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Background: Many individuals with hypertension remain undiagnosed. We aimed to develop a predictive model for hypertension using diagnostic codes from prevailing electronic medical records in Swedish primary care., Methods: This sex- and age-matched case-control (1:5) study included patients aged 30-65 years living in the Stockholm Region, Sweden, with a newly recorded diagnosis of hypertension during 2010-19 (cases) and individuals without a recorded hypertension diagnosis during 2010-19 (controls), in total 507,618 individuals. Patients with diagnoses of cardiovascular diseases or diabetes were excluded. A stochastic gradient boosting machine learning model was constructed using the 1,309 most registered ICD-10 codes from primary care for three years prior the hypertension diagnosis., Results: The model showed an area under the curve (95 % confidence interval) of 0.748 (0.742-0.753) for females and 0.745 (0.740-0.751) for males for predicting diagnosis of hypertension within three years. The sensitivity was 63 % and 68 %, and the specificity 76 % and 73 %, for females and males, respectively. The 25 diagnoses that contributed the most to the model for females and males all exhibited a normalized relative influence >1 %. The codes contributing most to the model, all with an odds ratio of marginal effects >1 for both sexes, were dyslipidaemia, obesity, and encountering health services in other circumstances., Conclusions: This machine learning model, using prevailing recorded diagnoses within primary health care, may contribute to the identification of patients at risk of unrecognized hypertension. The added value of this predictive model beyond information of blood pressure warrants further study., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

The high prevalence of stress-related disorders and depression underscores the urgent need to unravel their impact on individual well-being. This study aim to investigate common psychiatric and stress-related diagnoses, along with postviral fatigue, in individuals with prior stress-induced exhaustion disorder (SED) and prior depression compared to those without prior SED or depression, and to study whether the psychiatric comorbidity patterns differ. The study includes individuals in Region Stockholm who, in 2011, did not have a diagnosis of SED or depression. ICD-10 diagnosis of SED, depression, or both, recorded in 2012-2013, were compared to individuals without prior SED or depression in a cohort (n = 1,362,886), aged 18 to 65. Odds ratios (OR) with 99 % confidence intervals, adjusted for age and neighborhood socioeconomic status, were calculated for psychiatric disorders and post-viral fatigue in 2014-2022. Patients with prior SED showed associations primarily with stress related diagnoses, including acute stress reaction, reaction to severe stress, as well as post-COVID-19 and post-viral fatigue syndrome. These ORs were all larger for SED than depression. Depression was primarily associated with post-traumatic stress disorder (PTSD), alcohol related and substance use disorders, schizophrenia, schizotypal disorders, delusional disorders, manic episode, bipolar affective disorder, persistent mood disorder, neurotic disorder, borderline personality disorder, autistic disorder, Asperger's syndrome, attention -deficit hyperactivity disorder, attention-deficit disorders ADHD/ADD), and suicide attempt. These ORs were all higher for depression, although autistic disorders, ADHD/ADD and PTSD were also highly associated with prior SED (OR > 3.5). The divergent psychiatric comorbidity patterns suggest different underlying mechanisms and clinical prognosis., Competing Interests: Declaration of competing interest There's no financial/personal interest or belief that could affect our objectivity, i.e., there are no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Chronic stress and depression are potential risk factors for mild cognitive impairment and dementia, including Alzheimer disease. The aim was to investigate whether any such risk is additive., Methods: Cohort study including 1 362 548 people (665 997 women, 696 551 men) with records in the Region Stockholm administrative healthcare database (VAL). Exposure was a recorded ICD-10 diagnosis of chronic stress, depression, or both, recorded in 2012 or 2013. Outcome was a diagnosis of Alzheimer disease, other dementia, or mild cognitive impairment recorded from 2014 through 2022. Odds ratios with 99% confidence intervals (CI) adjusted for age, sex, neighborhood socioeconomic status, diabetes, and cardiovascular disorders were calculated., Results: During the exposure period, 4 346 patients were diagnosed with chronic stress, 40 101 with depression, and 1 898 with both. The average age at baseline was around 40 years in all groups. In the fully adjusted model, the odds ratio of Alzheimer disease was 2.45 (99% CI 1.22-4.91) in patients with chronic stress, 2.32 (99% CI 1.85-2.90) in patients with depression, and 4.00 (99% CI 1.67-9.58) in patients with chronic stress and depression. The odds ratio of mild cognitive impairment was 1.87 (99% CI 1.20-2.91) in patients with chronic stress, 2.85 (99% CI 2.53-3.22) in patients with depression, and 3.87 (99% CI 2.39-6.27) in patients with both. When other dementia was analyzed, the odds ratio was significant only in patients with depression, 2.39 (99% CI 1.92-2.96)., Conclusions: Documented chronic stress increased the risk of mild cognitive impairment and Alzheimer disease. The same was seen with depression. The novel finding is the potential additive effect of chronic stress to depression, on risk of MCI and AD., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: Mental health disorders are prevalent among individuals with intellectual disabilities (ID). However, there is a lack of research on the impact of concomitant autism spectrum disorders (ASD) or attention deficit hyperactivity disorder (ADHD) on the mental health within this population. We aimed to investigate the prevalence of mental health disorders and registered healthcare visits due to self-harm among individuals with ID., Method: We used administrative data for all healthcare with at least one recorded diagnosis of mental health disorder or self-harm during 2007-2017 among people with a diagnosis of Down syndrome (DS; n  = 1298) and with ID without DS (IDnonDS; n  = 10,671) using the rest of the population in Stockholm Region ( n  = 2,048,488) for comparison., Results: The highest odds ratios for a mental health disorder were present in females with IDnonDS (9.01) followed by males with IDnonDS (8.50), compared to the general population. The ORs for self-harm among individuals with IDnonDS were high (8.00 for females and 6.60 for males). There were no registered cases of self-harm among individuals with DS. The prevalence of an anxiety or affective disorder was higher among individuals with ID including DS with concomitant ASD or ADHD. Neighbourhood socio-economic status was associated with a lower occurrence of mental health disorders and self-harm in wealthier areas for all outcomes and for all groups., Conclusions: Self-harm and psychiatric comorbidities were common among individuals with ID without DS with an attenuated difference among those with concomitant ASD or ADHD, which calls for attention.

Objective: Association between some somatic diseases and primary open-angle glaucoma (POAG) are well-known. We aimed to study psychiatric diseases and dementia and their association with POAG in the total population of Region Stockholm., Methods: All living individuals above 18 years of age who resided in Stockholm County, Sweden, on 1 January 2017 ( N  = 1,703,675) were included. Data were obtained from administrative regional data. We identified individuals with specified psychiatric disorders in the years 2010-2019, and further identified those with an incident diagnosis of POAG during 2012-2018. Analyses were performed by age-group and sex. We calculated odds ratios (ORs) with 95% confidence intervals (95% CI), adjusted for age and neighborhood socio-economic status for individuals with POAG, and used individuals without POAG as referents., Results: A total of 16,299 cases of POAG were identified, of whom 9204 were women and 7095 men. Adjusted OR (95% CI) for the risk of POAG was 0.653 (0.610-0.698) for women and 0.714 (0.656-0.778) for men with dementia, respectively. The OR for POAG was 0.478 (0.355-0.643) for women with psychosis, and 1.164 (1.105-1.227) for women with depression. A high neighbourhood socio-economic status was associated with a higher risk of POAG. Other associations were non-significant., Conclusion: The prevalence of newly diagnosed POAG was decreased in men and women with dementia, and in women with psychosis, which could be an underestimation, owing to lack of investigation, which warrants attention. The risk of POAG was increased in women with depression, which could be secondary to the glaucoma diagnosis.KEY MESSAGESThe prevalence of newly diagnosed glaucoma was decreased in men and women with dementia, and in women with psychosis. A lower prevalence of newly diagnosed glaucoma may be due to an underestimation, owing to a lack of investigation.The risk of glaucoma was increased in women with depression, which could be secondary to the glaucoma diagnosis.

