Representativity of a postal public health questionnaire survey in Sweden, with special reference to ethnic differences in participation

Aim: Non-participation in health surveys is a common phenomenon. When differences between participants and non-participants are considerable, the external validity of the sample survey may decrease and false conclusions might be drawn about the health status of the population. For this reason, the authors aimed to investigate the representativity of a postal questionnaire survey performed in the county of Scania, Sweden, in 1999—2000. The survey, which was based on an 18- to 80-year-old population sample, had a 58% response rate (n = 13 604). Methods: For some variables, the information obtained using the questionnaire was compared with information obtained from a population register that covers all the population in the county (for the 18- to 80-year-old group, n = 850 476). The population register includes, among other data, information on age, gender, educational level, country of birth, and healthcare expenditure. Results: Men, individuals with a low level of education, and immigrants were under-represented in the survey. However, except for immigrants, the under-representation was not large. Among immigrants, particularly those born in former Yugoslavia, the Arabic-speaking countries, and Poland were very significantly under-represented in the study. By contrast, immigrants born in other Nordic countries had responded to almost the same extent as respondents born in Sweden. The survey sample had about the same healthcare utilization costs as did the general population. Conclusions: In summary, the ``Health Survey for Scania, 2000'' seems largely representative of the total Scanian population. A major concern, however, is the under-representation of the immigrant population.

P1-08-06: Breast Cancer among Patients with Diabetes, Obesity and Abnormal Blood Lipids – A Population-Based Register Study in Sweden

Objective: To study how the incidence of breast cancer is related to diabetes, obesity or abnormal blood lipids.

Methods: Diagnosis of diabetes, obesity or abnormal blood lipids was studied 0–10 years prior to the diagnosis of cancer in 2724 cases of cancer and in 20542 controls matched regarding age, sex and domicile in a population based material. Diagnoses were obtained by using out and inpatient population based registries. Also the use of glargine and metformin was studied in relation to cancer risk in diabetic patients using the national pharmacy prescription registry. Conditional logistic regression was used for the analyses.

Results: Diabetes was significantly more common prior to diagnosis in patients with breast cancer with diabetes diagnosed 0–4 years prior to the cancer diagnosis. The findings remained after adjusting for obesity and high blood lipids. Obesity was significantly more common in patients with breast cancer above the age of 60 years in those where obesity was diagnosed close to the diagnosis of cancer. High blood lipids were significantly less common in patients with breast cancer close to diagnosis.

Glargine use was associated with a doubled risk 2.88 (1.15−6.64) and metformin use with a lower risk of cancer in diabetic patients 0.92 (0.82−1.09).

Sickness absence among cancer patients in the pre-diagnostic and the post-diagnostic phases of five common forms of cancer

PURPOSE

The purpose of this study was to observe sickness absence before and after the cancer diagnosis among cancer patients with five common forms of cancer.

METHODS

Using cohort data, we observed sick leave in the pre- and post-diagnostic phase among patients with colon, rectal, breast, prostate, or lung cancer (n = 2,738). We also identified reference subjects without cancer (total n = 12,246) who were individually matched for age and gender for each specific cancer cohort in order to compare sickness absence between patients with a specific form of cancer and the background population without cancer.

RESULTS

Lung cancer patients had the highest increase in sick days both pre- and post-diagnosis and prostate cancer patients had the lowest increase. Irrespective of the form of cancer, cancer patients had significantly more sick days in the post-diagnostic phase compared to their reference subjects, ranging from 5 (prostate cancer) to 12 times the amount of sick days (colon and lung cancer). One year post-diagnosis, less than half of the cancer patients were on sick leave, except for lung cancer patients where 63% were still on sick leave.

CONCLUSION

Sick leave among cancer patients seems related not only to the cancer diagnosis and its treatment but also to the prodromal illness in the pre-diagnostic phase, especially for forms of cancer with heavier symptom burden such as colon and lung cancer. Although cancer results in substantial increase in sick leave, it is important to acknowledge that a major part of cancer patients return to work within 1 year after the cancer diagnosis.

