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Background: During recent years, stepwise approaches to health checks have been advanced as an alternative to general health checks. In 2013, we set up the Early Detection and Prevention project (Tidlig Opsporing og Forebyggelse, TOF) to develop a stepwise approach aimed at patients at high or moderate risk of a chronic disease. A novel feature was the use of a personal digital mailbox for recruiting participants. A personal digital mailbox is a secure digital mailbox provided by the Danish public authorities. Apart from being both safe and secure, it is a low-cost, quick, and easy way to reach Danish residents., Objective: In this study we analyze the association between the rates of acceptance of 2 digital invitations sent to a personal digital mailbox and the sociodemographic determinants, medical treatment, and health care usage in a stepwise primary care model for the prevention of chronic diseases., Methods: We conducted a cross-sectional analysis of the rates of acceptance of 2 digital invitations sent to randomly selected residents born between 1957 and 1986 and residing in 2 Danish municipalities. The outcome was acceptance of the 2 digital invitations. Statistical associations were determined by Poisson regression. Data-driven chi-square automatic interaction detection method was used to generate a decision tree analysis, predicting acceptance of the digital invitations., Results: A total of 8814 patients received an invitation in their digital mailbox from 47 general practitioners. A total of 40.22% (3545/8814) accepted the first digital invitation, and 30.19 % (2661/8814) accepted both digital invitations. The rates of acceptance of both digital invitations were higher among women, older patients, patients of higher socioeconomic status, and patients not diagnosed with or being treated for diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular disease., Conclusions: To our knowledge, this is the first study to report on the rates of acceptance of digital invitations to participate in a stepwise model for prevention of chronic diseases. More studies of digital invitations are needed to determine if the acceptance rates seen in this study should be expected from future studies as well. Similarly, more research is needed to determine whether a multimodal recruitment approach, including digital invitations to personal digital mailboxes will reach hard-to-reach subpopulations more effectively than digital invitations only., (©Lars Bruun Larsen, Jens Sondergaard, Janus Laust Thomsen, Anders Halling, Anders Larrabee Sønderlund, Jeanette Reffstrup Christensen, Trine Thilsing. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.01.2019.)

Background: Multimorbidity has already become common in primary care and will be a challenge in the future. Primary care in Sweden participates to a great extent in the care of patients with two severe, chronic conditions: chronic obstructive pulmonary disease (COPD) and heart failure. Both conditions are characterized by high mortality and often coexist. Age, sex, heart failure and other comorbidities are considered to be the major predictors of mortality in patients with COPD. We aimed to study the impact of heart failure, other comorbidities, age and sex on mortality in patients with COPD., Methods: A register-based, prospective cohort study conducted in Blekinge County in Sweden with about 150,000 inhabitants. The study population was comprised of people aged ≥35 years. The data about diagnoses of COPD and heart failure came from the 2007 health care register, in which we found 984 individuals with a diagnosis of COPD. Date of death was collected from January 1st, 2008 -August 31st, 2015. The diagnosis-based Adjusted Clinical Groups (ACG) Case-Mix System 7.1 was used to describe comorbidity. Each individual was assigned one of six comorbidity levels called resource utilization bands (RUB) graded from 0 to 5., Results: Estimated eight year mortality in patients with COPD and coexisting heart failure was seven times higher than in patients with COPD alone - odds ratio 7.06 (95% CI 3.88-12.84). Adjusting for age and male sex resulted in odds ratio 3.75 (95% CI 1.97-7.15). Further adjusting for other comorbidities resulted in odds ratio 3.26 (95% CI 1.70-6.25). The mortality was strongly associated with the highest comorbidity level - RUB 5 where the odds ratio was 5.19 (95% CI 2.59-10.38)., Conclusion: Heart failure has an important impact on mortality in patients with COPD. The mortality in patients with COPD and coexisting heart failure was strongly associated with age, male sex and other comorbidities. Of those three predictors, only other comorbidities can be influenced. Heart failure and other comorbidities should be recognized early and properly treated in order to improve survival in patients with coexisting COPD and heart failure.

