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Background and Objective: Population-based estimates of the socioeconomic burden of multiple sclerosis (MS) are limited, especially regarding primary healthcare. This study aimed to estimate the excess costs of people with MS that could be attributed to their MS, including primary healthcare., Methods: An observational study was conducted of the 2806 working-aged people with MS in Stockholm, Sweden and 28,060 propensity score matched references without MS. Register-based resource use was quantified for 2018. Annual healthcare costs (primary, specialised outpatient, and inpatient healthcare visits along with prescribed drugs) and productivity losses (operationalised by sickness absence and disability pension days) were quantified using bottom-up costing. The costs of people with MS were compared with those of the references using independent t-tests with bootstrapped 95% confidence intervals (CIs) to isolate the excess costs of MS from the mean difference., Results: The mean annual excess costs of MS for healthcare were €7381 (95% CI 6991-7816) per person with MS with disease-modifying therapies as the largest component (€4262, 95% CI 4026-4497). There was a mean annual excess cost for primary healthcare of €695 (95% CI 585-832) per person with MS, comprising 9.4% of the excess healthcare costs of MS. The mean annual excess costs of MS for productivity losses were €13,173 (95% CI 12,325-14,019) per person with MS, predominately from disability pension (79.3%)., Conclusions: The socioeconomic burden of MS in Sweden from healthcare consumption and productivity losses was quantified, updating knowledge on the cost structure of the substantial excess costs of MS., (© 2022. The Author(s).)

Objectives: Disease-modifying therapies (DMTs) can slow disease progression in multiple sclerosis (MS). The objective of this study was to explore the cost-of-illness (COI) progression among newly diagnosed people with MS in relation to the first DMT received., Design and Setting: A cohort study using data from nationwide registers in Sweden., Participants: People with MS (PwMS) in Sweden first diagnosed in 2006-2015, when aged 20-55, receiving first-line therapy with interferons (IFN), glatiramer acetate (GA) or natalizumab (NAT). They were followed up through 2016., Outcome Measures: Outcomes (in Euros, €) were: (1) secondary healthcare costs: specialised outpatient and inpatient care including out-of-pocket expenditure, DMTs including hospital-administered MS therapies, and prescribed drugs, and (2) productivity losses: sickness absence and disability pension. Descriptive statistics and Poisson regression were computed, adjusting for disability progression using the Expanded Disability Status Scale., Results: 3673 newly diagnosed PwMS who were treated with IFN (N=2696), GA (N=441) or NAT (N=536) were identified. Healthcare costs were similar for the INF and GA groups, while the NAT group had higher costs (p value<0.05), owing to DMT and outpatient costs. IFN had lower productivity losses than NAT and GA (p value>0.05), driven by fewer sickness absence days. NAT had a trend towards lower disability pension costs compared with GA (p value>0.05)., Conclusions: Similar trends over time for healthcare costs and productivity losses were identified across the DMT subgroups. PwMS on NAT maintained their work capacity for a longer time compared with those on GA, potentially leading to lower disability pension costs over time. COI serves as an objective measure to explore the importance of DMTs in maintaining low levels of progression of MS over time., Competing Interests: Competing interests: All authors (KK, HG, EF, CM, JH, AK, TO, KA) are employed or affiliated at the Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. KK is currently employed by Celgene/Bristol Myers Squibb; she initiated this study while being employed at Karolinska Institutet (employment ended in October 2019); since then, she has received no salary from Karolinska Institutet or other type of funding for this research. HG is currently employed part-time by Statfinn/EPID Research (which is part of IQVIA); both companies are contract research organisations that perform commissioned pharmacoepidemiological studies, and therefore are collaborating with several pharmaceutical companies. CM since submission of this paper has begun employment with Macanda AB. AK is currently also employed by Takeda Pharma AB. JH, KA and EF are collaborating with several pharmaceutical companies; EF has received an unrestricted MS research grant from Celgene/Bristol Myers Squibb. TO has received advisory board and/or lecture honoraria, and unrestricted MS research grants from Biogen, Novartis, Sanofi, Merck and Roche., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: The chimeric antigen receptor (CAR) T-cell therapy idecabtagene vicleucel (ide-cel) is approved for the treatment of adult patients with relapsed/refractory multiple myeloma (RRMM) who have already received an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 antibody and have progressed on their last therapy. The objective of this study was to assess the cost-effectiveness of ide-cel versus conventional care in Canada and France., Methods: A partitioned survival model was used to estimate the cost-effectiveness of ide-cel (target dose 450 × 10 6 CAR T cells) in its approved indication in terms of life-years (LYs), quality-adjusted LYs (QALYs), and costs. Patient-level data from the KarMMa Phase II clinical trial (clinicaltrials.gov NCT03361748) and KarMMa-RW study were used to inform the model; overall and progression-free survival were extrapolated using standard parametric functions after the observed periods. The model adopted Canadian and French societal perspectives over a lifetime horizon. Costs, utilities, discounting (Canada: 1.5%, France: 2.5%), and general population mortality were country-specific., Results: The base case demonstrated that ide-cel was associated with more additional LYs (+2.64 and +2.51) and QALYs (+2.31 and +2.54) than conventional care at incremental costs of CAN$588,490 and €392,251 in Canada and France, respectively. The resulting incremental cost-effectiveness ratio (ICER) for ide-cel was $255,245 per QALY in Canada, and €154,593 per QALY in France., Conclusion: Ide-cel was associated with significant survival improvements in terms of both LYs and QALYs in patients with progressive triple-class-exposed RRMM. The ICER for ide-cel was similar to that of other approved and reimbursed RRMM therapies.

