Search

Background: Life expectancy is significantly shorter for patients with chronic obstructive pulmonary disease (COPD) than the general population. Concurrent diseases are known to infer an increased mortality risk in those with COPD, but the effects of pharmacological treatments on survival are less established. This study aimed to examine any associations between commonly used drugs, comorbidities and mortality in Swedish real-world primary care COPD patients., Methods: Patients with physician-diagnosed COPD from a large primary care population were observed retrospectively, utilizing primary care records and mandatory Swedish national registers. The time to all-cause death was assessed in a stepwise multiple Cox proportional hazards regression model including demography, socioeconomic factors, exacerbations, comorbidities and medication., Results: During the observation period (1999-2009) 5776 (32.5%) of 17,745 included COPD patients died. Heart failure (hazard ratio [HR]: 1.88, 95% confidence interval [CI]: 1.74-2.04), stroke (HR: 1.52, 95% CI: 1.40-1.64) and myocardial infarction (HR: 1.40, 95% CI: 1.24-1.58) were associated with an increased risk of death. Use of inhaled corticosteroids (ICS; HR: 0.79, 95% CI: 0.66-0.94), beta-blockers (HR: 0.86, 95% CI: 0.76-0.97) and acetylsalicylic acid (ASA; HR: 0.87, 95% CI: 0.77-0.98) was dose-dependently associated with a decreased risk of death, whereas use of long-acting muscarinic antagonists (LAMA; HR: 1.33, 95% CI: 1.14-1.55) and N-acetylcysteine (NAC; HR: 1.26, 95% CI: 1.08-1.48) were dose-dependently associated with an increased risk of death in COPD patients., Conclusion: This large, retrospective, observational study of Swedish real-world primary care COPD patients indicates that coexisting heart failure, stroke and myocardial infarction were the strongest predictors of death, underscoring the importance of timely recognition and treatment of comorbidities. A decreased risk of death associated with the use of ICS, beta-blockers and ASA, and an increased risk associated with the use of LAMA and NAC, was also found., Competing Interests: JE has received honoraria for lectures from AstraZeneca, Novartis and Teva and has served on advisory boards arranged by Novartis. GJ has served on advisory boards arranged by AstraZeneca, Novartis and Teva. KjL has, during the last five years, on one or more occasion served as an advisory board member and/or served as speaker and/or participated in education activities arranged by AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Orion, Novartis, Teva and Takeda. KaL has received honoraria for educational activities from Novartis, AstraZeneca, Chiesi, Teva and Boehringer Ingelheim and served on advisory boards arranged by Novartis and GlaxoSmithKline. AM has no conflicts of interest to declare with regard to the topic of the present study. BS has received honoraria for educational activities and lectures from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, Meda and Teva, and has served on advisory boards arranged by AstraZeneca, Novartis, GlaxoSmithKline, Boehringer Ingelheim, Meda and Teva. MT has received personal fees from AstraZeneca, during the conduct of the study. CJ has received honoraria for educational activities from AstraZeneca, Boehringer Ingelheim, Chiesi, Novartis and Teva, and has served on advisory boards arranged by AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Teva. The authors report no other conflicts of interest in this work., (© 2020 Ellingsen et al.)

