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The literature around co-payment shows evidence of increasing consumption following reduced co-payment. We apply difference-in-difference methods to assess the effect of abolishing the co-payment on psychologist treatment of anxiety and depression in 18 to 21-year olds. We apply nationwide individual level data with individuals close to this age interval as control group. The population amounts to approximately 1.2 million individuals and a total of 51 million patient months of observations. We show that after removing co-payment, the use of psychologist treatment almost doubles. We find that this increase involves moderately positive spill over effects on outpatient psychiatric care and on prescriptions of antidepressants. In the heterogeneity analysis we find evidence of higher effects on adolescents from families with lower income, indicating that reduced co-payments may increase equality in access. We also see that effects are higher for individuals listed with general practitioners (GPs) with a reluctant referral style; indicating that these GPs' behavior is affected by patient co-payment rates. Interestingly, we find evidence of significant reductions in suicide attempts - primarily among high-income women and low-income men. This indicates that better access to mental health care for adolescents may have a positive impact on their mental health and well-being.

Objective: Telehealth is rapidly gaining ground from usual treatment, not least because of coronavirus disease 2019 (COVID-19) measures. Within rheumatology, telehealth has been used for, inter alia, follow-up for patients with rheumatoid arthritis (RA) with low disease activity or in remission. This study aims to assess the cost-effectiveness of such a telehealth intervention. Method: In a randomized controlled trial, 294 patients were randomized into patient-reported outcome-based telehealth follow-up by either a nurse (PRO-TN) or a rheumatologist (PRO-TR) or to conventional outpatient follow-up (control). Cost-effectiveness was evaluated using costs per quality-adjusted life-year (QALY) gained. Individual-level healthcare and productivity costs were retrieved from national Danish registers. Incremental cost-effectiveness ratios were calculated for the intervention groups compared to the control group. Bootstrapping with 10 000 replications was used to obtain confidence intervals. Furthermore, cost-effectiveness acceptability curves were generated. Results: The cost comparison showed that PRO-TR was significantly less costly than the control group, whereas the relative reduction in costs for PRO-TN was not significant. The telehealth groups experienced minor, non-significant declines in QALYs, whereas the control group experienced a slight, non-significant increase. The cost-effectiveness analysis showed that for PRO-TR, the willingness to accept a QALY loss was 89 328 EUR. A similar but smaller and non-significant result was seen for PRO-TN. Conclusion: PRO-TR and PRO-TN seem to cost less but provide broadly similar health outcomes compared with conventional follow-up. Between the intervention groups, PRO-TR was significantly less costly. More studies are needed to conclude whether rheumatologist- or nurse-led telehealth is more cost-effective than conventional follow-up.

Aim: To investigate the effect of screening for anxiety and depression (AD) in patients with ischaemic heart disease (IHD) on the likelihood of receiving treatment for AD. Methods: We used a nationwide dataset of all Danish patients with an incident IHD diagnosis in the period 2015–2018 ( N = 80,701) of which 20,461 (25%) were exposed to screening for AD as part of cardiac rehabilitation. A binary composite indicator for the use of any AD treatment (prescriptions of AD drugs, general practitioner (GP) counselling or referral to a psychologist), was modelled as the dependent variable. The probability of receiving AD treatment was estimated using linear probability and instrumental variable regression models. Results: Exposure to AD screening was lower for patients with low income (change in probability −0.67, 95% CI −0.76; −0.59), low education (change in probability −0.16, 95% CI −0.20; −0.13), and a high comorbidity burden (change in probability −0.09, 95% CI −0.10; −0.07). Screened patients had a lower conditional probability of AD treatment (change in probability −0.0061, p < 0.001) than non-screened patients. The patient’s GP also had an impact on the probability of being referred for AD treatment. Using an instrumental variable approach did not affect the results. Conclusions: Screening for AD was subject to selection at the patient level; patients at lower risk of AD had a higher probability of being screened. Hence, extending systematic screening to cover a larger population may not achieve a noticeable increase in the uptake of AD treatment if it is not supported by appropriate measures to reduce reverse selection into screening.

