Anders Halling

Increased incidence of Lyme borreliosis in southern Sweden following mild winters and during warm, humid summers

The aim of the present study was to investigate the long-term incidence rate of Lyme borreliosis and, additionally, to determine whether a correlation exists between climatic factors and summer-season variations in the incidence of Lyme borreliosis. Climatic variability acts directly on tick population dynamics and indirectly on human exposure to Lyme borreliosis spirochetes. In this study, conducted in primary healthcare clinics in southeastern Sweden, electronic patient records from 1997–2003 were searched for those that fulfilled the criteria for erythema migrans. Using a multilevel Poisson regression model, the influence of various climatic factors on the summer-season variations in the incidence of erythema migrans were studied. The mean annual incidence rate was 464 cases of erythema migrans per 100,000 inhabitants. The incidence was significantly higher in women than in men, 505 and 423 cases per 100,000 inhabitants, respectively (p<0.001). The summer-season variations in the erythema migrans incidence rate correlated with the monthly mean summer temperatures (incidence rate ratio 1.12; p<0.001), the number of winter days with temperatures below 0°C (incidence rate ratio 0.97; p<0.001), the monthly mean summer precipitation (incidence rate ratio 0.92; p<0.05), and the number of summer days with relative humidity above 86% (incidence rate ratio 1.04; p<0.05). In conclusion, Lyme borreliosis is highly endemic in southeastern Sweden. The climate in this area, which is favourable not only for human tick exposure but also for the abundance of host-seeking ticks, influences the summer-season variations in the incidence of Lyme borreliosis.

Validating the Johns Hopkins ACG Case-Mix System of the elderly in Swedish primary health care

BackgroundIndividualbased measures for comorbidity are of increasing importance for planning and funding health care services. No measurement for individualbased healthcare costs exist in Sweden. The aim of this study was to validate the Johns Hopkins ACG Case-Mix Systems predictive value of polypharmacy (regular use of 4 or more prescription medicines) used as a proxy for health care costs in an elderly population and to study if the prediction could be improved by adding variables from a population based study i.e. level of education, functional status indicators and health perception.MethodsThe Johns Hopkins ACG Case-Mix System was applied to primary health care diagnoses of 1402 participants (60–96 years) in a cross-sectional community based study in Karlskrona, Sweden (the Swedish National study on Ageing and Care) during a period of two years before they took part in the study. The predictive value of the Johns Hopkins ACG Case-Mix System was modeled against the regular use of 4 or more prescription medicines, also using age, sex, level of education, instrumental activity of daily living- and measures of health perception as covariates.ResultsIn an exploratory biplot analysis the Johns Hopkins ACG Case-Mix System, was shown to explain a large part of the variance for regular use of 4 or more prescription medicines. The sensitivity of the prediction was 31.9%, whereas the specificity was 88.5%, when the Johns Hopkins ACG Case-Mix System was adjusted for age. By adding covariates to the model the sensitivity was increased to 46.3%, with a specificity of 90.1%. This increased the number of correctly classified by 5.6% and the area under the curve by 11.1%.ConclusionThe Johns Hopkins ACG Case-Mix System is an important factor in measuring comorbidity, however it does not reflect an individuals capability to function despite a disease burden, which has importance for prediction of comorbidity. In this study we have shown that information on such factors, which can be obtained from short questionnaires increases the probability to correctly predict an individuals use of resources, such as medications.

Relationships between physical activity and perceived qualities of life in old age. Results of the SNAC study

Objectives: The aim of the present study was to investigate the relationships of different types of quality of life to strenuous and light physical activity in old age. Methods: The Swedish SNAC-Blekinge baseline database, consisting of data on 585 men and 817 women 60–96 years of age, was utilized. The independent variables were light and strenuous physical activity. Four dependent variables concerned with various quality of life components were employed (well-being, engagement, emotional support and social anchorage). Age, gender, functional ability and co-morbidity were included as possible confounders. Non-parametric bivariate and multivariate statistical tests were performed. Results: Correlations suggested there to generally be a positive relationship between physical activity and quality of life. Multivariate logistic regression analyses controlling for possible confounders showed light physical activity to increase the odds of experiencing well-being, engagement and social anchorage, whereas strenuous physical activity increased the odds of experiencing engagement and emotional support. Thus, light physical activity and strenuous physical activity differed in their relation to quality of life generally. Conclusions: The results indicate that physical activity has a salutogenic effect by enhancing the quality of life, and it can be assumed to be connected to quality of life by generating pleasure and relaxation.

