Aims Previous studies on the cost-effectiveness of screening for atrial fibrillation (AF) are based on assumptions of long-term clinical effects. The STROKESTOP study, which randomised 27 975 persons aged 75/76 years into a screening invitation group and a control group, has a median follow-up time of 6.9 years. The aim of this study was to estimate the cost-effectiveness of population-based screening for AF using clinical outcomes. Methods and results The analysis is based on a Markov cohort model. The prevalence of AF, the use of oral anticoagulation, clinical event data, and all-cause mortality were taken from the STROKESTOP study. The cost for clinical events, age-specific utilities, utility decrement due to stroke, and stroke death was taken from the literature. Uncertainty in the model was considered in a probabilistic sensitivity analysis. Per 1000 individuals invited to the screening, there were 77 gained life years and 65 gained quality-adjusted life years. The incremental cost was euro1.77 million lower in the screening invitation group. Gained quality-adjusted life years to a lower cost means that the screening strategy was dominant. The result from 10 000 Monte Carlo simulations showed that the AF screening strategy was cost-effective in 99.2% and cost-saving in 92.7% of the simulations. In the base-case scenario, screening of 1000 individuals resulted in 10.6 [95% confidence interval (CI): -22.5 to 1.4] fewer strokes (8.4 ischaemic and 2.2 haemorrhagic strokes), 1.0 (95% CI: -1.9 to 4.1) more cases of systemic embolism, and 2.9 (95% CI: -18.2 to 13.1) fewer bleedings associated with hospitalization. Conclusion Based on the STROKESTOP study, this analysis shows that a broad AF screening strategy in an elderly population is cost-effective. Efforts should be made to increase screening participation.

Objectives: In the aging population, the knee is the joint most commonly causing impaired function and incapacity. While definite treatment by prosthetic replacement is often performed late, symptomatic knee cartilage lesions cause much suffering also in younger ages. Early intervention could, therefore, be instituted at an early stage to the benefit of both patients and society. Small, metal surface, resurfacing implants have been tested with promising results. A system that features patient-specific implants and surgical instruments shows good clinical results and favorable survival rates. This study aims to assess the cost utility of this metal device compared with microfracture (MFX), being the standard procedure in Sweden. Methods: We constructed a simulation model in Excel. In the model, a cohort of 47-year-old patients (which is the mean age of patients treated with the metal implant) with symptomatic knee cartilage lesions received either MFX or metal implantation. Outcomes for the cohort were simulated over 40 years, such as in a previously published model based on MFX, and sensitivity analyses (deterministic and probabilistic) of the results were undertaken. Data on transition probabilities, costs, and quality of life were taken from clinical data, published literature, and official price lists. Only direct medical costs were included. Results: Results from the analysis showed that the metal device is a cost-effective treatment strategy compared with MFX. The incremental cost-effectiveness ratio (ICER) reached acceptable levels at similar to 5 years postoperatively. Over the full-time horizon of 40 years, the metal device was cost saving with concomitant gains in quality-adjusted life years (QALYs), translating to a dominant treatment strategy. Results were robust according to sensitivity analysis with the initial success rate of up to three years for both metal and MFX having the largest impact. Conclusions: A metal implant may be a cost-effective treatment alternative for patients in their 40s when compared to MFX in a Swedish setting.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but serious complication after a pulmonary embolism. Healthcare resource utilization (HCRU; hospitalization, outpatient visits, and drug utilization) as well as productivity loss (sick leave and disability pension) before and after the CTEPH diagnosis is sparsely studied. By linking several Swedish national databases, this study estimated the societal costs in a national CTEPH cohort (n = 369, diagnosed with CTEPH in 2008-2019) 5 years before and 5 years after diagnosis (index date) and compared to an age, sex, and geographically matched control group (n = 1845, 1:5 match). HCRU and productivity loss were estimated per patient per year. Patients were stratified as operated with pulmonary endarterectomy (PEA group) or not operated (non-PEA group). Direct and indirect societal costs were 2.1 times higher before, and 8.1 times higher after the index date for patients with CTEPH compared to the matched control groups. The higher costs were evident already several years preceding the index date. The main cost driver before the index date in both the PEA and the non-PEA groups was productivity loss. The productivity loss remained high for both groups in the 5-year period following the index date, but the main cost drivers were prescribed drugs and hospitalizations for patients that underwent PEA and prescribed drugs in the non-PEA group. In conclusion, CTEPH was associated with large societal costs related to healthcare consumption and productivity loss, both before and after diagnosis.

