User-defined outcomes of the Danish cardiovascular screening (DANCAVAS) trial: A post hoc analyses of a population-based, randomised controlled trial.

BACKGROUND: The Danish cardiovascular screening (DANCAVAS) trial, a nationwide trial designed to investigate the impact of cardiovascular screening in men, did not decrease all-cause mortality, an outcome decided by the investigators. However, the target group may have varied preferences. In this study, we aimed to evaluate whether men aged 65 to 74 years requested a CT-based cardiovascular screening examination and to assess its impact on outcomes determined by their preferences. METHODS AND FINDINGS: This is a post hoc study of the randomised DANCAVAS trial. All men 65 to 74 years of age residing in specific areas of Denmark were randomised (1:2) to invitation-to-screening (16,736 men, of which 10,471 underwent screening) or usual-care (29,790 men). The examination included among others a non-contrast CT scan (to assess the coronary artery calcium score and aortic aneurysms). Positive findings prompted preventive treatment with atorvastatin, aspirin, and surveillance/surgical evaluation. The usual-care group remained unaware of the trial and the assignments. The user-defined outcome was based on patient preferences and determined through a survey sent in January 2023 to a random sample of 9,095 men from the target group, with a 68.0% response rate (6,182 respondents). Safety outcomes included severe bleeding and mortality within 30 days after cardiovascular surgery. Analyses were performed on an intention-to-screen basis. Prevention of stroke and myocardial infarction was the primary motivation for participating in the screening examination. After a median follow-up of 6.4 years, 1,800 of 16,736 men (10.8%) in the invited-to-screening group and 3,420 of 29,790 (11.5%) in the usual-care group experienced an event (hazard ratio (HR), 0.93 (95% confidence interval (CI), 0.88 to 0.98; p = 0.010); number needed to invite at 6 years, 148 (95% CI, 80 to 986)). A total of 324 men (1.9%) in the invited-to-screening group and 491 (1.7%) in the usual-care group had an intracranial bleeding (HR, 1.17; 95% CI, 1.02 to 1.35; p = 0.029). Additionally, 994 (5.9%) in the invited-to-screening group and 1,722 (5.8%) in the usual-care group experienced severe gastrointestinal bleeding (HR, 1.02; 95% CI, 0.95 to 1.11; p = 0.583). No differences were found in mortality after cardiovascular surgery. The primary limitation of the study is that exclusive enrolment of men aged 65 to 74 renders the findings non-generalisable to women or men of other age groups. CONCLUSION: In this comprehensive population-based cardiovascular screening and intervention program, we observed a reduction in the user-defined outcome, stroke and myocardial infarction, but entail a small increased risk of intracranial bleeding. TRIAL REGISTRATION: ISRCTN Registry number, ISRCTN12157806 https://www.isrctn.com/ISRCTN12157806.

Danish men's experiences of cardiovascular screening and their views on preventive cardiovascular medication: A qualitative explorative nurse study.

OBJECTIVES: This study explored Danish men's experience of participating in a screening program for cardiovascular disease (CVD) and their perceptions of preventive medication for CVD before and after participation in the screening program. METHODS: An exploratory phenomenological-hermeneutical study. Fifteen men from a cardiovascular screening program for men aged 65-74 years participated. Semi-structured interviews were conducted before screening and one year later (2015-2017). The interviews were transcribed verbatim and analysed using Kvale and Brinkmann's approach to data analysis. RESULTS: Two main themes were identified: (i) seeking confirmation and control of health: familiarity with CVD; understanding the screening program; confirmation of health; perception of preventive medication, and (ii) sense of own health and prevention: experiences with the screening program; accept or denial of diagnosis and preventive medication. CONCLUSION: A minority of the men understood the nature of the diseases for which they were being examined. The invitation for screening and the outcome of the examinations must be communicated more skilfully. The health providers need to engage early in treatment after the screening and provide an individualised plan that addresses patients concerns and knowledge based on their needs.