Objective: We compare individuals with newly diagnosed HIV with sex-, age-, and socioeconomic status-matched HIV-negative controls, with the aim of studying the frequency of health care visits, the types of clinics visited, registered diagnoses, and psychopharmacotherapy., Methods: The data were collected through the Stockholm Region administrative database (Stockholm Regional Health Care Data Warehouse) for men and women (people) living with newly diagnosed HIV (PLWH) in their medical records (930 men, 450 women) and controls. The odds ratios (ORs) with 99% confidence intervals (CIs) for psychiatric comorbidities and relevant pharmacotherapies were calculated during the 2011-2018 period., Results: Substance use disorder was higher in PLWH than in controls, before and after newly diagnosed HIV in men (OR = 1 year before 4.36 [99% CI = 2.00-9.5] and OR = 1 year after 5.16 [99% CI = 2.65-10.08]) and women (OR = 1 year before 6.05 [99% CI = 1.89-19.40] and OR = 1 year after 5.24 [99% CI = 1.69-16.32]). Health care contacts and psychiatric disorders were more common in cases than controls 1 and 2 years after diagnosis, particularly for depression in men 1 year after HIV (OR = 3.14, 99% CI = 2.11-4.67), which was not found in women (1 year OR = 0.94, 99% CI = 0.50-1.77)., Conclusions: Before newly diagnosed HIV, PLWH have the same level of psychiatric diagnoses as their controls, except for substance use disorder. Psychiatric problems are more common in PLWH than in their controls after newly diagnosed HIV., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Psychosomatic Society.)

Background and Aims: Available epidemiological data on hepatocellular carcinoma (HCC) originate mainly from centre-based or disease-specific cohorts and may not reflect the general population. This population-based register study presents the incidence, aetiologies, treatments, survival, and differences related to sex or socioeconomic status in patients with HCC from Stockholm, which constitutes more than a fifth of the Swedish population., Methods: ICD-10 codes identified incident HCC cases in the regional administrative health care database 2003-2018. Administrative coding on diseases, socioeconomic status, and dispensed drugs were used to identify risk factors and therapies. Two validation analyses 2014-2015 studied the correctness of register-based aetiologies and reasons for providing only best supportive care (BSC)., Results: We identified 2,245 incident cases of HCC. The incidence increased from 6 to 7.5 per 100,000 inhabitants over the time-period. The most common aetiologies were hepatitis C (26%), non-alcoholic fatty liver disease (22%), and alcohol-related liver disease (19%). Five-year survival probability was 79% after liver transplantation, 60% after resection, and 35% after ablation but <10% for chemoembolization, Sorafenib, and BSC. The proportion receiving any treatment increased but half of the patients only received BSC. At least 14% of potentially treatable HCC (surveillance indicated but not performed) received only BSC 2014-2015. We found no significant differences in treatments or outcomes between socioeconomic groups., Conclusions: The incidence of HCC is rising in Stockholm, Sweden but is still low by global comparison. Near half of all patients still receive only BSC and study data suggest that surveillance practices are incomplete.

Objective: We aimed to study open-angle glaucoma in association with somatic comorbidities in the total population of adults in Region Stockholm., Methods: The study population included all living persons aged 19 years and above who resided in Stockholm County, Sweden, on 1 January 2017 (N = 1 703 675). Subjects with specified diseases were identified with data from all registered consultations and hospital stays during 2008-2019. As outcome, the risk of being associated with a diagnosis of open-angle glaucoma was identified during 2012-2018. Analyses were performed by gender, controlling for age and socio-economic status. Age-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for women and men with open-angle glaucoma, using individuals without this as referents, were calculated. Socio-economic status was assessed based on the neighbourhood the subjects lived in., Results: In total, 16,299 cases of open-angle glaucoma were identified during 2012-2018, 9204 women and 7095 men. Higher fully adjusted OR (95% CI) for risk of being associated with open-angle glaucoma was for women and men with diabetes 1.138 (1.074-1.207) and 1.216 (1.148-1.289), cancer 1.175 (1.120-1.233) and 1.106 (1.048-1.166), hypertension 1.372 (1.306-1.440) and 1.243 (1.179-1.311); and for women with thyroid diseases 1.086 (1.030-1.146), chronic lung diseases 1.153 (1.093-1.216), and inflammatory arthropathies 1.132 (1.006-1.275). Higher glaucoma incidence was observed in individuals residing in high socio-economic status neighbourhoods., Conclusion: The risk of glaucoma is increased in some somatic diseases, especially in individuals with diabetes, hypertension and cancer; and in higher socio-economic neighbourhoods as compared to lower socio-economic neighbourhoods., (© 2021. The Author(s).)

Background: An individual's drive to seek medical help remains a complex behavioural process, incorporating psychological, social and symptom-specific factors. Within irritable bowel syndrome (IBS), gastrointestinal symptoms only predict a small portion of the high healthcare-seeking experienced., Aim: To examine the moderating role of quality of life (QoL) domains on this relationship to help explain the variance observed., Methods: This is an analysis of a Swedish population-based prospective study of healthcare use over a 12-year period. At baseline, gastrointestinal symptoms were measured with the valid Gastrointestinal Symptom Rating Scale, and QoL via the SF-36. 1159 subjects (57% female; mean age 48.6 years) had their health records matched with the initial survey. 164 were classified as IBS by Rome II criteria. Negative binomial or logistic models were fit to evaluate the moderating effect of particular QoL domains on the relationship between gastrointestinal symptoms and prospective healthcare utilisation., Results: Gastrointestinal symptoms were associated with prospective healthcare use, but moderation in this relationship by particular QoL domains was not supported; most models did not reach statistical significance. Furthermore, the impact of IBS status did not alter the moderation hypotheses., Conclusions: Particular QoL domains did not impact the relationship between gastrointestinal symptoms on prospective healthcare seeking. Future research should continue to examine other psychological, social and symptom variables to identify predictors of high healthcare consumers in IBS., (© 2021 John Wiley & Sons Ltd.)

Background: Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively., Methods: This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18-64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses., Results: Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level < 95% or systolic blood pressure > 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients., Conclusions: Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients., (© 2021. The Author(s).)

Child sexual abuse (CSA) is a crime against human rights with severe health consequences, and suicidal actions, stress, eating disorders, and borderline disorder are common among survivors of CSA. The objective of this study was to analyze how health care consumption patterns developed among adolescent girls in the Stockholm Region, Sweden, 1 and 2 years after the first registration of CSA experience appeared in their medical record, as compared to age-matched controls without such registration. In this cohort study, number of healthcare visits, comorbidities, and prescribed drugs were collected through the Stockholm Region administrative database (VAL), for girls age 12-17 with registration of CSA experience in their medical record (n = 519) and age-matched controls (n = 4920) between 2011 and 2018. Healthcare consumption patterns remained higher among the girls with a registered CSA experience compared to the controls, both 1 and 2 years after the first CSA experience registration. Highest odds ratios (ORs) were found for suicide attempts [OR 26.38 (12.65-55.02) and 6.93 (3.48-13.49)]; stress disorders [25.97 (17.42-38.69) and 15.63 (9.82-24.88)]; psychosis [OR 19.39 (1.75-214.13) and 9.70 (1.36-68.95)], and alcohol abuse [OR 10.32 (6.48-16.44) and 6.09 (1.98-18.67)], 1 and 2 years, respectively, after the first CSA experience registration. The drug prescriptions were also significantly higher among the girls with a CSA experience registration than for the controls. The results highlight the need to systematically evaluate and develop assessment, treatment planning, and interventions offered to adolescent girls after their first CSA experience registration., (© 2020. The Author(s).)