Background: Early treatment with disease modifying therapies (DMTs) for multiple sclerosis (MS) has been associated with lower disability progression; the aim was to explore its association with cost of illness (COI) in MS., Methods: All people with relapsing-remitting MS in the Swedish MS register, aged 20-57 years and receiving their first MS DMT in 2006-2009, were followed in nationwide registers for 8 years. Healthcare costs (in- and outpatient healthcare, DMTs and other prescribed drugs), and productivity losses (sickness absence and disability pension) of individuals receiving therapy in ≤6 months after diagnosis (early treatment group) were compared to those receiving therapy >6 months (late treatment group). Using Poisson regressions, the mean COI per patient per year, and per group, was estimated, adjusted for disability progression., Results: The early treatment group comprised 74% of the 1562 individuals included in the study. The early treatment group had lower productivity losses over time. Both groups had similar healthcare costs, which first increased and then decreased over time., Conclusions: Early DMT in MS could result in lower productivity losses possibly through maintained work capacity. COI serves as an objective measure showing the advantage of early vs. late treatment initiation in MS., Competing Interests: Declaration of conflicting interests: All authors (KK, HG, CM, KA, JH, AK, TO, AM, EF) are employed or affiliated at the Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. KK is currently employed by Celgene/Bristol Myers Squibb; she initiated this study while being employed at Karolinska Institutet (employment ended in October 2019); since then, she has not received any salary from Karolinska Institutet or other type of funding for this research. HG is currently employed part-time by Statfinn/EPID Research (which is part of IQVIA); both companies are contract research organizations that perform commissioned pharmaco-epidemiological studies, and therefore are collaborating with several pharmaceutical companies. CM's employment at Karolinska Institutet is partly funded by research grant from Biogen. AM is supported by Margaretha af Ugglas foundation. KA has received unrestricted MS research grants from Biogen. JH has received honoraria for serving on advisory boards for Biogen, Celgene, Sanofi-Genzyme, Merck KGaA, Novartis and Sandoz and speaker's fees from Biogen, Novartis, Merck KGaA, Teva and Sanofi-Genzyme. He has served as P.I. for projects, or received unrestricted research support from, Biogen, Bristol-Myers-Squibb, Merck KGaA, Novartis, Roche and Sanofi-Genzyme. His MS research is funded by the Swedish Research Council and the Swedish Brain foundation. TO has received advisory board and/or lecture honoraria, and unrestricted MS research grants from Biogen, Novartis, Sanofi, Merck and Roche. EF is partly funded by research grants from Biogen, and has received an unrestricted MS research grant from Celgene/Bristol Myers Squibb., (© The Author(s), 2022.)