In the original publication of this article, Table 3 was published incorrectly. The corrected table is shown below.

Background: The consequences of lifestyle-related disease represent a major burden for the individual as well as for society at large. Individual preventive health checks to the general population have been suggested as a mean to reduce the burden of lifestyle-related diseases, though with mixed evidence on effectiveness. Several systematic reviews, on the other hand, suggest that health checks targeting people at high risk of chronic lifestyle-related diseases may be more effective. The evidence is however very limited. To effectively target people at high risk of lifestyle-related disease, there is a substantial need to advance and implement evidence-based health strategies and interventions that facilitate the identification and management of people at high risk. This paper reports on a non-randomized pilot study carried out to test the acceptability, feasibility and short-term effects of a healthcare intervention in primary care designed to systematically identify persons at risk of developing lifestyle-related disease or who engage in health-risk behavior, and provide targeted and coherent preventive services to these individuals., Methods: The intervention took place over a three-month period from September 2016 to December 2016. Taking a two-pronged approach, the design included both a joint and a targeted intervention. The former was directed at the entire population, while the latter specifically focused on patients at high risk of a lifestyle-related disease and/or who engage in health-risk behavior. The intervention was facilitated by a digital support system. The evaluation of the pilot will comprise both quantitative and qualitative research methods. All outcome measures are based on validated instruments and aim to provide results pertaining to intervention acceptability, feasibility, and short-term effects., Discussion: This pilot study will provide a solid empirical base from which to plan and implement a full-scale randomized study with the central aim of determining the efficacy of a preventive health intervention., Trial Registration: Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016 ). Registered 29 April 2016. The study adheres to the SPIRIT guidelines.

Introduction: The aim of the study was to describe potential shared risk factors for incident asthma and COPD in a population-based, 9-year follow-up study., Methods: From a cohort of 1191 individuals, aged 20-44, who participated in baseline survey including spirometry, bronchial challenge, and skin prick test (SPT) 742 subjects (62%) were reexamined at follow-up in 2012-2014., Results: A total of 27 incident cases of asthma and 22 cases of COPD were identified at follow-up corresponding to an incidence rate of 5.8 (95% CI 3.9-8.4) and 3.5 (2.2-5.3) per 1000 person years, respectively. Among the identified COPD cases a total of 12 were Asthma-COPD Overlap Syndrome (ACOS). Atopy defined by positive SPT was a risk factor for asthma in males (OR 7.54; 95% CI 1.24-45.90), whereas risk factors in females were nasal allergy (3.81; 1.20-12.11), FEV 1 <100% predicted (3.96; 1.07-14.62) and parental asthma (3.06; 1.00-9.40). Risk factors for COPD in males were bronchial hyperresponsiveness (23.13; 1.41-380.50) and FEV 1 <100% predicted (all male cases had FEV 1 <100% predicted) and in females current smoking (3.34; 1.16-9.59) and asthma at baseline (5.21; 1.48-18.34)., Conclusions: No shared risk factors for incident asthma and COPD were found. Despite low power when stratifying by sex risk factors for incident asthma and COPD emphasize considerable gender differences., (© 2017 John Wiley & Sons Ltd.)

