Catalog of 199 register-based definitions of chronic conditions

Low-density lipoprotein cholesterol response to statins according to comorbidities and co-medications: A population-based study

BACKGROUND

The response of low-density lipoprotein cholesterol (LDL-C) to statin therapy is variable, and may be affected by the presence of co-morbid conditions or the use of concomitant medications. Systematic variation in the response to statins based on these factors could affect the selection of the statin treatment regimen in population subgroups. We investigated whether common comorbidities and co-medications had clinically important effects on statin responses in individual patients.

METHODS

This register-based cohort study included 89,006 simvastatin or atorvastatin initiators with measurements of pre-statin and on-statin LDL-C levels, in Denmark, 2008-2018. We defined statin response as the percentage reduction in LDL-C, and used linear regression to estimate percentage reduction differences (PRD) according to 175 chronic comorbidities and 99 co-medications. We evaluated both the statistical significance (P-values corrected for multiple testing) and the clinical importance (PRD of 5 percentage points or more) of the observed associations.

RESULTS

Concomitant use of oral blood-glucose lowering drugs, which included metformin in 96% of treated individuals, was associated with a greater response to statin therapy that was both statistically significant and clinically important, with a PRD of 5.18 (95% confidence interval: 4.79 to 5.57). No other comorbidity or co-medication reached the prespecified thresholds for a significant, clinically important effect on statin response. Overall, comorbidities and co-medications had little effect on statin response, and altogether explained only 1.7% of the total observed population variance.

CONCLUSION

Most of the studied comorbidities and co-medications did not have a clinically important effect on statin response, suggesting no need to modify treatment regimens. However, use of metformin was associated with a significantly enhanced LDL-C response to statins, suggesting that lower statin doses may be effective in patients taking metformin.

Housing conditions and risk of incident COPD: a Danish cohort study, 2000-2018

BACKGROUND

More knowledge is needed on the risk of developing chronic obstructive pulmonary disease (COPD) associated with housing conditions and indoor environment based on cohort studies with a long follow-up time.

OBJECTIVE

To examine the association between housing conditions and indoor environment and the risk of developing COPD.

METHODS

In this cohort study, we followed 11,590 individuals aged ≥ 30 years free of COPD at baseline. Information on incident COPD and housing conditions and indoor environment was obtained from the Danish national registers and the Danish Health and Morbidity Survey year 2000. Poisson regression of incidence rates (IRs) were used to estimate incidence rate ratios (IRRs) of COPD.

RESULTS

The overall IR of COPD was 8.6 per 1,000 person-years. Individuals living outside the biggest cities vs. living in the biggest cities (≥ 50,000) had a lower risk of COPD (200-4,999; IRR 0.77 (95% CI 0.65-0.90). Individuals living in semi-detached houses had a higher risk compared to individuals living in detached houses (IRR 1.29 (95% CI 1.07-1.55)). Likewise, individuals living in rented homes had a higher risk (IRR 1.47 (95% CI 1.27-1.70)) compared to individuals living in owned homes. The IR of COPD was 17% higher among individuals living in dwellings build > 1982 compared with individuals living in older dwellings (< 1962), not statistically significant though (IRR 0.83 (95% CI 0.68-1.03)). Likewise, the IR of COPD was 15% higher among individuals living in the densest households compared with individuals living in the least dense households, not statistically significant though (IRR 1.15 (95% CI 0.92-1.45)). This was primary seen among smokers. There was no difference in risk among individuals with different perceived indoor environments. Overall, similar patterns were seen when stratified by smoking status with exception of perceived indoor environment, where opposite patterns were seen for smokers and never smokers.

CONCLUSION

Individuals living in semi-detached houses or rented homes had a higher risk of developing COPD compared to individuals living in detached or owned homes. Individuals living in cities with < 50.000 residents had a lower risk of COPD compared to individuals living in cities with ≥ 50.000 residents.

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

BACKGROUND

Empirical evaluation of inverse probability weighting (IPW) for self-selection bias correction is inaccessible without the full source population. We aimed to: (i) investigate how self-selection biases frequency and association measures and (ii) assess self-selection bias correction using IPW in a cohort with register linkage.

METHODS

The source population included 17 936 individuals invited to the Copenhagen Aging and Midlife Biobank during 2009-11 (ages 49-63 years). Participants counted 7185 (40.1%). Register data were obtained for every invited person from 7 years before invitation to the end of 2020. The association between education and mortality was estimated using Cox regression models among participants, IPW participants and the source population.

RESULTS

Participants had higher socioeconomic position and fewer hospital contacts before baseline than the source population. Frequency measures of participants approached those of the source population after IPW. Compared with primary/lower secondary education, upper secondary, short tertiary, bachelor and master/doctoral were associated with reduced risk of death among participants (adjusted hazard ratio [95% CI]: 0.60 [0.46; 0.77], 0.68 [0.42; 1.11], 0.37 [0.25; 0.54], 0.28 [0.18; 0.46], respectively). IPW changed the estimates marginally (0.59 [0.45; 0.77], 0.57 [0.34; 0.93], 0.34 [0.23; 0.50], 0.24 [0.15; 0.39]) but not only towards those of the source population (0.57 [0.51; 0.64], 0.43 [0.32; 0.60], 0.38 [0.32; 0.47], 0.22 [0.16; 0.29]).

CONCLUSIONS

Frequency measures of study participants may not reflect the source population in the presence of self-selection, but the impact on association measures can be limited. IPW may be useful for (self-)selection bias correction, but the returned results can still reflect residual or other biases and random errors.

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.

Multimorbidity prevalence and health outcome prediction: assessing the impact of lookback periods, disease count, and definition criteria in health administrative data at the population-based level

BACKGROUND

Health administrative databases play a crucial role in population-level multimorbidity surveillance. Determining the appropriate retrospective or lookback period (LP) for observing prevalent and newly diagnosed diseases in administrative data presents challenge in estimating multimorbidity prevalence and predicting health outcome. The aim of this population-based study was to assess the impact of LP on multimorbidity prevalence and health outcomes prediction across three multimorbidity definitions, three lists of diseases used for multimorbidity assessment, and six health outcomes.

METHODS

We conducted a population-based study including all individuals ages > 65 years on April 1st, 2019, in Québec, Canada. We considered three lists of diseases labeled according to the number of chronic conditions it considered: (1) L60 included 60 chronic conditions from the International Classification of Diseases (ICD); (2) L20 included a core of 20 chronic conditions; and (3) L31 included 31 chronic conditions from the Charlson and Elixhauser indices. For each list, we: (1) measured multimorbidity prevalence for three multimorbidity definitions (at least two [MM2+], three [MM3+] or four (MM4+) chronic conditions); and (2) evaluated capacity (c-statistic) to predict 1-year outcomes (mortality, hospitalisation, polypharmacy, and general practitioner, specialist, or emergency department visits) using LPs ranging from 1 to 20 years.

RESULTS

Increase in multimorbidity prevalence decelerated after 5-10 years (e.g., MM2+, L31: LP = 1y: 14%, LP = 10y: 58%, LP = 20y: 69%). Within the 5-10 years LP range, predictive performance was better for L20 than L60 (e.g., LP = 7y, mortality, MM3+: L20 [0.798;95%CI:0.797-0.800] vs. L60 [0.779; 95%CI:0.777-0.781]) and typically better for MM3 + and MM4 + definitions (e.g., LP = 7y, mortality, L60: MM4+ [0.788;95%CI:0.786-0.790] vs. MM2+ [0.768;95%CI:0.766-0.770]).

CONCLUSIONS

In our databases, ten years of data was required for stable estimation of multimorbidity prevalence. Within that range, the L20 and multimorbidity definitions MM3 + or MM4 + reached maximal predictive performance.

VEGF Inhibition Associates With Decreased Risk of Mortality in Patients With Neovascular Age-related Macular Degeneration

Purpose

Controversy exists regarding the systemic safety of intravitreal VEGF inhibitors in the treatment of neovascular age-related macular degeneration (nAMD). We aimed to investigate the potential impact of VEGF inhibitor treatment on the risk of all-cause mortality and cardiovascular disease (CVD) among patients with nAMD.

Design

A nationwide register-based cohort study with 16 years follow-up.

Participants

Patients with nAMD exposed with VEGF inhibitors (n = 37 733) and unexposed individuals without nAMD (n = 1 897 073) aged ≥ 65 years residing in Denmark between January 1, 2007, and December 31, 2022.

Methods

Cox proportional hazards analysis was conducted to assess the effect of intravitreal VEGF inhibitor treatment on all-cause mortality and incident CVD.

Main Outcome Measures

In a predefined analysis plan we defined primary outcomes as hazard ratios (HRs) of all-cause mortality and a composite CVD endpoint in patients with nAMD treated with VEGF inhibitors compared with individuals without nAMD. The secondary outcomes encompassed analyses that explored the impact of the number of doses and the association between exposure and outcome over a specific time period.

Results

Overall, 63.7% of patients with nAMD were women with an average age of 69.9 years (interquartile range 65.0-76.0 years). Patients exposed to VEGF inhibitors demonstrated a reduced risk of all-cause mortality compared with individuals without nAMD (HR, 0.79; 95% confidence interval [CI], 0.78-0.81), and an increased risk of composite CVD (HR, 1.04; 95% CI, 1.01-1.07). The decreased risk of all-cause mortality persisted, but there was no significant association between VEGF inhibitor treatment and CVD when patients with nAMD were grouped by the number of doses or considered exposed within 60 days postinjection.

