High lactose whey cheese consumption and risk of colorectal cancer - The Norwegian Women and Cancer Study

The incidence of colorectal cancer (CRC) has increased among Norwegian women, and is among the highest in the world. In order to understand this increase, country specific dietary exposures have been investigated. The aim of this study was to quantify the association between consumption of brown cheese, a common bread topping in Norway, and colorectal, colon, and rectal cancer in the prospective Norwegian Women and Cancer (NOWAC) Study. Data on brown cheese consumption and adjustment factors was available for 82 527 women. During a mean of 14.6 years of follow-up (1.2 million person-years), there were 1360 cases of colorectal cancer (907 colon; 453 rectal). Multivariable Cox proportional hazards models were used to calculate hazard ratios (HR) with 95% confidence intervals (CI) for colorectal, colon, and rectal cancer sites. We modelled restricted cubic splines with 4 knots, to assess a possible non-linear relationship between brown cheese intake and the investigated cancer sites. In the age-adjusted model, consumption of more than 2 slices (>16 grams) of brown cheese per day was associated with 13% reduced risk of colon cancer (95% CI 4%-21%) compared to women who did not consume brown cheese. The multivariable-adjusted model, however, showed no association between brown cheese consumption and the risk of colorectal, colon, or rectal cancer (colorectal: HR = 0.93, 95% CI 0.76–1.13, p-trend 0.37; colon: HR = 0.83, 95% CI 0.65–1.06; p-trend = 0.10; rectal: HR = 1.16, 95% CI 0.84–1.1.61, p-trend = 0.41). In this large, prospective cohort study of women, consumption of brown cheese was suggestively protective against colon cancer. However, adjustment attenuated the inverse risk association. Brown cheese consumption was not associated with rectal cancer, or colorectal cancer overall.

Associations between utilization rates and patients' health: a study of spine surgery and patient-reported outcomes (EQ-5D and ODI)

Background

A vast body of literature has documented regional variations in healthcare utilization rates. The extent to which such variations are “unwarranted” critically depends on whether there are corresponding variations in patients’ needs. Using a unique medical registry, the current paper investigated any associations between utilization rates and patients’ needs, as measured by two patient-reported outcome measures (PROMs).

Methods

This observational panel study merged patient-level data from the Norwegian Patient Registry (NPR), Statistics Norway, and the Norwegian Registry for Spine Surgery (NORspine) for individuals who received surgery for degenerative lumbar spine disorders in 2010–2015. NPR consists of hospital administration data. NORspine includes two PROMs: the generic health-related quality of life instrument EQ-5D and the disease-specific, health-related quality of life instrument Oswestry Disability Index (ODI). Measurements were assessed at baseline and at 3 and 12 months post-surgery and included a wide range of patient characteristics. Our case sample included 15,810 individuals. We analyzed all data using generalized estimating equations.

Results

Our results show that as treatment rates increase, patients have better health at baseline. Furthermore, increased treatment rates are associated with smaller health gain.

Conclusion

The correlation between treatment rates and patients health indicate the presence of unwarranted variation in treatment rates for lumbar spine disorders.

Improvements in Survival and Early Retirement Rates - Real-World Evidence on Danish Breast Cancer Patients 2004-2018

Background

Historically, Denmark has had poor survival for cancer patients relative to other western countries with comparable health-care systems. In this study, we examine the long-term cancer impact of a nationwide reform addressing all cancer diagnostics, implemented in 2006. The analyses include patients diagnosed with breast cancer and their spouses (informal caregivers). Patients and their spouses diagnosed before and after the reform were compared. Focus is on the potential impact on overall survival, early retirement, sick leave, unemployment as well as earnings (income).

Methods

In a nationwide retrospective cohort study utilizing the Danish National Patient Register we identified 77,474 breast cancer patients between 1st January 2002 and 31st December 2018. Data was merged with the National Cancer Register, the Central Person Register, the Education Register, the DREAM Register and the Income Register using citizens' personal identification number. Spouses of cancer patients were identified through the Central Person Register. Propensity score matching was applied to match populations before and after the reform. Analyses on matched as well as unmatched populations were performed.

Results

In a matched sample, risk of mortality was reduced by 15% for breast cancer patients diagnosed after the reform. Moreover, there was a 15% reduced risk of early retirement. The patients diagnosed after the reform had reduced income three to five years after diagnosis relative to those diagnosed before the reform, likely due to survival bias and labor market conditions. In an unmatched sample of patients diagnosed two years before or after the reform, mortality was reduced by 7%.

Conclusion

Implementation of the nationwide cancer reform together with advancement in new cancer treatments had a positive impact on survival and reduced risk of early retirement. The results from this study are reassuring that relevant health-care reforms improve cancer outcome.