Purpose: To determine the impact of socioeconomic position (SEP) and distance to provider on outpatient mental health care utilization among incident users of antidepressants., Method: A nationwide register-based cohort study of 50,374 person-years., Results: Persons in low SEP were more likely to have outpatient psychiatrist contacts [odds ratio (OR) 1.25; confidence interval (CI) 1.17-1.34], but less likely to consult a co-payed psychologist (OR 0.49; CI 0.46-0.53) and to get mental health service from a GP (MHS-GP) (OR 0.81; CI 0.77-0.86) compared to persons in high SEP after adjusting for socio-demographics, comorbidity and car ownership. Furthermore, persons in low SEP who had contact to any of these therapists tended to have lower rates of visits compared to those in high SEP. When distance to services increased by 5 km, the rate of visits to outpatient psychiatrist tended to decrease by 5% in the lowest income group (IRR 0.95; CI 0.94-0.95) and 1% in the highest (IRR 0.99; CI 0.99-1.00). Likewise, contact to psychologists decreased by 11% in the lowest income group (IRR 0.89; CI 0.85-0.94), whereas rate of visits did not interact., Conclusion: Patients in low SEP have relatively lower utilization of mental health services even when services are free at delivery; co-payment and distance to provider aggravate the disparities in utilization between patients in high SEP and patients in low SEP.

Exacerbation frequency is central in treatment strategies for chronic obstructive pulmonary disease. However, whether chronic obstructive pulmonary disease patients from the general population with frequent exacerbations continue to have frequent exacerbations over an extended period of time is currently unknown. In this study, we aimed to investigate the stability of the frequent exacerbator in a population-based setting. To this end, we conducted a nationwide register-based descriptive study with a 10-year follow-up period of chronic obstructive pulmonary disease patients with at least one medically treated exacerbation in 2003. Each subsequent year, we divided the population into frequent, infrequent and non-exacerbators and quantified the flow between categories. Further, we estimated the percentage of frequent exacerbators at baseline who stayed in this category each year during a 5-year follow-up. We identified 19,752 patients with chronic obstructive pulmonary disease and an exacerbation in 2003. Thirty percent were frequent exacerbators. Overall, the majority of exacerbators in 2003 were non-exacerbators in the following years (60% in 2004 increasing to 68% in 2012). Approximately half of frequent exacerbators in one year experienced a decrease in exacerbation frequency and had either zero or one exacerbation in the subsequent year. This pattern was stable throughout follow-up. During a 5-year follow-up period, a substantial proportion (42%) of frequent exacerbators in 2003 had no additional years as frequent exacerbators, while the minority (6%) remained in this category each year. In conclusion, the rate of exacerbations shows considerable variation over time among chronic obstructive pulmonary disease patients in the general population. This might hold implications for chronic obstructive pulmonary disease treatment guidelines and their practical application., Chronic Obstructive Lung Disease: VARIATIONS IN DISEASE PROGRESSION: Patients with chronic obstructive pulmonary disease (COPD) who suffer from frequent exacerbations do not necessarily persist with such severity over time. Exacerbations in COPD are defined by worsening respiratory symptoms that result in changes to treatment, hospitalization and, at worst, death. However, clarity is needed on whether frequent exacerbations is a stable feature of some patients' disease. Mette Reilev at the University of Southern Denmark and co-workers followed, over 10 years, 19,752 COPD patients living in Denmark who suffered at least one exacerbation in 2003. By 2004, 60% of patients were classed as infrequent or non-exacerbators, rising to 68% by 2012. Very few patients remained "frequent exacerbators", suggesting the rate of exacerbations changes considerably over time. This could hold implications for COPD treatment and challenge assumptions made about disease progression.