The impact of population screening for cardiovascular disease on quality of life.

Aims: To examine the impact of population screening-generated events on quality of life: invitation, positive test result, initiation of preventive medication, enrolment in follow-up at the surgical department, and preventive surgical repair. Methods and results: A difference-in-difference design based on data collected alongside two randomized controlled trials where general population men were randomized to screening for cardiovascular disease or to no screening. Repeated measurements of health-related quality of life (HRQoL) were conducted up to 3 years after inclusion using all relevant scales of the EuroQol instrument: the anxiety/depression dimension, the EuroQol 5-dimension profile index (using Danish preference weights), and the visual analogue scale for global health. We compare the mean change scores from before to after events for groups experiencing vs. not experiencing the events. Propensity score matching is additionally used to provide both unmatched and matched results. Invitees reported to be marginally better off than non-invitees on all scales of the EuroQol. For events of receiving the test result, initiating preventive medication, being enrolled in surveillance, and undergoing surgical repair, we observed no impact on overall HRQoL but a minor impact of being enrolled in surveillance on emotional distress, which did not persist after matching. Conclusion: The often-claimed detrimental consequences of screening to HRQoL could not be generally confirmed. Amongst the screening events assessed, only two possible consequences were revealed: a reassurance effect after a negative screening test and a minor negative impact to emotional distress of being enrolled in surveillance that did not spill over to overall HRQoL.

Is the socioeconomic inequality in stroke prognosis changing over time and does quality of care play a role?

Introduction: In a publicly financed healthcare system we aimed to study the development in socioeconomic disparity in ischemic stroke outcomes over time. In addition, we study whether the healthcare system affects these outcomes through the quality of early stroke care when adjustments are made for various patient characteristics incl. comorbidity and stroke severity. Patients and methods: Using nationwide, detailed individual-level register-data we analysed how income-related and education-related inequality in 30-day mortality and 30-day readmission risk developed between 2003 and 2018. In addition, focusing on income-related inequality, we applied mediation analyses to estimate the mediating role of quality of acute stroke care on 30-day mortality and 30-day readmission. Results: A total of 97,779 individual ischemic stroke patients were registered in Denmark with a first ever stroke in the study period. Three-point-seven percent died within 30 days of their index-admission and 11.5% were readmitted within 30 days of discharge. The income-related inequality in mortality remained virtually unchanged over time from an RR of 0.53 (95% CI: 0.38; 0.74) in 2003-06 to RR 0.69 (95% CI: 0.53; 0.89)) in 2015-18 when high income was compared to low income (Family income-time interaction: RR 1.00 (95% CI: 0.98-1.03)). A similar but less uniform trend was found for the education-related inequality in mortality (Education-time interaction: RR 1.00 (95% CI: 0.97-1.04)). The income-related disparity in 30-day readmission was smaller than in 30-day mortality and it diminished over time from 0.70 (95% CI: 0.58; 0.83) to 0.97 (95% CI: 0.87; 1.10). The mediation analysis showed no systematic mediating effect of quality of care on neither mortality nor readmission. However, it cannot be ruled out that residual confounding may have washed out some mediating effects. Discussion and Conclusion: The socioeconomic inequality in stroke mortality and re-admission risk has yet to be eliminated. Additional studies from different settings are warranted in order to clarify the impact of socioeconomic inequality of quality of acute stroke care.

Relevance of the Viborg Population Based Screening Programme (VISP) for Cardiovascular Conditions Among 67 Year Olds: Attendance Rate, Prevalence, and Proportion of Initiated Cardiovascular Medicines Stratified By Sex.

