Increased patient satisfaction by integration of palliative care into geriatrics-A prospective cohort study

BACKGROUND

Integration of oncology and palliative care has been shown to increase quality of life in advanced disease. To meet the needs of the growing older population, integration of palliative care and geriatrics has been proposed but scarcely described.

OBJECTIVES

The aim of this study was to integrate palliative care into geriatrics by a structured care guide, the Swedish Palliative Care Guide, and to evaluate its effect on patient satisfaction, health-related quality of life and symptom burden, compared to a control group.

METHODS

Geriatric in-patients over 65 years of age were included in the study, those with cognitive impairment were excluded. Data was collected before (baseline) and after the implementation (intervention) of the Swedish Palliative Care Guide. Patient satisfaction was evaluated two weeks after discharge with questions from a national patient survey. Health-related quality of life was measured with EQ-5D-3L and symptom burden with Edmonton Symptom Assessment Scale.

RESULTS

In total, 400 patients were included, 200 in the baseline- and intervention group, respectively. Mean age was 83 years in both groups. Patient satisfaction was significantly higher in nine out of ten questions (p = 0.02-<0.001) in the intervention group compared to baseline. No differences between the groups were seen in health-related quality of life or symptom burden.

CONCLUSION

A significant effect on patient satisfaction was seen after implementation of the Swedish Palliative Care Guide in geriatric care. Thus, integration of palliative care and geriatrics could be of substantial benefit in the growing population of older adults with multimorbidity and frailty.

Prolonged opioid use after distal radius fracture

BACKGROUND

Prolonged opioid use (more than 90 days) after injury puts the patient at risk for adverse effects. We investigated the patterns of opioid prescription after distal radius fracture and the effect of pre- and post-fracture factors on the risk for prolonged use.

METHODS

This register-based cohort study uses routinely collected health care data, including purchases of prescription opioids, in the county of Skåne, Sweden. 9369 adult patients with a radius fracture diagnosed 2015-2018 were followed for 1 year after fracture. We calculated proportions of patients with prolonged opioid use, both in total and according to different exposures. Using modified Poisson regression, we calculated adjusted risk ratios for the following exposures: previous opioid use, mental illness, consultation for pain, surgery for distal radius fracture and occupational/physical therapy after fracture.

RESULTS

Prolonged opioid use (4-6 months after fracture) was found in 664 (7.1%) of the patients. A previous, but discontinued, regular use of opioids up to 5 years before fracture increased the risk compared to opioid-naïve patients. Both regular and non-regular opioid use the year before fracture increased the risk. The risk was also higher for patients with mental illness, and those who were treated with surgery, we found no significant effect of pain consultation in previous year. Occupational/physical therapy lowered the risk for prolonged use.

CONCLUSION

Considering history of mental illness and previous opioid use while promoting rehabilitation can be important to prevent prolonged opioid use after distal radius fracture.

SIGNIFICANCE

We show that a common injury such as distal radius fracture can be a gateway to prolonged opioid use, especially among patients with previous history of opioid use or mental illness. Importantly, previous opioid use as far back as 5 years earlier greatly increases the risk of regular use after the reintroduction of opioids. Considering past use is important when planning treatment with opioids. Occupational or physical therapy after injury is associated with lower risk of prolonged use and should be encouraged.

Dying during the COVID-19 Pandemic in Sweden: Relatives' Experiences of End-of-Life Care (the CO-LIVE Study)