Pulmonary arterial hypertension (PAH) is a progressive disease with no cure. Healthcare resource utilization (HCRU; hospitalization, outpatient visits, and drug utilization) before diagnosis and productivity loss (sick leave and disability pension) before and after PAH diagnosis are not well known. By linking several Swedish national databases, this study have estimated the societal costs in a national PAH cohort (n = 749, diagnosed with PAH in 2008-2019) 5 years before and 5 years after diagnosis and compared to an age, sex, and geographically matched control group (n = 3745, 1:5 match). HCRU and productivity loss were estimated per patient per year.The PAH group had significantly higher HCRU and productivity loss compared to the control group starting already 3 and 5 years before diagnosis, respectively. HCRU peaked the year after diagnosis in the PAH group with hospitalizations (mean +/- standard deviation; 2.0 +/- 0.1 vs. 0.2 +/- 0.0), outpatient visits (5.3 +/- 0.3 vs. 0.9 +/- 0.1), and days on sick leave (130 +/- 10 vs. 13 +/- 1) significantly higher compared to controls. Total costs during the entire 10-year period were six times higher for the PAH group than the control group. In the 5 years before diagnosis the higher costs were driven by productivity loss (76%) and hospitalizations (15%), while the 5 years after diagnosis the main cost drivers were drugs (63%), hospitalizations (16%), and productivity loss (16%). In conclusion, PAH was associated with large societal costs due to high HCRU and productivity loss, starting several years before diagnosis. The economic and clinical burden of PAH suggests that strategies for earlier diagnosis and more effective treatments are warranted.

Although chronic pain is common in old age, previous studies on participation activities in old age seldom consider pain aspects and its related consequences. This study analyses associations between participation activities, pain severity, and psychological distress in an aging population of Swedish older adults (N = 6611). We examined older adults participation in five common leisure activities using the Multidimensional Pain Inventory (MPI), sociodemographic factors, pain severity, weight status, comorbidities, and pain-related psychological distress (anxiety, depression, insomnia severity, and pain catastrophising). We found that gender, body mass index (BMI) levels, and psychological distress factors significantly affected older adults participation in leisure activities. Pain severity and multimorbidity were not significantly associated with older adults participation in leisure activities nor with gender stratification in generalised linear regression models. The potentially modifiable factors, such as high levels of BMI and psychological distress, affected activity participation in men and women differently. Health professionals and social workers should consider gender and target potentially modifiable factors such as weight status and psychological distress to increase older adults participation in leisure activities.

n/a

BACKGROUND: Health problems due to musculoskeletal disorders (MSD) and common mental disorders (CMD) result in costs due to lost productivity. OBJECTIVE: This study aimed to increase knowledge of employers productivity loss due to employees presenteeism and sickness absence. METHODS: A web questionnaire was sent to employers of workers who were sick-listed for more than 30 days due to MSD or CMD, response rate: 50%, n = 198. Presenteeism and the impact on productivity before and after sick leave, and the performance of work tasks by replacement workers during sick leave, were measured using supervisors ratings. RESULTS: The average loss of productivity per sick-leave case amounted to almost 10 weeks, 53% of productivity loss was attributable to presenteeism and 47% to lower productivity by replacement workers. Employees with a CMD diagnosis had significantly higher presenteeism-related productivity loss than those with MSD. CONCLUSIONS: Employers experienced substantial productivity loss associated with employees presenteeism and sick leave. Whether the supervisory rating of presenteeism is preferable to employee self-rating needs to be studied further. The long duration of presenteeism is counter-productive to resource-efficient organisations and indicates the need for improved supervisory skills to identify workers with poor health, both before and after sick leave.