Low cancer rates among patients with dementia in a population-based register study in Sweden

BACKGROUND

Some studies have suggested a lower incidence of cancer in patients with dementia. We studied this further for 18 cancer types in population-based registers.

METHODS

In 19,756 cases and in 147,324 age- and sex-matched controls a diagnosis of dementia was studied 9-45 months prior to the diagnosis of cancer.

RESULTS

Overall a diagnosis of dementia was significantly less common among the cancer cases (risk ratio, RR = 0.60; 95% CI = 0.52-0.69).

CONCLUSION

The study confirms previous findings that patients with dementia have a lower risk of cancer. Because the effect was seen for all tumour types and especially for patients older than 70 years and since the deficit was more pronounced for patients with tumours situated within the body, the data suggest that malignancies are underdiagnosed for persons with dementia.

Sick leave of spouses to cancer patients before and after diagnosis

BACKGROUND

The impact of cancer on spouses of cancer patients may be considerable in many aspects. Our objective was to evaluate sick leave in spouses of cancer patients before and after the diagnosis.

MATERIAL AND METHODS

Using Swedish population-based registries, we studied sick leave of spouses to patients with newly diagnosed colon, rectal, lung, prostate, or breast cancer. We identified the cancer patients via the Swedish Cancer Registry and obtained information of their spouse through linkage with the population register. We assessed the number of sick leave episodes and sick days one year before until one year after the spouses' cancer diagnosis by cross-referencing with Swedish Social Insurance Agency data. We also compared the number of sick days of spouses with the general population adjusted for age, sex and partner status.

RESULTS

In general, spouses (N=1 923) to cancer patients had an increase in the frequency of new episodes of sick leave in the months before and after the cancer diagnosis. Spouses of lung cancer patients had most sick leave episodes, and the largest number of sick days per person. In comparison to the general population, spouses in the lung cancer group also had the highest standardised sick day ratio 1.76; 95% confidence interval 1.24, 2.40. The corresponding risk for spouses in other groups of cancer was not significantly increased.

DISCUSSION

In Sweden there is often increased sick leave of spouses to cancer patients. It may be due to emotional stress and physical reactions that follow with cancer which needs to be further explored in order to provide adequate support and care.

Influence on the Health of the Partner Affected by Tumor Disease in the Wife or Husband Based on a Population-Based Register Study of Cancer in Sweden

Purpose

To examine health care use and health care costs among partners of persons with cancer.

Patients and Methods

Partners of patients with colon, rectal, lung, breast, and prostate cancer (N = 11,076) were identified via linked data from the Tumor Registry of Southern Sweden and Census Registry of Sweden. Health care use, total costs of health care, and diagnosis of the partner were studied before and after diagnosis of the cancer patient.

Results

Health care use for partners increased in terms of in-patient care after the cancer diagnosis. A significant increase was seen the second year for partners of patients with colon cancer (risk ratio [RR], 1.55; 95% CI, 1.28 to 1.87) and lung cancer (RR, 1.50; 95% CI, 1.26 to 1.79). Psychiatric diagnoses increased after the cancer diagnosis in the total sample, with a significant increase for partners of colon (RR, 2.66; 95% CI, 1.71 to 4.22), lung (RR, 3.16; 95% CI, 2.23 to 4.57), and prostate cancer patients (RR, 1.68; 95% CI, 1.32 to 2.15). Costs of care increased more than the consumer price index the two years after the cancer diagnosis. Costs of care increased most for male partners and especially for younger male partners (age 25 to 64 years) of patients with colon, rectal, and lung cancers.

Conclusion

The results showed increased health care costs and an increase in psychiatric diagnoses after the cancer diagnosis among partners of cancer patients. Further research is needed to learn more about the situation of the partner and to identify persons at risk of psychiatric morbidity. Knowledge is also needed on how to support the partner in the most efficient way.