Objectives: Telephone advice nursing is introduced in many countries with one key aim being a reduction of avoidable healthcare visits. The aim of this study was to explore whether callers to a telephone advice nursing service followed the telenurses' recommendations, and whether there was a change in the level and trend of the rate of healthcare visits after the introduction of telephone advice nursing., Design: Observational study., Setting: Primary and secondary care in Jönköping Region, Sweden., Participants: Telephone advice nursing calls, 6:00-23:00, 2014-2015 (n=185 994) and outpatient healthcare visits 2012-2015 (n=6 877 266)., Primary Outcome: Proportion of callers who visited healthcare within the time period advised by the telenurse., Secondary Outcome: Change in level or trend of the overall rate of healthcare visits per 1000 persons and 4-week period after the introduction of telephone advice nursing, with subgroup analysis for primary and secondary care., Results: 77% of callers who were recommended either to visit healthcare within 24 hours or to 'wait and see' followed the recommendations. There was no significant change in level (-5.15; 95% CI -15.80 to 5.50; p=0.349) or trend (-0.24; 95% CI -0.86 to 0.38; p=0.448) of the overall rate of visits per 1000 persons and 4-week period after the introduction of telephone advice nursing. For the rate of primary care visits, an increase in level (8.01; 95% CI 6.36 to 9.66; p<0.001) and trend (1.28; 95% CI 1.17 to 1.39; p<0.001) were observed. For the rate of secondary care visits, a decrease in level (-8.77, 95% CI -14.41 to -3.13; p=0.004) and trend (-1.03, 95% CI -1.35 to -0.71; p<0.001) were observed., Conclusions: The introduction of telephone advice nursing may have contributed to a shift in the rate of healthcare visits from secondary to primary care., Competing Interests: Competing interests: AS is employed by Inera AB, a limited company owned by Swedish regions, municipalities as well as the Swedish Association of Local Authorities and Regions (SALAR) that administrates the technical solutions used in 1177. AS conducted this research as part of her master’s degree project in the Master’s programme in Public Health Sciences (track Health Economics, Policy and Management) at the Karolinska Institutet, while she was on leave of absence from her employment. The study findings have been interpreted scientifically by all coauthors, without the involvement of Inera AB, and not in the interest of 1177. All other coauthors (ACW, NZ, and KK) are employed at or affiliated with Karolinska Institutet, Stockholm, Sweden. KK is currently employed by BMS, a pharmaceutical company which is not involved with 1177 in Sweden., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Multiple sclerosis (MS) is a chronic disease associated with increased healthcare utilisation and productivity losses., Objective: The objective of this study was to explore the progression of healthcare costs and productivity losses before and after diagnosis of MS in comparison to that of a population-based matched reference group., Methods: We conducted a nationwide, Swedish register-based cohort study of working-aged people with MS diagnosed in 2010-12 (n = 1988) and population-based matched references without MS (n = 7981). Nine years of observation spanned from 4 years prior (Y -4 ) to 4 years (Y +4 ) after the year of diagnosis (Y 0 ). Differences in annual all-cause healthcare costs (inpatient and specialised outpatient healthcare as well as pharmacy-dispensed prescribed drugs) and costs of productivity loss (days with sickness absence and disability pension) were estimated between the people with MS and references using t tests with 95% confidence intervals. The average excess costs of MS were estimated using generalised estimating equation models., Results: People with multiple sclerosis had higher costs before the diagnosis of MS and also thereafter. The mean differences in healthcare costs and productivity losses between the people with MS and matched references in Y -4 were 216 EUR (95% confidence interval 58-374) and 1540 EUR (95% confidence interval 848-2233), with larger cost excesses observed in later study years. Summarising the 9 study years, people with MS had fivefold higher excess healthcare costs than references, and more than twice as high productivity losses., Conclusions: Excess healthcare costs and productivity losses occur already before the diagnosis of MS and increase with time. The excess costs findings before diagnosis could suggest that an earlier diagnosis might lead to reduced excess costs of MS over time.

