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Labori F, Persson J, Svensson M, Bonander C. The impact of stroke on spousal and family income: a difference-in-difference study from Swedish national registries. Top Stroke Rehabil 2024; 31:381-389. [PMID: 37842918 DOI: 10.1080/10749357.2023.2269674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
AIM To investigates the financial consequences in the overall population spouses of persons with stroke in Sweden as well as for subgroups based on spouses age, sex and modified Rankin Scale (mRS) of the person with stroke. METHODS The study population consists of spouses aged ≤ 60 during the year of their partner's stroke event. Each spouse was matched to four reference individuals. This longitudinal registry data covers spouses and a reference population between 2005 and 2016. We use difference-in-differences to estimate the impact on individual income from paid work, disposable individual income, and disposable family income. RESULTS The primary analysis shows a small and statistically insignificant decrease on spouses' individual income from paid work and disposable individual income. In the subgroup analysis based on mRS, the largest effect is seen in mRS 4-5, where spouses' individual income from paid work and disposable individual income increases after their partner's stroke. Further, younger female spouses' individual income from paid work decreases by 1 614 EUR (p = 0.008) on average. CONCLUSION The financial consequences are small in the overall population of spouses. However, for some subgroups, younger women, and spouses of persons with stroke and mRS 4-5, the financial consequences are more prominent.
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Affiliation(s)
- Frida Labori
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Josefine Persson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, USA
| | - Carl Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
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Abuloha S, Niu S, Adirika D, Harvey BP, Svensson M. A Review of the Cost-Effectiveness Evidence for FDA-Approved Cell and Gene Therapies. Hum Gene Ther 2024. [PMID: 38526393 DOI: 10.1089/hum.2023.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
Cell and gene therapy (CGT) innovations have provided several significant breakthroughs in recent years. However, CGTs often come with a high upfront cost, raising questions about patient access, affordability, and long-term value. This study reviewed cost-effectiveness analysis (CEA) studies that have attempted to assess the long-term value of Food and Drug Administration (FDA)-approved CGTs. Two reviewers independently searched the Tufts Medical Center CEA Registry to identify all studies for FDA-approved CGTs, per January 2023. A data extraction template was used to summarize the evidence in terms of the incremental cost-effectiveness ratio expressed as the cost per quality-adjusted life year (QALY) and essential modeling assumptions, combined with a template to extract the adherence to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. The review identified 26 CEA studies for seven CGTs. Around half of the base-case cost-effectiveness results indicated that the cost per QALY was below $100,000-$150,000, often used as a threshold for reasonable cost-effectiveness in the United States. However, the results varied substantially across studies for the same treatment, ranging from being considered very cost-effective to far from cost-effective. Most models were based on data from single-arm trials with relatively short follow-ups, and different long-term extrapolations between studies caused large differences in the modeled cost-effectiveness results. In sum, this review showed that, despite the high upfront costs, many CGTs have cost-effectiveness evidence that can support long-term value. Nonetheless, substantial uncertainty regarding long-term value exists because so much of the modeling results are driven by uncertain extrapolations beyond the clinical trial data.
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Affiliation(s)
- Sumaya Abuloha
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Department of Clinical Pharmacy and Pharmacy Practice, College of Pharmacy, Yarmouk University, Irbid, Jordan
| | - Shu Niu
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Darlene Adirika
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Benjamin P Harvey
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
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Ramadani RV, Svensson M, Hassler S, Hidayat B, Ng N. The impact of multimorbidity among adults with cardiovascular diseases on healthcare costs in Indonesia: a multilevel analysis. BMC Public Health 2024; 24:816. [PMID: 38491478 PMCID: PMC10941372 DOI: 10.1186/s12889-024-18301-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia. METHODS This retrospective cohort study analyzed the NHI database from 2016-2018 for individuals with chronic diseases (n = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households. RESULTS The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (β = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres. CONCLUSIONS CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease.
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Affiliation(s)
- Royasia Viki Ramadani
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Center for Health Economics and Policy Studies, Faculty of Public Health, Universitas Indonesia, Kota Depok, Indonesia.
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, USA
| | - Sven Hassler
- Department of Health Sciences, Karlstad University, Karlstad, Sweden
| | - Budi Hidayat
- Center for Health Economics and Policy Studies, Faculty of Public Health, Universitas Indonesia, Kota Depok, Indonesia
| | - Nawi Ng
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Svensson M, Strand GC, Bonander C, Johansson N, Jakobsson N. Analyses of quality of life in cancer drug trials - a review of measurements and analytical choices in post-reimbursement studies. BMC Cancer 2024; 24:311. [PMID: 38448848 PMCID: PMC10916053 DOI: 10.1186/s12885-024-12045-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/22/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES For drugs reimbursed with limited evidence of patient benefits, confirmatory evidence of overall survival (OS) and quality of life (QoL) benefits is important. For QoL data to serve as valuable input to patients and decision-makers, it must be measured and analyzed using appropriate methods. We aimed to assess the measurement and analyses of post-reimbursement QoL data for cancer drugs introduced in Swedish healthcare with limited evidence at the time of reimbursement. METHODS We reviewed any published post-reimbursement trial data on QoL for cancer drugs reimbursed in Sweden between 2010 and 2020 with limited evidence of improvement in QoL and OS benefits at the time of reimbursement. We extracted information on the instruments used, frequency of measurement, extent of missing data, statistical approaches, and the use of pre-registration and study protocols. RESULTS Out of 22 drugs satisfying our inclusion criteria, we identified published QoL data for 12 drugs in 22 studies covering multiple cancer types. The most frequently used QoL instruments were EORTC QLQ-C30 and EQ-5D-3/5L. We identified three areas needing improvement in QoL measurement and analysis: (i) motivation for the frequency of measurements, (ii) handling of the substantial missing data problem, and (iii) inclusion and adherence to QoL analyses in clinical trial pre-registration and study protocols. CONCLUSIONS Our review shows that the measurements and analysis of QoL data in our sample of cancer trials covering drugs initially reimbursed without any confirmed QoL or OS evidence have significant room for improvement. The increasing use of QoL assessments must be accompanied by a stricter adherence to best-practice guidelines to provide valuable input to patients and decision-makers.
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Affiliation(s)
- Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, 1225 Center Dr, Gainesville, FL, 32610, USA.
- School of Public Health & Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Gabriella Chauca Strand
- School of Public Health & Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Carl Bonander
- School of Public Health & Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
| | - Naimi Johansson
- University Health Care Research Center, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
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Fletcher-Sandersjöö A, Svedung Wettervik T, Tatter C, Tjerkaski J, Nelson DW, Maegele M, Svensson M, Lewén A, Enblad P, Bellander BM, Thelin EP. Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study. J Neurotrauma 2024; 41:705-713. [PMID: 38062766 PMCID: PMC10902499 DOI: 10.1089/neu.2023.0274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Contusion expansion (CE) is a potentially treatable outcome predictor in traumatic brain injury (TBI), and a suitable end-point for hemostatic therapy trials. However, there is no consensus on the definition of clinically relevant CE, both in terms of measurement criteria (absolute vs. relative volume increase) and cutoff values. In light of this, the aim of this study was to assess the predictive abilities of different CE definitions on outcome. We performed a multi-center observational cohort study of adults with moderate-to-severe TBI treated in an intensive care unit. The exposure of interest was CE, defined as the absolute and relative volume change between the first and second computed tomography scan. The primary outcome was the Glasgow Outcome Scale (GOS) at 6-12 months post-injury, dichotomized into unfavorable (GOS ≤3) or favorable (GOS ≥4). The secondary outcome was all-cause mortality. In total, 798 patients were included, with a median duration of 7.0 h between the first and second CT scan. The median absolute and relative CE was 1.5 mL (interquartile range [IQR] 0.1-8.3 mL) and 100% (IQR 10-530%), respectively. Both CE forms were independently associated with unfavorable GOS. Absolute CE outperformed relative CE in predicting both unfavorable GOS (area under the curve [AUC]: 0.65 vs. 0.60, p = 0.002) and all-cause mortality (AUC: 0.66 vs. 0.60, p = 0.003). For dichotomized CE, absolute cutoffs of 1-10 mL yielded the best results. We conclude that absolute CE demonstrates stronger outcome correlation than relative CE. In studies focusing on lesion progression in TBI, it may be advantageous to use absolute CE as the primary outcome metric. For dichotomized outcomes, cutoffs between 1 and 10 mL are suggested, depending on the desired sensitivity-specificity balance.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | | | - Charles Tatter
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Stockholm Southern Hospital, Stockholm, Sweden
| | - Jonathan Tjerkaski
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - David W. Nelson
- Function Perioperative Care and Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Mikael Svensson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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6
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Johansson N, Jakobsson N, Svensson M. Place or patient as the driver of regional variation in healthcare spending - Discrepancies by category of care. Soc Sci Med 2024; 342:116571. [PMID: 38215643 DOI: 10.1016/j.socscimed.2024.116571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 01/14/2024]
Abstract
We study how much regional variation in healthcare spending is driven by place- and patient-specific factors using a random sample of 53,620 regional migrants in Sweden. We find notable differences depending on the category of care, with place-specific factors having a significantly larger impact on specialized outpatient care compared to inpatient and pharmaceutical care. The place effect is estimated to 75% of variation in specialized outpatient care, but 26% or less in variations in inpatient care, and 5% in prescription drug spending. We also find that the empirical estimator has a substantial impact on the estimates of the place-specific effect. The results based on the traditional approach in the literature with two-way fixed effects and event-study models produce much larger estimates of the place-specific effect compared to results based on recently developed heterogeneity-robust models. For total healthcare spending, the traditional two-way fixed effects model estimates a place effect of 78%, while the heterogeneity-robust estimator finds a place effect around 10%. This finding indicates that previous results in this literature, all based on traditional two-way fixed-effects regressions, should be interpreted with care.
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Affiliation(s)
- Naimi Johansson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden; School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Sweden.
| | | | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Sweden; Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, USA
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Hansson E, Brorson F, Löfstrand J, Elander A, Svensson M. Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction. J Plast Surg Hand Surg 2024; 59:1-13. [PMID: 38189784 DOI: 10.2340/jphs.v59.19649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies. METHODS Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting. RESULTS AND CONCLUSIONS A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.
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Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Fredrik Brorson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Jonas Löfstrand
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA; School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Ramadani RV, Svensson M, Hassler S, Hidayat B, Ng N. Effects of the COVID-19 pandemic on healthcare utilization among older adults with cardiovascular diseases and multimorbidity in Indonesia: an interrupted time-series analysis. BMC Public Health 2024; 24:71. [PMID: 38166721 PMCID: PMC10763491 DOI: 10.1186/s12889-023-17568-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has disrupted healthcare utilization globally, but little is known about the effects among patients with cardiovascular diseases (CVDs) and other multimorbidities. This study analyzed the impacts of COVID-19 on healthcare utilization for patients aged 30 years and older with cardiovascular diseases (CVDs) with or without other chronic disease comorbidities in Indonesia. METHODS We designed a retrospective cohort study based on the Indonesian National Health Insurance (NHI) sample data from 2016-2020. We defined healthcare utilization as monthly outpatient and inpatient visits related to chronic diseases at the hospital and primary healthcare levels per 10,000 NHI members. We used interrupted time series analysis to evaluate how the healthcare utilization patterns had changed due to the COVID-19 pandemic. RESULTS Overall, hospital outpatient visits decreased by 39% when the pandemic occurred (95% Confidence Interval (CI): 0.48,0.76), inpatient visits by 28% (95% CI: 0.62,0.83), and primary healthcare visits by 34% (95% CI:0.55, 0.81). For patients with CVDs and multimorbidity, hospital outpatient and inpatient visit rates were reduced by 36% and 38%, respectively and primary healthcare visits by 32%. Some insignificant differences in the reduction of out-and inpatient visits were observed across diagnosis groups and regions. CONCLUSION Healthcare utilization among patients with chronic diseases decreased significantly during COVID-19 and consistently across different chronic diseases and regions. To cope with the unmet needs of healthcare utilization in the context of the pandemic, the healthcare system needs to be strengthened to cater to the needs of the population-at-risk, especially for patients with CVDs and multimorbidity.
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Affiliation(s)
- Royasia Viki Ramadani
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Center for Health Economics and Policy Studies, Faculty of Public Health, Universitas Indonesia, Jakarta, Indonesia.
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, USA
| | - Sven Hassler
- Department of Health Sciences, Karlstad University, Karlstad, Sweden
| | - Budi Hidayat
- Center for Health Economics and Policy Studies, Faculty of Public Health, Universitas Indonesia, Jakarta, Indonesia
| | - Nawi Ng
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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9
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Fledsberg S, Svensson M, Johansson N. Lifetime healthcare expenditures across socioeconomic groups in Sweden. Eur J Public Health 2023; 33:994-1000. [PMID: 37649353 PMCID: PMC10710355 DOI: 10.1093/eurpub/ckad140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Individuals of lower socioeconomic status generally have higher healthcare expenditures than individuals of higher socioeconomic status. However, little is known about how expenditures are distributed across socioeconomic groups over a lifetime, once accounting for differences in life expectancy. This study describes how lifetime healthcare expenditures are distributed across age, sex and socioeconomic groups in Sweden while adjusting for differences in life expectancy. METHODS Healthcare utilization from 2016 were linked to demographic and socioeconomic data for a random sample of individuals aged 20 and above in the four largest Swedish regions (n = 440 659). Mortality data were used to estimate income- and sex-specific survival rates. Expected lifetime healthcare expenditures were estimated by combining survival rates with mean healthcare expenditures over age, by sex, and income quintile. RESULTS We find that expected lifetime healthcare expenditures are highest among the first (lowest) income quintile despite their evident lower life expectancy. Expected lifetime expenditures were 17.9% (16.8%) higher in the first income quintile compared to the fifth (highest) quintile for women (men). Individuals in the first income quintile had higher expected lifetime expenditures for all care categories except for primary care. CONCLUSION We conclude that despite a lower life expectancy, the quintile of the lowest socioeconomic status still had higher lifetime healthcare expenditures.