Prostate cancerPrevalence‐based healthcare costs

OBJECTIVE

To calculate the total costs of in- and outpatient healthcare for patients with prostate cancer based on an episode-of-care approach. The cost analysis includes costs incurred during the first year of diagnosis, a longitudinal 3-year analysis and the incremental cost of prostate cancer during the first year of diagnosis.

MATERIAL AND METHODS

Patients registered with prostate cancer between 1998 and 2000, according to the data files of the Southern Swedish Regional Tumour Registry, were given encrypted identifiers that could also be used in the Patient Administrative System of the Region Skåne County Council, making it possible to identify consumption of healthcare on an episode-of-care basis. Itemized costs for resources used by each individual patient were calculated from the complete accounting system of the County Council.

RESULTS

Healthcare costs for prostate cancer during the first year varied between 45 000 and 51 000 SEK per patient. The second- and third-year costs were progressively lower, with an estimated total cost of 114 000 SEK over a period of 3 years. The age-standardized incremental cost of prostate cancer corresponded to 33 000 SEK during the first year, compared to the average cost per inhabitant.

CONCLUSIONS

The episode-of-care approach, based on encrypted identifiers for the identification of the diagnoses of individual patients and their utilization of healthcare, gives a unique opportunity to estimate the healthcare costs of specific diseases. The incremental healthcare cost per patient with prostate cancer corresponded to 33 000 SEK during the first year.

Comorbidity prior to diagnosis in patients with common cancer diagnoses

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Background: Chronic disease as diabetes, hypertonia and anemia may be associated with cancer risk as well as affect the short term survival of the malignancy. Methods: Using population based registry data from specialist and primary care in our health care region comorbidity in the form of anemia, hypertonia, diabetes, rheumatoid arthritis, chronic obstructive pulmonary diasease (KOL), and alcohol related diseases for patients with colon-, rectal-, lung-, prostate and breast cancer and survival were studied. Altogether 2047 colon cancer cases, 985 rectal cancer cases, 2017 lung cancer cases, 3578 breast cancer cases and 5106 prostate cancer cases diagnosed 2000–2005 were included. Results: were age and sex adjusted and one year survival was calculated. Comorbidity was studied prior to cancer diagnosis and in order to compare with the general population all first comorbidity diagnoses within 90 days were censored. Results The prevalence of the chronic diseases in the general population was for all ages diabetes 3.2%, rheumatoid arthritis 0.5%, hypertonia 6.8%, anemia 1.1%, KOL 1.0% and alcohol related diagnoses 0.7%. Patients with colon and rectal cancer had a higher prevalence of anemia, and diabetes. Patients with lung cancer had a higher prevalence of anemia, KOL, diabetes, rheumatoid arthritis for both men and women and for men also a higher prevalence of alcohol related diseases. Except for alcohol related diseases in females with breast cancer comorbidity for the above diseases was not significantly elevated for breast or prostate cancer. For all diagnoses hypertonia was significantly lower than in the general population. Survival of the different cancer diagnoses was not significantly related to the comorbidity except for a tendency of worse survival for patients with alcohol related disease. Conclusions: The prevalence of some common chronic diseases are elevated especially in colon-, rectal and lung cancer patients. The comorbidity does not seem to affect short term survival of the cancer patient except for alcohol related diagnoses. Our study also indicates the necessity to have all levels of care included in the study base of comorbidity and also emphasizes the need to censor time prior to diagnosis when comparing data with the general population.

No significant financial relationships to disclose.

Utility of a population-based case-control study model with a limited number of patients in estimating risks of hypertension

A population-based case-control study of the risks of hypertension was carried out in a primary care district where data on all patients have been registered in out- and in-patient computer schemes and where extensive studies and treatment programs regarding blood pressure have been performed for more than a decade. The results of the study, which comprised a limited number of patients, accord with those of more extensive and prospective studies. The hypertensives had high risks of developing myocardial infarction and stroke even though they were treated according to internationally accepted norms regarding blood pressure. The estimated population-attributable risk of hypertension in men was 30% with regard to myocardial infarction and 68% with regard to stroke. Smoking and hypertension were found to be independent risk indicators of myocardial infarction in men and hypertension was a strong risk indicator of stroke. Thus, a case-control study carried out in this way in a primary care district gives valid results regarding the efficacy of an antihypertensive treatment program and may therefore serve as a model for future studies in primary health care.

