Lars Bernfort

ADHD from a socio‐economic perspective

Aim: Attention deficit hyperactivity disorder (ADHD) and related disorders affect childrens ability to function in school and other environments. Awareness has increased in recent years that the same problems often persist in adulthood. Based on previous studies, we aimed to outline and discuss a descriptive model for calculation of the societal costs associated with ADHD and related disorders.

The incidence of permanent work disability in patients with rheumatoid arthritis in Sweden 1990–2010: before and after introduction of biologic agents

OBJECTIVE To explore the incidence of disability pension (DP) due to RA as an estimation of permanent work disability before and after introduction of biologic drugs. METHODS The annual incidence of DP was derived from the Swedish National Social Insurance Register and rates of DP due to RA were compared with the total amount of new DPs. RESULTS The incidence of DP due to RA has decreased over recent years, coinciding with earlier and more aggressive treatment with DMARDs and biologics. A similar declining incidence of DP was simultaneously seen in patients with all diagnoses in the general population. The decrease in DPs was, however, larger for RA and was evident even before introduction of biologics. In 1990, the proportion of DPs caused by RA was 1.9% out of total amount of DPs, decreasing to 1.5% in 2000 and to 1% in 2009. This may reflect effects of treatment, but may also be due to changing political policies as well as changes in age structure, increasing educational level and less physically demanding jobs. CONCLUSION The decrease in DPs due to RA coincides with new treatment strategies as well as with decreasing levels of DPs in patients with all diagnoses. Prevailing political and economic conditions have a large impact on permanent work disability and may affect patients with various diagnoses in different ways. To determine if the decline is a true effect of better treatment, there is a need for further investigations, taking possible confounding factors into account.

Costs of rheumatoid arthritis during the period 1990–2010: a register-based cost-of-illness study in Sweden

OBJECTIVES The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990-2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs. METHODS A prevalence-based cost-of-illness study was conducted based on data from national and regional registries. RESULTS There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990-2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010. CONCLUSION By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment.

Severity of chronic pain in an elderly population in Sweden-impact on costs and quality of life

Abstract Chronic pain is associated with large societal costs, but few studies have investigated the total costs of chronic pain with respect to elderly subjects. The elderly usually require informal care, care performed by municipalities, and care for chronic diseases, all factors that can result in extensive financial burdens on elderly patients, their families, and the social services provided by the state. This study aims to quantify the societal cost of chronic pain in people of age 65 years and older and to assess the impact of chronic pain on quality of life. This study collected data from 3 registers concerning health care, drugs, and municipal services and from 2 surveys. A postal questionnaire was used to collect data from a stratified sample of the population 65 years and older in southeastern Sweden. The questionnaire addressed pain intensity and quality of life variables (EQ-5D). A second postal questionnaire was used to collect data from relatives of the elderly patients suffering from chronic pain. A total of 66.5% valid responses of the 10,000 subjects was achieved; 76.9% were categorized as having no or mild chronic pain, 18.9% as having moderate chronic pain, and 4.2% as having severe chronic pain. Consumed resources increased with the severity of chronic pain. Clear differences in EQ-5D were found with respect to the severity of pain. This study found an association between resource use and severity of chronic pain in elderly subjects: the more severe the chronic pain, the more extensive (and expensive) the use of resources.

Health-Related Quality of Life of Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes—Results from the PLATO Trial

OBJECTIVES The purpose of this study was to compare the effects of ticagrelor versus clopidogrel on health-related quality of life in the PLATelet inhibition and patient Outcomes (PLATO) trial. BACKGROUND The PLATO trial showed that ticagrelor was superior to clopidogrel for the prevention of cardiovascular death, myocardial infarction, or stroke in a broad population of patients with acute coronary syndromes. METHODS HRQOL in the PLATO study was measured at hospital discharge, 6-month visit, and end of treatment (anticipated at 12 months) by using the EuroQol five-dimensional (EQ-5D) questionnaire. All patients who had an EQ-5D questionnaire assessment at discharge from the index hospitalization (n = 15,212) were included in the study. Patients who died prior to the end-of-treatment visit were assigned an EQ-5D questionnaire value of 0. RESULTS The EQ-5D questionnaire value at discharge among 7631 patients assigned to ticagrelor was 0.847 and among 7581 patients assigned to clopidogrel was 0.846 (P = 0.71). At 12 months, the mean EQ-5D questionnaire value was 0.840 for ticagrelor and 0.832 for clopidogrel (P = 0.046). Excluding patients who died resulted in mean EQ-5D questionnaire values of 0.864 among ticagrelor patients and 0.863 among clopidogrel patients (P = 0.69). CONCLUSIONS In patients hospitalized with acute coronary syndromes with or without ST-segment elevation, treatment with ticagrelor was associated with a lower mortality but otherwise no difference in quality of life relative to treatment with clopidogrel. The improved survival and reduction in cardiovascular events with ticagrelor are therefore obtained with no loss in quality of life.