OBJECTIVE: To report sex specific overall attendance rate, prevalence of screen detected cardiovascular conditions, proportion of unknown conditions before screening, and proportion initiating prophylactic medicine among 67 year olds in Denmark. DESIGN: Cross sectional cohort study. METHODS: Since 2014, all 67 year olds in Viborg, Denmark, have been invited to screening for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension, cardiac disease, and type 2 diabetes. Individuals with AAA, PAD, and or CP are recommended cardiovascular prophylaxis. Combining data with registries has facilitated estimation of unknown screen detected conditions. Up to August 2019, 5 505 had been invited; registry data were available for the first 4 826 who were invited. RESULTS: The attendance rate was 83.7%, without sex difference. Screen detected prevalence was significantly lower among women than men: AAA, 5 (0.3%) vs. 38 (1.9%) (p < .001); PAD, 90 (4.5%) vs. 134 (6.6%) (p = .011); CP, 641 (31.8%) vs. 907 (44.8%) (p < .001); arrhythmia, 26 (1.4%) vs. 77 (4.2%) (p < .001); blood pressure ≥ 160/100 mmHg, 277 (13.8%) vs. 346 (17.1%) (p = .004); and HbA1c ≥ 48 mmol/mol, 155 (7.7%) vs. 198 (9.8%) (p = .019), respectively. Pre-screening proportions of unknown conditions were particularly high for AAA (95.4%) and PAD (87.5%). AAA, PAD, and or CP were found in 1 623 (40.2%), of whom 470 (29.0%) received pre-screening antiplatelets and 743 (45.8%) lipid lowering therapy. Furthermore, 413 (25.5%) started antiplatelet therapy and 347 (21.4%) started lipid lowering therapy. Only smoking was significantly associated with all vascular conditions in multivariable analysis: odds ratios (ORs) for current smoking were AAA 8.11 (95% CI 2.27 - 28.97), PAD 5.60 (95% CI 3.61 - 8.67) and CP 3.64 (95% CI 2.95 - 4.47). CONCLUSION: The attendance rate signals public acceptability for attending cardiovascular screening. Men had more screen detected conditions than women, but prophylactic medicine was started equally frequently in both sexes. Sex specific cost effectiveness follow up is warranted.

Emergency department reorganisation introducing increased autonomy: A mixed effects approach to evaluate the effects of a national policy.

BACKGROUND: In 2007, a Danish national policy to future-proof emergency department (ED) performance was launched. The policy included several recommendations for the management and organisation of care that essentially introduced greater ED autonomy. In this study, we evaluate the effects of increased ED autonomy on readmission, mortality and episode costs for two large patient groups. METHOD: A non-randomised stepped wedge study-design where all EDs gradually implemented the policy at different steps during the study period (2008-2016). The timing and extent of policy implementation was determined from a retrospective cross-sectional survey of all 21 Danish EDs. This was linked to all episodes of hip fracture (n = 79,697) and erysipelas (n = 39,900) identified in the Nation Patient Registry and with episode-level outcomes. Mixed effect models were specified for the outcomes of 30-day readmission, 30-day mortality and episode costs, and adjusted for relevant ED- and episode-level heterogeneity. RESULTS: Increased ED autonomy was associated with more readmissions (p<0.05) and higher episode costs (p<0.001) in hip fracture episodes. In erysipelas episodes, no general associations were found. When restricted to night-time admissions, increased ED autonomy was associated with poorer outcomes for erysipelas episodes and increased episode costs for both patient groups. CONCLUSION: The intended policy effects were not found for these two patient groups; in fact, reorganisation appeared to have harmed hip fracture patients and increased episode costs. Uncertainty remains regarding the longer-term consequences.

Protocol for a cohort study to evaluate the effectiveness and cost-effectiveness of general population screening for cardiovascular disease: the Viborg Screening Programme (VISP).