Social capital, the miniaturisation of community, traditionalism and first time acute myocardial infarction: A prospective cohort study in southern Sweden

This longitudinal study investigates the impact of social participation, trust and the combinations of social participation and trust on the incidence of first time acute myocardial infarction (AMI) in the population of Scania, southern Sweden. It is based on the cross-sectional 2000 public-health survey in Scania with a 59% participation rate and 13,604 participants, and prospective morbidity/mortality data collected for three years (January 2000-December 2002). The study cohort was followed prospectively to examine first ever AMI. Hazard rate ratios (HRR) for first time AMI in the social participation, trust and social participation/trust combinations were calculated in a Cox regression model with adjustments for age, sex, education, economic stress, daily smoking, leisure time physical activity, body mass index (BMI), and self-reported health. The prevalence of low social participation was 32.8% among men and 31.5% among women. The prevalence of low trust was 40.0% among men and 44.2% among women. The three-year first time AMI rate was significantly higher among people with higher age, low education, daily smoking, poor self-reported health (among men), low social participation, and the combinations of low social participation/high trust and low social participation/low trust. The results show that low social participation but not trust was significantly associated with first time AMI after adjustment for age and sex. The positive association between low social participation and myocardial infarction remained significant after further adjustments for education, economic stress, daily smoking, physical activity and BMI, and became not significant only after additional adjustment for self-reported health, HRR 1.3 (0.9-2.0). High trust in combination with low social participation as well as low social capital (low trust/low social participation) were significantly associated with AMI, but after multiple adjustments only the low social participation/high trust category remained significant, HRR 1.6 (1.0-2.6).

The role country of birth plays in receiving disability pensions in relation to patterns of health care utilisation and socioeconomic differences: a multilevel analysis of Malmo, Sweden

Background

People of low socioeconomic status have worse health and a higher probability of being granted a disability pension than people of high socioeconomic status. It is also known that public and private general physicians and public and private specialists have varying practices for issuing sick leave certificates (which, if longstanding, may become the basis of disability pensions). However, few studies have investigated the influence of a patient's country of birth in this context.

Methods

We used multilevel logistic regression analysis with individuals (first level) nested within countries of birth (second level). We analysed the entire population between the ages of 40 and 64 years (n = 80 212) in the city of Malmo, Sweden, in 2003, and identified 73% of that population who had visited a physician at least once during that year. We studied the associations between individuals and country of birth socioeconomic characteristics, as well as individual utilisation of different kinds of physicians in relation to having been granted a disability pension.

Results

Living alone (OR_women = 1.72, 95% CI: 1.62–1.82; OR_men = 2.64, 95% CI: 2.46–2.83) and having limited educational achievement (OR_women = 2.14, 95% CI: 2.00–2.29; OR_men = 2.12, 95% CI: 1.98–2.28) were positively associated with having a disability pension. Utilisation of public specialists was associated with a higher probability (OR_women = 2.11, 95% CI: 1.98–2.25; OR_men = 2.16, 95% CI: 2.01–2.32) and utilisation of private GPs with a lower probability (OR_men = 0.76, 95% CI: 0.69–0.83) of having a disability pension. However, these associations differed by countries of birth. Over and above individual socioeconomic status, men from middle income countries had a higher probability of having a disability pension (OR_men = 1.61, 95% CI: 1.06–2.44).

Conclusion

The country of one's birth appears to play a significant role in understanding how individual socioeconomic differences bear on the likelihood of receiving a disability pension and on associated patterns of health care utilisation.