Background: Treatment of multimorbid patients can be improved. Development of patient-centred care of high-quality requires context-bound understanding of the multimorbid population's patterns of demographics, co-morbidities and medication use., Objective: The aim of this study was to identify patterns of multimorbidity in the total population of Region Stockholm, Sweden, by exploring demographics, claimed prescription drugs, risk of mortality and non-random association of conditions., Methods: In this cross-sectional descriptive population-based cohort study, we extracted data from the Swedish VAL database (N = 2 323 667) including all consultations in primary and specialized outpatient care, all inpatient care and all prescriptions claimed during 2017. We report number of chronic conditions and claimed prescription drugs, physical and mental co-morbidity, and 1-year mortality. We stratified the analyses by sex. We examined non-random associations between diseases using cluster analysis., Results: In total, 21.6% had multimorbidity (two or more chronic conditions) and 24.1% had polypharmacy (more than five claimed prescription drugs). Number of claimed drugs, co-occurrence of mental and physical conditions, and 1-year mortality increased as multimorbidity increased. We identified seven multimorbidity clusters with clinically distinct characteristics. The smallest cluster (7% of individuals) had prominent cardiovascular disease, the highest 1-year mortality rate, high levels of multimorbidity and polypharmacy, and was much older. The largest cluster (27% of individuals) was younger and heterogenous, with primarily mental health problems., Conclusions: Individuals with chronic conditions often show clinical complexity with both concordant and discordant conditions and polypharmacy. This study indicates that clinical guidelines addressing clustering of conditions may be one strategy for managing complexity., (© The Author(s) 2020. Published by Oxford University Press.)

Aim: Refugee children have been shown to underutilise psychiatric services in Scandinavia. The aim of this study was to investigate determinants of psychiatric care utilisation in adolescents in refugee families., Methods: The study used regional data on healthcare use linked to sociodemographic data from national registers in a total population of 93 537 adolescents in the Stockholm County born in 1995-2000, including 18 831 with a refugee background. Cox regression analyses were fitted to estimate Hazard ratios (HRs) of psychiatric care utilisation in the age-span 11-18 years., Results: Psychiatric care use was lower in the large majority of adolescents in refugee families that originated in low- and middle-income countries, with adjusted HRs 0.34 (95% CI 0.28-0.42) and 0.51 (95% CI 0.46-0.56), respectively, compared with the Swedish majority population. Among the foreign-born refugee adolescents, psychiatric care use increased with duration of residence in Sweden and was higher in children who obtained residency as asylum seekers compared with those who settled in family reunification., Conclusion: Adolescents in newly settled refugee families with a background in low- and middle-income countries should be a priority in mental health assessment of refugee children and referral to psychiatric care facilitated for children in need., (© 2020 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Objectives: Heart failure (HF) management is suboptimal in Sweden despite available evidence-based guidelines. To improve HF treatment, a comprehensive HF management program (4D project) was implemented in the Stockholm County (>2.1 million inhabitants). Design. A standardized care program centralized at five hospital-based HF clinics was implemented in 2014-2017. We registered from 2012 to 2017: (1) numbers of referrals and visits to HF clinics, (2) numbers of hospital admitted patients per million inhabitants, (3) dispensed HF medications after admission, and (4) covariate-adjusted 1-year all-cause mortality or HF readmission. Results. Yearly visits to the five HF outpatient clinics increased 3.4 times from 3,372 to 11,527. Dispensed HF drug prescriptions increased, in particular, for readmitted patients, compared to 2012 ( p <.0001 ) . Total number of hospital admitted HF patients as well as new-onset or readmitted HF patients decreased by 16, 13, and 20%, respectively ( p  < .0001). The combined 1-year mortality or HF readmission over the period was 48% ( n  = 17,124/35,880) and improved per year (HR 0.98 [0.97-0.99], p  < .001) from 2012. Conclusion. A comprehensive standardized care HF management program including expanded HF clinics was associated with improved evidence-based medication, reduced HF hospitalization, and improvement of the combined outcome of 1-year mortality or HF readmission in Stockholm.

The timing of influenza case incidence during epidemics can differ between regions within nations and states. We conducted a prospective 10-year evaluation (January 2008-February 2019) of a local influenza nowcasting (short-term forecasting) method in 3 urban counties in Sweden with independent public health administrations by using routine health information system data. Detection-of-epidemic-start (detection), peak timing, and peak intensity were nowcasted. Detection displayed satisfactory performance in 2 of the 3 counties for all nonpandemic influenza seasons and in 6 of 9 seasons for the third county. Peak-timing prediction showed satisfactory performance from the influenza season 2011-12 onward. Peak-intensity prediction also was satisfactory for influenza seasons in 2 of the counties but poor in 1 county. Local influenza nowcasting was satisfactory for seasonal influenza in 2 of 3 counties. The less satisfactory performance in 1 of the study counties might be attributable to population mixing with a neighboring metropolitan area.

Victims of sexual abuse have more co-morbidities than other persons in the same age and the most affected group are adolescent girls. Little is known about how this is reflected in health care consumption patterns prior to the registered diagnosis. The aim of this investigation was to study health care consumption patterns among girls, 12-17 years old, 1 and 2 years prior to their diagnoses of sexual abuse. Through the Stockholm Region administrative database (VAL), data of co-morbidities, number of health care visits, and prescribed drugs were collected for cases (girls age 12-17 with diagnoses of sexual abuse, n = 519) and controls matched for age and socio-economic status (n = 4920) between 2011-2018. Health care consumption and co-morbidities were significantly higher for the cases compared to controls, with a rise 1 year before the diagnoses: the total number of health care visits (including no shows) 1 year prior to the first recording of the diagnosis was 20.4 (18.1-22.7) for the cases and 6.2 (5.8-6.6) for the controls. The most frequent visits 1 year prior to the diagnosis were to outdoor clinics, with a mean value of 19.1 (16.9-21.3) visits for the cases and 5.7 (5.3-6.1) for the controls, followed by psychiatric clinics with a mean value of 12.7 (10.6-14.8) visits for the cases and 2.0 (1.7-2.3) visits for the controls. The least visited health care clinic 1 year prior to the diagnosis was the emergency ward with a mean value of 1.3 (1.1-1.5) visits for the cases and 0.5 (0.4-0.5) visits for the controls. The most common psychiatric co-morbidities registered among the cases during the first year before the diagnosis of sexual abuse were stress, suicide attempt, and psychosis. Neuroleptics, sleeping pills, antidepressants, and tranquilizers were more frequently dispensed in cases than in controls. Similar patterns were found 2 years prior to the diagnosis. We encourage clinicians to actively ask for exposure of sexual abuse in girls with high health care consumption, making early detection and treatment of sexual abuse available as soon as possible.

Background & Aims: There is controversy about whether psychological factors (anxiety and depression) increase health care seeking by patients with irritable bowel syndrome (IBS). We investigated whether psychological factors increase health care seeking by patients with IBS and the effects of extragastrointestinal (extra-GI) symptoms., Methods: We performed a population-based prospective study of health care use over a 12-year period in Sweden. From 2002 through 2006, 1244 subjects were selected randomly for an examination by a gastroenterologist and to complete questionnaires, including the Rome II modular questionnaire. Psychological factors were measured with the valid Hospital Anxiety and Depression scale and extra-GI symptoms were measured with a symptom checklist. Responses from 1159 subjects (57% female; mean age, 48.65 y) were matched with health records in 2016 (164 were classified as having IBS based on Rome II criteria)., Results: The overall association between depression or anxiety and health care use varied in subjects with and without IBS at baseline. The presence of extra-GI symptoms strengthened the relationship between anxiety and depression and prospective psychiatric visits for subjects with IBS and without IBS (incidence rate ratio, 1.14-1.26). Extra-GI symptoms did not alter the association of anxiety or depression with use of GI or extra-GI health care., Conclusions: In a population-based study in Sweden, we found that individuals with high baseline anxiety or depression were more likely to seek psychiatric health care, but not GI or extra-GI health care, in the presence of extra-GI symptoms at baseline. Patients with IBS might benefit from more thorough assessments that examine extra-GI and psychological symptoms, to reduce health care utilization., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Specialized home-based palliative care (HPC) services aim at reducing the number of visits to emergency departments (EDs) and hospitalizations at end of life. In addition, it offers patients the possibility to die at home. Objective: To investigate whether the last years' expansion of palliative care in Stockholm County, Sweden, reduced the health care resource use and/or increased the number of patients who died at home. Design: This is a population-based study of all registered 2780 patients referred to HPC in 2015 in the Stockholm region. The majority of the patients (2087) had cancer, but 693 patients had chronic medical illness, most often cardiovascular and pulmonary diseases. Results: HPC reduced visits to the ED and hospital admissions by 51% and 41%, respectively. The number of hospital admissions to the departments of oncology, medicine, and surgery was reduced, whereas admissions to palliative care units increased. For the 1773 patients alive after 90 days with HPC, the number of days spent in hospital reduced from 19,628 before HPC to 13,743 (30%) days with HPC. The most common place of death was at a specialized palliative care unit (48%), whereas 36% died at home. Conclusions: HPC reduced emergency health care resource use for the majority of patients, despite patients having progressing disease. To improve the quality of end-of-life care, we need to make early integration of palliative care available for a larger number of patients. In addition, we have to improve care pathways, especially for patients with gastrointestinal and lung cancer, who continued to be frequently admitted to hospital.