Purpose: Assess the clinical and economic consequences associated with an early versus late diagnosis in patients with COPD. Patients and methods: In a retrospective, observational cohort study, electronic medical record data (2000-2014) were collected from Swedish primary care patients with COPD. COPD indicators (pneumonia, other respiratory diseases, oral corticosteroids, antibiotics for respiratory infections, prescribed drugs for respiratory symptoms, lung function measurement) registered prior to diagnosis were applied to categorize patients into those receiving early (2 or less indicators) or late diagnosis (3 or more indicators registered >90 days preceding a COPD diagnosis). Outcome measures included annual rate of and time to first exacerbation, mortality risk, prevalence of comorbidities and health care utilization. Results: More patients with late diagnosis (n=8827) than with early diagnosis (n=3870) had a recent comorbid diagnosis of asthma (22.0% vs 3.9%; P <0.0001). Compared with early diagnosis, patients with late diagnosis had a higher exacerbation rate (hazard ratio [HR] 1.89, 95% confidence interval [CI]: 1.83-1.96; P <0.0001) and shorter time to first exacerbation (HR 1.61, 95% CI: 1.54-1.69; P <0.0001). Mortality was not different between groups overall but higher for late versus early diagnosis, after excluding patients with past asthma diagnosis (HR 1.10, 95% CI: 1.02-1.18; P =0.0095). Late diagnosis was also associated with higher direct costs than early diagnosis. Conclusion: Late COPD diagnosis is associated with higher exacerbation rate and increased comorbidities and costs compared with early diagnosis. The study highlights the need for accurate diagnosis of COPD in primary care in order to reduce exacerbations and the economic burden of COPD., Competing Interests: KjL has, during the last 5 years, on one or more occasion served in an advisory board and/or served as speaker and/or participated in education arranged by AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Orion, Takeda, Novartis, Chiesi and TEVA. CJ has received honoraria for educational activities and lectures from AstraZeneca, Boehringer Ingelheim, Chiesi, Novartis and TEVA, and has served on advisory boards arranged by AstraZeneca, TEVA and Boehringer Ingelheim. BS has received honoraria for educational activities and lectures from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, MEDA and TEVA, and has served on advisory boards arranged by AstraZeneca, Novartis, GlaxoSmithKline and Boehringer Ingelheim. KL has participated in the steering committee by Novartis for this study and received honoraria for educational activities and lectures from AstraZeneca, GlaxoSmithKline, Novartis, MEDA and TEVA and has served on advisory boards arranged by MEDA and Novartis. FSG and JBG are employees of Novartis Pharma AG. PO is an employee of Novartis AB. MU and LJ are employees of IQVIA, who received remuneration in relation to statistical analysis. GJ has participated in the steering committee by Novartis for this study and served on advisory boards arranged by AstraZeneca, Novo Nordisk and Takeda. BS reports personal fees from Novartis, during the conduct of the study; received personal fees from AstraZeneca, Novartis, Meda, Teva, Boehringer Ingelheim, and GlaxosSmithKline, outside the submitted work; KL reports personal fees from Novartis, during the conduct of the study; received personal fees from AstraZeneca, Novartis, Chiesi, TEVA, GlaxoSmithKline, and Boerhringer Ingelheim, outside the submitted work; KK was an employee of Novartis, the sponsor of the study, at the time of conduct of this analysis and until 31.10.2018. He is now affiliated with Respiratory Medicine Department, University of Ioannina, Ioannina, Greece. KK has received honoraria for educational activities and lectures from AstraZeneca, Boehringer Ingelheim, Chiesi, ELPEN, GlaxoSmithKline, MSD, Novartis, Takeda, and UCB, and has served on advisory boards arranged by AstraZeneca, Chiesi, ELPEN, Novartis and Takeda prior to 2015. The authors report no other conflicts of interest in this work.

Background: Severe and uncontrolled asthma is associated with increased risk of exacerbations and death. A substantial proportion of asthma patients have poor asthma control, and a concurrent COPD diagnosis often increases disease burden. The objective of the study was to describe the prevalence and managemant of severe asthma in a Swedish asthma popuöation., Methods: In this observational cohort study, primary care medical records data (2006-2013) from 36 primary health care centers were linked to data from national mandatory Swedish health registries. The studied population (>18 years) had a record of drug collection for obstructive pulmonary disease (ATC code R03) during 2011-2012, and a physician diagnosed asthma (ICD-10 code J45-J46) prior to drug collection. Severe asthma was classified as collection of high dose inhaled steroid (> 800 budesonide or equivalent per day) and leukotriene receptor antagonist and/or long-acting beta-agonist. Poor asthma control was defined as either collection of ≥600 doses of short-acting beta-agonists, and/or ≥1 exacerbation(s) during the year post index date., Results: A total of 18,724 asthma patients (mean 49 years, 62.8% women) were included, of whom 17,934 (95.8%) had mild to moderate and 790 (4.2%) had severe asthma. Exacerbations were more prevalent in severe asthma (2.59 [2.41-2.79], Relative Risk [95% confidence interval]; p < 0.001). Poor asthma control was observed for 28.2% of the patients with mild to moderate asthma and for more than half (53.6%) of the patients with severe asthma (<0.001). Prior to index, one in five severe asthma patients had had a contact with secondary care and one third with primary care. A concurrent COPD diagnosis increased disease burden., Conclusion: Severe asthma was found in 4.2% of asthma patients in Sweden, more than half of them had poor asthma control, and most patients had no regular health care contacts.