The Danish effect on Swedish alcohol costs. An analysis based on hospitalization data from southern Sweden

This study investigated: (a) the cost and change in hospitalizations related to alcohol misuse for the healthcare sector and (b) the effect of distance to the border on alcohol-related hospitalization costs. The first objective was analyzed using descriptive statistics and the second using ordinary least squares regression on aggregated municipality data. The total cost decreased marginally during the study period while the number of patient-cases decreased substantially, presenting evidence of a substitution towards outpatient care. The increase in average treatment cost and the almost constant total cost provide evidence for a societal increase in the burden of alcohol-related diseases. We found a negative effect for distance to Denmark on alcohol-related hospitalization cost for the year 2003. The effect was smaller for 1998, suggesting that the increase in private import quotas during the study period has affected individuals' consumption level and/or consumption pattern. We also found indications that the increase in import quotas lead to a higher cost increase for heavy consumers than for low consumers.

Children's exposure to nitrogen dioxide in Sweden: investigating environmental injustice in an egalitarian country

STUDY OBJECTIVE

Prior studies have shown that children are particularly sensitive to air pollution. This study examined whether children of low socioeconomic status suffered greater exposure to outdoor nitrogen dioxide than more affluent ones, both at their place of residence and at school, in a country with widespread state intervention for social equity.

DESIGN

Local scale data on outdoor nitrogen dioxide obtained from a validated air pollution model were analysed, along with all school children accurately geocoded to their building of residence and school.

PARTICIPANTS

All 29,133 children in grades one through nine (aged 7 to 15 years) residing and attending school in Malmö, Sweden, in 2001.

MAIN RESULTS

Defining the socioeconomic status of children according to the mean income in their residential building, the spatial scan statistic technique allowed the authors to identify eight statistically significant clusters of low socioeconomic status children, all of which were located in the most polluted areas of Malmö. Four clusters of high socioeconomic status children were found, all of them located in the least polluted areas. The neighbourhood socioeconomic status better predicted the nitrogen dioxide exposure of children than the socioeconomic status of their building of residence. Exposure to nitrogen dioxide at the place of residence and school of attendance regularly increased as the socioeconomic status of a child's neighbourhood of residence decreased.

CONCLUSIONS

Evidence of environmental injustice was found, even in a country noted for its egalitarian welfare state. Enforcement of environmental regulations may be necessary to achieve a higher level of environmental equity.

Understanding adherence to official guidelines on statin prescribing in primary health care--a multi-level methodological approach

OBJECTIVE

The aim was to investigate the role that municipalities and out-patient health care centres (HCCs) have in understanding adherence to official guidelines on statin prescribing. Our hypothesis was that after guideline publication, adherence to recommended statin prescription would increase and variance among HCCs and municipalities would decrease. Since multi-level regression analysis (MLRA) is a relatively new methodology in pharmacoepidemiology, we also aimed to explore the application of MLRA in our investigation.

METHODS

We obtained data from the Swedish Corporation of Pharmacies record of sales regarding all initial prescriptions of statins issued between April and December 2003. We applied multi-level analysis on 34,514 individual prescriptions (level 1) nested within 226 HCCs (level 2), which in turn were nested within 33 municipalities (level 3). Temporal trends and gender differences were investigated by means of random slope analysis. Variance was expressed using median odds ratio (MOR) and interval odds ratio.

RESULTS

HCCs appeared to be more relevant than municipalities for understanding the physicians' propensity to prescribe a recommended statin (MOR(HCC) = 1.96 and MOR(Municipality) = 1.41). Overall prevalence of adherence was very low (about 20%). After publication of the guidelines, prescription of recommended statins increased, and variance among HCCs decreased but only during the first 4 months of the observation period.

CONCLUSION

The publication of official guidelines in the county of Scania exerted a positive influence on statin prescription but, at the end of the observation period, adherence was still low and practice variation high. These facts may reflect inefficient therapeutic traditions and suggest that more intensive interventions may be necessary to promote rational statin prescription.

Low adherence with antihypertensives in actual practice: the association with social participation--a multilevel analysis

Background

Low adherence is a key factor in explaining impaired effectiveness and efficiency in the pharmacological treatment of hypertension. However, little is known about which factors determine low adherence in actual practice.

The purpose of this study is to examine whether low social participation is associated with low adherence with antihypertensive medication, and if this association is modified by the municipality of residence.