INTRODUCTION: The prevalence of cardiovascular disease (CVD) is increasing. Furthermore, asymptomatic individuals may not receive timely preventive initiatives to minimise the risk of further CVD events. Paradoxically, 80% of CVD events are preventable by early detection, followed by prophylactic initiatives. Consequently, we introduced the population-based Viborg Screening Programme (VISP) for subclinical and manifest CVD, focusing on commonly occurring, mainly asymptomatic conditions, followed by prophylactic initiatives.The aim of the VISP was to evaluate the health benefits, harms and cost-effectiveness of the VISP from a healthcare sector perspective. Furthermore, we explored the participants' perspectives. METHODS AND ANALYSIS: From August 2014 and currently ongoing, approximately 1100 men and women from the Viborg municipality, Denmark, are annually invited to screening for abdominal aortic aneurysm, peripheral arterial disease, carotid plaque, hypertension, diabetes mellitus and cardiac arrhythmia on their 67th birthday. A population from the surrounding municipalities without access to the VISP acts as a control. The VISP invitees and the controls are followed on the individual level by nationwide registries. The primary outcome is all-cause mortality, while costs, hospitalisations and deaths from CVD are the secondary endpoints.Interim evaluations of effectiveness and cost-effectiveness are planned every 5 years using propensity score matching followed by a Cox proportional hazards regression analysis by the 'intention-to-treat' principle. Furthermore, censoring-adjusted incremental costs, life-years and quality-adjusted life-years are estimated. Finally, the participants' perspectives are explored by semistructured face-to-face interviews, with participant selection representing participants with both negative and positive screening results. ETHICS AND DISSEMINATION: The VISP is not an interventional trial. Therefore, approval from a regional scientific ethical committee is not needed. Data collection from national registries was approved by the Regional Data Protection Agency (record no. 1-16-02-232-15). We ensure patient and public involvement in evaluating the acceptability of VISP by adopting an interviewing approach in the study. TRIAL REGISTRATION NUMBER: NCT03395509.

Cost effectiveness of population screening vs. no screening for cardiovascular disease: the Danish Cardiovascular Screening trial (DANCAVAS).

AIMS: A recent trial has shown that screening of men for cardiovascular disease (CVD) may reduce all-cause mortality. This study assesses the cost effectiveness of such screening vs. no screening from the perspective of European healthcare systems. METHODS AND RESULTS: Randomized controlled trial-based cost-effectiveness evaluation with a mean 5.7 years of follow-up. Screening was based on low-dose computed tomography to detect coronary artery calcification and aortic/iliac aneurysms, limb blood pressure measurement to detect peripheral artery disease and hypertension, telemetric assessment of the heart rhythm to detect atrial fibrillation, and measurements of the cholesterol and HgbA1c levels. Censoring-adjusted incremental costs, life years (LY), and quality-adjusted LY (QALY) were estimated and used for cost-effectiveness analysis. The incremental cost of screening for the entire health care sector was €207 [95% confidence interval (CI) -24; 438, P = 0.078] per invitee for which gains of 0.019 LY (95% CI -0.007; 0.045, P = 0.145) and 0.023 QALY (95% CI -0.001; 0.046, P = 0.051) were achieved. The corresponding incremental cost-effectiveness ratios were of €10 812 per LY and €9075 per QALY, which would be cost effective at probabilities of 0.73 and 0.83 for a willingness to pay of €20 000. Assessment of population heterogeneity showed that cost effectiveness could be more attractive for younger men without CVD at baseline. CONCLUSIONS: Comprehensive screening for CVD is overall cost effective at conventional thresholds for willingness to pay and also competitive to the cost effectiveness of common cancer screening programmes. The screening target group, however, needs to be settled.

Five-Year Outcomes of the Danish Cardiovascular Screening (DANCAVAS) Trial.

