The value of the Skåne Health-care Register: Prospectively collected individual-level data for population-based studies

Uncovering sociodemographic disparities in temporal trends of osteoarthritis incidence and age-at-diagnosis, 2006-2019

AIM

To describe sociodemographic disparities in temporal trends of incidence and age distributions of first registered osteoarthritis (OA) diagnosis in southern Sweden.

METHODS

We identified all Skåne residents aged 35+ who had lived in the region at any point during the period 2006-2019 with no previous OA diagnosis (ICD-10 codes M15-M19) for 8 years prior to inclusion in the study (n = 849,061). We calculated person-years from inclusion until OA diagnosis, death, emigration, or 31 December 2019, whichever occurred first. Combining sex (female, male), education (low, medium, high) and nativity (Swedish, immigrant), we created a variable with 12 strata. Average annual percent changes in age-standardized incidence rates were estimated using joinpoint regression. Changes in the median age-at-diagnosis (year of diagnosis minus birth year), weighted to the mid-2005 Swedish population, were explored.

RESULTS

Cumulative age-standardized incidence rates ranged from 116 (95% CI: 111, 121) per 10,000 person-years for immigrant males with low education to 205 (95% CI: 200, 210) for immigrant females with medium education. The estimated average annual percent changes (ranging from 3.4% to 6.1%) were generally similar, with slightly greater variations among immigrants than Swedes. The weighted median age-at-diagnosis was higher for Swedes and low educated people. Immigrant females with low education were the only stratum with a reduction (3 years) in the weighted median age-at-diagnosis over time. Sociodemographic patterns in knee OA incidence were different from patterns for hip OA.

CONCLUSIONS

There were few sociodemographic disparities in temporal trends of OA incidence and age-at-diagnosis, suggesting persistent sociodemographic disparities in OA burden in southern Sweden.

Presurgical management of ulnar nerve entrapment in patients with and without diabetes mellitus

Diabetes mellitus (DM) is a risk factor for the development of ulnar nerve entrapment (UNE). Differences in surgical outcomes for UNE between patients with and without DM have been reported, but studies on presurgical management are scarce. This study aimed to evaluate the presurgical management of UNE in patients with (DM diagnosis < 2 years of UNE diagnosis) and without DM regarding the level of care for diagnosis and the proportion that proceeds to surgery. Data from 6600 patients with UNE between 2004 and 2019 were included from the Skåne Health Care Register (SHR) and cross-linked with data from the Swedish National Diabetes Register (NDR). The group with UNE and DM was compared to the group with UNE without DM and prevalence ratios were calculated using Cox regression analysis. Patients with DM more often got their first UNE diagnosis in secondary care than in primary care (643/667, 96% vs. 5361/5786; 93%). Patients with and without DM, regardless of the type of DM, presence of retinopathy, or HbA1c levels, were surgically treated for UNE to the same extent (258/667, 39% of patients with DM vs. 2131/5786, 37% of patients without DM). The proportion of surgically treated was significantly lower among patients diagnosed with UNE in primary care compared to secondary care (59/449, 13% vs. 2330/5786, 38%). Men were more often surgically treated than women (1228/3191, 38% vs.1161/3262 36%). Patients with UNE and DM are surgically treated to the same extent as patients with UNE but without DM and are more likely to be diagnosed in specialized care.

Influence of the COVID-19 pandemic on births and induced abortions in Southern Sweden: a register-based study

BACKGROUND

Pandemics are linked with declining birth rates, but little is known about how the COVID-19 pandemic has influenced childbearing decisions. We aimed to investigate the associations between the COVID-19 pandemic and reproductive decisions, specifically to identify potential changes in the frequency of deliveries and induced abortions in Skåne, Sweden.

METHODS

Using the Skåne Healthcare Register, we identified women aged 15-45 years who had at least one pregnancy-related care visit registered between 1 January 2013 and 11 November 11 2021. Deliveries and induced abortions were identified, and changes in weekly delivery and abortion counts were assessed using an interrupted time series design. Relative risks (RRs) and 95% confidence intervals (CIs) were estimated from a Poisson regression model.

RESULTS

During the study period we identified 129 131 deliveries and 38 591 abortions. Compared with the counterfactual (exposed interval assuming COVID-19 had not occurred), pandemic exposure was associated with fewer deliveries (RR 0.93; 95% CI 0.89 to 0.98). For abortions, pandemic exposure appeared to be associated with fewer abortions (RR 0.95; 95% CI 0.90 to 1.00); however, age-related differences were found. Among women aged 25 years and over, pandemic exposure was more strongly associated with fewer abortions. Contrastingly, among women aged under 25 years, abortions appeared to increase.

CONCLUSIONS

The COVID-19 pandemic seemed to have contributed to a decline in births in Southern Sweden. During the same period, abortions declined in women in the older age range, but contrastingly increased among younger women.

Surgery for carpal tunnel syndrome in patients with and without diabetes-Is there a difference in the frequency of surgical procedures?

Carpal tunnel syndrome (CTS) occurs more often among individuals with diabetes. The aim of this retrospective observational registry study was to examine whether individuals with diabetes and CTS are treated surgically to the same extent as individuals with CTS but without diabetes. Data on CTS diagnosis and surgery were collected from the Skåne Healthcare Register (SHR). A total of 35,105 individuals (age ≥ 18 years) diagnosed with CTS from 2004-2019 were included. Data were matched to the Swedish National Diabetes Register (NDR. Cox regression models were used to calculate the risk of the use of surgical treatment. Of the 35,105 included individuals with a CTS diagnosis, 17,662 (50%) were treated surgically, and 4,966 (14%) had diabetes. A higher number of individuals with diabetes were treated surgically (2,935/4,966, 59%) than individuals without diabetes (14,727/30,139, 49%). In the Cox regression model, diabetes remained a significant risk factor for surgical treatment (PR 1.14 (95% CI 1.11-1.17)). Individuals with type 1 diabetes were more frequently treated surgically (490/757, 65%) than individuals with type 2 diabetes (2,445/4,209, 58%). There was no difference between the sexes and their treatment. The duration of diabetes was also a risk factor for surgical treatment in diabetes type 2, but high HbA1c levels were not. Individuals with diabetes are more likely to be treated surgically for CTS than individuals without diabetes. Individuals with type 1 diabetes are more likely to be treated surgically for CTS than individuals with type 2 diabetes.

Myocardial infarction in a population-based cohort of patients with biopsy-confirmed giant cell arteritis in southern Sweden

OBJECTIVES

To determine the incidence rate (IR) of myocardial infarction (MI), relative risk of MI, and impact of incident MI on mortality in individuals with biopsy-confirmed giant cell arteritis (GCA).