Background: We assessed direct and indirect costs associated with COPD in Sweden and examined how these costs vary across time, age, and disease stage in a cohort of patients with COPD and matched controls in a real-world, primary care (PC) setting., Patients and Methods: Data from electronic medical records linked to the mandatory national health registers were collected for COPD patients and a matched reference population in 52 PC centers from 2000 to 2014. Direct health care costs (drug, outpatient or inpatient, PC, both COPD related and not COPD related) and indirect health care costs (loss of income, absenteeism, loss of productivity) were assessed., Results: A total of 17,479 patients with COPD and 84,514 reference controls were analyzed. During 2013, direct costs were considerably higher among the COPD patient population (€13,179) versus the reference population (€2,716), largely due to hospital nights unrelated to COPD. Direct costs increased with increasing disease severity and increasing age and were driven by higher respiratory drug costs and non-COPD-related hospital nights. Indirect costs (~€28,000 per patient) were the largest economic burden in COPD patients of working age during 2013., Conclusion: As non-COPD-related hospital nights represent the largest direct cost, management of comorbidities in COPD would offer clinical benefits and relieve the financial burden of disease., Competing Interests: Disclosure Karin Lisspers has received honoraria for educational activities and lectures from AstraZeneca, GlaxoSmithKline, Novartis, MEDA, and Takeda and has served on advisory boards arranged by MEDA and Novartis. She has also participated in the steering committee for this study funded by Novartis. Kjell Larsson has, during the last 5 years, on one or more occasion served in an advisory board, served as a speaker, and/or participated in education arranged by AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Takeda, Novartis, Chiesi, Orion and Teva. Gunnar Johansson has participated in the steering committee organized by Novartis for this study and served on advisory boards arranged by Astra Zeneca, Novo Nordisk, and Takeda. Christer Janson has received honoraria for educational activities and lectures from Novartis, AstraZeneca, Glaxo-SmithKline, and Boehringer Ingelheim outside the submitted work. Björn Ställberg has received honoraria for educational activities and lectures from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, MEDA, and TEVA and has served on advisory boards arranged by AstraZeneca, Novartis, GSK, Boehringer Ingelheim and MEDA. Florian S Gutzwiller, and Jean-Bernard Gruenberger are employees of Novartis Pharma AG. Madlaina Costa-Scharplatz is an employee of Novartis AB. Milica Uhde and Leif Jorgensen are employees of IQVIA, who received remuneration in relation to statistical analysis. The authors report no other conflicts of interest in this work.

Aims: To describe weight-change pathways in patients with type 2 diabetes (T2D) and associated healthcare costs using repeated BMI measurements and healthcare utilization data., Methods: Patients with newly-diagnosed T2D with body mass index (BMI, kg/m 2 ) at diagnosis and subsequent measures at year 1-3 were identified. Based on three-year BMI change, patients were assigned to one of 27 BMI change pathways defined by annual BMI change: BMI↗ (≥1 BMI unit increase), BMI→ (<1 BMI unit change), and BMI↘ (≥1 BMI unit decrease). Mean annual and three-year cumulative healthcare costs were estimated for each pathway by combining Swedish unit costs with resource use from primary care and national patient registers., Results: Cohort consisted of 15,819 patients; 44% women, mean age of 61 years, HbA1c of 6.7% (50mmol/mol), BMI of 30.6kg/m 2 . Most common BMI pathways (mean costs): BMI→→→ (€5,311), BMI↘→→ (€5,461), and BMI→→↘ (€6,281). General trends: BMI→→→ linked to lowest, BMI↗→↗ linked to highest costs., Conclusion: In patients with newly-diagnosed T2D, weight stability was the most common BMI change pattern over 3 years and associated with lowest healthcare costs. Relationship between weight change and healthcare costs appears complex warranting further investigation., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aims and Objectives: To describe overweight persons' experiences with weight reduction and participation in the dietary advice on prescription., Background: Approximately 20% of overweight individuals are able to successfully lose weight. Experiences from earlier weight reduction programmes indicate that those who succeed typically manage to avoid overeating to handle stress and have high motivation to lose weight. Those who fail have low self-control and engage in negative health behaviours such as eating when experiencing negative emotions and stress., Design: The study used a descriptive qualitative design and was conducted at a Primary Health Care Centre in south-west Sweden., Methods: The first nineteen study participants who completed the weight reduction programme in two years responded in writing to five open questions about their experiences with the programme. Data were analysed using inductive content analysis., Results: The participants appreciated the face-to-face meetings with the nurse because they felt seen and listened to during these sessions. They also felt their life situations and self-discipline had an impact on how well they were able to follow the programme. Dietary advice on prescription advice was considered to be helpful for achieving behavioural changes and losing weight. People who succeeded in sustainably losing weight described the importance of support from partners or close friends., Conclusions: To achieve sustainable weight reduction, it is important to individualise the programme in order to address each person's life situation and the unique difficulties they may encounter., Relevance to Clinical Practice: Motivational interviewing appears to be a good technique for developing a successful relationship between the nurse and the patient. The dietary advice on prescription advice was perceived to be a good way to improve food habits and can easily be used at many Primary Health Care Centres. Patient's partners should also be offered the opportunity to participate in the programme., (© 2016 John Wiley & Sons Ltd.)