Burden of disease and cost of illness of infants less than 6 months of age hospitalised with respiratory syncytial virus in Denmark - a 10-year national register-based study

BACKGROUND

Respiratory syncytial virus (RSV) is the most common cause of hospitalisation in infants aged ≤ 6 months in Western countries. Nearly 1,500 infants under six months of age are hospitalised with RSV annually in Denmark. This nationwide study describes the healthcare resource utilisation and costs related to RSV hospitalisation in this vulnerable age group.

METHODS

RSV cases were identified in the Danish National Patient Register. Infants were included if they at the age of 0-5 months had a (1) respiratory related hospital admission (duration > 12 h), (2) within 10 days of a positive RSV test, (3) between January 2013 and December 2022. Each case was matched with five individuals never diagnosed with RSV on age, sex, region of residence, birth (pre/full term), number of siblings < 7 years old, and parents' education. An episode of RSV was defined as the seven days prior to hospitalisation to 30 days after initial hospitalisation. Study outcomes included contacts with hospital and primary care, and total healthcare costs defined as the sum cost of hospital care, primary care, and prescription medicine. Cost and contacts attributable to RSV was calculated in a diff-in-diff framework, as the difference between case and reference group.

RESULTS

The study population comprised of 8,428 RSV cases and 41,725 reference individuals. Cases generated 1.58 (p < 0.001) attributable inpatient contacts, 0.84 (p < 0.001) outpatient contacts, and 1.19 (p < 0.001) primary care contacts during their RSV episode. An additional 0.6 (p < 0.001) inpatient, 1.08 (p < 0.001) outpatient and 2.42 (p < 0.001) primary care contacts were attributed to RSV in the year following the RSV episode. Total cost of an RSV episode was EUR 2,997 (p < 0.001) with an additional EUR 1,428 (p < 0.001) in the following year.

CONCLUSION

RSV hospitalisations of infants are associated with substantial healthcare utilisation and costs. The same pattern was observed in the year following the RSV episode. If the new RSV prevention options are introduced nationwide, the overall burden of RSV is expected to be substantially reduced in the future.

Occurrence, mortality, and economic burden of brain disorders in Denmark, 2015-2021: a population-based cohort study

Background

Brain disorders (neurological and mental disorders) are common and burdensome diseases. We examined occurrence, mortality, and economic burden of brain disorders in Denmark from 2015 to 2021.

Methods

We conducted a nationwide population-based cohort study using individual-level registry data. We computed the prevalence of any brain disorder and 25 individual brain disorders for each year from 2015 to 2021 and incidence for 2011-2015 and 2016-2021. We computed one-year hazard ratios (HRs) for all-cause mortality by comparing individuals with brain disorders to matched controls without and calculated attributable direct and indirect costs (i.e., economic burden) of brain disorders.

Findings

The prevalence of any brain disorder in Denmark was 1,893,318/5,705,540 = 33.2% in 2015, increasing to 2,059,852/5,856,666 = 35.2% in 2021. The most prevalent conditions were depression (793,419/5,856,666 = 13.5% in 2021), sleep disorders (788,209/5,856,666 = 13.5% in 2021), and headache (461,353/5,856,666 = 7.9% in 2021). The incidence rate of any brain disorder was 1792 and 1634 per 100,000 person-years in 2011-2015 and 2016-2021, respectively. The one-year HR of mortality for any brain disorder was 5.5 (95% confidence interval [CI]: 5.4; 5.6) for 2011-2015 and 5.3 (95% CI: 5.2; 5.3) for 2016-2021. The total attributable direct costs for individuals with any brain disorder were €7.5 billion in both 2015 and 2021. Total indirect costs increased from €17.7 billion in 2015 to €23.2 billion in 2021.

Interpretation

Brain disorders remain common, with a fivefold higher one-year mortality compared to persons without brain disorders. While total direct costs were similar in 2015 and 2021, total indirect costs increased over this period.

Funding

The Lundbeck Foundation (R433-2023-1140).

Burden of Disease of Duchenne Muscular Dystrophy in Denmark - A National Register-Based Study of Individuals with Duchenne Muscular Dystrophy and their Closest Relatives

Background

Duchenne Muscular Dystrophy (DMD) is a progressive genetic disease with a prevalence of 1 per 3,600-6,000 male births. Individuals with DMD are typically diagnosed at age 4-7 years; median survival is 30 years. They require multidisciplinary care, personal assistance, and often special education.

Objective

The aim was to assess the burden of disease in DMD in Denmark. This includes incidence, prevalence, use of healthcare services, labour market participation, educational outcomes, and overall attributable costs due to DMD. Impact on the closest relatives (siblings and parents) was also investigated.

