The Danish health care system and epidemiological research: from health care contacts to database records

Rehabilitation outcomes after comprehensive post-acute inpatient rehabilitation following moderate to severe acquired brain injury-study protocol for an overall prognosis study based on routinely collected health data

BACKGROUND

The initial theme of the PROGRESS framework for prognosis research is termed overall prognosis research. Its aim is to describe the most likely course of health conditions in the context of current care. These average group-level prognoses may be used to inform patients, health policies, trial designs, or further prognosis research. Acquired brain injury, such as stroke, traumatic brain injury or encephalopathy, is a major cause of disability and functional limitations, worldwide. Rehabilitation aims to maximize independent functioning and meaningful participation in society post-injury. While some observational studies can allow for an inference of the overall prognosis of the level of independent functioning, the context for the provision of rehabilitation is rarely described. The aim of this protocol is to provide a detailed account of the clinical context to aid the interpretation of our upcoming overall prognosis study.

METHODS

The study will occur at a Danish post-acute inpatient rehabilitation facility providing specialised inpatient rehabilitation for individuals with moderate to severe acquired brain injury. Routinely collected electronic health data will be extracted from the healthcare provider's database and deterministically linked on an individual level to construct the study cohort. The study period spans from March 2011 to December 2022. Four outcomes will measure the level of functioning. Rehabilitation needs will also be described. Outcomes and rehabilitation needs will be described for the entire cohort, across rehabilitation complexity levels and stratified for relevant demographic and clinical parameters. Descriptive statistics will be used to estimate average prognoses for the level of functioning at discharge from post-acute rehabilitation. The patterns of missing data will be investigated.

DISCUSSION

This protocol is intended to provide transparency in our upcoming study based on routinely collected clinical data. It will aid in the interpretation of the overall prognosis estimates within the context of our current clinical practice and the assessment of potential sources of bias independently.

Early mobilisation after hip fracture surgery reduces the risk of infection: an inverse probability of treatment weighted analysis

BACKGROUND

Mobilisation within the first day following hip fracture surgery is recommended. However, an in-depth analysis of the association between early mobilisation and the risk of infection is lacking.

OBJECTIVE

To examine the association between early mobilisation and the subsequent risk of hospital-treated infections following hip fracture surgery.

METHODS

Using nationwide registries, we included 36 229 patients aged ≥65 who underwent surgery for hip fracture (2016-21). Exposure was time from surgery to first mobilisation in hours. Outcomes were any hospital-treated infection, pneumonia, urinary tract infection and sepsis within 2-30 days and reoperation due to surgical-site infection within 2-365 days of surgery. We calculated cumulative incidences (risks), risk differences (RD) and hazard ratios (HR) with 95% confidence intervals (CIs) using the inverse probability of treatment (IPT) weighted method to account for confounding.

RESULTS

Overall, 27 174 (75%) patients were mobilised ≤24 h, 2890 (8%) between 24 and 36 h, and 6165 (17%) were mobilised >36 h of surgery or had no registration of mobilisation time.In the weighted analysis, the risk of any infection was 12.9% (CI 11.7%-14.2%) in patients mobilised 24-36 h of surgery and 10.9% (CI 10.5%-11.7%) in those mobilised ≤24 h, corresponding to RD of 2.0% (CI 0.7-3.3) and HR of 1.2 (CI 1.1-1.3). Similar associations were observed for pneumonia and urinary tract infection but not for sepsis and reoperation.

CONCLUSIONS

Infection is a common complication after hip fracture surgery. Mobilisation within 24 h is clearly associated with reduced infection risk. Our results emphasise the importance of early mobilisation and suggest a possible pathway for reducing complications and mortality after hip fracture.

Bleeding risk using non-steroidal anti-inflammatory drugs with anticoagulants after venous thromboembolism: a nationwide Danish study

BACKGROUND AND AIMS

The bleeding risk of using non-steroidal anti-inflammatory drugs (NSAIDs) in patients treated with oral anticoagulants for venous thromboembolism (VTE) remains unclear.

METHODS

A nationwide cohort study of 51 794 VTE patients initiating oral anticoagulants between 1 January 2012 and 31 December 2022 was conducted. Time-dependent multivariate cause-specific Cox regression was used to compute adjusted hazard ratios between NSAID use and hospital-diagnosed bleeding episodes.

RESULTS

Event rates for any bleeding per 100 person-years were 3.5 [95% confidence interval (CI), 3.4-3.7] during periods without NSAID use and 6.3 (95% CI, 5.1-7.9) during periods with NSAID use (number needed to harm = 36 patients treated for 1 year). Compared with non-use, the adjusted hazard ratios for any bleeding associated with NSAID use were 2.09 (95% CI, 1.67-2.62) overall, 1.79 (95% CI, 1.36-2.36) for ibuprofen, 3.30 (95% CI, 1.82-5.97) for diclofenac, and 4.10 (95% CI, 2.13-7.91) for naproxen. Compared with non-use, the adjusted hazard ratios associated with NSAID use were 2.24 (95% CI, 1.61-3.11) for gastrointestinal bleeding, 3.22 (95% CI, 1.69-6.14) for intracranial bleeding, 1.36 (95% CI, .67-2.77) for thoracic and respiratory tract bleeding, 1.57 (95% CI, .98-2.51) for urinary tract bleeding, and 2.99 (95% CI, 1.45-6.18) for anaemia caused by bleeding. Results were consistent for anticoagulant and VTE subtypes.

CONCLUSIONS

Patients treated with oral anticoagulants for VTE had a more than two-fold increased bleeding rate when using NSAIDs. This increased bleeding rate was not restricted to the gastrointestinal tract.

Impact of elexacaftor/tezacaftor/ivacaftor on utilization of routine therapies in cystic fibrosis: Danish nationwide register study

BACKGROUND

Elexacaftor/tezacaftor/ivacaftor (ETI) has been effective in improving several outcomes in people living with cystic fibrosis (pwCF). Although clinical guidance regarding maintenance therapies has not changed, staff reports indicate that individuals reduce some therapies. This study aimed to evaluate ETI's effect on utilization of routine therapies among pwCF in Denmark.

METHODS

We included all pwCF initiating ETI between 1 September 2020 and 31 October 2022. Utilization of routine therapies was analysed by drug class (e.g., gastrointestinal medications) and individual treatments (e.g., pancreatic enzymes) before and after ETI initiation using national registry data. Odds ratios (ORs) for prescription redemptions pre- and post-ETI were calculated to assess ETIs impact on the use of routine therapies.

RESULTS

The study population consisted of 351 individuals. Median age was 23 years (IQR 14-32) and mean ppFEV1 was 76 (SD 22) at index. Two-year follow-up was available for 205 individuals. Two years post ETI initiation, the one-year prevalence was reduced for airway medications, (89.5 % to 75.1 %) and inhaled antibiotics (59.5 % to 42.9 %.). OR for redeeming a prescription two years post-ETI initiation (95 % CI) was reduced for four out of five drug classes: airway medications (OR: 0.24 [0.19; 0.29]), inhaled antibiotics (OR: 0.28 [0.2; 0.39]), oral antibiotics (OR: 0.49 [0.41; 0.58]), gastrointestinal medications (OR: 0.66 [0.57; 0.77]).

CONCLUSION

Two years after ETI initiation, reductions in the use of several routine therapies were observed in a national cohort of pwCF, with the largest declines in airway medications and antibiotics. These findings highlight ETI's real-world impact beyond conventional clinical metrics.

Fast processing of gynecologic cancer tissue in Danish Cancer Biobank makes them well-suited for biomarker studies

Gynecologic cancers remain a frequent and deadly diagnosis. Historically, treatment has focused on a "one size fits all" approach, but there is an urgent need for more personal medicine. Hence, to enhance personal medicine, new biomarkers are needed. Samples from the Danish Cancer Biobank (DCB) may be well-suited for biomarker studies, as the biobank contains samples from more than 100.000 cancer patients, and the samples are annotated with pre-analytical variables. The aim of this study was to investigate if the recorded pre-analytical variables indicate the gynecologic tissue in DCB are suited for biomarker studies. Data on processing time, transport time, and registration- and verification status were extracted from all patients with a gynecologic tissue sample collected between 2020 and 2022 in DCB. The mean processing time across centers was found to be 1.03 h (SD = 0.71), and the mean transport time was found to be 0.32 h (SD = 0.70). In total, 69% of the tissue samples were pathologically examined, and 91.5% of the pathologically examined samples were found to be concordant with the patient's final diagnosis. While differences were observed, 98% of the samples were processed within 3 h, indicating the majority of gynecologic tissue samples in DCB are of high quality and optimal for biomarker studies.

Use of antithrombotic therapy and the risk of cardiovascular outcomes and bleeding in cancer patients at the end of life: a Danish nationwide cohort study

BACKGROUND

Despite uncertain benefit-risk profile near the end of life, antithrombotic therapy (ATT) is prevalent in patients with terminal cancer.

OBJECTIVES

To examine adherence and persistence with ATT in terminally ill cancer patients and investigate risks of major and clinically relevant bleeding, venous thromboembolism (VTE), and arterial thromboembolism (ATE) by ATT exposure.

METHODS

Using a Danish nationwide cohort of terminal cancer patients, ATT adherence in the year following terminal illness declaration was measured by the proportion of days covered (PDC) by prescription. Discontinuation was defined as a treatment gap of ≥30 days between prescription renewals. One-year cumulative incidences of bleeding complications, VTE, and ATE were calculated, considering the competing risk of death.

RESULTS

During 2013-2022, 86 732 terminally ill cancer patients were identified (median age, 75 years; 47% female; median survival, 57 days). At terminal illness declaration, 37.5% were receiving ATT (66.6% platelet inhibitors, 23.0% direct oral anticoagulants, and 10.4% vitamin K antagonists [VKAs]). The mean PDC with ATT was 88% (SD, 30%), highest among platelet inhibitor users (mean PDC, 89%) and lowest among VKA users (73%). One-year ATT discontinuation incidence was 7.9% (95% CI, 7.7%-8.1%). Most patients continued ATT until death (74.8% platelet inhibitors, 58.8% direct oral anticoagulants, and 61.6% VKAs). Patients receiving ATT had a lower 1-year VTE risk but higher risks of ATE and major bleeding.