Aims: To describe healthcare resource use patterns and estimate healthcare costs of newly diagnosed Type 2 diabetes mellitus (T2DM) patients in Sweden., Methods: Patients with a newly diagnosed T2DM between 1999 and 2009 were identified from 84 Swedish primary care centres. Healthcare resource use data, excluding pharmaceuticals, were extracted from electronic patient records and a national patient register, and reported as per patient mean number of primary care contacts, laboratory tests and hospitalizations. Per patient mean healthcare costs are reported as annual and cumulative costs., Results: During a median (maximum) of 4.6 (9.0) years follow-up; 38,956 patients (183,513 patient years) on average made 81 primary care contacts, was hospitalized 2.14 times, and took 31 laboratory tests. Mean per patient annual healthcare costs were €4128 (95% CI, 4054-4199) the first year after diagnosis, €2708 (95% CI, 2641-2776) the second year, and €3030 (95% CI, 2854-3204) in year 9 (2012 values). Mean per patient cumulative healthcare costs were €26,503 (95% CI, 26,025-26,970) at 9 years of follow-up. Hospitalizations accounted for the majority of healthcare costs., Conclusions: Although newly diagnosed T2DM patients require a substantial amount of healthcare services in primary care, hospitalizations account for the majority of healthcare costs., (Copyright © 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Background: Chronic obstructive pulmonary disease (COPD) guidelines emphasize the importance of patient education to improve quality of life and avoid exacerbations. Longitudinal evaluations of structured management of COPD in primary care are lacking., Aim: To evaluate the impact of primary care asthma/COPD clinics on exacerbations, hospitalizations, and associated costs in COPD., Methods: This population-based, retrospective, observational study, linking primary care medical records data to mandatory Swedish national registries, included patients with COPD from 76 primary healthcare centers (1999-2009). A questionnaire on access to an asthma/COPD clinic was retrospectively answered. Propensity score matching was performed at index (COPD diagnosis) by center type (with and without an asthma/COPD clinic). Poisson regression was used to compare the yearly rate of exacerbations (hospitalization, emergency visits, or prescription for oral steroids or antibiotics) and COPD-related prescriptions at the centers. An economic analysis was performed from the Swedish healthcare perspective using 2011 unit costs and the incremental cost-effectiveness ratio was calculated., Results: The study included 21,361 patients (mean age, 68.0 years; 53% female). Access to asthma/COPD clinics increased from 34% to 85% during the study period. Patients at primary healthcare centers with asthma/COPD clinics had 27% fewer exacerbations (0.71 vs. 0.98) and 37% fewer hospitalizations annually (0.36 vs. 0.58) (p < 0.0001). Asthma/COPD clinics reduced the annual cost of medication and healthcare contacts by 37% (SEK 52,892 [€5858] to SEK 33,410 [€3700] per patient)., Conclusions: Patients at primary healthcare centers with asthma/COPD clinics experienced fewer COPD exacerbations and hospitalizations, and overall treatment costs were substantially reduced. ClinicalTrials.gov identifier: NCT01146392., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Determinants of vitamin D status measured as 25-OH-vitamin D in blood are exposure to sunlight and intake of vitamin D through food and supplements. It is unclear how large the contributions are from these determinants in Swedish primary care patients, considering the low radiation of UVB in Sweden and the fortification of some foods. Asian and African immigrants in Norway and Denmark have been found to have very low levels, but it is not clear whether the same applies to Swedish patients. The purpose of our study was to identify contributors to vitamin D status in Swedish women attending a primary health care centre at latitude 60°N in Sweden., Methods: In this cross-sectional, observational study, 61 female patients were consecutively recruited between January and March 2009, irrespective of reason for attending the clinic. The women were interviewed about their sun habits, smoking, education and food intake at a personal appointment and blood samples were drawn for measurements of vitamin D and calcium concentrations., Results: Plasma concentration of 25-OH-vitamin D below 25 nmol/L was found in 61% (19/31) of immigrant and 7% (2/30) of native women. Multivariate analysis showed that reported sun holiday of one week during the last year at latitude below 40°N with the purpose of sun-bathing and native origin, were significantly, independently and positively associated with 25-OH-vitamin D concentrations in plasma with the strongest association for sun holiday during the past year., Conclusions: Vitamin D deficiency was common among the women in the present study, with sun holiday and origin as main determinants of 25-OH-vitamin D concentrations in plasma. Given a negative effect on health this would imply needs for vitamin D treatment particularly in women with immigrant background who have moved from lower to higher latitudes.