Background A reliable central venous access device is a cornerstone in the treatment of cancer. Both peripherally inserted central catheters (PICC) and totally implanted chest ports (PORT) are commonly used for the delivery of chemotherapy. Both types of catheter can cause adverse events such as catheter-related deep venous thrombosis (CR-DVT), infection and mechanical complications. Method We conducted a randomized controlled trial including 399 patients with cancer and performed a health economic evaluation investigating the cost related to PICCs and PORTs using several clinically relevant dimensions from a healthcare perspective. The cost was determined using process and cost estimate models. Result PICCs are associated with a higher total cost when compared with PORTs. Combining the costs of all categories, the prize per inserted device was 824.58 EUR for PICC and 662.34 EUR for PORT. When adjusting for total catheter dwell time the price was 6.58 EUR/day for PICC and 3.01 EUR/day for PORT. The difference in CR-DVT was the main contributor to the difference in cost. The daily cost of PICC is approximately twice to that of PORT. Conclusion We have demonstrated that the cost from a healthcare perspective is higher in cancer patients receiving a PICC than to those with a PORT. The difference is driven mainly by the cost related to the management of adverse events. Our findings are relevant to anaesthetists, oncologists and vascular access clinicians and should be considered when choosing vascular access device prior to chemotherapy.

IntroductionType 2 diabetes (T2D) is a complex chronic disease with an increasing prevalence worldwide. It is commonly associated with complications, such as cardiovascular disease (CVD). Patients with both T2D and established CVD are exposed to increased risk of further cardiovascular events, which means increased healthcare costs and impairments to quality of life and survival. To determine the added burden of CVD for T2D patients, we have analyzed the consumption and costs of healthcare and mortality in two T2D patient cohorts, with and without established CVD, respectively, during a 5-year follow-up in a Swedish region.MethodsPatients with T2D on 1 January 2012 were identified using the administrative database of Region ostergotland and the Swedish National Diabetes Register. Established CVD was defined as the presence of a CVD-related healthcare visit in the period 2002-2011. Identified T2D patients were then followed retrospectively for 5 years (2012-2016) and data collected on utilization of healthcare resources, healthcare costs, and survival. Data pertinent to the study were retrieved from regional databases and national registries.ResultsOn the index date (1 January 2012) there were 19,731 patients with T2D (prevalence 4.5%) in Region ostergotland, of whom 5490 had established CVD. Those patients with established CVD were older, more often men, and had longer diabetes duration and worse kidney function than those without. Compared to T2D patients without CVD, those with CVD had a significantly higher healthcare consumption, experienced higher costs, and had lower survival during the follow-up.ConclusionThis study confirms that established CVD is common among patients with T2D (approximately 30%). Established CVD has negative effects on the utilization of healthcare resources, healthcare costs, and mortality. It is therefore very important to improve the treatment strategy of this patient group.

Background: Chronic pain in later life is a worldwide problem. In younger patients, chronic pain affects life satisfaction negatively; however, it is unknown whether this outcome will extend into old age.

Objective: This study examines which factors determine life satisfaction in older adults who suffer from chronic pain with respect to socio-demographics, lifestyle behaviors, pain, and comorbidities.

Methods: This cross-sectional study recruited a random sample of people ≥ 65 years old living in south-eastern Sweden (N= 6611). A postal survey addressed pain aspects and health experiences. Three domains from the Life Satisfaction Questionnaire (LiSat-11) were used to capture the individual’s estimations of overall satisfaction (LiSat-life), somatic health (LiSat-somhealth), and psychological health (LiSat-psychhealth).

Results: Respondents with chronic pain (2790, 76.2± 7.4 years old) rated lower on life satisfaction than those without chronic pain, with medium effect size (ES) on LiSat-somhealth (r = 0.38, P < 0.001) and small ES on the other two domains (r < 0.3). Among the respondents with chronic pain, severe pain (OR 0.29– 0.59) and pain spreading (OR 0.87– 0.95) were inversely associated with all three domains of the LiSat-11. Current smoking, alcohol overconsumption, and obesity negatively affected one or more domains of the LiSat-11. Most comorbidities were negatively related to LiSat-somhealth, and some comorbidities affected the other two domains. For example, having tumour or cancer negatively affected both LiSat-life (OR 0.62, 95% CI 0.44– 0.88) and LiSat-somhealth (OR 0.42, 95% CI 0.24– 0.74). Anxiety or depression disorders had a negative relationship both for LiSat-life (OR 0.54, 95% CI 0.38– 0.78) and LiSat-psychhealth (OR 0.10, 95% CI 0.06– 0.14).Conclusion: Older adults with chronic pain reported lower life satisfaction but the difference from their peers without chronic pain was trivial, except for satisfaction with somatic health. Pain management in old age needs to consider comorbidities and severe pain to improve patients’ life satisfaction.