Objectives: To explore sequences of annual states of activity and sickness absence (SA) or disability pension (DP) (SA/DP) among working-aged people with multiple sclerosis (PwMS) as well as characteristics associated with the identified types of working-life sequences., Design: Nationwide Swedish register-based cohort study from 1 year prior to 5 years after the year of multiple sclerosis (MS) diagnosis., Setting: Sweden., Participants: PwMS diagnosed in 2008-2011 when aged 20-55 (n=2652, 69.9% women)., Primary and Secondary Outcome Measures: Individual-level sequences spanning 7 years were constructed with annual states regarding activity (income from paid work, student allowances, parental leave or unemployment compensation) and/or SA/DP. Types of working-life sequences were identified among the individuals' sequences using hierarchical cluster analysis with optimal matching dissimilarity measures., Results: Six types of working-life sequences were identified. The largest cluster, Stable High Activity, represented 48.4% of the cohort. Other types were: Stable High SA/DP (14.5%); Other (4.5%); and three types with mixed activity and varying SA/DP regarding the number of days/year and timing (32.6%). Characteristics of the different identified types of sequences were subsequently investigated. All types of sequences had lower odds for university education (OR range: 0.18-0.72) compared with Stable High Activity. Increasingly higher odds of having anxiety/depression compared with Stable High Activity were observed across the types of sequences, by increasing proportions of SA/DP. Stable High SA/DP sequences were less likely than Stable High Activity to be prescribed MS drugs in the MS diagnosis year (OR 0.61; 95% CI 0.47 to 0.78). All types of sequences had higher disposable income in the final study year than the first, except for Stable High SA/DP sequences (Swedish Krona 4669, 95% CI -1892 to 11 230)., Conclusions: Diversity in working life was influenced by sociodemographic and clinical characteristics resulting in different activity and SA/DP patterns across the six identified types of working-life sequences., Competing Interests: Competing interests: CM, KA, and EF were partly funded by Biogen. KA has received unrestricted researcher-initiated grants from Biogen. EF has received unrestricted researcher-initiated grants from Celgene. PT has previously received salaries partly funded by Biogen. KK is only affiliated with Karolinska Institutet, not receiving financial compensation for her involvement in this study; she is working full time at Gilead Sciences AB. JH received honoraria for serving on advisory boards for Biogen and Novartis and speaker’s fees from Biogen, Merck-Serono, Bayer-Schering, Teva and Sanofi-Aventis. He has served as P.I. for projects sponsored by, or received unrestricted research support from, Biogen, Merck-Serono, TEVA, Novartis, and Bayer-Schering. His MS research is also funded by the Swedish Research Council., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Comorbidities are common among people with multiple sclerosis (PwMS); yet, their impact on the cost-of-illness (COI) in MS is unknown., Objective: Explore the heterogeneity in COI trajectories among newly diagnosed PwMS in relation to type of comorbidity., Methods: A nationwide longitudinal cohort study, using prospectively collected Swedish register data for seven years. The COI/year of 639 PwMS diagnosed in 2006, when aged 25-60, was estimated until 2013. Using healthcare data, PwMS were categorised into six comorbidity groups: ocular; cardiovascular, genitourinary or cancer disease; musculoskeletal; mental; neurological other than MS; and injuries. One group of PwMS without comorbidity was also created. Group-based trajectory modelling was applied, examining different COI trajectories within each comorbidity group., Results: Across the seven follow-up years, PwMS with mental comorbidities had the highest COI overall (€36,482). Four COI trajectories were identified within each comorbidity group; the largest trajectory had high healthcare costs and productivity losses (36.3%-59.6% of PwMS, across all comorbidity groups). 59.6% of PwMS with mental comorbidity had high healthcare costs and productivity losses., Conclusion: High COI and heterogeneity in COI trajectories could be partly explained by the presence of chronic comorbidities in the year around MS diagnosis, including the presence of mental comorbidity., Competing Interests: CM and EF were partly funded by Biogen. EF has received an unrestricted research grant from Celgene. KA has received unrestricted researcher-initiated grants from Biogen. GB and AE conducted this work as part of their master’s thesis and have received funding by Biogen after the completion of their master thesis to draft this manuscript and present their results of their thesis. KK is only affiliated with Karolinska Institutet, not receiving financial compensation for her involvement in this study; she is working full time at Gilead Sciences AB. JH received honoraria for serving on advisory boards for Biogen and Novartis and speaker’s fees from Biogen, Merck-Serono, Bayer-Schering, Teva and Sanofi-Aventis. He has served as P.I. for projects sponsored by, or received unrestricted research support from, Biogen, Merck-Serono, TEVA, Novartis, and Bayer-Schering. His MS research is funded by the Swedish Research Council., (© The Author(s) 2020.)

