Associations between outpatient care and later hospital admissions for patients with chronic obstructive pulmonary disease - a registry study from Norway.

BACKGROUND: Although chronic obstructive pulmonary disease (COPD) admissions put a substantial burden on hospitals, most of the patients' contacts with health services are in outpatient care. Traditionally, outpatient care has been difficult to capture in population-based samples. In this study we describe outpatient service use in COPD patients and assess associations between outpatient care (contact frequency and specific factors) and next-year COPD hospital admissions or 90-day readmissions. METHODS: Patients over 40 years of age residing in Oslo or Trondheim at the time of contact in the period 2009-2018 were identified from the Norwegian Patient Registry (in- and outpatient hospital contacts, rehabilitation) and the KUHR registry (contacts with GPs, contract specialists and physiotherapists). These were linked to the Regular General Practitioner registry (characteristics of the GP practice), long-term care data (home and institutional care, need for assistance), socioeconomic and-demographic data from Statistics Norway and the Cause of Death registry. Negative binomial models were applied to study associations between combinations of outpatient care, specific care factors and next-year COPD hospital admissions and 90-day readmissions. The sample consisted of 24,074 individuals. RESULTS: A large variation in the frequency and combination of outpatient service use for respiratory diagnoses (GP, emergency room, physiotherapy, contract specialist and outpatient hospital contacts) was apparent. GP and outpatient hospital contact frequency were strongly associated to an increased number of next-year hospital admissions (1.2-3.2 times higher by increasing GP frequency when no outpatient hospital contacts, 2.4-5 times higher in combination with outpatient hospital contacts). Adjusted for healthcare use, comorbidities and sociodemographics, outpatient care factors associated with lower numbers of next-year hospitalisations were fees indicating interaction between providers (7% reduction), spirometry with GP or specialist (7%), continuity of care with GP (15%), and GP follow-up (8%) or rehabilitation (18%) within 30 days vs. later following any current year hospitalisations. For 90-day readmissions results were less evident, and most variables were non-significant. CONCLUSION: As increased use of outpatient care was strongly associated with future hospitalisations, this further stresses the need for good communication between providers when coordinating care for COPD patients. The results indicated possible benefits of care continuity within and interaction between providers.

Cost structure in specialist mental healthcare: what are the main drivers of the most expensive episodes?

BACKGROUND: Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes. METHODS: Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode]. RESULTS: One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease. CONCLUSIONS: The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.

Geographical variation in cardiovascular disease mortality in Norway: The role of life course socioeconomic position and parental health.

Despite substantial geographical variation in cardiovascular (CVD) mortality within countries, little is known about whether this variation can be explained by individuals' life course socioeconomic position (SEP) or differences in family history of premature CVD deaths. Cox proportional hazards models were used to investigate the association between the county of residence at ages 50-59 and CVD death in Norwegians born between 1940 and 1959 and survived to at least age 60, using national data. Individual life course SEP and family history of premature CVD death reduced the geographical variation in CVD mortality across Norwegian counties, but some significant differences remained. Furthermore, CVD risk varied by residents' migration histories between two counties with distinct CVD and socioeconomic profiles.

Combination of health care service use and the relation to demographic and socioeconomic factors for patients with musculoskeletal disorders: a descriptive cohort study.