Conclusions

Our study revealed a decreased risk of all-cause mortality and a 4% increased risk of CVD among patients with nAMD exposed with VEGF inhibitors. The decreased risk of mortality is unlikely to be directly pathophysiologically related to VEGF inhibitor treatment. Instead, we speculate that patients undergoing VEGF inhibitor treatment are, on average, individuals in good health with adequate personal resources. Therefore, they also have a higher likelihood of overall survival. These findings strongly support the safety of VEGF inhibitor treatment in terms of all-cause mortality and CVD among patients with nAMD.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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

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

The Association of Children and Their Educational Attainment With Diabetes-related Complications and Mortality Among Older Adults With Type 2 Diabetes: A Nationwide Cohort Study

OBJECTIVE

Socioeconomic resources and family support have been shown to improve adherence to treatment in people with type 2 diabetes (T2D) and are associated with a lower risk of diabetes-related complications and death. We investigated the associations of having children and their educational level with diabetes-related complications and death among older adults with T2D.

METHODS

We included 74,588 adults who were at least 65 years of age at the time of T2D diagnosis over the period from 2000 to 2018 in Denmark and grouped them based on having children (yes [reference]/no), and their children's highest educational level (low/medium/high [reference]). Multistate models were performed with 3 states: T2D diagnosis, diabetes-related complications, and death. All models were stratified by other chronic diseases at baseline (yes/no).

RESULTS

During follow-up (mean, 5.5 years), 14.6% of the adults developed a complication and 24.8% died with or without complications. Not having children was associated with a higher hazard of death without complications among adults without (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.17 to 1.33) and with (HR, 1.10; 95% CI, 1.02 to 1.18) other chronic diseases and after complications among adults without other chronic diseases (HR, 1.25; 95% CI, 1.12 to 1.38). Having children with a lower educational level was associated with a higher hazard of complications (HRlow, 1.14; 95% CI, 1.05 to 1.24; HRmedium, 1.11; 95% CI, 1.05 to 1.17), death without complications (HRlow, 1.26; 95% CI, 1.17 to 1.36; HRmedium, 1.07; 95% CI, 1.02 to 1.14), and after complications (HRlow, 1.22; 95% CI, 1.07 to 1.39) among adults without other chronic diseases.

CONCLUSIONS

Among adults without other chronic diseases, having no children or having children with lower educational levels was associated with a higher hazard of death. Among these adults, having children with lower educational levels was also associated with a higher hazard of diabetes-related complications.

The interplay between the impact of household's and children's education on the risk of type 2 diabetes and death among older adults: a Danish register-based cohort study

OBJECTIVES

This study aims to assess the association of household's and children's education on the risk of type 2 diabetes (T2D) and subsequent death.

STUDY DESIGN

Danish register-based cohort study.

METHODS

In total, 1,021,557 adults were included at their 65th birthday between 2000 and 2018. A multistate survival model was performed to estimate the association of household's and children's education on the transition between the three states: 1) 65th birthday; 2) diagnosis of T2D; and 3) all-cause death.

RESULTS

The incidence rates per 1000 person-years were 9.1 for T2D, 18.4 for death without T2D, and 45.0 for death with T2D. Compared to long household's education and children's education, long household's education combined with either short-medium children's education or no children were associated with a 1.49- (95% confidence interval [CI]: 1.44; 1.54] and 1.69-times (95% CI: 1.61;1.78) higher hazard of T2D, respectively. Short-medium household's education combined with either long children's education or no children were associated with 0.64- (95% CI: 0.62; 0.66) and 0.77-times (95% CI: 0.74; 0.79) lower hazard of T2D, respectively. Compared to long household's education and children's education, any other combination of household's and children's education was associated with higher hazards of death both without and with T2D.

CONCLUSION

Older adults living in households with long education with no children or children with short-medium education had higher hazards of T2D. Households with short-medium education and no children or children with long education were associated with lower hazards of T2D. Both household's and children's education were associated with higher hazard of death without and with T2D.

Are self-reported medical conditions and medicine use from middle-aged and older adults credible? A validation study comparing Danish SHARE-data with National Health Register data

PURPOSE

Self-reported information on medical conditions and medicine use is widely used in epidemiological research. We investigated the validity of self-reported medical conditions and medicine use from Danish participants in the Survey of Health, Ageing and Retirement in Europe.

METHODS

Self-reported health data were linked at individual level with the National Patient Registry and the Danish National Prescription Registry (n = 5572). Agreement was assessed by kappa value and presented as sensitivity, specificity, predictive values, and odds ratios.

RESULTS

The agreement of self-reported medical conditions varied by type (κ = 0.23-0.67), lowest for cholesterol-related diseases, highest for diabetes. Self-reported medicine use varied by medication type (κ = 0.33-0.90) lowest for painkillers, highest for diabetes. Women had lower odds for self-reporting medicine use correctly but higher odds for self-reported diseases. Higher age was associated with lower agreement, while higher education with higher agreement.

CONCLUSIONS

Although Danish data from the Survey of Health, Ageing and Retirement in Europe on medical conditions and medicine vary, the data are valid for epidemiological use for most medicine data, and for diseases associated with hospitalizations or influencing everyday life. Caution is warranted for self-reported data from 70+ year olds and people with lower educational level.

Catalogues of EQ-5D-3L Health-Related Quality of Life Scores for 199 Chronic Conditions and Health Risks for Use in the UK and the USA

BACKGROUND

Health-related quality of life (HRQoL) measures are essential in economic evaluation, but sometimes primary sources are unavailable, and information from secondary sources is required. Existing HRQoL UK/US catalogues are based on earlier diagnosis classification systems, amongst other issues. A recently published Danish catalogue merged EQ-5D-3L data from national health surveys with national registers containing patient information on ICD-10 diagnoses, healthcare activities and socio-demographics.

AIMS

To provide (1) UK/US EQ-5D-3L-based HRQoL utility population catalogues for 199 chronic conditions on the basis of ICD-10 codes and health risks and (2) regression models controlling for age, sex, comorbidities and health risks to enable predictions in other populations.

METHODS

UK and US EQ-5D-3L value sets were applied to the EQ-5D-3L responses of the Danish dataset and modelled using adjusted limited dependent variable mixture models (ALDVMMs).

RESULTS

Unadjusted mean utilities, percentiles and adjusted disutilities based on two ALDVMMs with different control variables were provided for both countries. Diseases from groups M, G, and F consistently had the smallest utilities and the largest negative disutilities: fibromyalgia (M797), sclerosis (G35), rheumatism (M790), dorsalgia (M54), cerebral palsy (G80-G83), post-traumatic stress disorder (F431), dementia (F00-2), and depression (F32, etc.). Risk factors, including stress, loneliness, and BMI30+, were also associated with lower HRQoL.

CONCLUSIONS

This study provides comprehensive catalogues of UK/US EQ-5D-3L HRQoL utilities. Results are relevant in cost-effectiveness analysis, for NICE submissions, and for comparing and identifying facets of disease burden.

Cardiovascular morbidity and all-cause mortality in patients with retinal vein occlusion: a Danish nationwide cohort study

BACKGROUND/AIMS

Associations between retinal vein occlusion (RVO) and subsequent cardiovascular disease (CVD) or mortality have not been evaluated in a recent cohort, after novel therapeutic options have increased referrals for treatment of the condition. We aimed to evaluate overall and subtype-stratified risk of CVD and all-cause mortality following RVO and assess any alterations after the introduction of angiostatic therapy in Denmark in 2011.

METHODS

This nationwide, registry-based cohort study from 1998 to 2018 evaluated 4 194 781 individuals. Hazard ratios (HRs) were reported for RVO as an overall measure and subclassified as branch and central RVO.

RESULTS

Patients with RVO (n=15 665) were median 71.8 years old at the time of exposure and 50.7% were women. RVO associated with incident CVD (adjusted HR 1.13, 95% CI 1.09 to 1.17) but not mortality (adjusted HR 1.00, 95% CI 0.97 to 1.03). Almost similar risks of CVD were found for patients with branch and central RVO (adjusted HRs 1.14, 95% CI 1.03 to 1.25, and 1.12, 95% CI 1.00 to 1.25, respectively), but only patients with central RVO exhibited increased mortality (adjusted HR 1.12, 95% CI 1.04 to 1.21). Risk of CVD, especially non-ischaemic, was higher for patients diagnosed after 2011 (adjusted HRs 1.24, 95% CI 1.15 to 1.33 vs 1.06, 95% CI 1.01 to 1.12).

CONCLUSION

In a cohort of the Danish population aged 40 years or more, patients with RVO had a 13% increased risk of incident CVD compared with unexposed individuals. Risk of CVD was increased after 2011, when intravitreal angiostatic treatment was introduced and referral practices altered.

Impact of offspring and their educational level on readmission and death among older adults with chronic obstructive pulmonary disease: a nationwide cohort study using multistate survival models

BACKGROUND

It is well described that there is social inequality in the disease course of chronic obstructive pulmonary disease (COPD), but the impact of social relations is less explored. We aimed to investigate the impact of adult offspring and their educational level on readmission and death among older adults with COPD.

METHODS

In total, 71 084 older adults born 1935-53 with COPD diagnosed at age ≥65 years in 2000-2018 were included. Multistate survival models were performed to estimate the impact of adult offspring (offspring (reference) vs no offspring) and their educational level (low, medium or high (reference)) on the transition intensities between three states: COPD diagnosis, readmission and all-cause death.