Methods

The comprehensive Danish national health and administrative registers were used to assess the burden of disease following individuals with DMD and closest relatives from five years before, and up to 20 years after DMD diagnosis. Individuals with DMD (and relatives) from 1994-2021 were included. All outcomes were compared to matched control groups without the disease drawn from the Danish population.

Results

213 unique individuals with DMD were identified. They had lower grades in school, required more special education and more healthcare and home care compared to their control group. The extra costs of special education summed to EUR 180,900 over the course of 11 years elementary school. They had an annual average productivity loss of EUR 20,200 between the age of 18 to 30. The extra healthcare costs of DMD in the 20 years after diagnosis were estimated to EUR 1,524,000. If an individual with DMD lives to be 30, total extra costs sum to EUR 2,365,800.

Conclusions

Using national register data this study presented detailed results on the burden of disease of DMD, including impact on closest relatives. With 60 additional hospital admissions and 200 extra outpatient contacts in 20 years healthcare costs, but also costs of home care and special education, increases as disease progresses.

A nationwide study of patients operated for cervical degenerative disorders in public and private hospitals

During the last decades, there has been an increase in the rate of surgery for degenerative disorders of the cervical spine and in the use of supplementary private health insurance. Still, there is limited knowledge about the differences in characteristics of patients operated in public and private hospitals. Therefore, we aimed at comparing sociodemographic-, clinical- and patient management data on patients operated for degenerative cervical radiculopathy and degenerative cervical myelopathy in public and private hospitals in Norway. This was a cross-sectional study on patients in the Norwegian Registry for Spine Surgery operated for degenerative cervical radiculopathy and degenerative cervical myelopathy between January 2012 and December 2020. At admission for surgery, we assessed disability by the following patient reported outcome measures (PROMs): neck disability index (NDI), EuroQol-5D (EQ-5D) and numerical rating scales for neck pain (NRS-NP) and arm pain (NRS-AP). Among 9161 patients, 7344 (80.2%) procedures were performed in public hospitals and 1817 (19.8%) in private hospitals. Mean age was 52.1 years in public hospitals and 49.7 years in private hospitals (P < 0.001). More women were operated in public hospitals (47.9%) than in private hospitals (31.6%) (P < 0.001). A larger proportion of patients in private hospitals had high education (≥ 4 years of college or university) (42.9% vs 35.6%, P < 0.001). Patients in public hospitals had worse disease-specific health problems than those in private hospitals: unadjusted NDI mean difference was 5.2 (95% CI 4.4 – 6.0; P < 0.001) and adjusted NDI mean difference was 3.4 (95% CI 2.5 – 4.2; P < 0.001), and they also had longer duration of symptoms (P < 0.001). Duration of surgery (mean difference 29 minutes, 95% CI 27.1 – 30.7; P < 0.001) and length of hospital stay (mean difference 2 days, 95% CI 2.3 – 2.4; P < 0.001) were longer in public hospitals. In conclusion, patients operated for degenerative cervical spine in private hospitals were healthier, younger, better educated and more often men. They also had less and shorter duration of symptoms and seemed to be managed more efficiently. Our findings indicate that access to cervical spine surgery in private hospitals could be skewed in favour of patients with higher socioeconomic status.

Identifying Mild-to-Moderate Atopic Dermatitis Using a Generic Machine Learning Approach: A Danish National Health Register Study

Atopic dermatitis is a chronic skin disease, causing itching and recurrent eczematous lesions. In Danish national register data, adults with atopic dermatitis can only be identified if they have a hospital-diagnosed atopic dermatitis. The purpose of this study was to develop a machine learning model to identify all patients with atopic dermatitis by proxy, using data for contacts with primary care, prescription medication, and hospital contacts not related to skin diseases. Individuals redeeming a prescription for dermatological preparations were extracted as potential patients with atopic dermatitis. Individuals with a registered hospital diagnosis of atopic dermatitis were classified as "Known AD", "Other skin disease" (registrations of other dermatological diagnosis codes indicating other skin disease), or "Uncertain AD status"' (no hospital diagnosis registered). Patients categorized as "Known AD" and "Other skin disease" were used to develop the model. All uses of healthcare services 2 years prior to hospital diagnosis were used as potential predictors. The data were split into training and validation sets (70/30). From 1996 to 2022, 385,135 individuals had uncertain atopic dermatitis status. The most important predictors were corticosteroid prescriptions for dermatological use, consultations with dermatologist, and age. Of the 385,135 individuals, the model predicted that 230,522 individuals likely have atopic dermatitis.