BACKGROUND: Patients with musculoskeletal disorders (MSDs) access health care in different ways. Despite the high prevalence and significant costs, we know little about the different ways patients use health care. We aim to fill this gap by identifying which combinations of health care services patients use for new MSDs, and its relation to clinical characteristics, demographic and socioeconomic factors, long-term use and costs, and discuss what the implications of this variation are. METHODS: The study combines Norwegian registers on health care use, diagnoses, comorbidities, demographic and socioeconomic factors. Patients (≥ 18 years) are included by their first health consultation for MSD in 2013-2015. Latent class analysis (LCA) with count data of first year consultations for General Practitioners (GPs), hospital consultants, physiotherapists and chiropractors are used to identify combinations of health care use. Long-term high-cost patients are defined as total cost year 1-5 above 95th percentile (≥ 3 744€). RESULTS: We identified seven latent classes: 1: GP, low use; 2: GP, high use; 3: GP and hospital; 4: GP and physiotherapy, low use; 5: GP, hospital and physiotherapy, high use; 6: Chiropractor, low use; 7: GP and chiropractor, high use. Median first year health care contacts varied between classes from 1-30 and costs from 20€-838€. Eighty-seven percent belonged to class 1, 4 or 6, characterised by few consultations and treatment in primary care. Classes with high first year use were characterised by higher age, lower education and more comorbidities and were overrepresented among the long-term high-cost users. CONCLUSION: There was a large variation in first year health care service use, and we identified seven latent classes based on frequency of consultations. A small proportion of patients accounted for a high proportion of total resource use. This can indicate the potential for more efficient resource use. However, the effect of demographic and socioeconomic variables for determining combinations of service use can be interpreted as the health care system transforming unobserved patient needs into variations in use. These findings contribute to the understanding of clinical pathways and can help in the planning of future care, reduction in disparities and improvement in health outcomes for patients with MSDs.

Estimating healthcare expenditures after becoming divorced or widowed using propensity score matching.

Becoming divorced or widowed are stressful life events experienced by a substantial part of the population. While marital status is a significant predictor in many studies on healthcare expenditures, effects of a change in marital status, specifically becoming divorced or widowed, are less investigated. This study combines individual health claims data and registered sociodemographic characteristics from all Dutch inhabitants (about 17 million) to estimate the differences in healthcare expenditure for individuals whose marital status changed (n = 469,901) compared to individuals who remained married, using propensity score matching and generalized linear models. We found that individuals who were (long-term) divorced or widowed had 12-27% higher healthcare expenditures (RR = 1.12, 95% CI 1.11-1.14; RR = 1.27, 95% CI 1.26-1.29) than individuals who remained married. Foremost, this could be attributed to higher spending on mental healthcare and home care. Higher healthcare expenditures are observed for both divorced and widowed individuals, both recently and long-term divorced/widowed individuals, and across all age groups, income levels and educational levels.

Impact of systematic medication review in emergency department on patients' post-discharge outcomes-A randomized controlled clinical trial.

INTRODUCTION: The main objective of this study was to investigate whether systematic medication review conducted by clinical pharmacists can impact clinical outcomes and post-discharge outcomes for patients admitted to the emergency department. METHOD: This parallel group, non-blinded, randomized controlled trial was conducted in the emergency department, Diakonhjemmet Hospital, Oslo, Norway. The study was registered in ClinicalTrials.gov, Identifier: NCT03123640 in April 2017. From April 2017 to May 2018, patients ≥18 years were included and randomized (1:1) to intervention- or control group. The control group received standard care from emergency department physicians and nurses. In addition to standard care, the intervention group received systematic medication review including medication reconciliation conducted by pharmacists, during the emergency department stay. The primary outcome was proportion of patients with an unplanned contact with hospital within 12 months from inclusion stay discharge. RESULTS: In total, 807 patients were included and randomized, 1:1, to intervention or control group. After excluding 8 patients dying during hospital stay and 10 patients lacking Norwegian personal identification number, the primary analysis comprised 789 patients: 394 intervention group patients and 395 control group patients. Regarding the primary outcome, there was no significant difference in proportion of patients with an unplanned contact with hospital within 12 months after inclusion stay discharge between groups (51.0% of intervention group patients vs. 53.2% of control group patients, p = 0.546). CONCLUSION: As currently designed, emergency department pharmacist-led medication review did not significantly influence clinical- or post-discharge outcomes. This study did, however pinpoint important practical implementations, which can be used to design tailored pharmacist-led interventions and workflow regarding drug-related issues in the emergency department setting.

Stroke survival and the impact of geographic proximity to family members: A population-based cohort study.