RESULTS

During follow-up, 29 828 (42.0%) had a readmission and 18 504 (26.0%) died with or without readmission. Not having offspring was associated with higher hazards of death without readmission (HRwomen: 1.52 (95% CI: 1.39 to 1.67), HRmen: 1.29 (95% CI: 1.20 to 1.39)) and a higher hazard of death after readmission for women only (HRwomen: 1.19 (95% CI: 1.08 to 1.30). Having offspring with low educational level was associated with higher hazards of readmission (HRwomen: 1.12 (95% CI: 1.06 to 1.19)), (HRmen: 1.06 (95%CI: 1.002 to 1.12)), death without readmission (HRwomen: 1.24 (95% CI: 1.11 to 1.39)), HRmen: 1.16 (95% CI: 1.05 to 1.29) and death after readmission for men only (HRmen: 1.15 (95% CI: 1.05 to 1.25)). Having offspring with medium educational level was associated with a higher hazard of death without readmission for women (HRwomen: 1.11 (95% CI: 1.02 to 1.21)).

CONCLUSION

Adult offspring and their educational level were associated with higher risk of readmission and death among older adults with COPD.

Retinal artery occlusion does not act as an independent marker of upcoming dementia: results from a Danish 20-year cohort study

PURPOSE

Retinal artery occlusion (RAO) is a vision threatening disease associated with cerebral vascular dysfunction, which may reflect initial signs of cerebral pathology. Early detection of patients in risk of dementia could allow for preventative treatment. Hence, this study aimed to investigate RAO as an independent biomarker of incident dementia.

METHODS

This study was a nationwide, 20-year longitudinal cohort study in Denmark with inclusion from 1998 to 2020 and follow up until the end of 2022. We identified 2 205 159 individuals aged 65 or older through the Danish national health registers and monitored RAO (exposure) and dementia (outcome) status. We calculated incidence rate and performed a Cox regression analysis with hazard ratio (HR) and 95% confidence interval (CI) for RAO as a marker of dementia in a crude, a semi-adjusted (age and sex), and a fully adjusted model (furthermore adjusted for marital status and systemic comorbidity.) RESULTS: We identified 8 863 individuals with RAO. Incidence rates were higher among exposed compared to unexposed individuals (12.28 and 8.18 per 1000 person-years at risk, respectively). Individuals with RAO were more likely to be male and older at inclusion, to have hypertension, dyslipidaemia, cardiovascular disease, chronic kidney disease, and diabetes (p < 0.001). RAO was not associated with all-cause dementia in the crude analysis (HR 1.07 CI [1.00-1.17]) or in the fully adjusted analysis (HR 0.98 CI [0.91-1.06].

CONCLUSION

Although individuals with RAO had a higher incidence of dementia compared to unexposed individuals, these associations were lost when confounders were taken into account.

Children of parents with different severities of mental health conditions have higher risk of somatic morbidity: a Danish nationwide register-based cohort study

BACKGROUND

Children with the most severe parental mental health conditions have an elevated risk of numerous adversities including somatic morbidity. However, there is no knowledge concerning physical health in most children affected by parental mental health conditions. Therefore, the aim was to examine the association between different severities of parental mental health conditions and somatic morbidity in children of different age-groups and further explore the combinations of maternal and paternal mental health conditions on child somatic morbidity.

METHODS

In this register-based cohort study, we included all children born in Denmark between 2000-2016 and linked parents. Parental mental health conditions were categorised into four severity groups (no, minor, moderate, and severe). Somatic morbidity in offspring was categorised into broad disease categories corresponding to the International Classification of Diseases. We estimated the risk ratio (RR) using Poisson regression, of the first registered diagnosis in different age-groups.

RESULTS

Of the around 1 million children in the study > 14.5% were exposed to minor parental mental health conditions and < 2.3% were exposed to severe parental mental health conditions. Overall, the analyses revealed a higher risk of morbidity in exposed children across all disease categories. The strongest association was observed for digestive diseases in children aged < 1 year exposed to severe parental mental health conditions (RR: 1.87 (95% CI: 1.74-2.00). Generally, the risk of somatic morbidity increased the more severe the parental mental health conditions. Both paternal and especially maternal mental health conditions were associated with a higher risk of somatic morbidity. The associations were strongest if both parents had a mental health condition.

CONCLUSION

Children with different severities of parental mental health conditions experience a higher risk of somatic morbidity. Although children with severe parental mental health conditions had the highest risk, children with minor parental mental health conditions should not be neglected as more children are exposed. Children with both parents having a mental health condition were the most vulnerable to somatic morbidity and maternal mental health conditions were more strongly associated with somatic morbidity than paternal. More support and awareness of families with parental mental health conditions is highly needed.

Longitudinal models for the progression of disease portfolios in a nationwide chronic heart disease population

BACKGROUND AND AIM

With multimorbidity becoming increasingly prevalent in the ageing population, addressing the epidemiology and development of multimorbidity at a population level is needed. Individuals subject to chronic heart disease are widely multimorbid, and population-wide longitudinal studies on their chronic disease trajectories are few.

METHODS

Disease trajectory networks of expected disease portfolio development and chronic condition prevalences were used to map sex and socioeconomic multimorbidity patterns among chronic heart disease patients. Our data source was all Danish individuals aged 18 years and older at some point in 1995-2015, consisting of 6,048,700 individuals. We used algorithmic diagnoses to obtain chronic disease diagnoses and included individuals who received a heart disease diagnosis. We utilized a general Markov framework considering combinations of chronic diagnoses as multimorbidity states. We analyzed the time until a possible new diagnosis, termed the diagnosis postponement time, in addition to transitions to new diagnoses. We modelled the postponement times by exponential models and transition probabilities by logistic regression models.

FINDINGS

Among the cohort of 766,596 chronic heart disease diagnosed individuals, the prevalence of multimorbidity was 84.36% and 88.47% for males and females, respectively. We found sex-related differences within the chronic heart disease trajectories. Female trajectories were dominated by osteoporosis and male trajectories by cancer. We found sex important in developing most conditions, especially osteoporosis, chronic obstructive pulmonary disease and diabetes. A socioeconomic gradient was observed where diagnosis postponement time increases with educational attainment. Contrasts in disease portfolio development based on educational attainment were found for both sexes, with chronic obstructive pulmonary disease and diabetes more prevalent at lower education levels, compared to higher.

CONCLUSIONS

Disease trajectories of chronic heart disease diagnosed individuals are heavily complicated by multimorbidity. Therefore, it is essential to consider and study chronic heart disease, taking into account the individuals' entire disease portfolio.

Vascular endothelial growth factor inhibition in retinal vein occlusion does not associate with cardiovascular morbidity and mortality

PURPOSE

Intravitreal treatment with vascular endothelial growth factor (VEGF) inhibitors have proven safe in clinical trials, but often on selected patient groups and without statistical power to investigate rare safety events. Data on anti-VEGF treatment in retinal vein occlusion (RVO) patients are sparsely represented and studies providing population-based, long-term follow-up are needed to assess the risks in a nationwide setting. We aimed to evaluate the association between treatment with anti-VEGF and risk of incident cardiovascular disease (CVD) and all-cause mortality in patients with RVO, and whether this association was affected by selected risk factors.

DESIGN

Cohort study from January 2012 to December 2018 using Danish nationwide registries linked on an individual level. Subjects, Participants, and/or Controls: RVO patients (n=7235), exposed (n=3508) and unexposed (n=3727) to anti-VEGF, aged 40 years or more, alive and living in Denmark. Methods, Intervention, or Testing: Cox proportional hazards analysis evaluating the effect of intravitreal VEGF inhibitory treatment on incident CVD and all-cause mortality.

MAIN OUTCOME MEASURES

A pre-defined analysis plan specified primary outcomes as hazard ratios (HR) of a composite CVD endpoint and all-cause mortality in patients treated with anti-VEGF compared with untreated. Secondary outcomes included cumulative dose analysis, HRs on subgroups of CVD and stratified analyses evaluating the effect of sex, age, diabetes, intensive treatment, and pre-existing CVD on the HRs.

RESULTS

We found no increased risk of composite CVD (HR 1.07, 95% CI 0.89 to 1.29) or all-cause mortality (HR 0.88, 95% CI 0.77 to 1.00) in RVO patients treated with anti-VEGF. In the secondary analyses we found no dose-response relationship. We found an increased risk of intracranial hemorrhage (HR 1.66, 95% CI 1.02 to 2.71), but no increased risks in remaining subgroups of CVD. We found no increased risk associated with selected pre-disposing risk factors, and no increased risk in patients with pre-existing CVD.

CONCLUSIONS

Treatment with anti-VEGF in RVO patients is safe, when evaluated in a nationwide, population-based setting. An increased risk of intracranial hemorrhage might be present, but cannot be reliably quantified and should be further elucidated by larger population-based studies including all indications for anti-VEGF treatment.