Methods

1288 users of antihypertensive medication were identified from The Health Survey in Scania 2000, Sweden. The outcome was low adherence with antihypertensives during the last two weeks. Multilevel logistic regression with participants at the first level and municipalities at the second level was used for analyses of the data.

Results

Low social participation was associated with low adherence with antihypertensives during the last two weeks (OR = 2.05, 95% CI: 1.05–3.99), independently of low educational level. However, after additional adjustment for poor self-rated health and poor psychological health, the association between low social participation and low adherence with antihypertensives during the last two weeks remained but was not conclusive (OR = 1.80, 95% CI: 0.90–3.61). Furthermore, the association between low social participation and low adherence with antihypertensives during the last two weeks varied among municipalities in Scania (i.e., cross-level interaction).

Conclusion

Low social participation seems to be associated with low adherence with antihypertensives during the last two weeks, and this association may be modified by the municipality of residence. Future studies aimed at investigating health-related behaviours in general and low adherence with medication in particular might benefit if they consider area of residence.

Country of birth, socioeconomic position, and healthcare expenditure: a multilevel analysis of Malmö, Sweden

STUDY OBJECTIVE

The principle of equity aims to guarantee allocation of healthcare resources on the basis of need. Therefore, people with a low income and persons living alone are expected to have higher healthcare expenditures. Besides these individual characteristics healthcare expenditure may be influenced by country of birth. This study therefore aimed to investigate the role of country of birth in explaining individual healthcare expenditure.

DESIGN

Multilevel regression model based on individuals (first level) and their country of birth (second level).

SETTING

The city of Malmö, Sweden.

PARTICIPANTS

All the 52 419 men aged 40-80 years from 130 different countries of birth, who were living in Malmö, Sweden, during 1999.

MAIN RESULTS

At the individual level, persons with a low income and persons living alone showed a higher healthcare expenditure, with regression coefficients (and 95% confidence intervals) being 0.358 (0.325 to 0.392) and 0.197 (0.165 to 0.230), respectively. Country of birth explained a considerable part (18% and 13%) of the individual differences in the probability of having a low income and living alone, respectively. However, this figure was only 3% for having some health expenditure, and barely 0.7% with regard to costs in the 74% of the population with some health expenditure.

CONCLUSIONS

Malmö is a socioeconomically segregated city, in which the country of birth seems to play only a minor part in explaining individual differences in total healthcare expenditure. These differences seem instead to be determined by individual low income and living alone.

Utilisation of antibiotics in young children: opposite relationships to adult educational levels in Danish and Swedish counties

BACKGROUND

Antibiotic utilisation varies profoundly among and within countries, and the extent of antibiotic utilisation correlates with the frequency of bacterial resistance, particularly among children. Hence, it is important to assess which factors may influence prescribing. In addition to variations in morbidity, health-care organisation, drug regulatory and supply systems, prescriber's attitudes, parents' behaviour, attitudes and socio-economic positions seem important. We compared socio-economic position (educational level of adults) and antibiotic utilisation in children in the municipalities within a Danish and a Swedish county which are geographically close, have similar social and economic development, and similar drug regulatory and supply systems.

METHODS

Data on antibiotic utilisation (1998), expressed in defined daily doses per 1000 inhabitants per day (DDD/TID), were obtained from the Copenhagen County Health Insurance register and from the National Corporation of Swedish Pharmacies. Data on municipal educational levels were obtained from Statistics Denmark and Statistics Sweden.

RESULTS

The utilisation of antibiotics in 0- to 6-year-old children was higher in the Swedish than in the Danish county but varied between the municipalities within both the Swedish (9.6-17.7 DDD/TID) and the Danish (8.0-12.9 DDD/TID) counties. Most notably, utilisation rates correlated negatively with the education levels in the Danish (r=-0.539, P=0.021) but positively in the Swedish (r=+0.390, P=0.025) municipalities.