INTRODUCTION: Familial support may be important for post-stroke survival. OBJECTIVE: To determine if geographical proximity between stroke survivors and their family members, i.e having a spouse/partner or distance to a nearest first-degree relative (parents, siblings, and offspring), as a proxy for familial support, is related to survivor mortality. METHODS: This study included all stroke survivors (n=128,227) hospitalised in Norway from 1994 to 2009, who were 30 years or older at the time of the stroke (born before 1965). National registries and censuses were used to calculate the distance to the nearest first-degree relative in the hospitalisation year. Cox proportional hazards models estimated hazard ratios (HRs) of all-cause mortality from 1994 to 2014 (mean 6.4 years follow-up), adjusting for sociodemographic and clinical covariates. RESULTS: Living up to 30 km from the nearest first-degree relative was associated with a higher mortality (HR 1.04, 95% CI: 1.03 to 1.06) than those living in the same household or neighbourhood as their nearest first-degree relatives. The association was more pronounced (1.13, 1.08 to 1.19 for ≤30 km; 1.25, 1.16 to 1.35 for >30 km) in survivors hospitalised at age ≤65 years, compared to older survivors. Among familial care predictors, having a spouse/partner was the most prominent predictor of reduced mortality (0.80, 0.78 to 0.82) in stroke survivors. CONCLUSION: Living close to first-degree relatives was weakly associated with better survival in stroke patients while having a spouse/partner exhibited a stronger association. Both associations were larger for survivors hospitalised at age ≤65 years. Our findings thus suggest that the impact of familial support on survival after stroke may differ by familial support condition and patient's age at a stroke hospitalisation.

Costs and Effects of Implementing Digital Tomosynthesis in a Population-Based Breast Cancer Screening Program: Predictions Using Results from the To-Be Trial in Norway.

BACKGROUND: Although several studies from Europe and the US have shown promising screening results favoring digital breast tomosynthesis compared with standard digital mammography (DM), both costs and effects of implementing tomosynthesis in routine screening programs remain uncertain. The cost effectiveness of using tomosynthesis in routine screening is debated in the literature, and model inputs from randomized trials are lacking. Using parameters mainly from a randomized controlled trial (the To-Be trial), we simulated costs and effects of implementing tomosynthesis in the national screening program BreastScreen Norway. METHODS: The To-Be trial was performed in Bergen from 2016 to 2017 within BreastScreen Norway, where females were randomized to either digital breast tomosynthesis including synthetic mammograms (DBT) or DM. The trial was followed by a cohort study offering all females DBT in 2018-2019. The trial included over 37,000 females, and allowed for estimation of short-term costs and effects related to screening, recall examinations and cancer detection. Using these and recent Norwegian estimates for 10-year stage-specific survival and treatment costs, the cost effectiveness of replacing DM with DBT in BreastScreen Norway was simulated in a decision tree model with probabilistic sensitivity analyses. Outcomes included false-positive screening results, screen-detected and interval cancers, stage at diagnosis, all-cause deaths, life-years gained, costs at recall and treatment and incremental cost-effectiveness ratio. RESULTS: The estimated additional cost of DBT was €8.10. Simulating ten rounds of screening from 2018 and 10-year survival and costs, 500 deaths were averted and 2300 life-years gained at an additional screening cost of €29 million for females screened with DBT versus DM. Taking over-diagnosis, recall and treatment costs into account, DBT was dominant in the deterministic analysis. The incremental cost-effectiveness ratio indicated cost savings of €1400 per life-year gained. Probabilistic sensitivity analyses showed that DBT was cost effective in over 50% of the simulations at all willingness-to-pay levels per life-year gained, and in 80% of the simulations at levels above €22,000. If willingness-to-pay levels up to €35,000 were assumed, DBT would be cost effective in over 50% of the simulations for additional costs of DBT of up to €32, almost four times the estimated additional cost of €8.10. CONCLUSION: DBT may be cost effective if implemented in BreastScreen Norway. However, generalizability of results could depend on factors varying between countries, such as recall rates, program sensitivity and specificity, treatment cost and willingness-to-pay levels.

Myocardial Infarction Care Among The Elderly: Declining Treatment With Increasing Age In Two Countries.

The elderly account for the majority of medical spending in many countries, raising concerns about potentially unnecessary spending, especially during the final months of life. Using a well-defined starting point (hospitalization for an initial acute myocardial infarction) with evidence-based postevent treatments, we examined age trends in treatments in the US and Norway, two countries with high levels of per capita medical spending. After accounting for comorbidities, we found marked decreases within both countries in the use of invasive treatments with age (for example, less use of percutaneous coronary interventions and surgery) and the use of relatively inexpensive medications (for example, less use of anticholesterol [statin] drugs for which generic versions are widely available). The treatment decreases with age were larger in Norway compared with those in the US. The less frequent treatment of the oldest of the old, without even use of basic medications, suggests potential age-related bias and a disconnect with the evidence on treatment value. Hospital organization and payment in both countries should incentivize greater equity in treatment use across ages.