Catalog of EQ-5D-3L Health-Related Quality-of-Life Scores for 199 Chronic Conditions and Health Risks in Denmark

Background. Assessments of health-related quality of life (HRQoL) are essential in estimating quality-adjusted life-years. It is sometimes not feasible to collect primary HRQoL data, and reliable secondary sources are necessary. Current "off-the-shelf" HRQoL catalogs are based on older diagnosis classifications and include a limited number of diseases. This article aims to provide 1) a Danish EQ-5D-3L-based HRQoL catalog for 199 nationally representative chronic conditions based on ICD-10 codes and 2) a complementary model-based catalog controlling for age, sex, comorbidities, lifestyle, and health risks. Design. A total of 55,616 respondents from 3 national health survey samples were pooled and combined with 7 national registers containing patient-level information on diagnoses, health care activity, and sociodemographics. EQ-5D-3L data were converted to utility scores using the Danish EQ-5D-3L value set to estimate the mean utility for each chronic disease population. Adjusted limited dependent variable mixture models were estimated and used to provide a regression-based catalog of utilities/disutilities. Results. Diseases with the lowest mean EQ-5D score in the Danish population were systemic sclerosis (M34; score = 0.432), fibromyalgia (M797; score = 0.490), rheumatism (M790; score = 0.515), dementia (F00, G30; score = 0.546), posttraumatic stress syndrome (F431; score = 0.557), and systemic atrophies (G10-G14; score = 0.583. Based on the estimated models, the largest estimated disutilities were cystic fibrosis, cerebral palsy, depression, dorsalgia, sclerosis, and fibromyalgia. Lifestyle factors, including perceived stress, loneliness, and body mass index, were also significantly associated with low HRQoL. Conclusions. This study provides a comprehensive nationally representative catalog and a model-based catalog of EQ-5D-3L-based HRQoL scores for Denmark that can be used to describe aspects of disease burden and allocate resources within health care. Additional Stata programs are also provided to facilitate predictions in other populations.

Highlights

A Danish national representative catalog of health-related quality-of-life scores for 199 chronic conditions is presented, which provides population estimates for chronic conditions subgroups that can be used for health economic evaluation.Two separate regression models of EQ-5D-3L utility scores with different sets of control variables are estimated to allow researchers to adjust for differences in the composition of the subgroups and provide a tool that can be used in other settings.Results indicate that health-related quality of life varies across disease groups but is lowest for renal disease, mental and behavioral disorders, benign neoplasms and diseases of the blood, digestive systems, and nervous systems.Health risks and lifestyle factors such as perceived stress, loneliness, and a large body mass index are highly correlated with health-related quality of life, and, in many cases, the correlation is higher than with individual diseases.

Catalog of EQ-5D-3L Health-Related Quality-of-Life Scores for 199 Chronic Conditions and Health Risks in Denmark

Background. Assessments of health-related quality of life (HRQoL) are essential in estimating quality-adjusted life-years. It is sometimes not feasible to collect primary HRQoL data, and reliable secondary sources are necessary. Current "off-the-shelf" HRQoL catalogs are based on older diagnosis classifications and include a limited number of diseases. This article aims to provide 1) a Danish EQ-5D-3L-based HRQoL catalog for 199 nationally representative chronic conditions based on ICD-10 codes and 2) a complementary model-based catalog controlling for age, sex, comorbidities, lifestyle, and health risks. Design. A total of 55,616 respondents from 3 national health survey samples were pooled and combined with 7 national registers containing patient-level information on diagnoses, health care activity, and sociodemographics. EQ-5D-3L data were converted to utility scores using the Danish EQ-5D-3L value set to estimate the mean utility for each chronic disease population. Adjusted limited dependent variable mixture models were estimated and used to provide a regression-based catalog of utilities/disutilities. Results. Diseases with the lowest mean EQ-5D score in the Danish population were systemic sclerosis (M34; score = 0.432), fibromyalgia (M797; score = 0.490), rheumatism (M790; score = 0.515), dementia (F00, G30; score = 0.546), posttraumatic stress syndrome (F431; score = 0.557), and systemic atrophies (G10-G14; score = 0.583. Based on the estimated models, the largest estimated disutilities were cystic fibrosis, cerebral palsy, depression, dorsalgia, sclerosis, and fibromyalgia. Lifestyle factors, including perceived stress, loneliness, and body mass index, were also significantly associated with low HRQoL. Conclusions. This study provides a comprehensive nationally representative catalog and a model-based catalog of EQ-5D-3L-based HRQoL scores for Denmark that can be used to describe aspects of disease burden and allocate resources within health care. Additional Stata programs are also provided to facilitate predictions in other populations.

HIGHLIGHTS

A Danish national representative catalog of health-related quality-of-life scores for 199 chronic conditions is presented, which provides population estimates for chronic conditions subgroups that can be used for health economic evaluation.Two separate regression models of EQ-5D-3L utility scores with different sets of control variables are estimated to allow researchers to adjust for differences in the composition of the subgroups and provide a tool that can be used in other settings.Results indicate that health-related quality of life varies across disease groups but is lowest for renal disease, mental and behavioral disorders, benign neoplasms and diseases of the blood, digestive systems, and nervous systems.Health risks and lifestyle factors such as perceived stress, loneliness, and a large body mass index are highly correlated with health-related quality of life, and, in many cases, the correlation is higher than with individual diseases.

Catalogue of socioeconomic disparities and characteristics of 199+ chronic conditions-A nationwide register-based population study

BACKGROUND

Real-world information on socioeconomic differences within and between chronic conditions represents an important data source for treatments and decision-makers executing and prioritising healthcare resources.

AIMS

The aim of this study was to estimate the prevalence and mean of socioeconomic disparities from educational, income, and socioeconomic positions of 199 chronic conditions and disease groups, including sex and age group estimates, for use in planning of care services and prioritisation, by healthcare professionals, decision-makers and researchers.

METHODS

The study population includes all Danish residents 16 years and above, alive on 1 January 2013 (n = 4,555,439). The data was established by linking seven national registers encompassing educational achievements, incomes, socioeconomic positions, hospital- and general practice services, and filled-in out-of-hospital prescriptions. The health register data were used to identify the 199+ chronic conditions. Socioeconomic differences were primarily measured as differences in educational prevalence levels from low to high educational achievements using a ratio. Furthermore, multiple binary logistic regression models were carried out to control for potential confounding and residual correlations of the crude estimates.

RESULTS

The prevalence of having one or more chronic conditions for patients with no educational achievement was 768 per thousand compared to 601.3 for patients with higher educational achievement (ratio 1.3). Across disease groups, the highest educational differences were found within disease group F-mental and behavioural (ratio 2.5), E-endocrine, nutritional and metabolic disease (ratio 2.4), I-diseases of the circulatory system (ratio 2.1) and, K-diseases of the digestive system (ratio 2.1). The highest educational differences among the 29 common diseases were found among schizophrenia (ratio 5.9), hyperkinetic disorders (ratio 5.2), dementia (ratio 4.9), osteoporosis (ratio 3.9), type 2 diabetes (ratio 3.8), chronic obstructive pulmonary disease COPD (ratio 3.3), heart conditions and stroke (ratios ranging from 2.3-3.1).

CONCLUSIONS

A nationwide catalogue of socioeconomic disparities for 199+ chronic conditions and disease groups is catalogued and provided. The catalogue findings underline a large scope of socioeconomic disparities that exist across most chronic conditions. The data offer essential information on the socioeconomic disparities to inform future socially differentiated treatments, healthcare planning, etiological, economic, and other research areas.

Catalogue of multimorbidity mean based severity and associational prevalence rates between 199+ chronic conditions-A nationwide register-based population study

BACKGROUND

Real-world data on multimorbidity represents an important but underutilised source of evidence for the planning of healthcare services, including prevention, treatments, and health economic modelling.

AIMS

This study aimed to estimate means of multimorbidity and provide associated prevalence rates and frequencies between 199 x 199 chronic conditions and disease groups based on the total adult Danish population and sex, age, and educational attainment. Thus, this study provides an off-the-shelf catalogue for use in treatments and planning by clinicians, decision-makers and researchers.

METHODS

The study population contained all Danish residents above 16 years on 1 January 2013 (n = 4,555,439). The data was based on the linkage of six national registers covering hospital contacts, services in general practice, filled-in out-of-hospital prescriptions, and educational attainments. The health registers were used to identify the 199 chronic conditions based on the ICD-10 classification system.

RESULTS

The mean number of chronic conditions (NCC) was 2.2. The mean increased with age, women had a higher mean than men, and there was a social gradient with the mean increasing with lower educational attainment. The mean NCC varied from 3.3-9.8 among all conditions. Across disease groups, the highest mean NCC were found within disease group N (chronic renal failure, mean = 8.8), D (in situ and benign neoplasms; mean = 6.5), K (diseases of the digestive system; mean = 5.7), and H (diseases of the eye and the ear; mean = 5.6). The highest mean NCC among the 29 common diseases was heart failure, ischemic heart diseases, angina pectoris, stroke, and dementia, with a mean above 6.5. Several prevalent conditions like hypertension, arthritis, chronic lower respiratory diseases, depression, type 2 diabetes, and overweight transcended other conditions regarding the associated prevalence rates. As one of the most frequent, hypertensive diseases were highly associated with arthritis (50.4%), depression (37.4%), type 2 diabetes (75.4%), cancers (49.7%), and being overweight (39.7%)-meaning that 50.4% of people with arthritis, 37.4% of people with depression and so on also had hypertensive diseases. The largest differences in means between individuals with no educational attainment and individuals with high educational attainment were found within disease groups J (diseases of the respiratory system, ratio = 1.8), Q (congenital malformations, deformations, and chromosomal abnormalities, ratio = 1.7), and B (viral hepatitis and human immunodeficiency virus disease, ratio = 1.7).

CONCLUSIONS

The current study provides a nationwide off-the-shelf catalogue of multimorbidity means and real-world associations estimates of 199+ chronic conditions for future clinical treatments and health care systems planning. The findings described are just one example of numerous results and underline that multimorbidity is highly prevalent in the adult Danish population and that it is a vital condition transcending all future medical treatment. The data offer essential information on the multimorbidity burden of disease in future differentiated treatments, healthcare planning, and economic, aetiological, and other research.