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Affiliation(s)
- Stephanie Fledsberg
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Gothia Forum for Clinical Trials, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Naimi Johansson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
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Pietilä R, Del Gaudio F, He L, Vázquez-Liébanas E, Vanlandewijck M, Muhl L, Mocci G, Bjørnholm KD, Lindblad C, Fletcher-Sandersjöö A, Svensson M, Thelin EP, Liu J, van Voorden AJ, Torres M, Antila S, Xin L, Karlström H, Storm-Mathisen J, Bergersen LH, Moggio A, Hansson EM, Ulvmar MH, Nilsson P, Mäkinen T, Andaloussi Mäe M, Alitalo K, Proulx ST, Engelhardt B, McDonald DM, Lendahl U, Andrae J, Betsholtz C. Molecular anatomy of adult mouse leptomeninges. Neuron 2023; 111:3745-3764.e7. [PMID: 37776854 DOI: 10.1016/j.neuron.2023.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 07/07/2023] [Accepted: 09/05/2023] [Indexed: 10/02/2023]
Abstract
Leptomeninges, consisting of the pia mater and arachnoid, form a connective tissue investment and barrier enclosure of the brain. The exact nature of leptomeningeal cells has long been debated. In this study, we identify five molecularly distinct fibroblast-like transcriptomes in cerebral leptomeninges; link them to anatomically distinct cell types of the pia, inner arachnoid, outer arachnoid barrier, and dural border layer; and contrast them to a sixth fibroblast-like transcriptome present in the choroid plexus and median eminence. Newly identified transcriptional markers enabled molecular characterization of cell types responsible for adherence of arachnoid layers to one another and for the arachnoid barrier. These markers also proved useful in identifying the molecular features of leptomeningeal development, injury, and repair that were preserved or changed after traumatic brain injury. Together, the findings highlight the value of identifying fibroblast transcriptional subsets and their cellular locations toward advancing the understanding of leptomeningeal physiology and pathology.
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Affiliation(s)
- Riikka Pietilä
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Francesca Del Gaudio
- Department of Medicine Huddinge, Karolinska Institutet, 14157 Huddinge, Sweden; Department of Cell and Molecular Biology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Liqun He
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Elisa Vázquez-Liébanas
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Michael Vanlandewijck
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden; Department of Medicine Huddinge, Karolinska Institutet, 14157 Huddinge, Sweden
| | - Lars Muhl
- Department of Medicine Huddinge, Karolinska Institutet, 14157 Huddinge, Sweden
| | - Giuseppe Mocci
- Department of Medicine Huddinge, Karolinska Institutet, 14157 Huddinge, Sweden
| | - Katrine D Bjørnholm
- Department of Neurobiology, Care Sciences and Society, Division of Neurogeriatrics, Center for Alzheimer Research, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Department of Neurosurgery, Uppsala University Hospital, 75185 Uppsala, Sweden; Department of Medical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Alexander Fletcher-Sandersjöö
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Department of Neurosurgery, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Department of Neurology, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Department of Neurology, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Jianping Liu
- Department of Medicine Huddinge, Karolinska Institutet, 14157 Huddinge, Sweden
| | - A Jantine van Voorden
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Monica Torres
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Salli Antila
- Wihuri Research Institute and Translational Cancer Medicine Program, University of Helsinki, 00014 Helsinki, Finland
| | - Li Xin
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland
| | - Helena Karlström
- Department of Neurobiology, Care Sciences and Society, Division of Neurogeriatrics, Center for Alzheimer Research, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Jon Storm-Mathisen
- Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, 0317 Oslo, Norway
| | - Linda Hildegard Bergersen
- Brain and Muscle Energy Group, Institute of Oral Biology, University of Oslo, 0316 Oslo, Norway; Center for Healthy Aging, Copenhagen University, 2200 Copenhagen, Denmark
| | - Aldo Moggio
- Department of Cell and Molecular Biology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Emil M Hansson
- Department of Cell and Molecular Biology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Maria H Ulvmar
- Department of Medical Biochemistry and Microbiology, Uppsala University, 75123 Uppsala, Sweden
| | - Per Nilsson
- Department of Neurobiology, Care Sciences and Society, Division of Neurogeriatrics, Center for Alzheimer Research, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Taija Mäkinen
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Maarja Andaloussi Mäe
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Kari Alitalo
- Wihuri Research Institute and Translational Cancer Medicine Program, University of Helsinki, 00014 Helsinki, Finland
| | - Steven T Proulx
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland
| | - Britta Engelhardt
- Theodor Kocher Institute, University of Bern, 3012 Bern, Switzerland
| | - Donald M McDonald
- Cardiovascular Research Institute, UCSF Helen Diller Family Comprehensive Cancer Center, and Department of Anatomy, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Urban Lendahl
- Department of Cell and Molecular Biology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Johanna Andrae
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Christer Betsholtz
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden; Department of Medicine Huddinge, Karolinska Institutet, 14157 Huddinge, Sweden.
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11
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Labori F, Bonander C, Svensson M, Persson J. Long-term effects on healthcare utilisation among spouses of persons with stroke. BMC Health Serv Res 2023; 23:1298. [PMID: 38001419 PMCID: PMC10675871 DOI: 10.1186/s12913-023-10286-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Stroke is a common and costly disease affecting the person with stroke and their relatives. If the negative effect on the health of informal caregivers to a person with stroke translates into an increased healthcare consumption has not yet been studied. Further, the importance of including costs and health consequences of informal caregiving in health economic evaluation supporting decision-making is an ongoing discussion. Therefore, this study aims to estimate the long-term effect on healthcare utilisation among spouses of persons with a first-ever stroke. METHOD The study population consists of spouses of persons with first-ever stroke events in 2010-2011 and a reference population matched on age, sex and municipality of residence. We have access to information on healthcare utilisation five years before and five years after the stroke event for the whole study population. Using a difference-in-difference approach, the main analysis estimates the effects on primary and specialist outpatient care visits and days with inpatient care per year. Further, we analyse the healthcare utilisation among spouses depending on the modified Rankin Scale (mRS) of the person with stroke. RESULTS Our main analysis indicates that spouses have slightly more days with inpatient care five years after the stroke event than the reference population (p = 0.03). In contrast, spouses have fewer primary and specialist outpatient care visits than the reference population following the stroke event. In the analysis where spouses' healthcare utilisation is analysed according to the mRS status of the person with stroke, we identify the most notable change in the number of visits to specialist outpatient and days with inpatient care among spouses of persons with mRS 3 (dependency in daily activities). CONCLUSION Our study suggests that being the spouse of a person with stroke has minor effects on healthcare utilisation. Further, healthcare utilisation is most affected among the spouses of persons with stroke and dependency in daily activities (mRS 3). According to our results, it does not seem vital to include spouses of persons with stroke healthcare utilisation in health economic evaluations.
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Affiliation(s)
- Frida Labori
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg, 405 30, Sweden.
| | - Carl Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg, 405 30, Sweden
| | - Mikael Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg, 405 30, Sweden
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, US
| | - Josefine Persson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg, 405 30, Sweden
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12
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Baldvinsdóttir B, Klurfan P, Eneling J, Ronne-Engström E, Enblad P, Lindvall P, Aineskog H, Friðriksson S, Svensson M, Alpkvist P, Hillman J, Kronvall E, Nilsson OG. Adverse events during endovascular treatment of ruptured aneurysms: A prospective nationwide study on subarachnoid hemorrhage in Sweden. Brain Spine 2023; 3:102708. [PMID: 38021017 PMCID: PMC10668086 DOI: 10.1016/j.bas.2023.102708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/10/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction A range of adverse events (AEs) may occur in patients with subarachnoid hemorrhage (SAH). Endovascular treatment is commonly used to prevent aneurysm re-rupture. Research question The aim of this study was to identify AEs related to endovascular treatment, analyze risk factors for AEs and how AEs affect patient outcome. Material and methods Patients with aneurysmal SAH admitted to all neurosurgical centers in Sweden during a 3.5-year period (2014-2018) were prospectively registered. AEs related to endovascular aneurysm treatment were thromboembolic events, aneurysm re-rupture, vessel dissection and puncture site hematoma. Potential risk factors for the AEs were analyzed using multivariate logistic regression. Functional outcome was assessed at one year using the extended Glasgow outcome scale. Results In total, 1037 patients were treated for ruptured aneurysms. Of which, 715 patients were treated with endovascular occlusion. There were 115 AEs reported in 113 patients (16%). Thromboembolic events were noted in 78 patients (11%). Aneurysm re-rupture occurred in 28 (4%), vessel dissection in 4 (0.6%) and puncture site hematoma in 5 (0.7%). Blister type aneurysm, aneurysm smaller than 5 mm and endovascular techniques other than coiling were risk factors for treatment-related AEs. At follow-up, 230 (32%) of the patients had unfavorable outcome. Patients suffering intraprocedural aneurysm re-rupture were more likely to have unfavorable outcome (OR 6.9, 95% CI 2.3-20.9). Discussion and conclusion Adverse events related to endovascular occlusion of a ruptured aneurysm were seen in 16% of patients. Aneurysm re-rupture during endovascular treatment was associated with increased risk of unfavorable functional outcome.
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Affiliation(s)
| | - Paula Klurfan
- Department of Clinical Neuroscience, University of Gothenburg, Gothenburg, Sweden
| | - Johanna Eneling
- Department of Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Peter Lindvall
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
| | - Helena Aineskog
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
| | - Steen Friðriksson
- Department of Clinical Neuroscience, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Peter Alpkvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hillman
- Department of Clinical Sciences, Linköping University, Linköping, Sweden
| | - Erik Kronvall
- Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
| | - Ola G. Nilsson
- Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
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13
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Ashby F, Park H, Svensson M, Heldermon CD. Economic Burden of Sanfilippo Syndrome in the United States. Res Sq 2023:rs.3.rs-3001450. [PMID: 37398464 PMCID: PMC10312916 DOI: 10.21203/rs.3.rs-3001450/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Introduction Sanfilippo syndrome is a rare disease and fatal genetic disorder with no FDA-approved treatment in the United States (US), and no comprehensive assessment of economic disease burden is available. Objectives To develop a model to estimate the economic burden associated with Sanfilippo syndrome in the US using direct costs, indirect costs and valued intangibles (disability-adjusted life years, or DALYs) from 2023 onward. Design and Setting A multistage comorbidity model was generated based on Sanfilippo syndrome symptoms, and disability weights from the 2010 Global Burden of Disease Study. Attributable increase in caregiver mental health burden were estimated using data from the CDC National Comorbidity Survey and retrospective studies on caregiver burden. Direct costs were approximated from the 2019 EveryLife Foundation survey, and indirect costs were estimated from Federal income data. Monetary valuations were adjusted to USD 2023 and given a 3% discount rate from 2023 onward. Main Outcome Measures Incidence of Sanfilippo syndrome was calculated for each year, and year-over-year DALYs due to patient years lived with disability (YLDs) and years life lost (YLLs) were calculated by comparing to the health-adjusted life expectancy (HALE) in the US. Direct and indirect costs were calculated for each simulated patient from onset of symptoms to death. Results From 2023-2043, overall economic burden in the US attributable to Sanfilippo syndrome was estimated to be $2.04 billion USD present value (2023) with current standard of care. The burden to individual families exceeded $8 million present value from time of birth per child born with Sanfilippo syndrome. Conclusion Sanfilippo syndrome is a rare lysosomal storage disease, however the severe burden associated with the disease for individual families demonstrates a considerable cumulative impact. Our model represents the first disease burden value estimate associated with Sanfilippo syndrome, and underscores the substantial morbidity and mortality burden of Sanfilippo syndrome.
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Affiliation(s)
- Frederick Ashby
- College of Medicine, University of Florida - Gainesville, Florida, USA
| | - Haesuk Park
- College of Pharmacy, University of Florida - Gainesville, Florida, USA
| | - Mikael Svensson
- College of Pharmacy, University of Florida - Gainesville, Florida, USA
| | - Coy D Heldermon
- College of Medicine, University of Florida - Gainesville, Florida, USA
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Eklund E, Holmberg R, Svensson M, Gustavsson J, Bonander C. Quasi-experimental evaluation of municipal ice cleat distribution programmes for older adults in Sweden. Inj Prev 2023; 29:378-383. [PMID: 37217288 PMCID: PMC10579486 DOI: 10.1136/ip-2022-044808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/05/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Fall injuries caused by icy road conditions are a prevalent public health problem during winters in Sweden, especially in older populations. To combat this problem, many Swedish municipalities have distributed ice cleats to older adults. While previous research has shown promising results, there is a lack of comprehensive empirical data on the effectiveness of ice cleat distribution. We address this gap by investigating the impact of these distribution programmes on ice-related fall injuries among older adults. METHODS We combined survey data on ice cleat distribution in Swedish municipalities with injury data from the Swedish National Patient Register (NPR). The survey was used to identify municipalities that have distributed ice cleats to older adults at some point between 2001 and 2019. Data from NPR were used to identify municipality-level data on patients who have been treated for injuries related to snow and ice. We used a triple differences design-a generalisation of difference in differences-that compared ice-related fall injury rates before and after intervention in 73 treatment and 200 control municipalities, with unexposed age groups serving as within-municipality controls. RESULTS We estimate that the average ice cleat distribution programmes reduced ice-related fall injury rates by -0.24 (95% CI -0.49 to 0.02) per 1000 person-winters. The impact estimate was larger in municipalities that distributed more ice cleats (-0.38 (95% CI -0.76 to -0.09)). No similar patterns were found for fall injuries unrelated to snow and ice. CONCLUSION Our results suggest that ice cleat distribution can decrease the incidence of ice-related injuries among older adults.