METHODS

MIs in individuals diagnosed with GCA 1998-2016 in Skåne, Sweden were identified by searching the SWEDEHEART register, a record of all patients receiving care for MI in a coronary care unit (CCU). The regional diagnosis database, with subsequent case review, identified GCA patients receiving care for MI outside of a CCU. A cohort of 10 reference subjects for each GCA case, matched for age, sex and area of residence, was used to calculate the incidence rate ratio (IRR) of MI in GCA to that in the general population.

RESULTS

The GCA cohort comprised 1134 individuals. During 7958 person-years of follow-up, 102 were diagnosed with incident MI, yielding an IR of 12.8 per 1000 person-years (95% CI 10.3 to 15.3). The IR was highest in the 30 days following GCA diagnosis and declined thereafter. The IRR of MI in GCA to that of the background population was 1.29 (95% CI 1.05 to 1.59). Mortality was higher in GCA patients who experienced incident MI than in those without MI (HR 2.8; 95% CI 2.2 to 3.6).

CONCLUSIONS

The highest incidence of MI occurs within the 30 days following diagnosis of GCA. Individuals with GCA have a moderately increased risk of MI compared with a reference population. Incident MI has a major impact on mortality in GCA.

The prevalence of chronic obstructive pulmonary disease in patients with spondyloarthritis compared to the general population in the southernmost region of Sweden: a case-control study

Spondyloarthritis (SpA) has been associated with comorbidities, e.g., cardiovascular disease. However, little is known about the relation between SpA and chronic obstructive pulmonary disease (COPD). The aim of the study was to compare the prevalence of COPD in SpA to the general population. Patients with prevalent SpA in Skåne, Sweden, on December 31, 2018, were identified based on diagnostic codes in a regional register on primary care, secondary outpatient care and inpatient care. Population-based controls (5 per SpA case) were matched for age, sex and municipality. The base case definition for COPD required at least two prior visits with a registered COPD diagnosis. Stricter definitions included dispensed prescriptions for COPD and a COPD diagnosis made by a specialist in lung medicine. The prevalence of COPD in patients with SpA and controls, overall and stratified by sex and age, and the corresponding prevalence ratios, were estimated. A total of 3571 patients with SpA (51% male, mean age 53 years) were compared to 17,855 matched controls. The prevalence of COPD in patients with SpA was 37.8/1000, with a prevalence ratio compared to controls of 1.03 (95% CI 0.85-1.24). There were no significant differences in COPD prevalence between patients with SpA and controls in men or women, in any of the age groups, or in analyses using stricter definitions of COPD. In this regional study including data from primary care, the prevalence of COPD was not increased in patients with SpA compared to the background population.

Does a prior diagnosis of infectious disease confer an increased risk of latent autoimmune diabetes in adults?

AIMS

Infections are proposed risk factors for type 1 diabetes in children. We examined whether a diagnosis of infectious disease also confers an increased risk of latent autoimmune diabetes in adults (LADA).

MATERIALS AND METHODS

We used data from a population-based Swedish case-control study with incident cases of LADA (n = 597) and matched controls (n = 2386). The history of infectious disease was ascertained through national and regional patient registers. We estimated adjusted odds ratios (OR) with 95% confidence intervals for ≥1 respiratory (any/upper/lower), gastrointestinal, herpetic, other or any infectious disease episode, or separately, for 1 and ≥2 infectious disease episodes, within 0-1, 1-3, 3-5 and 5-10 years before LADA diagnosis/matching. Stratified analyses were performed on the basis of HLA risk genotypes and Glutamic acid decarboxylase antibodies (GADA) levels.

RESULTS

Individuals who developed LADA did not have a higher prevalence of infectious disease 1-10 years before diabetes diagnosis. For example, OR was estimated at 0.87 (0.66, 1.14) for any versus no respiratory infectious disease within 1-3 years. Similar results were seen for LADA with high-risk HLA genotypes (OR 0.95 [0.64, 1.42]) or high GADA levels (OR 1.10 [0.79, 1.55]), ≥2 episodes (OR 0.89 [0.56, 1.40]), and in infections treated using antibiotics (OR 1.03 [0.73, 1.45]). The only significant association was observed with lower respiratory disease the year preceding LADA diagnosis (OR 1.67 [1.06, 2.64]).

CONCLUSIONS

Our findings do not support the idea that exposure to infections increases the risk of LADA. A higher prevalence of respiratory infection in the year before LADA diagnosis could reflect increased susceptibility to infections due to hyperglycemia.

Joint tenderness at 3 months follow-up better predicts long-term pain than baseline characteristics in early rheumatoid arthritis patients

OBJECTIVE

To investigate pain course over time and to identify baseline and 3-month predictors of unacceptable pain with or without low inflammation in early RA.

METHODS

A cohort of 275 patients with early RA, recruited in 2012-2016, was investigated and followed for 2 years. Pain was assessed using a visual analogue scale (VAS; 0-100 mm). Unacceptable pain was defined as VAS pain >40, and low inflammation as CRP <10 mg/l. Baseline and 3-month predictors of unacceptable pain were evaluated using logistic regression analysis.

RESULTS

After 2 years, 32% of patients reported unacceptable pain. Among those, 81% had low inflammation. Unacceptable pain, and unacceptable pain with low inflammation, at 1 and 2 years was significantly associated with several factors at 3 months, but not at baseline. Three-month predictors of these pain states at 1 and 2 years were higher scores for pain, patient global assessment, and the health assessment questionnaire, and more extensive joint tenderness compared with the number of swollen joints. No significant associations were found for objective inflammatory measures.

CONCLUSION

A substantial proportion of patients had unacceptable pain with low inflammation after 2 years. Three months after diagnosis seems to be a good time-point for assessing the risk of long-term pain. The associations between patient reported outcomes and pain, and the lack of association with objective inflammatory measures, supports the uncoupling between pain and inflammation in RA. Having many tender joints, but more limited synovitis, may be predictive of long-term pain despite low inflammation in early RA.

Predictors at diagnosis for start of biologic disease-modifying antirheumatic drugs in patients with early rheumatoid arthritis: a cohort study

OBJECTIVES

To investigate the relation between patient characteristics at rheumatoid arthritis (RA) diagnosis and subsequent initiation of treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs).

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

Consecutive patients (N=330) with early RA (symptom duration <12 months) diagnosed at Skåne University Hospital, Malmö/Lund, Sweden, from 2012 to 2016, were included. Data on demographics, education, comorbidities and treatment were obtained from national registers.

OUTCOME

The relation between patient characteristics at diagnosis and time to first bDMARD/tsDMARD initiation was analysed using Cox regression models. As a secondary outcome, the relation between characteristics at diagnosis and b/tsDMARD initiation within 3 years was analysed using logistic regression.