CONCLUSION

Despite uncertain benefit-risk profile, most terminally ill cancer patients continue ATT until the end of life. These findings provide insights into current ATT utilization and discontinuation dynamics in the challenging context of terminal illness.

Changes in Symptoms and General Well-being After Reversal of Roux-en-Y Gastric Bypass: A Questionnaire Survey

PURPOSE

After Roux-en-Y gastric bypass (RYGB), few patients develop severe complications, which ultimately may require reversal of RYGB. We aimed to examine the effect of reversal of RYGB on symptoms and well-being.

MATERIALS AND METHODS

Via contact to medical and surgical departments treating patients with RYGB, we identified 18 patients, who had undergone reversal, 2009-2019. We conducted a Danish, nationwide questionnaire survey concerning symptoms before and after reversal of the RYGB including the patients' own perceptions of their well-being.

RESULTS

Fourteen patients responded to the questionnaire (86% female; median age at RYGB, 36.2 years [IQR, 30.9-38.6 years]). The median time from RYGB to reversal was 5.8 years (IQR, 5.1-7.5 years). After RYGB, 13 patients (93%) reported abdominal pain, while 12 patients still had abdominal pain after reversal. Six out of 11 patients (45%) reported complete remission of dumping/post-bariatric hypoglycemia (PBH) after reversal. Malabsorption disappeared in 10 out of 11 patients (90%). Reversal had minor effect on neuropathy. The median weight loss from RYGB was 61 kg (IQR, 56-75 kg), while the median weight regain after reversal was 30 kg (IQR, 13-46 kg). Regarding the well-being, 72 of the patients felt better or much better after reversal.

CONCLUSION

In total, 72% of the patients felt better or much better after reversal of RYGB, though some still had RYGB-related symptoms. The reversal relieved dumping/PBH and malabsorption, but not abdominal pain and neuropathy. Finally, half of the weight loss was regained after reversal. Reversal of RYGB may be an option in highly selected cases.

Validity of out-of-hospital and in-hospital cardiac arrest algorithms in the Danish National Patient Registry

Aims

Cardiac arrest is registered in the Danish National Patient Registry (DNPR) with the International Classification of Diseases 10th revision code I46. However, it does not distinguish between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). We validated an algorithm to identify cardiac arrest subtypes (out-of-hospital vs. in-hospital).

Methods

From Aarhus University Hospital, Denmark, we sampled patients with a primary or secondary cardiac arrest discharge diagnosis during 2019-2023. The algorithm categorized these patients as OHCA if they (1) only had a single department course during their hospitalization or (2) had multiple department courses during their hospitalization but were discharged with a cardiac arrest diagnosis from the first department course. The algorithm categorized the remaining patients as IHCA. We randomly sampled 200 patients with algorithm-based OHCA (n = 100) and IHCA (n = 100). Using medical record review as the reference, we calculated positive predictive values (PPVs) with 95% confidence intervals (CIs).

Results

Cardiac arrest was confirmed in 192 of 200 cases, yielding a PPV for cardiac arrest overall of 96% (95% CI: 92-98%). The PPV was 87% (95% CI: 79-92%) for OHCA and 61% (95% CI: 51-70%) for IHCA. The results were robust in age and sex strata.

Conclusions

The validity of a cardiac arrest diagnosis in the DNPR was overall high. The algorithm to distinguish cardiac arrest subtypes showed a high PPV for OHCA but a poor PPV for IHCA.

Sex-specific temporal trends in incidence and prevalence of chronic kidney disease: a Danish population-based cohort study

Background

Rates of chronic kidney disease (CKD) may change with ageing populations, rising metabolic and cardiovascular disease prevalence, increasing CKD awareness and new treatments. We examined sex-specific temporal trends in CKD incidence and prevalence from 2011 through 2021.

Methods

We conducted a population-based cohort study among adults residing in the North and Central Denmark Regions (population ∼1.5 million in 2021), utilizing routinely collected individual-level laboratory data. We identified individuals with incident or prevalent CKD, using data on plasma creatinine and urine albumin-creatinine ratios from samples performed in outpatient hospital settings or primary care. We estimated annual sex-specific crude and age-standardized incidence and prevalence and tabulated clinical characteristics.

Results

Throughout 2011-2021, CKD incidence and prevalence remained higher among females than males. A transient increase in the crude incidence was observed during 2011-2013, followed by a decrease from 11.8 per 1000 person-years in 2013 [95% confidence interval (CI) 11.5-12.1] to 10.7 in 2021 (95% CI 10.5-11.0) among females and from 10.9 (95% CI 10.7-11.2) to 10.6 (95% CI 10.3-10.8) among males. During 2011-2021, the crude prevalence increased among females from 85.1 per 1000 individuals (95% CI 84.4-85.8) to 99.9 (95% CI 99.2-100.6), and among males from 55.3 (95% CI 54.7-55.9) to 82.4 (95% CI 81.8-83.0). After age standardization, declines in incidence persisted, while the prevalence was stable among females, and the increase persisted among males.

Conclusions

The CKD incidence and prevalence remained higher among females than males during 2011-2021. Despite a notable decline in incidence rates from 2013 onwards, the crude prevalence increased during 2011-2021.

Adult Patients' Experiences of Closed Reduction Treatment for Distal Radius Fracture in the Emergency Department - A Qualitative Descriptive Study

INTRODUCTION

Distal radius fractures are common injuries managed frequently in emergency departments. While numerous studies focus on the surgical treatment of distal radius fractures, there is a lack of research about non-surgically treated patients' early experiences post-injury. The objective of this study was to explore adult patients' initial experiences following closed reduction treatment of distal radius fracture in the emergency department.

METHODS

This qualitative study involved semi-structured telephone interviews with 21 patients who underwent closed-reduction treatment at 2 hospitals in Southern Denmark. Interviews were conducted within the first week following ED treatment and analyzed thematically.

RESULTS

Patients were aged 42 to 91, and 3 were men. Three major themes emerged: (1) Pain Management: Patients reported significant pain during waiting periods and treatment, indicating a need for improved pain management strategies; (2) Information Dissemination: Participants expressed a need for clearer, continuous communication about their treatment and recovery expectations; and (3) Beyond the fracture: Patients were anxious about future functional abilities, especially those with dominant hand fractures, underscoring the need for holistic patient care that addresses psychological and social dimensions.

DISCUSSION

Effective pain management, both pharmacological and non-pharmacological, as well as comprehensive, clear communication, is crucial in the initial treatment phase of distal radius fracture. Acknowledging patients' broader concerns can enhance the quality of care and support improved recovery outcomes. These findings imply that future emergency nursing practice should prioritize swift and effective pain management, clear and empathetic communication, and a holistic approach to patient care to optimize recovery outcomes.

Influenza vaccine effectiveness in immunocompromised patients with cancer: A Danish nationwide register-based cohort study

BACKGROUND

Influenza vaccination is free of charge for Danish citizens with acquired immunodeficiency but recommendations do not specifically target patients with cancer. This study investigated whether influenza vaccination reduces the main outcome of overall mortality and the secondary outcomes of influenza requiring treatment, pneumonia, myocardial infarction, stroke, heart failure, and venous thromboembolism in patients with cancer.

METHODS

This was a register-based nationwide cohort study. Adjusted hazard ratios (aHRs) and 95% confidence intervals (95% CIs) for overall mortality and secondary outcomes were estimated using Cox proportional hazards models. Analyses were conducted separately for four subgroups: patients aged <65 years with solid tumors, patients aged ≥65 years with solid tumors, patients aged <65 years with hematological cancer, and patients aged ≥65 years with hematological cancer.

RESULTS

A total of 53,249 adult patients with solid tumors who received chemotherapy and 22,182 adult patients with hematological cancer were followed for up to five influenza seasons in the study period of 2007-2018. In the main analysis covering December-March, influenza vaccination was associated with reduced overall mortality in all four subgroups. The reduction was most pronounced in patients with hematological cancer aged <65 years (aHR, 0.66; 95% CI, 0.51-0.87) and smallest in patients with solid tumors aged <65 years (aHR, 0.91; 95% CI, 0.84-0.99). In sensitivity analyses covering January-March, the aHR was 0.87 (95% CI, 0.65-1.16) in patients with hematological cancer aged <65 years and 1.01 (95% CI, 0.92-1.10) in patients with solid tumors aged <65 years. Results for the secondary outcomes were inconclusive.

CONCLUSIONS

The results of this study cannot reject that influenza vaccination reduces overall mortality in immunocompromised patients with cancer. The results must be interpreted with caution because of potential unmeasured confounding, which can result in the overestimation of influenza vaccine effectiveness.

Long-term exposure to green and blue space and incidence of cardiovascular disease: A Danish Nurse Cohort study

BACKGROUND

Few cohort studies have examined the associations of natural surroundings (green and blue space) with cardiovascular disease (CVD) and show mixed findings. We aimed to investigate the associations between long-term exposure to green and blue space and incidence of CVD in the Danish Nurse Cohort.

METHODS

We followed 19,070 female nurses living in Denmark from 1993/1999 to 2018. The shortest Euclidian distance from a residence to three types of green space (park, woodland, and heathland) and four types of blue space (lake, river, coast, and wetland), along with total count of all types of natural surroundings within a 500 meter (m), 1000 m, and 5000 m radius from a residence, were calculated using GeoDanmark data from 2005. Distance was log-transformed to correct for a right-skewed data distribution. Residential air pollution and road traffic noise data for 2005 were estimated by the Danish air pollution modeling system ('DEHM/UBM/AirGIS') and Nord2000 model, respectively. Cox proportional hazards models were used to estimate associations between green and blue space and the first-ever incidence of total CVD and certain CVD subtypes after adjusting for individual factors, air pollution, and noise. We examined effect modification by age, smoking status, occupational status, household income, and urbanicity level. Hazard ratio (HR) and 95% confidence interval (95% CI) were presented per e unit (equivalent to ∼2.72 fold) increase in distance.

RESULTS

8179 new cases of CVD were observed over 344,084 person-years. Living further from woodland was associated with higher stroke incidence (HR: 1.153; 95% CI: 1.029-1.293), while living further from heathland was associated with reduced total CVD incidence (HR: 0.975; 95% CI: 0.955-0.996). No associations were found between distance to park, woodland, lake, river, coast, or wetland and total CVD incidence. Total count of all types of green and blue spaces within a 5000 m radius was linked to a reduced risk of CVD incidence. Adjusting for air pollution or road traffic noise did not alter observed associations. Younger individuals (<50 years old) were observed to have lower HRs when living closer to all types of natural surroundings.