Objective: Back pain is the leading cause for years lived with disability globally and among the main reasons for sickness absence (SA) and disability pension (DP). The objective of this study was to explore the occurrence of SA and DP and to estimate productivity losses among individuals with back pain compared with among matched population-based references., Design: Explorative prospective cohort study using register microdata., Participants and Setting: A total of 23 176 people, aged 19-60 years, with a first visit to inpatient or specialised outpatient healthcare for back pain (International Statistical Classification of Diseases and Related Health Problems code M54) in 2010 in Sweden and a matched population-based reference group (n=115 880)., Outcomes: Long-term SA (in SA spells >14 days) and DP and productivity losses, measured in € (2018 prices) by multiplying the SA and DP net days by the societal cost of each such day., Results: In the back-pain group, 42% had SA or DP days; in the reference group, the corresponding proportion was 15%. Productivity loss per patient with back pain was €8928 during the 12-month follow-up period; in the reference group, it was €3499 (p<0.0001)., Conclusions: SA and DP, leading to excess productivity losses among people with back pain, reflect the challenges these patients are facing to maintain their work capacity. Interventions to promote that individuals with back pain remain in paid work should be a priority in order to address the high costs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Multiple sclerosis (MS) typically onsets when of working age and may reduce work capacity. Previous studies have examined the risk of sickness absence (SA) and disability pension (DP) among MS patients, however, limited knowledge is available on whether MS patients have an excess risk for SA/DP when compared with the general population in Sweden. Moreover, no information exists on the actual diagnoses for SA and DP among MS patients and whether the patterns of SA/DP diagnoses differs to those without MS. We aimed to explore diagnosis-specific SA and DP among working-aged MS patients both before and after MS diagnosis, in comparison to the levels and distributions of SA and DP diagnoses of a matched reference group and analyze the risk of diagnosis-specific DP., Materials and Methods: Longitudinal Swedish register data of the 2567 MS patients diagnosed with MS in 2009-2012 when aged 25-59 and 10,268 population-based matched references (matched on sex, age, educational level, type of living area, and country of birth) were analysed regarding annual diagnosis-specific SA and DP in the four years before and four years after MS diagnosis. Annual differences in the mean numbers of SA and/or DP net days were calculated with 95% confidence intervals (CI). Hazard ratios (HR) with 95% CI from Cox proportional hazard models were used to compare risks for new all-cause and diagnosis-specific DP after MS diagnosis among the MS patients and references., Results: The mean SA/DP net days/year increased among MS patients over follow-up, due to both MS and other diagnoses. During follow-up, around 50% of MS patients had some SA/DP compared to 20% of references. The mean days of SA/DP among the MS patients compared to references increased from 10.3 more days (95% CI: 6.6-14.2) four years prior to MS diagnosis to 68.9 days (62.8-75.1) 4 years after MS diagnosis. Although most new DP among MS patients were due to MS, 15% were not. The adjusted HR for all-cause DP was 23.1 (18.1-29.5). MS patients also had higher risks of new DP due to all diagnoses except MS (HR 3.4; 2.4-4.8), musculoskeletal (HR 2.6; 1.1-6.0) and mental (HR 2.0; 1.1-3.6) diagnoses compared with references., Conclusion: MS patients had higher levels of SA/DP days/year than the references, already 4 years before the MS diagnosis, and increasingly so thereafter. The excess of SA/DP prior to MS diagnosis could be related to MS onset. However, the excess of SA/DP days were not all due to MS diagnoses, even after being diagnosed with MS. MS patients had a higher risk of having a new DP after being diagnosed with MS in total, but also for diagnoses other than MS., Competing Interests: Acknowledgements None, (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: The aim was to longitudinally explore the healthcare, sickness absence (SA), and disability pension (DP) cost trajectories among newly diagnosed people with multiple sclerosis (MS), and investigate whether trajectories differ by year of MS diagnosis, sociodemographics, and multi-morbidity., Methods: People with MS in Sweden, aged 25-60 years and with a new MS diagnosis in the years 2006, 2007, 2008, or 2009 (four different cohorts) were identified in nationwide registers and followed prospectively for 5 years, determining the annual, per patient, direct (inpatient and specialised outpatient healthcare, co-payments, and dispensed drugs) and indirect (SA and DP) costs. Descriptive statistics and group-based trajectories were computed., Results: In total, 3272 people with new MS were identified. In all cohorts, direct costs increased the year after diagnosis and thereafter declined (e.g. from €8261 to €9128, and to €7953, 5 years after diagnosis, for the 2006 cohort). SA costs continuously decreased over 5 years, while DP costs increased (e.g. from €9795 to €2778 vs. from €7277 to €15,989, respectively, for the 2006 cohort). When pooling all cohorts, four trajectories of direct and indirect costs were identified. A total of 32.1% of people with MS had high direct and indirect costs, which first increased and then decreased; the contrary was seen for trajectories with low direct and indirect costs., Conclusions: There is heterogeneity in the development of MS costs over time after diagnosis; decreasing cost trajectories could be associated with the use of innovative MS therapies, slowing disease progression over time.