RESULTS

A total of 330 patients (mean age 59.2 years; SD 16.4) were included. During follow-up, 41% received a bDMARD (never preceded by a tsDMARD). Higher age at diagnosis was associated with a lower probability of starting bDMARD treatment (multivariable-adjusted HR 0.66 per SD; 95% CI 0.56 to 0.78). Anticitrullinated protein antibody (ACPA) positivity and higher tender joint count at diagnosis were also associated with subsequent bDMARD treatment initiation in multivariable analysis. A higher level of formal education and absence of comorbidities predicted start of a bDMARD in crude, but not in age-adjusted, analyses.

CONCLUSIONS

Older patients with RA were less likely to start bDMARDs, whereas ACPA-positive patients, and those with extensive joint involvement at diagnosis, were more likely to receive early bDMARD treatment. The impact of age on the subsequent start of bDMARD therapy was not explained by level of education or comorbidities, suggesting that other aspects of age influence treatment decisions in early RA.

Epidemiology and clinical characteristics of biopsy-confirmed adult-onset IgA vasculitis in southern Sweden

OBJECTIVE

Immunoglobulin A vasculitis (IgAV) is the most prevalent primary childhood vasculitis in Sweden, but is considerably rarer in adults. This study aims to describe the epidemiology, clinical characteristics and renal outcome of adult-onset IgAV in Skåne, Sweden.

METHODS

The study area consisted of Skåne, the southernmost region of Sweden, with a population ≥18 years of 990 464 on 31 December 2010. Adult patients assigned the International Classification of Diseases-10 code for IgAV (D69.0) from 2000 through 2019 were retrospectively identified in a population-based database. Medical records were reviewed to validate the diagnosis of IgAV and extract data. Only patients with clinical manifestations of IgAV and biopsy-confirmed disease were included. The annual incidence and point prevalence of biopsy-confirmed IgAV were estimated.

RESULTS

Fifty-nine patients (19 women) were classified as having adult-onset IgAV. The incidence was 3 per 1 000 000 and was higher among men than women (4 vs 2/1 000 000, p=0.004). Ninety-seven per cent of patients presented with non-thrombocytopenic purpura, 78% with renal involvement, 59% with arthritis/arthralgia and 39% with gastrointestinal symptoms. Fifteen per cent developed chronic kidney disease stage ≥G3 a and one patient progressed to end-stage kidney disease during follow-up.

CONCLUSION

Adult-onset IgAV is rare in southern Sweden with the incidence higher in men than in women. IgAV frequently affects the kidneys and leads to chronic kidney disease in adults, although the long-term renal outcome appears favourable compared with other small-vessel vasculitides affecting the kidneys.

The association between loneliness, social isolation, and sleep disturbances in older adults: A follow-up study from the Swedish good aging in Skåne project

Objectives

The aim of this follow-up study was to investigate whether loneliness and social isolation in a sample of older adults, mean age of 67.4 years at baseline examination, were associated with sleep disturbances at re-examination at a mean age of 76.4 years.

Methods

The study sample consisted of 2897 participants. Data on loneliness, social isolation, and sleep disturbances were collected through questionnaires and medical examinations. Logistic regression models were constructed to identify associations between levels of loneliness and social isolation at baseline and sleep disturbances at follow-up. Sociodemographic and health-related confounding factors were controlled for in the models.

Results

Sleep disturbances were reported by 25.6% (95% CI: 24.0%-27.2%) at baseline and 23.7% (95% CI: 22.1%-25.3%) at re-examination. Odds ratios for sleep disturbances at re-examination in relation to not being lonely or socially isolated were as follows: single occasions of loneliness (OR: 1.37, 95% CI: 1.05-1.78), recurring periods/constant loneliness (OR: 1.92, 95% CI: 1.01-1.99), less severe social isolation (OR: 1.18, 95% CI: 0.78-1.79), and severe social isolation (OR: 1.88, 95% CI: 1.01-3.49).

Discussion

Sleep disturbances are common among older adults and are associated with loneliness and social isolation. Healthcare professionals should be aware of the potential effects of loneliness and social isolation when investigating sleep disturbances in older adults.

Identifying Predictors of First-Line Subcutaneous TNF-Inhibitor Persistence in Patients with Inflammatory Arthritis: A Decision Tree Analysis by Indication

INTRODUCTION

Treatment persistence is a proxy for efficacy, safety and patient satisfaction, and a switch in treatment or treatment discontinuation has been associated with increased indirect and direct costs in inflammatory arthritis (IA). Hence, there are both clinical and economic incentives for the identification of factors associated with treatment persistence. Until now, studies have mainly leveraged traditional regression analysis, but it has been suggested that novel approaches, such as statistical learning techniques, may improve our understanding of factors related to treatment persistence. Therefore, we set up a study using nationwide Swedish high-coverage administrative register data with the objective to identify patient groups with distinct persistence of subcutaneous tumor necrosis factor inhibitor (SC-TNFi) treatment in IA, using recursive partitioning, a statistical learning algorithm.

METHODS

IA was defined as a diagnosis of rheumatic arthritis (RA), ankylosing spondylitis/unspecified spondyloarthritis (AS/uSpA) or psoriatic arthritis (PsA). Adult swedish biologic-naïve patients with IA initiating biologic treatment with a SC-TNFi (adalimumab, etanercept, certolizumab or golimumab) between May 6, 2010, and December 31, 2017. Treatment persistence of SC-TNFi was derived based on prescription data and a defined standard daily dose. Patient characteristics, including age, sex, number of health care contacts, comorbidities and treatment, were collected at treatment initiation and 12 months before treatment initiation. Based on these characteristics, we used recursive partitioning in a conditional inference framework to identify patient groups with distinct SC-TNFi treatment persistence by IA diagnosis.

RESULTS

A total of 13,913 patients were included. Approximately 50% had RA, while 27% and 23% had AS/uSpA and PsA, respectively. The recursive partitioning algorithm identified sex and treatment as factors associated with SC-TNFi treatment persistence in PsA and AS/uSpA. Time on treatment in the groups with the lowest treatment persistence was similar across all three indications (9.5-11.3 months), whereas there was more variation in time on treatment across the groups with the highest treatment persistence (18.4-48.9 months).

CONCLUSIONS

Women have low SC-TNFi treatment persistence in PsA and AS/uSpA whereas male sex and golimumab are associated with high treatment persistence in these indications. The factors associated with treatment persistence in RA were less distinct but may comprise disease activity and concurrent conventional systemic disease-modifying anti-rheumatic drug (DMARD) treatment.

Can active sun exposure decrease the risk of giant cell arteritis and polymyalgia rheumatica in women?

Objectives

To study if active sun exposure among women affects the risk of developing GCA or PMR in a prospective cohort study with restricted latitudinal variability.

Methods

We linked the response to questions relating to sun exposure from the Melanoma Inquiry in Southern Sweden (MISS) prospective cohort study in women to the risk of developing GCA or PMR. Healthcare data were gathered from the Skåne Healthcare Register (SHR), covering all public healthcare consultations. The direct effect of active sun exposure on the risk of developing GCA or PMR was assessed using Cox proportional hazards models adjusted for covariates based on a directed acyclic graph.