Background: The objective was to identify predictors of societal costs covering formal and informal care utilization by older home care clients in 11 European countries., Methods: Societal costs of 1907 older clients receiving home care for 12 months from the Aged in Home care (AdHoc) study were estimated using the InterRAI Minimum Data Set for Home Care's (MDS-HC) resource use items. Predictors (medical, functional, and psychosocial domains) of societal costs were identified by performing univariate and multivariate generalized linear model analyses., Results: Mean societal costs per participant were €36 442, ranging from €14 865 in Denmark to €78 836 in the United Kingdom. In the final multivariate model, country, being married, activities of daily living (ADL) dependency, cognitive impairment, limitations of going out, oral conditions, number of medications, arthritis, and cerebro vascular accident (CVA) were significantly associated with societal costs., Conclusions: Of the predictors, ADL dependency and limitations of going out may be modifiable. Developing interventions targeted at improving these conditions may create opportunities to curtail societal costs., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The aim of this study was to examine the value of predischarge exercise electrocardiogram (ECG) testing of chest pain patients in whom acute myocardial infarction (MI) had been ruled out by means of high-sensitivity troponins, ECG and history., Methods: All patients hospitalised for chest pain who underwent exercise ECG testing before discharge from the Department of Cardiology, Södersjukhuset, Stockholm, Sweden from January 2011 to June 2012 were included. Endpoints were death, MI and post-discharge revascularisation within 90 and 365 days, respectively. The background one-year risk of death and MI for a corresponding age, gender and calendar time-matched Swedish population was also examined., Results: A total of 951 patients were included. In 585 patients (61.5%) the exercise ECG test was negative, in 94 (9.9%) positive and in 272 (28.6%) inconclusive. There were no significant differences regarding death or MI between patients with a positive or a negative test, neither at 90 ( n=1 (1.1%) vs. n=1 (0.2%)) nor at 365 days ( n=2 (2.1%) vs. n=4 (0.7%)) of follow-up. In total there were nine (0.9%) deaths and 10 (1.1%) MIs within 365 days. The one-year rates of death (1.3%) and MI (0.5%) in a matched Swedish population were comparable., Conclusions: Predischarge exercise ECG testing after rule out of MI did not predict subsequent death or MI in a population of patients hospitalised for chest pain. Furthermore, the risks of death and MI in this population were comparable to a matched Swedish population. These findings suggest that patients could be discharged without this test.

Background: Prior research based on self-reports has proven sexual abuse to be a risk factor for pain and psychiatric disorders. However, less is known about how this is reflected within the healthcare system. The aim of this study was to study the 2-year prevalence of diagnosis of sexual abuse and concomitant conditions., Methods: Using data from VAL, the study population included all living persons in Stockholm County, Sweden, between 1 January 2008 and 31 December 2014 (N=2 549 496). Diagnoses of sexual abuse were identified during 2013-2014, with information on the concomitant conditions somatic pain, depression, anxiety, psychotic disorders and bipolar disorders, stress disorders and alcohol and substance abuse. All diagnoses were prospectively registered. Age and neighbourhood socioeconomic status-adjusted ORs with 95% CIs for individuals with a diagnosis of sexual abuse, using individuals without sexual abuse as referents, were calculated., Results: Girls at the ages 13-17 years had the highest 2-year prevalence (0.69%) of sexual abuse followed by girls 5-12 years (0.11%), and girls 0-4 years (0.04%). For women 45 years and older the 2-year prevalence rates were substantially lower (0.008-0.004%). The highest 2-year prevalence of sexual abuse in men was seen in boys 5-12 (0.03%) years. The total 2-year prevalence of diagnoses of sexual abuse among the population in the material was 0.04%. The highest ORs of comorbidities for girls (ages 0-17 years) with sexual abuse versus those without sexual abuse were: Stress disorder; 15.7 (13.1 to 18.9), drug abuse; 10.0 (7.7 to 13.0), and alcohol abuse; 9.7(7.8 to 12.0). For boys (ages 0-17 years), the highest ORs of comorbidities were: Stress disorder 12.4 (6.0 to 25.7), anxiety disorders; 5.5 (2.6 to 11.5), and alcohol abuse; 3.9 (1.4 to 11.3). The highest ORs of comorbidities for women (18-) with sexual abuse versus those without sexual abuse were: alcohol abuse; 19.3 (12.6 to 29.6), drug abuse; 16.7 (10.7 to 26.1) and psychotic disorders; 15.3 (8.0 to 29.4). For men (18-) the highest ORs of comorbidities were: alcohol abuse; 25.8 (15.2 to 43.9), anxiety disorders; 14.3 (8.5 to 24.2) stress disorder; 12.9 (7.5 to 22.1) and drug abuse; 12.9 (6.9 to 24.1)., Conclusions: Diagnoses of drug and alcohol abuse, psychotic, bipolar, stress anxiety disorders, depression and somatic pain are more common among individuals with a diagnosis of sexual abuse than among individuals without a diagnosis of sexual abuse., Competing Interests: Competing interests: GR is the founder and secretary general of the non-profit organisation World of No Sexual Abuse, WONSA., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Context: The Greater Stockholm HIV Cohort Study is an initiative to provide longitudinal information regarding the health of people living with HIV., Objective: Our aim was to explore the prevalence of HIV and its association with psychiatric co-morbidities., Design, Setting and Participants: All patients with a recorded diagnosis of HIV (any position of the ICD-10 codes B20-B24) were identified during the period 2007-2014 and related to the total population in Stockholm by January 1, 2015, N = 2.21 million. The age at diagnosis, gender, and first occurrence of an HIV diagnosis was recorded. Analyses were done by age and gender. Prevalence of psychiatric co-morbidities amongst HIV patients were recorded., Main Outcome Measures: Age-adjusted odds ratios with 95% confidence intervals were calculated with logistic regression for prevalent psychiatric co-morbidities in HIV infected individuals compared to the prevalence in the general population., Results: The total prevalence of HIV was 0.16%; females 0.10% (n = 1134) and males 0.21% (n = 2448). HIV-infected people were more frequently diagnosed with psychiatric illnesses and drug abuse. In females and males with HIV-diagnosis respectively, drug dependence disorder was 7.5 (7.76% vs 1.04%) and 5.1 (10.17% vs 1.98%) times higher, psychotic disorders were 6.3 (2.65% vs 0.42%) and 2.9 (1.43% vs 0.49%) times higher, bipolar disorder was 2.5 (1.41% vs 0.57%) and 3 (1.02% vs 0.34%) times higher, depression diagnosis was 1.5 (8.47% vs 5.82%) and 3.4 (10.17% vs 2.97%) higher, trauma-related disorder was 1.5 (6.00% vs 4.10%) respectively 2.9 (4.45% vs 1.56%) times higher, anxiety disorder was 1.2 (6.88% vs 5.72%) and 2.2 (6.54% vs 2.93%) times higher than in their non-infected peers., Conclusion: Despite effective ART, many individuals with HIV have an impaired mental health and a history of drug abuse that may threaten the vision of a contained epidemic., (Copyright © 2016 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Background: Impaired emotional well-being has detrimental effects on health outcomes in patients with chronic heart failure (CHF)., Aims: To evaluate a nurse-led Coping Effectiveness Training (CET) group intervention for patients with CHF. It was hypothesized that CET would increase emotional well-being (primary outcome) and health-related quality (HRQoL) of life and improve clinical outcomes. Furthermore, changes in appraisal and coping as mediators of the intervention effect were examined., Methods: Participants were randomized to either control group (n=51) receiving standard health care or CET intervention group (n=52). Self-assessments of positive affect, negative affect, depression, anxiety, HRQoL, illness perception, coping strategies and social support were performed pre- and post-intervention and after six weeks, six months and 12 months. Time to death and hospitalizations were measured during the entire follow-up (median 35 months, interquartile range 11 months)., Results: No significant improvements for emotional well-being and HRQoL in the intervention group compared with the control group were found. After excluding patients with clinical anxiety and depression at baseline the intervention group had significantly lower negative affect (p = 0.022). There were no significant differences regarding cardiovascular events between the groups. The intervention group had greater sense of control over their illness in the short-term (p = 0.036)., Conclusion: CET intervention was found to increase sense of control over the illness in the short term. Psychosocial support programmes, like CET, for patients with CHF is currently lacking evidence for implementing in clinical practice. However, the results provide a basis for future studies with a modified CET intervention design and increased study size., (© The European Society of Cardiology 2016.)