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Affiliation(s)
- Elin Eklund
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Robin Holmberg
- Department of Political, Historical and Cultural Studies, Karlstad University, Karlstad, Sweden
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
| | - Johanna Gustavsson
- Department of Political, Historical and Cultural Studies, Karlstad University, Karlstad, Sweden
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
| | - Carl Bonander
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
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15
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Ulfsdottir H, Bäck M, Cider Å, Jivegård L, Sandberg A, Nordanstig J, Svensson M. Cost-Effectiveness of Exercise Therapy in Patients with Intermittent Claudication-A Comparison of Supervised Exercise, Home-Based Structured Exercise, and Walk Advice from the SUNFIT Trial. J Clin Med 2023; 12:5277. [PMID: 37629318 PMCID: PMC10455939 DOI: 10.3390/jcm12165277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/19/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Hospital-based supervised exercise (SEP) is a guideline-recommended intervention for patients with intermittent claudication (IC). However, due to the limited availability of SEP, home-based structured exercise programs (HSEP) have become increasingly popular alongside the "go home and walk" advice. We evaluated the cost-effectiveness of walk advice (WA) with Nordic pole walking vs. SEP combined with WA or HSEP combined with WA. We used data from the SUNFIT RCT (NCT02341716) to measure quality-adjusted life-years (QALYs) over a 12-month follow-up, and economic costs were obtained from a hospital cost-per-patient accounting system. Incremental cost-effectiveness ratios (ICERs) were calculated, and uncertainty was assessed using nonparametric bootstrapping. The average health-care-cost per patient was similar in the WA (EUR 1781, n = 51) and HSEP (EUR 1820, n = 48) groups but higher in the SEP group (EUR 4619, n = 50, p-value < 0.01). Mean QALYs per patient during the follow-up were similar with no statistically significant differences. The findings do not support SEP as a cost-effective treatment for IC, as it incurred significantly higher costs without providing additional health improvements over WA with or without HSEP during the one-year observation period. The analysis also suggested that HSEP may be cost-effective compared to WA, but only with a 64% probability.
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Affiliation(s)
- Hildigunnur Ulfsdottir
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Sidekick Health, 413 90 Gothenburg, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Åsa Cider
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Lennart Jivegård
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Health Technology Assessment Centre Region Västra Götaland, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden
| | - Anna Sandberg
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Department of Vascular Surgery, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32610, USA
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Wang GHM, Svensson M, Shao H, Vouri SM, Park H. Cost-effectiveness analysis of monthly, 3-monthly, and 6-monthly long-acting injectable and oral paliperidone in adults with schizophrenia. J Manag Care Spec Pharm 2023; 29:884-895. [PMID: 37523313 PMCID: PMC10397333 DOI: 10.18553/jmcp.2023.29.8.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND: Paliperidone is among the most cost-effective antipsychotics in adults with schizophrenia, and it has different formulations, including oral paliperidone extended-release (ER) and long-acting injectable (LAI) paliperidone formulations administered every month (PP1M), 3 months (PP3M), or 6 months (PP6M). However, cost-effectiveness analyses comparing different paliperidone formulations were limited. OBJECTIVE: To compare the cost-effectiveness across different paliperidone formulations. METHODS: A Markov model was developed to simulate 1,000 adults aged 40 years with stable schizophrenia transitioning among stable disease-medication adherent, stable disease-medication nonadherent, relapse with hospitalization, relapse with ambulatory care, and death states every 3 months for 5 years. Drug costs were estimated using the prices listed in the Veterans Affairs Federal Supply Schedule, and costs for treating complications were estimated from published studies. All costs were estimated from the US health care system perspective and standardized to 2022 US dollars using the Consumer Price Index Inflation Calculator. Quality-adjusted life-years (QALYs) were estimated using relapse rates from randomized clinical trials and health-related quality of life scores from observational studies. The estimated future costs and QALYs were discounted at 3%. We reported incremental net monetary benefits between alternative formulations at the $50,000 willingness-to-pay (WTP) threshold with a positive value indicating cost-effectiveness. The impact of parameter uncertainty on study outcomes was assessed using 1-way deterministic and probabilistic sensitivity analyses. RESULTS: In adults with schizophrenia stabilized with paliperidone ER, switching to LAI formulations was associated with increased QALY (PP1M = 0.05, PP3M = 0.14, PP6M = 0.15) and increased cost (PP1M = 49,433, PP3M = 26,698, PP6M = 26,147), leading to a negative incremental net monetary benefit (PP1M = -$46,804, PP3M = -$19,508, PP6M = -$18,886) compared with continuing ER. Among LAI formulations, PP6M was cost-saving with the most QALYs gained (cost = $63,277, QALY = 3.731), followed by PP3M (cost = $63,828, QALY = 3.729) and PP1M (cost = $86,563, QALY = 3.638). At the $50,000 WTP threshold, the probabilities for PP1M, PP3M, and PP6M being cost-effective compared with paliperidone ER were 0.4%, 10.2%, and 9.8%, respectively. The probability of PP6M being cost-effective was 92.6% for the PP6M-PP1M pair and 55.2% for the PP6M-PP3M pair, and 91.1% of PP3M use was cost-effective in the PP3M-PP1M pair. The results were generally robust in the sensitivity analyses, even at the $190,000 WTP threshold. CONCLUSIONS: For patients with schizophrenia stabilized with paliperidone ER, switching to LAI formulations was not cost-effective, suggesting the high drug costs for LAI may not justify the improved quality of life within 5 years. Among LAI formulations, PP6M was cost-effective over PP1M and PP3M.
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Affiliation(s)
- Grace Hsin-Min Wang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
| | - Hui Shao
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
| | - Scott Martin Vouri
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
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Perlander A, Broeren M, Österberg K, Svensson M, Nordanstig J. Disease Specific Health Related Quality of Life in Patients With Chronic Limb Threatening Ischaemia Undergoing Revascularisation of Femoropopliteal Lesions. Eur J Vasc Endovasc Surg 2023; 66:245-251. [PMID: 37201719 DOI: 10.1016/j.ejvs.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Patients with chronic limb threatening ischaemia (CLTI) suffer from pain and non-healing ulcers, which impact negatively on both their physical and mental health. While maintaining and improving quality of life is a principal aim with all treatments, little is known about the health related quality of life (HRQoL) of CLTI patients and how revascularisation procedures impact on HRQoL endpoints. The aim of this study was to investigate disease specific HRQoL before and after revascularisation in patients with CLTI undergoing femoropopliteal revascularisation. METHODS HRQoL was prospectively analysed in 190 CLTI patients with main atherosclerotic target lesions in the femoropopliteal segment, who were planned for endovascular or open revascularisation. The choice of revascularisation method was made by the vascular team, represented by both open and endovascular expertise. The Vascular Quality of Life (VascuQoL) questionnaire was used to assess disease specific HRQoL before revascularisation and one month, one year, and two years after the procedure. Main endpoints were mean VascuQoL score changes, effect sizes of observed changes and the proportion reaching a minimally important difference (half a standard deviation change from baseline) during two years after revascularisation. RESULTS Patient reported VascuQoL scores were low at baseline (mean 2.68, 95% CI 1.18 - 4.17). After revascularisation, the mean VascuQoL score improved statistically significantly over time, with the largest improvement observed after one year (difference from baseline 2.02, 95% CI 1.75 - 2.29; p < .001). No differences in HRQoL change over time were observed between patients treated with endovascular approaches compared with bypass surgery. Approximately half the patients reached the minimally important threshold at one year (53%), which was largely maintained also at two years (41%). CONCLUSION While CLTI profoundly affected HRQoL, a large and clinically meaningful HRQoL increase was observed after revascularisation. This confirms the value of CLTI revascularisation on HRQoL and underlines the importance of including patient reported outcomes when evaluating revascularisation procedures in CLTI patients.
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Affiliation(s)
- Angelica Perlander
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Monica Broeren
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Klas Österberg
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Joakim Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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Chauca Strand G, Johansson N, Jakobsson N, Bonander C, Svensson M. Cancer Drugs Reimbursed with Limited Evidence on Overall Survival and Quality of Life: Do Follow-Up Studies Confirm Patient Benefits? Clin Drug Investig 2023; 43:621-633. [PMID: 37505421 PMCID: PMC10480259 DOI: 10.1007/s40261-023-01285-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND OBJECTIVE Cancer drug costs have increased considerably within healthcare systems, but many drugs lack quality-of-life (QoL) and overall survival (OS) data at the time of reimbursement approval. This study aimed to review the extent of subsequent literature documenting improvements in OS and QoL for cancer drug indications where no such evidence existed at the time of reimbursement approval. METHODS Drug indications with claims of added therapeutical value but a lack of evidence on OS and QoL that were reimbursed between 2010 and 2020 in Sweden were included for review. Searches were conducted in PubMed and ClinicalTrial.gov for randomized controlled trials examining OS and QoL. RESULTS Of the 22 included drug indications, seven were found to have at least one trial with conclusive evidence of improvements in OS or QoL after a mean follow-up of 6.6 years. The remaining 15 drug indications either lacked subsequent randomized controlled trial data on OS or QoL (n = 6) or showed no statistically significant improvements (n = 9). Only one drug demonstrated evidence of improvement in both OS and QoL for its indication. CONCLUSIONS A considerable share of reimbursed cancer drug indications continue to lack evidence of improvement in both OS and QoL. With limited healthcare resources and an increasing cancer burden, third-party payers have strong incentives to require additional post-reimbursement data to confirm any improvements in OS and QoL.
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Affiliation(s)
- Gabriella Chauca Strand
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden.
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Medicinaregatan 18 A, PO Box 463, 405 30, Gothenburg, Västra Götalands Län, Sweden.
| | - Naimi Johansson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Örebro Län, Sweden
| | - Niklas Jakobsson
- Karlstad Business School, Faculty of Arts and Social Sciences, Karlstads Business School, Karlstad University, Karlstad, Värmlands Län, Sweden
| | - Carl Bonander
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden
- Centre for Societal Risk Management, Faculty of Arts and Social Sciences, Karlstad University, Karlstad, Värmlands Län, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
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19
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Lindblad C, Neumann S, Kolbeinsdóttir S, Zachariadis V, Thelin EP, Enge M, Thams S, Brundin L, Svensson M. Stem cell-derived brainstem mouse astrocytes obtain a neurotoxic phenotype in vitro upon neuroinflammation. J Inflamm (Lond) 2023; 20:22. [PMID: 37370141 DOI: 10.1186/s12950-023-00349-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Astrocytes respond to injury and disease through a process known as reactive astrogliosis, of which inflammatory signaling is one subset. This inflammatory response is heterogeneous with respect to the inductive stimuli and the afflicted central nervous system region. This is of plausible importance in e.g. traumatic axonal injury (TAI), where lesions in the brainstem carries a particularly poor prognosis. In fact, astrogliotic forebrain astrocytes were recently suggested to cause neuronal death following axotomy. We therefore sought to assess if ventral brainstem- or rostroventral spinal astrocytes exert similar effects on motor neurons in vitro. METHODS We derived brainstem/rostroventral spinal astrocyte-like cells (ES-astrocytes) and motor neurons using directed differentiation of mouse embryonic stem cells (ES). We activated the ES-astrocytes using the neurotoxicity-eliciting cytokines interleukin- (IL-) 1α and tumor necrosis factor-(TNF-)α and clinically relevant inflammatory mediators. In co-cultures with reactive ES-astrocytes and motor neurons, we assessed neurotoxic ES-astrocyte activity, similarly to what has previously been shown for other central nervous system (CNS) regions. RESULTS We confirmed the brainstem/rostroventral ES-astrocyte identity using RNA-sequencing, immunocytochemistry, and by comparison with primary subventricular zone-astrocytes. Following cytokine stimulation, the c-Jun N-terminal kinase pathway down-stream product phosphorylated c-Jun was increased, thus demonstrating ES-astrocyte reactivity. These reactive ES-astrocytes conferred a contact-dependent neurotoxic effect upon co-culture with motor neurons. When exposed to IL-1β and IL-6, two neuroinflammatory cytokines found in the cerebrospinal fluid and serum proteome following human severe traumatic brain injury (TBI), ES-astrocytes exerted similar effects on motor neurons. Activation of ES-astrocytes by these cytokines was associated with pathways relating to endoplasmic reticulum stress and altered regulation of MYC. CONCLUSIONS Ventral brainstem and rostroventral spinal cord astrocytes differentiated from mouse ES can exert neurotoxic effects in vitro. This highlights how neuroinflammation following CNS lesions can exert region- and cell-specific effects. Our in vitro model system, which uniquely portrays astrocytes and neurons from one niche, allows for a detailed and translationally relevant model system for future studies on how to improve neuronal survival in particularly vulnerable CNS regions following e.g. TAI.
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Affiliation(s)
- Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden.
| | - Susanne Neumann
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
| | | | | | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Enge
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Thams
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Lou Brundin
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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20
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Olsson DS, Svensson M, Labori F, De Geer A, Johannsson G. Healthcare cost and survival in patients with non-functioning pituitary adenoma. Eur J Endocrinol 2023:7180094. [PMID: 37232269 DOI: 10.1093/ejendo/lvad057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Pituitary adenomas and their consequences impact mortality and morbidity. We studied the healthcare costs, survival and cost effectiveness of growth hormone (GH) versus no GH replacement in patients with non-functioning pituitary adenoma (NFPA). DESIGN AND METHODS A cohort study including all NFPA patients followed from 1987 or the date of diagnosis until time of death or 31 December 2019 in Västra Götaland region, Sweden. Data to assess resource use, costs, survival and cost-effectiveness were collected from patient records, and regional/national healthcare registries. RESULTS 426 patients with NFPA (274 men) with a follow-up of 13.6 ± 6.8 years (mean ± S.D.) were included. Total annual healthcare cost was higher in patients receiving GH (€9287) than those without GH (€6770), mainly driven by a higher pharmaceutical cost. Glucocorticoid replacement therapy (P = 0.02), diabetes insipidus (P = 0.04), body mass index (P < 0.01) and hypertension (P < 0.01) were all individually associated with higher total annual cost. Survival rate was higher in the GH group (HR 0.60; P = 0.01) and reduced in patients with glucocorticoid replacement (HR 2.02; P < 0.01) or diabetes insipidus (HR 1.67; P = 0.04). The cost per gained life-year for GH versus no GH replacement was about €37 000. CONCLUSIONS This healthcare utilisation study identified several factors driving the cost of care in NFPA patients, such as GH replacement, adrenal insufficiency and diabetes insipidus. Life expectancy was increased in those with GH replacement and reduced in patients with adrenal insufficiency and diabetes insipidus.