Related variations: A novel approach for detecting patterns of regional variations in healthcare utilisation rates

Regional variations in healthcare utilisation rates are ubiquitous and persistent. In settings where an aggregate national health service budget is allocated primarily on a per capita basis, little regional variation in total healthcare utilisation rates will be observed. However, for specific treatments, large variations in utilisation rates are observed, iymplying a substitution effect at some point in service delivery. The current paper investigates the extent to which this substitution effect occurs within or between specialties, particularly distinguishing between emergency versus elective care. We used data from Statistics Norway and the Norwegian Patient Registry on eight somatic surgeries for all patients treated from 2010 to 2015. We calculated Diagnosis-Related Group (DRG) -weight per capita in 19 hospital regions. We applied principal component analysis (PCA) to demonstrate patterns in DRG-weight, annual relative changes in DRG-weight, and DRG-weight production for elective care. We show that treatments with similar characteristics cluster within regions. Treatment frequency explains 29% of the total variation in treatment rates. In a dynamic model, treatments with a high degree of emergency care are negatively correlated with treatments with a high degree of elective care. Furthermore, when considering only elective care treatments, the substitution effect occurs between specialties and explains 49% of the variation. When designing policies aimed at reducing regional variations in healthcare utilisation, a distinction between elective and emergency care as well as substitution effects need to be considered.

Societal costs and survival of patients with biopsy-verified non-alcoholic steatohepatitis: Danish nationwide register-based study

INTRODUCTION AND OBJECTIVES

Studies on the societal burden of patients with biopsy-confirmed non-alcoholic fatty liver disease (NAFLD) are sparse. This study examined this question, comparing NAFLD with matched reference groups.

MATERIALS AND METHODS

Nationwide Danish healthcare registers were used to include all patients (≥18 years) diagnosed with biopsy-verified NAFLD (1997-2021). Patients were classified as having simple steatosis or non-alcoholic steatohepatitis (NASH) with or without cirrhosis, and all matched with liver-disease free reference groups. Healthcare costs and labour market outcomes were compared from 5 years before to 11 years after diagnosis. Patients were followed for 25 years to analyse risk of disability insurance and death.

RESULTS

3,712 patients with biopsy-verified NASH (n = 1,030), simple steatosis (n = 1,540) or cirrhosis (n = 1,142) were identified. The average total costs in the year leading up to diagnosis was 4.1-fold higher for NASH patients than the reference group (EUR 6,318), 6.2-fold higher for cirrhosis patients and 3.1-fold higher for simple steatosis patients. In NASH, outpatient hospital contacts were responsible for 49 % of the excess costs (EUR 3,121). NASH patients had statistically significantly lower income than their reference group as early as five years before diagnosis until nine years after diagnosis, and markedly higher risk of becoming disability insurance recipients (HR: 4.37; 95 % CI: 3.17-6.02) and of death (HR: 2.42; 95 % CI: 1.80-3.25).

CONCLUSIONS

NASH, simple steatosis and cirrhosis are all associated with substantial costs for the individual and the society with excess healthcare costs and poorer labour market outcomes.

Multiorgan Involvement and Mortality in Individuals With Adult-Onset Myotonic Dystrophy (DM1)-A Danish Register-Based Study I

BACKGROUND AND PURPOSE

Adult-onset myotonic dystrophy type 1 (DM1) is characterized by a diagnostic delay due to milder symptoms than the infantile and juvenile forms. Despite this, there is a risk of negative biopsychosocial consequences, particularly due to the cognitive impact. Individuals with adult-onset DM1 may receive less attention and have lower adherence to hospital follow-ups, which increases the risk of adverse events and early death. The aim of this study was to provide knowledge on the time of diagnosis, multiorgan involvement, and mortality in a national cohort of individuals with adult-onset DM1.

METHODS

Data from individuals with DM1 were extracted from the Danish National Health and administrative registers in the period 1994-2022; each individual with DM1 was paired with 10 reference individuals from the general Danish population.

RESULTS

Analyses were based on 949 individuals with DM1 and 9427 controls. The median age at diagnosis was 43 years; 40% of individuals had a parent-child relationship. Respiratory insufficiency and cataracts were the most common involvements among individuals with DM1. The average age at death was 58 years; risk of mortality was 5.87 times higher than controls (p < 0.001) and individuals with DM1 and cardiovascular disease had a higher mortality rate compared to controls (HR: 2.63, CI: 2.14-3.23, p < 0.001). The risk of mortality tended to decline in the later years of the study period.

CONCLUSION

Despite adult-onset DM1 often being characterized as mild, comorbidities and an excess risk of death are major concerns. This calls for attention from health professionals to improve rehabilitation and survival for this population.