Aim: To evaluate outcomes for patients attending primary care centres with and without asthma clinics., Methods: A cross-sectional survey at 42 primary health care centres randomly selected according to organisation of asthma care, 14 with complete, 14 with incomplete and 14 with no asthma clinic according to national criteria. 1,477 randomly selected patients 15-45 years received two questionnaires. Outcomes were: patients' knowledge of asthma; asthma control; and quality of life., Results: Patients attending primary health care centres with asthma clinics reported more knowledge of asthma but similar levels of asthma control and quality of life. Patients who reported they had visited the asthma nurse during the last year had more knowledge but similar asthma control and quality of life compared to patients who reported they had not. However, with more time allocated for the nurse, 44% achieved asthma control compared with 27% at asthma clinics with less time (p<0.003)., Conclusions: Having an asthma clinic at a primary health care centre improves asthma patients' knowledge of the disease, and better asthma control is achieved if the nurse is allocated more time.

Aim: To compare the degree of asthma control in 2001 and 2005 in a primary care setting in Sweden., Method: Two similar questionnaire surveys were performed in 2001 and 2005 with 1,012 and 224 asthma patients aged 18-45 randomly selected from 42 and 56 primary health care centres, respectively. A classification of asthma control similar to the GINA guidelines was made using information obtained from the questionnaire., Results: In 2001, 36.6% had achieved asthma control, 23.8% were partly controlled and 39.6% uncontrolled. In 2005, the corresponding figures were 40.2%, 26.8% and 33.0%, respectively, with no difference between the two surveys (p=0.114). Uncontrolled asthma was more common in women (p<0.001 in the first and p<0.05 in the second survey) and smokers (p<0.01 in the first and p<0.01 in the second survey). The use of combination corticosteroid/long-acting bronchodilator inhalers had increased - 34.2% and 48.2%, respectively (p<0.001) - and many patients used their inhaled corticosteroids periodically., Conclusion: In spite of treatment guidelines many patients in Swedish primary care still have insufficient asthma control.

Aim: To study quality of life and asthma control in primary care. A total of 1,477 patients 15 to 45 years of age received questionnaires regarding asthma control (77% responded) and quality of life, Mini Asthma Quality of Life Questionnaire (MiniAQLQ), (74% responded). Patients using short-acting beta-agonists more than twice in the last week had clinically significant lower MiniAQLQ scores (5.17 versus 5.91). This finding was consistent for night awakenings during the previous week (4.42 versus 5.86), courses of oral corticosteroids (4.82 versus 5.69), and reported emergency consultations during the last 6 months (4.85 versus 5.71). Good asthma control is associated with better quality of life in asthma patients in primary care.