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Affiliation(s)
- Daniel S Olsson
- Department of Endocrinology at Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainsville, FL, USA
- School of Public Health & Community Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frida Labori
- School of Public Health & Community Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Gudmundur Johannsson
- Department of Endocrinology at Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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21
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Baldvinsdóttir B, Kronvall E, Ronne-Engström E, Enblad P, Lindvall P, Aineskog H, Friðriksson S, Klurfan P, Svensson M, Alpkvist P, Hillman J, Eneling J, Nilsson OG. Adverse events associated with microsurgial treatment for ruptured intracerebral aneurysms: a prospective nationwide study on subarachnoid haemorrhage in Sweden. J Neurol Neurosurg Psychiatry 2023:jnnp-2022-330982. [PMID: 36931713 DOI: 10.1136/jnnp-2022-330982] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/03/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Adverse events (AEs) or complications may arise secondary to the treatment of aneurysmal subarachnoid haemorrhage (SAH). The aim of this study was to identify AEs associated with microsurgical occlusion of ruptured aneurysms, as well as to analyse their risk factors and impact on functional outcome. METHODS Patients with aneurysmal SAH admitted to the neurosurgical centres in Sweden were prospectively registered during a 3.5-year period (2014-2018). AEs were categorised as intraoperative or postoperative. A range of variables from patient history and SAH characteristics were explored as potential risk factors for an AE. Functional outcome was assessed approximately 1 year after the bleeding using the extended Glasgow Outcome Scale. RESULTS In total, 1037 patients were treated for ruptured aneurysms, of which, 322 patients were treated with microsurgery. There were 105 surgical AEs in 97 patients (30%); 94 were intraoperative AEs in 79 patients (25%). Aneurysm rerupture occurred in 43 patients (13%), temporary occlusion of the parent artery >5 min in 26 patients (8%) and adjacent vessel injury in 25 patients (8%). High Fisher grade and brain oedema on CT were related to increased risk of AEs. At follow-up, 38% of patients had unfavourable outcome. Patients suffering AEs were more likely to have unfavourable outcome (OR 2.3, 95% CI 1.10 to 4.69). CONCLUSION Intraoperative AEs occurred in 25% of patients treated with microsurgery for ruptured intracerebral aneurysm in this nationwide survey. Although most operated patients had favourable outcome, AEs were associated with increased risk of unfavourable outcome.
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Affiliation(s)
| | - Erik Kronvall
- Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
| | | | - Per Enblad
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Peter Lindvall
- Department of Clinical Sciences, Neurosurgery, Umea University, Umea, Sweden
| | - Helena Aineskog
- Department of Clinical Sciences, Neurosurgery, Umea University, Umea, Sweden
| | - Steen Friðriksson
- Department of Clinical Neuroscience, Neurosurgery, University of Gothenburg, Gothenburg, Sweden
| | - Paula Klurfan
- Department of Clinical Neuroscience, Neurosurgery, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institute, Stockholm, Sweden
| | - Peter Alpkvist
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institute, Stockholm, Sweden
| | - Jan Hillman
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johanna Eneling
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ola G Nilsson
- Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
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22
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Wennerholm UB, Bergman L, Kuusela P, Ljungström E, Möller AC, Hongslo Vala C, Ekelund AC, Liljegren A, Petzold M, Sjögren P, Svensson M, Strandell A, Jacobsson B. Progesterone, cerclage, pessary, or acetylsalicylic acid for prevention of preterm birth in singleton and multifetal pregnancies - A systematic review and meta-analyses. Front Med (Lausanne) 2023; 10:1111315. [PMID: 36936217 PMCID: PMC10015499 DOI: 10.3389/fmed.2023.1111315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
Background Preterm birth is the leading cause of childhood mortality and morbidity. We aimed to provide a comprehensive systematic review on randomized controlled trials (RCTs) on progesterone, cerclage, pessary, and acetylsalicylic acid (ASA) to prevent preterm birth in asymptomatic women with singleton pregnancies defined as risk of preterm birth and multifetal pregnancies. Methods Six databases (including PubMed, Embase, Medline, the Cochrane Library) were searched up to February 2022. RCTs published in English or Scandinavian languages were included through a consensus process. Abstracts and duplicates were excluded. The trials were critically appraised by pairs of reviewers. The Cochrane risk-of-bias tool was used for risk of bias assessment. Predefined outcomes including preterm birth, perinatal/neonatal/maternal mortality and morbidity, were pooled in meta-analyses using RevMan 5.4, stratified for high and low risk of bias trials. The certainty of evidence was assessed using the GRADE approach. The systematic review followed the PRISMA guideline. Results The search identified 2,309 articles, of which 87 were included in the assessment: 71 original RCTs and 16 secondary publications with 23,886 women and 32,893 offspring. Conclusions were based solely on trials with low risk of bias (n = 50).Singleton pregnancies: Progesterone compared with placebo, reduced the risk of preterm birth <37 gestational weeks: 26.8% vs. 30.2% (Risk Ratio [RR] 0.82 [95% Confidence Interval [CI] 0.71 to 0.95]) (high certainty of evidence, 14 trials) thereby reducing neonatal mortality and respiratory distress syndrome. Cerclage probably reduced the risk of preterm birth <37 gestational weeks: 29.0% vs. 37.6% (RR 0.78 [95% CI 0.69 to 0.88]) (moderate certainty of evidence, four open trials). In addition, perinatal mortality may be reduced by cerclage. Pessary did not demonstrate any overall effect. ASA did not affect any outcome, but evidence was based on one underpowered study.Multifetal pregnancies: The effect of progesterone, cerclage, or pessary was minimal, if any. No study supported improved long-term outcome of the children. Conclusion Progesterone and probably also cerclage have a protective effect against preterm birth in asymptomatic women with a singleton pregnancy at risk of preterm birth. Further trials of ASA are needed. Prevention of preterm birth requires screening programs to identify women at risk of preterm birth. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021234946].
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Affiliation(s)
- Ulla-Britt Wennerholm
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lina Bergman
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Pihla Kuusela
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Södra Älvsborg Hospital, Department of Obstetrics and Gynecology, Borås, Sweden
| | - Elin Ljungström
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | - Anna C. Möller
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | | | - Ann-Catrin Ekelund
- Region Västra Götaland, Skaraborg Hospital, Medical Library, Skövde, Sweden
| | - Ann Liljegren
- Region Västra Götaland, Sahlgrenska University Hospital, Medical Library, Gothenburg, Sweden
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Annika Strandell
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, HTA-centrum, Gothenburg, Sweden
| | - Bo Jacobsson
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Division of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
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23
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Nuwamanya E, Babigumira JB, Svensson M. Cost-effectiveness of increased contraceptive coverage using family planning benefits cards compared with the standard of care for young women in Uganda. Contracept Reprod Med 2023; 8:21. [PMID: 36782307 PMCID: PMC9926799 DOI: 10.1186/s40834-022-00206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/04/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Uganda has a high population growth rate of 3%, partly due to limited access to and low usage of contraception. This study assessed the cost-effectiveness of the family planning benefits cards (FPBC) program compared to standard of care (SOC). The FPBC program was initiated to increase access to modern contraception among young women in slums in Kampala, Uganda. METHODS We developed a decision-analytic model (decision tree) and parameterized it using primary intervention data together with previously published data. In the base case, a sexually active woman from an urban slum, aged 18 to 30 years, was modelled over a one-year time horizon from both the modified societal and provider perspectives. The main model outcomes included the probability of unintended conception, costs, and incremental cost-effectiveness ratio (ICER) in terms of cost per unwanted pregnancy averted. Both deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of the modelling results. All costs were reported in 2022 US dollars, and analyses were conducted in Microsoft Excel. RESULTS In the base case analysis, the FPBC was superior to the SOC in outcomes. The probability of conception was lower in the FPBC than in the SOC (0.20 vs. 0.44). The average societal and provider costs were higher in the FPBC than in the SOC, i.e., $195 vs. $164 and $193 vs. $163, respectively. The ICER comparing the FPBC to the SOC was $125 per percentage reduction in the probability of unwanted conception from the societal perspective and $121 from the provider perspective. The results were robust to sensitivity analyses. CONCLUSION Given Uganda's GDP per capita of $1046 in 2022, the FPBC is highly cost-effective compared to the SOC in reducing unintended pregnancies among young women in low-income settings. It can even get cheaper in the long run due to the low marginal costs of deploying additional FPBCs. TRIAL REGISTRATION MUREC1/7 No. 10/05-17. Registered on July 19, 2017.
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Affiliation(s)
- Elly Nuwamanya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, 40530, Uganda. .,GHE Consulting, P.O Box 27011, Kampala, Uganda. .,Department of Community Medicine and Public Health, Sahlgrenska Academy, University of Gothenburg, P. O Box 414, 40530, Gothenburg, Sweden.
| | | | - Mikael Svensson
- grid.8761.80000 0000 9919 9582Department of Community Medicine and Public Health, Sahlgrenska Academy, University of Gothenburg, P. O Box 414, 40530 Gothenburg, Sweden
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24
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Fletcher-Sandersjöö A, Tatter C, Tjerkaski J, Bartek J, Maegele M, Nelson DW, Svensson M, Thelin EP, Bellander BM. Time Course and Clinical Significance of Hematoma Expansion in Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study. Neurocrit Care 2023; 38:60-70. [PMID: 36167951 PMCID: PMC9935722 DOI: 10.1007/s12028-022-01609-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Preventing intracranial hematoma expansion has been advertised as a possible treatment opportunity in traumatic brain injury (TBI). However, the time course of hematoma expansion, and whether the expansion affects outcome, remains poorly understood. In light of this, the aim of this study was to use 3D volume rendering to determine how traumatic intracranial hematomas expand over time and evaluate its impact on outcome. METHODS Single-center, population-based, observational cohort study of adults with moderate-to-severe TBI. Hematoma expansion was defined as the change in hematoma volume from the baseline computed tomography scan until the lesion had stopped progressing. Volumes were calculated by using semiautomated volumetric segmentation. Functional outcome was measured by using the 12 month Glasgow outcome scale (GOS). RESULTS In total, 643 patients were included. The mean baseline hematoma volume was 4.2 ml, and the subsequent mean hematoma expansion was 3.8 ml. Overall, 33% of hematomas had stopped progressing within 3 h, and 94% of hematomas had stopped progressing within 24 h of injury. Contusions expanded significantly more, and for a longer period of time, than extra-axial hematomas. There was a significant dose-response relationship between hematoma expansion and 12 month GOS, even after adjusting for known outcome predictors, with every 1-ml increase in hematoma volume associated with a 6% increased risk of 1-point GOS deduction. CONCLUSIONS Hematoma expansion is a driver of unfavorable outcome in TBI, with small changes in hematoma volume also impacting functional outcome. This study also proposes a wider window of opportunity to prevent lesion progression than what has previously been suggested.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden. .,Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 , Solna, Stockholm, Sweden.
| | - Charles Tatter
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Jonathan Tjerkaski
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Jiri Bartek
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden ,grid.475435.4Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany ,grid.412581.b0000 0000 9024 6397Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - David W. Nelson
- grid.4714.60000 0004 1937 0626Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Function Perioperative Care and Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Eric Peter Thelin
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
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25
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Ronne Engström E, Baldvinsdóttir B, Aineskog H, Alpkvist P, Enblad P, Eneling J, Fridriksson S, Hillman J, Klurfan P, Kronvall E, Lindvall P, Von Vogelsang AC, Nilsson OG, Svensson M. The impact of previous health on the mortality after aneurysmal subarachnoid hemorrhage: analysis of a prospective Swedish multicenter study. Acta Neurochir (Wien) 2023; 165:443-449. [PMID: 36633685 PMCID: PMC9922219 DOI: 10.1007/s00701-022-05464-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/14/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE There is an an increasing awareness of the importance of health and lifestyle for stroke diseases like spontaneous subarachnoid hemorrhage (SAH). However, the importance of pre-existing medical conditions for clinical course and mortality after SAH has not been studied. The aim of the present study was to identify pre-existing conditions contributing to mortality after SAH. METHODS Data were extracted from a Swedish national prospective study on patients with SAH. Variables were defined for age, sex, body mass index (BMI), clinical condition at admission, and for 10 pre-existing medical conditions. Models predicting mortality in three time intervals with all possible subsets of these variables were generated, compared and selected using Akaike's information criterion. RESULTS 1155 patients with ruptured aneurysms were included. The mortality within 1 week was 7.6%, 1 month 14.3%, and 1 year 18.7%. The most common pre-existing medical conditions were smoking (57.6%) and hypertension (38.7%). The model's best predicting mortality within 1 week and from 1 week to 1 month included only the level of consciousness at admission and age, and these two variables were present in all the models among the top 200 in Akaike score for each time period. The most predictive model for mortality between 1 month and 1 year added previous stroke, diabetes, psychiatric disease, and BMI as predictors. CONCLUSION Mortality within the first month was best predicted simply by initial level of consciousness and age, while mortality within from 1 month to 1 year was significantly influenced by pre-existing medical conditions.