Physical resilience after a diagnosis of cardiovascular disease among offspring of long-lived siblings

Health benefits of longevity-enriched families transmit across generations and a lower incidence of cardiovascular diseases (CVD) have been shown to contribute to this phenomenon. In the current study, we investigated whether the offspring of long-lived siblings also have better survival after a CVD diagnosis compared to matched controls, i.e., are they both robust and resilient? Offspring of long-lived siblings were identified from three nationwide Danish studies and linked to national registers. Offspring with first diagnosis of acute myocardial infarction, chronic ischemic heart disease, heart failure or cerebrovascular disease between 1996 and 2011 were included and matched with two controls from the Danish population on sex, year of birth and diagnosis, and type of CVD. Stratified Cox proportional-hazards models on the matching data were performed to study 10-year overall survival. A total of 402 offspring and 804 controls were included: 64.2% male with a median age at diagnosis of 63.0. For offspring and controls, overall survival was 73% and 65% at 10 years from diagnosis, respectively. Offspring of long-lived siblings had a significantly better survival than controls, and this association was slightly attenuated after controlling for marital status, medication and Charlson Comorbidity Index score simultaneously. This study suggested that offspring of long-lived siblings not only show lower CVD incidence but also a better survival following CVD diagnosis compared to matched population controls. The higher biological resilience appears to be a universal hallmark of longevity-enriched families, which makes them uniquely positioned for studying healthy aging and longevity mechanisms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10433-021-00641-7.

Intra-Cardiac Arrest Transport and Survival from Out-of-Hospital Cardiac Arrest: A Nationwide Observational Study

AIM

To assess whether intra-cardiac arrest transport as compared to continued on-scene resuscitation was associated with improved clinical outcomes among out-of-hospital cardiac arrest patients in Denmark.

METHODS

This was an observational study using data from population-based registries in Denmark. Adults (aged ≥18 to ≤65 years) with an out-of-hospital cardiac arrest attended by Emergency Medical Services (EMS) between 2016 and 2018 were included. The primary outcome was survival to 30 days. Time-dependent propensity score matching was used to match patients transported to the hospital within 20 minutes of EMS arrival to patients with assumed on-scene resuscitation (with or without subsequent intra-cardiac arrest transport) at risk of being transported within the same minute.

RESULTS

The full cohort included 2,873 cardiac arrests. The median age was 56 (quartiles: 48 to 62) years, 1987 (69%) were male, and 104 (4%) were transported within 20 minutes. A total of 87 transported patients were matched to 87 patients at risk of being transported based on the propensity score. Although not reaching statistical significance, in comparison with on-scene resuscitation, intra-cardiac arrest transport was associated with increased survival to 30 days (risk ratio, 1.55; 95%CI, 0.99 to 2.44; P = 0.06). Similar associations were observed for return of spontaneous circulation and survival to one year.

CONCLUSIONS

Among patients aged 18 to 65 years, intra-cardiac arrest transport was associated with a non-significant increase in survival within 20 minutes of EMS on-scene arrival. However, the results did not eliminate the potential for bias and the results should be interpreted carefully.

Development and Validation of a Nordic Multimorbidity Index Based on Hospital Diagnoses and Filled Prescriptions

Purpose

To develop the Nordic Multimorbidity Index (NMI), a multimorbidity measure specifically suited to the Nordic health and administrative registry data based on current diagnosis, treatment, and coding practices.

Methods

The NMI was developed to predict 5-year mortality in a population-based cohort of randomly sampled Danish residents aged ≥40 years (n = 425,087) followed from 2013 to 2018. Included predictors were selected from hospital diagnoses and filled drug prescriptions based on a combination of subject matter knowledge and a data-driven approach using backwards elimination. The performance of the NMI was assessed in a temporal validation cohort of Danish residents followed from 2007 to 2012 and in six cohorts of new users of selected drugs. The discriminative performance of the NMI, Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) was assessed using the c-statistic from logistic regression models with 5-year mortality as dependent variable and the multimorbidity index score, age, and sex as independent variables.

Results

The NMI included 50 predictors. In the temporal validation cohort, the c-statistic of the NMI (0.887, 95% CI 0.883–0.890) exceeded that of the CCI (0.871, 95% CI 0.868–0.874) and ECI (0.866, 95% CI 0.863–0.870). In all new user cohorts, the NMI outperformed the other indices with c-statistics ranging from 0.781 (95% CI 0.779–0.784) to 0.838 (95% CI 0.834–0.842).

Conclusion

The NMI predicted 5-year mortality in a general Danish population and six cohorts of new users of selected drugs and was superior to the CCI and ECI. The NMI could be preferred over these indices to quantify the level of multimorbidity for, eg, descriptive purposes or confounding control. The NMI should be validated in other patient populations and other Nordic countries.

Polypharmacy occurrence and the related risk of premature death among older adults in Denmark: A nationwide register-based cohort study

Background

Polypharmacy, defined as the concurrent use of ≥5 medications, increases the risk of drug-drug and drug-disease interactions as well as non-adherence to drug therapy. This may have negative health consequences particularly among older adults due to age-related pharmacokinetic and pharmacodynamic changes. This study aims to uncover the occurrence of polypharmacy among older adults in Denmark and investigate how polypharmacy relates to mortality.

Method

This nationwide register-based study included 1,338,058 adults aged 65+ years between January 2013 and December 2017 in Denmark. Polypharmacy prevalence was measured at time of inclusion while incidence and the association between polypharmacy and mortality were measured over the five-year follow-up using Cox regression. In an attempt to adjust for confounding by indication, propensity scores with overlap weighting were introduced to the regression model.

Results

At time of inclusion, polypharmacy prevalence was 29% and over the five years follow-up, 47% of the remaining adults transitioned into polypharmacy. Identified risk factors included multimorbidity (2+ morbidities: HR = 3.51; 95% CI = 3.48–3.53), age (95+ years: HR = 2.85; 95% CI = 2.74–2.96), socioeconomic factors (Highest income quartile: HR = 0.81; 95% CI = 0.80–0.81), region of birth region (Non-western migrants: HR = 0.77; 95% CI = 0.75–0.79), marital status (Divorced: HR = 1.10; 95% CI = 1.10–1.12) and year of inclusion (2017: HR = 1.19; 95% CI = 1.19–1.22). Further analyses showed that polypharmacy involves many different drug cocktails with medication for the cardiovascular system (95%), blood and blood-forming organs (69%), alimentary tract and metabolism (61%) and nervous system (54%) contributing the most. After adjustment for propensity scores with OW, both polypharmacy (HR = 3.48, CI95% = 3.41–3.54) and excessive polypharmacy (HR = 3.48, CI95% = 3.43–3.53) increased the risk of death substantially.

Conclusion

A considerable proportion of older adults in Denmark were exposed to polypharmacy dependent on health status, socio-economic status, and societal factors. The associated three- to four-fold mortality risk indicate a need for further exploration of the appropriateness of polypharmacy among older adults.

The risk of preterm birth in combinations of socioeconomic position and mental health conditions in different age groups: a Danish nationwide register-based cohort study

Background

Inequality in preterm birth is a world-wide challenge that has proved difficult for maternity care services to meet. Reducing the inequality requires identification of pregnant women at particularly high risk of preterm birth in order to target interventions. Therefore, the aim was to estimate the risk of preterm birth in women with different combinations of socioeconomic position, mental health conditions, and age.

Methods

In this nationwide register-based cohort study, we included all first-time mothers that gave birth to a singleton liveborn infant in Denmark between 2000 and 2016. The absolute and relative risk of preterm birth (< 37 weeks of gestation) was examined in different combinations of educational level (high, intermediate, and low) and mental health conditions (no, minor, and moderate/severe) in three age strata (≤23, 24–30, and ≥ 31 years). We estimated the relative risk using Poisson regression with a robust error variance. As additive interaction can help identify subgroups where limited resources can be of best use, we measured the attributable proportion to assess the risk that is due to interaction of the different exposures.

Results

Of the 415,523 included first-time mothers, 6.3% gave birth prematurely. The risk of preterm birth increased with decreasing educational level and increasing severity of mental health conditions in all age strata, but most in women aged ≥31 years. The highest absolute risk was 12.9% [95% CI: 11.2;14.8%] in women aged ≥31 years with low education and moderate/severe mental health conditions resulting in a relative risk of 2.23 [95% CI: 1.93–2.58] compared to the unexposed reference group in that age strata. We found positive additive interaction between low education and mental health conditions in women aged 24–30 and ≥ 31 years and between age ≥ 31 years and combinations of mental health conditions and educational levels.

Conclusion

The inequality in preterm birth increased with increasing age. To reduce inequality in preterm birth focused attention on women with higher age further combined with lower educational levels and mental health conditions is essential.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04138-0.