Background: The COVID-19 pandemic has seen many deaths, but the majority were for causes other than COVID-19. However, end-of-life care in all settings has been affected by measures limiting the spread of the virus, for patients with and without COVID-19. The Swedish coronavirus strategy was different compared to many other countries, which might have affected end-of-life care. The aim was to describe the experiences of end-of-life care for bereaved relatives in Sweden during the “first wave” and to compare the experiences for deaths due to COVID-19 with the experiences for deaths for other reasons. Methods: A random sample of addresses for 2400 people who died during March−September 2020 was retrieved from the Swedish Person Address Registry. Relatives were contacted with a questionnaire regarding their experience of end-of-life care, with a focus on communication, participation, and trust. Results: In total, 587 relatives (25% response rate) answered the questionnaire (14% COVID-19-deaths, 65% non-COVID-19-deaths, 21% uncertain). In the COVID-19 group 28% of the relatives were allowed visits without restrictions compared to 60% in the non-COVID-19 group (p < 0.01). Only 28% of the relatives in the COVID-19 group reported that the person received “enough care from physicians”, significantly fewer than the non-COVID group (65%, p < 0.01). Conclusion: Relatives’ experience of end-of-life care for persons with COVID-19 was significantly worse than relatives of persons without COVID-19, but relatives for persons without COVID-19 were also negatively affected.

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.

Sedation in specialized palliative care: A cross-sectional study

Background

Palliative sedation is used to relieve refractory symptoms and is part of clinical practice in Sweden. Yet we do not know how frequently this practice occurs, how decision-making takes place, or even which medications are preferentially used.

Objectives

To understand the current practice of palliative sedation in Sweden.

Methods

We conducted a retrospective cross-sectional medical record-based study. For 690 consecutive deceased patients from 11 of 12 specialized palliative care units in the southernmost region of Sweden who underwent palliative sedation during 2016, we collected data on whether the patient died during sedation and, for sedated patients, the decision-making process, medication used, and depth of sedation.

Results

Eight percent of patients were sedated. Almost all (94%) were given midazolam, sometimes in combination with propofol. The proportions of sedation were similar in the patient groups with and without cancer. The largest proportion of the sedated patients died in inpatient care, but 23% died at home, with specialized palliative home care. Among the patients with a decision to sedate, 42% died deeply unconscious, while for those without such a decision the corresponding figure was 16%. In only one case was there more than one physician involved in the decision to use palliative sedation.

Conclusion

8% of patients in specialized palliative care received palliative sedation, which is lower than international measures but much increased compared to an earlier Swedish assessment. The level of consciousness achieved often did not correspond to the planned level; this, together with indications of a scattered decision process, shows a need for clear guidelines.

Pain Over Two Years After Start of Biologic Versus Conventional Combination Treatment in Early Rheumatoid Arthritis: Results From a Swedish Randomized Controlled Trial

OBJECTIVE

To compare the pain course between methotrexate (MTX)-refractory early rheumatoid arthritis (RA) patients randomized to infliximab (IFX) versus sulfasalazine (SSZ) plus hydroxychloroquine (HCQ).

METHODS

The randomized, controlled, open-label Swedish Pharmacotherapy (SWEFOT) trial enrolled new-onset RA patients from October 2002 to December 2005. After 3 months of receiving MTX, patients not reaching low disease activity (Disease Activity Score in 28 joints score ≤3.2) were randomized to adding IFX (n = 128) or SSZ plus HCQ (n = 130) and followed for 21 months. Here, outcomes included area under the curve (AUC) for visual analog scale (VAS) scores for pain, unacceptable pain (VAS pain score >40 mm [range 0-100]), and unacceptable pain despite inflammation control (refractory pain; VAS pain score >40 plus C-reactive protein level <10 mg/liter). Between-group differences were analyzed with multivariate regression models.

RESULTS

Overall, 50% of randomized patients (n = 258) in the crude setting reported unacceptable pain at randomization, declining to 29% at 21 months (P < 0.001), when refractory pain constituted 82% of all unacceptable pain. Comparing randomized arms (intent-to-treat analysis), the AUC for VAS pain was lower in the MTX plus IFX group (P = 0.01), and at 21 months, 32% of patients receiving MTX plus IFX and 45% receiving MTX plus SSZ plus HCQ had unacceptable pain (adjusted relative risk 0.68 [95% confidence interval 0.51, 0.90]; P = 0.008). Regarding refractory pain, no between-group differences were observed.

CONCLUSION

Despite active combination treatment, almost one-third of new-onset RA patients reported unacceptable pain after 21 months, and refractory pain constituted more than 4/5 of this pain load. Adding IFX versus SSZ plus HCQ to MTX reduced both cumulative pain and unacceptable pain at 21 months, suggesting less long-term pain for the biologic therapy. These results display insufficient effects of current treatment strategies on inflammation-independent pain components, warranting alternative approaches in affected patients.