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Affiliation(s)
| | | | - Helena Aineskog
- Neurosurgery, Clinical Sciences, Umea University, Umeå, Sweden
| | - Peter Alpkvist
- Neurosurgery, Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Per Enblad
- Neurosurgery, Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Johanna Eneling
- Neurosurgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Steen Fridriksson
- Neurosurgery, Clinical Neuroscience, Gothenburg University, Gothenburg, Sweden
| | - Jan Hillman
- Neurosurgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Paula Klurfan
- Neurosurgery, Clinical Neuroscience, Gothenburg University, Gothenburg, Sweden
| | - Erik Kronvall
- Neurosurgery, Clinical Sciences, Lund University, Lund, Sweden
| | - Peter Lindvall
- Neurosurgery, Clinical Sciences, Umea University, Umeå, Sweden
| | | | - Ola G. Nilsson
- Neurosurgery, Clinical Sciences, Lund University, Lund, Sweden
| | - Mikael Svensson
- Neurosurgery, Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Lin IH, Kamnaksh A, Aniceto R, McCullough J, Bekdash R, Eklund M, Ghatan PH, Risling M, Svensson M, Bellander BM, Nelson DW, Thelin EP, Agoston DV. Time-Dependent Changes in the Biofluid Levels of Neural Injury Markers in Severe Traumatic Brain Injury Patients-Cerebrospinal Fluid and Cerebral Microdialysates: A Longitudinal Prospective Pilot Study. Neurotrauma Rep 2023; 4:107-117. [PMID: 36895820 PMCID: PMC9989523 DOI: 10.1089/neur.2022.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Monitoring protein biomarker levels in the cerebrospinal fluid (CSF) can help assess injury severity and outcome after traumatic brain injury (TBI). Determining injury-induced changes in the proteome of brain extracellular fluid (bECF) can more closely reflect changes in the brain parenchyma, but bECF is not routinely available. The aim of this pilot study was to compare time-dependent changes of S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), total Tau, and phosphorylated Tau (p-Tau) levels in matching CSF and bECF samples collected at 1, 3, and 5 days post-injury from severe TBI patients (n = 7; GCS 3-8) using microcapillary-based western analysis. We found that time-dependent changes in CSF and bECF levels were most pronounced for S100B and NSE, but there was substantial patient-to-patient variability. Importantly, the temporal pattern of biomarker changes in CSF and bECF samples showed similar trends. We also detected two different immunoreactive forms of S100B in both CSF and bECF samples, but the contribution of the different immunoreactive forms to total immunoreactivity varied from patient to patient and time point to time point. Our study is limited, but it illustrates the value of both quantitative and qualitative analysis of protein biomarkers and the importance of serial sampling for biofluid analysis after severe TBI.
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Affiliation(s)
- I-Hsuan Lin
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Alaa Kamnaksh
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Roxanne Aniceto
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Jesse McCullough
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Ramsey Bekdash
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael Eklund
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Per Hamid Ghatan
- Department of Neuroscience, Uppsala University Hospital, Uppsala, Sweden
| | - Mårten Risling
- Department of Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - David W Nelson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Denes V Agoston
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
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Johansson N, de New SC, Kunz JS, Petrie D, Svensson M. Reductions in out-of-pocket prices and forward-looking moral hazard in health care demand. J Health Econ 2023; 87:102710. [PMID: 36450181 DOI: 10.1016/j.jhealeco.2022.102710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 07/23/2022] [Accepted: 11/18/2022] [Indexed: 06/17/2023]
Abstract
Little is known about how patients dynamically respond to a forthcoming reduction in health care out-of-pocket prices. Using a kinked Donut Regression Discontinuity design with kinks entering and exiting the donut, we evaluate a Swedish cost-sharing policy, where primary care out-of-pocket prices were eliminated at age 85. We find evidence of forward-looking moral hazard with older adults delaying primary care visits up to four months before the out-of-pocket elimination and shifting these visits until shortly after. These health care delays are driven by non-urgent care: non-physician visits, planned visits and follow up visits. We find no evidence of severe negative health effects in the short-term as a result of the delay. Contrary to our finding of forward-looking behavior with respect to out-of-pocket prices, we do not find evidence of typical moral hazard, as we do not find a persistent increase in primary health care use after the copayment elimination.
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Affiliation(s)
- Naimi Johansson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Medicinaregatan 18A, Gothenburg SE-40530, Sweden; Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Sweden.
| | - Sonja C de New
- Centre for Health Economics, Monash University, Level 5 Building H, Caulfield, Victoria 3145, Australia; IZA Institute of Labor Economics, ARC Centre of Excellence for Children and Families over the Life Course, RWI Research Network, Germany
| | - Johannes S Kunz
- Centre for Health Economics, Monash University, Level 5 Building H, Caulfield, Victoria 3145, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash University, Level 5 Building H, Caulfield, Victoria 3145, Australia
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Medicinaregatan 18A, Gothenburg SE-40530, Sweden; Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida 32610, USA
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28
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Sangskär H, Berglin L, Sengpiel V, Svanberg T, Svensson M, Berter B, Elden H, Sjögren P, Strandell A, Carlsson Y. Safety, effectiveness, women's experience, and economic costs of outpatient induction in women with uncomplicated pregnancies: A systematic review and meta-analyses. Int J Gynaecol Obstet 2022; 161:343-355. [PMID: 36522151 DOI: 10.1002/ijgo.14625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/23/2022] [Accepted: 10/30/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Induction of labor is increasing worldwide, and some countries have started to introduce outpatient induction in low-risk women. OBJECTIVES To assess current knowledge concerning the safety, efficacy, women's experience, and economic costs of outpatient induction compared with inpatient induction. SEARCH STRATEGY Multiple databases were last searched on October 19, 2021. Studies were selected according to our pre-specified inclusion, selection, and exclusion criteria. SELECTION CRITERIA PICO; P-women with low-risk pregnancy planned for induction of labor. I-Outpatient induction C-Inpatient induction O-Outcomes according to the core outcome set for induction of labor (COSIOL). DATA COLLECTION AND ANALYSIS Pooled in meta-analyses. The certainty of evidence was assessed using the GRADE system. MAIN RESULTS The 20 included studies, including 7956 women, showed an overall low incidence of adverse events and indicated comparable results for inpatient and outpatient induction, but the studies were underpowered for safety-related outcomes. Women's experiences of outpatient induction were mostly positive. Based on three studies, the economic costs consequence is inconclusive. CONCLUSIONS Due to early randomization, heterogenic study design, and underpowered studies regarding safety outcome, the certainty of evidence is very low. It is uncertain whether outpatient induction affects the risk for neonatal and maternal complications.
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Affiliation(s)
- Heléne Sangskär
- Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lisa Berglin
- Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Verena Sengpiel
- Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Therese Svanberg
- Region Västra Götaland, Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden.,Region Västra Götaland, HTA centrum, Gothenburg, Sweden
| | - Mikael Svensson
- Region Västra Götaland, HTA centrum, Gothenburg, Sweden.,Department of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Beatrice Berter
- Region Västra Götaland, NU-hospital Group, Trollhättan, Sweden
| | - Helen Elden
- Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Annika Strandell
- Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, HTA centrum, Gothenburg, Sweden
| | - Ylva Carlsson
- Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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29
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Gamba S, Jakobsson N, Svensson M. The impact of cost-sharing on prescription drug demand: evidence from a double-difference regression kink design. Eur J Health Econ 2022; 23:1591-1599. [PMID: 35212886 PMCID: PMC9666319 DOI: 10.1007/s10198-022-01446-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 02/11/2022] [Indexed: 06/14/2023]
Abstract
Pharmaceuticals represent the third-largest expenditure item in health care spending in the OECD countries, and cost growth is around 5% per year in many OECD countries. One possible way to contain the rise in pharmaceutical spending is the use of cost-sharing schemes that makes insured individuals directly bear parts of the cost of a drug. This study estimates the price sensitivity of demand for prescription drugs using data on all prescription drug purchases from a random sample of 400,000 Swedes followed from 2010 to 2013. We use a regression kink design (RKD) by exploiting the kinked Swedish cost-sharing scheme to assess the price elasticity. Further, since the cost-sharing scheme has changed over time, we also use a double-difference RKD to account for potential confounding nonlinearities around the kink. Our results indicate that the standard RKD results are biased and exaggerate the price sensitivity. Our preferred double-difference RKD specifications show no or minor price sensitivity (95% CI price elasticity from - 0.12 to 0.02). The results are similar in several sub-group analyses across age groups, sexes, and income quartiles.
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Affiliation(s)
- Simona Gamba
- Department of Economics and Finance, Universitá Cattolica Del Sacro Cuore, Milan, Italy
| | | | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden.
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30
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Balogun FM, Omotade OO, Svensson M. Stated preferences for human papillomavirus vaccination for adolescents in selected communities in Ibadan, Southwest Nigeria: A discrete choice experiment. Hum Vaccin Immunother 2022; 18:2124091. [PMID: 36383765 DOI: 10.1080/21645515.2022.2124091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Administration of the human papillomavirus (HPV) vaccine in early adolescence is effective in preventing cervical cancer, a common cancer in sub-Saharan Africa. Nigeria is in the pre-introduction era of the HPV vaccine. Understanding the preferences of the population for the vaccine can help design the HPV immunization program to ensure high uptake of the vaccine. This study explored the preferences for the HPV vaccine among stakeholders in selected communities in Ibadan, Nigeria. A discrete choice experiment survey based on six attributes of the HPV vaccine (which were the number of doses, the efficacy of the vaccine, cost of the vaccine, location of the service point, other benefits of the vaccine apart from prevention of cervical cancer and the odds of a side effect from the vaccine) was carried out in five communities. Data were analyzed using conditional and mixed logit models. Seven hundred community members were recruited, 144 (20.7%) were adolescents and 248 (35.4%) were males. In line with expectations, respondents preferred vaccines with higher efficacy, less severe side effects and lower costs. Preference heterogeneity was identified for adolescents that were less price-sensitive and other community members who were less likely to prefer using schools as the service point. The high socioeconomic class preferred a vaccine that also prevents genital warts. There were variabilities in the preferences for the attributes of the HPV vaccine in the study communities. These variabilities need to be considered in the introduction of the HPV vaccine to ensure high uptake of the vaccine.
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Affiliation(s)
- Folusho M Balogun
- Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Institute of Child Health, University College Hospital, Ibadan, Nigeria
| | - Olayemi O Omotade
- Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Institute of Child Health, University College Hospital, Ibadan, Nigeria
| | - Mikael Svensson
- School of Public Health & Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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31
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Rossignol P, Duarte K, Bresso E, A Å, Devignes MD, Eriksson N, Girerd N, Glerup R, Jardine AG, Holdaas H, Lamiral Z, Leroy C, Massy Z, März W, Krämer B, Wu PH, Schmieder R, Soveri I, Christensen JH, Svensson M, Zannad F, Fellström B. NT-proBNP and stem cell factor plasma concentrations are independently associated with cardiovascular outcomes in end-stage renal disease hemodialysis patients. Eur Heart J Open 2022; 2:oeac069. [PMID: 36600882 PMCID: PMC9797490 DOI: 10.1093/ehjopen/oeac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/14/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
Aims End-stage renal disease (ESRD) treated by chronic hemodialysis (HD) is associated with poor cardiovascular (CV) outcomes, with no available evidence-based therapeutics. A multiplexed proteomic approach may identify new pathophysiological pathways associated with CV outcomes, potentially actionable for precision medicine. Methods and results The AURORA trial was an international, multicentre, randomized, double-blind trial involving 2776 patients undergoing maintenance HD. Rosuvastatin vs. placebo had no significant effect on the composite primary endpoint of death from CV causes, nonfatal myocardial infarction or nonfatal stroke. We first compared CV risk-matched cases and controls (n = 410) to identify novel biomarkers using a multiplex proximity extension immunoassay (276 proteomic biomarkers assessed with OlinkTM). We replicated our findings in 200 unmatched cases and 200 controls. External validation was conducted from a multicentre real-life Danish cohort [Aarhus-Aalborg (AA), n = 331 patients] in which 92 OlinkTM biomarkers were assessed. In AURORA, only N-terminal pro-brain natriuretic peptide (NT-proBNP, positive association) and stem cell factor (SCF) (negative association) were found consistently associated with the trial's primary outcome across exploration and replication phases, independently from the baseline characteristics. Stem cell factor displayed a lower added predictive ability compared with NT-ProBNP. In the AA cohort, in multivariable analyses, BNP was found significantly associated with major CV events, while higher SCF was associated with less frequent CV deaths. Conclusions Our findings suggest that NT-proBNP and SCF may help identify ESRD patients with respectively high and low CV risk, beyond classical clinical predictors and also point at novel pathways for prevention and treatment.