Background: Medical engagement is a mutual concept of the active and positive contribution of doctors to maintaining and enhancing the performance of their health care organization, which itself recognizes this commitment in supporting and encouraging high quality care. A Medical Engagement Scale (MES) was developed by Applied Research Ltd (2008) on the basis of emerging evidence that medical engagement is critical for implementing radical improvements., Objectives: To study the importance of medical engagement in general practice and to analyse patterns of association with individual and organizational characteristics., Design and Setting: A cross-sectional study using a sampled survey questionnaire and the official register from the Danish General Practitioners' Organization comprising all registered Danish GPs., Method: The Danish version of the MES Questionnaire was distributed and the survey results were analysed in conjunction with the GP register data., Results: Statistically adjusted analyses revealed that the GPs' medical engagement varied substantially. GPs working in collaboration with colleagues were more engaged than GPs from single-handed practices, older GPs were less engaged than younger GPs and female GPs had higher medical engagement than their male colleagues. Furthermore, GPs participating in vocational training of junior doctors were more engaged than GPs not participating in vocational training., Conclusion: Medical engagement in general practice varies a great deal and this is determined by a complex interaction between both individual and organizational characteristics. Working in collaboration, having staff and being engaged in vocational training of junior doctors are all associated with enhanced levels of medical engagement among GPs., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Patients with depression have significantly increased mortality from somatic disease. The purpose of this article was to review studies that investigate if there is a prognostic association with depression as co-morbidity in patients with chronic obstructive pulmonary disease (COPD). We chose the following outcomes: mortality, suicide behaviour, risk of COPD exacerbation, use of primary care and prescription data., Methods: A literature review was performed on 16 December 2014 in PubMed, Embase, OVID Medline and Cochrane for cohort studies. Only studies with mortality and exacerbation/hospital admissions were found. Studies failing to meet relevant criteria in terms of design or/and outcome, and studies with significant methodological faults were excluded., Results: A total of 22 cohort studies were included. Of these studies, 20 were prospective, one retrospective and one was a combined retro- and prospective study. There was a tendency for studies with more patients and higher methodological quality to show a positive correlation. Sixteen of the studies showed that depression was associated with increased mortality (relative risk (RR): 1.02-3.6) and more COPD exacerbations (RR: 1.3-7.0)., Conclusions: The results showed that not only is depression a debilitating disease on its own, it also predisposes to COPD exacerbations and increased mortality in patients with COPD. Depression in patients with COPD is under-diagnosed and undertreated, and a stronger focus on the clinical significance of depression as co-morbidity is warranted.

Background and Objectives: Danish general practitioners (GPs) follow a voluntary continuous professional development (CPD) programme based on accredited activities. Inspired by a current interest in CPD, this study investigates GPs' preferences for future CPD programmes., Methods: The preferences were tested in a Discrete Choice Experiment (DCE) sent to 1079 randomly chosen GPs. The GPs were asked to choose between hypothetical CPD programmes, based on educational questions generated from discussions with educational stakeholders., Results: The response rate was 686/1079 (63%). GPs had the following preferences for a future CPD programme: 1) option to exchange experience with colleagues, 2) focus on implementation of new knowledge into practice, 3) ensure 10 days of CPD activities per year, 4) to have CPD programmes where 50% are planned by a central organisation and 50% are planned by the individual GP, 5) to have teachers with a profound insight and knowledge about general practice. There was neither an overall request for appraisal, nor for more CPD activities based on interactive learning strategies. There was, however, variability in GPs' preferences regarding some of the elements., Conclusion: A prioritised list of Danish GPs' preferences for future CPD has been identified. However, variation in preferences suggests there should be room for individual variation.