Factors related to frequent usage of the primary healthcare services in old age: findings from The Swedish National Study on Aging and Care

People aged 60 or more are the most frequent users of healthcare services. In this age range, however, both frequent and infrequent users can be found. Frequent users have high rates of illnesses. Previous research has found that the frequency may be influenced also by psychological and social factors. The aim of this study was to investigate to what degree such factors add to the explanation of differences in number of visits to a physician. A cross-sectional study was conducted with a random sample consisting of 1017 individuals, aged 60 to 78 years, from the Blekinge part of the Swedish National Study on Aging and Care database. The data were collected during 2001 to 2003. Hierarchical logistic regression analyses were used with frequent (three visits or more during a year) and infrequent use as a dichotomous dependent variable. The final statistical analyses included 643 individuals (63% of the sample). Independent variables were sense of coherence (SOC), internal locus of control, education level and social anchorage. Control variables were age, gender, functional ability and comorbidity. The results showed that comorbidity was most strongly related to frequent use [adjusted odds ratio (OR) = 8.17, 95% confidence interval (CI) 5.54–12.04]. In addition, SOC and internal locus of control had small, but significant effects on the odds of being a frequent user (adjusted OR = 1.03, 95% CI 1.00–1.06 and adjusted OR = 1.14, 95% CI 1.02–1.27, respectively). The lower the SOC and the internal locus of control were, the higher were the odds of frequent use. Education level and social anchorage were unrelated to frequency of use. The results indicate that frequent healthcare services users are more ill than infrequent users. Psychological factors influence the use only marginally, and social factors as well as age and gender are not by themselves reason for frequent healthcare services use.

Validation of ACG Case-mix for equitable resource allocation in Swedish primary health care

BackgroundAdequate resource allocation is an important factor to ensure equity in health care. Previous reimbursement models have been based on age, gender and socioeconomic factors. An explanatory model based on individual need of primary health care (PHC) has not yet been used in Sweden to allocate resources. The aim of this study was to examine to what extent the ACG case-mix system could explain concurrent costs in Swedish PHC.MethodsDiagnoses were obtained from electronic PHC records of inhabitants in Blekinge County (approx. 150,000) listed with public PHC (approx. 120,000) for three consecutive years, 2004-2006. The inhabitants were then classified into six different resource utilization bands (RUB) using the ACG case-mix system. The mean costs for primary health care were calculated for each RUB and year. Using linear regression models and log-cost as dependent variable the adjusted R2 was calculated in the unadjusted model (gender) and in consecutive models where age, listing with specific PHC and RUB were added. In an additional model the ACG groups were added.ResultsGender, age and listing with specific PHC explained 14.48-14.88% of the variance in individual costs for PHC. By also adding information on level of co-morbidity, as measured by the ACG case-mix system, to specific PHC the adjusted R2 increased to 60.89-63.41%.ConclusionThe ACG case-mix system explains patient costs in primary care to a high degree. Age and gender are important explanatory factors, but most of the variance in concurrent patient costs was explained by the ACG case-mix system.

Age and gender effect on the use of herbal medicine products and food supplements among the elderly

Objective. To describe the users of herbal medicine products and food supplements with regard to age and gender specifically among persons aged ≥60 years. Design. A descriptive study with baseline data from a longitudinal study of the elderly, stratified into different age cohorts (60–69, 70–79, 80–89, and ≥90 years). Setting. Blekinge county, situated in south-eastern Sweden. Subjects. In total 1380 persons aged 60–96 years (median age 78 years). Main outcome measures. Current use of herbal medicine products and the use of food supplements. Results. Of the participants, 264/1380 (19.1%) used at least one herbal medicine product, 184/1380 (13.3%) used at least one food supplement and 382/1380 (27.7%) used herbal medicine products and/or food supplements. In all regression models, women had a higher probability of using herbal medicine and/or food supplements in comparison with men. Focusing on the use of herbal medicine products alone and the combination of using herbal medicine and/or food supplements, decreased use was seen with increasing age. However, 27.9% were still users of herbal medicine products and/or food supplements in the age group 80–89 years. In comparison, 14% were users in the age group ≥90 years. Age did not have an impact on the probability of taking food supplements. Conclusion. General practitioners need to consider the high use of herbal medicine products and food supplements among the elderly when making decisions on treatment.

Acute and permanent growth effects in the mouse uterus after neonatal treatment with estrogens

Acute and late effects of neonatal estrogen treatment were studied in NMRI mice treated with diethylstilbestrol (DES) or estradiol-17 beta (E2) on days 1 to 5 after birth (estrogenized females). The uterine wet weight (UWW) response in 6-day-old females, after 5 daily treatments with DES, had a peak at a daily dose of 10(-2) micrograms DES and declined with higher doses. Females (26-day-old) treated with DES or E2 neonatally had a reduced UWW response to a challenge with DES; on a dose basis, DES was more effective neonatally than E2. A single injection with DES or E2 in the neonatal period stimulated mitotic activity in the uterine horn epithelium; the UWW response to a 24-h DES pulse increased from day 2 to 6 after birth, but the uterine epithelial mitotic rate response decreased. Epidermal growth factor (EGF) was a more potent stimulator of mitotic activity than DES or E2. DES inhibited mitotic activity in the uterine cervical epithelium; EGF protected from this DES effect. In adult estrogenized females, EGF-induced uterine stimulation of 3H-thymidine incorporation subsided more rapidly than in control females; uterine epithelium did not respond to EGF in vitro. Uterine stroma of adult estrogenized females is postulated to house a population of cells under nonovarian proliferation control while the uterine epithelium may be under influence of an ovary-dependent proliferation inhibiting factor that is gradually lost under culture conditions.