Objectives: To describe how disposable income (DI) and three main components changed, and analyse whether DI development differed from working-aged people with multiple sclerosis (MS) to a reference group from 7 years before to 4 years after diagnosis in Sweden., Design: Population-based cohort study, 12-year follow-up (7 years before to 4 years after diagnosis)., Setting: Swedish working-age population with microdata linked from two nationwide registers., Participants: Residents diagnosed with MS in 2009 aged 25-59 years (n=785), and references without MS (n=7847) randomly selected with stratified matching (sex, age, education and country of birth)., Primary and Secondary Outcome Measures: DI was defined as the annual after tax sum of incomes (earnings and benefits) to measure individual economic welfare. Three main components of DI were analysed as annual sums: earnings, sickness absence benefits and disability pension benefits., Results: We found no differences in mean annual DI between people with and without MS by independent t-tests (p values between 0.15 and 0.96). Differences were found for all studied components of DI from diagnosis year by independent t-tests, for example, in the final study year (2013): earnings (-64 867 Swedish Krona (SEK); 95% CI-79 203 to -50 528); sickness absence benefits (13 330 SEK; 95% CI 10 042 to 16 500); and disability pension benefits (21 360 SEK; 95% CI 17 380 to 25 350). A generalised estimating equation evaluated DI trajectory development between people with and without MS to find both trajectories developed in parallel, both before (-4039 SEK; 95% CI -10 536 to 2458) and after (-781 SEK; 95% CI -6988 to 5360) diagnosis., Conclusions: The key finding of parallel DI trajectory development between working-aged MS and references suggests minimal economic impact within the first 4 years of diagnosis. The Swedish welfare system was responsive to the observed reductions in earnings around MS diagnosis through balancing DI with morbidity-related benefits. Future decreases in economic welfare may be experienced as the disease progresses, although thorough investigation with future studies of modern cohorts are required., Competing Interests: Competing interests: Declare the following interests with respect to the research, authorship and/or publication of this article: CM, PT, EF and MW received financial support from Biogen for the submitted work. KA has received unrestricted research grants from Biogen. OM and KK had no competing interests to declare., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: The objective of this study was to analyse how hospitalisation after the age of 60 affected individuals' health-related quality of life (HRQoL). The main hypothesis was that a hospital admission in old age can be seen as a proxy of ill health and possibly as a health divider, separating life into a healthy and an unhealthy part. The extent to which this is true depends on which disease individuals face and how functional ability and HRQoL are affected., Settings: This was a longitudinal study, based on an older cohort of individuals who participated in the Stockholm Public Health Cohort (SPHC) survey in 2006; the survey took place in Stockholm, Sweden. Information regarding hospitalisations and deaths, which is available through Swedish administrative registers, was linked to the survey from the National Patient Register and Cause of Death Register., Participants: 2101 individuals, 65+ years old at inclusion, with no previous hospitalisations at baseline (2006), were followed for 4 years until 2010 (end of follow-up)., Primary and Secondary Outcome Measures: HRQoL was assessed through a utility index derived from the EuroQol 5D questionnaire, at baseline and at 2010. The change in HRQoL after admission(s) to the hospital was estimated as the difference between the 2010 and 2006 levels using linear regression, also considering several covariates., Results: A single hospitalisation did not reduce individuals' HRQoL, either for men or women. On the other hand, multiple any-cause hospitalisations reduced HRQoL between 3.2% and 6.5%. When looking into hospitalisations for specific causes, such as hip fractures, a decrease in HRQoL was observed as well; however, conclusions regarding this were impeded by the small sample size., Conclusions: Hospital admissions in old age may indicate a shift from a healthy life to a life of compromised health when considering their frequency and cause over a period of time., (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/)

Background: Hip fracture is a common cause of disability and mortality among the elderly. Declining incidence trends have been observed in Sweden. Still, this condition remains a significant public health problem since Sweden has one of the highest incidences worldwide. Yet, no Swedish lifetime risk or survival trends have been presented. By examining how hip fracture incidence, post-fracture survival, as well as lifetime risk have developed between 1995 and 2010 in Sweden, this study aims to establish how the burden hip fractures pose on the elderly changed over time, in order to inform initiatives for improvements of their health., Material and Methods: The entire Swedish population 60 years-old and above was followed between 1987 and 2010 in the National Patient Register and the Cause of Death Register. Annual age-specific hip fracture cumulative incidence was estimated using hospital admissions for hip fractures. Three-month and one-year survival after the first hip fracture were also estimated. Period life table was used to assess lifetime risk of hip fractures occurring from age 60 and above, and the expected mean age of the first hip fracture., Results: The age-specific hip fracture incidence decreased between 1995 and 2010 in all ages up to 94 years, on average by 1% per year. The lifetime risk remained almost stable, between 9% and 11% for men, and between 18% and 20% for women. The expected mean age of a first hip fracture increased by 2.5 years for men and by 2.2 years for women. No improvements over time were observed for the 3-month survival for men, while for women a 1% decrease per year was observed. The 1-year survival slightly increased over time for men (0.4% per year) while no improvement was observed for women., Conclusions: The age-specific hip fracture incidence has decreased over time. Yet the lifetime risk of a hip fracture has not decreased because life expectancy in the population has increased in parallel. Overall, survival after hip fracture has not improved., (Copyright © 2015. Published by Elsevier Inc.)