Results

A total of 14 574 women were included in the study; 601 women were diagnosed with GCA or PMR (144 and 457, respectively) during the follow-up time. Women with moderate or high sun exposure were not less likely to develop GCA or PMR compared with women that indicated they avoided sun exposure [hazard ratio (HR) 1.2 (CI 0.9, 1.6) and 1.3 (0.9, 1.9), respectively] when adjusted for diabetes, hyperlipidaemia, hypertension, smoking, obesity and stratified by age. Similar patterns were observed when studying only GCA [HR 1.2 (CI 0.7, 2.3) and 1.3 (0.7, 2.6)] and only PMR [HR 1.3 (CI 0.9, 1.8) and 1.4 (0.9, 2.0)].

Conclusion

Active sun exposure did not affect the risk of developing GCA or PMR in women in a cohort with restricted latitudinal variability.

High risk of stroke in ANCA-associated vasculitis-a population-based study

OBJECTIVE

To determine the incidence rate, predictors and outcome of stroke in a population-based cohort of individuals with ANCA-associated vasculitis (AAV).

METHODS

The study included 325 patients diagnosed with AAV from 1997 through 2016 in a defined geographic area of Sweden. Patients who suffered a stroke were identified from Riksstroke, a national Swedish stroke register established in 1994, and the Skåne Healthcare Register (SHR), which includes data for all inhabitants of Skåne since 1998. Case record review was carried out to confirm the diagnosis of stroke in AAV patients identified in the SHR. The incidence rate of stroke was calculated per 1000 person-years of follow-up. Using data from the Swedish general population, the standardized incidence ratio (SIR) of stroke was estimated. Cox regression analysis was utilized to investigate survival and predictors of stroke.

RESULTS

Twenty-five subjects (8%) suffered a stroke during 2206 person-years of follow-up. The incidence rate of stroke in AAV was 11.3/1000 person-years (95% CI 6.9, 15.8). Patients with AAV showed an increased risk of stroke compared with the general population [SIR 1.85 (95% CI 1.27, 2.59)], with a greater risk for those <65 years of age [SIR 3.19 (95% CI 1.53, 5.88)]. Higher platelet count at AAV diagnosis was an independent predictor of stroke [hazard ratio 1.14 (95% CI 1.00, 1.29)]. There were no differences in survival or other outcome measures between AAV patients with and without stroke.

CONCLUSIONS

The incidence rate of stroke in AAV is higher than in the general population. High platelet count at AAV diagnosis was associated with an increased risk of stroke.

Stable incidence but increase in prevalence of ANCA-associated vasculitis in southern Sweden: a 23-year study

OBJECTIVE

To update the epidemiology of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) in a defined geographical area of southern Sweden.

METHODS

The study area comprised 14 municipalities with a combined adult population (≥18 years) of 623 872 in 2019. All cases diagnosed with AAV in 1997-2019 in the study area were included in the estimate of incidence. Diagnosis of AAV was verified by case record review, and cases were classified using the European Medicines Agency algorithm. Point prevalence was estimated on 01 January 2020.

RESULTS

Three hundred and seventy-four patients (median age 67.5 years, 47% female) were diagnosed with new-onset AAV during the study period. One hundred and ninety-two were classified as granulomatosis with polyangiitis (GPA), 159 as microscopic polyangiitis (MPA) and 23 as EGPA. The average annual incidence/million adults was 30.1 (95% CI 27.0 to 33.1) for AAV: 15.4 (95% CI 13.3 to 17.6) for GPA, 12.8 (95% CI 10.8 to 14.8) for MPA and 1.8 (95% CI 1.1 to 2.6) for eosinophilic GPA (EGPA). Incidence was stable during the study period, 30.3/million 1997-2003, 30.4/million 2004-2011 and 29.5/million 2012-2019. The incidence increased with age and was highest in age group 70-84 years (96/million adults). On 1 January 2020, the prevalence was 428/million adults and was higher in males than in females (480 vs 378/million).

CONCLUSIONS

The incidence of AAV in southern Sweden was found stable over the course of 23 years; while the prevalence has increased, which might indicate better management and treatment of AAV resulting in improved survival.

The risk of depression and anxiety is not increased in individuals with juvenile idiopathic arthritis - results from the south-Swedish juvenile idiopathic arthritis cohort

BACKGROUND

Children with chronic diseases are reported to have increased risk of psychiatric comorbidity. Few studies have investigated this risk in juvenile idiopathic arthritis (JIA), with conflicting results. We performed a population-based, longitudinal cohort study of the risk of depression and anxiety in south-Swedish patients with juvenile arthritis.

METHODS

The south-Swedish JIA cohort (n = 640), a population-based cohort with validated JIA diagnosis 1980 - 2010 and comparators, a reference group of 3200 individuals free from JIA, matched for sex, year of birth and residential region, was used. Data on comorbid diagnosis with depression or anxiety were obtained from the Skåne Healthcare Register, containing all healthcare contacts in the region, from 1998 to 2019. We used Cox proportional models for the calculation of hazard ratios.

RESULTS

During the study period, 1998 to 2019, 93 (14.5%) of the individuals in the JIA group were diagnosed with depression, and 111 (17.3%) with anxiety. Corresponding numbers among the references was 474 (14.8%) with depression and 557 (17.4%) with anxiety. Hazard ratio for depression was 1.1 (95% CI 0.9 - 1.5) in females and 0.8 (95% CI 0.5 - 1.4) in males, and for anxiety 1.2 (95% CI 0.9 - 1.5) in females and 0.6 (95% CI 0.4 - 1.1) in males. There were no statistically significant hazard ratios when analyzing subgroups of JIA patients with long disease duration or treatment with disease-modifying antirheumatic drugs.

CONCLUSIONS

Individuals with JIA do not have any statistically increased risk of being diagnosed with depression or anxiety compared to matched references.

High HbA1c Levels Are Associated With Development of Trigger Finger in Type 1 and Type 2 Diabetes: An Observational Register-Based Study From Sweden

OBJECTIVE

Trigger finger (TF) is a hand disorder causing the fingers to painfully lock in flexion. Diabetes is a known risk factor; however, whether strict glycemic control effectively lowers risk of TF is unknown. Our aim was to examine whether high HbA1c was associated with increased risk of TF among individuals with diabetes.

RESEARCH DESIGN AND METHODS

The Swedish National Diabetes Register (NDR) was cross-linked with the health care register of the Region of Skåne in southern Sweden. In total, 9,682 individuals with type 1 diabetes (T1D) and 85,755 individuals with type 2 diabetes (T2D) aged ≥18 years were included from 2004 to 2019. Associations between HbA1c and TF were calculated with sex-stratified, multivariate logistic regression models with 95% CIs, with adjustment for age, duration of diabetes, BMI, and systolic blood pressure.