Does rehabilitation setting influence risk of institutionalization? A register-based study of hip fracture patients in Oslo, Norway.

BACKGROUND: Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients' subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6-12 months from the index admission). METHODS: Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients' age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo's boroughs to control for supply-side and unobserved effects. RESULTS: The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23-0.76) of living in a nursing home at 6-12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF. CONCLUSIONS: The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

Cost differences between digital tomosynthesis and standard digital mammography in a breast cancer screening programme: results from the To-Be trial in Norway.

BACKGROUND: Several studies in Europe and the US have shown promising results favouring digital breast tomosynthesis compared to standard digital mammography (DM). However, the costs of implementing the technology in screening programmes are not yet known. METHODS: A randomised controlled trial comparing the results from digital breast tomosynthesis including synthetic mammograms (DBT) vs. DM was performed in Bergen during 2016 and 2017 as a part of BreastScreen Norway. The trial included 29,453 women and allowed for a detailed comparison of procedure use and screening, recall and treatment costs estimated at the individual level. RESULTS: The increased cost of equipment, examination and reading time with DBT vs. DM was €8.5 per screened woman (95% CI 8.4-8.6). Costs of DBT remained significantly higher after adding recall assessment costs, €6.2 (95% CI 4.6-7.9). Substantial reductions in either examination and reading times, price of DBT equipment or price of IT storage and connectivity did not change the conclusion. Adding treatment costs resulted in too wide confidence intervals to draw definitive conclusions (additional costs of tomosynthesis €9.8, 95% CI -56 to 74). Performing biopsy at recall, radiation therapy and chemotherapy was significantly more frequent among women screened with DBT. CONCLUSION: The results showed lower incremental costs of DBT vs. DM, compared to what is found in previous cost analyses of DBT and DM. However, the incremental costs were still higher for DBT compared with DM after including recall costs. Further studies with long-term treatment data are needed to understand the complete costs of implementing DBT in screening.

Comparisons of readmissions and mortality based on post-discharge ambulatory follow-up services received by stroke patients discharged home: a register-based study.

BACKGROUND: Few studies have focused on post-discharge ambulatory care for stroke patients and subsequent differences in readmission and mortality rates. Identifying groups at higher risk according to services received is important when planning post-discharge follow-up in ambulatory care. According to a recent Whitepaper by the Norwegian Government, patients receiving ambulatory care should have follow-up with a general practitioner (GP) within 14 days of hospital discharge. METHODS: All home discharged stroke cases occurring in Oslo from 2009 to 2014 were included. 90- and 365-day all-cause readmissions and mortality were compared separately for patients categorized based on services received (no services, home nursing, ambulatory rehabilitation and home nursing with ambulatory rehabilitation) and early GP follow-up within 14 days following discharge. Variables used to adjust for differences in health status and demographics at admission included inpatient days and comorbidities the year prior to admission, calendar year, sex, age, income, education and functional score. Cox regression reporting hazard ratios (HR) was used. RESULTS: There were no significant differences in readmission rates for early GP follow-up. Patients receiving home nursing and/or rehabilitation had higher unadjusted 90- and 365-day readmission rates than those without services (HR from 1.87 to 2.63 depending on analysis, p < 0.001), but the 90-day differences disappeared after risk adjustment, except for patients receiving only rehabilitation. There were no significant differences in mortality rates according to GP follow-up after risk adjustment. Patients receiving rehabilitation had higher mortality than those without services, even after adjustment (HR from 2.20 to 2.69, p < 0.001), whereas the mortality of patients receiving only home nursing did not differ from those without services. CONCLUSIONS: Our results indicate that the observed differences in unadjusted readmission and mortality rates according to GP follow-up and home nursing were largely due to differences in health status at admission, likely unrelated to the stroke. On the other hand, mortality for patients receiving ambulatory rehabilitation was twice as high compared to those without, even after adjustment and irrespective of also receiving home nursing. Hence, assessing the needs of these patients during discharge planning and providing careful follow-up after discharge seems important.