Introduction

Cardiovascular disease (CVD) affects approximately 30% of patients with diabetes mellitus type 2 (T2D) and leads to increased morbidity, decreased survival and increased healthcare utilization. The aim of this study was to estimate the impact of treating these patients with the sodium–glucose cotransporter 2 (SGLT2) inhibitor empagliflozin on survival and healthcare utilization.

Methods

Actual survival and healthcare utilization data from a 5-year retrospective cohort study on patients with T2D and CVD in the Region of Östergötland, Sweden were used as a starting point. Actual data were adjusted in accordance with risk reductions for mortality and CV events related to empagliflozin treatment as reported in the EMPA-REG OUTCOME study.

Results

Applying the risk reductions related to empagliflozin treatment on the cohort of patients with T2D and CVD in Östergötland resulted in an increase in 5-year survival of 96 days per patient and reduced costs for healthcare and drugs other than empagliflozin. Including the cost of empagliflozin, treatment led to an increased net cost per patient of approximately SEK 18,000 over 5 years.

Conclusion

Empagliflozin treatment would reduce mortality and healthcare utilization in the patient group. The treatment strategy should be considered cost-effective, supporting a broad implementation of empagliflozin for patients with T2D and established CVD, in line with current national and international guidelines.

Ett vanligt problem i samband med förlossningar, inte minst bland förstagångsföderskor, är att värkarbetet avstannar och förlossningen riskerar att dra ut på tiden. Värksvaghet ökar risken för födsel genom instrumentell förlossning eller med akut kejsarsnitt vilket i sin tur ökar risken för komplikationer (t.ex. blödningar).

Den vedertagna behandlingen av en värksvaghet är ett användande av Oxytocin, som dock riskerar att överstimulera livmodermuskeln och istället förlänga förlossningstiden. Obstecare har tagit framen smidig, pålitlig och icke-invasiv metod för mätning av laktatnivåer i fostervatten. Med ledning av dessa mätningar kan välgrundade beslut fattas om huruvida oxytocin ska sättas in eller inte vid värksvaghet. Att undvika insättning av oxytocin vid redan höga laktatnivåer skulle leda till färre onödigt långa förlossningar och färre akuta kejsarsnitt och instrumentella förlossningar.

För att undersöka huruvida kostnaden för användning av Obstecares AFL-metod uppvägs av inbesparade kostnader till följd av förändringar i förlossningsutfall genomfördes en hälsoekonomisk (kostnads)analys av att använda denna metod på förstföderskor jämfört med att inte göra det. Analysen är begränsad till den vårdepisod då förlossningen sker och till kostnader.

De mest framträdande resultaten av analysen var att antalet akuta kejsarsnitt beräknades minska med cirka 30% och instrumentella förlossningar med cirka 12%. Hälso- och sjukvårdens kostnader beräknades minska med 1 662 kronor (-4%) per förlossning med avstannat värkarbete (inräknat kostnad för laktatmätning).

Resultatet av denna analys tyder på att mätning av laktatnivåer vid värksvaghet hos förstföderskor är kostnadsbesparande. Tillgänglig evidens tyder på att strategin borde införas i svensk hälso- och sjukvård.