RESULTS

In total, 486 women and 271 men with T1D and 1,143 women and 1,009 men with T2D were diagnosed with TF. Increased levels of HbA1c were associated with TF among individuals with T1D (women OR 1.26 [95% CI 1.1-1.4], P = 0.001, and men 1.4 [1.2-1.7], P < 0.001) and T2D (women 1.14 [95% CI 1.2-1.2], P < 0.001, and men 1.12 [95% CI 1.0-1.2], P = 0.003).

CONCLUSIONS

Hyperglycemia increases the risk of developing TF among individuals with T1D and T2D. Optimal treatment of diabetes seems to be of importance for prevention of diabetic hand complications such as TF.

Diabetic retinopathy as a predictor for peripheral compression neuropathies, a registry-based study

Diabetes is characterized by hyperglycaemia and entails many complications, including retinopathy and entrapment neuropathies, such as ulnar nerve entrapment (UNE) and carpal tunnel syndrome (CTS). Hyperglycaemia damages the nerves of the retina, as well as peripheral nerves. There is a correlation between entrapment neuropathies and retinopathy in patients with diabetes, but whether patients with diabetic retinopathy are more prone to develop CTS and UNE is uncertain. Hence, the aim was to investigate if retinopathy can be used as a factor predicting the development of CTS and UNE. Data from 95,437 individuals from the National Diabetes Registry were merged with data from the Skåne Healthcare Registry. The population was analysed regarding prevalence of CTS or UNE and retinopathy status. Population characteristics were analysed using the Chi2-test, Student's Independent T-test, and the Mann-Whitney U-test. Two logistic regression models were used to analyse the odds ratio (OR) for development of CTS and UNE depending on retinopathy status, adjusted for possible confounders. Both CTS and UNE were more frequent among those with retinopathy, compared to those without (CTS: 697/10,678 (6.5%) vs. 2756/83,151 (3.3%; p<0.001), (UNE: 131/10,678 (1.2%) vs. 579/83,151 (0.7%; p<0.001)). The OR for developing CTS for individuals with type 1 diabetes and retinopathy was 2.40 (95% CI 2.06-2.81; p<0.001) and of developing UNE was 1.53 (0.96-2.43; p = 0.08). The OR for developing CTS for individuals with type 2 diabetes and retinopathy was 0.93 (0.81-1.08; p = 0.34) and for UNE 1.02 (0.74-1.40; p = 0.90). Diabetic retinopathy is associated with a higher risk of developing CTS and UNE, but the association seems to be mediated by the duration of the diabetes. Higher HbA1c levels, longer diabetes duration and higher BMI are significant risk factors for developing CTS and UNE in type 1 and type 2 diabetes.

Infertility, pregnancy loss and assisted reproduction in women with asthma: a population-based cohort study

STUDY QUESTION

Is the chance of childbirth, and risk of infertility, pregnancy loss and need for assisted reproduction different for women with asthma compared to women without asthma?

SUMMARY ANSWER

Women with asthma had comparable chances of giving birth compared to the reference population, however, their risk of both infertility and pregnancy loss, as well their need for medically assisted reproduction, was higher.

WHAT IS KNOWN ALREADY

Reproductive dysfunction has been reported among women with asthma, including longer time to pregnancy, increased risk of pregnancy loss and a higher need of medically assisted reproduction, but their risk of clinical infertility is unknown.

STUDY DESIGN, SIZE, DURATION

This longitudinal register-based cohort study included all women with a healthcare visit for delivery, infertility, pregnancy loss or induced abortion in the southernmost county in Sweden, over the last 20 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using the Skåne Healthcare Register, we identified all women aged 15-45 between 1998 and 2019, who received a diagnosis of asthma before their first reproductive outcome (n = 6445). Chance of childbirth and risk of infertility, pregnancy loss and assisted reproduction were compared to a healthcare seeking population of women without any asthma (n = 200 248), using modified Poisson regressions.

MAIN RESULTS AND THE ROLE OF CHANCE

The chance of childbirth was not different between women with asthma versus those without, adjusted risk ratio (aRR) = 1.02, 95% CI: 1.01-1.03. The risk of seeking care for infertility was increased, aRR = 1.29, 95% CI: 1.21-1.39, and women with asthma more often needed assisted reproduction aRR = 1.34 95% CI: 1.18-1.52. The risk of suffering a pregnancy loss was higher, aRR = 1.21, 95% CI: 1.15-1.28, and induced abortions were more common, aRR = 1.15, 95% CI: 1.11-1.20, among women with asthma.

LIMITATIONS, REASONS FOR CAUTION

The study was an observational study based on healthcare visits and lacked detailed anthropometric data, thus residual confounding cannot be excluded. Only women with a healthcare visit for a reproductive outcome were included, which cannot be translated into pregnancy intention. A misclassification, presumed to be non-differential, may arise from an incorrect or missing diagnosis of asthma or female infertility, biasing the results towards the null.

WIDER IMPLICATIONS OF THE FINDINGS

This study points towards reproductive dysfunction associated with asthma, specifically in regards to the ability to maintain a pregnancy and the risk of needing medically assisted reproduction following clinical infertility, but reassuringly the chance of subsequently giving birth was not lower for these women.

STUDY FUNDING/COMPETING INTEREST(S)

This article is part of the ReproUnion collaborative study, co-financed by EU Interreg ÖKS, Capital Region of Denmark, Region Skåne and Ferring Pharmaceuticals. The authors have no competing interests to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Annual decline rate in FEV1s in community-dwelling older adults diagnosed with mild to moderate COPD

Information about the decline rate in forced expiratory volume in 1 s (FEV1s) in older adults with COPD is scarce. A total of 4082 community-dwelling older adults from the population-based study Good Aging in Skåne were followed for 12 years and 143 participants developed COPD. The average FEV1s decline is estimated to be 66.3 mL/year, (95% CI [56.4; 76.3]) and 43.3 mL/year (1.7%/year, 95% CI [41.2; 45.5]) for COPD and non-COPD participants, respectively.

Health care utilization among individuals who die by suicide as compared to the general population: a population-based register study in Sweden

Background

Globally, 700 000 people die every year by suicide. Health care consultation patterns the period before suicide could be one potential way to identify people at risk for suicide. Therefore, this study examines health care patterns up to one year prior to the suicide by age, sex and prior diagnoses and specifically investigates if and how this differs from the general population of Skåne, Sweden.

Methods

This cohort study includes all individuals, aged 15 and older, that died by suicide in Region Skåne, Sweden from 2004 to 2015 (n = 1653). The individuals were identified through the Cause of death register and then linked to the Skåne healthcare register. Health care data was analyzed as proportions consulting different types of health care the month and year preceding the suicide, we also investigated the impact of age, sex and the occurrence of prior psychiatric and pain diagnoses. Additionally, we compared the proportion of consulting care among the suicide victims and the general population of Skåne.