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Affiliation(s)
- P Rossignol
- Corresponding author. Tel: +33383157322, Fax: +33383157324,
| | - K Duarte
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- 1433, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, 4, rue du Morvan, 54500 Nancy, France
| | - E Bresso
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- 1433, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, 4, rue du Morvan, 54500 Nancy, France,LORIA (CNRS, Inria NGE, Université de Lorraine), F-CRIN INI-CRCT, Vandœuvre-lès-Nancy, France
| | - Åsberg A
- Department of Transplantation Medicine Oslo University Hospital–Rikshospitalet, Oslo, Norway,Norway and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | - M D Devignes
- LORIA (CNRS, Inria NGE, Université de Lorraine), F-CRIN INI-CRCT, Vandœuvre-lès-Nancy, France
| | - N Eriksson
- UCR Uppsala Clinical Research Center, Uppsala Science Park, Uppsala, Sweden
| | - N Girerd
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- 1433, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, 4, rue du Morvan, 54500 Nancy, France
| | - R Glerup
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - A G Jardine
- Renal Research Group, British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Z Lamiral
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- 1433, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, 4, rue du Morvan, 54500 Nancy, France
| | - C Leroy
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- 1433, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, 4, rue du Morvan, 54500 Nancy, France
| | - Z Massy
- CESP, Center for Research in Epidemiology and Population Health, University Paris-Saclay, University Paris-Sud, UVSQ, Villejuif, France,Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne, Billancourt and FCRIN INI-CRCT, Paris, France
| | - W März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria,Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany,SYNLAB Academy, SYNLAB Holding Deutschland GmbH, Mannheim and Augsburg, Germany
| | - B Krämer
- Medical Clinic V, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - P H Wu
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden,Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - R Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
| | - I Soveri
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - J H Christensen
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - M Svensson
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
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Larsson S, Edlund C, Nauclér P, Svensson M, Ternhag A. Cost-Effectiveness Analysis of Temocillin Treatment in Patients with Febrile UTI Accounting for the Emergence of Antibiotic Resistance. Appl Health Econ Health Policy 2022; 20:835-843. [PMID: 35989360 PMCID: PMC9596505 DOI: 10.1007/s40258-022-00748-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 05/13/2023]
Abstract
BACKGROUND Antibiotic resistance has been listed as one of the biggest threats to global health today. A recent study has shown that treating febrile urinary tract infections with temocillin instead of cefotaxime leads to a reduced selection of antibiotic-resistant bacteria. However, a potential challenge with prioritizing temocillin over cefotaxime is the cost consequences. OBJECTIVE This study aimed to assess the cost effectiveness of using temocillin compared to cefotaxime in treating febrile urinary tract infections in a model that takes the emergence of antibiotic resistance into account. METHODS We used a Markov cohort model to estimate the costs and health effects of temocillin and cefotaxime treatment in febrile urinary tract infections in a Swedish setting. Health effects were assessed in terms of quality-adjusted life-years, and the primary outcome was the cost per quality-adjusted life-year gained with temocillin compared to cefotaxime. We used a 5-year time horizon. RESULTS The model results showed that temocillin treatment led to better health outcomes at a higher total cost. The cost per quality-adjusted life-year gained was approximately 38,400 EUR. Results from the sensitivity analysis suggested a 63% probability of temocillin being cost effective at a threshold of 50,000 EUR. Furthermore, results showed that the cost effectiveness of temocillin in febrile urinary tract infections is highly dependent on the drug cost. CONCLUSIONS As antibiotic consumption is a driving force of resistance, it is essential to consider the development of resistance when studying the health economic consequences of antibiotic treatments. In doing so, this study found temocillin to be cost effective for febrile urinary tract infections.
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Affiliation(s)
- Sofie Larsson
- Public Health Agency of Sweden, Solna, Sweden.
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | | | - Pontus Nauclér
- Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Anders Ternhag
- Public Health Agency of Sweden, Solna, Sweden
- Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
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33
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Schubert J, Svensson M, Denstedt G, Johnston N, Cars T, Gustafsson S, Schalin L, Hagstrom E. Long-term assessment and target achievement of LDL-C and systolic blood pressure in primary care after acute coronary syndrome. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Hospital-based cardiac rehabilitation and risk factor control decreases the risk of recurrent events after acute coronary syndrome (ACS). Little is known on long-term assessment and target achievement after referral to primary care. Patients with diabetes, regardless of ACS, have yearly follow-up visits in primary care, whereas there is no structured follow-up after ACS for patients without diabetes.
Purpose
To describe long-term assessment and target achievement of LDL-C and systolic blood pressure (SBP) in ACS patients after referral to primary care. Further, to compare patients with and without diabetes at the time of index ACS.
Methods
A non-interventional population-based observational study of patients with first ever ACS in a Swedish region with 390,000 inhabitants. Data on clinical measurements after ACS were collected from the electronic medical records between 2012 and 2020. Patients were followed until new ACS event, death, moving out of the county, or end of study. Target levels studied were LDL-C <1.8 mmol/L and SBP <140 mmHg. The same assessments with the addition of target levels of HbA1c ≤70 mmol/mol were evaluated in patients with diabetes.
Results
Median follow-up was 2.9 years (inter quartile range [IQR]: 1.0–5.4) and 4,733 patients were detected. Median age was 72 years (IQR 63–80) and 34% were female. Follow-up data were available for 3,579 (76%) patients any time during the first, 2,891 (61%) during the second, and 2,308 (49%) during the third year after the index ACS event. The number of patients with diabetes was 1311 (28%), and of these 921, 723, and 562 could be followed for the first, second, and third year. During the first three years, 898 (19%) of all patients with available follow-up died.
The proportion of patients with assessments of LDL-C and SBP declined for each year of follow-up and target achievement was low (Table). Among patients with diabetes a larger proportion had measurements for LDL-C and SBP, while the target achievement was similar to that of the whole study population. HbA1c was measured equally frequently as SBP and was at target in 81% of patients with diabetes during the three years of follow-up (Table).
Conclusion
The proportion of patients with follow-up assessment and measurements in primary care declined each year after the index ACS event. Patients with diabetes had more frequent LDL-C and SBP measurements but the same low target achievement after an ACS compared with patients without diabetes. This could potentially be due to an increased focus on glycaemic control at these visits. A structured long-term follow-up for ACS patients in primary care might improve both assessment and target achievement and prevent recurrent ACS events.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): AmgenSwedish Heart Lung Foundation
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Affiliation(s)
- J Schubert
- Uppsala University, Medical Sciences, Cardiology , Uppsala , Sweden
| | - M Svensson
- Uppsala University, Medical Sciences, Renal Medicine , Uppsala , Sweden
| | | | - N Johnston
- Uppsala University, Medical Sciences, Cardiology , Uppsala , Sweden
| | - T Cars
- Sence Research , Uppsala , Sweden
| | | | | | - E Hagstrom
- Uppsala University, Medical Sciences, Cardiology , Uppsala , Sweden
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Chauca Strand G, Bonander C, Jakobsson N, Johansson N, Svensson M. Assessment of the clinical and cost-effectiveness evidence in the reimbursement decisions of new cancer drugs. ESMO Open 2022; 7:100569. [PMID: 36037568 PMCID: PMC9588887 DOI: 10.1016/j.esmoop.2022.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/06/2022] [Accepted: 07/24/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND This study aimed to describe the clinical and cost-effectiveness evidence supporting reimbursement decisions of new cancer drugs and analyze the influence of trial characteristics and the cost per quality-adjusted life years (QALYs) on the likelihood of reimbursement in Sweden. PATIENTS AND METHODS Data were extracted from all appraisal dossiers for new cancer drugs seeking reimbursement in Sweden and claiming added therapeutical value between the years 2010 and 2020. The data were analyzed using descriptive statistics, and logistic regression models were also used with the cost per QALY, study design, comparator, and evidence on final outcomes in the clinical trials as predictors of reimbursement. RESULTS All 60 included appraisals were based on trial evidence that assessed at least one final outcome (overall survival [OS] or quality of life [QoL]), although rarely as a primary outcome. Of the appraisals with a final decision (n = 58), 79% were approved for reimbursement. Among the reimbursed drugs, only half had trial evidence demonstrating improved OS or QoL. Only one drug had trial evidence supporting improvements in both OS and QoL. The average cost per QALY for reimbursed cancer drugs was estimated to be 748 560 SEK (€73 583). A higher cost per QALY was found to decrease the likelihood of reimbursement by 9.4% for every 100 000 SEK (€9830) higher cost per QALY (P = 0.03). For cost-effectiveness models without direct evidence of improvements in final outcomes, a larger QALY gain was observed compared with those with evidence mainly relying on intermediate and surrogate outcomes. CONCLUSIONS There are substantial uncertainties in the clinical and cost-effectiveness evidence underlying reimbursement decisions of new cancer drugs. Decision makers should be cautious of the limited evidence on patient-centered outcomes and the implications of allocating resources to expensive treatments with uncertain value for money.
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Affiliation(s)
- G Chauca Strand
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg.
| | - C Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg
| | - N Jakobsson
- Karlstad Business School, Karlstad University Faculty of Arts and Social Sciences, Karlstads Business School, Karlstad
| | - N Johansson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg; Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
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35
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Johansson N, Svensson M. Regional variation in prescription drug spending: Evidence from regional migrants in Sweden. Health Econ 2022; 31:1862-1877. [PMID: 35709331 PMCID: PMC9543270 DOI: 10.1002/hec.4552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 06/15/2023]
Abstract
There is substantial variation in drug spending across regions in Sweden, which can be justified if caused by differences in health need, but an indication of inefficiencies if primarily caused by differences in place-specific supply-side factors. This paper aims to estimate the relative effect of individual demand-side factors and place-specific supply-side factors as drivers of geographical variation in drug spending in Sweden. We use individual-level register data on purchases of prescription drugs matched with demographic and socioeconomic data of a random sample of about 900,000 individuals over 2007-2016. The primary empirical approach is a two-way fixed effect model and an event study where we identify demand- and supply-side effects based on how regional and local migrants change drug spending when moving across regional and municipal borders. As an alternative approach in robustness checks, we also use a decomposition analysis. The results show that the place-specific supply-side effect accounts for only about 5%-10% of variation in drug spending and remaining variation is due to individual demand-side effects. These results imply that health policies to reduce regional variation in drug spending would have limited impact if targeted at place-specific characteristics.
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Affiliation(s)
- Naimi Johansson
- Health Economics and PolicySchool of Public Health and Community MedicineInstitute of MedicineUniversity of GothenburgGoteborgSweden
- University Health Care Research CenterFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Mikael Svensson
- Health Economics and PolicySchool of Public Health and Community MedicineInstitute of MedicineUniversity of GothenburgGoteborgSweden
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36
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Holmberg R, Gustavsson J, Svensson M, Bonander C. Ice cleat distribution programmes and ice cleat use among older adults: repeated cross-sectional evidence from 63 municipal interventions in Sweden. Inj Prev 2022; 28:539-544. [PMID: 35922138 DOI: 10.1136/ip-2022-044681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/24/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Ice cleats may help prevent ice-related falls in places with icy roads, but there is limited evidence about the association between ice cleat distribution and ice cleat use. Our study examined the association between Swedish municipal distribution programmes and ice cleat use among older adults (65+ years). METHODS We combined data on municipal ice cleat distribution programmes (n=63) with repeated cross-sectional self-reports of ice cleat use in Sweden from 2007, 2010, 2014 and 2018. Respondents (n=63 234) were classified as exposed if they lived in a municipality with a programme, belonged to an eligible age group and responded after distribution (n=2507). Dose-response was assessed using distributed ice cleat pairs per capita (mean: 0.38). Linear probability models were used to estimate probability differences in ice cleat use between exposed and unexposed respondents, adjusting for age, sex, country of birth, education, survey wave and municipality. Ineligible age groups living in programme municipalities, who should be unaffected by ice cleat distribution, were used for bias assessment. RESULTS Exposure to ice cleat distribution programmes was associated with 7.5 percentage points (95% CI 4.2 to 10.9) higher self-reported ice cleat use after confounding adjustment. The association was larger in municipalities that distributed one pair of ice cleats per capita (17.3 percentage points (95% CI 11.2 to 23.4)). No association was found among the ineligible age groups (-2.3 (95% CI -5.5 to 1.0)). CONCLUSION Distributing ice cleats to older adults may help increase their use of ice cleats in settings with icy road conditions.
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Affiliation(s)
- Robin Holmberg
- Department of Political, Historical and Cultural Studies, Karlstad University, Karlstad, Sweden.,Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
| | - Johanna Gustavsson
- Department of Political, Historical and Cultural Studies, Karlstad University, Karlstad, Sweden.,Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | - Carl Bonander
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden .,School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
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Hu Y, Jiang Y, Behnan J, Ribeiro MM, Kalantzi C, Zhang MD, Lou D, Häring M, Sharma N, Okawa S, Del Sol A, Adameyko I, Svensson M, Persson O, Ernfors P. Neural network learning defines glioblastoma features to be of neural crest perivascular or radial glia lineages. Sci Adv 2022; 8:eabm6340. [PMID: 35675414 PMCID: PMC9177076 DOI: 10.1126/sciadv.abm6340] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Glioblastoma is believed to originate from nervous system cells; however, a putative origin from vessel-associated progenitor cells has not been considered. We deeply single-cell RNA-sequenced glioblastoma progenitor cells of 18 patients and integrated 710 bulk tumors and 73,495 glioma single cells of 100 patients to determine the relation of glioblastoma cells to normal brain cell types. A novel neural network-based projection of the developmental trajectory of normal brain cells uncovered two principal cell-lineage features of glioblastoma, neural crest perivascular and radial glia, carrying defining methylation patterns and survival differences. Consistently, introducing tumorigenic alterations in naïve human brain perivascular cells resulted in brain tumors. Thus, our results suggest that glioblastoma can arise from the brains' vasculature, and patients with such glioblastoma have a significantly poorer outcome.
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Affiliation(s)
- Yizhou Hu
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Yiwen Jiang
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Jinan Behnan
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Mariana Messias Ribeiro
- Computational Biology Group, Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, 4362 Esch-sur-Alzette, Luxembourg
| | - Chrysoula Kalantzi
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Ming-Dong Zhang
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Daohua Lou
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Häring
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Nilesh Sharma
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Satoshi Okawa
- Computational Biology Group, Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, 4362 Esch-sur-Alzette, Luxembourg
| | - Antonio Del Sol
- Computational Biology Group, Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, 4362 Esch-sur-Alzette, Luxembourg
- CIC bioGUNE, Bizkaia Technology Park, 48160 Derio, Spain
- IKERBASQUE, Basque Foundation for Science, 48013 Bilbao, Spain
| | - Igor Adameyko
- Department of Molecular Neurosciences, Center for Brain Research, Medical University Vienna, Vienna, Austria
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Ernfors
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
- Corresponding author.