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.

Psychiatric Disorders and Cardiovascular Diseases During the Diagnostic Workup of Suspected Prostate Cancer

Background

It is unknown whether the rate of psychiatric disorders and cardiovascular disease increases during the diagnostic workup of suspected prostate cancer.

Methods

We designed a population-based cohort study including 579 992 men living during 2005-2014 in Skåne, Sweden, according to the Swedish Total Population Register and the Skåne Healthcare Register (SHR). We used the Swedish Cancer Register and the SHR to identify all men with a new diagnosis of prostate cancer (N = 10 996), and all men underwent a prostate biopsy without receiving a cancer diagnosis (biopsy group, N = 20 482) as exposed to a diagnostic workup. Using Poisson regression, we compared the rates of psychiatric disorders and cardiovascular disease during the period before diagnosis or biopsy of exposed men with the corresponding rates of unexposed men.

Results

We found an increased rate of psychiatric disorders during the period before diagnosis or biopsy among men with prostate cancer (incidence rate ratio [IRR] = 1.87, 95% confidence interval [CI] = 1.67 to 2.10) and men in the biopsy group (IRR = 2.22, 95% CI = 2.08 to 2.37). The rate of cardiovascular disease increased during the period before diagnosis or biopsy among men with prostate cancer (IRR = 2.22, 95% CI = 2.12 to 2.32) and men in the biopsy group (IRR = 2.56, 95% CI = 2.49 to 2.63). Greater rate increases were noted for a diagnostic workup due to symptoms than due to other reasons.

Conclusions

There was an increased risk of psychiatric disorders and cardiovascular disease during the diagnostic workup of suspected prostate cancer regardless of the final cancer diagnosis.

Risk of Injuries around Diagnosis of Cervical Cancer and Its Precursor Lesions: A Nationwide Cohort Study in Sweden

BACKGROUND

Highly increased risk of injuries has been noted around the time of cancer diagnosis. Whether there is a similar increase in risk around the diagnosis of cervical cancer and its precursor lesions was unknown.

METHODS

We performed a cohort study including 3,016,307 Swedish women that participated in cervical screening during 2001 to 2012. We calculated the incidence rates (IR) of hospitalized iatrogenic or noniatrogenic injuries during the diagnostic workup, and the time interval from smear or punch biopsy until surgical treatment or 2 months after the last smear or biopsy, among women with invasive cervical cancer (ICC) or its precursor lesions. We calculated the IRs of injuries during the 2 months after a normal smear among the other women as reference. IR ratios (IRR) and 95% confidence intervals (CI) were calculated using Poisson regression.

RESULTS

Compared with other women, there was an increased rate of iatrogenic injuries during the diagnostic workup of women with ICC (IR, 0.58 per 1,000 person-months; IRR, 8.55; 95% CI, 3.69-19.80) as well as of women with cervical intraepithelial neoplasia grade 3 and adenocarcinoma in situ (IR, 0.09 per 1,000 person-months; IRR, 3.04; 95% CI, 1.73-5.34). We also found an increased rate of noniatrogenic injuries during the diagnostic workup of women with invasive cancer (IR, 0.65 per 1,000 person-months; IRR, 2.48; 95% CI, 1.30-4.47).

CONCLUSIONS

Although rare, there was an increased risk of inpatient care for iatrogenic and noniatrogenic injuries during the diagnostic workup of women with ICC.

IMPACT

Women experienced burden of medical complications and psychologic distress around diagnosis of a potential cervical cancer.

Consultation prevalence among children, adolescents and young adults with pain conditions: A description of age- and gender differences

BACKGROUND

Pain is a common complaint presented in healthcare, but most epidemiological pain research has focused either on single pain conditions or on the adult population. The aim of this study was to investigate the 2017 consultation prevalence of a wide range of pain conditions in the general population of young people.