Objectives: Smoking, diabetes, male sex, hypercholesterolaemia and hypertension are well-established risk factors for the development of coronary artery disease (CAD). However, less is known about their role in influencing the outcome in the event of an acute coronary syndrome (ACS). The aim of this study was to determine if these risk factors are associated specifically with acute myocardial infarction (MI) or unstable angina (UA) in patients with suspected ACS., Design: Cross-sectional study., Setting: Patients admitted to the coronary care unit, via the emergency room, at a central county hospital over a 4-year period (1992-1996)., Participants: From 5292 patients admitted to the coronary care unit, 908 patients aged 30-74 years were selected, who at discharge had received the diagnosis of either MI (527) or UA (381). A control group consisted of 948 patients aged 30-74 years in whom a diagnosis of ACS was excluded., Main Outcome Measures: MI or UA., Results: Current smoking (OR 2.42 (1.61 to 3.62)), impaired glucose homoeostasis defined as glycated haemoglobin ≥5.5% + blood glucose ≥7.5 mM (OR 1.78 (1.19 to 2.67)) and male sex (OR 1.71 (1.21 to 2.40)) were significant factors predisposing to MI over UA, in the event of an ACS. Compared with the non-ACS group, impaired glucose homoeostasis, male sex, cholesterol level and age were significantly associated with development of an ACS (MI and UA). Interestingly, smoking was significantly associated with MI (OR 2.00 (1.32 to 3.02)), but not UA., Conclusions: Smoking or impaired glucose homoeostasis is an acquired risk factor for a severe ACS outcome in patients with CAD. Importantly, smoking was not associated with UA, suggesting that it is not a risk factor for all clinical manifestations of CAD, but its influence is important mainly in the acute stages of ACS. Thus, on a diagnosis of CAD, the cessation of smoking and management of glucose homoeostasis are of upmost importance to avoid severe subsequent ACS consequences., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: In primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined., Objectives: To examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures., Methods: We applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics., Results: Out of the individual expenditures, 31.6% were explained by age, gender and RUB, and around 18% were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0-RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44%; 3.8-9.4% of the variation in expenditures was related to the GP clinic in which the patient was treated., Conclusions: Morbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.

Background: In several countries, morbidity burdens have prompted authorities to change the system for allocating resources among patients from a demographic-based to a morbidity-based casemix system. In Danish general practice clinics, there is no morbidity-based casemix adjustment system., Aim: The aim of this paper was to assess what proportions of the variation in fee-for-service (FFS) expenditures are explained by type 2 diabetes mellitus (T2DM) patients' co-morbidity burden and illness characteristics., Methods and Data: We use patient morbidity characteristics such as diagnostic markers and co-morbidity casemix adjustments based on resource utilisation bands and FFS expenditures for a sample of 6706 T2DM patients in 59 general practices for the year 2010. We applied a fixed-effect approach., Results: Average annual FFS expenditures were approximately 398 euro per T2DM patient. Expenditures increased progressively with the patients' degree of co-morbidity and were higher for patients who suffered from diagnostic markers. A total of 17-25% of the expenditure variation was explained by age, gender and patients' morbidity patterns., Conclusion: T2DM patient morbidity characteristics are significant patient related FFS expenditure drivers in diabetes care. To address the specific health care needs of T2DM patients in GP clinics, our study indicates that it may be advisable to introduce a morbidity based casemix adjustment system., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: There is a great variability in licit prescription drug use in the population and among patients. Factors other than purely medical ones have proven to be of importance for the prescribing of licit drugs. For example, individuals with a high age, female gender and low socioeconomic status are more likely to use licit prescription drugs. However, these results have not been adjusted for multi-morbidity level. In this study we investigate the odds of using licit prescription drugs among individuals in the population and the rate of licit prescription drug use among patients depending on gender, age and socioeconomic status after adjustment for multi-morbidity level., Methods: The study was carried out on the total population aged 20 years or older in Östergötland county with about 400 000 inhabitants in year 2006. The Johns Hopkins ACG Case-mix was used as a proxy for the individual level of multi-morbidity in the population to which we have related the odds ratio for individuals and incidence rate ratio (IRR) for patients of using licit prescription drugs, defined daily doses (DDDs) and total costs of licit prescription drugs after adjusting for age, gender and socioeconomic factors (educational and income level)., Results: After adjustment for multi-morbidity level male individuals had less than half the odds of using licit prescription drugs (OR 0.41 (95% CI 0.40-0.42)) compared to female individuals. Among the patients, males had higher total costs (IRR 1.14 (95% CI 1.13-1.15)). Individuals above 80 years had nine times the odds of using licit prescription drugs (OR 9.09 (95% CI 8.33-10.00)) despite adjustment for multi-morbidity. Patients in the highest education and income level had the lowest DDDs (IRR 0.78 (95% CI 0.76-0.80), IRR 0.73 (95% CI 0.71-0.74)) after adjustment for multi-morbidity level., Conclusions: This paper shows that there is a great variability in licit prescription drug use associated with gender, age and socioeconomic status, which is not dependent on level of multi-morbidity.