CONCLUSION

We found that proximity to woodland was associated with a reduced risk of stroke, whilst no significant or even inverse associations were observed between proximity to other types of natural surroundings and CVD incidence. Total count of all types of natural surroundings within a 5000 m radius was negatively associated with CVD incidence, suggesting cumulative benefits of these areas.

Drug use and acute kidney injury: a Drug-Wide Association Study (DWAS) in Denmark and Sweden

Background

Knowledge of which medications may lead to acute kidney injury (AKI) is limited, relying mostly on spontaneous reporting in pharmacovigilance systems. We here conducted an exploratory drug-wide association study (DWAS) to screen for associations between dispensed drugs and AKI risk.

Methods

Using two large Danish and Swedish data linkages, we identified AKI hospitalizations occurring between April 1997 and December 2021 in Denmark and between March 2007 and December 2021 in Sweden. We used a case-time control design comparing drug dispensing in the 3 months prior to the AKI with earlier periods for the same patient. Odds ratios (ORs) for the association between each drug and AKI were estimated using conditional logistic regression and adjusting for the presence of comorbidities. We sought replication of signals in both health systems and explored the plausibility of findings through pharmacovigilance system analysis in the US Food and Drug Administration Adverse Event Reporting System (FAERS) database, appearance in the RESCUE list of medications that report AKI as a side effect, PubMed evidence review and causality assessment through direct acyclic graphs.

Results

We included 20 622 adults in Denmark and 13 852 in Sweden hospitalized for AKI. In total, 16 unique medications were identified in both cohorts as associated to increased AKI occurrence. Of these, 10 medications had higher reporting ORs in the FAERS database, 9 were listed by RESCUE, and 7 appearing in PubMed. This analysis identified some medications with known AKI risks (i.e. likely true positives such as furosemide, penicillin, spironolactone and omeprazole), medications that may have initiated in response to conditions that lead to AKI (i.e. false positives like metoclopramide provided to treat nausea/vomiting) and other candidates (e.g. opioids) that warrant further evaluation in subsequent studies.

Conclusions

This hypothesis-generating study identifies medications with potential involvement in AKI that require confirmation and validation.

Risk of psychiatric neurodevelopmental disorders after meningitis in childhood: a nationwide, population-based cohort study

BACKGROUND

Few studies have investigated the risk of psychiatric neurodevelopmental disorders (PNDD) after childhood meningitis.

METHODS

Nationwide population-based cohort study (Denmark, 1995-2021) of children with positive cerebrospinal fluid for bacteria or enterovirus, stratified on age as young infants (0 to <90 days, n = 637) or older children (≥90 days to <17 years, n = 1,218). We constructed a comparison cohort from the general population (n = 18,550), and cohorts of siblings of participants. As risk estimates of PNDD we calculated age- and sex-adjusted hazard ratios (aHRs) with 95% confidence intervals (95%CI).

RESULTS

Children with bacterial meningitis had increased risks of PNDD, especially learning and intellectual developmental disorders (young infants: aHR 4.2, 95%CI: 2.4-7.1; older children: aHR 1.5, 95%CI: 1.0-2.3), attention deficit disorder (ADHD) (young infants: aHR 2.8, 95%CI: 1.5-5.2; older children: 1.4, 95%CI: 0.9-2.2) and redemption of ADHD medication (young infants: aHR 2.2, 95%CI: 1.0-4.7; older children: 1.5, 95%CI: 1.0-2.3). Young infants with bacterial meningitis additionally had increased risks of autism spectrum disorders (aHR 1.9, 95%CI: 0.9-4.1) and behavioural and emotional disorders (aHR 2.0, 95%CI: 1.0-3.9). In young infants, the excess risk of PNDD was especially observed in premature children. Siblings of older children with bacterial meningitis also had increased risks of PNDD. Children with enteroviral meningitis at any age did not have increased risks of PNDD or redemption of ADHD medication.

CONCLUSIONS

Bacterial meningitis in childhood is associated with subsequent diagnosis of PNDD, while enteroviral meningitis is not. The association appears to be partly explained by prematurity and familial and socioeconomic factors.

Myeloproliferative Neoplasms and Dementia Risk: A Population-Based Cohort Study

Objectives

To estimate dementia risk for persons diagnosed with Philadelphia chromosome–negative myeloproliferative neoplasms (MPNs), which serve as a human chronic inflammation model.

Methods

We identified 9895 individuals in Denmark newly diagnosed with MPNs from 1995 to 2017; matched them 10:1 by age and sex with a general population cohort of 95 770 individuals; and followed them until dementia identification, death, emigration, or December 31, 2018. We applied a Cox proportional‐hazards regression model to estimate the cause‐specific hazard ratios (HRs) and 95% confidence intervals (CIs) for dementia. We included control diseases, like chronic lymphocytic leukemia (CLL), which is not characterized by chronic inflammation.

Results

Patients with MPNs showed a 1.15‐fold (95% CI: 1.04–1.27) increased incidence of dementia compared with members of the general population. Associations were stronger for men with MPNs (HR: 1.40, 95% CI: 1.19–1.63) than for women (HR: 1.02, 95% CI: 0.89–1.15). Patients with CLL showed a decreased dementia incidence (HR: 0.81, 95% CI: 0.72–0.90). The findings for CLL could be explained by depletion‐of‐susceptibles bias, suggesting that the findings for MPNs were underestimated by a similar bias.

Conclusions

The findings support MPNs as risk factors for dementia and the role of chronic inflammation in dementia development.

Time trends in mortality for people with severe mental illness in Denmark 2000-2018

PURPOSE

People with a severe mental illness (SMI) have a marked reduction in life expectancy which is largely attributable to somatic morbidity. Life expectancy has increased in Global North populations, yet it remains unclear whether people with SMI have benefitted equally from this increase. Our objective was to explore time trends of all-cause and selected cause-specific mortality among all people in Denmark with registered diagnosis codes of SMI: depression, bipolar disorder, or schizophrenia at psychiatric out- and in-patient settings.

MATERIALS AND METHODS

In consecutive yearly cohorts from 2000 to 2018, we examined all-cause and cause-specific mortality in all adults (aged ≥18) with and without diagnosis codes of SMI.

RESULTS

We found that all-cause mortality, and mortality from cardiovascular, cancer, respiratory, infections, trauma, and suicide were consistently elevated in those registered with SMI. While the crude all-cause mortality decreased substantially for all, also in people registered with SMI, after adjustment for sex and age, the mortality relative to people without SMI, remained unchanged or slightly increased for people registered with SMI, particularly among people registered with schizophrenia.

CONCLUSION

Despite a decrease in crude all-cause mortality, the consistently elevated mortality for people registered with SMI relative to the general population suggests that concerted efforts to reduce health inequity remain important.

Genetic variants and social benefit receipt in premenopausal women with breast cancer treated with docetaxel: a Danish population-based cohort study

PURPOSE

Breast cancer patients' need for social benefits may increase following taxane-based chemotherapy, due to long-lasting side effects. Specific single nucleotide polymorphisms (SNPs) may mediate such side effects. We investigated the association between SNPs related to taxane metabolism, transport, toxicity, or DNA and neural repair, and receipt of social benefits.

METHODS

From the Danish Breast Cancer Group, we identified premenopausal women diagnosed with stage I-III breast cancer during 2007-2011 and treated with docetaxel-based chemotherapy. We genotyped 21 SNPs from archived breast tumors using TaqMan assays. We ascertained social benefit payments from 1 year before to 5 years after diagnosis, using nationwide, administrative registry data. For each week, we categorized women as receiving health-related benefits (including sick leave and disability pension), labor market-related benefits (including unemployment benefits), or as being self-supporting. We computed rate ratios (RRs) of social benefit receipt for variant carriers (heterozygotes plus homozygotes) vs. non-carriers, using negative binominal regression with robust variance estimation.

RESULTS

Among 2430 women, 12% received health-related benefits before diagnosis, 80% at diagnosis, and ~ 24% 2 to 5 years after diagnosis. Labor market-related benefits were uncommon (3-6%). All RRs were near-null and/or imprecise.

CONCLUSION

We found no clinically meaningful impact of the selected SNPs on social benefit receipt among premenopausal breast cancer survivors treated with docetaxel.

Potential medicine waste in the process of outpatients receiving cost-free medicines from medicine pick-up lockers in the North Denmark region

OBJECTIVES

In the Danish healthcare system, restructuring is an ongoing process to accommodate the rising number of patients and to optimise resource allocation. To ease departmental burdens at hospitals in the North Denmark Region, outpatients are empowered to collect their cost-free medicines from medication pick-up lockers. The lockers function similarly to a package box, thereby enhancing patient freedom. Due to lack of evidence within the published literature regarding cost-free medicines and medicine waste, the aim of our study was to identify the common medications delivered to medicine pick-up lockers and secondly, to evaluate potential medicine waste.

METHODS

Data from ApoVision provided insights into medications delivered to medicine pick-up lockers from March to October 2023 in the North Denmark Region. To estimate unused medicines we obtained data on the number of medications returned from medicine pick-up lockers.

RESULTS

From 2020 to 2023, the number of patients receiving cost-free medicines at medication pick-up lockers increased. In total, approximately 30 000 packages of medicine were delivered to medicine pick-up lockers from March to October 2023 in the North Denmark Region; 1.7% were returned. Methotrexate, adalimumab, and omalizumab were among the most common deliveries and were also the three most returned from the medicine pick-up lockers.

CONCLUSIONS

This study is an initial attempt to investigate potential medicine waste in cost-free medicines dispensed to outpatients via pick-up lockers. Antineoplastic and immunomodulating agents were the most common medicines delivered to medication pick-up lockers in the North Denmark Region from March to October 2023. In this period, approximately 2% of all delivered medicine packages were returned to the hospital pharmacy. Our analysis solely focuses on waste associated with medications left uncollected from medicine pick-up lockers. Addressing the impact of medicine waste in a hospital setting requires a comprehensive approach, thus future studies should also focus on other sites relevant for medication waste as, for example, the patient's household.

