospitalization, and death. RESULTS: A total of 84 399 ASCVD adults were included (46% female, mean age 71 years, 59% with C-reactive protein ≥ 2 mg/L). Female sex, older age, lower kidney function, albuminuria, diabetes, hypertension, and recent anaemia were associated with higher odds of C-reactive protein ≥ 2 mg/L. The use of renin-angiotensin system inhibitors, antiplatelets, and lipid-lowering therapy was associated with lower odds. Over a median of 6.4 years, compared with C-reactive protein < 2 mg/L, patients with C-reactive protein ≥ 2 mg/L had higher rates of hospitalizations, days spent in hospital, outpatient consultations, and dispensed medications (P < .05 for all). They also had a higher rate of major adverse cardiovascular events [hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.27-1.33], heart failure (HR 1.24; 95% CI 1.20-1.30), and death (HR 1.35; 95% CI 1.31-1.39). Results were consistent across subgroups and granular C-reactive protein categories and robust to the exclusion of extreme C-reactive protein values or early events. CONCLUSIONS: Three in five adults with ASCVD have systemic inflammation, which is associated with excess healthcare resource utilization and increased rates of cardiovascular events and death.

Adult offspring's education and parental mortality: A nationwide cohort study of the mediating role of lifestyle-related diseases.

Aim: The mechanisms behind the association between adult offspring's socioeconomic position and their parents' mortality are not well understood. This study investigates lifestyle-related diseases as a potential mediating pathway between adult offspring's education and parental mortality. Methods: This nationwide register-based cohort study consists of 963,742 older adults aged 65 years between 2000 and 2018. Lifestyle-related diseases were measured between 60 and 65 years and those with prior lifestyle-related diseases were excluded. Natural Effect Models were performed to assess potential mediation through lifestyle-related diseases of the association between offspring's education and parental mortality measured by additive hazard estimates with 95% confidence intervals (CIs). Results: Between 60 and 65 years, 150,501 (15.6%) older adults were diagnosed with lifestyle-related diseases and 149,647 (15.5%) died during follow-up. Compared with having offspring with long education, short education was associated with 631 (95% CI: 555; 707) and 581 (95% CI: 525; 638) additional deaths per 100,000 person-years for women and men, respectively, of which 15.4% (95% CI: 9.0; 21.6) and 16.8% (95% CI: 14.6; 18.9) were mediated by lifestyle-related diseases. The corresponding numbers for medium education were 276 (95% CI: 205; 347) and 299 (95% CI: 255; 343) with 26.2% (95% CI: 12.0; 40.6) and 27.6% (95% CI: 25.1; 31.8) mediated by lifestyle-related diseases. Conclusions: Lifestyle-related diseases accounted for 15-28% of the association between offspring's education and parental mortality for both men and women.

Challenges and lessons learnt from conducting a health survey in an ethnically diverse population.

Aim: To document the challenges of developing and executing an interviewer-driven survey questionnaire in an ethnically diverse and deprived social housing area undergoing reconstruction in Denmark. Methods: The survey was initially planned to be conducted in three waves (before, during and after reconstruction of the housing area), based on a questionnaire covering health, wellbeing and social relations. The first two waves took place in 2018 and 2019 (invited n=~600 per wave) and the third wave will be conducted once the reconstruction is finalised. The approach to the third wave is under revision by the research team. The questionnaire was translated from Danish into the seven most common languages in the housing area. A bilingual interview team went door to door interviewing residents. Field notes were collected systematically during each wave to document the process. Results: The response rates were 35% (n=209) and 22% (n=132) for waves 1 and 2, respectively. There was an overall decrease in response rates between waves 1 and 2 for all language groups, but particularly for Arabic and Turkish-speaking men. The most frequently stated reasons for non-participation included illness and language barriers. The key lessons learnt were that overcoming linguistic and cultural barriers to conducting research among residents in this social housing area requires time and resources. Conclusions: Several challenges are associated with conducting a survey in ethnically diverse and deprived social housing areas. Documenting the challenges and learning from experience are both important, in order to include this hard-to-reach population in health research.

Impact of hypothetical improvements in the psychosocial work environment on sickness absence rates: a simulation study.