Cost-effectiveness of peginterferon alfa-2b in combination with ribavirin as initial treatment for chronic hepatitis C in Sweden

The aim of the study was to assess the cost-effectiveness of peginterferon alfa-2b (pegIFN) compared to interferon alfa-2b (IFN), both in combination with ribavirin, as initial therapy for chronic hepatitis C in Sweden. A computer based Markov model describing the natural course of chronic hepatitis C was used to assess costs and quality-adjusted life-y (QALY) for the treatment strategies. Study population was a cohort of hepatitis C patients from the age of 43 y until death. Natural history and response data were obtained from the literature and from Swedish clinical experts. Costs were obtained from different health care providers in Sweden and based on Swedish clinical practice. In our base case analysis for genotype 1 patients, pegIFN plus ribavirin therapy generated 0.29 incremental QALYs and was cost saving (dominant strategy). Corresponding results for genotype 2/3 patients were 0.09 QALYs at an incremental cost of 941 euros (10,500 euros/QALY). A probabilistic sensitivity analysis was performed to study the stability of our results. From the results we conclude that for genotype 1 patients treatment with pegIFN and ribavirin increased quality-adjusted life expectancy and was cost-effective as initial therapy for hepatitis C. The cost-effectiveness for patients infected with genotype 2/3 was less obvious.

Early rheumatoid arthritis 6 years after diagnosis is still associated with high direct costs and increasing loss of productivity: the Swedish TIRA project

Objectives: To calculate total costs over 6 years after diagnosis of early rheumatoid arthritis (RA). Method: In the longitudinal prospective multicentre TIRA study, 239 patients from seven units, diagnosed in 1996–98, reported regularly on health-care utilization and the number of days lost from work. Costs were obtained from official databases and calculated using unit costs (Swedish kronor, SEK) from 2001. Indirect costs were calculated using the human capital approach (HCA). Costs were inflation adjusted to Euro June 2012, using the Swedish Consumer Price Index and the exchange rate of June 2012. Statistical analyses were based on linear mixed models (LMMs) for changes over time. Results: The mean total cost per patient was EUR 14 768 in year 1, increasing to EUR 18 438 in year 6. Outpatient visits and hospitalization decreased but costs for surgery increased from EUR 92/patient in year 1 to EUR 444/patient in year 6. Drug costs increased from EUR 429/patient to EUR 2214/patient, mainly because of the introduction of biologics. In year 1, drugs made up for 10% of direct costs, and increased to 49% in year 6. Sick leave decreased during the first years but disability pensions increased, resulting in unchanged indirect costs. Over the following years, disability pensions increased further and indirect costs increased from EUR 10 284 in year 1 to EUR 13 874 in year 6. LMM analyses showed that indirect costs were unchanged whereas direct costs, after an initial fall, increased over the following years, leading to increasing total costs. Conclusions: In the 6 years after diagnosis of early RA, drug costs were partially offset by decreasing outpatient visits but indirect costs remained unchanged and total costs increased.