Social disconnectedness, subsequent medical conditions, and, the role of pre-existing mental disorders: a population-based cohort study

AIMS

Individuals with diminished social connections are at higher risk of mental disorders, dementia, circulatory conditions and musculoskeletal conditions. However, evidence is limited by a disease-specific focus and no systematic examination of sex differences or the role of pre-existing mental disorders.

METHODS

We conducted a cohort study using data on social disconnectedness (loneliness, social isolation, low social support and a composite measure) from the 2013 and 2017 Danish National Health Survey linked with register data on 11 broad categories of medical conditions through 2021. Poisson regression was applied to estimate incidence rate ratios (IRRs), incidence rate differences (IRDs), and explore sex differences and interaction with pre-existing mental disorders.

RESULTS

Among 162,497 survey participants, 7.6%, 3.5% and 14.8% were classified as lonely, socially isolated and with low social support, respectively. Individuals who were lonely and with low social support had a higher incidence rate in all 11 categories of medical conditions (interquartile range [IQR] of IRRs, respectively 1.26-1.49 and 1.10-1.14), whereas this was the case in nine categories among individuals who were socially isolated (IQR of IRRs, 1.01-1.31). Applying the composite measure, the highest IRR was 2.63 for a mental disorder (95% confidence interval [CI], 2.38-2.91), corresponding to an IRD of 54 (95% CI, 47-61) cases per 10,000 person-years. We found sex and age differences in some relative and absolute estimates, but no substantial deviations from additive interaction with pre-existing mental disorders.

CONCLUSIONS

This study advances our knowledge of the risk of medical conditions faced by individuals who are socially disconnected. In addition to the existing evidence, we found higher incidence rates for a broad range of medical condition categories. Contrary to previous evidence, our findings suggest that loneliness is a stronger determinant for subsequent medical conditions than social isolation and low social support.A preregistered analysis plan and statistical code are available at Open Science Framework (https://osf.io/pycrq).

Hope is Not a Strategy: Key Lessons from COVID-19 for Future Health Crises

Introduction

The COVID-19 pandemic disrupted global economies, social structures, and public health systems. However, Denmark stood out as an exception, maintaining steady life expectancy during this period. This raises important questions about the factors that strengthened the Danish healthcare system and society against the pandemic's challenges.

Methods

The Danish healthcare system serves 5.8 million citizens with free care, advanced digital infrastructure, and comprehensive health registers. Under the auspices of the Danish Society for Patient Safety, insights from Denmark's response to COVID-19 were collected from the onset of the pandemic. This paper builds on these collected experiences, covering crucial areas such as strategies to reduce transmission, digitalization, management of non-COVID diseases, tracking adverse events, workplace well-being, development and use of predictive models, and maintaining public trust. Patient-level data on contacts, contact types, and clinical procedures were obtained from health administrative systems and clinical quality registries. All results were reported as raw counts, with no statistical analyses applied.

Results

During COVID-19, Denmark's healthcare system demonstrated resilience by adapting swiftly, achieving a high vaccination rate, shifting to virtual care, enhancing response capacity through real-time adverse event tracking, and supporting healthcare workers through crisis teams minimizing prolonged sick leave. Predictive models accurately forecasted healthcare demands, while public health strategies focused on monitoring public behavior and trust in authorities.

Discussion

A key lesson from Denmark's handling of COVID-19 is that much of the observed resilience stemmed from pre-existing structures that could be reused, further developed, and expanded. This resilience was further enhanced by an unprecedented readiness for change, cross-sectoral and interdisciplinary collaboration, and the removal of typical barriers. These experiences aim to further improve the quality and resilience of healthcare in Denmark and inspire other countries' healthcare systems. Moving forward, acknowledging chronic conflicts as the new normal, coupled with the reminder that "hope is not a strategy", could serve as a pivotal approach.

Hospital-Acquired Bloodstream Infections in Relation to Intensive Care Unit Stays During Hospitalization-A Population-Based Cohort Study

Background: Little is known about the clinical characteristics and pathogens causing hospital-acquired bloodstream infections (HA-BSIs) in relation to an intensive care unit (ICU) stay. Methods: Population-based cohort study, comprising 35% of the Danish population, 2009-2016. We derived four patient groups with first-time HA-BSIs: no ICU stay during the admission (non-ICU patients) and HA-BSI acquired before, in, or after an ICU stay (before-ICU, in-ICU, and after-ICU patients). These groups were compared in relation to microbiological and clinical characteristics, including 28- and >28-day mortality. Results: Among 6888 HA-BSI patients, 4017, 792, 1388, and 691 were non-ICU, before-ICU, in-ICU, and after-ICU, respectively. The rates of several microorganisms differed between the patient groups, e.g., Enterococci (9.4% of non-ICU and 32.0% of in-ICU patients). The 28-day mortality was 26.3% in non-ICU, 45.0% in before-ICU, 35.6% in in-ICU, and 19.0% in after-ICU patients. The corresponding adjusted hazard ratios (95% confidence interval) were 2.10 (1.85-2.36), 1.67 (1.50-1.87), and 0.76 (0.63-0.91) (reference: non-ICU patients). There were few differences as regards >28-day mortality. Conclusions: We found large differences between common microorganisms and prognosis between the four patient groups. After-ICU patients had the lowest 28-day mortality despite age and comorbidity characteristics similar to the other three groups.

Lifetime risk of lower extremity peripheral arterial disease: a Danish nationwide longitudinal study

BACKGROUND AND AIMS

Lower extremity peripheral arterial disease (PAD) presents a substantial disease burden, yet lifetime estimates remain scant. This nationwide study quantified the lifetime risk of PAD and its clinical outcomes in Denmark.

METHODS

This cohort study included 4 275 631 individuals in Denmark aged 40-99 years between 1998 and 2018. We estimated the lifetime risk using a modified survival analysis method, considering death as a competing risk event.

RESULTS

Over a median 15.5-year follow-up, 151 846 individuals were diagnosed with PAD (median age at diagnosis 71.5 years, interquartile range 63.1-79.2). The overall lifetime risk of PAD from age 40 was 11.6% (95% confidence interval 11.6%-11.7%), decreasing from 12.9% in 1998-2002 to 10.7% in 2013-18. Males had a higher lifetime risk than females (12.8% vs. 10.5%). Socioeconomic disparities were evident, with higher risks for those with lower educational levels (risk difference 3.4%, 95% confidence interval 3.2%-3.6%) and lower income (risk difference 0.4%, 95% confidence interval 0.2%-0.5%). One year after PAD diagnosis, 21.4% had undergone lower limb revascularization, 8.0% had experienced a major amputation, and 16.2% had died. At 5 years, the corresponding proportions were 26.4%, 10.8%, and 40.8%, respectively. The risk of lower limb revascularization showed little variation by sex and socioeconomic status, whereas there was a strong socioeconomic gradient for major amputation and all-cause death.

CONCLUSIONS

More than one in 10 Danish individuals are diagnosed with symptomatic PAD during their lifetime. Peripheral arterial disease diagnosis is associated with high morbidity and mortality at 1 and 5 years.

Association between socioeconomic position and discontinuation of pharmacotherapy for heart failure after cardiac resynchronization therapy

AIMS

Pharmacological therapy remains a cornerstone in heart failure (HF) treatment despite the implantation of a cardiac resynchronization therapy (CRT) device. The aim of this study was to investigate the association between (i) drug discontinuation and (ii) long-term adherence to HF pharmacotherapy after CRT implantation and socioeconomic position and multimorbidity.

METHODS AND RESULTS

We conducted a registry-based cohort study including all patients who underwent a first-time CRT implantation at Aarhus University Hospital from 2000 to 2017. Heart failure pharmacotherapy included beta-blockers (BBs), renin-angiotensin system inhibitors [angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB)], and mineralocorticoid receptor antagonists (MRAs). Patients were identified using the Danish Pacemaker and International Classification for Disease Registry, and information about medication and comorbidities was obtained through linkage to the Danish health registries. We identified 2007 patients, of whom 1880 (94%) were eligible for inclusion. The cumulative incidence of drug discontinuation at 10 years was 6% [95% confidence interval (CI) 5-8%] for BB, 10% (95% CI 9-12%) for ACEI/ARB, and 24% (95% CI 20-27%) for MRAs. Living alone was associated with higher BB discontinuation rates [hazard ratio (HR) 1.83, 95% CI 1.20-2.79], whereas patients with multimorbidity were more likely to discontinue ACEI/ARB (HR 1.92, 95% CI 1.33-2.80) and MRA therapy (HR 1.51, 95% CI 1.10-2.09). Income and educational level did not influence drug discontinuation rates, and similar adherence patterns were observed across all strata of socioeconomic position and multimorbidity.

CONCLUSION

In patients with CRTs, drug discontinuation rates were low, and adherence to HF pharmacotherapy was comparable regardless of socioeconomic position. Living alone and multimorbidity were associated with the discontinuation of specific HF drugs.

Nonattendance in preventive child health examinations associated with increased risk of school-aged obesity in Denmark

AIM

The aim of this study is to investigate associations between attending routine preventive child health examinations in general practice and the risk of obesity and overweight at age six, focusing on psychosocial risk factors.

METHODS

Data from nationwide Danish registers on 725 926 children born between 2000 and 2012 were analysed. Information on examination attendance and BMI was obtained. Regression analyses assessed the association between examination attendance and obesity or overweight risk.

RESULTS

Non-attendance in preventive child health examinations was associated with a risk of obesity of 18%-31% at age six. The highest risk was observed in children of parents with low educational attainment who missed all examinations, a four- to five-fold increase compared to children of parents with high educational attainment who attended all or missed only one exam. A smaller association of one to 2% was found between missing examinations and risk of overweight in the general population. However, children of parents with low educational attainment who did not attend were 8%-9% more likely to have overweight.

CONCLUSION

Associations were found between obesity and overweight and not attending preventive child health examinations in general practice. Further research is needed to understand the mechanisms and develop targeted interventions to address health disparities in childhood obesity.

Incidence and mortality of ALS: a 42-year population-based nationwide study

BACKGROUND AND AIM

Recent studies have suggested that the incidence rate (IR) and the rate of death (MR) of amyotrophic lateral sclerosis (ALS) are increasing. Still, it remains unclear whether this is due to improved case ascertainment or represents a true increase. We examined the development in the incidence and mortality of ALS in Denmark for 42 years.