A nationwide population-based register study.To investigate the socioeconomic consequences of traumatic (tSCI) and non-traumatic (ntSCI) spinal cord injuries (SCI) in relation to health care costs, risk of job loss, and divorce.Denmark.All survivors admitted for specialized SCI rehabilitation from 2008 to 2018 were included (n = 1751), together with their relatives (n = 3084). Control groups for the SCI group (n = 8139) and their relatives (n = 15,921) were identified. Data on socioeconomics up to 2 years before and up to 4 years after the injury year were included.Survivors of tSCI and ntSCI had significantly increased health care costs 2 years before injury compared to their controls, and increased health care cost was maintained 4 years after the injury (all p values 0.0001). The SCI group had significantly increased risk of job loss (OR = 9.26; 95% CI: 7.70-11.15) and higher risk of divorce (OR = 1.44; 95% CI: 1.08-1.87) the 3 following years after injury compared to controls, but risk of divorce was only significant for the ntSCI group (OR = 1.58; 95% CI: 1.09-2.29). No significant differences on health care cost and job loss between the group of relatives of SCI survivors and their controls were found, except for the relatives (n = 1604) of SCI survivors18 years old, where a higher risk of job loss was found (OR = 1.43, 95% CI 0.97-2.1).These results emphasize that socioeconomic consequences for survivors of both tSCI and ntSCI are pervasive and long-lasting.

Jugendlichen wird in der Öffentlichkeit wie in der Wissenschaft gerne Politikverdrossenheit und Desinteresse an politischen Themen unterstellt. Merle-Marie Kruse zeigt in ihrer Studie zu medienbezogenen Aushandlungen des Politischen dagegen auf, dass das den konkreten Sichtweisen junger Menschen nicht gerecht wird. Aus der Perspektive eines mediatisierten Alltags und eines erweiterten Politikverständnisses rekonstruiert sie anhand von Gruppendiskussionen, wie Jugendliche Politik begreifen, kommunikativ mit Bedeutung versehen und politische Identitäten aushandeln. Dabei zeigt ihre Analyse auch, welche Rolle populärkulturelle Medien für das Involvement mit Politischem spielen.

Aim: to assess whether participation in cardiac rehabilitation affects the probability of returning to work after ischaemic heart disease. Methods: the study population consisted of 24,509 patients (18–70 years of age) discharged from an inpatient admission at a Danish hospital during 2014–2018 and who were working before their admission. Only patients with a percutaneous coronary intervention or coronary artery bypass grafting surgery procedure and ICD-10 codes I20–I25 as their main diagnosis or ICD-10 codes I21, I240, I248 or I249 as secondary diagnosis during an emergency admission were included. Exposure was defined as participation in cardiac rehabilitation ( N = 15,742), and binary indicator of being at work in the last week of a given month were used as primary outcomes. Coarsened exact matching (CEM) of exposed and unexposed patients was used to reduce selection bias. Logistic regression models were applied on the matched population ( N = 15,762). Results: Less deprived and less comorbid patients were more likely to receive cardiac rehabilitation. CEM succeeded in arriving at a population where this selection was reduced and in this population we found that patients who received cardiac rehabilitation had a lower probability of returning to work after 3 months (OR 0.81, 95%CI: 0.77–0.84), a higher but insignificant probability after 6 (OR 1.02, 95%CI: 0.97–1.08), and a higher probability after 9 (OR 1.08, 95%CI: 1.02–1.15) and 12 months (OR 1.20, 95%CI: 1.13–1.28). Conclusions: Deprived and comorbid patients have lower use of cardiac rehabilitation. In a matched population where this bias is reduced, cardiac rehabilitation will increase the probability of returning to work.

This study examined the association between interpersonal violence and a range of psychiatric and physical health outcomes and assessed whether these associations changed when controlling for a stress-related diagnosis. An observational case–control study was conducted on a sample of 4,059 victims of violence. Using propensity score matching a number of risk factors (assessed five years prior assault) were used. Controls were matched 10:1 using the Danish Central Registry System. Outcomes were ICD-10 diagnoses of a range of psychiatric and physical health outcomes in the 15 years post-injury. Statistically significant associations were found for all psychiatric conditions and a diagnosis of a drug or substance misuse disorder. These findings remained even after controlling for a diagnosis of a stress-related disorder. Large scale case–control studies using the Danish nationwide registers enables a powerful way of assessing the relative impact of exposure to interpersonal violence on the development of psychiatric and physical health problems.