Cognitive models of pain propose that catastrophic thinking is negatively associated with chronic pain. However, pain catastrophizing is a complex phenomenon requiring a multivariate examination. This study estimates the effects of mood variables (anxiety and depression) on pain catastrophizing in older adults with chronic pain. A postal survey addressing pain aspects was sent to 6611 people &gt;= 65 years old living in south-eastern Sweden. Pain catastrophizing was measured using the pain catastrophizing scale. Anxiety and depression were assessed using two subscales of the general well-being schedule. Data were analysed using a path analysis approach. A total of 2790 respondents (76.2 +/- 7.4 years old) reported chronic pain (&gt;= three months). The mediation model accounted for 16.3% of anxiety, 17.1% of depression, and 30.9% of pain catastrophizing variances. Pain intensity, insomnia, number of comorbidities, and lifestyle factors (smoking, alcohol consumption, and weight) significantly affected both pain catastrophizing and mood. Anxiety (standardized path coefficient (b(std)) = 0.324,p&lt; 0.001) in comparison to depression (b(std)= 0.125,p&lt; 0.001) had a greater effect on pain catastrophizing. Mood mediated the relationship between pain catastrophizing and pain-related factors accounting for lifestyle and sociodemographic factors.

Background

Patient‐controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation.

Methods

Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine‐scopolamine or glycopyrronium.

Results

Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine‐scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups.

Conclusion

Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

Objective To analyse healthcare utilization, loss of productivity, and disease activity in relation to presence of anti-citrullinated protein antibodies (ACPAs). Method In total, 447 ACPA-positive and 224 ACPA-negative patients from two early rheumatoid arthritis cohorts, recruited 1996-1998 (cohort 1) and 2006-2009 (cohort 2), were followed during 3 years. Data on disease activity were collected, and patients reported healthcare utilization and days lost from work. Disease activity, healthcare costs, and loss of productivity were compared between ACPA groups. Linear regression was performed, controlling for confounders. Results Healthcare costs did not differ significantly by ACPA status (EUR 3214 for vs EUR 2174 for ACPA-positive vs ACPA-negative patients in cohort 1, ns; EUR 4150 vs EUR 3820 in cohort 2, ns). Corresponding values for loss of productivity were EUR 9148 vs EUR 7916 (ns) and EUR 5857 vs EUR 5995 (ns). Total prescription of traditional disease-modifying anti-rheumatic drugs was higher in cohort 2 than in cohort 1. Methotrexate prescription was higher in ACPA-positive patients, but biologics did not differ significantly between ACPA groups. Disease activity was significantly more improved in cohort 2, but there was no difference in achieving remission in relation to ACPA status. In cohort 1, 25% of ACPA-positive patients were in remission vs 31% of ACPA-negative (ns) and in cohort 2, 55% vs 60% (ns). Conclusions With increasing drug treatment for both ACPA-positive and ACPA-negative patients, outcome in ACPA-positive was no more severe than in ACPA-negative patients. Healthcare costs and loss of productivity were similar in the two groups.

Allergier orsakar mycket besvär för drabbade individer och stora kostnader för hälso- och sjukvården och samhället. Tidigare forskning tyder på att allergen immunterapi (AIT) kan vara ett framgångsrikt sätt att behandla personer med allergisk rinit/rinokonjunktivit. Tidigare genomförda hälsoekonomiska studier tyder också på en acceptabel kostnadseffektivitet för AIT jämfört med enbart symtomatisk behandling.

Syftet med denna studie var att kartlägga evidensläget för att undersöka möjligheterna att uttala sig om för vilka patienter som AIT är lämpligt, samt när förskrivning kan bedömas som kostnadseffektiv. Grundtanken var att försöka dela in patienter i subgrupper med olika egenskaper, behandlingseffekt och kostnadseffektivitet. Indelningen i subgrupper var i första hand tänkt att baseras på ålder, typ av allergen, symtomens svårighetsgrad och symtomens varaktighet.

Tidigt beslutades att evidensläget inte tillåter analys av subkutan (SCIT) och sublingual (SLIT) immunterapi separat, utan dessa behandlas i klump med det förenklade antagandet om en jämn fördelning mellan SCIT och SLIT. Denna analys genomfördes som en modellanalys med antagandet att personer startar AIT-behandling vid 25 års ålder. Det generella resultatet av analysen var att med ett samhällsperspektiv är AIT dominant, dvs. att behandlingen både sparar kostnader och genererar hälsovinster jämfört med enbart symtomatisk behandling. Med ett hälso- och sjukvårdsperspektiv blev kostnadseffektivitetskvoten av AIT jämfört med enbart symtomatisk behandling cirka 245 000 kronor per kvalitetsjusterat levnadsår (QALY).