METHODS

We retrieved individual-level data of all patients aged above 18 years with first-time ALS diagnosed at any Danish department of neurology. The IR and MR were calculated based on data from 1980 to 2021, stratified by gender and age.

RESULTS

We identified 5,943 patients with ALS and identified a total of 5,069 deaths in the nationwide population. Overall, the IR was 3.4 per 100,000 persons per year (95% CI 3.4-3.5). ALS incidence rose gradually during the study period, and the IR was 2.8 times higher (95% CI 2.4-3.2) when comparing the latest period (2018-2021) with the first (1980-1983). Parallel to the IR, the MR increased over time and was associated with male gender and rose with age at diagnosis, peaking in the 70-79-year age group.

CONCLUSION

In Denmark, the IR and MR of ALS increased threefold from 1980 to 2021, with steadily increasing risk related to male gender and in particular to higher age. Considering our aging societies, the number of elderly patients with ALS can be expected to increase considerably.

Cardiovascular Data Quality in the Danish National Patient Registry (1977-2024): A Systematic Review

Background

The increasing use of routinely collected health data for research puts great demands on data quality. The Danish National Patient Registry (DNPR) is renowned for its longitudinal data registration since 1977 and is a commonly used data source for cardiovascular epidemiology.

Objective

To provide an overview and examine determinants of the cardiovascular data quality in the DNPR.

Methods

We performed a systematic literature search of MEDLINE (PubMed) and the Danish Medical Journal, and identified papers validating cardiovascular variables in the DNPR during 1977-2024. We also included papers from reference lists, citations, journal e-mail notifications, and colleagues. Measures of data quality included the positive predictive value (PPV), negative predictive value, sensitivity, and specificity.

Results

We screened 2,049 papers to identify 63 relevant papers, including a total of 229 cardiovascular variables. Of these, 200 variables assessed diagnoses, 24 assessed treatments (10 surgeries and 14 other treatments), and 5 assessed examinations. The data quality varied substantially between variables. Overall, the PPV was ≥90% for 36% of variables, 80-89% for 26%, 70-79% for 16%, 60-69% for 7%, 50-59% for 4%, and <50% for 11% of variables. The predictive value was generally higher for treatments (PPV≥95% for 92%) and examinations (PPV≥95% for 100%) than for diagnoses (PPV≥80% for 71%). Moreover, the PPV varied for individual diagnoses depending on the algorithm used to identify them. Key determinants for validity were patient contact type (inpatient vs outpatient), diagnosis type (primary vs secondary), setting (university vs regional hospitals), and calendar year.

Conclusion

The validity of cardiovascular variables in the DNPR is high for treatments and examinations but varies considerably between individual diagnoses depending on the algorithm used to define them.

The Western Denmark Myocardial Perfusion Imaging Registry: A Review and Validation Study

Purpose

Myocardial perfusion imaging (MPI) procedures from single photon emission computed tomography and positron emission tomography imaging have been registered in the Western Denmark Heart Registry (WDHR) since 2017 as a sub-registry (WDHR-MPI). The aim was to review the content, quality, and research potential of the WDHR-MPI and assess the completeness and validity of its key variables.

Patients and Methods

Using the Danish National Patient Registry (DNPR) as a reference, we calculated the completeness of procedure registration as the proportion of procedures registered in the WDHR-MPI from 2017 to 2021. We defined completeness of variable registration as the proportion of non-missing values for a given variable and examined it for 38 key variables. We assessed validity by estimating the positive predictive values (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) for 26 selected key variables using corresponding extracted information from 300 randomly selected patient records.

Results

We identified 19,084 procedures in 17,871 patients from all seven cardiac centers performing nuclear cardiology procedures in the WDHR uptake area. The registry accumulated 4000-6000 procedures each year from 2019 to 2021. The overall completeness of procedure registration was 72% (95% CI 72-73), increasing from 14% (95% CI 13-15) in 2017 to 98% (95% CI 98-98) in 2021. The mean completeness of variable registration was 89%. The validity of entered data was high, with an overall PPV for the selected key variables of 95% (95% CI 94-95) and NPV of 94% (95% CI 93-96).

Conclusion

The WDHR-MPI is one of the largest systematic MPI cohorts. The overall high completeness and validity of the data support its potential for cardio-epidemiological research.

Biological Heterogeneity in Susceptibility to Glucocorticoid-Induced Bone Loss: Short- and Long-Term Hip BMD Trajectories

CONTEXT

Glucocorticoids (GCs) are widely used for their anti-inflammatory and immunosuppressive properties. Their effect on bone health is predominantly negative by decreasing bone formation and increasing risk of fractures.

OBJECTIVE

This work aimed to quantify the short- and long-term changes in total hip bone mineral density (THBMD) after initiating systemic GC treatment in previously GC treatment-naive adults without bone protective agents.

METHODS

An observational study was conducted using THBMD data from dual-energy x-ray absorptiometry (DXA). Individuals were stratified by sex and tertiles of GC exposure. Individuals not GC-exposed served as a reference group. Routine-care DXA scans were obtained from the main public hospitals servicing the Island of Funen in Denmark. A total of 15 099 adults underwent routine DXA at Odense University Hospital between 2006 and 2021. Data were enriched with Danish national registers. Intervention included systemic GCs (observational data). The short-term outcome included annualized THBMD changes between first 2 DXA scans. The long-term outcome included greater than 5% annualized THBMD loss over a 10-year follow-up.

RESULTS

Strong associations between GC exposure and THBMD loss was found for both outcomes, with larger losses in the middle and upper tertiles of GC exposure. The risk of experiencing greater than 5% annualized THBMD loss was elevated, especially in the first 2 years of initiating GC treatment. There is significant heterogeneity in THBMD responses, with approximately 1 in 5 patients experiencing no nominal bone loss despite receiving upper tertile levels of GC exposure.

CONCLUSION

The findings confirm the association between initial GC exposure and significant bone loss. The heterogeneity in individual responses emphasizes the need for early monitoring and personalized approaches in managing bone health for patients undergoing GC treatment.

Prevalence and clinical characteristics of incontinentia pigmenti: a nationwide population-based study

BACKGROUND

Incontinentia pigmenti (IP) is an X-linked dominant multisystemic disorder caused by pathogenic variants in the IKBKG gene. Population-based research into the epidemiology of IP is lacking.

METHODS

This nationwide cross-sectional study from Jan 1st, 1995 to August 25th, 2021, searched the Danish National Patient Registry (DNPR), the Danish National Database of Rare Genetic Diseases (RareDis) and the Danish Genodermatosis Database to identify patients recorded with a diagnosis of IP. This search was followed by diagnosis validation and collection of clinical data from patient medical records. We investigated the clinical characteristics and genetics of the final cohort of validated IP cases. We estimated the point prevalence in the Danish population, based on non-deceased IP patients currently living in Denmark. Furthermore, we estimated the birth prevalence from 1995 to 2020, assuming a diagnostic delay of up to six months.

RESULTS

We identified a validated cohort of 75 IP patients, including 71 (94.7%) females and 4 (5.3%) males. We estimated a birth prevalence of 2.37 (95% CI: 1.74-3.25) per 100,000 or 1 in 42,194. A total of 54 (72%) patients had a genetic diagnosis, including 39 (72.2%) with the recurrent exon 4-10 deletion and 10 (18.5%) with point mutations in IKBKG. A positive family history was reported in 53.3%. Besides the recognizable blaschkolinear skin lesions reported in 70 (93.3%) of the patients, commonly reported manifestations included the involvement of the teeth (58.7%), the central nervous system (30.7%), hair (26.7%), and eyes (22.6%), as well as nail dystrophy (16.0%).

CONCLUSIONS

We identified and characterized a nationwide population-based cohort of IP patients and report a birth prevalence of 2.37 per 100,000 live births, which is twice as high as previous estimates.

Risk factors associated with clinically relevant pericardial effusion after primary cardiac implantable electronic device implantation

INTRODUCTION

Pericardial effusion, a known complication to implantation of cardiac implantable electronic devices (CIED), may cause life-threatening cardiac tamponade. Limited knowledge is available about risk factors for clinically relevant procedural pericardial effusion. The aim is to identify the patient- and procedure-related risk factors associated with clinically relevant procedural pericardial effusion.

METHOD

A nationwide observational cohort study based on data on 55 121 patients from the Danish Pacemaker Register between 2000 and 2018. We defined a clinically relevant procedural pericardial effusion related to the implantation if it occurred within 90 days after the primary CIED-procedure. Prespecified risk factors were analysed by multivariable logistic regression models to estimate the association with pericardial effusion.

RESULTS

There were 115 (0.21%) patients diagnosed with clinically relevant procedural pericardial effusion, with a median age of 75 years and 38.3% were females. Of these, 80.9% lead to a subsequent pericardiocentesis procedure. In adjusted logistic regression analysis, an increased risk of clinically relevant pericardial effusion was associated with female sex (OR:1.49 [95%CI: 1.03-2.16]), heart failure (OR:1.54 [95%CI: 1.06-2.23]), previous cardiac surgery (OR:1.63 [95%CI: 1.05-2.55]), CRT-device (OR:2.05 [95%CI: 1.23-3.41]), tertiary-centres (OR:1.8 [95%CI: 1.18-2.73]), increased procedural volume per year (>1000) (OR:1.85 [95%CI: 1.03-3.30]), indication of device-implantation (atrioventricular block) (OR:2.37 [95CI: 1.45-3.87]), and increasing number of leads implanted (two leads (OR:2.39 [95%CI: 1.43-4.00]), three leads (OR:4.77 [95%CI: 2.50-9.10])).

CONCLUSION

Clinically relevant procedural pericardial effusion is a rare complication after CIED-implantation in Denmark. This study reveals important patient- and procedure-related risk factors associated with clinically relevant procedural pericardial effusion.

Risk of post-injection endophthalmitis peaks within the first three injections of anti-vascular endothelial growth factor therapy: A nationwide registry-based study

PURPOSE

To report the incidence of post-injection endophthalmitis (PIE) and the cumulative risk associated with repeated injections of intravitreal anti-vascular endothelial growth factor (anti-VEGF).

METHODS

We employed nationwide registries in Denmark to include all individuals aged ≥40 years who received at least one intravitreal anti-VEGF injection in 2007-2022. Our primary endpoint PIE was identified using specific diagnostic codes for endophthalmitis and procedure codes for vitreous biopsy within 10 days prior to and 120 days post-injection. Patients were stratified according to the underlying diagnoses for which they received the treatment. The relative risk (RR) for PIE was calculated between groups based on the number of injections received by the patients.