People aged 60 or more are the most frequent users of healthcare services. In this age range, however, both frequent and infrequent users can be found. Frequent users have high rates of illnesses. Previous research has found that the frequency may be influenced also by psychological and social factors. The aim of this study was to investigate to what degree such factors add to the explanation of differences in number of visits to a physician. A cross-sectional study was conducted with a random sample consisting of 1017 individuals, aged 60 to 78 years, from the Blekinge part of the Swedish National Study on Aging and Care database. The data were collected during 2001 to 2003. Hierarchical logistic regression analyses were used with frequent (three visits or more during a year) and infrequent use as a dichotomous dependent variable. The final statistical analyses included 643 individuals (63% of the sample). Independent variables were sense of coherence (SOC), internal locus of control, education level and social anchorage. Control variables were age, gender, functional ability and comorbidity. The results showed that comorbidity was most strongly related to frequent use [adjusted odds ratio (OR) = 8.17, 95% confidence interval (CI) 5.54–12.04]. In addition, SOC and internal locus of control had small, but significant effects on the odds of being a frequent user (adjusted OR = 1.03, 95% CI 1.00–1.06 and adjusted OR = 1.14, 95% CI 1.02–1.27, respectively). The lower the SOC and the internal locus of control were, the higher were the odds of frequent use. Education level and social anchorage were unrelated to frequency of use. The results indicate that frequent healthcare services users are more ill than infrequent users. Psychological factors influence the use only marginally, and social factors as well as age and gender are not by themselves reason for frequent healthcare services use.

Background: Convincing scientific evidence exists that smoking has devastating effects on health. The use of smokeless tobacco (snuff) as a tobacco habit has been reported to be considerably less harmful, and has been suggested as an aid to smoking cessation, among other things., Methods: Cross-sectional data on general health and tobacco habits were obtained through a self-administered mail questionnaire in 2002 representing 50-year-old (n = 6236) and 60-year-old (n = 6232) Swedes in two counties. Participation rates were 70.2 and 75.7% in the both age cohorts, respectively. Of all participants 46.2% were male and 53.8% female. A general health index encompassing five items (score 0-5) was designed, with the best general health attributed to those scoring 5., Results: Male daily smokers accounted for 15.6% of the 50-year-olds and 18.7% of the 60-years-olds compared with 21.1 and 16.6%, respectively, for females. Corresponding figures for daily snuffing were 21.1 and 11.9% for men and 1.7 and 0.4% for women. When adjusting for age, sex, place of living, social network, education, and marital status, and related to subjects who never used tobacco, 'best general health' score 5, significant differences were found for ex-smokers (OR 0.82; 95% CI 0.74-0.90; P < 0.001) and ex-snuffers (OR 0.74; 95% CI 0.61-0.90; P < 0.01)., Conclusion: Those who have stopped smoking or snuffing seem to be in a vulnerable condition with respect to general health and in need of extra support and health-promoting activities.

Aim: The aim in this survey was to study the clinical characteristics of infections caused by Borrelia genospecies in patients with erythema migrans where borrelial origin was confirmed by polymerase chain reaction. The aim was also to study factors influencing the clinical appearance of erythema migrans., Methods: The study was conducted in southern Sweden from May 2001 to December 2003 on patients 18 years and older attending with erythema migrans at outpatient clinics. All erythema migrans were verified by polymerase chain reaction, photographed and categorized as "annular" or "non-annular" lesions. A logistic regression model was used to analyze relations between the appearance of the erythema migrans (i.e. annular or non-annular) and factors that influenced its clinical appearance., Results: A total of 118 patients, 54 women (45.8%) and 64 men (54.2%), fulfilled the inclusion criteria. Of these patients, 74% were infected by B. afzelii and 26% by B. garinii (p < 0.001). A total of 45% (38/85) of the erythema migrans were annular, 46% (39/85) were nonannular and 9.4% (8/85) were atypical. For men infected by B. afzelii, the odds ratio of developing non-annular erythema migrans was 0.09 (95% CI: 0.03-0.33) in comparison with women with the same infection., Conclusions: In this prospective study of a large series of erythema migrans, where infecting genospecies were confirmed by polymerase chain reaction, the sex of patients infected with B. afzelii had a strong influence on the appearance of the rash. Patients infected by B. garinii more often had non-annular erythema migrans and a more virulent infection with more individuals presenting with fever, raised levels of C-reactive protein and seroreactivity in the convalescence sera.