Objectives: We aimed to investigate the cost-utility and cost-effectiveness of a modified Individual Placement and Support intervention for people with mood and anxiety disorders (IPS-MA). Methods: Costs were assessed from a societal perspective. Health care costs were derived from registers and combined with data on use of IPS-MA services, municipal social care, and labour market services. EQ-5D was used to compute QALY. Missing data were imputed in a sensitivity analysis. We also computed the cost per gain in hours worked. Incremental cost-effectiveness ratios (ICER) were computed and bootstrapped to obtain confidence intervals for QALY and gain in hours worked. Results: We found no difference in overall costs between groups. A significant saving was found in use of labour market services in the IPS-MA group. But the IPS-MA group had significantly lower wage earnings compared to the control group. The intervention group had a higher, though statistically in-significant, increase in QALYs than the control group. The ICER did not show statistically significant results, but there was a tendency, that IPS-MA could have a positive effect on health-related quality of life without any additional costs. However, participants in the IPS-MA group had a significantly lower gain in hours worked compared to the control group. Conclusions: Despite a significant saving in use of labour market services, IPS-MA was not cost-effective. Participants in the IPS-MA group worked significantly fewer hours and earned significantly less than participants in the control group at 1-year follow-up.

Background Internationally, older patients (≥65 years) account for more than 40% of acute admissions. Older patients admitted to the emergency department (ED) are frequently malnourished and exposed to inappropriate medication prescribing, due in part to the inaccuracy of creatinine-based equations for estimated glomerular filtration rate (eGFR). The overall aims of this trial are to investigate: (1) the efficacy of a medication review (MED intervention) independent of nutritional status, (2) the accuracy of eGFR equations based on various biomarkers compared to measured GFR (mGFR) based on 99mTechnetium–diethylenetriaminepentaacetic acid plasma clearance, and (3) the efficacy of an individualized multimodal and transitional nutritional intervention (MULTI-NUT-MED intervention) in older patients with or at risk of malnutrition in the ED. Methods The trial is a single-center block randomized, controlled, observer-blinded, superiority and explorative trial with two parallel groups. The population consists of 200 older patients admitted to the ED: 70 patients without malnutrition or risk of malnutrition and 130 patients with or at risk of malnutrition defined as a Mini Nutritional Assessment-Short Form score ≤11. All patients without the risk of malnutrition receive the MED intervention, which consists of a medication review by a pharmacist and geriatrician in the ED. Patients with or at risk of malnutrition receive the MULTI-NUT-MED intervention, which consists of the MED intervention in addition to, dietary counseling and individualized interventions based on the results of screening tests for dysphagia, problems with activities of daily living, low muscle strength in the lower extremities, depression, and problems with oral health. Baseline data are collected upon study inclusion, and follow-up data are collected at 8 and 16 weeks after discharge. The primary outcomes are (1) change in medication appropriateness index (MAI) score from baseline to 8 weeks after discharge, (2) accuracy of different eGFR equations compared to mGFR, and (3) change in health-related quality of life (measured with EuroQol-5D-5L) from baseline to 16 weeks after discharge. Discussion The trial will provide new information on strategies to optimize the treatment of malnutrition and inappropriate medication prescribing among older patients admitted to the ED. Trail registration ClinicalTrials.gov NTC03741283. Retrospectively registered on 14 November 2018.