BACKGROUND: Limited data suggest a benefit of population-based screening for cardiovascular disease with respect to the risk of death. METHODS: We performed a population-based, parallel-group, randomized, controlled trial involving men 65 to 74 years of age living in 15 Danish municipalities. The participants were randomly assigned in a 1:2 ratio to undergo screening (the invited group) or not to undergo screening (the control group) for subclinical cardiovascular disease. Randomization was based on computer-generated random numbers and stratified according to municipality. Only the control group was unaware of the trial-group assignments. Screening included noncontrast electrocardiography-gated computed tomography to determine the coronary-artery calcium score and to detect aneurysms and atrial fibrillation, ankle-brachial blood-pressure measurements to detect peripheral artery disease and hypertension, and a blood sample to detect diabetes mellitus and hypercholesterolemia. The primary outcome was death from any cause. RESULTS: A total of 46,611 participants underwent randomization. After exclusion of 85 men who had died or emigrated before being invited to undergo screening, there were 16,736 men in the invited group and 29,790 men in the control group; 10,471 of the men in the invited group underwent screening (62.6%). In intention-to-treat analyses, after a median follow-up of 5.6 years, 2106 men (12.6%) in the invited group and 3915 men (13.1%) in the control group had died (hazard ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00; P = 0.06). The hazard ratio for stroke in the invited group, as compared with the control group, was 0.93 (95% CI, 0.86 to 0.99); for myocardial infarction, 0.91 (95% CI, 0.81 to 1.03); for aortic dissection, 0.95 (95% CI, 0.61 to 1.49); and for aortic rupture, 0.81 (95% CI, 0.49 to 1.35). There were no significant between-group differences in safety outcomes. CONCLUSIONS: After more than 5 years, the invitation to undergo comprehensive cardiovascular screening did not significantly reduce the incidence of death from any cause among men 65 to 74 years of age. (Funded by the Southern Region of Denmark and others; DANCAVAS ISRCTN Registry number, ISRCTN12157806.).

Impact of diabetes on long-term all-cause re-hospitalization after revascularization with percutaneous coronary intervention.

PURPOSE: The purpose of the study was to investigate the incidence, cause and probability of re-hospitalization within 30 and 365 days after percutaneous coronary intervention (PCI) in patients with diabetes. METHOD: Between January 2010 and September 2014, 2763 patients with diabetes were treated with PCI at two Hospitals in Western Denmark. Reasons for readmission within 30 and 365 days were identified. RESULTS: Readmission risks for patients with diabetes were 58% within 365 days and 18% within 30 days. Reason for readmission was ischemic heart disease (IHD) in 725 patients (27%), and non-IHD-related reasons in 826 patients (31%). IHD-related readmission within 365 days was associated with female gender (OR 1.3, 95% CI: 1.1-1.5), and non-ST-segment elevation myocardial infarction, compared to stable angina at the index hospitalization (OR 1.3, 95% CI: 1.1-1.6). Among patients with diabetes, increased risk of readmission due to other reasons were age (OR 1.3, 95% CI: 1.2-1.5) and higher scores of modified Charlson Comorbidity index (CCI): CCI ≥3 (OR 3.6, 95% CI: 2.8-4.6). CONCLUSION: More than half of the patients with diabetes mellitus undergoing PCI were readmitted within 1 year. Comorbidities were the strongest predictor for non-IHD-related readmission, but did not increase the risk for IHD-related readmissions.

Geographical Variation in the Management of Peripheral Arterial Occlusive Disease: A Nationwide Danish Cohort Study.

OBJECTIVE: Equal access for equal needs is a key goal for many healthcare systems but geographical variation research has shown that this is often not the case in areas other than vascular surgery. This study assessed the variation across specialised vascular centres of an entire healthcare system in the costs and outcomes for patients having first time revascularisation for peripheral arterial occlusive disease. METHODS: This was a national study of all first time revascularisations performed in the Danish healthcare system between 2009 and 2014. Episodes were identified in the Danish Vascular Registry (n = 10 300) and data on one year follow up in terms of the costs of specialised healthcare (€) and amputation status were acquired from national registers. Generalised gamma and logit regressions were used to predict margins between centres while adjusting for population heterogeneity (age, sex, education, smoking, hypertension, diabetes, use of prophylactic pharmacological therapy, indication and type of revascularisation). Cost effectiveness frontiers were used to identify efficient providers and to illustrate the cost of reducing the system level risk of amputation. RESULTS: For each of the indications of chronic limb threatening and acute limb ischaemia, the one year amputation risks varied from 11% to 16% across centres (p = .003, p = .006) whereas for intermittent claudication there was no significant difference across centres. The corresponding costs of care varied across centres for all indications (p = .027, p = .028, p = .030). Linking costs and outcomes, three of seven centres were observed to provide poorer quality at higher costs. Exponentially increasing costs to obtain the maximum reduction of the amputation risk were observed. CONCLUSION: The results suggest that there is substantial variation in the clinical management of peripheral arterial occlusive disease across the Danish healthcare system and that this results in very different levels of efficiency - on top of potentially unequal treatment for equal needs. Further research is warranted.