Purpose: Triptans are widely used in acute migraine, and in some countries, they are also available over-the-counter (OTC). In Sweden, sales have increased for both prescription and OTC triptans. This study aimed to describe current prescribing and utilisation patterns of prescription and OTC triptans in Stockholm, Sweden., Methods: Register data from 4759 patients dispensed triptans in 2014 were used to study documented diagnosis of migraine, concomitant acute and preventive treatment for migraine, and contraindications. Survey data from 49 patients purchasing OTC triptans in three pharmacies were used to capture physician-diagnosed migraine, concomitant acute and preventive treatment for migraine, a behaviour of combining or alternating between prescription and OTC triptans, and pharmacy counselling rates., Results: Among the prescription triptan users, 52 % had a recorded diagnosis of migraine, 48 % had no other acute treatment, preventive treatment was rare (12 %) and contraindications were found in 2 % of the patients. Among the OTC triptan users, the majority (63 %) had been diagnosed by a physician and had a history of prescription triptan use, but combining or alternating between OTC and prescription triptans was rare. Concomitant acute treatment was reported in 53 % and preventive treatment was rare (4 %), despite high self-reported migraine frequencies. Some off-label use was detected, despite moderate to high counselling rates., Conclusion: Triptans are prescribed with attention to safety but with poor recording of migraine diagnosis. OTC triptan users generally have a history of prescription triptan use. Preventive treatment rates are low in both groups. Strategies to discern patients who need other treatment options should be considered.

Objective: The objective of this study was to investigate the prevalence of concomitant hypertension and psychiatric disorders in the general population, using administrative healthcare data in Stockholm County., Design and Method: The study population, included all living persons who resided in Stockholm County 1 January 2011 (N = 2 ,058 ,408). Individuals with a diagnosis of hypertension were identified with data from all consultations in primary care, specialized outpatient care, and inpatient care 2009-2013. As outcome, data were obtained on all consultations because of certain psychiatric diagnoses between 2011 and 2013, including specifically depression, anxiety disorders, bipolar disorder, and schizophrenia. Age-adjusted odd ratios (ORs) with 95% confidence intervals (95% CI) were calculated for men and women with and without hypertension, with individuals without hypertension as referents., Results: The age-adjusted ORs for depression in persons with hypertension were 1.293 (95% CI 1.256-1.331,) for men and 1.036 (95% CI 1.013-1.058) for women. The age-adjusted ORs for anxiety in persons with hypertension were 1.279 (95% CI 1.238-1.322) for men and 1.050 (95% CI 1.024-1.076) for women. The OR for bipolar disease were 0.904 (95% CI 0.826-0.990) for men and 0.709 (95% CI 0.656-0.767) for women. For schizophrenia, the ORs were 0.568 (95% CI 0.511-0.632) for men and 0.537 (95% CI 0.478-0.603) for women., Conclusion: Increased awareness of the risk of depression and anxiety among hypertensive patients is needed to combat hypertension, its complications, and psychiatric suffering in the population. Hypertension is probably underdiagnosed and neglected in individuals with severe psychiatric disorders. We warrant efforts to integrate psychiatric and hypertensive care.

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline., (© The Author(s) 2015.)

Objective: Study of prevalence of gout with concomitant diseases., Methods: Study population included all living persons in Stockholm County, Sweden, on January 1st 2013 (N=2,124,959). A diagnosis of gout was identified during 2013-2014, with information of diabetes mellitus and insulin resistance, hypertension, chronic heart failure, chronic kidney disease, alcohol abuse, and malignancies. Age-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for women and men with gout, using individuals without gout as referents, were calculated., Results: Age-adjusted odds of co-morbidities among individuals with gout vs. those without gout were: diabetes mellitus and insulin resistance 3.97 (95% CI 3.65-4.31) in women and 1.88 (95% CI 1.78-1.99) in men; hypertension 4.02 (95% CI 3.69-4.37) in women and 3.21 (95% CI 3.06-3.37) in men; chronic heart failure 4.72 (95% CI 4.31-5.19) in women and 2.84 (95% CI 2.66-3.04) in men; chronic kidney disease 2.08 (95% CI 1.50-2.87) in women and 2.39 (95% CI 2.15-2.66) in men; alcohol abuse 8.98 (95% CI 8.15-9.80) in women and 4.38 (95% CI 4.10-4.69) in men; and malignancies 1.32 (95% CI 1.17-1.48) in women and 1.13 (95% CI 1.06-1.21) men., Conclusion: Gout is a warning sign for concomitant diseases, e.g. alcoholism, diabetes, cardiovascular diseases, and cancer. KEY MESSAGES., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background and Purpose: With the "graying" of the population, hip fractures place an increasing burden on health systems and call for efficient forms of care. The aim was to compare two models of organizing hip fracture care at one university hospital working at two sites. The differences in organization were coordinated care provided in one of the sites and traditional care, divided between different institutions, in the other., Material and Methods: The study was conducted at a Swedish university hospital and included all 503 hip fracture patients, admitted during the 1-year period of February 2009 through January 2010. Patient gender, age, type of fracture, admission and discharge dates were documented. The patients were surveyed of their health-related quality of life at the time of admission and at 4 and 12 months after discharge. The costs for the inpatient care episode were estimated using three costing methods., Results: The coordinated care model resulted in a shorter hospital stay and consistently lower costs. There was no difference between patient-reported quality of life., Interpretation: The care of hip fracture patients coordinated by a geriatric ward throughout the whole care episode is more cost-efficient than uncoordinated where patients are transferred to other institutions for rehabilitation., (© 2014 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Our aim was to study the prevalence and incidence of patients with human immunodeficiency virus (HIV) in the general population in Stockholm, Sweden. We also aimed to study mortality among individuals with HIV and to explore co-morbidities. The study population included all living persons who resided in Stockholm County, Sweden, as of 31 December 2012 (N = 2,212,435). Information on all consultations between 2007 and 2012 was obtained from primary health care, specialist outpatient care and inpatient care. Analyses were done by age and gender. All patients with a recorded diagnosis of HIV were included. The prevalence of HIV was calculated using 2012 data. The prevalence of HIV in Stockholm area as per end of December 2012 was as low as 0.1% in females and 0.2% in males, and the annual incidence of HIV continued to decline over the years. In recent years, cancers, diabetes and hypertension were about as common in individuals with HIV as in the general population. Males with HIV had 3- to 4-fold higher age-adjusted odds of being diagnosed with depression and 3-fold higher odds of anxiety disorders and women had 1.6 to 2-fold higher age-adjusted odds of depression and anxiety disorders, than males and females in the general population, respectively. The relatively good somatic health observed in this study could be attributed to nearly optimal HIV therapy in Sweden. The mental health of HIV patients was significantly worse than that in the general population and needs further attention.