Background Administrators and policymakers are increasingly interested in individual placement and support (IPS) as a way of helping people with severe mental illness (SMI) obtain employment or education. It is thus important to investigate the cost-effectiveness to secure that resources are being used properly. Methods In a randomized clinical trial, 720 people diagnosed with SMI were allocated into three groups; (a) IPS, (b) IPS supplemented with cognitive remediation a social skills training (IPSE), and (c) Service as usual (SAU). Health care costs, municipal social care costs, and labor market service costs were extracted from nationwide registers and combined with data on use of IPS services. Cost-utility and cost-effectiveness analyses were conducted with two primary outcomes: quality-adjusted life years (QALY) and hours in employment. Incremental cost-effectiveness ratios (ICER) were computed for both QALY, using participant’s responses to the EQ-5D questionnaire, and for hours in employment. Results Both IPS and IPSE were less costly, and more effective than SAU. Overall, there was a statistically significant cost difference of €9,543 when comparing IPS with SAU and €7,288 when comparing IPSE with SAU. ICER’s did generally not render statistically significant results. However, there was a tendency toward the IPS and IPSE interventions being dominant, that is, cheaper with greater effect in health-related quality of life and hours in employment or education compared to usual care. Conclusion Individual placement support with and without a supplement of cognitive remediation tends to be cost saving and more effective compared to SAU.

ObjectivesFrailty is a major clinical geriatric syndrome associated with serious adverse events including functional disability, falls, hospitalisation, increased morbidity and mortality. The aim of this study was to study the associations between frailty defined as Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA-7) score ≥3 and use of healthcare resources in hospital and in the municipality as well as association between frailty and mortality.DesignRegister-based retrospective study.SettingThe target population consists of patients aged 75 years or above who, during hospital stay, were assessed by a physiotherapist, and at discharge from hospital were prescribed further physical training in the community.Participants973 individuals aged 75+ years were included.Outcome measuresWe examined associations between frailty and use of healthcare resources in hospital and in the municipality as well as the association between frailty and mortality.Results973 individuals aged 75+ years were included. Of these, 63.9% had a PRISMA-7 score ≥3 and were thus defined as frail. Frail individuals were older compared with non-frail with mean ages of 84.6 and 80.4 years, respectively, p>0.001. Age and gender-adjusted mortality after 1 year was higher among the frail (OR 2.46, 95% CI 1.53 to 3.97). Use of healthcare services in the municipality as well as hospital admissions was significantly higher among frail individuals.ConclusionsBased on these findings we consider PRISMA-7 to be useful in an in-hospital setting as a screening tool to identify frail elderly patients who may profit from further geriatric assessment during hospital stay.Trial registration numberID REG-070-2017.

Background The course of coronavirus disease 2019 (COVID-19) seems to be aggravated by air pollution, and some industrial chemicals, such as the perfluorinated alkylate substances (PFASs), are immunotoxic and may contribute to an association with disease severity. Methods From Danish biobanks, we obtained plasma samples from 323 subjects aged 30–70 years with known SARS-CoV-2 infection. The PFAS concentrations measured at the background exposures included five PFASs known to be immunotoxic. Register data was obtained to classify disease status, other health information, and demographic variables. We used ordered logistic regression analyses to determine associations between PFAS concentrations and disease outcome. Results Plasma-PFAS concentrations were higher in males, in subjects with Western European background, and tended to increase with age, but were not associated with the presence of chronic disease. Of the study population, 108 (33%) had not been hospitalized, and of those hospitalized, 53 (16%) had been in intensive care or were deceased. Among the five PFASs considered, perfluorobutanoic acid (PFBA) showed an unadjusted odds ratio (OR) of 2.19 (95% confidence interval, CI, 1.39–3.46) for increasing severities of the disease. Among those hospitalized, the fully adjusted OR for getting into intensive care or expiring was 5.18 (1.29, 20.72) when based on plasma samples obtained at the time of diagnosis or up to one week before. Conclusions Measures of individual exposures to immunotoxic PFASs included short-chain PFBA known to accumulate in the lungs. Elevated plasma-PFBA concentrations were associated with an increased risk of a more severe course of COVID-19. Given the low background exposure levels in this study, the role of exposure to PFASs in COVID-19 needs to be ascertained in populations with elevated exposures.