Objective: The objective was to study primary healthcare patients' understanding of their diagnosis of heart failure (HF), using patients treated for diabetes mellitus (DM) as a comparative group., Design: A cross-sectional community based study., Setting: Karlskrona community situated on the Swedish south-east coast with 60,600 inhabitants., Subjects: A total of 1402 subjects, aged 60-96 years in 10 age cohorts, selected randomly from the national population registry participating in the Swedish National study on Ageing and Care - Blekinge., Main Outcome Measures: Understanding of diagnosis of HF or DM in primary healthcare. Prevalence of cognitive impairment., Results: In all, 39.8% of patients with a diagnosis of HF treated in primary healthcare and 97.1% of patients with DM had an understanding of their respective diagnosis. Cognitive impairment was significantly more prevalent in the groups of patients treated for HF (OR 1.9, 95% CI 1.2 to 3.0) and DM (OR 1.8, 95% CI 1.1 to 3.1), when compared with those not treated for either HF or DM. The odds ratio for understanding of diagnosis was 0.013 (95% CI 0.003 to 0.052, p < 0.001) in patients treated for HF, compared with patients treated for DM, when adjusted for the subject's age, sex, and cognitive function., Conclusion: In this study it was shown that patients' understanding of their diagnosis was highly dependent on diagnosis, independently of age, sex, or cognitive function. The results suggest that there is room for improvement of care in primary healthcare, to increase HF patients' understanding of their diagnosis.

Osteopenia/osteoporosis affect many elderly people and might not be detected until symptoms of fractures occur. Early detection of osteopenia/osteoporosis is important and would allow preventive measures and treatment. Access to screening for osteopenia/osteoporosis is often limited, whereas panoramic radiography is commonly used in dentistry. The aim of this study was to determine the validity of the Klemetti index (KI), measured on panoramic radiographs, in the diagnosis of osteopenia/osteoporosis as defined by a bone mineral density (BMD) measurement below -1.5 standard deviations (SDs) of a community based sample. In total, 211 consecutive participants (102 men and 109 women) 60-96 years in the SNAC-Blekinge study (Swedish National Study on Ageing and Care) underwent bone densitometry [by dual-energy X-ray absorptiometry (DXA)] of both heels. A panoramic radiograph was taken of each participant, and mandibular cortex on a panoramic radiograph was classified as '0' or normal (even and sharp endosteal margin), '1', moderately eroded (evidence of lacunar resorption or endosteal cortical residues), or '2', severely eroded (unequivocal porosity). From logistic regression, the odds ratio of having a BMD measurement below -1.5 SD was 8.04 (95% CI 2.39 to 27.12, P<0.001) in the 'osteopenic' (KI category 2), compared with the 'normal' group (KI categories 0 and 1). Receiver operating characteristic (ROC) curve analysis was used to measure the validity of the KI indicating osteopenia (KI category 2) in predicting reduced BMD. This point provided a sensitivity of 50% and a specificity of 89%. Positive and negative predictive values were 21% and 97%, respectively. There were 87% correctly classified subjects. The area under the ROC curve was 0.64. The present study demonstrated that a negative finding (KI category <2) is highly predictive of the absence of osteopenia/osteoporosis as defined by the DXA measurements.