Tillgänglig evidens tillåter tyvärr inte subgruppsanalyser på det sätt som var tänkt. Detta beroende på att behandlingseffekt specificerat på allergentyp, allergins svårighetsgrad och symtomens varaktighet inte analyserats och rapporterats i tidigare publicerade studier. Den enda uppdelningen som befanns vara någorlunda meningsfull var den baserad på ålder. Inte heller avseende denna variabel har skillnader i behandlingseffekt studerats. Däremot antogs olika indirekta kostnader (produktionsförluster) för barn, ungdomar och vuxna. Dessa kostnader saknar betydelse i en analys med hälso- och sjukvårdsperspektiv varför detta resultat inte påverkas. Med ett samhällsperspektiv däremot befanns AIT mest kostnadseffektiv riktad till vuxna (dominant), följt av barn (179 000 kronor/QALY) och ungdomar (245 000 kronor/QALY). För att kunna genomföra en mer komplett kostnadseffektanalys behövs en del information som i dagsläget saknas. Exempel på kunskapsluckor som identifierats är:

• En meningsfull uppdelning i tillstånd baserat på svårighetsgrad (lindrig/måttlig/svår), utifrån biomarkörer och/eller symtom.
• Effektiviteten av AIT och dess inverkan på övergångar mellan tillstånd.
• Livskvalitet och kostnader förknippade med olika tillstånd.
• Skillnader i behandlingseffektivitet för olika subgrupper (ålder, svårighet och varaktighet av symtom, olika allergener).
• Evidens som möjliggör jämförelse mellan SCIT och SLIT, när är den ena respektive den andra mest effektiv/kostnadseffektiv?
• Långtidseffekt av vissa AIT-terapier.

Diabetes mellitus typ 2 är en kronisk sjukdom med en prevalens på cirka 4% i Sverige. T2D behandlas genom omläggning av matvanor och viktnedgång, eller om detta inte är tillräckligt med antingen blodsockerreglerande läkemedel eller insulin. Sjukdomen är förknippad med ökad risk för följdsjukdomar, bland annat hjärt-kärlsjuklighet som är i fokus i denna rapport. I EMPA REG Outcome studien analyserades effekterna av att som tillägg till standardbehandling ge den glukossänkande SGLT-2-hämmaren empagliflozin till patienter med T2D och etablerad hjärt-kärlsjukdom. I studien konstaterades att empagliflozin minskade risken för hjärt-kärlhändelser samt gav förbättrad överlevnad. Syftet med denna studie var tudelat. I den första delen gjordes en kartläggning och beräkning av sjukvårdskonsumtion och kostnader för patienter med T2D, med och utan etablerad hjärtkärlsjukdom, i Östergötland under en femårsperiod (2012–2016). I den andra delen beräknades hur kostnader och mortalitet relaterade till hjärt-kärlhändelser skulle påverkas av att behandla patienter med T2D och etablerad hjärt-kärlsjukdom i Östergötland med empagliflozin.

Sjukvårdskonsumtion, kostnader och mortalitet i Östergötland kartlades och beräknades med hjälp av nationella och regionala register. Resultaten från EMPA REG Outcome studien tillämpades på kohorten av patienter med T2D och etablerad hjärt-kärlsjukdom i Östergötland för att på så sätt estimera effekterna av behandling med empagliflozin med avseende på sjukvårdskostnader och mortalitet.

Kartläggningen visade att i Östergötland fanns 1 januari 2012 18 586 patienter med T2D, varav 5 490 (30%) även hade etablerad hjärt-kärlsjukdom. Patienter med T2D och etablerad hjärt-kärlsjukdom (CVD-kohorten) var jämfört med övriga patienter med T2D i genomsnitt äldre, i större utsträckning män, samt hade längre diabetesduration och sämre njurfunktion. CVD-kohorten hade under uppföljningsperioden signifikant högre sjukvårdskostnader och sämre överlevnad.