CONCLUSION

The observed variations in antibiotic prescribing may reflect different parental and/or prescriber attitudes towards use of antibiotics and they emphasise that antibiotic prescribing is influenced by factors other than the prevalence of bacterial infections. Relationships between socio-economic position (educational level) and drug utilisation should not be generalised from one area to another.

Social inequalities in health- do they diminish with age? Revisiting the question in Sweden 1999

BACKGROUND: Individuals with low income have poorer health and should, therefore, have higher health expenditure than people with high income particularly in countries with a universal health care system. However, it has been discussed if social inequities in health diminish with age and we, hence, aimed to analyse this question. METHODS: We performed an age stratified cross-sectional analysis using averages, logistic and linear regression modelling of health care contacts, health care expenditures and mortality in relation to individual income in five groups by quintiles. The population consisted of all the 249,855 men aged 40 to 80 years living in the county of Skåne, Sweden during 1999. RESULTS: For working-age people (40-59 year old) we find a clear socioeconomic gradient with increasing probability of health care contact, relative expenditure and mortality as income decreased. The point estimations for 1st (highest)-2nd-3rd-4th and 5th (lowest) income groups were: (1.00-1.13-1.21-1.42 and 1.15), (1.00-1.16-1.29-1.69 and 1.89) and (1.00-1.35-1.44-2.82 and 4.12) for health care contact, relative expenditure and mortality respectively. However, in the elderly (75-80 year old) these point estimates were (1.00-0.83-0.59-0.61 and 0.39), (1.00-1.04-1.05-1.02 and 0.96) and (1.00-1.06-1.30-1.33 and 1.49). CONCLUSIONS: As expected among working-age individuals, lower income was associated with higher health care contact, relative expenditure and mortality. However, the existence of opposite socioeconomic gradients in health care utilisation and mortality in the elderly suggests that factors related to a high income might condition allocation of resources, or that current medical care is ineffective to treat determinants of income differences in mortality occurring earlier in the lifecourse.

[Multilevel analysis of regional disparities in survival after heart failure: differences between county health services affect little patients' prognosis]

The prognosis for patients suffering from heart failure in Sweden differs from county to county, indicating a need for a comparative study in order to uncover the reasons. Conventional single-level analytical methods, however, underestimate the statistical uncertainty in such studies, leading to an inappropriate ranking of regions. Consequently, public opinion and decision-making may be misled. Conventional methods are also unable to disentangle the extent to which differences in prognosis may depend on individual or regional factors. Multilevel analysis, on the other hand, provides a better estimate of statistical uncertainty, and can both identify and quantify the extent to which differences in prognosis depend on either patient-related or regional factors. Using multilevel analysis, we examined the one-year mortality of 38,343 heart failure patients for the period 1992-1995 in every county in Sweden. Regional differences in one-year mortality were found to be very small, the most relevant factors being individual ones. The limited differences distinguishable at the county level may be explained in part by physician density: the more physicians in a county, the better an individual patient's prognosis.

Benzodiazepine prescribing patterns in a high-prescribing Scandinavian community

Sales statistics indicate large variations in benzodiazepine consumption between the Scandinavian countries: the current difference between Denmark (highest) and Sweden (lowest) is almost two-fold. There are also large within-country variations: e.g. benzodiazepine sales in the Swedish city of Helsingborg, which is close to Denmark, were at the average Danish level and were the highest in Sweden. Repeated prescription analyses were carried out in Helsingborg, and register data were used to compare the extent of psychiatric morbidity and psychosocial problems in this city with those in neighbouring cities. Benzodiazepine consumption was higher than the national average in all age groups. However, neither the choice of the predominant benzodiazepine agents nor the dose size or number of doses per prescription showed any major deviation. Hence, Helsingborg may have a larger proportion of benzodiazepine users or longer exposure periods among users. The latter is supported by the fact that about 40% of all benzodiazepine prescriptions were repeated. Psychiatric morbidity, suicide rate, alcohol-related diseases, unemployment and the proportion of socially isolated subjects were higher than the county average. On the other hand, within the county, there were cities that despite lower benzodiazepine sales had an equal or higher rate of suicide, unemployment and alcohol-related diseases. Of all benzodiazepine prescriptions processed in Helsingborg, > 30% were issued by < 5% of the prescribers (> or = 15 prescriptions per prescriber and per week). Thus, the higher usage of benzodiazepines in Helsingborg may partly be related to higher psychiatric morbidity and more psychosocial problems, but deviant prescribing habits among a minority of physicians are also important.

