Effects of initiating insulin pump therapy in the real world: A nationwide, register-based study of adults with type 1 diabetes.

AIMS: We aimed to estimate effects of insulin pump therapy (IPT) on HbA1c level, HbA1c variability, and risk of hospitalised diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH), compared with multiple daily insulin injections (MDI). METHODS: We identified a cohort of all adults with type 1 diabetes in Denmark using national registry data and assigned each individual to either IPT (treatment) or MDI (control) from 2010 to 2020. We estimated average treatment effects on the treated (ATT) and treatment effects among population subgroups using treatment-staggered difference-in-differences. RESULTS: The cohort consisted of 26,687 individuals with a collective 243,601 person-years of observation; 38,823 (16 %) were IPT person-years. We identified an ATT for HbA1c of -0.33 % (95 % CI -0.39 to -0.27; -3.6 mmol/mol [95 % CI -4.2 to -2.9]). ATTs were larger among women and individuals who were older, had highest baseline HbA1c, and used continuous glucose monitoring. ATT for HbA1c variability (-0.016 % [-0.028 to -0.0041); -0.17 mmol/mol [95 % CI -0.30 to -0.045]) corresponded to a 6.5 % decrease in the standard deviation of HbA1c. ATTs for DKA and SH corresponded to 0.52 additional and 0.11 fewer hospitalisations per 1,000 person-years, respectively. CONCLUSIONS: IPT significantly reduced HbA1c level and variability, compared with MDI. However, it also marginally increased the risk of hospitalised DKA.

Socio-demographic patient profiles and hospital efficiency: does patient mix affect a hospital's ability to perform?

This study investigates whether inclusion of patient profiles impacts on the inferences drawn from measuring performance using patient level data. Performance is in this setting defined by resources used in treating patients in a given diagnose related group where use of resources is approximated by length of stay (LOS). The analysis is based on Danish registry data from 2006. Patient data include registry data on income, employment status and information on whether the patient receives benefits or lives alone. Considerable variation in the socio-demographic characteristics of patients across Danish hospitals was observed, and some patient characteristics were shown to drive the need for longer hospital stays beyond what is captured in DRG scores. Ranking of hospitals based on observed versus expected LOS remained largely unaffected when controlling for patient characteristics, suggesting that variation in LOS across hospitals is mainly driven by other factors than patients' socio-demographic characteristics. Nevertheless, the results of this study indicate that the current Danish remuneration system discriminates hospitals that more often serve older patients and patients with a less developed social network. These hospitals tend to have a reduced turnover of patients and their ability to generate revenue is therefore constrained.

Differences in general practice initiated expenditures across Danish local health authorities-A multilevel analysis.

OBJECTIVE: To assess differences in expenditures of general practice services across local health authorities (counties). METHODS: A multilevel analysis of 2123 general practices nested within 15 counties is used to assess between county variations in general practice expenditures in year 2006. Schmidt and Sickles' fixed effect efficiency estimator is used to assess the potential for reducing expenditures (fee-for-service, prescriptions, and referrals). RESULTS: Expenditures associated with general practice constitute 38% of total health care expenditures. 42% of the variation in these expenditures is attributable to geographical location (county). Mean efficiency is estimated to 87% corresponding to a savings potential of 700 DKK per insured person. Referrals to specialised care are the main source of variation in GP initiated expenditures across the counties. Expenditures associated with out-patient referrals and referrals to practicing specialist are negatively correlated (p<0.01) indicating a substitution effect. CONCLUSIONS: Our results indicate that primary care reforms aiming at reducing GP initiated expenditures should focus on general practice access to low level specialised care rather than reforming GP remuneration systems.

Cost-effectiveness of surveillance programs for families at high and moderate risk of hereditary non-polyposis colorectal cancer.

OBJECTIVES: Surveillance programs are recommended to both families at high risk (Amsterdam-positive families with known- and unknown mutation) and moderate risk (families not fulfilling all Amsterdam criteria) of colorectal cancer (CRC). Cost-effectiveness has so far only been estimated for the group at high risk. The aim of the present study is to determine cost-effectiveness of surveillance programs where families at both high and moderate risk of HNPCC participate. METHODS: A decision analytic model (Markov model) is developed to assess surveillance programs where families at high and moderate risk of HNPCC are offered surveillance from age 25 and age 45, respectively. The model includes costs for all families referred to genetic counseling, including genetic risk assessment, mutation analysis, and surveillance in relevant families with or without known mutation, plus the costs related to any surgical treatment. The risk of metachronous CRC is also modeled. RESULTS: Incremental costs per life year gained are estimated to be euro 980 when families at both high and moderate risk of HNPCC undergo surveillance (euro 508 for high risk and euro 1600 for moderate risk) and euro 1947 when the moderate risk group is evaluated genetically but not offered surveillance. Sensitivity analysis showed these findings to be robust, although cost-effectiveness can be improved in cases of more conservative referrals to genetic counseling. CONCLUSIONS: The result for high risk families confirms the findings in similar studies. Somewhat surprisingly, cost-effectiveness improves when surveillance of the moderate risk groups are included in the decision model.

Agreement between reported use of interventions for liver diseases and research evidence in Cochrane systematic reviews.

BACKGROUND/AIMS: This study evaluates the agreement between reported use of interventions for patients with liver diseases and research evidence in Cochrane systematic reviews. METHODS: In July 2002, the Cochrane Hepato-Biliary Group had completed 28 systematic reviews on 36 interventions that were available in Denmark. Based on the reviews, three interventions (n-acetylcysteine for paracetamol overdose, terlipressin for bleeding oesophageal varices, and antibiotics for patients with cirrhosis and gastrointestinal bleeding) with significant beneficial effects on clinical outcomes were classified as 'evidence-based', whereas 19 were classified as 'possibly evidence-based', and 14 as 'not evidence-based'. Questionnaires on reported use and perceived intervention effects were mailed to 108 physicians practising in Danish hospitals. Sixty-six returned their questionnaire. RESULTS: The proportion of physicians who reported that they never used the three evidence-based interventions varied considerably (2, 62, and 57%, respectively). The perceived intervention effect, duration of clinical experience, employment as head of department, and university hospital employment were significant predictors of more frequent use of evidence-based interventions. Physicians also reported that they used the interventions that were not evidence-based more often if they were employed at a university hospital. CONCLUSIONS: Considerable disagreements between reported use and research evidence were identified. Additional research on methods to introduce evidence-based medicine in practice seems warranted.