Prevalence of parental mental health conditions among children aged 0-16 years in Denmark: A nationwide register-based cross-sectional study

Aim: Parental mental health conditions adversely affect the children. Information on the prevalence of parental mental health conditions is needed to help policymakers allocate resources appropriately. Therefore, the aim of this study was to estimate the prevalence of children with parental mental health conditions in Denmark and further estimate the age-specific prevalence and geographical variation. Methods: In this nationwide register-based cross-sectional study, we included all children born between 2000 and 2016 if they resided in Denmark on 31 December 2016. Information on both maternal and paternal mental health conditions was retrieved from primary and secondary healthcare registers. Parental mental health conditions were categorised in three severity groups: minor, moderate, and severe. We estimated the proportion of children with parental mental health conditions on 31 December 2016. Results: Of the 1,106,459 children aged 0-16 years, 39.1% had at least one parent with a mental health condition. The prevalence increased with age of the children until the age of six years. Geographical variation in the prevalence ranged from 29.0% to 48.3% in the 98 municipalities. Minor parental mental health conditions (23.5%) were more common than moderate (13.5%) and severe parental mental health conditions (2.2%). Hospital-diagnosed parental mental health conditions were prevalent in 12.8% of the children. Conclusions: Two in five children aged 0-16 years in Denmark have parents with a mental health condition and geographical variation exists. The high prevalence of children with parental mental health conditions is an important public health challenge, which calls for attention.

Discontinuation of antidepressants: Is there a minimum time on treatment that will reduce relapse risk?

BACKGROUND

Several national guidelines include recommendations for a minimum duration of antidepressant treatment, but these vary from 4-9 months after remission. We aimed to investigate whether there is an optimal minimum duration of antidepressant treatment to reduce relapse risk.

METHODS

A Danish population-based cohort study among 89,442 adults who initiated antidepressants for depression treatment aged 18-60 years, from 2006-2015. We defined antidepressant discontinuation as ≥30 days without treatment. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) to indicate the risk of restarting antidepressants among those who discontinued antidepressants with <4, 4-6, and 7-9 months of use compared with discontinuation after 10-12 months.

RESULTS

For individuals on antidepressant treatment <4, 4-6, 7-9 and 10-12 months, cumulative incidence of restarting treatment within one year was 37.4% (95% CI: 36.9-37.8%), 35.1% (95% CI: 34.6-35.7%), 35.0% (95% CI: 34.2-35.8%) and 32.8% (95% CI: 31.7-34.0%), respectively. Individuals on antidepressants <10 months versus 10-12 months had higher risk of restarting antidepressants: the HR for antidepressant treatment <4 months was 1.21 (95% CI: 1.16-1.27), 4-6 months 1.11 (95% CI: 1.06-1.17), and 7-9 months 1.09 (95% CI: 1.04-1.15).

LIMITATIONS

We were not able to ascertain the reasons why individuals discontinued antidepressants, and systematic errors from unmeasured confounders cannot be ruled out.

CONCLUSIONS

Based on our findings, a minimum of 10-12 months of treatment appears to be preferable if there is concern about relapse after discontinuation.

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

BACKGROUND

In 2013, Denmark implemented a reform that tightened the criteria for disability pension, expanded a subsidized job scheme ('flexi-job') and introduced a new vocational rehabilitation scheme. The overall aim of the reform was to keep more persons attached to the labour market. This study investigates the impact of the reform among persons with chronic disease and whether this impact differed across groups defined by labour market affiliation and chronic disease type.

METHODS

The study was conducted as a register-based, nationwide cohort study. The study population included 480 809 persons between 40 and 64 years of age, who suffered from at least one of six chronic diseases. Hazard ratios (HR) and 95% confidence intervals (CI) of being awarded disability pension or flexi-job in the 5 years after vs. the 5 years prior to the reform were estimated.

RESULTS

Overall, the probability of being awarded disability pension was halved after the reform (HR = 0.49, CI: 0.47-0.50). The impact was largest for persons receiving sickness absence benefits (HR = 0.31, CI: 0.24-0.39) and for persons with functional disorders (HR = 0.38, CI: 0.32-0.44). Also, the impact was larger for persons working in manual jobs than for persons working in non-manual jobs. The probability of being awarded a flexi-job was decreased by one-fourth (HR = 0.76, CI: 0.74-0.79) with the largest impact for high-skilled persons working in non-manual jobs.

CONCLUSION

Access to disability pension and flexi-job decreased after the reform. This impact varied according to labour market affiliation and chronic disease type.

Early ovarian ageing: is a low number of oocytes harvested in young women associated with an earlier and increased risk of age-related diseases?

STUDY QUESTION

Do young women with early ovarian ageing (EOA), defined as unexplained, and repeatedly few oocytes harvested in ART have an increased risk of age-related events?

SUMMARY ANSWER

At follow-up, women with idiopathic EOA had an increased risk of age-related events compared to women with normal ovarian ageing (NOA).

WHAT IS KNOWN ALREADY

Early and premature menopause is associated with an increased risk of cardiovascular diseases (CVDs), osteoporosis and death. In young women, repeated harvest of few oocytes in well-stimulated ART cycles is a likely predictor of advanced menopausal age and may thus serve as an early marker of accelerated general ageing.

STUDY DESIGN, SIZE, DURATION

A register-based national, historical cohort study. Young women (≤37 years) having their first ART treatment in a public or private fertility clinic during the period 1995-2014 were divided into two groups depending on ovarian reserve status: EOA (n = 1222) and NOA (n = 16 385). Several national registers were applied to assess morbidity and mortality.

PARTICIPANTS/MATERIALS, SETTING, METHODS

EOA was defined as ≤5 oocytes harvested in a minimum of two FSH-stimulated cycles and NOA as ≥8 oocytes in at least one cycle. Cases with known causes influencing the ovarian reserve (endometriosis, ovarian surgery, polycystic ovary syndrome, chemotherapy etc.) were excluded. To investigate for early signs of ageing, primary outcome was an overall risk of ageing-related events, defined as a diagnosis of either CVD, osteoporosis, type 2 diabetes, cancer, cataract, Alzheimer's or Parkinson's disease, by death of any-cause as well as a Charlson comorbidity index score of ≥1 or by registration of early retirement benefit. Cox regression models were used to assess the risk of these events. Exposure status was defined 1 year after the first ART cycle to assure reliable classification, and time-to-event was measured from that time point.

MAIN RESULTS AND THE ROLE OF CHANCE

Median follow-up time from baseline to first event was 4.9 years (10/90 percentile 0.7/11.8) and 6.4 years (1.1/13.3) in the EOA and NOA group, respectively. Women with EOA had an increased risk of ageing-related events when compared to women with a normal oocyte yield (adjusted hazard ratio 1.24, 95% CI 1.08 to 1.43). Stratifying on categories, the EOA group had a significantly increased risk for CVD (1.44, 1.19 to 1.75) and osteoporosis (2.45, 1.59 to 3.90). Charlson comorbidity index (1.15, 0.93 to 1.41) and early retirement benefit (1.21, 0.80 to 1.83) was also increased, although not reaching statistical significance.

LIMITATIONS, REASONS FOR CAUTION

Cycles never reaching oocyte aspiration were left out of account in the inclusion process and we may therefore have missed women with the most severe forms of EOA. We had no information on the total doses of gonadotrophin administered in each cycle.

WIDER IMPLICATIONS OF THE FINDINGS

These findings indicate that oocyte yield may serve as marker of later accelerated ageing when, unexpectedly, repeatedly few oocytes are harvested in young women. Counselling on life-style factors as a prophylactic effort against cardiovascular and other age-related diseases may be essential for this group of women.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received for this study. All authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Deliberative and Paternalistic Interaction Styles for Conversational Agents in Digital Health: Procedure and Validation Through a Web-Based Experiment

Background

Recent years have witnessed a constant increase in the number of people with chronic conditions requiring ongoing medical support in their everyday lives. However, global health systems are not adequately equipped for this extraordinarily time-consuming and cost-intensive development. Here, conversational agents (CAs) can offer easily scalable and ubiquitous support. Moreover, different aspects of CAs have not yet been sufficiently investigated to fully exploit their potential. One such trait is the interaction style between patients and CAs. In human-to-human settings, the interaction style is an imperative part of the interaction between patients and physicians. Patient-physician interaction is recognized as a critical success factor for patient satisfaction, treatment adherence, and subsequent treatment outcomes. However, so far, it remains effectively unknown how different interaction styles can be implemented into CA interactions and whether these styles are recognizable by users.

Objective

The objective of this study was to develop an approach to reproducibly induce 2 specific interaction styles into CA-patient dialogs and subsequently test and validate them in a chronic health care context.

Methods

On the basis of the Roter Interaction Analysis System and iterative evaluations by scientific experts and medical health care professionals, we identified 10 communication components that characterize the 2 developed interaction styles: deliberative and paternalistic interaction styles. These communication components were used to develop 2 CA variations, each representing one of the 2 interaction styles. We assessed them in a web-based between-subject experiment. The participants were asked to put themselves in the position of a patient with chronic obstructive pulmonary disease. These participants were randomly assigned to interact with one of the 2 CAs and subsequently asked to identify the respective interaction style. Chi-square test was used to assess the correct identification of the CA-patient interaction style.

Results

A total of 88 individuals (42/88, 48% female; mean age 31.5 years, SD 10.1 years) fulfilled the inclusion criteria and participated in the web-based experiment. The participants in both the paternalistic and deliberative conditions correctly identified the underlying interaction styles of the CAs in more than 80% of the assessments (X²_1,88=38.2; P<.001; phi coefficient r_φ=0.68). The validation of the procedure was hence successful.

Conclusions

We developed an approach that is tailored for a medical context to induce a paternalistic and deliberative interaction style into a written interaction between a patient and a CA. We successfully tested and validated the procedure in a web-based experiment involving 88 participants. Future research should implement and test this approach among actual patients with chronic diseases and compare the results in different medical conditions. This approach can further be used as a starting point to develop dynamic CAs that adapt their interaction styles to their users.