Continuity of care and its effect on readmissions for COPD patients: A comparative study of Norway and Germany.

BACKGROUND: This study compares continuity of care between Germany - a social health insurance country, and Norway - a national health service country with gatekeeping and patient lists for COPD patients before and after initial hospitalization. We also investigate how subsequent readmissions are affected. METHODS: Continuity of Care Index (COCI), Usual Provider Index (UPC) and Sequential Continuity Index (SECON) were calculated using insurance claims and national register data (2009-14). These indices were used in negative binomial and logistic regressions to estimate incident rate ratios (IRR) and odds ratios (OR) for comparing readmissions. RESULTS: All continuity indices were significantly lower in Norway. One year readmissions were significantly higher in Germany, whereas 30-day rates were not. All indices measured one year after discharge were negatively associated with one-year readmissions for both countries. Significant associations between indices measured before hospitalization and readmissions were only observed in Norway - all indices for one-year readmissions and SECON for 30-day readmissions. CONCLUSION: Our findings indicate higher continuity is associated with reductions in readmissions following initial COPD admission. This is observed both before and after hospitalization in a system with gatekeeping and patient lists, yet only after for a system lacking such arrangements. These results emphasize the need for policy strategies to further investigate and promote care continuity in order to reduce hospital readmission burden for COPD patients.

Retrospective cohort study of breast cancer incidence, health service use and outcomes in Europe: a study of feasibility.

Background: Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries. Methods: Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24 years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region. Results: In total, 24 576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.2-98.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix. Conclusion: Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy.

Risk adjustment in measurements of predicted mortality after myocardial infarction.

BACKGROUND: In 2014, the government introduced elements of quality-based funding (pay-for-performance) for the hospital sector. Survival is included as a quality indicator. If such quality indicators are to be used for funding purposes, it must be established that the observed variations are caused by conditions that the hospital trusts are able to influence, and not by any underlying variables. The objective of this study was to investigate how the predicted mortality after myocardial infarction was influenced by various forms of risk adjustment. MATERIAL AND METHOD: Data from the Norwegian Patient Register on 10,717 patients who had been discharged with the diagnosis of myocardial infarction in 2009 were linked to data on socioeconomic status, comorbidity, travel distances and mortality. The predicted 30-day mortality after myocardial infarction was analysed at the hospital-trust level, using three different models for risk adjustment. RESULTS: Unadjusted 30-day mortality was highest in the catchment area of Førde Hospital Trust (12.5%) and lowest in Asker og Bærum (5.2%). Risk adjustment changed the estimates of mortality for many of the hospital trusts. In the model involving the most comprehensive risk adjustment, mortality was highest in the catchment area of Akershus University Hospital (10.9%) and lowest in the catchment areas of Sunnmøre Hospital Trust (5.2%) and Nordmøre og Romsdal Hospital Trust (5.2%). INTERPRETATION: The variation in treatment quality between the hospital trusts, as measured by predicted mortality after myocardial infarction, is influenced by the methods used for risk adjustment. If the quality-based funding scheme is to continue, well-documented models for risk adjustment of the quality indicators need to be established.

Ethnic differences in the incidence of type 1 diabetes in Norway: a register-based study using data from the period 2002-2009.

BACKGROUND: Few studies have looked at variation in type 1 diabetes incidence between immigrant groups within a country. OBJECTIVE: To investigate differences in incidence rates of childhood-onset type 1 diabetes between immigrant groups and ethnic Norwegians, and their contribution to the number of incident cases of type 1 diabetes in Norway. SUBJECTS: The study includes 2221 individuals with newly onset type 1 diabetes diagnosed during 2002-2009 in children of 0-14 yr in Norway registered in the nationwide and population-based Norwegian Childhood Diabetes Registry. METHODS: Incident cases were classified in seven groups based on country of maternal birth and three age groups. Statistics Norway provided the corresponding population sizes. Incidence rates were compared by Poisson regression. RESULTS: The overall incidence rate was 34.0 cases per 100,000 person-years (95% CI: 32.6, 35.5). There were large variations in incidence across the immigrant groups (p < 0.001), ranging from 6.8 per 100,000 person-years (95% CI: 1.9-17.5) for South/East Asians to 26.0 cases per 100,000 person-years (95% CI: 11.9-49.3) for sub-Saharan Africans. The differences remained significant after adjusting for age and gender. CONCLUSIONS: There are large variations in the rate of incidence of type 1 diabetes across the ethnic groups, and several immigrant groups have significantly lower incidence than ethnic Norwegians. Immigrant groups contributed ca. 5% of the total cases of type 1 diabetes and influence the overall incidence in Norway only to a small extent.