Objective: To estimate the economic burden of multiple sclerosis (MS) in Turkey, including the relapses and disease severity, and to evaluate the quality-of-life of MS patients., Methods: The Treatment Experience, Burden and Unmet Needs (TRIBUNE) study was a multi-national, cross-sectional, retrospective, burden-of-illness survey. Total costs were calculated using unit costs derived from price lists or published literature, where relevant, and inflated to 2011 TL prices., Results: A total of 295 MS patients (74% females) were included in the analysis. The population had a mean age of 36 years; 73% had the relapsing-remitting form. Mean Expanded Disability Status Scale (EDSS) score was 2.2. Twenty-two per cent of the MS patients required hospitalization in the past year and spent an average of 29.2 days/year in hospital. These values were 43% and 5.6 days for the outpatients, respectively. Total cost per patient/year was 18,700 TL (Turkish Lira). Total costs for patients with mild, moderate, and severe disability were 15,418 TL, 26,002 TL, and 44,208 TL per patient/year, respectively. The mean EuroQol 5D scores in the same groups were 0.73, 0.52, and 0.05, respectively., Conclusions: Multiple sclerosis imposes a significant economic burden on patients and society in Turkey.

Background: Life expectancy and time to first hospitalization have been prolonged, indicating that people live longer without needing hospital care. Life expectancy increased partially due to improved survival from severe diseases, which, however, could lead to a more fragile population. If so, time to a subsequent hospitalization could decrease. Alternatively, the overall trend of improved health could continue after the first hospitalization, prolonging also the time to subsequent hospitalizations. This study analyzes trends in subsequent hospitalizations among Swedish men and women above the age of 60, relating them to first hospitalization. It also looks at trends in the proportion of never hospitalized., Methods: Individuals were followed in national registers for hospital admissions and deaths between 1972 and 2010. The proportion of never hospitalized individuals at given ages and time points, and the annual change in the risks of first and subsequent hospitalizations, were calculated., Findings: An increase in the proportion of never hospitalized was seen over time. The risks of first as well as subsequent hospitalizations were reduced by almost 10% per decade for both men and women. Improvements were observed mainly for individuals below the ages of 90 and up to the year 2000., Conclusions: The reduction in annual risk of both first and subsequent hospitalizations up to 90 years of age speaks in favor of a postponement of the overall morbidity among the elderly and provides no support for the hypothesis that the population becomes more fragile due to increased survival from severe diseases.

Objectives: To examine whether the first admission to hospital after the age of 60 has been postponed to higher ages for men and women in Sweden, in line with the shift in mortality., Design: This nationwide observational study was based on data obtained from national registries in Sweden. The study cohort was created by linking the Register of the Total Population in Sweden with the National Patient Register and the Swedish Cause of Death Register., Setting: The entire Swedish population born between 1895 and 1950 was followed up between 1987 and 2010 with respect to hospital admissions and deaths using the national registry data., Primary Outcome Measures: The time from age 60 until the first admission to the hospital, regardless of the diagnosis, and the time from age 60 until death (remaining life expectancy, LE) were estimated for the years 1995-2010. The difference between these two measures was also estimated for the same period., Results: Between 1995 and 2010 mortality as well as first hospital admission shifted to higher ages. The average time from age 60, 70, 80 and 90 until the first hospital admission increased at all ages. The remaining LE at age 60, 70 and 80 increased for men and women. For the 90-year-olds it was stable., Conclusions: In Sweden, the first hospital admission after the age of 60 has been pushed to higher ages in line with mortality for the ages 60 and above. First admission to the hospital could indicate the onset of first severe morbidity; however, the reorganisation of healthcare may also have influenced the observed trends.