Background: The severity of asthma varies in patients in primary care. The aim of this study was to identify factors related to asthma severity in a primary care setting., Methods: In this cross-sectional asthma study a random sample of 1477 patients, aged 15-45 years, from 42 primary health care centres received two questionnaires: one disease oriented and one quality of life oriented, MiniAQLQ. A classification of the asthma severity similar to the GINA guidelines was made with the information obtained from the questionnaire. The classification was based on current treatment, use of rescue medication, night symptoms, emergency consultations and use of oral steroids for treatment of exacerbations., Results: Thirty-five per cent of the women and 24% of the men were classified as having severe asthma. Women used more inhaled corticosteroids, more often took long acting beta-2 agonists or a leukotrien antagonist in addition to corticosteroids, experienced more frequent night awakenings and were more often smokers than men. In a multivariable analysis, female sex increased the odds of having severe asthma by 60% as compared with male sex, age by 3% per year, not having the asthma prescription filled owing to cost by 59%, daily smoking by 66% and pollen allergy by 85%., Conclusions: Female sex, age, pollen and pet allergy, not having the asthma prescription filled owing to cost, and daily smoking were all independently associated with asthma severity.

COPD is a common and under-diagnosed disease which is increasing in prevalence worldwide. A more aggressive and optimistic approach must be adopted towards its management in primary care. This IPCRG Guideline on the management of COPD in primary care is fully consistent with GOLD guidelines. It highlights the goals of COPD treatment and the need for spirometric testing to make the diagnosis. It covers the classification of the disease according to disease severity, non-pharmacologic therapy including smoking cessation, avoidance of risk factors, patient education, pharmacologic therapy including the use of oxygen treatment, the management of exacerbations, the role of pulmonary rehabilitation, and the need for monitoring and ongoing care for COPD patients.

Aims: To compare long-term changes in healthcare utilization and costs for type 2 diabetes patients before and after insulin initiation, as well as healthcare costs after insulin versus non-insulin anti-diabetic (NIAD) initiation.Methods: Patients newly initiated on insulin (n=2823) were identified in primary health care records from 84 Swedish primary care centers, between 1999 to 2009. First, healthcare costs per patient were evaluated for primary care, hospitalizations and secondary outpatient care, before and up to seven years after insulin initiation. Second, patients prescribed insulin in second line were matched to patients prescribed NIAD in second line, and the healthcare costs of the matched groups were compared.Results: The total mean annual healthcare cost increased from €1656 per patient 2 years before insulin initiation to €3814 seven years after insulin initiation. The total cumulative mean healthcare cost per patient at year 5 after second-line treatment was €13,823 in the insulin group compared to €9989 in the NIAD group.Conclusions: Initiation of insulin in type 2 diabetes patients was followed by increased healthcare costs. The increases in costs were larger than those seen in a matched patient population initiated on NIAD treatment in second-line. [ABSTRACT FROM AUTHOR]

Background: Immigration to Sweden from lower latitude countries has increased in recent years. Studies in the general population in other Nordic countries have demonstrated that these groups are at risk of developing vitamin D deficiency, but studies in primary health care patients are rare. Objectives: The aim of this study is to examine possible differences in plasma-25(OH)-vitamin D levels and intake of vitamin D between Swedish and immigrant female patients in a primary health care centre located at 60°N, where half of the inhabitants have an immigrant background. Another objective was to estimate what foods contribute with most vitamin D. Design: Thirty-one female patients from the Middle East and Africa and 30 from Sweden were recruited. P-25(OH)D was measured and intake of vitamin D was estimated with a modified food frequency questionnaire (FFQ). Results: Vitamin D deficiency (plasma-25(OH)D <25 nmol/L) was common among immigrant women (61%). One immigrant woman and half of the Swedish women had optimal levels (plasma-25(OH)D > 50 nmol/L). There was a positive correlation between the intake of vitamin D from food and plasma-25(OH)D. Only three women, all Swedish, reached the recommended intake of vitamin D from food. The immigrant women had lower intake compared to Swedish women (median: 3.1 vs. 5.1 µg/day). The foods that contributed with most vitamin D were fatty fish, fortified milk and margarine. Immigrant women consumed less fortified milk and margarine but more meat. Irrespective of origin, patients with plasma-25(OH)D <25 nmol/L consumed less margarine but more meat. Conclusion: Vitamin D deficiency was common in the immigrant patients and their intake of vitamin D was lower. This highlights the need to target information about vitamin D to immigrant women in order to decrease the risk for vitamin D deficiency. The FFQ was well adapted to its purpose to estimate intake of vitamin D. [ABSTRACT FROM AUTHOR]