RESULTS

We identified 60 825 patients who received intravitreal anti-VEGF treatment during study time, with a median age of 77.2 years and females constituting 58.1%. We identified 232 cases of PIE after 1 051 549 injections during follow-up, resulting in an incidence of 0.022% [95% CI 0.019%-0.025%]. Despite a linear growth in annual anti-VEGF use, the incidence remained stable at 0.020% [95% CI 0.017%-0.023%] from 2013 to 2022. Compared to patients receiving 1-3 injections, RR for patients receiving 4-20, 21-40, and >40 injections were 0.46 [95% CI 0.34-0.63], 0.32 [95% CI 0.21-0.50], and 0.54 [95% CI 0.36-0.81], respectively. Findings were similar across the different diagnoses.

CONCLUSIONS

Based on 16 years of nationwide registry data, this study identified a low and stable incidence of PIE. Notably, the highest risk of endophthalmitis was within the first three anti-VEGF injections.

Healthcare Utilisation in Danish Primary Care Among Patients With Low Back or Neck/Thoracic Spine Pain Before and After Assessment in Secondary Care

OBJECTIVES

To describe characteristics and primary healthcare utilisation in Danish patients with low back pain (LBP) or neck/thoracic spine pain (NTP) 8 years before and 2 years after assessment in secondary care.

METHODS

In this cohort study, we included patients aged ≥ 18 who were assessed at an outpatient spine clinic from 2013 to 2021 and linked self-reported information with national registry data. We calculated the prevalence of all-cause healthcare utilisation in primary care. Then, we determined changes in the number of consultations from before to after assessment in secondary care using generalised estimating equations.

RESULTS

We included 56,949 LBP patients and 18,926 NTP patients. The baseline characteristics were similar overall. For both LBP and NTP, all-cause healthcare utilisation increased slightly over time, with a substantial increase in the quarter before the secondary care assessment and a decrease after. Before the assessment, almost all patients consulted general practitioners (95%), while some consulted physiotherapists or chiropractors (60%). Overall, consultations decreased by 19% and 17% for patients with LBP and NTP from 12 to 1 month before to 1-12 months after the assessment. In contrast, 13-24 months after assessment, we found a slight increase in consultations in both groups compared to the same period before.

CONCLUSIONS

Patients with LBP and NTP were similar and used similar primary healthcare, which slightly increased over the 10 years. As physiotherapists and chiropractors are first-line providers of guideline-recommended spine pain treatment, the finding that 40% did not consult these professions the year before the secondary care assessment indicates that not all patients receive recommended care before referral.

Risk of recurrence in early-onset versus late-onset non-metastatic colorectal cancer, 2004-2019: a nationwide cohort study

Background

The incidence of colorectal cancer (CRC) in individuals younger than 50 years of age (early-onset CRC) is increasing. Early-onset CRC often present at advanced stage, suggesting a more aggressive cancer course compared to late-onset CRC (age 50-79). This nationwide cohort study estimates the incidence of recurrence following early-onset CRC and late-onset CRC.

Methods

The study included all Danish patients <80 years old operated for first-time Union for International Cancer Control (UICC) stage I-III CRC between January 2004 and December 2019. Recurrence status was determined by applying a validated algorithm to individual-level data from nationwide health registries. The 5-year cumulative incidence functions (CIF) of recurrence were reported for early-onset versus late-onset CRC. The difference in time to recurrence was estimated as a time ratio (TR) using an accelerated failure time model.

Findings

Among 25,729 CRC patients, 1441 (5.6%) had early-onset CRC. Compared to late-onset CRC, early-onset was associated with advanced disease stages and higher treatment intensity. The 5-year CIF of recurrence was 29% (95% CI: 26%-31%) in early-onset versus 21% (95% CI: 21%-22%) in late-onset CRC. The higher CIF of recurrence for early-onset patients persisted in stage-stratified analysis. Time to recurrence was shorter in early-onset versus late-onset patients with TR = 0.76 (95% CI: 0.67-0.85). The 5-year CIF of recurrence decreased from 2004 to 2019 for both early- and late-onset patients-most prominent for early-onset patients.

Interpretation

Early-onset CRC was associated with higher incidence of recurrence at all disease stages. Indicating that the increased risk is not explained by delayed diagnosis. The excess risk diminished from 2004 to 2019, suggesting that early-onset CRC may achieve a similar recurrence risk as late-onset CRC in a contemporary setting.

Funding

Aarhus University, Novo Nordisk Foundation, Innovation Fund Denmark, and the Danish Cancer Society.

Comparing budesonide treatment in eosinophilic esophagitis: a specialized center cohort versus a population-based cohort

OBJECTIVE

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease. The budesonide orodispersible tablet (BOT) is recommended as second-line treatment according to the Danish guideline. This study aimed to compare potential treatment disparities before BOT initiation, follow-up practices, clinico-histologic remission rates during BOT treatment, and adherence to the national guideline between the highly specialized EoE-Cph cohort and the population-based DanEoE cohort.

MATERIAL AND METHODS

This cohort study compared 65 adult patients from the EoE-Cph cohort with 65 patients from the DanEoE cohort. All patients were diagnosed between 2015-2021. The diagnosis of EoE was defined according to the AGREE consensus. Data were extracted manually from medical records and registries.

RESULTS

In the EoE-Cph cohort, 88% were prescribed proton pump inhibitors (PPIs) before started on BOT compared to 100% in the DanEoE cohort (p = 0.0035). Symptomatic follow-up occurred in 89% of EoE-Cph patients compared to 97% of DanEoE patients after BOT treatment (p = 0.0841). No difference was found between patients who underwent histologic follow-up after topical steroid treatment (83% versus 82%, p = 0.8162). Complete clinico-histologic remission was frequently observed, and no significant difference was observed between the two cohorts (67% versus 80%, p =0.1789). One out of four patients had conflicting symptomatic and histological responses.

CONCLUSIONS

This study did not provide conclusive evidence favoring the treatment of EoE patients exclusively at highly specialized EoE centers. However, the authors acknowledge that further evidence is necessary before considering changes in clinical practice. Conflicting treatment responses, and discontinuation of treatment due to side effects remains a notable concern.

Incidence and clinical course of chronic thromboembolic pulmonary hypertension with or without a history of venous thromboembolism in Denmark

BACKGROUND

A considerable number of patients with chronic thromboembolic pulmonary hypertension (CTEPH) lack a history of venous thromboembolism (VTE).

OBJECTIVES

We aimed to examine the annual incidence and prevalence of CTEPH in Denmark and to compare the rates of VTE, bleeding, and mortality between CTEPH patients with and without a history of VTE.

METHODS

The Danish National Patient Registry covering all Danish hospitals was used to identify all CTEPH cases between 2009 and 2018, based on combinations of discharge diagnoses using International Classification of Diseases, 10th Revision codes for CTEPH and relevant diagnostic and/or therapeutic interventions. Incidence rates of CTEPH per 100 000 person-years, rates of VTE and bleeding, and 5-year survival estimates were calculated.

RESULTS

In total, 509 CTEPH patients were identified, of whom 82% had a history of VTE. The yearly incidence rate of CTEPH was 0.5 to 0.8 per 100 000 person-years during the study period. Patients with a history of VTE experienced a 2.5-fold rate of VTE compared with those without prior VTE (2571 vs 980 per 100 000 person-years), while the rate of bleeding events was lower (5008 vs 7139 per 100 000 person-years). The 5-year survival of CTEPH patients with a VTE history was 65% (95% CI, 58%-71%) compared with 45% (95% CI, 31%-58%) in patients without a history of VTE.

CONCLUSION

The Danish incidence rate of CTEPH was comparable with that of other European countries. We identified notable differences in the prognosis of patients with CTEPH with or without a history of VTE. These findings may support generation of hypotheses regarding the pathophysiology of CTEPH and inform current patient care.

Healthcare-seeking behaviour preceding diagnosis of Lyme neuroborreliosis: population-based nationwide matched nested case-control study

OBJECTIVES

To identify diagnostic opportunities, we investigated healthcare-seeking behaviour among patients with Lyme neuroborreliosis (LNB) within 28 weeks before diagnosis.

METHODS

We conducted a population-based, nationwide matched nested case-control study (Denmark, 2009-2021). As cases, we included all Danish residents with LNB (positive Borrelia burgdorferi intrathecal antibody index test and cerebrospinal fluid pleocytosis). We randomly selected controls from the general population and matched 10:1 on date of birth and sex. Exposures were assignment of diagnostic codes for symptoms, contact to medical specialties, medical wandering, and undergoing diagnostic procedures. We calculated the weekly and 3-month proportions of individuals with exposures and calculated absolute risk differences with corresponding 95% CI.

RESULTS

We included 1056 cases with LNB and 10 560 controls. Within 3 months before diagnosis, the most frequent assigned symptoms were pain (difference: 13.0%, 95% CI: 10.9-15.1). Cases with LNB exhibited increased contact with most specialties, particularly general practitioners (difference: 48.7%, 95% CI: 46.0-51.4), neurology (difference: 14.3%, 95% CI: 11.7-16.8), and internal medicine (difference: 11.1%, 95% CI: 8.7-13.5), and medical wandering (difference: 17.1%, 95% CI: 14.3-20.0). Common diagnostic procedures included imaging of the brain (difference: 10.2, 95% CI: 8.3-12.1), the spine (difference: 8.8%, 85% CI: 7.0-10.6), and the abdomen (difference: 7.2%, 95% CI: 5.4-9.1). The increase in healthcare-seeking behaviour was observed ≤12 weeks preceding diagnosis.

DISCUSSION

Pain appears to be an ambiguous symptom of LNB, potentially contributing to delays in establishing the correct diagnosis. It would be difficult to identify patients with LNB more effectively as the increased healthcare-seeking behaviour preceding diagnosis is distributed across many medical specialties.

Psychiatric disorders among survivors of childhood acute lymphoblastic leukemia in Denmark and Sweden

BACKGROUND

The diagnosis and treatment of childhood acute lymphoblastic leukemia (ALL) may impact mental health. We investigated the long-term risk of psychiatric disorders among survivors of ALL in a population-based cohort study.