Background: Multiple sclerosis (MS) is an important, highly disabling neurological disease, common among young adults in The Netherlands. Nevertheless, only a few studies to date have measured the burden imposed by MS on society in The Netherlands., Objectives: To estimate the cost and quality-of-life associated with MS in The Netherlands, while focusing on the burden of relapses and increasing disease severity., Methods: MS patients in The Netherlands (n = 263) completed a web-based questionnaire which captured information on demographics, disease characteristics and severity (Expanded Disability Status Scale [EDSS]), co-morbidities, relapses, resource consumption, utilities, fatigue and activities of daily living (ADL)., Results: Most patients included in the study were receiving treatment for MS (76% of the sample). The mean cost per patient per year increased with worsening disability and was estimated at €30,938, €51,056, and €100,469 for patients with mild (EDSS 0-3), moderate (EDSS 4-6.5), and severe (EDSS 7-9) disability, respectively. The excess cost of relapses was estimated at €8195 among relapsing-remitting patients with EDSS score ≤5. The quality-of-life of patients decreased with disease progression and existence of relapses., Conclusions: The cost of MS in The Netherlands was higher compared to the results of previous studies. The TRIBUNE study provides an important update on the economic burden of MS in The Netherlands in an era of more widespread use of disease-modifying therapies. It explores the cost of MS linked to relapses and disease severity and examines the impact of MS on additional health outcomes beyond utilities such as ADL and fatigue., Study Limitations: Patients were selected from specialized treatment centers, therefore this sample may not be representative of the entire MS population in The Netherlands, i.e., few patients not receiving MS therapies were included. In addition, only a few patients with severe disability were included in the study sample; therefore, results for this disease severity sub-group should be interpreted with caution.

Background: Multiple sclerosis (MS) is a common cause of neurological disability in young adults. The TRIBUNE study provides a detailed exploration of costs in relation to relapses and disease severity, and assesses the quality of life impact on MS patients in terms of utilities, fatigue and activities of daily living (ADL)., Methods: Patients in five European countries (France, Germany, Italy, Spain and the United Kingdom) completed a self-administered web-based questionnaire capturing information on demographics, disease characteristics and severity (EDSS), co-morbidities, relapses, resource consumption, utilities, fatigue, and activities of daily living., Results: In total, 1261 MS patients completed the questionnaire. More than half of the patients (68%) had the relapsing-remitting form of the disease; 87% of the sample reported receiving MS treatments. Costs were higher with advancing disease severity; for mild patients (EDSS score ≤ 3) the costs ranged between €13,534 and €22,461 across countries; for moderate (EDSS score 4 - 6.5) between €28,524 and €43,948; for severe (EDSS ≥ 7) between €39,592 and €65,395. Relapses were also associated with increasing costs; the difference in the cost per patient per year for relapsing-remitting patients with EDSS score ≤ 5 that did experience at least one relapse during the past 12 months and those who did not ranged between €3321 and €9430. The quality of life of patients decreased with disease progression and existence of relapses., Conclusion: The TRIBUNE study provides an important update on the economic burden of MS in an era of more widespread use of disease-modifying therapies. It explores the cost of MS linked to relapses and disease severity, and examines the impact of MS on additional health outcomes beyond utilities such as ADL and fatigue.

Background: Multiple sclerosis (MS) is the most common neurological disease among young adults in Canada, but few studies to date have measured the burden imposed by MS on Canadian society., Objectives: To estimate the costs and quality of life of MS patients in Canada, while focusing on the burden of relapses and increasing disease severity., Methods: MS patients in Canada (N=241) completed a web-based questionnaire which captured information on demographics, disease characteristics, severity (Expanded Disability Status Scale [EDSS]), comorbidities, relapses, as well as resource consumption and quality of life associated with MS., Results: Most patients (74%) reported treatment with disease modifying therapies (DMTs). 54% of patients with the relapsing-remitting form of the disease with an EDSS score ≤ 5 had experienced at least one relapse in the past year. The mean cost per patient per year increased with worsening disability, and was estimated at Can $30,836 for patients with mild disability (EDSS score 0-3), Can $46,622 for patients with moderate disability (EDSS 4-6.5), and Can $77,981 for patients with severe disability due to MS (EDSS score 7-9). The excess costs of relapsing-remitting MS patients with EDSS score ≤ 5 that could be attributable to relapse(s) were estimated at Can $10,512. More severe disease and experiencing a relapse were also associated with poorer quality of life of MS patients., Conclusions: Costs of MS patients are higher today than shown in previous studies. Disease progression and relapses are associated with increased economic and quality of life burden. Effective treatment that reduces relapse frequency and prevents progression could impact both costs and quality of life and may help to reduce the societal burden of MS.

Background: The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people., Aims: To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country., Methods: The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010., Results: The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US., Discussion: This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges., Recommendations: Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives., (Copyright © 2011. Published by Elsevier B.V.)