National all-cause mortality during the COVID-19 pandemic: a Danish registry-based study

Denmark implemented early widespread social distancing to reduce pressure on the healthcare system from the coronavirus disease 2019 (COVID-19) pandemic, with the aims to reduce mortality. Unintended consequences might be delays in treatment for other diseases and subsequent mortality. We examined national all-cause mortality comparing weeks 1–27 in 2020 and 2015–2019. This registry-based study used Danish national registry data until 5 July 2020. We examined all-cause mortality rates among all deaths recorded from 2015 to 2020 and among chronic conditions (cardiovascular (cardiac & circulatory), chronic pulmonary, chronic kidney disease, cancer, and diabetes), comparing each week in 2020 to weeks in 2015–2019. In 2020, there were 28,363 deaths in weeks 1–27 (30 December 2019–5 July 2020), the mean deaths in 2015–2019 were 28,630 deaths (standard deviation 784). Compared to previous years, the mortality rate in weeks 3–10 of 2020 was low, peaking in week 14 (17.6 per 100,000 persons in week 9, 19.9 per 100,000 in week 14). Comorbidity prevalence among deceased individuals was similar in 2020 and 2015–2019: 71.1% of all deceased had a prior cardiovascular diagnosis, 30.0% of all deceased had a prior cardiac diagnosis. There were 493 deaths with COVID-19 in weeks 11–27, (59.8% male), and 75.1% had a prior cardiovascular diagnosis. Weekly mortality rates for pre-existing chronic conditions peaked in week 14, and then declined. During the COVID-19 pandemic, due to timely lockdown measures, the mortality rate in Denmark has not increased compared to the mortality rates in the same period during 2015–2019.

Artificial Intelligence-Based Conversational Agents for Chronic Conditions: Systematic Literature Review

BACKGROUND

A rising number of conversational agents or chatbots are equipped with artificial intelligence (AI) architecture. They are increasingly prevalent in health care applications such as those providing education and support to patients with chronic diseases, one of the leading causes of death in the 21st century. AI-based chatbots enable more effective and frequent interactions with such patients.

OBJECTIVE

The goal of this systematic literature review is to review the characteristics, health care conditions, and AI architectures of AI-based conversational agents designed specifically for chronic diseases.

METHODS

We conducted a systematic literature review using PubMed MEDLINE, EMBASE, PyscInfo, CINAHL, ACM Digital Library, ScienceDirect, and Web of Science. We applied a predefined search strategy using the terms "conversational agent," "healthcare," "artificial intelligence," and their synonyms. We updated the search results using Google alerts, and screened reference lists for other relevant articles. We included primary research studies that involved the prevention, treatment, or rehabilitation of chronic diseases, involved a conversational agent, and included any kind of AI architecture. Two independent reviewers conducted screening and data extraction, and Cohen kappa was used to measure interrater agreement.A narrative approach was applied for data synthesis.

RESULTS

The literature search found 2052 articles, out of which 10 papers met the inclusion criteria. The small number of identified studies together with the prevalence of quasi-experimental studies (n=7) and prevailing prototype nature of the chatbots (n=7) revealed the immaturity of the field. The reported chatbots addressed a broad variety of chronic diseases (n=6), showcasing a tendency to develop specialized conversational agents for individual chronic conditions. However, there lacks comparison of these chatbots within and between chronic diseases. In addition, the reported evaluation measures were not standardized, and the addressed health goals showed a large range. Together, these study characteristics complicated comparability and open room for future research. While natural language processing represented the most used AI technique (n=7) and the majority of conversational agents allowed for multimodal interaction (n=6), the identified studies demonstrated broad heterogeneity, lack of depth of reported AI techniques and systems, and inconsistent usage of taxonomy of the underlying AI software, further aggravating comparability and generalizability of study results.

CONCLUSIONS

The literature on AI-based conversational agents for chronic conditions is scarce and mostly consists of quasi-experimental studies with chatbots in prototype stage that use natural language processing and allow for multimodal user interaction. Future research could profit from evidence-based evaluation of the AI-based conversational agents and comparison thereof within and between different chronic health conditions. Besides increased comparability, the quality of chatbots developed for specific chronic conditions and their subsequent impact on the target patients could be enhanced by more structured development and standardized evaluation processes.

Work related sexual harassment and risk of suicide and suicide attempts: prospective cohort study

OBJECTIVE

To analyse the relation between exposure to workplace sexual harassment and suicide, as well as suicide attempts.

DESIGN

Prospective cohort study.

SETTING

Sweden.

PARTICIPANTS

86 451 men and women of working age in paid work across different occupations responded to a self-report questionnaire including exposure to work related sexual harassment between 1995 and 2013. The analytical sample included 85 205 people with valid data on sexual harassment, follow-up time, and age.

MAIN OUTCOME MEASURES

Suicide and suicide attempts ascertained from administrative registers (mean follow-up time 13 years).

RESULTS

Among the people included in the respective analyses of suicide and suicide attempts, 125 (0.1%) died from suicide and 816 (1%) had a suicide attempt during follow-up (rate 0.1 and 0.8 cases per 1000 person years). Overall, 11 of 4095 participants exposed to workplace sexual harassment and 114 of 81 110 unexposed participants committed suicide, and 61/4043 exposed and 755/80 513 unexposed participants had a record of suicide attempt. In Cox regression analyses adjusted for a range of sociodemographic characteristics, workplace sexual harassment was associated with an excess risk of both suicide (hazard ratio 2.82, 95% confidence interval 1.49 to 5.34) and suicide attempts (1.59, 1.21 to 2.08), and risk estimates remained significantly increased after adjustment for baseline health and certain work characteristics. No obvious differences between men and women were found.

CONCLUSIONS

The results support the hypothesis that workplace sexual harassment is prospectively associated with suicidal behaviour. This suggests that suicide prevention considering the social work environment may be useful. More research is, however, needed to determine causality, risk factors for workplace sexual harassment, and explanations for an association between work related sexual harassment and suicidal behaviour.

Patterns of multimorbidity and demographic profile of latent classes in a Danish population-A register-based study

Background

Multimorbidity is an increasing public health concern and is associated with a range of further adverse outcomes. Identification of disease patterns as well as characteristics of populations affected by multimorbidity is important for prevention strategies to identify those at risk.

Aim

The aim of the study was to identify and describe demographic characteristics of multimorbidity classes in three age groups (16–44 years, 45–64 years, and 65+ years).

Methods

Based on register information on 47 chronic diseases and conditions, we used latent class analysis to identify multimorbidity classes in a random sample of the Danish population (n = 470,794). Information on sociodemographic characteristics (age, sex, region of origin, educational level, employment status, and marital status) was obtained from registers and linked to the study population. Age- and sex-adjusted multinomial logistic regression models were used to examine associations between multimorbidity classes and sociodemographic characteristics.

Results

We identified seven classes among individuals in the age groups 45–64 years and 65+ years and five classes in the age group 16–44 years. Overall, the classes were similar in the three age groups, but varied in size, i.e. the class ‘No or few diseases’ was larger in the younger age group. The class ‘Many diseases’ (a class with both somatic diseases and mental illnesses) was only seen in individuals aged 45–64 years and 65+ years. There were social inequalities in odds of belonging to the multimorbidity classes compared to the healthier class. These social inequalities varied but were especially strong in the classes named ‘Many diseases’ and ‘Mental illness, epilepsy’.

Conclusion

The results of the study suggest that there are social inequalities in multimorbidity but that these inequalities are not universal to all types of multimorbidity. This supports that multimorbidity is diverse and should be prevented and treated accordingly.

Physical robustness and resilience among long-lived female siblings: a comparison with sporadic long-livers

Long-lived individuals are central in studies of healthy longevity. However, few pro-longevity factors have been identified, presumably because of “phenocopies”, i.e. individuals that live long by chance. Familial longevity cases may include less phenocopies than sporadic cases and provide better insights into longevity mechanisms. Here we examined whether long-lived female siblings have a better ability to avoid diseases at ages 65+ (proxy for “robustness”) and/or survive to extreme ages (proxy for “resilience”) compared to sporadic long-livers. A total of 1,156 long-lived female siblings were selected from three nationwide Danish studies and age-matched with sporadic long-lived female controls. Outcomes included cumulative incidence of common health disorders from age 65 and overall survival. Long-lived female siblings had lower risks of some but not all health conditions, most significantly, depression (OR=0.74; 95%CI=0.62-0.88), and less significantly hypertensive (OR=0.84; 95%CI=0.71-0.99) and cerebrovascular (OR=0.73; 95%CI=0.55-0.96) diseases. They also had consistently better survival to extreme ages (HR=0.71; 95%CI= 0.63-0.81) compared to sporadic long-livers. After adjustment for the diseases, the association with mortality changed only marginally suggesting central role of better physiological resilience in familial longevity. Due to their consistently better resilience, familial longevity cases could be more informative than sporadic cases for studying mechanisms of healthy longevity.

A Nationwide Study of Prevalence Rates and Characteristics of 199 Chronic Conditions in Denmark

BACKGROUND

Real-world data of disease prevalence represents an important but underutilised source of evidence for health economic modelling.

AIMS

The aim of this study was to estimate nationwide prevalence rates and summarise the characteristics of 199 chronic conditions using Danish population-based health registers, to provide an off-the-shelf tool for decision makers and researchers.

METHODS

The study population comprised all Danish residents aged 16 years or above on 1 January 2013 (n = 4,555,439). The study was based on the linkage of national registers covering hospital contacts, contacts with primary care (including general practitioners) and filled-in out-of-hospital prescriptions.