Results

In the month before their death, 53% of the suicide victims had any health care consultation, compared with 20% in the general population of Skåne, a given month (p < 0.0001). The corresponding figures for the year prior to suicide was 86% among those who died by suicide, compared to 69% in the general population of Skåne, a given year (p < 0.0001). Women, and those having a documented history of psychiatric diagnosis were more likely to have health care consultations in the month and year preceding suicide (p < 0.001), compared to men and suicide victims without a history of psychiatric disease. Older adults that died by suicide, were less likely to consult psychiatric care compared to the younger suicide victims (p < 0.001).

Conclusion

A majority of the suicide victims consulted health care in the near time before death and the proportion of seeking health care was significantly higher than in the general population of Skåne and higher among female suicide victims as compared to males. Alternative preventive screening measures should be considered for individuals consulting health care, especially for older people and individuals outside the psychiatric care.

Patterns of Communication About Serious Illness in the Years, Months, and Days before Death

Background:

Communication with patients and families about serious illness impacts quality of life and helps facilitate decision-making.

Objective:

To elucidate the pattern of communication about serious illness for patients who have died in an inpatient setting.

Design:

Three hundred patients from the Swedish Registry of Palliative Care 2015–2017 were randomly selected for manual chart review.

Setting:

Patients who died in a palliative care, oncology, or internal medicine unit in Sweden were selected.

Measurements:

We report on the frequency of conversations at three time points, 6 months or longer before death (“Years”), 15 days–6 months before death (“Months”), and 0–14 days before death (“Days”). We also report the timing of the conversation about dying.

Results:

A total of 249 patients were included after exclusions; they had an average of 2.1 conversations (range 1–6). The first conversation took place a median of 53 days before death and the last conversation took place a median of 9 days before death. Separate conversations with the next of kin took place a median of two days before death. We could verify a conversation about dying in only 156/249 (63%) medical records.

Conclusions:

Communication about serious illness between clinicians, patients, and families occurs iteratively over a period before death. Measuring the quality of communication about serious illness using a years, months, and days framework may help ensure that patients and families have sufficient information for medical and personal decision making.

Infection is associated with increased risk of MPO- but not PR3-ANCA-associated vasculitis

OBJECTIVES

To determine whether development of ANCA-associated vasculitis (AAV) shows a relationship with a prior infection and if prior infection affects disease characteristics and outcome.

METHODS

All incident cases of AAV diagnosed in a defined region of Sweden from 2000 through 2016 were identified. For each case, 10 individuals from the general population, matched for age, sex and area of residence, were selected. Infections occurring in AAV patients and controls prior to the date of AAV diagnosis (index date for respective controls) were identified using an administrative database. Conditional logistic regression models were used to calculate odds ratios (OR) of developing AAV. Occurrence, clinical characteristics and outcome of AAV were analysed with respect to prior infection.

RESULTS

Two-hundred and seventy patients with AAV (48% female) and 2687 controls were included. Prior to diagnosis/index date, 146 (54%) AAV patients had been diagnosed with infection vs 1282 (48%) controls, with OR for AAV 1.57 (95% CI 1.18, 2.19) in those with infections of the upper respiratory tract and 1.68 (1.02, 2.77) in those with pneumonia. Difference from controls was significant in patients with MPO-ANCA 1.99 (95% CI 1.25, 3.1) but not in those with PR3-ANCA 1.0 (0.61, 1.52). Patients with prior infection showed higher disease activity at AAV diagnosis. No differences in disease characteristics, comorbidities or outcome in those with and without prior infections were observed.

CONCLUSIONS

Respiratory tract infections are positively associated with development of MPO- but not PR3-ANCA vasculitis. Prior infection is associated with higher disease activity at AAV diagnosis.

Utilization of healthcare and prescription medicines after non-pharmacological interventions for depression - A 3-year register follow-up of an RCT in primary care

•

A 3-year register follow-up of an RCT for depression interventions was conducted.

•

Healthcare utilization and dispensed medicines were used as register outcomes.

•

The interventions had no effect on consultations for mental illness during follow-up.

•

Both interventions are appropriate additions to mild-moderate depression care.

Depression is a common, recurrent disorder. There is a need for readily available treatments with few negative side effects, that demands little resources and that are effective both in the short- and long term.

Our aim was to investigate the long-term effectiveness of two different interventions; physical exercise and internet-based cognitive behavioural therapy (internet-CBT), compared to usual care in patients with mild to moderate depression in a Swedish primary care setting.

We performed a register-based 3-year follow-up study of participants in the randomized controlled trial REGASSA (n = 940) using healthcare utilization and dispensed medicines as outcomes.

We found no difference between the three groups regarding proportion of participants consulting healthcare due to mental illness or pain during follow-up. Regarding number of consultations, there was no difference between the groups, except for consultations related to pain. For this outcome both treatment arms had significantly fewer consultations compared to usual care, during year 2–3, the risk ratio (RR) for physical exercise and internet-CBT was 0.64 (95% CI = 0.43–0.95) and 0.61 (95% CI = 0.41–0.90), respectively.

A significantly lower proportion of patients in both treatment arms were dispensed hypnotics and sedatives year 2–3 compared to the usual care arm, RR for both physical exercise and internet-CBT was 0.72 (95% CI = 0.53–0.98). No other differences between the groups were found.

In conclusion, considering long-term effects, both physical exercise and internet-CBT, being resource-efficient treatments, could be considered as appropriate additions for patients with mild to moderate depression in primary care settings.

Trial registration: The original RCT was registered with the German Clinical Trial Register (DRKS study ID: DRKS00008745).

Diabetic hand: prevalence and incidence of diabetic hand problems using data from 1.1 million inhabitants in southern Sweden

INTRODUCTION

'The diabetic hand' has traditionally referred to hand complications due to diabetes mellitus (DM), including trigger finger (TF) and Dupuytren's disease (DD). Recent publications have also proposed DM as a risk factor for carpal tunnel syndrome (CTS), ulnar nerve entrapment (UNE), and possibly osteoarthritis (OA) of the first carpometacarpal (CMC-1) joint. This study aimed to explore prevalence and incidence of diabetic hand complications among the population in southern Sweden.

RESEARCH DESIGN AND METHODS

Approximately 1.1 million inhabitants in the region of Skåne aged ≥18 years, whereof 50 000 with DM, were included. Data on incident CTS, UNE, TF, DD, and OA of the CMC-1 joint between 2004 and 2019 were collected from the Skåne Healthcare Register and cross-linked with the National Diabetes Register. Prevalences on December 31, 2019 and 10-year incidence ratios were calculated for type 1 diabetes (T1D), type 2 diabetes (T2D), and the population without DM, stratified for sex. Prevalence ratios and incidence rate ratios with 95% CIs were used for group comparisons.