Summary: Aim:: To investigate the organisation of asthma care in 240 primary health care centres (PHCCs) in Mid-Sweden. Methods:: A cross-sectional study. Main outcomes were occurrence and structure of nurse-based asthma clinics according to nationally recommended criteria, and access and use of spirometers. Results:: 238 PHCCs (99%) responded. 16% reported a complete, and 37% an incomplete, asthma clinic. 47% of PHCCs had no asthma clinic. The incomplete asthma clinics usually lacked sufficient asthma nurse time, a scheduled nurse surgery and a responsible GP. 77% of the PHCCs had access to a spirometer and on average 19spirometries/1000 inhabitants/year were performed. There was a large variation in the use of spirometers. Conclusion:: Half of the PHCCs had an asthma clinic and a majority had access to a spirometer. More frequent use of spirometry and increased time provision for the asthma nurse would be likely to produce a substantial improvement in the standard of asthma care in primary health care. [Copyright &y& Elsevier]

Background: Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). Other factors such as severity of airflow limitation and concurrent asthma may further raise the possibility of developing pneumonia. This study assessed the risk of pneumonia associated with ICS in patients with COPD.Methods: Electronic Medical Record data linked to National Health Registries were collected from COPD patients and matched reference controls in 52 Swedish primary care centers (2000-2014). Levels of ICS treatment (high, low, no ICS) and associated comorbidities were assessed. Patients were categorized by airflow limitation severity.Results: A total of 6623 patients with COPD and 48,566 controls were analyzed. Patients with COPD had a more than 4-fold increase in pneumonia versus reference controls (hazard ratio [HR] 4.76, 95% confidence interval [CI]: 4.48-5.06). ICS use increased the risk of pneumonia by 20-30% in patients with COPD with forced expiratory volume in 1 s ≥ 50% versus patients not using ICS. Asthma was an independent risk factor for pneumonia in the COPD population. Multivariate analysis identified independent predictors of pneumonia in the overall population. The highest risk of pneumonia was associated with high dose ICS (HR 1.41, 95% CI: 1.23-1.62).Conclusions: Patients with COPD have a greater risk of pneumonia versus reference controls; ICS use and concurrent asthma increased the risk of pneumonia further. [ABSTRACT FROM AUTHOR]

Background: In the development of new drugs for severe asthma, it is a challenge from an ethical point of view to randomize severe asthma patients to placebo, and to obtain long-term safety data due to discontinuations. The aim of this study was to evaluate the feasibility of using electronic health record (EHR) data to create a real-world reference population of uncontrolled asthmatic patients to supplement the concurrent control/placebo group in long-term studies of asthma.Methods: EHR data from 36 primary care centres and a University hospital in Sweden were linked to Swedish mandatory health registers (2005-2013), creating a population covering 33 890 asthma patients, including data on co-morbidities, risk factors and laboratory/respiratory measurements. A severe asthma EHR reference cohort was established. We used logistic regression to estimate the propensity score (probability) of each RCT or EHR patient existing in the EHR cohort given their covariates.Results: We created an EHR-derived reference cohort of 240 patients, matching the placebo group (N = 151) in an RCT of severe asthma. The exacerbation rate during follow-up in the EHR study population was 1.24 (weighted) compared to 0.9 in the RCT placebo group. Patients in the EHR cohort were of similar age as in the RCT placebo group, 50.6 years versus 50.1 years; had slightly higher body mass index 27.0 kg/m2 versus 27.3 kg/m2; and consisted of 40% versus 34% males.Conclusions: The results indicate that EHRs provide an opportunity to supplement the control group in RCTs of severe diseases. [ABSTRACT FROM AUTHOR]