This study examined if acquiring a traumatic brain injury (TBI) increases utilization of health care costs, increases risk of job loss for the patient and the closest relatives, and increases the risk of divorce 1 to 5 years following the injury. The study was conducted as a Danish national population-based register study with follow-up. Participants included a cohort of patients with TBI (n = 18,328) admitted to a hospital or treated in an emergency room (ER) and a matching control group (n = 89,155). For both the TBI group and the matching controls, relatives were identified, using national registers (TBI relatives: n = 25,708 and control relatives: n = 135,325). The outcome measures were utilization of health care costs (including hospital services, use of general practitioner and practicing specialists, and prescribed medication), risk of job loss, and risk of divorce among the TBI group and the control group and their relatives. Patients with TBI had significantly increased health care costs at baseline (i.e., the year before the injury) and during the following 4 years. Further, TBI relatives had a significantly higher utilization of health care costs the first and the third year after injury. The TBI group had a significant increased risk of job loss (odds ratio [OR] = 2.88; confidence interval [CI]: 2.70-3.07) and divorce (OR = 1.44; CI: 1.27-1.64) during the first 3 years following injury. In conclusion, the TBI group had significantly higher utilization of health care costs, both pre-morbidly and post-injury. Further, increased risk of job loss and divorce were found, emphasizing that the socioeconomic consequences of TBI last for years post-injury.

Aims: This article describes and discusses the extension of performance measurement using an episode-based approach so that the measurement includes primary care, and social and long-term-care services. By using data on incident stroke patients from the capital areas of four Nordic countries, this pilot study: (a) extended the disease-based performance analysis to include new indicators that better describe patient care pathways at different levels of care; (b) described and compared the performance of care given in the four areas; (c) evaluated how additional information changed the rankings of performance between the areas; and (d) described the trends in performance in the capital areas. Methods: The construction of data was based on a common protocol that used routinely collected national registers and statistics linked with local municipal registers. We created new variables describing the timing of discharge to home and institutionalisation, as well as describing the use and cost of primary and social hospital services. Risk adjustment was performed with four different sets of confounders. Results: Differences existed in various performance indicators between the four metropolitan areas. The ranking was sensitive to the risk-adjustment method. The study showed that for stroke patients a performance comparison with data that are only from secondary and tertiary care, and without a valid severity measure, is not sufficient for international comparisons. Conclusions: Extending and deepening international performance analysis in order to cover patient pathways, including primary care and social services, is very useful for benchmarking activities when focusing on diseases affecting older people.

This study explores health and social care consumption in two groups of patients with risk of alcohol use disorder (AUD), following a brief outreach alcohol intervention in a general hospital setting in Denmark. The Relay intervention aims to decrease health care contacts and thus primarily, in the long run, to reduce health care costs and secondarily to reduce labour market consequences and social costs for patients with alcohol problems. The study took place in somatic hospital departments with high prevalence of alcohol related injuries and illnesses. Patients admitted to the hospital between October 2013 and June 2016 were screened using the Alcohol Use Identification Test (AUDIT) and everyone scoring 8 points and above were randomised to either intervention (Relay group) or control group (TAU group). The patients (n=561) were followed for 12 months after discharge from the hospital. Data was gathered on somatic and psychiatric hospital admissions, GP visits and other primary health care visits as well as the costs associated with the health care contacts. In addition, data on social costs and productivity was gathered. All data was gathered from the Danish registers using personal identification numbers. We modelled the association using generalised linear modelling and investigated the costs further by performing a quantile analysis. We found no statistically significant difference in health care costs, social costs or productivity between the two groups. A longer follow-up is needed to fully investigate effects of the Relay intervention on changes in patients’ health behaviour and subsequently on health care costs.