RESULTS

The prevalences of all five studied diagnoses were higher in both men and women with T1D and T2D (p<0.01) and both T1D and T2D had more concomitant prevalent diagnoses (p<0.0001). The 10-year incidence rates of all diagnoses were higher among T1D and T2D (p<0.0001), except OA of the CMC-1 joint in men with T1D (p=0.055).

CONCLUSIONS

CTS, UNE, and possibly also OA of the CMC-1 joint should be included together with TF and DD when referring to 'the diabetic hand'. The incidence of hand disorders was up to eight times higher among T1D, and both T1D and T2D had more concomitant prevalent diagnoses compared with the population without DM. Future studies should elucidate the pathophysiology behind diabetic hand complications to enable development of effective preventive measures in patients with diabetes.

Variability in end-of-life healthcare use in patients with osteoarthritis: a population-based matched cohort study

PURPOSE

To investigate the patterns of healthcare use (HCU) at the last year of life in persons with osteoarthritis (OA).

METHODS

Using linked registers, we identified persons aged≥ 65 years who died during 2003-2014 and were resided in the Skåne region during 5-year prior to death. Among these, we randomly matched decedents with a principal OA diagnosis prior to the last year of life (OA cohort, n = 17,993) with up to 4 comparators without OA by sex, age at death, and year of death (n = 59,945). We measured monthly HCU for each decedent during last year of life and applied two-part regression models to estimate HCU attributable to OA. Group-based trajectory modelling (GBTM) was used to detect distinct trajectories of HCU within the OA cohort.

RESULTS

During last 12-month of life, each person with OA had, on average, 2.5 (95% CI 2.2, 2.7) excess healthcare consultations and 1.8 (95% CI 1.3, 2.2) more inpatient days than those without OA. While both cohorts observed increasing trends in HCU towards death, excess healthcare consultations attributable to OA declined and inpatient days increased as death approached. For both healthcare consultations and inpatient days, GBTM identified four distinct trajectory classes. While underlying cause of death and age were the most important predictors of class membership, the overall predictive accuracy was poor.

CONCLUSION

OA was associated with excess HCU especially hospital-based care during the last year of life. However, there seem to be distinct trajectory classes within the OA patient population.

Cardiovascular drug treatment, statins and biopsy-confirmed giant cell arteritis: a population-based case-control study

Objective

To determine whether exposure to cardiovascular medications and statins is associated with increased risk of giant cell arteritis (GCA).

Design

The population-based case–control study comprised a cohort of patients with biopsy-confirmed GCA linked to the Swedish Prescribed Drug Register to identify all exposure to drugs prior to diagnosis of GCA. Ten controls per GCA case, matched for age, sex and residential area, were included. Using corresponding Anatomical Therapeutic Chemical codes, ACE inhibitors, angiotensin II receptor blockers, beta-blocking agents, calcium antagonists, diuretics, statins and cardiac therapy drugs were investigated from July 1, 2005 to the diagnosis/index date. A conditional logistic regression model was fitted adjusted for income, education level and marital status. We repeated the analyses including only new drug users excluding those with any prescription during the year from July 1, 2005 to July 1, 2006.

Results

574 cases (29% men) of diagnosed GCA and 5740 controls (29% men) were included. The mean age at diagnosis is 75 years (SD 8). Of the GCA cases, 71% had at least one dispensation of a cardiovascular drug prior to the index date, compared to 74% of controls. The ORs for the association of target drug exposure with GCA were <1 for most drugs, but close to 1 in the analysis of new users. Statins were consistently associated with lower risk of GCA, OR 0.74 (95% CI 0.61 to 0.90).

Conclusion

Statins may be associated with lower risk of incident biopsy-confirmed GCA. No association was evident for other studied drugs.

Fertility outcomes in women with pre-existing type 2 diabetes-a prospective cohort study

OBJECTIVE

To study childbirth and the risk of miscarriage and infertility among women who have received a diagnosis of type 2 diabetes before the start of their reproductive journey.

DESIGN

Register-based cohort study using the Skåne Healthcare Register SETTING: All healthcare visits for the whole population of the southernmost region in Sweden over the past 20 years PATIENT(S): All women who were aged 18-45 years between January 1, 1998 and December 31, 2019 and who received a clinical diagnosis of type 2 diabetes before their first childbirth, miscarriage, or infertility diagnosis (n = 230) were compared with a healthcare-seeking population of women without any type of diabetes, matched for calendar year and age (n = 179,434).

INTERVENTION(S)

None MAIN OUTCOME MEASURE(S): Childbirth, miscarriage, and infertility diagnosis RESULT(S): The birthrate was lower among women with type 2 diabetes (62.6% vs. 83.8%), and they were less likely to give birth (crude risk ratio [RR] = 0.73, 95% confidence interval [CI]: 0.66-0.81). They had a higher risk of experiencing a miscarriage (RR = 1.88, 95% CI: 1.50-2.36). The risk of infertility was increased (RR = 3.44, 95% CI: 2.88-4.10) as was the risk of having infertility and not giving birth (RR = 4.47, 95% CI: 3.44-5.82). All results remained the same after adjustment for polycystic ovary syndrome and obesity.

CONCLUSION(S)

Women with type 2 diabetes with onset before their reproductive journey were more often childless compared with women without diabetes and had a higher risk of experiencing both miscarriage and infertility. This patient group may be in need of targeted information regarding potential fertility issues as part of their clinical treatment.

Diagnostic codes of cancer in Skåne healthcare register: a validation study using individual-level data in southern Sweden

Background

The Swedish healthcare is decentralised to 21 regions. Detailed information on all delivered care in the southernmost region, Skåne, is prospectively collected in the Skåne Healthcare Register (SHR). The data is updated daily and hence a good source for epidemiological studies. However, the diagnostic codes used to identify cancer patients in SHR have not yet been validated.

Methods

We conducted a validation study including 1,473,204 residents in Skåne region during 2005–2014, with at least one physical consultation in SHR. Newly diagnosed cancer from the Swedish Cancer Register was considered the ‘gold standard’ reference. We estimated the positive predictive value (PPV), sensitivity, and area under the curve (AUC) of a cancer diagnosis based on SHR by level of consultation, for any cancer, and for different cancer types.

Results

There were 61,693 cancers from the Swedish Cancer Register, and 87,650 cancers from SHR. The PPV of SHR-based diagnosis of any cancer was 63.76% (95% confidence interval (CI): 63.44–64.08%) with a sensitivity of 90.58% (95% CI: 90.35–90.81%). The AUC was 0.94, for any cancer. The measures of PPV, sensitivity and AUC varied across levels of care and were higher in specialized care than in primary care. The highest PPV was observed for specialist inpatient care in SHR (89.17, 95% CI 88.89–89.45%) whereas the highest sensitivity was observed for specialized outpatient care in SHR (86.39, 95%CI 86.12–86.66%). Robust validity was noted among most cancers, except for cancers of soft tissues, central nervous system and eye, and endocrine glands.