METHODS

We used the Skåne Healthcare Register, covering prospectively collected data on all healthcare delivered (primary and secondary care) to the population in the region of Skåne, southern Sweden (population 2017 n = 1,344,689). For individuals aged 1-24 in 2017 (n = 373,178), we calculated the consultation prevalence, stratified by sex and age, and the standardised morbidity ratio (SMR) to assess overall healthcare consultation.

RESULTS

A total of 58,981 (15.8%) individuals consulted at least once for any of the predefined pain conditions. Of these, 13.5% (n = 7,996) consulted four or more times for pain. Abdominal pain, joint pain/myalgia, headache and back/neck pain were the most common complaints. Overall, females had higher consultation prevalence than males: 17.6% versus 14.1% (p < .0001). SMR was 1.82 (95% CI = 1.74-1.87) for females with pain and 1.51 (95% CI = 1.42-1.56) for males with pain. Consultation prevalence increased with age, but this pattern varied between sex and pain condition.

CONCLUSIONS

Among individuals under the age of 25, a significant proportion consult for pain already in early ages, and they also have high healthcare consultation rates for conditions other than pain. The even higher consultation rates among young females need additional attention, both in the clinic and in research.

SIGNIFICANCE

We present comprehensive 1-year healthcare consultation prevalence data covering all levels of care. A significant proportion of children, adolescents and young adults consult for different pain conditions at multiple occasions warranting greater clinical awareness.

Psychiatric disorders and cardiovascular diseases during the diagnostic workup of potential breast cancer: a population-based cohort study in Skåne, Sweden

Background

An increasing number of women are evaluated for potential breast cancer and may experience mental distress during evaluation. We aim to assess the risks of psychiatric disorders and cardiovascular diseases during the diagnostic workup of potential breast cancer.

Methods

All women with a new diagnosis of unspecified lump in breast (N = 15,714), benign tumor or breast cancer in situ (N = 4435), or breast cancer (N = 8512) during 2005–2014 in Skåne, Sweden, were considered as exposed to a breast diagnostic workup. We used multivariable Poisson regression to compare rates of psychiatric disorders and cardiovascular diseases during the 6 weeks before the date of diagnosis of these women with the corresponding rates of women not undergoing such workup. The commonest waiting time for breast cancer patients was 6 weeks during the study period. A within-individual comparison was performed to control for potential unmeasured time-stationary confounders.

Results

Compared to the reference, we found a higher rate of psychiatric disorders during the 6 weeks before diagnosis of benign tumor or breast cancer in situ (incidence rate ratio [IRR], 1.3; 95% confidence interval [CI], 1.1 to 1.5) and breast cancer (IRR, 1.4; 95% CI, 1.2 to 1.6). A higher rate was also noted for cardiovascular diseases (IRR, 1.3; 95% CI, 1.1 to 1.6 for benign tumor or breast cancer in situ, and IRR, 1.9; 95% CI, 1.8 to 2.0 for breast cancer). The rate increases for breast cancer were greater comparing a diagnostic workup due to symptoms to a workup due to screening. Little rate increase of neither psychiatric disorders nor cardiovascular diseases was noted during the 6 weeks before the diagnosis of unspecified lump in breast. The within-individual comparison largely confirmed these findings.

Conclusions

Women with benign and malignant breast tumor had increased rates of psychiatric disorders and cardiovascular diseases during the waiting for a final diagnosis.

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

Aims: This study aimed to examine the population-based Skåne Health-care Register (SHR) regarding feasibility for scientific research and also strengths and weaknesses. Methods: To analyse the feasibility of the SHR, we performed a bibliographic search for peer-reviewed articles based on SHR data from 2000 to 2018. To analyse strengths and weaknesses, we used original SHR data about coverage and validity. Results: We identified 58 articles based on SHR data, covering different study designs and disorders. Most studies focused on musculoskeletal disorders with a cohort design. The majority of all consultations recorded in the SHR have an assigned diagnosis. However, this differs between the levels of care and between types of consultation. For inpatient care, the proportion of consultations with an assigned diagnosis was close to 100% between 1998 and 2017. The proportion of consultations with an assigned diagnosis was lowest within primary care, although the proportion markedly increased in 2004 when the prerequisite for consultation reimbursement was linked to the requirement for an assigned diagnosis. Limitations are that the SHR does not cover health-care provided within nursing homes and equivalent facilities or treatments received by the population of Skåne outside the region. Conclusions: The SHR may be used as a reliable data source for analyses of clinical changes and improvements. Extended use of the SHR in a research context may highlight important shortcomings within the register and thus serve as a way of indirect quality control. To enhance the use of the SHR further, better harmonisation between registers, within and outside of the region and internationally, is of crucial importance.