Objective: Concomitant psychiatric disorders in people with diabetes affect morbidity and mortality. We aimed to study psychiatric morbidity in people with diabetes and the general population using administrative health care data in Stockholm County., Methods: The study population included all living persons who resided in Stockholm County, Sweden, on January 1, 2011 (N=2,058,408). Subjects with a diagnosis of diabetes were identified with data from all consultations in primary health care, specialist outpatient care and inpatient care during the time span 2009-2013. As outcome, information was obtained on all consultations due to any psychiatric diagnosis as well as, specifically, schizophrenia, bipolar disorders, depression, and anxiety disorders, in 2011-2013. Analyses were performed by age group and gender. Age-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for women and men with diabetes, using individuals without diabetes as referents, were calculated., Results: Age-adjusted OR for all psychiatric diagnoses among people with diabetes was 1.296 (95% CI 1.267-1.326) for women and 1.399 (95% CI 1.368-1.432) for men. The greatest excess risk was found for schizophrenia, with OR 3.439 (95% CI 3.057-3.868) in women and 2.787 (95% CI 2.514-3.089) in men, with ORs between 1.276 (95% CI 1.227-1.327) and 1.714 (95% CI 1.540-1.905) for the remaining diagnoses., Conclusion: The prevalence of psychiatric disorders is elevated in people with diabetes, which calls for preventive action to be taken to minimize suffering and costs to society., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context., Methods: A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression., Results: A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved., Conclusions: Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs., (© 2014 by the Society for Academic Emergency Medicine.)

Study Objective: We examine functional profiles and presence of geriatric syndromes among older patients attending 13 emergency departments (EDs) in 7 nations., Methods: This was a prospective observational study of a convenience sample of patients, aged 75 years and older, recruited sequentially and mainly during normal working hours. Clinical observations were drawn from the interRAI Emergency Department Screener, with assessments performed by trained nurses., Results: A sample of 2,282 patients (range 98 to 549 patients across nations) was recruited. Before becoming unwell, 46% were dependent on others in one or more aspects of personal activities of daily living. This proportion increased to 67% at presentation to the ED. In the ED, 26% exhibited evidence of cognitive impairment, and 49% could not walk without supervision. Recent falls were common (37%). Overall, at least 48% had a geriatric syndrome before becoming unwell, increasing to 78% at presentation to the ED. This pattern was consistent across nations., Conclusion: Functional problems and geriatric syndromes affect the majority of older patients attending the ED, which may have important implications for clinical protocols and design of EDs., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Background: The most commonly reported diagnoses in primary care are useful to identify and meet health care needs in society. We estimated the rates of the most common diagnoses in primary health care in total and also by gender., Methods: This was a cross-sectional study including all 2.0 million inhabitants living in Stockholm County, Sweden, on 1 January 2009. Data on all health care appointments made in primary care in 2011 and during 2009-11 were extracted from the Stockholm County Council data warehouse VAL (Vårdanalysdatabasen; Stockholm regional health care data warehouse). Primary care data were analysed by underlying population and age. Appropriate specialist open care and inpatient data were used for comparison., Results: The five most common diagnoses in primary care (in 2011) were acute upper respiratory tract infections (6.0% of the population), essential hypertension (5.6%), coughing (2.6%), dorsalgia (2.6%) and acute tonsillitis (2.4%). Female-to-male ratios were higher for 27 of the 30 most common diagnoses, the exceptions being type 2 diabetes, unspecified types of diabetes and multiple wounds., Conclusions: The 30 most common diagnoses in primary care reflect the complexity of disorders cared for in the first line of health care. Knowledge of these patterns is important when aiming at using primary health care resources in a proper way.

Aims: The epidemiology of congestive heart failure (CHF) is likely to have changed due to changes in demography, risk factors, diagnostic procedures, and medical care. Prevailing information is in part old, incomplete, and to some extent contradictory. We determined the current prevalence, incidence, mortality, and 5-year survival rate of CHF, and possible temporal changes in Sweden., Methods and Results: This was a cross-sectional study on individual patient data from an administrative health data register in the Stockholm region, Sweden, comprising 2.1 million inhabitants. This contained all recorded diagnoses on all consultations in primary and secondary care (defined as specialist outpatient care), and on all hospitalizations. Prevalence, incidence, and mortality were estimated for the entire Swedish population, adjusted for demographic composition in 2010. The study population consisted of 88 038 patients (51% women). The prevalence was 2.2% (both women and men), the incidence was 3.8/1000 person-years (both women and men), and mortality was 3.2/1000 person-years in women and 3.0/1000 person-years in men (P < 0.001); the 5-year survival rate was 48%. Mortality (age adjusted; hazard ratio and 95% confidence intervals) was higher in men, 1.29, 1.24-1.34; P < 0.001. Prevalence remained essentially unchanged from 2006 to 2010, while incidence decreased by 24% (P < 0.001) and mortality by 19% (both women and men; P < 0.001)., Conclusions: The estimated prevalence of CHF in Sweden is 2.2%, incidence 3.8/1000 person-years, and mortality 3.1/1000 person-years. There has been a decrease in incidence and mortality from 2006 to 2010 in both women and men, with no major change in prevalence over time.

Background: There is limited knowledge on the prevalence of disease in total populations. Such studies have historically been difficult to conduct but the development of health data registers has facilitated large-scale studies on recorded diagnoses in entire regions. The aim of this study was to analyze the prevalence of diagnosis of six common diseases in the Swedish capital region., Methods: The study population included all living persons who resided in Stockholm County, Sweden, on December 31st 2011 (N=2 093 717). Information on all consultations between 2007 and 2011 was obtained from primary health care, specialist outpatient care and inpatient care. Prevalence was defined as the proportion of individuals with a recorded diagnosis of diabetes, depression, anxiety disorders, hypertension, asthma and chronic obstructive pulmonary disease during the five year period, respectively. Analyses were done by age and gender., Results: Hypertension had the highest five-year prevalence (12.2%), followed by depression (6.6%), diabetes mellitus (6.2%), asthma (5.9%), anxiety disorders/phobia (4.8%), and COPD (1.8%). Diabetes was more common in men (5.3% of women and 7.1% of men) while depression (8.7% in women and 4.4% in men) and anxiety (6.3% in women and 3.4% in men) were considerably more common in women. Smaller gender differences were also found for hypertension (13.0% in women and 11.4% in men), asthma (6.4% in women and 5.4% in men) and COPD (2.1% in women and 1.6% in men). Diabetes, hypertension and COPD increased markedly with age, whereas anxiety, depression and asthma were fairly constant in individuals above 18 years. During one year of observation, more than half of all patients had only been diagnosed in primary health care, with hypertension being the diagnosis with the largest proportion of patients only identified in primary health care (70.6%)., Conclusion: The prevalence of common diseases in the population can be estimated by combining data gathered during consecutive years from primary care, specialist outpatient care and inpatient care. However, accuracy of disease prevalence is highly dependent on the quality of the data. The high prevalence of the six diagnoses analysed in this study calls for preventive action to minimize suffering and costs to society.