Background Being homeless entails higher mortality, morbidity, and prevalence of psychiatric diseases. This leads to more frequent and expensive use of health care services. Medical respite care enables an opportunity to recuperate after a hospitalization and has shown a positive effect on readmissions, but little is known about the cost-effectiveness of medical respite care for homeless people discharged from acute hospitalization. Therefore, the aim of the present study was to investigate the cost-effectiveness of a 2-week stay in post-hospital medical respite care. Methods A randomized controlled trial and cost-utility analysis, from a societal perspective, was conducted between April 2014 and March 2016. Homeless people aged > 18 years with an acute admission were included from 10 different hospitals in the Capital Region of Denmark. The intervention group (n = 53) was offered a 2-week medical respite care stay at a Red Cross facility and the control group (n = 43) was discharged without any extra help (usual care), but with the opportunity to seek help in shelters and from street nurses and doctors in the municipalities. The primary outcome was the difference in health care costs 3 months following inclusion in the study. Secondary outcomes were change in health-related quality of life and health care costs 6 months following inclusion in the study. Data were collected through Danish registries, financial management systems in the municipalities and at the Red Cross, and by using the EQ-5D questionnaire. Results After 3 and 6 months, the intervention group had €4761 (p = 0.10) and €8515 (p = 0.04) lower costs than the control group, respectively. Crude costs at 3 months were €8448 and €13,553 for the intervention and control group respectively. The higher costs in the control group were mainly related to acute admissions. Both groups had minor quality-adjusted life year gains. Conclusions This is the first randomized controlled trial to investigate the cost-effectiveness of a 2-week medical respite care stay for homeless people after hospitalization. The study showed that the intervention is cost-effective. Furthermore, this study illustrates that it is possible to perform research with satisfying follow-up with a target group that is hard to reach. Trial registration ClinicalTrials.gov Identifier: NCT02649595.

Background The aim of this study was to examine associations between exposure to violence, quality of life, and psychological distress. Women aged 19–54 years who had been exposed to violence by someone in a close relationship were compared with women unexposed to violence in Finland. We also aimed to investigate associations between different forms of violence (physical, sexual, emotional, or any combination of these) with quality of life and psychological distress. Methods We selected a sample of 22,398 women who had returned self-completed questionnaires from a Finnish population-based health survey between 2013 and 2016. Exposure to violence during the past year was assessed through specific questions from the survey. The EUROHIS-QOL 8-item index was used to measure quality of life, and ordinary least square regressions were fitted. The mental health inventory (MHI-5) was used to measure psychological distress. We investigated associations with multivariate logistic regression analysis. Results Among women in Finland, the prevalence of exposure to violence in any type of close relationship during the past year was 7.6%. Women who had been exposed to violence had significantly worse scores of the EUROHIS-QOL 8-item index, and psychological distress was significantly worse (p p p Conclusions This study found that experience of close relationship violence had a negative influence on both quality of life and psychological distress among women in the general Finnish population. Comparison with victims of violence by strangers shows that some of the lower quality-of-life scores among victims are driven by the perpetrator and victim being in a close relationship. Preventive policies in primary care settings aimed at screening and educating young people should be considered as an early form of intervention to reduce the negative mental health consequences of violence.

Objective To evaluate the reduction of surgical site infections by prophylactic incisional negative pressure wound therapy compared with standard postoperative dressings in obese women giving birth by caesarean section. Design Multicentre randomised controlled trial. Setting Five hospitals in Denmark. Population Obese women (prepregnancy body mass index (BMI) ≥30 kg/m2) undergoing elective or emergency caesarean section. Method The participants were randomly assigned to incisional negative pressure wound therapy or a standard dressing after caesarean section and analysed by intention‐to‐treat. Blinding was not possible due to the nature of the intervention. Main outcome measures The primary outcome was surgical site infection requiring antibiotic treatment within the first 30 days after surgery. Secondary outcomes included wound exudate, dehiscence and health‐related quality of life. Results Incisional negative pressure wound therapy was applied to 432 women and 444 women had a standard dressing. Demographics were similar between groups. Surgical site infection occurred in 20 (4.6%) women treated with incisional negative pressure wound therapy and in 41 (9.2%) women treated with a standard dressing (relative risk 0.50, 95% CI 0.30–0.84; number needed to treat 22; P = 0.007). The effect remained statistically significant when adjusted for BMI and other potential risk factors. Incisional negative pressure wound therapy significantly reduced wound exudate whereas no difference was found for dehiscence and quality of life between the two groups. Conclusion Prophylactic use of incisional negative pressure wound therapy reduced the risk of surgical site infection in obese women giving birth by caesarean section. Tweetable abstract RCT: prophylactic incisional NPWT versus standard dressings postcaesarean in 876 women significantly reduces the risk of SSI., Tweetable abstract RCT: prophylactic incisional NPWT versus standard dressings postcaesarean in 876 women significantly reduces the risk of SSI.