BACKGROUND: The association between psychosocial working environments and sickness absence is well-known. However, the potential for reducing sickness absences of different lengths through improvements in psychosocial work factors is not fully understood. We aim to quantify the potential for reducing short-, intermediate- and long-term sickness absence rates, respectively, through hypothetical improvements in several psychosocial work factors. METHODS: This longitudinal study includes 24 990 public hospital employees from the 2014 wave of the Well-being in Hospital Employees study. The 1-year sickness absence rate was divided into short- (1-3 days), intermediate- (4-28 days) and long-term (29 days or more) periods. We simulated hypothetical scenarios with improvements in 17 psychosocial work factors using the parametric g-formula and estimated resulting changes in sickness absence rate ratios (RRs) with 95% confidence intervals (95% CIs). RESULTS: Setting all 17 psychosocial work factors to their most desirable levels (vs. least desirable levels) was associated with an overall 54% lower rate of sickness absence (95% CI: 48-60%). Reducing bullying (no vs. yes RR: 0.86, 95% CI: 0.83-0.90) and perceived stress (low vs. high RR: 0.90, 95% CI: 0.87-0.92), and increasing skill discretion (high vs. low RR: 0.91, 95% CI: 0.89-0.94) held the largest potential for reducing the total sickness absence rate. Overall, associations were similar for short-, intermediate- and long-term sickness absence. CONCLUSIONS: The psychosocial working environment was strongly associated with sickness absence. Improving the working environment may have a great impact on short-, intermediate- and long-term sickness absence rates.

'Standing together - at a distance': Documenting changes in mental-health indicators in Denmark during the COVID-19 pandemic.

Aims: There is a need to document the mental-health effects of the COVID-19 pandemic and its associated societal lockdowns. We initiated a large mixed-methods data collection, focusing on crisis-specific worries and mental-health indicators during the lockdown in Denmark. Methods: The study incorporated five data sources, including quantitative surveys and qualitative interviews. The surveys included a time series of cross-sectional online questionnaires starting on 20 March 2020, in which 300 (3×100) Danish residents were drawn every three days from three population groups: the general population (N=1046), families with children (N=1032) and older people (N=1059). These data were analysed by trend analysis. Semi-structured interviews were conducted with 32 people aged 24-83 throughout Denmark to provide context to the survey results and to gain insight into people's experiences of the lockdown. Results: Absolute level of worries, quality of life and social isolation were relatively stable across all population groups during the lockdown, although there was a slight deterioration in older people's overall mental health. Many respondents were worried about their loved ones' health (74-76%) and the potential long-term economic consequences of the pandemic (61-66%). The qualitative interviews documented significant variation in people's experiences, suggesting that the lockdown's effect on everyday life had not been altogether negative. Conclusions: People in Denmark seem to have managed the lockdown without alarming changes in their mental health. However, it is important to continue investigating the effects of the pandemic and various public-health measures on mental health over time and across national contexts.

Disability pension among persons with chronic disease: Differential impact of a Danish policy reform.

BACKGROUND: In 2013, Denmark implemented a reform that tightened the criteria for disability pension, expanded a subsidized job scheme ('flexi-job') and introduced a new vocational rehabilitation scheme. The overall aim of the reform was to keep more persons attached to the labour market. This study investigates the impact of the reform among persons with chronic disease and whether this impact differed across groups defined by labour market affiliation and chronic disease type. METHODS: The study was conducted as a register-based, nationwide cohort study. The study population included 480 809 persons between 40 and 64 years of age, who suffered from at least one of six chronic diseases. Hazard ratios (HR) and 95% confidence intervals (CI) of being awarded disability pension or flexi-job in the 5 years after vs. the 5 years prior to the reform were estimated. RESULTS: Overall, the probability of being awarded disability pension was halved after the reform (HR = 0.49, CI: 0.47-0.50). The impact was largest for persons receiving sickness absence benefits (HR = 0.31, CI: 0.24-0.39) and for persons with functional disorders (HR = 0.38, CI: 0.32-0.44). Also, the impact was larger for persons working in manual jobs than for persons working in non-manual jobs. The probability of being awarded a flexi-job was decreased by one-fourth (HR = 0.76, CI: 0.74-0.79) with the largest impact for high-skilled persons working in non-manual jobs. CONCLUSION: Access to disability pension and flexi-job decreased after the reform. This impact varied according to labour market affiliation and chronic disease type.

Education and incident type 2 diabetes: quantifying the impact of differential exposure and susceptibility to being overweight or obese.