Costs of production loss and primary health care interventions for return-to-work of sick-listed workers in Sweden

Abstract Purpose: The aim of this study was to investigate, from the perspective of society, the costs of sick leave and rehabilitation of recently sick-listed workers with musculoskeletal disorders (MSD) or mental disorders (MD). Methods: In a prospective cohort study, 812 sick-listed workers with MSD (518) or MD (294) were included. Data on consumption of health care and production loss were collected over six months from an administrative casebook system of the health care provider. Production loss was estimated based on the number of sick-leave days. Societal costs were based on the human capital approach. Results: The mean costs of production loss per person were EUR 5978 (MSD) and EUR 6381 (MD). Health care interventions accounted for 9.3% (MSD) and 8.2% (MD) of the costs of production loss. Corresponding figures for rehabilitation activities were 3.7% (MSD) and 3.1% (MD). Health care interventions were received by about 95% in both diagnostic groups. For nearly half of the cohort, no rehabilitation intervention at all was provided. Conclusions: Costs associated with sick leave were dominated by production loss. Resources invested in rehabilitation were small. By increasing investment in early rehabilitation, costs to society and the individual might be reduced. Implications for Rehabilitation Resources invested in rehabilitation for sick-listed with musculoskeletal and mental disorders in Sweden are very small in comparison with the costs of production loss. For policy makers, there may be much to gain through investments into improved rehabilitation processes for return to work. Health care professionals need to develop rehabilitative activities aiming for return to work, rather than symptoms treatment only.

Decisions on inclusion in the Swedish basic health care package--roles of cost-effectiveness and need.

AbstractBackground: Inclusion or not of a treatment strategy in the publicly financed health care is really a matter of prioritisation. In Sweden priority setting decisions are governed by law in which it is stated that decisions should be guided by firstly the principle of need and secondly the principle of cost-effectiveness. Objective: The purpose of the paper is to discuss and illustrate the roles of need and cost-effectiveness in decisions on inclusion or not of treatment strategies in the publicly financed health care. Methods: The theoretical backgrounds of need and cost-effectiveness are discussed in short, both with respect to their meaning and to their potential roles in decisions on priority setting. Four treatment strategies, Viagra, Rivastigmine, statins, and lung transplants, are analysed with respect to whether either cost-effectiveness or need, or both, seem to have played a role in the decisions of inclusion or not in the basic health care package. Results: Both need and cost-effectiveness are important and should be important aspects when making decisions on priority setting. From the examples of the four treatment strategies it seems that decisions are almost exclusively made with reference to the principle of need. Conclusions: The most evident conclusion to be drawn from this study is that decisions on priority setting are almost solely based on the principle of need. This implies that the principle of cost-effectiveness is given very little space, which is a problem as this means an obvious risk of inefficient resource use.

Prevalence of different pain categories based on pain spreading on the bodies of older adults in Sweden: a descriptive-level and multilevel association with demographics, comorbidities, medications, and certain lifestyle factors (PainS65+)

Background and objective There is limited knowledge about the prevalence of pain and its relation to comorbidities, medication, and certain lifestyle factors in older adults. To address this limitation, this cross-sectional study examined the spreading of pain on the body in a sample of 6611 subjects ≥65 years old (mean age = 75.0 years; standard deviation [SD] = 7.7) living in southeastern Sweden. Methods Sex, age, comorbidities, medication, nicotine, alcohol intake, and physical activity were analyzed in relation to the following pain categories: local pain (LP) (24.1%), regional pain medium (RP-Medium) (20.3%), regional pain heavy (RP-Heavy) (5.2%), and widespread pain (WSP) (1.7%). Results RP-Medium, RP-Heavy, and WSP were associated more strongly with women than with men (all p<0.01). RP-Heavy was less likely in the 80–84 and >85 age groups compared to the 65–69 age group (both p<0.01). Traumatic injuries, rheumatoid arthritis/osteoarthritis, and analgesics were associated with all pain categories (all p<0.001). An association with gastrointestinal disorders was found in LP, RP-Medium, and RP-Heavy (all p<0.01). Depressive disorders were associated with all pain categories, except for LP (all p<0.05). Disorders of the central nervous system were associated with both RP-Heavy and WSP (all p<0.05). Medication for peripheral vascular disorders was associated with RP-Medium (p<0.05), and hypnotics were associated with RP-Heavy (p<0.01). Conclusion More than 50% of older adults suffered from different pain spread categories. Women were more likely to experience greater spreading of pain than men. A noteworthy number of common comorbidities and medications were associated with increased likelihood of pain spread from LP to RP-Medium, RP-Heavy, and WSP. Effective management plans should consider these observed associations to improve functional deficiency and decrease spreading of pain-related disability in older adults.