METHODS

We identified patients diagnosed with ALL in Denmark and Sweden before age 20 during 1982-2008. Survivors of ALL (n = 2026), their siblings (n = 3027), and population comparison subjects (n = 9713) were followed for hospital contacts for psychiatric disorders from 5 years after ALL diagnosis (or corresponding index date) until 2017.

RESULTS

By age 30, the absolute risk of psychiatric hospital contacts was 19.9% (95% confidence interval [CI]: 17.9-22.1) for ALL survivors, 18.5% (95% CI: 16.9-20.2) for siblings, and 18.3% (95% CI: 17.3-19.2) for population comparison subjects. Overall, survivors were at higher risk of any psychiatric disorders than siblings (hazard ratio [HR] = 1.25; 95% CI: 1.04-1.50), and population comparison subjects (HR = 1.20; 95% CI: 1.06-1.35). The subgroup of survivors (n = 332) who received a hematopoietic stem cell transplantation (HSCT) and/or had a relapse were at highest risk of psychiatric disorders (HR = 2.07; 95% CI: 1.26-3.41 compared to siblings; HR = 1.67; 95% CI: 1.25-2.23 compared to population comparison subjects).

CONCLUSIONS

The overall absolute risk of psychiatric hospital contacts among ALL survivors was close to that in siblings and population comparison subjects. The modestly increased relative risk was mainly driven by the subgroup of survivors who received HSCT and/or had a relapse. Our findings are reassuring for the large subgroup of ALL survivors without HSCT or relapse, and provide novel insight on both absolute and relative risk of hospital contacts for psychiatric disorders.

Gastroschisis Prevalence and Co-occurring Malformations Among Danish Live Births During 1994-2021: A Nationwide Register-Based Study

BACKGROUND

Gastroschisis prevalence has increased for decades with corresponding increases in the need for immediate and follow-up care. Such care can be complicated by presence of co-occurring malformations. This study explores prevalence of gastroschisis and co-occurring malformations among a 28-year cohort of Danish live-born infants.

METHODS

This retrospective cohort study used data from 1,695,992 infants born in Denmark during 1994-2021 and registered in the neonatal screening program. Infants were identified from the Danish Civil Registration System and Danish National Patient Register accessed through the Danish Biobank Register. Data on co-occurring malformations were ascertained to classify infants as syndromic or non-syndromic (either isolated or with co-occurring major malformations) and on selected infant and parental characteristics. Poisson regression models were used to estimate prevalence and corresponding 95% confidence intervals (CIs).

RESULTS

Prevalence (per 10,000 live births) of gastroschisis was 1.64 (CI: 1.45-1.84). Temporal trend analyses showed a statistically significant annual increase of 2.8% (CI: 1.4-3.3). Infants with gastroschisis most often presented as isolated (77.7%; CI: 72.3-82.5), followed by those with co-occurring malformations (21.9%; CI: 17.2-27.3) or a diagnosed syndrome (0.4%, CI: <0.1-2.0). Among infants with co-occurring malformations, cardiovascular (10.9%; CI: 6.8; 12.2) and intestinal (9.0%; CI: 5.9-12.2) malformations were most frequently recorded. Prevalence was higher among infants classified as premature but not influenced by infant sex or parental nativity.

CONCLUSION

Gastroschisis prevalence in Denmark increased during 1994-2021, similar to international reports, without increase in co-occurring malformations. Future work with this cohort will characterize healthcare received, comorbidities, and outcomes across the lifespan.

LEVELS OF EVIDENCE

Level III (High-quality prospective cohort study).

The Western Denmark Heart Registry and Population-Based National Health Registries

The Western Denmark Heart Registry (WDHR) is a semi-national, multicenter-based clinical registry with unique potential for cardiovascular research. The registry has provided detailed prospectively registered information on patient and procedure characteristics since 1999. WDHR data can be linked to additional data in other healthcare registries in Denmark. Therefore, the WDHR is a valuable data resource for cardiovascular research, providing a foundation for numerous research projects and publications. This review describes three currently available cohorts from the WDHR containing individual-level information on: i) 200,647 first-time coronary angiographies from 2003 to 2021, ii) 88,630 first-time percutaneous coronary interventions from 1999 to 2022, and iii) 85,512 first-time coronary computed tomography angiographies from 2008 to 2021. Furthermore, we describe other frequently cross-linked Danish healthcare registries containing information on various patient characteristics and outcomes, such as vital status, cause of death, hospitalizations, medications, and laboratory test results. The comprehensive overview of these cohorts aims to assist researchers, collaborators, and other interested parties in understanding the scope and potential applications of the available data. All cohorts are regularly updated, thereby supporting continuing research on cardiovascular clinical practice and prognosis in Denmark.

Omphalocele prevalence and co-occurring malformations: a nationwide register-based study of Danish live births in 1997-2021

PURPOSE

Omphalocele is a congenital abdominal wall defect associated with a high risk of morbidity and mortality, with co-occurring congenital malformations often being the most important prognostic factor. High rates of spontaneous and medical terminations have been reported among pregnancies with omphalocele and co-occurring malformations. Few studies have focused on co-occurring malformations, particularly non-gastrointestinal malformations among live births. This study examined birth prevalence of omphalocele and co-occurring major malformations among a 25-year Danish liveborn cohort.

METHODS

This nationwide retrospective prevalence study used data from the Danish National Patient Register and Danish Civil Registration System for infants who were delivered in Denmark during 1997-2021 and included in the Danish neonatal screening biobank. Diagnoses of omphalocele and co-occurring malformations were ascertained and prevalence estimated using Poisson regression.

RESULTS

Among 1,498,685 live births, 147 infants with omphalocele were identified, yielding a combined and stable prevalence (per 10,000 infants) of 0.98 (95% CI 0.83-1.15). Over one-half (53.7%) presented with one or more major malformations, and an additional 17.0% were diagnosed with a syndrome.

CONCLUSIONS

Omphalocele birth prevalence in Denmark was stable over a recent 25-year period. The proportion of infants with co-occurring major malformations or diagnosed syndrome has important implications for long-term healthcare demands.

Ibuprofen for Acute Pericarditis and Associated Cardiovascular Risks: A Danish Nationwide, Population-Based Cohort Study

Purpose

Ibuprofen is used to treat acute pericarditis, but high-dose ibuprofen has also been associated with increased cardiovascular risks. We examined the cardiovascular safety of using ibuprofen for acute pericarditis.

Patients and Methods

A Danish nationwide, population-based cohort study including patients ≥18 years with first-time acute pericarditis (n=12,381) during 1996-2020 was conducted. Ibuprofen use was modelled in two ways: First, we considered patients exposed based on the tablet strength of their first ibuprofen filling (a proxy for an intention-to-treat analysis). Second, we considered patients exposed in a time-varying manner (a proxy for an as-treated analysis). The primary outcome of major adverse cardiovascular events (MACE) was a composite of myocardial infarction, ischemic stroke, congestive heart failure, and cardiovascular death.

Results

In the intention-to-treat analysis, the 1-year risk of MACE was 1.37% (95% confidence interval [CI]: 1.03-1.79) for ibuprofen initiators and 4.32% (95% CI: 3.89-4.78) for non-initiators. Compared with non-initiators within 1-year follow-up, the adjusted hazard ratio for MACE was 0.75 (95% CI: 0.67-0.85) for initiators overall, 0.38 (95% CI: 0.28-0.52) for initiators of >400 mg tablets, and 0.87 (95% CI: 0.76-0.99) for initiators of ≤400 mg tablets. In the as-treated analysis, compared with no use, the hazard ratio associated with ibuprofen use was 0.69 (95% CI: 0.54-0.89) for MACE, 0.82 (95% CI: 0.54-1.26) for myocardial infarction, 0.74 (95% CI: 0.45-1.22) for ischemic stroke, 0.67 (95% CI: 0.47-0.96) for congestive heart failure, and 0.60 (95% CI: 0.31-1.17) for cardiovascular death.

Conclusion

Ibuprofen use for acute pericarditis was not associated with increased cardiovascular risks, supporting its safety in current practice.

The Danish National Hospital Medication Register: A Resource for Pharmacoepidemiology

Background

The Danish National Hospital Medication Register (DHMR), one of the first nationwide in-hospital medication registries in the world, contains detailed information on medication administration and dispensing.

Objective

To provide an overview of the information recorded in the DHMR and to highlight its strengths and limitations as a pharmacoepidemiological research tool.

Methods

We reviewed the registry´s geographic and clinical specialty coverage and medications recorded according to the main groups of the Anatomical Therapeutic Chemical classification system.

Results

From May 2018 through December 2023, the DHMR recorded data on more than 1.9 million unique patients from all approximately 50 public hospitals and associated hospital outpatient clinics, totaling 105.3 million recordings of hospital medication use. The registry records detailed data on the indication for medication, medication type, pharmaceutical form, dosage, and administration time, collected through electronic medical record systems. Although the data quality has not yet been evaluated in a scientific context, some potential limitations are known. These include regional differences in the data collection and a lack of data from certain clinical specialties. Due to its recent establishment in 2018, the registered number of patients treated may still be limited for some rarely used medications.

Conclusion

The DHMR is an important new resource for research in Denmark. Combined with the Danish National Prescription Registry, which covers all community pharmacies, it offers access to accurate data on medication exposure in the Danish population. Users should be aware of potential issues with lack of information before 2018.

Time trends in incidence of pilonidal sinus disease from 1996 to 2021: A Danish population-based cohort study

AIM

Pilonidal sinus disease (PSD) is a common condition, but no data on disease occurrence exist outside highly selected settings. The aim of this study was to assess time trends in the incidence of PSD in a nationwide setting.

METHOD

Using data from nationwide Danish registries, we identified 48 247 patients recorded with diagnostic or surgical procedure codes representing PSD between 1996 and 2021. We stratified by sex and computed the age-adjusted and age-specific incidence rate, comparing 5-year intervals with the incidence rate ratio (IRR).