AIMS/HYPOTHESIS: Educational inequality in type 2 diabetes incidence is evident in many high-income countries. Previous studies have shown that differential exposure to being overweight/obese across educational groups may partly explain this inequality. Whether differential susceptibility to being overweight/obese across educational groups contributes to this inequality has been investigated less frequently, even though it is a plausible mechanism. The two mechanisms may even be highly intertwined. In this longitudinal cohort study, we investigated the simultaneous contribution of differential exposure and differential susceptibility to being overweight/obese to educational inequality in type 2 diabetes incidence. METHODS: The study population comprised 53,159 Danish men and women aged 50-64 years at baseline who were followed for a mean of 14.7 years. We estimated rate differences of type 2 diabetes by education level per 100,000 person-years. Using counterfactual mediation analysis, these rate differences were decomposed into proportions attributable to differential exposure, differential susceptibility and all other pathways, respectively. We compared this approach with conventional approaches to mediation and interaction analysis. RESULTS: Compared with a high level of education, a low education level was associated with 454 (95% CI 398, 510) additional cases of type 2 diabetes, and a medium education level with 316 (CI 268, 363) additional cases. Differential exposure to being overweight/obese accounted for 37% (CI 31%, 45%) of the additional cases among those with a low education level and 29% (CI 24%, 36%) of the additional cases among those with a medium education level. Differential susceptibility accounted for 9% (CI 4%, 14%) and 6% (CI 3%, 10%) of the additional cases among those with a low and medium education level, respectively. Compared with the counterfactual approach, the conventional approaches suggested stronger effects of both mechanisms. CONCLUSIONS/INTERPRETATION: Differential exposure and susceptibility to being overweight/obese are both important mechanisms in the association between education and type 2 diabetes incidence.

Inverse probability weighting for self-selection bias correction in the investigation of social inequality in mortality.

BACKGROUND: Empirical evaluation of inverse probability weighting (IPW) for self-selection bias correction is inaccessible without the full source population. We aimed to: (i) investigate how self-selection biases frequency and association measures and (ii) assess self-selection bias correction using IPW in a cohort with register linkage. METHODS: The source population included 17 936 individuals invited to the Copenhagen Aging and Midlife Biobank during 2009-11 (ages 49-63 years). Participants counted 7185 (40.1%). Register data were obtained for every invited person from 7 years before invitation to the end of 2020. The association between education and mortality was estimated using Cox regression models among participants, IPW participants and the source population. RESULTS: Participants had higher socioeconomic position and fewer hospital contacts before baseline than the source population. Frequency measures of participants approached those of the source population after IPW. Compared with primary/lower secondary education, upper secondary, short tertiary, bachelor and master/doctoral were associated with reduced risk of death among participants (adjusted hazard ratio [95% CI]: 0.60 [0.46; 0.77], 0.68 [0.42; 1.11], 0.37 [0.25; 0.54], 0.28 [0.18; 0.46], respectively). IPW changed the estimates marginally (0.59 [0.45; 0.77], 0.57 [0.34; 0.93], 0.34 [0.23; 0.50], 0.24 [0.15; 0.39]) but not only towards those of the source population (0.57 [0.51; 0.64], 0.43 [0.32; 0.60], 0.38 [0.32; 0.47], 0.22 [0.16; 0.29]). CONCLUSIONS: Frequency measures of study participants may not reflect the source population in the presence of self-selection, but the impact on association measures can be limited. IPW may be useful for (self-)selection bias correction, but the returned results can still reflect residual or other biases and random errors.

Workplace Psychosocial Resources and Risk of Sleep Disturbances Among Employees.

