The risk of preterm birth in combinations of socioeconomic position and mental health conditions in different age groups: a Danish nationwide register-based cohort study.

BACKGROUND: Inequality in preterm birth is a world-wide challenge that has proved difficult for maternity care services to meet. Reducing the inequality requires identification of pregnant women at particularly high risk of preterm birth in order to target interventions. Therefore, the aim was to estimate the risk of preterm birth in women with different combinations of socioeconomic position, mental health conditions, and age. METHODS: In this nationwide register-based cohort study, we included all first-time mothers that gave birth to a singleton liveborn infant in Denmark between 2000 and 2016. The absolute and relative risk of preterm birth (< 37 weeks of gestation) was examined in different combinations of educational level (high, intermediate, and low) and mental health conditions (no, minor, and moderate/severe) in three age strata (≤23, 24-30, and ≥ 31 years). We estimated the relative risk using Poisson regression with a robust error variance. As additive interaction can help identify subgroups where limited resources can be of best use, we measured the attributable proportion to assess the risk that is due to interaction of the different exposures. RESULTS: Of the 415,523 included first-time mothers, 6.3% gave birth prematurely. The risk of preterm birth increased with decreasing educational level and increasing severity of mental health conditions in all age strata, but most in women aged ≥31 years. The highest absolute risk was 12.9% [95% CI: 11.2;14.8%] in women aged ≥31 years with low education and moderate/severe mental health conditions resulting in a relative risk of 2.23 [95% CI: 1.93-2.58] compared to the unexposed reference group in that age strata. We found positive additive interaction between low education and mental health conditions in women aged 24-30 and ≥ 31 years and between age ≥ 31 years and combinations of mental health conditions and educational levels. CONCLUSION: The inequality in preterm birth increased with increasing age. To reduce inequality in preterm birth focused attention on women with higher age further combined with lower educational levels and mental health conditions is essential.

Inequality in oral anticoagulation use and clinical outcomes in atrial fibrillation: a Danish nationwide perspective.

Aim: To explore the potential of small-area variation analysis as a tool for identifying unwarranted variation in oral anticoagulation (OAC) use and clinical outcomes in patients with atrial fibrillation (AF) and thereby identify locations with opportunity for improvement in AF care. Methods and results: Based on Danish health care registries, we conducted a nationwide historical cohort study including first-time AF patients with a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75, diabetes, thromboembolism, vascular disease, age 65-74, and sex category) score ≥ 2 between 2007 and 2014 (n = 94 482). For each administrative region and municipality, we assessed OAC initiation and persistence as well as the risk of ischaemic stroke, haemorrhagic stroke, and other major bleeding, respectively. In addition, potential temporal changes were examined for all outcomes. Initiation of OAC varied among regions from 49.5% to 62.4%. In patients initiating OAC, the proportion of patients still receiving OAC after 1 year varied from 73.9% to 79.3%. Oral anticoagulation use increased in all regions during the study period, particularly after 2010, but regional variation in OAC initiation persisted. Generally, the regions and municipalities with the highest initiation of OAC also had the highest OAC persistence. The risk of ischaemic stroke and other major bleeding was lower in these regions and municipalities. We found no significant difference between regions in risk of haemorrhagic stroke. Conclusion: Substantial geographical variation in OAC use and clinical outcomes occurs in Denmark demonstrating the potential of small-area variation analysis as a tool for identifying unwarranted variation in AF care and clinical outcomes. Our findings demonstrate the need for additional initiatives to ensure uniform high-quality care for AF patients.

Cardioversion of atrial fibrillation in a real-world setting: non-vitamin K antagonist oral anticoagulants ensure a fast and safe strategy compared to warfarin.

Aims: Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used as thromboembolic prophylaxis in cardioversion. We examined the waiting time to cardioversion and the outcomes in patients with non-valvular atrial fibrillation (AF) of > 48 h of duration who were treated with either NOACs or warfarin. Methods and results: Anticoagulation was handled in a structured, multidisciplinary AF-clinic. The objectives were the waiting time to cardioversion, and thromboembolism and major bleeding events within 60 days. In total, 2150 electrical cardioversions were performed; 684 (31.8%) of patients were on NOACs and 1466 (68.2%) were on warfarin. The waiting time to non-TOE-guided cardioversion was significantly shorter in the NOAC group compared with the warfarin group for all cardioversions (P < 0.001 for log-rank test) and for first-time cardioversions (P < 0.001 for log-rank test). For all non-TOE-guided cardioversions, 80% of procedures on NOACs and 67% of procedures on warfarin were performed within 25 days (P < 0.001). Thromboembolism occurred in one patient (0.15%) receiving NOAC and in two patients (0.14%) receiving warfarin (risk ratio (RR) 1.07; 95% confidence interval (CI) 0.10-11.81). Major bleeding events occurred in four patients (0.58%) in the NOAC group and 11 patients (0.75%) in the warfarin group (RR 0.78; 95% CI 0.25-2.43). Conclusion: In a real-world clinical setting with anticoagulation handled in a structured multidisciplinary AF clinic, the waiting time to cardioversion was shorter with NOACs compared to warfarin. The rates of thromboembolism and major bleeding events were low, with NOACs shown to be as effective and safe as warfarin.