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Wikström T, Kuusela P, Jacobsson B, Hagberg H, Lindgren P, Svensson M, Wennerholm U, Valentin L. Cost-effectiveness of cervical length screening and progesterone treatment to prevent spontaneous preterm delivery in Sweden. Ultrasound Obstet Gynecol 2022; 59:778-792. [PMID: 35195310 PMCID: PMC9327505 DOI: 10.1002/uog.24884] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/04/2022] [Accepted: 02/11/2022] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To estimate the cost-effectiveness of strategies to prevent spontaneous preterm delivery (PTD) in asymptomatic singleton pregnancies, using prevalence and healthcare cost data from the Swedish healthcare context. METHODS We designed a decision analytic model based on the Swedish CERVIX study to estimate the cost-effectiveness of strategies to prevent spontaneous PTD in asymptomatic women with a singleton pregnancy. The model was constructed as a combined decision-tree model and Markov model with a time horizon of 100 years. Four preventive strategies, namely 'Universal screening', 'High-risk-based screening' (i.e. screening of high-risk women only), 'Low-risk-based screening' (i.e. treatment of high-risk population and screening of remaining women) and 'Nullipara screening' (i.e. treatment of high-risk population and screening of nulliparous women only), included second-trimester cervical length (CL) screening by transvaginal ultrasound followed by vaginal progesterone treatment in the case of a short cervix. A fifth preventive strategy involved vaginal progesterone treatment of women with previous spontaneous PTD or late miscarriage but no CL screening ('No screening, treat high-risk group'). For comparison, we used a sixth strategy implying no specific intervention to prevent spontaneous PTD, reflecting the current situation in Sweden ('No screening'). Probabilities for a short cervix (CL ≤ 25 mm; base-case) and for spontaneous PTD at < 33 + 0 weeks and at 33 + 0 to 36 + 6 weeks were derived from the CERVIX study, and probabilities for stillbirth, neonatal mortality and long-term morbidity (cerebral palsy) from Swedish health data registers. Costs were based on Swedish data, except costs for cerebral palsy, which were based on Danish data. We assumed that vaginal progesterone reduces spontaneous PTD before 33 weeks by 30% and spontaneous PTD at 33-36 weeks by 10% (based on the literature). All analyses were from a societal perspective. We expressed the effectiveness of each strategy as gained quality-adjusted life years (QALYs) and presented cost-effectiveness as average (ACER; average cost per gained QALY compared with 'No screening') and incremental (ICER; difference in costs divided by the difference in QALYs for each of two strategies being compared) cost-effectiveness ratios. We performed deterministic and probabilistic sensitivity analysis. The results of the latter are shown as cost-effectiveness acceptability curves. Willingness-to-pay was set at a maximum of 500 000 Swedish krona (56 000 US dollars (USD)), as suggested by the Swedish National Board of Health and Welfare. RESULTS All interventions had better health outcomes than did 'No screening', with fewer screening-year deaths and more lifetime QALYs. The best strategy in terms of improved health outcomes was 'Low-risk-based screening', irrespective of whether screening was performed at 18 + 0 to 20 + 6 weeks (Cx1) or at 21 + 0 to 23 + 6 weeks (Cx2). 'Low-risk-based screening' at Cx1 was cost-effective, while 'Low-risk-based screening' at Cx2 entailed high costs compared with other alternatives. The ACERs were 2200 USD for 'Low-risk-based screening' at Cx1 and 36 800 USD for 'Low-risk-based screening' at Cx2. Cost-effectiveness was particularly sensitive to progesterone effectiveness and to productivity loss due to sick leave during pregnancy. The probability that 'Low-risk-based screening' at Cx1 is cost-effective compared with 'No screening' was 71%. CONCLUSION Interventions to prevent spontaneous PTD in asymptomatic women with a singleton pregnancy, including CL screening with progesterone treatment of cases with a short cervix, may be cost-effective in Sweden. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T. Wikström
- Centre of Perinatal Medicine and Health, Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of ObstetricsGothenburgSweden
| | | | - B. Jacobsson
- Centre of Perinatal Medicine and Health, Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of ObstetricsGothenburgSweden
| | - H. Hagberg
- Centre of Perinatal Medicine and Health, Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of ObstetricsGothenburgSweden
| | - P. Lindgren
- Department of Clinical Science, Intervention and Technology, Karolinska InstitutetStockholmSweden
- Centre for Fetal MedicineKarolinska University HospitalStockholmSweden
| | - M. Svensson
- School of Public Health and Community Medicine, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - U.‐B. Wennerholm
- Centre of Perinatal Medicine and Health, Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of ObstetricsGothenburgSweden
| | - L. Valentin
- Department of Obstetrics and GynecologySkåne University HospitalMalmöSweden
- Department of Clinical Sciences MalmöLund UniversityMalmöSweden
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Kjell J, Svensson M. Advancing Peripheral Nerve Graft Transplantation for Incomplete Spinal Cord Injury Repair. Front Cell Neurosci 2022; 16:885245. [PMID: 35573831 PMCID: PMC9097274 DOI: 10.3389/fncel.2022.885245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Peripheral nerves have a propensity for axon growth and regeneration that the central nervous system lacks (CNS). However, CNS axons can also grow long distances if introduced to a graft harvested from a peripheral nerve (PNGs), which is the rationale for using PNGs as repair strategy for injuries of the spinal cord. From a clinical perspective, PNGs provide interesting possibilities with potential to repair the injured spinal cord. First, there are numerous options to harvest autologous grafts associated with low risk for the patient. Second, a PNG allow axons to grow considerable distances and can, by the surgical procedure, be navigated to specific target sites in the CNS. Furthermore, a PNG provides all necessary biological substrates for myelination of elongating axons. A PNG can thus be suited to bridge axons long distances across an injury site and restore long tracts in incomplete SCI. Experimentally, locomotor functions have been improved transplanting a PNG after incomplete injury. However, we still know little with regard to the formation of new circuitries and functional outcome in association to when, where, and how grafts are inserted into the injured spinal cord, especially for sensory functions. In this perspective, we discuss the advantages of PNG from a clinical and surgical perspective, the need for adding/repairing long tracts, how PNGs are best applied for incomplete injuries, and the unexplored areas we believe are in need of answers.
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Affiliation(s)
- Jacob Kjell
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Neurosurgery, Karolinska University Hospital, Solna, Sweden
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Larsson S, Svensson M, Ternhag A. Production loss and sick leave caused by antibiotic resistance: a register-based cohort study. BMC Public Health 2022; 22:527. [PMID: 35300650 PMCID: PMC8932015 DOI: 10.1186/s12889-022-12947-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Adverse economic consequences of antibiotic resistance, both in health care systems and in society at large, have been estimated to emerge and significantly affect the global economy. To date, most studies of the societal costs of antibiotic resistance have had a macroeconomic perspective, using the number of attributable deaths as a quantifier for production loss. In contrast, there have been few studies of the consequences of antibiotic resistance in terms of the length of sick leave and hence the impact of morbidity on production loss. The aim of our study was to estimate the production loss from ill health caused by antibiotic resistance. Method To estimate additional production loss due to antibiotic resistance, we used Swedish register-based cohort data to determine days of long-term sick leave (LTSL) for episodes of infection caused by resistant and susceptible bacteria respectively. We collected patient data for four common infection types (bloodstream infection, urinary tract infection, skin and soft tissue infection, and pneumonia), as well as, antibiotic susceptibility test data, and total days of LTSL. We used a two-part model to estimate the number of LTSL days attributable to resistance, and controlled for comorbidities and demographic variables such as age and gender. Results The results show that antibiotic resistance adds an additional 8.19 days of LTSL compared with a similar infection caused by susceptible bacteria, independent of infection type and resistance type. Furthermore, the results suggest that production loss due to temporary sick leave caused by antibiotic resistance in a working-age population amounts to about 7% of total health care costs attributable to antibiotic resistance in Sweden. Conclusion Estimating the effect of antibiotic resistance in terms of temporary production loss is important to gain a better understanding of the economic consequences of antibiotic resistance in society and, by extension, enable more effective resource allocation to combat further emergence of resistance. Society’s economic costs of antibiotic resistance are, however, probably much greater than those of sick leave due to disease alone. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12947-x.
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Affiliation(s)
- Sofie Larsson
- Public Health Agency of Sweden, SE-171 82, Solna, Sweden. .,School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Anders Ternhag
- Public Health Agency of Sweden, SE-171 82, Solna, Sweden.,Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
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Ho-Henriksson CM, Svensson M, Thorstensson CA, Nordeman L. Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial. BMC Musculoskelet Disord 2022; 23:260. [PMID: 35300671 PMCID: PMC8932301 DOI: 10.1186/s12891-022-05201-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 03/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial. Methods Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve. Results 69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72–80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care. Conclusion These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients’ perception of this model of care are needed. Clinical trial registration The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05201-3.
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Affiliation(s)
- Chan-Mei Ho-Henriksson
- Region Västra Götaland, Primary Care Rehabilitation, Närhälsan Lidköping Rehabmottagning, Lidköping, Sweden. .,Department of Health and rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.
| | - Mikael Svensson
- University of Gothenburg, Sahlgrenska Academy, Institute of Medicine, School of Public Health and Community Medicine, Gothenburg, Sweden
| | - Carina A Thorstensson
- Department of Health and rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Research and Development Department at Region Halland, Halmstad, Sweden
| | - Lena Nordeman
- Department of Health and rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Region Västra Götaland, Research, Education, Development and Innovation, Primary Health Care, Research, Education, Development and Innovation Centre Södra Älvsborg, Borås, Sweden
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Fletcher-Sandersjöö A, Tatter C, Tjerkaski J, Bartek J, Svensson M, Thelin EP, Bellander BM. Clinical Significance of Vascular Occlusive Events following Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study. Semin Thromb Hemost 2022; 48:301-308. [PMID: 34991168 DOI: 10.1055/s-0041-1740567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Preventing hemorrhage progression is a potential therapeutic opportunity in traumatic brain injury (TBI) management, but its use has been limited by fear of provoking vascular occlusive events (VOEs). However, it is currently unclear whether VOE actually affects outcome in these patients. The aim of this study was to determine incidence, risk factors, and clinical significance of VOE in patients with moderate-to-severe TBI. A retrospective observational cohort study of adults (≥15 years) with moderate-to-severe TBI was performed. The presence of a VOE during hospitalization was noted from hospital charts and radiological reports. Functional outcome, using the Glasgow Outcome Scale (GOS), was assessed at 12 months posttrauma. Univariate and multivariate logistic regressions were used for endpoint assessment. In total, 848 patients were included, with a median admission Glasgow Coma Scale of 7. A VOE was detected in 54 (6.4%) patients, of which cerebral venous thrombosis was the most common (3.2%), followed by pulmonary embolism (1.7%) and deep vein thrombosis (1.3%). Length of ICU stay (p < 0.001), body weight (p = 0.002), and skull fracture (p = 0.004) were independent predictors of VOE. VOE development did not significantly impact 12-month GOS, even after adjusting for potential confounders using propensity score matching. In conclusion, VOE in moderate-to-severe TBI patients was relatively uncommon, and did not affect 12-month GOS. This suggests that the potential benefit of treating bleeding progression might outweigh the risks of VOE.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Charles Tatter
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jonathan Tjerkaski
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Mikael Svensson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Labori F, Persson J, Bonander C, Jood K, Svensson M. Cost-effectiveness analysis of left atrial appendage occlusion in patients with atrial fibrillation and contraindication to oral anticoagulation. Eur Heart J 2021; 43:1348-1356. [PMID: 34919652 PMCID: PMC8970986 DOI: 10.1093/eurheartj/ehab847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/08/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Aims This study aims to estimate the cost-effectiveness of percutaneous left atrial appendage occlusion (LAAO) compared to standard stroke prevention care for patients with atrial fibrillation (AF) and contraindication to oral anticoagulation (OAC) in a Swedish healthcare and public sector perspective. Methods and results We used a combined decision tree and cohort Markov model to estimate costs and quality-adjusted life-years (QALYs) over a lifetime horizon with LAAO compared to standard of care where the treatment effect is based on a recent meta-analysis. According to our analysis, LAAO gives more QALYs than standard of care (7.11 vs. 6.12). Furthermore, LAAO treatment is related to the first-year cost of 14 984 Euro (EUR) and higher average healthcare costs over the lifetime by about 4010 EUR, which gives an incremental cost-effectiveness ratio of LAAO vs. standard of care at 4047 EUR per gained QALY. From a public sector perspective, LAAO reduces average costs due to substantial reductions in long-term care and, thus, implies that LAAO is dominant from a public sector perspective (lower average costs and better health outcomes). Conclusion From both Swedish healthcare and public sector perspectives, LAAO can be considered cost-effective compared to standard of care for individuals with AF and contraindication to OAC. However, these results must be confirmed in health economic evaluations alongside the ongoing randomized clinical trials. Key Question Is left atrial appendage occlusion (LAAO) cost-effective for patients with atrial fibrillation (AF) and contraindication to oral anticoagulation (OAC) compared to the standard of care from a Swedish healthcare and public sector perspective? Key Finding LAAO is associated with lower cost than the standard of care from a public sector perspective and an incremental cost of 4010 Euro from a healthcare perspective. Furthermore, LAAO is related to better health outcomes than the standard of care. Take Home Message Treatment with LAAO among individuals with AF and contraindication to OAC can be considered as cost-effective compared to the standard of care from a Swedish healthcare and public sector perspective.
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Affiliation(s)
- Frida Labori
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg 405 30, Sweden
| | - Josefine Persson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg 405 30, Sweden
| | - Carl Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg 405 30, Sweden
| | - Katarina Jood
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Blå stråket 7, Gothenburg 413 45, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Neurology, Blå Stråket 7, Gothenburg 413 45, Sweden
| | - Mikael Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, Gothenburg 405 30, Sweden
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Djerf H, Svensson M, Nordanstig J, Gottsäter A, Falkenberg M, Lindgren H. Cost Effectiveness of Primary Stenting in the Superficial Femoral Artery for Intermittent Claudication: Two Year Results of a Randomised Multicentre Trial. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Alkmark M, Wennerholm UB, Saltvedt S, Bergh C, Carlsson Y, Elden H, Fadl H, Jonsson M, Ladfors L, Sengpiel V, Wesström J, Hagberg H, Svensson M. Induction of labour at 41 weeks of gestation versus expectant management and induction of labour at 42 weeks of gestation: a cost-effectiveness analysis. BJOG 2021; 129:2157-2165. [PMID: 34534404 DOI: 10.1111/1471-0528.16929] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/07/2021] [Accepted: 05/19/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of induction of labour (IOL) at 41 weeks of gestation compared with expectant management until 42 weeks of gestation. DESIGN A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial. SETTING Fourteen Swedish hospitals during 2016-2018. POPULATION Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41 weeks of gestation to IOL or to expectant management and induction at 42 weeks of gestation. METHODS Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping. MAIN OUTCOME MEASURES The cost per gained life year and per gained QALY. RESULTS The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was €4108 in the IOL group (n = 1373) and €4037 in the expectant management group (n = 1373), with a mean difference of €71 (95% CI -€232 to €379). The ICER for IOL compared with expectant management was €545 per life year gained and €623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes. CONCLUSIONS Induction of labour at 41 weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42 weeks of gestation using standard threshold values for acceptable cost per life year/QALY. TWEETABLE ABSTRACT Induction of labour at 41 weeks of gestation is cost-effective compared with expectant management until 42 weeks of gestation.