Organisational determinants and consequences of diagnostic discrepancy in two large patient groups in the emergency departments: a national study of consecutive episodes between 2008 and 2016.

BACKGROUND: Diagnostic discrepancy (DD) is a common phenomenon in healthcare, but little is known about its organisational determinants and consequences. Thus, the aim of the study was to evaluate this among selected emergency department (ED) patients. METHOD: We conducted an observational study including all consecutive ED patients (hip fracture or erysipelas) in the Danish healthcare sector admitted between 2008 and 2016. DD was defined as a discrepancy between discharge and admission diagnoses. Episode and department statistics were retrieved from Danish registers. We conducted a survey among all 21 Danish EDs to gather information about organisational determinants. To estimate the results while adjusting for episode- and department-level heterogeneity, we used mixed effect models of ED organisational determinants and 30-day readmission, 30-day mortality and episode costs (2018-DKK) of DDs. RESULTS: DD was observed in 2308 (3.3%) of 69,928 hip fracture episodes and 3206 (8.5%) of 37,558 erysipelas episodes. The main organisational determinant of DD was senior physicians (nonspecific medical specialty) being employed at the ED (hip fracture: odds ratio (OR) 2.74, 95% confidence interval (CI) 2.15-3.51; erysipelas: OR 3.29, 95% CI 2.65-4.07). However, 24-h presence of senior physicians (nonspecific medical specialty) (hip fracture) and availability of external senior physicians (specific medical specialty) (both groups) were negatively associated with DD. DD was associated with increased 30-day readmission (hip fracture, mean 9.45% vs 13.76%, OR 1.46, 95% CI 1.28-1.66, p < 0.001) and episode costs (hip fracture, 61,681 DKK vs 109,860 DKK, log cost 0.58, 95% CI 0.53-0.63, p < 0.001; erysipelas, mean 20,818 DKK vs 56,329 DKK, log cost 0.97, 95% CI 0.92-1.02, p < 0.001) compared with episodes without DD. CONCLUSION: DD was found to have a negative impact on two out of three study outcomes, and particular organisational characteristics seem to be associated with DD. Yet, the complexity of organisations and settings warrant further studies into these associations.

Index-Based Inequality in Quality of Care: An Empirical Comparison of Apples and Pears.

PURPOSE: Socioeconomic inequalities have been studied for decades using a variety of methods, but limited attention has been paid to the way methodological differences influence research findings. We aimed to compare index-based measures of socioeconomic inequality in quality of care. PATIENTS AND DATA: A national cohort of 110,848 unique stroke patients admitted to publicly funded hospitals in Denmark from 2004-2014 was studied. We used individual-level data from national registers and the Danish Stroke Registry. Quality of care was defined as fulfilment of process performance measures based on clinical guidelines recommendations (range 0-100%). Socioeconomic position was operationalised using information on disposable family income (continuous, DKK) and education (categorical, 7 levels). METHODS: Income- and education-related inequality in quality of care was assessed using concentration indices and the slope index of inequality. All indices were estimated both in absolute and relative terms. RESULTS: Income-related inequality appeared to be generally higher than education-related inequality. Depending on the choice of index, the inequality in quality of care increased by 5% or declined by up to 43% during the study period. Unlike the concentration indices the slope index of inequality was highly sensitive to changes in how the income and educational levels were operationalised. CONCLUSION: Careful reporting and interpretation of inequality studies is warranted in order not to misguide decision makers. Unless the policy objective reflects an explicit focus on one specific type of inequality, the use of different inequality indices can lead to different conclusions.