Parameter Heterogeneity In Breast Cancer Cost Regressions - Evidence From Five European Countries.

We investigate parameter heterogeneity in breast cancer 1-year cumulative hospital costs across five European countries as part of the EuroHOPE project. The paper aims to explore whether conditional mean effects provide a suitable representation of the national variation in hospital costs. A cohort of patients with a primary diagnosis of invasive breast cancer (ICD-9 codes 174 and ICD-10 C50 codes) is derived using routinely collected individual breast cancer data from Finland, the metropolitan area of Turin (Italy), Norway, Scotland and Sweden. Conditional mean effects are estimated by ordinary least squares for each country, and quantile regressions are used to explore heterogeneity across the conditional quantile distribution. Point estimates based on conditional mean effects provide a good approximation of treatment response for some key demographic and diagnostic specific variables (e.g. age and ICD-10 diagnosis) across the conditional quantile distribution. For many policy variables of interest, however, there is considerable evidence of parameter heterogeneity that is concealed if decisions are based solely on conditional mean results. The use of quantile regression methods reinforce the need to consider beyond an average effect given the greater recognition that breast cancer is a complex disease reflecting patient heterogeneity.

Socio-economic Inequality in the Use of Procedures and Mortality Among AMI Patients: Quantifying the Effects Along Different Paths.

It is not known whether inequality in access to cardiac procedures translates into inequality in mortality. In this paper, we use a path analysis model to quantify both the direct effect of socio-economic status on mortality and the indirect effect of socio-economic status on mortality as mediated by the provision of cardiac procedures. The study links microdata from the Finnish and Norwegian national patient registers describing treatment episodes with data from prescription registers, causes-of-death registers and registers covering education and income. We show that socio-economic variables affect access to percutaneous coronary intervention in both countries, but that these effects are only moderate and that the indirect effects of the socio-economic factors on mortality through access to percutaneous coronary intervention are minor. The direct effects of income and education on mortality are significantly larger. We conclude that the socio-economic gradient in the use of percutaneous coronary intervention adds to socio-economic differences in mortality to little or no extent.

Spatial navigation measured by the Floor Maze Test in patients with subjective cognitive impairment, mild cognitive impairment, and mild Alzheimer's disease.

BACKGROUND: Impaired spatial navigation is an early sign of Alzheimer's disease (AD), but this can be difficult to assess in clinical practice. We examined how the performance on the Floor Maze Test (FMT), which combines navigation with walking, differed between patients with subjective cognitive impairment (SCI), mild cognitive impairment (MCI), and mild AD. We also explored if there was a significant relationship between the FMT and the cognitive tests or sociodemographic factors. METHODS: The study included 128 patients from a memory clinic classified as having SCI (n = 19), MCI (n = 20), and mild AD (n = 89). Spatial navigation was assessed by having the patients walk through the FMT, a two-dimensional maze. Both timed measures and number of errors were recorded. Cognitive function was assessed by the Word List Memory test, the Clock Drawing test, the Trail Making tests (TMT) A and B, and the Mini Mental Status Examination (MMSE). RESULTS: The patients with MCI were slower than those with SCI, while the patients with mild AD more frequently completed the FMT with errors or gave up than the patients with MCI. Performance on the FMT was significantly associated with executive function (measured by TMT-B). CONCLUSIONS: The performances on the FMT worsened with increasing severity of cognitive impairment, and the FMT was primarily associated with executive function. The explained variance was relatively low, which may indicate that the standard cognitive test battery does not capture impairments of spatial navigation.