Dying With Unrelieved Pain-Prescription of Opioids Is Not Enough

CONTEXT

Fear of pain resonates with most people, in particular, in relation to dying. Despite this, there are still people dying with unrelieved pain.

OBJECTIVES

We quantified the risk, and investigated risk factors, for dying with unrelieved pain in a nationwide observational cohort study.

METHODS

Using data from Swedish Register of Palliative Care, we analyzed 161,762 expected deaths during 2011-2015. The investigated risk factors included cause of death, place of death, absence of an end-of-life (EoL) conversation, and lack of contact with pain management expertise. Modified Poisson regression models were fitted to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for dying with unrelieved pain.

RESULTS

Unrelieved pain during the final week of life was reported for 25% of the patients with pain, despite prescription of opioids PRN in 97% of cases. Unrelieved pain was common both among patients dying of cancer and of nonmalignant chronic diseases. Statistically significant risk factors for unrelieved pain included hospital death (RR = 1.84, 95% CI 1.79-1.88) compared with dying in specialist palliative care, absence of an EoL conversation (RR = 1.42, 95% CI 1.38-1.45), and dying of cancer in the bones (RR = 1.13, 95% CI 1.08-1.18) or lung (RR = 1.10, 95% CI 1.06-1.13) compared with nonmalignant causes.

CONCLUSION

Despite almost complete prescription of opioids PRN for patients with pain, patients die with unrelieved pain. Health care providers, hospitals in particular, need to focus more on pain in dying patients. An EoL conversation is one achievable intervention.

A diagnosis of rheumatoid arthritis, endometriosis or IBD is associated with later onset of fibromyalgia and chronic widespread pain

BACKGROUND

Widespread pain is a common comorbidity in several chronic diseases and is suspected to be caused by pain resulting from the underlying disease that has provoked a state of central sensitization. However, this argument is currently limited by evidence that has insufficiently captured the temporal nature of the relationship between diagnosis of the underlying disease and onset of widespread pain. The aim of this study was to investigate if patients with rheumatoid arthritis (RA), endometriosis or inflammatory bowel disease (IBD), have a higher risk of developing widespread pain (fibromyalgia or chronic widespread pain [CWP]).

METHODS

Using the Swedish Skåne Healthcare register on health care consultation, a cohort of 889,938 adult patients were followed from 2007 to 2016 and incident cases of RA, endometriosis or IBD and of fibromyalgia and CWP were identified by registered diagnoses. Using Poisson regression, we calculated incidence rate ratios (IRR) adjusted for sex, age, education and propensity to seek health care.

RESULTS

For patients with RA the IRR for later fibromyalgia was 3.64 (95% CI: 2.75-4.81) compared to patients without RA, for CWP it was 2.96 (95% CI: 1.81-4.86). For endometriosis patients the IRR for fibromyalgia was 2.83 (95% CI: 1.96-4.08) and for CWP 5.02 (95% CI: 3.10-8.13). IBD patients had an IRR = 2.32 (95% CI: 1.58-3.42) for fibromyalgia and 1.42 (95% CI: 0.93-2.17) for CWP.

CONCLUSIONS

This study shows that RA, endometriosis and IBD are all risk factors for later fibromyalgia and CWP, consistent with a hypothesis of central sensitization as an effect of a painful underlying condition.

SIGNIFICANCE

We show that RA, endometriosis and IBD predisposes for later fibromyalgia and CWP, a common hypothesis previously difficult to verify due to lack of longitudinal data. The results inform further research regarding the aetiology of fibromyalgia and CWP and stress the need of clinical focus on the pain itself in chronic diseases with pain as a symptom.