Importance: Workplace psychosocial resources naturally tend to cluster in some work teams. To inform work-related sleep health promotion interventions, it is important to determine the associations between clustering of workplace resources and sleep disturbances when some resources are high while others are low and to mimic an actual intervention using observational data. Objective: To examine whether clustering of and changes in workplace psychosocial resources are associated with sleep disturbances among workers. Design, Setting, and Participants: This population-based cohort study used data from the Swedish Longitudinal Occupational Survey of Health (2012-2018), the Work Environment and Health in Denmark study (2012-2018), and the Finnish Public Sector Study (2008-2014), collected biennially. Statistical analysis was conducted from November 2020 to June 2022. Exposure: Questionnaires were distributed measuring leadership quality and procedural justice (ie, vertical resources) as well as collaboration culture and coworker support (ie, horizontal resources). Resources were divided into clusters of general low, intermediate vertical and low horizontal, low vertical and high horizontal, intermediate vertical and high horizontal, and general high. Main Outcomes and Measures: Odds ratios (ORs) and 95% CIs were reported from logistic regression models for the associations between the clustering of resources and concurrent and long-term sleep disturbances. Sleep disturbances were measured by self-administered questionnaires. Results: The study identified 114 971 participants with 219 982 participant-observations (151 021 [69%] women; mean [SD] age, 48 [10] years). Compared with participants with general low resources, other groups showed a lower prevalence of sleep disturbances, with the lowest observed in the general high group concurrently (OR, 0.38; 95% CI, 0.37-0.40) and longitudinally after 6 years (OR, 0.52; 95% CI, 0.48-0.57). Approximately half of the participants (27 167 participants [53%]) experienced changes in resource clusters within 2 years. Improvements in vertical or horizontal dimensions were associated with reduced odds of persistent sleep disturbances, and the lowest odds of sleep disturbances was found in the group with improvements in both vertical and horizontal dimensions (OR, 0.53; 95% CI, 0.46-0.62). A corresponding dose-response association with sleep disturbances was observed for decline in resources (eg, decline in both dimensions: OR, 1.74; 95% CI, 1.54-1.97). Conclusions and Relevance: In this cohort study of workplace psychosocial resources and sleep disturbances, clustering of favorable resources was associated with a lower risk of sleep disturbances.

Chronic disorders, work-unit leadership quality and long-term sickness absence among 33 025 public hospital employees.

OBJECTIVE: This study aimed to examine the association between work-unit level leadership quality and individual-level long-term sickness absence (LTSA) in the hospital sector and effect modification by chronic disorders. METHODS: This longitudinal analysis included 33 025 Danish public hospital employees who were followed-up for one year after baseline in March 2014. Leadership quality was assessed by questionnaire with mean responses aggregated by work-unit and characterized in tertiles. LTSA during follow-up was determined from employer records. Chronic disorders at baseline was assessed from the Danish hospital and prescription registers. We performed multilevel logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) adjusting for potential confounders. We evaluated interaction between chronic illness and low leadership quality on multiplicative and additive scales. RESULTS: We identified employees as healthy (60.8%) or with somatic (31.6%), mental (3.3%), or both somatic and mental (4.3%) disorders. During follow-up, 6% of employees registered a LTSA. Medium and high leadership quality were associated with lower risk of LTSA with OR of 0.84 (95% CI 0.76-0.94) and 0.73 (95% CI 0.65-0.82) respectively, compared to low leadership quality. Associations were similar for healthy employees and employees with only somatic disorders, whereas no association was observed for employees with mental disorders (in presence or absence of somatic disorders). No statistically significant (α=0.05) interactions between leadership quality and chronic disorders on LTSA were observed. CONCLUSION: The findings suggest that the quality of leadership in work units is associated with risk of long-term sick leave in the Danish public hospital sector and that strong leadership protects employees against LTSA.

Workplace psychosocial resources and risk of cardiovascular disease among employees: a multi-cohort study of 135 669 participants.

OBJECTIVE: In terms of prevention, it is important to determine effects on cardiovascular disease (CVD) when some workplace psychosocial resources are high while others are low. The aim of the study was to assess the prospective relationship between clustering of workplace psychosocial resources and risk of CVD among employees. METHODS: We pooled data from three cohort studies of 135 669 employees (65% women, age 18-65 years and free of CVD) from Denmark, Finland and Sweden. Baseline horizontal resources (culture of collaboration and support from colleagues) and vertical resources (leadership quality and procedural justice) were measured using standard questionnaire items. Incident CVD, including coronary heart and cerebrovascular disease, was ascertained using linked electronic health records. We used latent class analysis to assess clustering (latent classes) of workplace psychosocial resources. Cox proportional hazard models were used to examine the association between these clusters and risk of CVD, adjusting for demographic and employment-related factors and pre-existing physical and mental disorders. RESULTS: We identified five clusters of workplace psychosocial resources from low on both vertical and horizontal resources (13%) to generally high resources (28%). High horizontal resources were combined with either intermediate [hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.74-0.95] or high (HR 0.88, 95% CI 0.78-1.00) vertical resources were associated with lower risks of CVD compared to those with generally low resources. The association was most prominent for cerebrovascular disease (eg, general high resources: HR 0.80, 95% CI 0.67-0.96). CONCLUSIONS: Individuals with high levels of workplace psychosocial resources across horizontal and vertical dimensions have a lower risk of CVD, particularly cerebrovascular disease.