Concordance between elderly patients’ understanding of and their primary healthcare physician's diagnosis of heart failure

Objective. The objective was to study primary healthcare patients’ understanding of their diagnosis of heart failure (HF), using patients treated for diabetes mellitus (DM) as a comparative group. Design. A cross-sectional community based study. Setting. Karlskrona community situated on the Swedish south-east coast with 60 600 inhabitants. Subjects. A total of 1402 subjects, aged 60–96 years in 10 age cohorts, selected randomly from the national population registry participating in the Swedish National study on Ageing and Care – Blekinge. Main outcome measures. Understanding of diagnosis of HF or DM in primary healthcare. Prevalence of cognitive impairment. Results. In all, 39.8% of patients with a diagnosis of HF treated in primary healthcare and 97.1% of patients with DM had an understanding of their respective diagnosis. Cognitive impairment was significantly more prevalent in the groups of patients treated for HF (OR 1.9, 95% CI 1.2 to 3.0) and DM (OR 1.8, 95% CI 1.1 to 3.1), when compared with those not treated for either HF or DM. The odds ratio for understanding of diagnosis was 0.013 (95% CI 0.003 to 0.052, p<0.001) in patients treated for HF, compared with patients treated for DM, when adjusted for the subjects age, sex, and cognitive function. Conclusion. In this study it was shown that patients’ understanding of their diagnosis was highly dependent on diagnosis, independently of age, sex, or cognitive function. The results suggest that there is room for improvement of care in primary healthcare, to increase HF patients’ understanding of their diagnosis.

Distance to hospital and socioeconomic status influence secondary health care use

Abstract Objective. The aim of this study was to investigate how distance to hospital and socioeconomic status (SES) influence the use of secondary health care (SHC) when taking comorbidity into account. Design and setting. A register-based study in Östergötland County. Subjects. The adult population of Östergötland County. Main outcome measures. Odds of SHC use in the population and rates of SHC use by patients were studied after taking into account comorbidity level assigned using the Adjusted Clinical Groups (ACG) Case-Mix System. The baseline for analysis of SES was individuals with the lowest education level (level 1) and the lowest income (1st quartile). Results. The study showed both positive and negative association between SES and use of SHC. The risk of incurring SHC costs was 12% higher for individuals with education level 1. Individuals with income in the 2nd quartile had a 4% higher risk of incurring SHC costs but a 17% lower risk of emergency department visits. Individuals with income in the 4th quartile had 9% lower risk of hospitalization. The risk of using SHC services for the population was not associated with distance to hospital. Patients living over 40 km from hospital and patients with higher SES had lower use of SHC services. Conclusions. It was found that distance to hospital and SES influence SHC use after adjusting for comorbidity level, age, and gender. These results suggest that GPs and health care managers should pay a higher degree of attention to this when planning primary care services in order to minimize the potentially redundant use of SHC.

Licit prescription drug use in a Swedish population according to age, gender and socioeconomic status after adjusting for level of multi-morbidity

BackgroundThere is a great variability in licit prescription drug use in the population and among patients. Factors other than purely medical ones have proven to be of importance for the prescribing of licit drugs. For example, individuals with a high age, female gender and low socioeconomic status are more likely to use licit prescription drugs. However, these results have not been adjusted for multi-morbidity level. In this study we investigate the odds of using licit prescription drugs among individuals in the population and the rate of licit prescription drug use among patients depending on gender, age and socioeconomic status after adjustment for multi-morbidity level.MethodsThe study was carried out on the total population aged 20 years or older in Östergötland county with about 400 000 inhabitants in year 2006. The Johns Hopkins ACG Case-mix was used as a proxy for the individual level of multi-morbidity in the population to which we have related the odds ratio for individuals and incidence rate ratio (IRR) for patients of using licit prescription drugs, defined daily doses (DDDs) and total costs of licit prescription drugs after adjusting for age, gender and socioeconomic factors (educational and income level).ResultsAfter adjustment for multi-morbidity level male individuals had less than half the odds of using licit prescription drugs (OR 0.41 (95% CI 0.40-0.42)) compared to female individuals. Among the patients, males had higher total costs (IRR 1.14 (95% CI 1.13-1.15)). Individuals above 80 years had nine times the odds of using licit prescription drugs (OR 9.09 (95% CI 8.33-10.00)) despite adjustment for multi-morbidity. Patients in the highest education and income level had the lowest DDDs (IRR 0.78 (95% CI 0.76-0.80), IRR 0.73 (95% CI 0.71-0.74)) after adjustment for multi-morbidity level.ConclusionsThis paper shows that there is a great variability in licit prescription drug use associated with gender, age and socioeconomic status, which is not dependent on level of multi-morbidity.