Comorbidity between pain and mental illness - Evidence of a bidirectional relationship

BACKGROUND

Pain from various locations in the body and mental illness are common and the comorbidity between the two is well-known although the temporal relationship remains to be determined. Our aim was to follow patients over time to study if pain (here dorsalgia/abdominal pain) or fibromyalgia lead to an increased risk of developing mental illness (here depression/anxiety) and/or the reverse, that is whether patients with mental illness have an increased risk to develop pain or fibromyalgia, compared to the rest of the population.

METHODS

This prospective cohort study used the Skåne Healthcare Register, covering all care in the region of Skåne, southern Sweden (population ~1.3 million). The cohort included healthcare consultations in primary care, outpatient specialized care and inpatient care between 2007 and 2016 for all patients without prior registered diagnosis of mental illness or pain, aged 18 or older (n = 504,365).

RESULTS

The incidence rate ratio (IRR) for developing mental illness after pain was 2.18 (95% CI = 2.14-2.22) compared to without pain. IRR for developing pain after mental illness was 2.02 (95% CI = 1.98-2.06) compared to without mental illness. Corresponding IRR for developing mental illness after fibromyalgia was 4.05 (95% CI = 3.58-4.59) and for developing fibromyalgia after mental illness 5.54 (95% CI = 4.99-6.16).

CONCLUSIONS

This study shows a bidirectional influence of similar magnitude of pain and mental illness, respectively. In monitoring patients with pain or mental illness, a focus on both conditions is thus important to develop appropriate, targeted interventions and may increase the likelihood of improved outcomes.

SIGNIFICANCE

We followed a population-based cohort over a period of 10 years, including incident cases of both exposure and outcome and found a bidirectional relationship between pain and mental illness. Clinicians need to pay attention on both conditions, in patients seeking care due to mental illness or pain.

Injuries before and after diagnosis of cancer: nationwide register based study

OBJECTIVE

 To examine the relative risks of iatrogenic and non-iatrogenic injuries during the period shortly before and after a diagnosis of cancer.

DESIGN

 Nationwide register based study.

SETTING

 Swedish national population and health registers.

PARTICIPANTS

 720 901 patients with diagnosis of cancer, 1991-2009, in Sweden.

MAIN OUTCOME MEASURES

 All hospital admissions in patients with cancer with a main discharge diagnosis of iatrogenic (from medical complications) or non-iatrogenic injuries in 1990-2010 identified from the Swedish patient register. Conditional Poisson regression was used to compare the incidence rate of injuries during the "diagnostic period" (16 weeks before to 16 weeks after diagnosis) with the incidence rate during a "pre-diagnostic period" (the same 32 weeks one year before diagnosis) among the same patients.

RESULTS

 During the diagnostic period, there were 7306 iatrogenic (incidence rate 0.60 per 1000 person months) and 8331 non-iatrogenic injuries (incidence rate 0.69 per 1000 person months). For iatrogenic injuries, the incidence rate ratio was 7.0 (95% confidence interval 6.6 to 7.4) during the diagnostic period compared with the pre-diagnostic period. The increase in risk started two weeks before cancer diagnosis and peaked during the two weeks after diagnosis (48.6, 37.3 to 63.5). For non-iatrogenic injuries, the incidence rate ratio was 1.9 (1.8 to 2.0) during the diagnostic period compared with the pre-diagnostic period. The increase in risk began four weeks before diagnosis and peaked during the two weeks before diagnosis (5.3, 4.6 to 6.1). There were increased risks of both types of injury during the diagnostic period for all common cancers, with the smallest risk increase noted for non-melanoma skin cancer.

CONCLUSIONS

 Patients with cancer have highly increased risks of both iatrogenic and non-iatrogenic injuries requiring inpatient care : shortly before and after their diagnosis. These findings shed further light on the total burden of medical complications and call for prevention of intentional and unintentional injuries during the diagnostic process of cancer.