Reducing employee turnover in hospitals: estimating the effects of hypothetical improvements in the psychosocial work environment.

OBJECTIVES: Poor psychosocial work environments in hospitals are associated with higher employee turnover. In this prospective cohort study, we aimed to identify and quantify which aspects of the psychosocial work environment have the greatest impact on one-year employee turnover rates within a hospital setting, both overall and within occupational groups. METHODS: The study population included 24 385 public hospital employees enrolled in the Danish Well-being in Hospital Employees cohort in 2014. We followed the participants for one year and registered if they permanently left their workplace. Using baseline sociodemographic, workplace, and psychosocial work environment characteristics, we applied the parametric g-formula to simulate hypothetical improvements in the psychosocial work environment and estimated turnover rate differences (RD) per 10 000 employees per year and 95% confidence intervals (95% CI). RESULTS: Of the 24 385 participants, 2552 (10.5%) left the workplace during the one-year follow-up. Up to 44% of this turnover was potentially preventable through hypothetical improvements in the psychosocial work environment. The specific hypothetical improvements with the largest effects were in satisfaction with work prospects (RD -522 turnovers per 10 000 person-years, 95% CI -536- -508), general job satisfaction (RD -339, 95% CI -353- -325) and bullying (RD -200, 95% CI -214- -186). The potential for preventing turnover was larger for nurses than for physicians and other healthcare employees. CONCLUSIONS: Improvements in the psychosocial work environment may have great potential for reducing turnover among hospital staff, particularly among nurses.

How does socioeconomic development in Brazil shape social inequalities in diabetes?

Many countries, including Brazil, are facing growing social inequalities in diabetes prevalence. The different states in Brazil represent different levels of development and by comparing diabetes inequalities across states we aim to get a better understanding of how educational inequalities in diabetes are linked to social development. We use the latest cross-sectional national health survey of Brazil - PNS-2013 (N = 60,202) and analyse the disparities in diabetes as well as the differential exposure and susceptibility to the effect of obesity across states for men and women. Among women in high-HDI states the prevalence of diabetes is 11.7 percentage units (CI: 9.3; 14.0) higher among the lowest compared to the highest educated. In less-developed states the disparity is smaller. Among men, there is no social gradient found for diabetes, but obesity is positively associated with education. The association between obesity and diabetes is stronger among the low educated particularly for men in high-HDI states. Here the interaction effect between low education and obesity is 11.7 (CI 8.1; 15.4) percentage units. The fact that economic development is associated with increasingly unequal levels of diabetes and with unequal levels of exposure and susceptibility to obesity indicates that other interacting determinants are important for the development of the diabetes epidemic in Brazil.

Health, well-being and social relations in a changing neighbourhood: protocol for a prospective, multimethods study of the consequences of large structural changes in an ethnic diverse social housing area in Denmark.

INTRODUCTION: Residential areas constitute an important arena for health, well-being and social relations. Structural interventions such as demolition and area renewal have been used to reduce inequality in health and well-being in disadvantaged areas. However, the effects of larger structural interventions are inconclusive. In a longitudinal perspective, this study aims to analyse how large-scale structural changes in an ethnic diverse social housing area are associated with the residents' health, well-being and social relations. METHODS AND ANALYSIS: In this multimethods study, we examine this aim among middle-aged and older residents in a multiethnic social housing area in a Danish municipality by the inclusion of comprehensive survey (in 2018, 2019 and 2020), register (yearly 2015-2025) and qualitative (2018-2020) data. Municipal Health Profile survey data from 2017 and 2021 will be used for comparison. The area will undergo large structural changes in the built environment during 2018-2021. A 'natural experiment' (n=6000) compares differences in health and social outcomes across the study period between the study area and a similar neighbouring area not undergoing structural changes. Through user engagement in the design of the study, throughout the different phases of the study and in the two co-created interventions embedded in the study design, a focus on empowerment and recognition of the resources and perspectives of residents are encouraged. ETHICS AND DISSEMINATION: The study is registered in the University of Copenhagen's record of biobanks and research projects containing personal data and will be conducted in accordance with the principles of the Helsinki Declaration. Residential and municipal representatives and local non-governmental organisations are engaged in the design and execution of the study to ensure the usefulness, reflexive interpretation of data, and relevance of interventions. Results will be published in international peer-reviewed scientific journals, presented at conferences and as short reports through the use of both written and visual outputs.