RESULTS

A total of 65.6% had one or more chronic condition. The ten conditions with the highest degree of prevalence were hypertension (23.3%), respiratory allergy (18.5%), disorders of lipoprotein metabolism (14.3%), depression (10.0%), bronchitis (9.2%), asthma (7.9%), type 2 diabetes (5.3%), chronic obstructive lung disease (4.7%), osteoarthritis of the knee (3.9%) and finally osteoporosis (3.5%) and ulcers (3.5%) in joint tenth place. Characteristics by gender, age and national geographical differences were also presented.

CONCLUSIONS

A nationwide catalogue of the prevalence rates and characteristics of patients with chronic conditions based on a nationwide population is provided. The prevalence rates of the 199 conditions provide important information on the burden of disease for use in healthcare planning, as well as for economic, aetiological and other research.

Mobility limitation as determinant of primary care use and ambulatory care sensitive conditions

PURPOSE

First, to investigate associations between mobility limitations and use of general practitioners and hospitalizations of acute care sensitive conditions, respectively. Second, to investigate whether these associations vary by socio-demographic factors.

METHODS

The study included 3574 females and males aged 75 or 80 years from the Danish Intervention Study on Preventive Home Visits. Fixed-effects logistic and poisson regression models were applied to study the relationship between mobility limitations (measured two-four times) and general practitioner consultations and hospitalizations with acute care sensitive conditions each subsequent year, respectively.

RESULTS

Each additional mobility limitation was associated with 15% higher odds of general practitioner home consultation (Odds ratio 1.15, 95% CI 1.07;1.23) and 4% increased incidence rate of general practitioner consultations among those with ≥ 1 consultation (Incidence rate ratio 1.04, 95% CI 1.03;1.04). There were no associations between mobility limitations and whether older adults had at least one general practitioner consultation nor acute care sensitive condition hospitalization. Test of interactions (p < 0.03) showed that more mobility limitations were associated with greater incidence rate of general practitioner consultations among males compared to females, married compared to unmarried, and older adults with high compared to low financial assets.

CONCLUSIONS

Older adults with more mobility limitations had more often a general practitioner home consultation. Mobility limitations were not associated with whether older adults had at least one general practitioner consultation, but increased mobility limitations were associated with higher contact rate among those who had ≥ 1 consultation, especially among males and older adults who were married or had high financial assets.

Inequality in oral anticoagulation use and clinical outcomes in atrial fibrillation: a Danish nationwide perspective

Aim

To explore the potential of small-area variation analysis as a tool for identifying unwarranted variation in oral anticoagulation (OAC) use and clinical outcomes in patients with atrial fibrillation (AF) and thereby identify locations with opportunity for improvement in AF care.

Methods and results

Based on Danish health care registries, we conducted a nationwide historical cohort study including first-time AF patients with a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75, diabetes, thromboembolism, vascular disease, age 65-74, and sex category) score ≥ 2 between 2007 and 2014 (n = 94 482). For each administrative region and municipality, we assessed OAC initiation and persistence as well as the risk of ischaemic stroke, haemorrhagic stroke, and other major bleeding, respectively. In addition, potential temporal changes were examined for all outcomes. Initiation of OAC varied among regions from 49.5% to 62.4%. In patients initiating OAC, the proportion of patients still receiving OAC after 1 year varied from 73.9% to 79.3%. Oral anticoagulation use increased in all regions during the study period, particularly after 2010, but regional variation in OAC initiation persisted. Generally, the regions and municipalities with the highest initiation of OAC also had the highest OAC persistence. The risk of ischaemic stroke and other major bleeding was lower in these regions and municipalities. We found no significant difference between regions in risk of haemorrhagic stroke.

Conclusion

Substantial geographical variation in OAC use and clinical outcomes occurs in Denmark demonstrating the potential of small-area variation analysis as a tool for identifying unwarranted variation in AF care and clinical outcomes. Our findings demonstrate the need for additional initiatives to ensure uniform high-quality care for AF patients.

Mortality Following Trajectories of Mobility Limitations: The Modifying Impact of Social Factors

Objective: How are trajectories of mobility limitations (MLs) among older adults associated with mortality? Do social factors modify these associations? Method: Group-based trajectory modeling was used to identify four trajectories of MLs over a period of 4.5 years among 3,055 older Danes. Mortality analyses were conducted using additive hazard regression models. Results: Compared to older adults without MLs, older adults with high level of MLs who experienced further increase in MLs were associated with the most additional deaths followed by older adults with no MLs at baseline who later experienced limitations and older adults with a medium ML level at baseline who later experienced further increase in limitations. Men and 80-year olds experienced more additional deaths following adverse ML trajectories than women and 75-year olds. Discussion: Trajectories that led to higher ML levels were associated with most additional deaths especially among men and in the oldest age group.

Interplay between financial assets and social relations on decline in physical function and mortality among older people

It is well established that socioeconomic position (SEP) and social relations impact physical function and mortality in old age. Due to differential vulnerability, few social relations may lead to greater decline in physical function and mortality among older people with low compared to high SEP. The aim was to investigate whether older people with few social relations experience greater decline in physical function and mortality when also subject to low financial assets? The study population included 4060 older people aged 75 or 80 years at baseline in 1998-1999. Social relations at baseline and physical function at baseline and after 1.5, 3.0 and 4.5 years were obtained from questionnaires. Financial assets at baseline and mortality during 10 years of follow-up were obtained from registers. Analyses of the associations between financial assets combined with social relations and decline in physical function and mortality, respectively, were conducted. Among males, but not females, low financial assets and few social relations were associated with the greatest decline in physical function. Yet, interaction only reached significance between financial assets and visits. Among males and females, low financial assets and few social relations were associated with the highest mortality. Interactions only reached significance between financial assets and visits for females and social activity for males. In conclusion, few social relations implied greater decline in physical function among older males and higher mortality among older males and females with low financial assets; however, the study only supports the presence of differential vulnerability for visits and social activity.

Workplace bullying and violence as risk factors for type 2 diabetes: a multicohort study and meta-analysis

AIMS/HYPOTHESIS

The aim of this multicohort study was to examine whether employees exposed to social stressors at work, such as workplace bullying and violence, have an increased risk of type 2 diabetes.

METHODS

The study included 45,905 men and women (40-65 years of age and free of diabetes at baseline) from four studies in Sweden, Denmark and Finland. Workplace bullying and violence were self-reported at baseline. Incident diabetes was ascertained through national health and medication records and death registers. Marginal structural Cox models adjusted for age, sex, country of birth, marital status and educational level were used for the analyses.

RESULTS

Nine per cent of the population reported being bullied at work and 12% were exposed to workplace violence or threats of violence. Bullied participants had a 1.46 (95% CI 1.23, 1.74) times higher risk of developing diabetes compared with non-bullied participants. Exposure to violence or threats of violence was also associated with a higher risk of diabetes (HR 1.26 [95% CI 1.02, 1.56]). The risk estimates attenuated slightly when taking BMI into account, especially for bullying. The results were similar for men and women, and were consistent across cohorts.

CONCLUSIONS/INTERPRETATION

We found a higher risk of incident type 2 diabetes among employees exposed to bullying or violence in the workplace. Further research is needed to determine whether policies to reduce bullying and violence at work may reduce the incidence of type 2 diabetes in working populations. Research on the mechanisms is also highly warranted.

Associations between the structural and functional aspects of social relations and poor mental health: a cross-sectional register study

Background

Social relations influence mental health through different pathways. To capture the complexity of social relations, it is beneficial to consider both the structural (e.g., reachability of social network and social integration) and functional (e.g., instrumental and emotional support) aspects of the concept. Both aspects are rarely investigated simultaneously. This study aimed to examine the association between the structural and functional aspects of social relations and poor mental health.

Methods

The study was designed as a cross-sectional register study. We used data on mental health and social relations from 15,839 individuals aged 16–92 years with a mean age of 49.0 years (SD 17.9) who responded to The North Denmark Region Health Survey 2013 among residents in Northern Jutland, Denmark. The 12-Item Short-Form Health Survey measured mental health; a cut-off point of 44.5 was used to dichotomize participants into poor and good mental health. The categorization of social relations was inspired by Berkman et al.’s conceptual model of social relations and health. The analyses were performed with survey logistic regression.

Results

We found that 21.6% (n = 3422) of participants reported poor mental health, and 59% (n = 2020) of these were women. Being in contact with family and friends less than once a month statistically significantly increased the risk for poor mental health (Family OR = 1.78, 95% CI = 1.51–2.10 and Friends OR = 2.65, 95% CI = 2.30–3.06). The individuals who were not in contact with their network as often as they liked had a significantly higher risk for poor mental health (OR = 2.40, 95% CI = 2.20–2.62). Lack of instrumental support was associated with a higher risk for poor mental health (OR = 2.81, 95% CI = 2.26–3.48). We found an interaction between age and emotional support; the youngest population had the highest risk for poor mental health when they did not have access to emotional support (Young OR = 5.26, 95% CI = 3.91–7.09; Adult OR = 3.69, 95% CI = 3.17–4.30; and Elderly OR = 2.73, 95% CI = 2.23–3.34).

Conclusions

Both structural and functional aspects of social relations were associated with poor mental health in our study. Rarely being in contact with friends and a lack of network reachability were associated with poor mental health. Likewise, low levels of emotional and instrumental support were associated with poor mental health.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4871-x) contains supplementary material, which is available to authorized users.