Background: Although numerous risk factors for adverse outcomes for older persons after an acute hospital stay have been : identified, a decision making tool combining all available information in a clinically meaningful way would be helpful for daily hospital practice. The purpose of this study was to evaluate the ability of the Method for Assigning Priority Levels for Acute Care (MAPLe-AC) to predict adverse outcomes in acute care for older people and to assess its usability as a decision making tool for discharge planning., Methods: Data from a prospective multicenter study in five Nordic acute care hospitals with information from admission to a one year follow-up of older acute care patients were compared with a prospective study of acute care patients from admission to discharge in eight hospitals in Canada. The interRAI Acute Care assessment instrument (v1.1) was used for data collection. Data were collected during the first 24 hours in hospital, including pre-morbid and admission information, and at day 7 or at discharge, whichever came first. Based on this information a crosswalk was developed from the original MAPLe algorithm for home care settings to acute care (MAPLe-AC). The sample included persons 75 years or older who were admitted to acute internal medical services in one hospital in each of the five Nordic countries (n = 763) or to acute hospital care either internal medical or combined medical-surgical services in eight hospitals in Ontario, Canada (n = 393). The outcome measures considered were discharge to home, discharge to institution or death. Outcomes in a 1-year follow-up in the Nordic hospitals were: living at home, living in an institution or death, and survival. Logistic regression with ROC curves and Cox regression analyses were used in the analyses., Results: Low and mild priority levels of MAPLe-AC predicted discharge home and high and very high priority levels predicted adverse outcome at discharge both in the Nordic and Canadian data sets, and one-year outcomes in the Nordic data set. The predictive accuracy (AUC's) of MAPLe-AC's was higher for discharge outcome than one year outcome, and for discharge home in Canadian hospitals but for adverse outcome in Nordic hospitals. High and very high priority levels in MAPLe-AC were also predictive of days to death adjusted for diagnoses in survival models., Conclusion: MAPLe-AC is a valid algorithm based on risk factors that predict outcomes of acute hospital care. It could be a helpful tool for early discharge planning although further testing for active use in clinical practice is still needed.

Introduction and Hypothesis: the incidence of obstetric anal sphincter injuries is used in Sweden as a measurement of quality of care and this might influence the reporting. However, the correlation between reported diagnosis of pelvic floor injury at delivery and pelvic floor symptoms a year later is unknown. A questionnaire could identify such symptoms and provide beneficial feedback to obstetrical practices., Methods: we made a cross-sectional study by sending out a questionnaire about pelvic floor dysfunction to 599 women depending on reported injury at delivery. The answers provided by the groups were then compared., Results: the questionnaire identified women with pelvic floor dysfunction. Anal incontinence was most common among women with obstetric anal sphincter injuries but also occurred among women delivered vaginally without known tears., Conclusion: we suggest that a questionnaire is used 12-18 months after delivery to establish the short-time outcome in terms of pelvic floor dysfunction.

Background: Many older people believe sensory problems are inevitably, a part of growing old, and avoid assessment and help. Such problems are often also overlooked by health professionals. The aim of this study was to find the prevalence of hearing and vision impairment and their associations with loss of instrumental activities in daily living (IADL) and risk of falling in patients aged 75 years or older, admitted to a medical ward in an acute hospital in each of the five Nordic countries., Method: The Minimum Data Set for Acute Care was used for data collection in 770 patients. Premorbid data, admission data and history of falls over 3 months were obtained on admission by interview and observation. Hearing impairment was present if the patient required a quiet setting to be able to hear normal speech. Vision impairment was defined as unable to read regular print in a newspaper., Results: Bivariate and logistic regression analyses were performed. Forty-eight per cent of the patients had a hearing impairment, 32.3% had vision impairment and 20.1% had both. Hearing impairment was associated with falling but not in the logistic regression model. Hearing and vision impairment were associated with loss of IADL but only combined impairment was independently., Conclusion: Hearing and vision impairments were frequent among older patients in the medical wards. Falling was associated with hearing loss and IADL loss with hearing, vision and combined impairments. Sensory loss was also associated with fear of falling. It is recommended routinely to screen sensory functions in older patients in a medical setting. Intervention studies are needed to determine whether improvements in hearing and vision can prevent falls and further loss of function in this patient population.

Background: The International Classification of Functioning, Disability and Health (ICF) is embraced as a framework to conceptualize human functioning and disability. Health professionals choose measures to represent the domains of the framework. The ICF coding classification is an administrative system but multiple studies have linked diverse clinical assessments to ICF codes. InterRAI-HC (home care) is an assessment designed to assist planning of care for patients receiving home care. Examining the relationship between the ICF and the interRAI HC is of particular interest because the interRAI assessments are widely used in clinical practice and research, are computerized, and uploaded to databases that serve multiple purposes including public reporting of quality in Canada and internationally. The objective of this study was to examine the relationship between the interRAI HC (home care) assessment and the ICF. Specifically, the goal was to determine the proportion of interRAI HC items that can be linked to each of the major domains of the ICF (Body Function, Body Structure, Activities and Participation, and the Environmental Factors), the chapters and the specific ICF codes., Methods: Three coders who were familiar with both the home care assessment and the ICF independently assigned ICF codes to inter-RAI HC items. Subsequently, a series of teleconference meetings were held to reach consensus on the primary code and much later consensus was used to finalize codes for additional items added to the interRAI HC., Results: Following exclusion of administrative and diagnostic sections, 175 interRAI items were examined for potential assignment of codes. Of these 52 were assigned codes related to body function, 43 to activities and participation, 34 to environment, 1 to body structure, 17 to not coded, and 26 to not defined. Considering all 3-digit ICF codes, interRAI items addressed 43.2% of Body Function and 50.6% of Activities and Participation codes., Conclusion: The conceptual overlap in content, offers an excellent opportunity to operationalize the ICF domains and the codes particularly in the areas of Body Function and Activities and Participation. Use of measures such as the interRAI assessments with common elements across settings facilitates standardized reporting for organizations, regions and nations.

Aim: The aim of this study was to obtain evidenced-based knowledge about older persons in home care; we conducted a population-based study at 11 sites in Europe (2001/2002). This article focuses on urinary incontinence and need for help in home care., Methods: A sample of 4010 respondents 65 years or older were assessed by the Resident Assessment Instrument for Home Care. Urinary incontinence was defined as leakage once a week or more including use of catheters., Results: A total of 1478 individuals had urinary incontinence, 45% men and 47% women. The use of pads ran from 29% to 52% between the sites. The associates of urinary incontinence were: moderate or severe cognitive impairment, dependency in toileting and other activities of daily living compared with less impaired; urinary infections, obesity and faecal incontinence. Caregivers to persons with urinary incontinence reported burden or stress more often then carers to nonurinary incontinence individuals (OR = 2.2, 95% CI 1.8-2.7)., Conclusions: To enable older people with incontinence to stay at home with a better quality of life, they need caring assistance during toileting on a regular basis.

Background: A multi-domain suite of instruments has been developed by the interRAI research collaborative to support assessment and care planning in mental health, aged care and disability services. Each assessment instrument comprises items common to other instruments and specialized items exclusive to that instrument. This study examined the reliability of the items from five instruments supporting home care, long term care, mental health, palliative care and post-acute care., Methods: Paired assessments on 783 individuals across 12 nations were completed within 72 hours of each other by trained assessors who were blinded to the others' assessment. Reliability was tested using weighted kappa coefficients., Results: The overall kappa mean value for 161 items which are common to 2 or more instruments was 0.75. The kappa mean value for specialized items varied among instruments from 0.63 to 0.73. Over 60% of items scored greater than 0.70., Conclusion: The vast majority of items exceeded standard cut-offs for acceptable reliability, with only modest variation among instruments. The overall performance of these instruments showed that the interRAI suite has substantial reliability according to conventional cut-offs for interpreting the kappa statistic. The results indicate that interRAI items retain reliability when used across care settings, paving the way for cross domain application of the instruments as part of an integrated health information system.