Impairment of grip function in rheumatoid arthritis--studies with a simple hand test

A new, simple and quick method for assessment of impaired grip function was evaluated in a rheumatology department, 208 of 211 patients with definite rheumatoid arthritis were unable to do the test, 48 of these patients had regarded their hands as unaffected when questioned. The impairment of grip function was closely related to clinical and functional observations but not related to the most common laboratory tests. The study confirms the hypothesis that almost all patients with RA are unable to do the hand test, even those who consider their hand function as normal.

Construction of a simple test for assessment of hand function in primary care. Theories and experimental trials for the test situation

This paper describes a hand test consisting of three steps to test the subject's ability to grasp firmly another person's hand to hold a pencil firmly with fingers II-V with straight knuckles and maximally flexed finger joints, while the investigator pulls the pencil to hold on to a piece of paper with a rounded pinch grip between thumb and index finger while the investigator pulls the paper with a rounded pinch grip with submaximal strength. All three steps must be performed with each hand without causing pain. The test was an adequate parameter for the grip function, and at the same time could register work-load elicited pain, strength, and mobility. The test can be carried out by healthy subjects, but not by patients with rheumatoid arthritis. The test is logically constructed and has a high validity and reliability.

Hand handicap and rheumatoid arthritis in a fish-eating society (the Faroe Islands)

In the county of Klaksvik, the Faroes, a simple hand test was used for screening all inhabitants between the ages of 40 and 74 years. With its high sensitivity and specificity it revealed a diagnostic panorama entirely different from that seen in previous investigations in other nordic countries. In Klaksvik the prevalence of hand handicap was about 40%, which is due to the high incidence of osteoarthrosis. The prevalence of rheumatoid arthritis was 1.1%. The high functional capacity and the lower occurrence of rheumatic nodules and erosions found in the patients with rheumatoid arthritis as compared with previous studies suggest that the disease takes a milder course in Klaksvik. This should support the hypothesis that RA patients benefit from a diet rich in fish.

Chronic arthritis. Prevalence, severity and distribution between primary care and referral centres in a defined rural population

By a simple self-administered hand test, hand handicap was revealed in 689 out of a population of 5262 individuals aged 40-70 years. Subsequent medical examination showed inflammatory hand disease in 119, 67 of whom had previously been in contact with the public health service at some level because of hand dysfunction. These 67 patients formed the material for our study, whose purpose was to analyse the distribution, treatment and follow-up of patients with inflammatory joint disease on different health care levels. In primary health care, rheumatoid arthritis (RA) was found to be underreported. For half the cases the interval between onset of disease and assessment by a rheumatologist exceeded 5 years, and follow-ups were few and far between. In the referral centres, RA cases were dealt with more adequately. The prevalence of definite and probable RA was found to be 0.7 and 0.4%, respectively.

Detection of suspected inflammatory joint disease with a new simple self-administered hand test

A self-administered hand test was used to screen 5262 persons aged 40-70 living in a rural district in southern Sweden. It revealed evidence of hand impairment in 13%. The prevalence of RA was 1.1%. At the screening procedure a subgroup of 48 previously unrecognized individuals with inflammatory joint disease was identified. They were assessed by a rheumatologist, who established the following diagnoses: four definite RA, eight probable RA, three psoriatic arthritis, one unclassifiable arthritis, 10 osteoarthritis and 22 non-specific arthralgia. No advanced RA was detected. Two were seropositive and another was erosive. One with RA, one with psoriatic arthritis and three with arthralgic symptoms were unable to work. Most had only a minor need for further medical aid. The test was thus able to identify persons with hand impairment. Follow-up studies will address the practical implications of the screening procedure.