RESULTS

The overall incidence of PSD increased from 26.1 to 39.6/100 000 person-years (PY) from the period 1996-2000 to the period 2016-2021 (IRR 1.52, 95% CI 0.78-2.94). The incidence increased from 35.8 to 56.9/100 000 PY (IRR 1.59, 95% CI 0.52-4.89) in male patients and from 16.4 to 22.5/100 000 PY (IRR 1.37, 95% CI 0.68-2.76) in female patients. The peak of age-specific incidence was 215.7/100 000 PY (95% CI 206.1-245.4) among 20-year-old men and 107.9/100.000 PY (95% CI 100.0-114.0) among 18-year-old women. Over the study period, the median age at first hospital contact decreased from 27 years [interquartile range (IQR) 22-34 years) to 25 years (IQR 20-34 years) in men but remained stable around 23 years (IQR 18-32 years) in women. However, for both sexes, the highest increase in incidence was seen in early adolescence.

CONCLUSION

The incidence of PSD has increased significantly over the last decades. The increase is driven primarily by men and boys, with the highest increase in incidence seen in early adolescence. The increased burden of disease is not reflected in the literature, and more studies are warranted to understand the drivers of this development.

Detection of colorectal cancer and advanced neoplasia during first surveillance interval after detection of adenomas in fecal immunochemical test cancer screening: a nationwide study

BACKGROUND

Adenoma surveillance guidelines are based on non-fecal immunochemical test (FIT)-based screening settings. However, colorectal cancer (CRC) risk may be different in FIT-positive screening populations. We evaluated the CRC and advanced adenoma risk within the recommended surveillance periods in the Danish FIT-based CRC screening program for participants with intermediate or high risk adenomas according to 2010 European guidelines. Furthermore, we estimated CRC risk for those who were not recommended surveillance according to European Society of Gastrointestinal Endoscopy (ESGE) 2020 guidelines.

METHODS

Using nationwide health registries, we identified 17 936 FIT-screening participants from 2014-2017 with adenomas undergoing surveillance (high risk 1 year, intermediate risk 3 years). Participants with a follow-up examination were included (N = 10 068). Relative risk (RR) of CRC and advance adenoma was compared between intermediate and high risk groups and between intermediates who were recommended surveillance (S) or no surveillance (NS) according to 2020 ESGE guidelines.

RESULTS

During surveillance, CRC occurred in 0.59% of the high risk group and 1.11% of the intermediate risk group (RR 0.53 [95%CI 0.34-0.84]). The high risk group had a 24% increased risk of advanced adenoma. CRC occurred in 1.69% of the intermediateNS group and 0.87% of the intermediateS group (RR 1.94 [95%CI 1.18-3.21]), and RR for advanced adenoma was 1.19 (95%CI 1.03-1.37).

CONCLUSION

CRC detection was lower among participants rated at higher risk at initial CRC screening. Findings at first screen-derived colonoscopy might not be as good a predictor of CRC risk in a FIT-positive screening population.

Development of A structured integrated post-Pulmonary Embolism care model: The Attend-PE model

BACKGROUND

More than 50% of patients with pulmonary embolism (PE) experience persistent functional limitations. Despite guideline recommendations for a structured integrated care model for patients with PE, consensus on an optimal follow-up strategy is lacking, and evidence is insufficient.

OBJECTIVES

To describe the development of a structured model for PE follow-up using coproduction methods.

METHODS

Coproduction of A structured integrated postPulmonary Embolism care (Attend-PE) model was conducted from October 2021 to June 2022, featuring participatory design techniques. This was combined with a stepwise approach based on Intervention Mapping to ensure that the developed model was evidence-based and theoretically grounded.

RESULTS

Development of the Attend-PE model included 1) a needs assessment mapping follow-up at 18 sites treating PE in Denmark; 2) definition of the overall goal and performance objectives of the Attend-PE model, based on the needs assessment in combination with a literature review; 3) coproduction of the Attend-PE model in workshops with patient representatives, healthcare professionals, and experts in the field; and 4) refinement of the structure and organization of the Attend-PE model and production of the patient education material. The Attend-PE model outlines a structured approach for in-hospital follow-up, involving group-based patient education, individual consultations, and patient-reported outcomes to assess physical and psychological well-being. The model supports a personalized posthospitalization care plan.

CONCLUSION

The coproduction process was successful in developing a structured follow-up model aligned with patients' needs, health provider perspectives, and existing guidelines. The Attend-PE model is currently undergoing clinical evaluation to determine its effectiveness and usability.

Evaluating Cost-Effectiveness of Antiretroviral Therapy over Time: A Cohort and Cost-Effectiveness Study

OBJECTIVE

To estimate the costs and cost-effectiveness of introducing highly active antiretroviral therapy (HAART) in Denmark based on real-world evidence for the three treatment eras pre-HAART (1985-1995), early HAART (1996-2005), and late HAART (2006-2017).

METHODS

We performed a cohort study using Danish clinical and administrative registries to estimate costs, quality-adjusted life-years (QALYs), and life-years (LY) gained per person living with human immunodeficiency virus (PLHIV) in three treatment eras. The study utilized Markov modeling for a health economic evaluation, which summarized inputs from real-world evidence and estimated the cost-effectiveness in 2017 prices of the introduction of HAART in Denmark. We performed deterministic and probabilistic sensitivity analyses to assess the robustness of the results.

RESULTS

The total annual costs per PLHIV increased with the introduction of HAART for the index year but decreased in the incremental years and the last year of life. The total lifetime discounted (and undiscounted) cost for an average PLHIV was €91,010 (€128,981) in pre-HAART, €103,130 (€199,062) in early HAART, and €126,317 (€254,964) in late HAART. The estimated incremental cost-effectiveness ratios showed that early HAART was cost-effective compared with pre-HAART with an incremental cost-effectiveness ratio (ICER) of €1378 per QALY, and that late HAART was cost-effective compared with early HAART with an ICER of €7385 per QALY. Sensitivity analyses confirmed cost-effectiveness in all scenarios.

CONCLUSIONS

The introduction and implementation of HAART in Danish healthcare was cost-effective, and in some scenarios, even disruptive, i.e., led to both cheaper and more effective care of PLHIV.

Impact of CCR5Δ32 on the risk of infection, Staphylococcus aureus carriage, and plasma concentrations of chemokines in Danish blood donors

BACKGROUND

The CC chemokine receptor 5 (CCR5) is a suggested receptor for Staphylococcus aureus leukotoxin ED. Homozygosity for the Δ32 deletion (CCR5Δ32) protects against human immunodeficiency virus infection and possibly also against leukotoxin ED. We examined the impact of CCR5Δ32 on the susceptibility to S. aureus infection, all-cause infections, and S. aureus nasal carriage, respectively, and on the concentrations of circulating chemokines in blood donors.

METHODS

We included 95,406 participants from the Danish Blood Donor Study (DBDS) genotyped for >650,000 single nucleotide polymorphisms. The CCR5Δ32 (rs333, MAF: 0.12) was imputed from a reference panel and validated. Infectious outcomes were identified by diagnosis codes and redeemed prescription of antibiotics in national health registers. Data on S. aureus nasal carriage and forty-seven inflammatory biomarkers were available for 6721 and 7811 participants, respectively. Cox, logistic, and linear regression models adjusted for relevant confounders were used to explore said associations.

FINDINGS

During more than 700,000 person-years of observation, we found that CCR5Δ32 was associated with neither an increased risk of redeemed dicloxacillin, hospital-treated S. aureus-associated infection (replicated in 345,996 Icelanders), redeemed antibiotics, all-cause infection, and nor with S. aureus nasal carriage. We discovered an association between CCR5Δ32 and elevated CCL4 concentrations, which were 1.26-fold higher in Δ32-heterozygotes (95%-CI: 1.23-1.30) and 2.64-fold higher in Δ32-homozygotes (95%-CI: 2.41-2.90) compared with wildtype homozygotes. Conversely, concentrations of CCL2, CXCL-10, and CCL11 were slightly lower among Δ32-heterozygotes.

INTERPRETATION

Results from this CCR5Δ32 high-prevalent cohort do not support the idea that CCR5Δ32 affects the risk of S. aureus carriage or infection to any relevant degree, in this northern European context. CCL4 was the main chemokine affected by CCR5Δ32 and was observed in higher concentration among Δ32-carriers. This study cannot rule out that S. aureus is a previous driver of CCR5Δ32 selection.

FUNDING

The Health Research Fund of Central Denmark Region, Aarhus University, Danish Administrative Regions, Bio- and Genome Bank Denmark, Danish Blood Donor Research Foundation, Aase & Ejnar Danielsens Foundation, Højmosegård Grant, National Institute of Allergy and Infectious Diseases, and A.P. Møller Foundation for the Advancement of Medical Science.

Prenatal and Early-Life Anti-Infectives and Obesity at Age 7 Years

PURPOSE

To examine associations of prenatal and early-life anti-infective exposures with obesity at 7 years.

METHODS

In this nationwide, registry-based, prevalence study, we included all children with an anthropometric assessment at age 7 years from the Children's Database and linked their data with Danish population-based registries from 2001 to 2018. We defined exposure to anti-infectives (anti-bacterials, anti-virals, and anti-fungals) by outpatient dispensings or by infection diagnoses at hospital encounters. The earliest date defined the exposure timing category: prenatal (-9 months- < 0 months), infancy (0- < 2 years), and early childhood (2- < 5 years). We computed prevalence ratios (aPRs) for associations of anti-infective exposure with obesity prevalence at 7 years of age, adjusting for maternal and perinatal factors.

RESULTS

We included 460 363 children (51% boys). Prevalence of obesity at 7 years of age was 38% higher (aPR = 1.38, 95% confidence interval (CI): 1.27-1.49) among children exposed to any anti-infective, 21% higher (aPR = 1.21, 95% CI: 1.12-1.31) among children exposed to anti-infectives in infancy, and 14% higher (aPR = 1.14, 95% CI: 1.03-1.26) among children exposed to anti-infectives in early childhood. Exposure to anti-bacterials was associated with obesity in a similar time-dependent pattern [prenatal: aPR = 1.39 (95% CI: 1.29-1.50), infancy: aPR = 1.21 (95% CI: 1.12-1.30), and early childhood: aPR = 1.14 (95% CI: 1.03-1.25)]. For anti-virals and anti-fungals, exposure during infancy and early childhood was associated with larger aPRs than prenatal exposure. Furthermore, obesity prevalence increased monotonically with number of the anti-infective prescriptions.

CONCLUSION

These findings suggest that prenatal and early-life exposure to anti-infectives increases the risk of childhood obesity and that the magnitude of the associations depends on anti-infective type, timing, and dose.