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Affiliation(s)
- M Alkmark
- Department of Obstetrics and Gynaecology, Centre of Perinatal Medicine & Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - U-B Wennerholm
- Department of Obstetrics and Gynaecology, Centre of Perinatal Medicine & Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S Saltvedt
- Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - C Bergh
- Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Y Carlsson
- Department of Obstetrics and Gynaecology, Centre of Perinatal Medicine & Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Elden
- Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Health and Caring Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - H Fadl
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - L Ladfors
- Department of Obstetrics and Gynaecology, Centre of Perinatal Medicine & Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - V Sengpiel
- Department of Obstetrics and Gynaecology, Centre of Perinatal Medicine & Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J Wesström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Center for Clinical Research Dalarna, Falu Hospital, Falun, Sweden
| | - H Hagberg
- Department of Obstetrics and Gynaecology, Centre of Perinatal Medicine & Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Svensson
- School of Public Health & Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Widmark-Jensen E, Bernhardsson S, Eriksson M, Hallberg H, Jepsen C, Jivegård L, Liljegren A, Petzold M, Svensson M, Wärnberg F, Hansson E. A systematic review and meta-analysis of risks and benefits with breast reduction in the public healthcare system: priorities for further research. BMC Surg 2021; 21:343. [PMID: 34511096 PMCID: PMC8436537 DOI: 10.1186/s12893-021-01336-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/28/2021] [Indexed: 11/12/2022] Open
Abstract
Background There is no consensus for when publicly funded breast reduction is indicated and recommendations in guidelines vary greatly, indicating a lack of evidence and unequal access. The primary aim of this review was to examine risks and benefits of breast reduction to treat breast hypertrophy. Secondary aims were to examine how the studies defined breast hypertrophy and indications for a breast reduction. Methods A systematic literature search was conducted in PubMed, MEDLINE All, Embase, the Cochrane Library, and PsycInfo. The included articles were critically appraised, and certainty of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible. Results Fifteen articles were included; eight reporting findings from four randomised controlled trials, three non-randomised controlled studies, three case series, and one qualitative study. Most studies had serious study limitations and problems with directness. Few of the studies defined breast hypertrophy. The studies showed significantly improved health-related quality of life and sexuality-related outcomes in patients who had undergone breast reduction compared with controls, as well as reduced depressive symptoms, levels of anxiety and pain. Most effect sizes exceeded the reported minimal important difference for the scale. Certainty of evidence for the outcomes above is low (GRADE ⊕ ⊕). Although four studies reported significantly improved physical function, the effect is uncertain (very low certainty of evidence, GRADE ⊕). None of the included studies reported data regarding work ability or sick leave. Three case series reported a 30-day mortality of zero. Reported major complications after breast reduction ranged from 2.4 to 14% and minor complications from 2.4 to 69%. Conclusion There is a lack of high-quality studies evaluating the results of breast reduction. A breast reduction may have positive psychological and physical effects for women, but it is unclear which women benefit the most and which women should be offered a breast reduction in the public healthcare system. Several priorities for further research have been identified. Pre-registration The study is based on a Health Technology Assessment report, pre-registered and then published on the website of The Regional HTA Centre of Region Västra Götaland, Sweden. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01336-7.
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Affiliation(s)
- Emmelie Widmark-Jensen
- Department of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden.,Department of Plastic and Reconstructive Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden
| | - Susanne Bernhardsson
- Region Västra Götaland, Research and Development Primary Health Care, Kungsgatan 12, SE-411 19, Gothenburg, Sweden.,Health Technology Assessment Centre, Region Västra Götaland, Sahlgrenska University Hospital, Röda Stråket 8, 413 45, Gothenburg, Sweden.,Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maud Eriksson
- Health Technology Assessment Centre, Region Västra Götaland, Sahlgrenska University Hospital, Röda Stråket 8, 413 45, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Medical Library, Vita Stråket 12, SE-413 45, Gothenburg, Sweden
| | - Håkan Hallberg
- Department of Plastic and Reconstructive Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden
| | - Christian Jepsen
- Department of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden.,Department of Plastic and Reconstructive Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden
| | - Lennart Jivegård
- Health Technology Assessment Centre, Region Västra Götaland, Sahlgrenska University Hospital, Röda Stråket 8, 413 45, Gothenburg, Sweden
| | - Ann Liljegren
- Health Technology Assessment Centre, Region Västra Götaland, Sahlgrenska University Hospital, Röda Stråket 8, 413 45, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Medical Library, Vita Stråket 12, SE-413 45, Gothenburg, Sweden
| | - Max Petzold
- Health Technology Assessment Centre, Region Västra Götaland, Sahlgrenska University Hospital, Röda Stråket 8, 413 45, Gothenburg, Sweden.,School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Health Technology Assessment Centre, Region Västra Götaland, Sahlgrenska University Hospital, Röda Stråket 8, 413 45, Gothenburg, Sweden.,Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Wärnberg
- Department of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Blå Stråket, 413 46, Gothenburg, Sweden
| | - Emma Hansson
- Department of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden. .,Department of Plastic and Reconstructive Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna Stråket 8, SE-413 45, Gothenburg, Sweden.
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Djerf H, Svensson M, Nordanstig J, Gottsäter A, Falkenberg M, Lindgren H. Editor's Choice - Cost Effectiveness of Primary Stenting in the Superficial Femoral Artery for Intermittent Claudication: Two Year Results of a Randomised Multicentre Trial. Eur J Vasc Endovasc Surg 2021; 62:576-582. [PMID: 34454817 DOI: 10.1016/j.ejvs.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 07/02/2021] [Accepted: 07/11/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Invasive treatment of intermittent claudication (IC) is commonly performed, despite limited evidence of its cost effectiveness. IC symptoms are mainly caused by atherosclerotic lesions in the superficial femoral artery (SFA), and endovascular treatment is performed frequently. The aim of this study was to investigate its cost effectiveness vs. non-invasive treatment. METHODS One hundred patients with IC due to lesions in the SFA were randomised to treatment with primary stenting, best medical treatment (BMT) and exercise advice (stent group), or to BMT and exercise advice alone (control group). Patients were recruited at seven hospitals in Sweden. For this analysis of cost effectiveness after 24 months, 84 patients with data on quality adjusted life years (QALY; based on the EuroQol Five Dimensions EQ-5D 3L™ questionnaire) were analysed. Patient registry and imputed cost data were used for accumulated costs regarding hospitalisation and outpatient visits. RESULTS The mean cost per patient was €11 060 in the stent group and €4 787 in the control group, resulting in a difference of €6 273 per patient between the groups. The difference in mean QALYs between the groups was 0.26, in favour of the stent group, which resulted in an incremental cost effectiveness ratio (ICER) of € 23 785 per QALY. CONCLUSION The costs associated with primary stenting in the SFA for the treatment of IC were higher than for exercise advice and BMT alone. With concurrent improvement in health related quality of life, primary stenting was a cost effective treatment option according to the Swedish national guidelines (ICER < €50 000 - €70 000) and approaching the UK's National Institute for Health and Care Excellence threshold for willingness to pay (ICER < £20 000 - £30 000). From a cost effectiveness standpoint, primary stenting of the SFA can, in many countries, be used as an adjunct to exercise training advice, but it must be considered that successful implementation of structured exercise programmes and longer follow up may alter these findings.
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Affiliation(s)
- Henrik Djerf
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department for Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Lindgren
- Vascular Centre, Skåne University Hospital, Malmö, Sweden; Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
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Holst A, Labori F, Björkelund C, Hange D, Svenningsson I, Petersson EL, Westman J, Möller C, Svensson M. Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: 12-month economic evaluation of a pragmatic randomised controlled trial. Cost Eff Resour Alloc 2021; 19:52. [PMID: 34404426 PMCID: PMC8369323 DOI: 10.1186/s12962-021-00304-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/29/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives To study the cost-effectiveness of a care manager organization for patients with mild to moderate depression in Swedish primary care in a 12-month perspective. Methods Cost-effectiveness analysis of the care manager organization compared to care as usual (CAU) in a pragmatic cluster randomised controlled trial including 192 individuals in the care manager group and 184 in the CAU group. Cost-effectiveness was assessed from a health care and societal perspectives. Costs were assessed in relation to two different health outcome measures: depression free days (DFDs) and quality adjusted life years (QALYs). Results At the 12-month follow-up, patients treated at the intervention Primary Care Centres (PCCs) with a care manager organization had larger health benefits than the group receiving usual care only at control PCCs. Mean QALY per patient was 0.73 (95% CI 0.7; 0.75) in the care manager group compared to 0.70 (95% CI 0.66; 0.73) in the CAU group. Mean DFDs was 203 (95% CI 178; 229) in the care manager group and 155 (95% CI 131; 179) in the CAU group. Further, from a societal perspective, care manager care was associated with a lower cost than care as usual, resulting in a dominant incremental cost-effectiveness ratio (ICER) for both QALYs and DFDs. From a health care perspective care manager care was related to a low cost per QALY (36,500 SEK / €3,379) and DFD (31 SEK/€3). Limitations A limitation is the fact that QALY data was impaired by insufficient EQ-5D data for some patients. Conclusions A care manager organization at the PCC to increase quality of care for patients with mild-moderate depression shows high health benefits, with no decay over time, and high cost-effectiveness both from a health care and a societal perspective. Trial registration details: The trial was registered in ClinicalTrials.com (https://clinicaltrials.gov/ct2/show/NCT02378272) in 02/02/2015 with the registration number NCT02378272. The first patient was enrolled in 11/20/2014. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00304-5.
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Affiliation(s)
- Anna Holst
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Allmänmedicin, Box 453, 405 30, Gothenburg, Sweden.
| | - Frida Labori
- Health Economics and Policy/School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Allmänmedicin, Box 453, 405 30, Gothenburg, Sweden
| | - Dominique Hange
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Allmänmedicin, Box 453, 405 30, Gothenburg, Sweden
| | - Irene Svenningsson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Allmänmedicin, Box 453, 405 30, Gothenburg, Sweden.,Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
| | - Eva-Lisa Petersson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Allmänmedicin, Box 453, 405 30, Gothenburg, Sweden.,Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
| | - Jeanette Westman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Christina Möller
- Primary Health Care Head Office, Närhälsan, Region Västra Götaland, Gothenburg, Sweden
| | - Mikael Svensson
- Health Economics and Policy/School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Bonander C, Svensson M. Using causal forests to assess heterogeneity in cost-effectiveness analysis. Health Econ 2021; 30:1818-1832. [PMID: 33942950 DOI: 10.1002/hec.4263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Revised: 12/17/2020] [Accepted: 02/25/2021] [Indexed: 06/12/2023]
Abstract
We develop a method for data-driven estimation and analysis of heterogeneity in cost-effectiveness analyses (CEA) with experimental or observational individual-level data. Our implementation uses causal forests and cross-fitted augmented inverse probability weighted learning to estimate heterogeneity in incremental outcomes, costs and net monetary benefits, as well as other parameters relevant to CEA. We also show how the results can be visualized in relevant ways for the analysis of heterogeneity in CEA, such as using individual-level cost effectiveness planes. Using a simulated dataset and an R package implementing our methods, we show how the approach can be used to estimate the average cost-effectiveness in the entire sample or in subpopulations, explore and analyze the heterogeneity in incremental outcomes, costs and net monetary benefits (and their determinants), and learn policy rules from the data.
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Affiliation(s)
- Carl Bonander
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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50
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Labori F, Bonander C, Persson J, Svensson M. Clinical follow-up of left atrial appendage occlusion in patients with atrial fibrillation ineligible of oral anticoagulation treatment-a systematic review and meta-analysis. J Interv Card Electrophysiol 2021; 61:215-225. [PMID: 33580847 PMCID: PMC8324592 DOI: 10.1007/s10840-021-00953-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/01/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE The recommended stroke prevention for patients with atrial fibrillation (AF) and increased risk of ischemic stroke is oral anticoagulation (OAC). Parts of the patient population are not eligible due to contraindication, and percutaneous left atrial occlusion (LAAO) can then be a preventive treatment option. The aim of this systematic review and meta-analysis is to estimate the long-term clinical effectiveness of LAAO as stroke prevention in patients with AF, increased risk of ischemic stroke, and contraindication to OAC. METHODS We performed a systematic review and meta-analysis, using Poisson random effect models, to estimate the incidence rate (events per 100 patient-years) of ischemic stroke, transient ischemic attack, major bleeding, and all-cause death after LAAO treatment. We also calculated the risk reduction of ischemic stroke with LAAO compared with no stroke prevention estimated through a predicted risk in an untreated population (5.5 per 100 patient-years). RESULTS We included 29 observational studies in our meta-analysis, including 7 951 individuals and 12 211 patient-years. The mean CHA2DS2-VASc score among the patients in the included studies is 4.32. The pooled incidence rate of ischemic stroke is 1.38 per 100 patient-years (95% CI 1.08; 1.77). According to a meta-regression model, the estimated incidence rate of ischemic stroke at CHA2DS2-VASc 4 is 1.39 per 100 patient-years. This implies a risk reduction of 74.7% with LAAO compared to predicated risk with no stroke prevention. CONCLUSIONS Our results suggest that LAAO is effective as stroke prevention for patients with AF, increased risk of stroke, and contraindication to oral anticoagulation.
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Affiliation(s)
- Frida Labori
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden.
| | - Carl Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
| | - Josefine Persson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
| | - Mikael Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
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