Conclusions

Our study supports that SHR is a valid and robust healthcare register for cancer diagnosis, with varying validities across levels of care and cancer types. This makes SHR a useful data source for cancer epidemiological studies, especially because the data covers the entire cancer care pathways without time lags for further linkage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08481-5.

Complex sociodemographic inequalities in consultations for low back pain: lessons from multilevel intersectional analysis

Supplemental Digital Content is Available in the Text.

We found substantial individual heterogeneity in consultation for low back pain that could not be explained by combination of age, sex, education, income, and nativity.

Sociodemographic inequalities in the occurrence of low back pain (LBP) are well-studied. This study aimed to examine complex sociodemographic inequalities in the risk of LBP consultation in the population from a socioeconomical intersectional perspective. Using register data, we identified 458,852 individuals aged 35 to 75 years residing in Skåne in 2013, with no previous LBP consultation since 2006. We created 108 strata using categories of age, sex, education, income, and nativity. With individuals nested within strata, we modelled the absolute risk of LBP consultation during 2014 in a series of multilevel logistic regression models. We quantified discriminatory accuracy (DA) of these variables by computing the variance partition coefficient and area under the receiver operating characteristic curve (AUC). We identified 13,657 (3.0%) people with an LBP consultation. The absolute risk ranged from 2.1% (95% credible interval: 1.9%-2.3%) among young native men with high education and high income to 4.8% (4.3%-5.5%) among young foreign-born women with medium education and low income (2.3-fold relative difference). Discriminatory accuracy of intersectional strata was very low (variance partition coefficient 1.1% (0.7-1.6); and AUC 0.56 [0.55-0.56]). Sex (35.6%) and nativity (19.2%) had the largest contributions in explaining the initially small between-strata variation in risk of LBP. The low DA of the intersectional strata indicates the existence of limited intersectional inequalities in LBP consultation. Therefore, interventions to reduce LBP risk should be universal rather than targeted to specific socioeconomic groups with a higher average risk. Before planning targeted intervention, other risk factors with higher DA need to be identified.

Trajectory of Healthcare Resource Utilization in Giant Cell Arteritis: A Population-based Study

OBJECTIVE

To estimate the healthcare resource utilization (HRU) in patients with giant cell arteritis (GCA) compared with the general population in southern Sweden.

METHODS

The study sample comprised 653 patients with GCA along with 10 age-, sex-, and residency area-matched reference subjects per patient. Data on public and private healthcare consultations and hospitalizations were extracted from the Skåne Healthcare Register. We assessed trajectories of primary and specialist healthcare visits, as well as hospital admissions and inpatient days from 3 years before through 5 years after the date of GCA diagnosis for patients and matched references. HRU was analyzed using generalized estimating equations adjusted for sex, age at the index year, calendar year of diagnosis, education, income, marital status, place of birth, and Charlson Comorbidity Index. Inverse probability weighting was used to account for dropout during study.

RESULTS

Patients with GCA had higher rates of healthcare visits than the references from the year before GCA diagnosis and up to 4 years after diagnosis, with the largest relative (rate ratio 1.85, 95% CI 1.68-2.05) and absolute (mean difference 10.2, 95% CI 8.1-12.3 visits per person) differences in the year of diagnosis. Similar trajectories were observed for primary and specialist healthcare visits. For hospital admissions and inpatient days, the differences disappeared 1 year after diagnosis date.

CONCLUSION

Patients with GCA utilized healthcare services at a significantly higher rate than the reference population. The increased utilization among Swedish patients with GCA was evident 1 year before and prolonged up to 4 years after diagnosis date.

Trajectory of excess healthcare consultations, medication use, and work disability in newly diagnosed knee osteoarthritis: a matched longitudinal register-based study

PURPOSE

To estimate the excess healthcare use and work disability attributable to knee osteoarthritis (OA) in the first 5 years following diagnosis.

METHODS

Among individual aged 40-80 years who resided in Skåne on 31^st December 2008, we identified those with a main diagnosis of knee OA during 2009-2014 and no previous diagnosis of any OA from 1998 (n = 16,888). We created a comparison cohort matched (1:1) by sex, age, and municipality from individuals with no OA diagnosis (at any site) during 1998-2016. We compared healthcare use and net disability days for 60 months following diagnosis between the two groups. We applied a survival-adjusted regression technique controlling for sociodemographic characteristics as well as pre-diagnosis outcome and comorbidity.

RESULTS

The estimated 5-year incremental effects of knee OA per-patient were 16.8 (95% CI: 15.8, 17.7) healthcare consultations, 0.7 (0.4, 1.1) inpatient days, 420 (372, 490) defined daily dose of prescribed medications, and 21.8 (15.2, 30.0) net disability days. Primary care consultations constituted about 73% of the excess healthcare consultations. Most of these incremental effects occurred in the first year after diagnosis. Better survival in the knee OA group accounted for 0.7 (95% CI: 0.5, 0.8) and 1.4 (0.7, 2.6) of the excess healthcare consultations and net disability days, respectively. Both estimated total and incremental resources use were generally greater for women than men with knee OA.

CONCLUSION

Knee OA was associated with considerable excess healthcare use and work disability independent of pre-diagnosis resources use, comorbidity, and sociodemographic characteristics.

Infections Are Associated With Increased Risk of Giant Cell Arteritis: A Population-based Case-control Study from Southern Sweden

OBJECTIVE

To investigate the association between infections and the subsequent development of giant cell arteritis (GCA) in a large population-based cohort from a defined geographic area in Sweden.

METHODS

Patients diagnosed with biopsy-confirmed GCA between 2000 and 2016 were identified through the database of the Department of Pathology in Skåne, the southernmost region of Sweden. For each GCA case, 10 controls matched for age, sex, and area of residence were randomly selected from the general population. Using the Skåne Healthcare Register, we identified all infection events prior to patients' date of GCA diagnosis and controls' index date. With infection as exposure, a conditional logistic regression model was employed to estimate the OR for developing GCA. The types of infections contracted nearest in time to the GCA diagnosis/index date were identified.

RESULTS

A total of 1005 patients with biopsy-confirmed GCA (71% female) and 10,050 controls were included in the analysis. Infections were more common among patients subsequently diagnosed with GCA compared to controls (51% vs 41%, OR 1.78, 95% CI 1.53-2.07). Acute upper respiratory tract infection (OR 1.77, 95% CI 1.47-2.14), influenza and pneumonia (OR 1.72, 95 % CI 1.35-2.19), and unspecified infections (OR 5.35, 95 % CI 3.46-8.28) were associated with GCA. Neither skin nor gastrointestinal infections showed a correlation.

CONCLUSION

Infections, especially those of the respiratory tract, were associated with subsequent development of biopsy-confirmed GCA. Our findings support the hypothesis that a range of infections may trigger GCA.