Background and Aims: The purpose of this study is to describe predictors for discharge and one-year outcomes of acute-care hospital patients, 75 years of age or over, based on admission status information. We carried out a prospective study of a randomly selected patient population, from one urban acute-care hospital in each of the Nordic countries. 763 persons aged 75+ were randomly selected from acute admissions to the participating hospitals. 749 observations at discharge and 655 observations at one year were used in analyses., Methods: Data were collected with the MDS-AC 1.1 instrument within 24 hours of admission, and at day 7 or discharge, whichever came first. Outcome information was collected either by interviewing the patient or from patient records or registers. Discharge and one-year outcome (home, institution, death) were modeled by multinomial logistic regression, with admission status variables as predictors., Results: At discharge, 84% of subjects returned home, 11% went to an institution and 5.6% had died. At one year, 64% were still living at home, 24% had died, and 12% had moved to an institution. For discharge outcome, those having hospital admission due to a new problem or exacerbation of an old one had a higher risk of dying (OR 3.3) than returning home. Moderate to severe cognitive problems predicted death (OR 2.2) and institutionalization (OR 8.6) compared with discharge home. Problems in instrumental activities of daily living predicted death (OR 3.1) and institutionalization (OR 6.0). At one year, those with exacerbation of an old problem (OR 2.1) or with a new or exacerbated existing problem (OR 2.3) had a higher risk of dying than of institutionalization or discharge home. Having some cognitive problems (OR 2.8) or moderate to severe cognitive problems (OR 6.6) predicted institutionalization, but not dying or discharge home. Those with some problems in activities of daily living had a higher risk of both dying (OR 1.7) and of institutional care (OR 2.7). Those with moderate to severe problems in activities of daily living had also a higher risk of institutional care (OR 4.7) compared with those living at home., Conclusions: Evidence predictive of discharge and one-year outcomes in older acute hospital medical care patients seems to be visible from the beginning of the hospital stay. In order to increase the efficient use of health care services and quality of care, systematic standardized and streamlined assessment should be performed during the admission process.

Aim: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries., Method: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland., Findings: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases., Conclusions: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.

Background and Aims: The increase in the proportion of elderly people and a consequent increase in the demand for care have caused healthcare systems to become overloaded. This paper describes the use of Home Care Quality Indicators (HCQIs), derived from the Minimum Data Set for Home Care, for monitoring quality of care. Research questions were, "Do HCQI scores vary between home care organizations in different countries?" and "Are one or more country-specific sites consistently scoring better on most or all HCQIs"?, Methods: a cross-sectional observational study of 65+ randomly selected clients of home care organizations in urban areas in 11 European countries who had been receiving home care for at least two weeks. Data were collected with the MDS-HC. The scoring of 16 prevalent quality indicators for home care, adjusted for population differences, was calculated with baseline data., Results: Population size at baseline was 4,007 clients. Among home care clients in Europe, "rehabilitation potential in Activities of Daily Living and no therapies" (average 75.9%) and "inadequate pain control" were the most common quality problems. The prevalence between populations studied in various countries varied substantially. No country-specific site consistently scored worst or best., Conclusions: HCQIs derived from the MDS-HC detect variance in quality scores between home care in the 11 partner countries. The highest prevalence of unwanted outcomes were most often found in the Czech Republic, Italy and Germany. Although further research is necessary, we believe that HCQIs may be of great value for quality improvement in home care.

Purpose: To propose an integration index of home care delivery to older persons, to study its validity and to apply it to home care services of European cities., Theory: Home care delivery integration was based on two dimensions referring to process-centred integration and organisational structure approach., Method: Items considered as part of both dimensions according to an expert consensus (face validity) were extracted from a standardised questionnaire used in "Aged in Home care" (AdHoc) study to capture basic characteristics of home care services. Their summation leads to a services' delivery integration index. This index was applied to AdHoc services. A factor analysis was computed in order to empirically test the validity of the theoretical constructs. The plot of the settings was performed., Results: Application of the index ranks home care services in four groups according to their score. Factor analysis identifies a first factor which opposes working arrangement within service to organisational structure bringing together provisions for social care. A second factor corresponds to basic nursing care and therapies. Internal consistency for those three domains ranges from 0.78 to 0.93. When plotting the different settings different models of service delivery appear., Conclusion: The proposed index shows that behind a total score several models of care delivery are hidden. Comparison of service delivery integration should take into account this heterogeneity.

Objective: To describe possible differences/patterns in the use of indwelling urinary catheters (IUC) in Europe., Design: A prospective, population-based, assessment study., Setting: The target population was 4,455 (random sample of 405 from each of 11 countries) aged 65+ receiving home care., Methods: The clients were assessed by using the Resident Assessment Instrument MDS-HC; epidemiological and medical characteristics of clients and service utilisation were recorded., Measurements: The frequency of use of IUC related to the patients' activities of daily living (ADL) and cognitive functioning., Results: The sample consisted of 4,010 informants: 74% female, with mean age 82.3 +/-7.3 years; men 80.9 +/-7.5 years and female 82.8 +/-7.3 years. A total of 216 (5.4%) clients were using IUC. In Italy 23% were using a catheter compared with 0% in The Netherlands. Catheter use was more common in men than in women (11.5% versus 3.3%). Use of IUC was significantly correlated to certain diseases and symptoms and increase in care burden and formal services. Twenty-six per cent of the informants with indwelling catheters scored three or more on a hierarchical ADL scale (0-6). The clients using IUC in the Nordic countries were less dependent on care than in the other European countries. Models built on multivariate analysis explained 37% of the use of IUC. Tradition and attitudes may explain the differences between the sites., Conclusions: Catheter use is associated with formal or family care burden. The need for nursing home placement ought to be considered in some cases. A stricter criterion for using IUC may be considered in the southern European countries.

Background and Aims: Community care for older people is increasing dramatically in most European countries as the preferred option to hospital and long-term care. While there has been a rapid expansion in Evidence-Based Medicine, apart from studies of specific interventions such as home visiting and hospital at home (specialist visits or hospital services provided to people in their own homes in the community), there is little evidence of characteristics of the recipients of community care services or the organisation of services that produce the best outcomes for them and their informal carers. The AdHOC Study was designed to compare outcomes of different models of community care using a structured comparison of services and a comprehensive standardised assessment instrument across 11 European countries. This paper describes the study and baseline data., Methods: 4,500 people 65 years and older already receiving home care services within the urban areas selected in each country were randomly sampled. They were assessed with the MDS-HC (Minimum Data Set-Home Care) instrument, containing over 300 items, including socio-demographic, physical and cognitive characteristics of patients as well as medical diagnoses and medications received. These data were linked to information on the setting, services structures and services utilization, including use of hospital and long-term care. After baseline assessment, patients were re-evaluated at 6 months with an abbreviated version of the instrument, and then at the end of one year. Data collection was performed by specially-trained personnel. In this paper, socio-demographics, physical and cognitive function and provision of hours of formal care are compared between countries at baseline., Results: The final study sample comprised 3,785 patients; mean age was 82+/-7.2 years, 74.2% were females. Marital and living status reflected close family relationships in southern Europe relative to Nordic countries, where 5 times as many patients live alone. Recipients of community care in France and Italy are characterised by very high physical and cognitive impairment compared with those in northern Europe, who have comparatively little impairment in Activities of Daily Living and cognitive function. The provision of formal care to people with similar dependency varies extremely widely with very little formal care in Italy and more than double the average across all levels of dependency in the UK., Conclusions: The AdHOC study, by virtue of the use of a common comprehensive standardised assessment instrument, is a unique tool in examining older recipients of community care services in European countries and their widely varied organisation. The extreme differences seen in dependency and hours of care illustrate the probable contribution the study will make to developing an evidence based on the structure, quantity and targeting of community care, which will have major policy implications.

Objective: Societal services after traumatic spinal cord injury in Sweden were investigated, including self-rated levels of satisfaction with the application process and resource allocation., Design: Survey of an incidence population., Subjects: Thirty-four persons of a total regional incidence population (n = 48) with traumatic spinal cord injury., Methods: Structured interviews using a standardized questionnaire., Results: About 25 separate services were identified being available for persons with traumatic spinal cord injury. The average number of applications per person was 5 (range 0-11). The most common service was "transportation service". Of the applications, 17% were partially or totally rejected. Most subjects received information about available services from a social worker. For 13 available services at least 1 subject claimed ignorance about its existence., Conclusions: In Sweden, significant resources are allocated for allowing independence and financial compensation for individuals with traumatic spinal cord injury. However, this support system sometimes also results in frustration and disappointment. Insufficient information and co-ordination are reported as weaknesses. The persons' efforts to acquire knowledge of how the system works take time which could be better used for rehabilitation and full integration into the community.