Clinical Benefit, Harm, and Cost Effectiveness of Screening Men for Peripheral Artery Disease: A Markov Model Based on the VIVA Trial.

OBJECTIVE: Although screening for peripheral arterial disease (PAD) seems obvious due to its two to three times increased mortality, high prevalence in the elderly, ease of detection, and relatively harmless prevention, the evidence is sparse. METHODS: A Markov decision model was created to model the lifetime effectiveness and cost effectiveness of general population PAD screening and relevant intervention in 65 year old men. The model was informed by original estimates from the VIVA trial data except for ankle brachial systolic blood pressure index test accuracy, quality of life, and background mortality, which were adopted from the literature. A Markov model was designed for 65 year old men, who were distributed in the starting states of no/detected/undetected PAD. The main outcomes were life years, quality adjusted life years, and costs of healthcare. RESULTS: Screening for PAD reduced the rates of amputations and stroke by 10.9% and 2.4%, respectively, while it increased the rates of revascularisation, acute myocardial infarction, and major bleeding by 5.5%, 7.1%, and 4.3% respectively. The overall life expectancy was increased by 14 days per invited subject. The cost per life year/quality adjusted life year was estimated at €16 717/€20 673. On the addition of low dose rivaroxaban reduced the costs per life year gained by 40%. If the model ran for only five follow up years, screening reduced relative mortality by 1.71%, suggesting PAD screening accounts for one fourth of the reported overall 7% relative mortality risk reduction of combined abdominal aortic aneurysm, PAD, and hypertension screening. CONCLUSION: Screening of men for PAD is likely to be both clinically effective and cost effective in a lifetime perspective.

Instrumental variable-based assessment of the effect of psychotherapy on suicide attempts, health, and economic outcomes in schizophrenia.

The literature on the effect of psychotherapy for schizophrenia is limited and characterized by small samples and possible bias from risk selection. We examined the effects of psychotherapy on suicide attempts and health and economic outcomes using an instrumental variable (IV) approach that exploits the variation in the propensities of hospital departments to prescribe psychotherapy. This was supplemented with naïve probit models as exogeneity could not be ruled out for all of the outcomes. The validity of the instrument was examined by distributional plots and various tests. The assumed randomness in referring patients to providers with high versus low propensities to psychotherapy appeared to be a critical aspect. Splitting the sample into homogeneous provider types did not substantially alter the results. Based on the IV results, we found no support for the effect of psychotherapy on suicide attempt, psychiatric readmission, assisted living, or labor market attachment. However, we cannot rule out smaller effects due to confidence intervals including the probit estimates. The main contribution of this study is new evidence on a broad range of outcomes and a large and representative population.

Randomised trial of telephone counselling to improve participants' adherence to prescribed drugs in a vascular screening trial.

A total of 1446 participants, 65- to 74-year-old men diagnosed with abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD) or high blood pressure (HB) in the Viborg Vascular (VIVA) screening trial, were consecutively included and randomised to a telephone counselling (TC) or no TC 3 months after being screened positive. Data from VIVA were linked to data from Danish registers from 2007 to 2016. The primary outcome was a composite outcome of proportion of days covered by statin, antithrombotic drugs and antihypertensive agents and for each specific drug class at 6-month follow-up. The same outcomes were assessed at 12 and 60 months and considered secondary outcomes. Outcome measures are reported as risk differences (RD). There were no differences between the groups in relation to the composite of all three drug classes over 6 months of follow-up, RD = 4.1 (95% CI: -1.0; 9.1). A significant increase in redeemed statin prescriptions was observed in the intervention group at 6 months, RD = 9.8% (CI 95%: 0.5; 19.0). There was no intervention effect observed after 12 and 60 months. TC 3 months after screening improved adherence to statin at 6-month follow-up, but had no effect on the composite treatment, statins, antithrombotic or antihypertensive treatment over 60 months of follow-up.