Förskrivning av empagliflozin till patienter med T2D och etablerad hjärt-kärlsjukdom i Östergötland beräknades resultera i minskade genomsnittliga sjukvårdskostnader per patient motsvarande cirka 4 100 kronor över fem år, varav cirka 2 300 kronor kunde relateras till minskade kostnader på grund av hjärtsvikt. Mot detta ska ställas ökade läkemedelskostnader. Totalt ger behandling med empagliflozin ökade kostnader på cirka 18 000 kronor per patient över fem år. Den stora vinsten av empagliflozin till patienter med T2D och etablerad hjärt-kärlsjukdom utgörs av tydligt minskad mortalitet. I genomsnitt lever en patient behandlad med empagliflozin 96 dagar längre än om empagliflozin inte förskrivs, sett över en femårsperiod.

Förskrivning av empagliflozin minskar behovet av andra glukossänkande läkemedel vilket visades av en upptitrering av glukossänkande läkemedel i placebogruppen i EMPA-REG Outcome studien. Obeaktat minskad förskrivning av övriga glukossänkare och insulin leder resultaten till att empagliflozin (jämfört med standardbehandling) beräknas generera hälsovinster till en kostnad av cirka 69 000 kronor per levnadsår, eller 85 000 kronor per kvalitetsjusterat levnadsår, vilket Socialstyrelsen i sina riktlinjer bedömer som en låg kostnad.

Slutsatsen är att behandling med empagliflozin i den tämligen utsatta patientgrupp som har T2D och etablerad hjärt-kärlsjukdom är såväl medicinskt effektivt som kostnadseffektivt.

BackgroundInsomnia is one of the most common complaints in chronic pain. This study aimed to evaluate the association of insomnia with well-being, quality of life and health care costs. MethodsThe sample included 2790 older individuals (median age=76; interquartile range [IQR]=70-82) with chronic pain. The participants completed a postal survey assessing basic demographic data, pain intensity and frequency, height, weight, comorbidities, general well-being, quality of life and the insomnia severity index (ISI). Data on health care costs were calculated as costs per year (Euro prices) and measured in terms of outpatient and inpatient care, pain drugs, total drugs and total health care costs. ResultsThe overall fraction of clinical insomnia was 24.6% (moderate clinical insomnia: 21.9% [95% CI: 18.8-23.3]; severe clinical insomnia: 2.7% [95% CI: 1.6-3.2]). Persons who reported clinical insomnia were more likely to experience pain more frequently with higher pain intensity compared to those reported no clinically significant insomnia. Mean total health care costs were Euro 8469 (95% CI: Euro4029-Euro14,271) for persons with severe insomnia compared with Euro 4345 (95% CI: Euro4033-Euro4694) for persons with no clinically significant insomnia. An association between severe insomnia, well-being, quality of life, outpatient care, total drugs costs and total health care costs remained after controlling for age, sex, pain intensity, frequency, body mass index and comorbidities using linear regression models. ConclusionsOur results determine an independent association of insomnia with low health-related quality of life and increased health care costs in older adults with chronic pain. SignificanceThe concurrence and the severity of insomnia among older adults with chronic pain were associated with decreased well-being and quality of life, and increased health care costs to society.

Objective: To evaluate changes in healthcare utilization, costs, and disease activity from 1996 to 2011 for patients with early rheumatoid arthritis (RA).Method: Two cohorts of patients with early RA, included in 1996-1998 (T1) and 2006-2009 (T2), were followed regularly. Healthcare utilization, costs, and disease activity were compared between cohorts during 2years after diagnosis.Results: Disease activity was significantly improved in T2 vs T1. Drug costs increased in T2 vs T1 (EUR 911 vs EUR 535, respectively; p=0.017), and costs for RA-related hospitalization decreased. More than 90% in T2 were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion compared to 50% in T1. At 2year follow-up, levels were still amp;gt;90% in T2, while corresponding values in T1 were just above 70%. Comparing T2 to T1, total direct costs were slightly higher in T2 (EUR 3941 vs EUR 3364, respectively; ns), sick leave decreased (EUR 3511 vs EUR 5672; p=0.025), while disability pension increased slightly (EUR 4889 vs EUR 4244; ns), but total indirect costs remained unchanged (EUR 8400 vs EUR 9916; ns). Total direct and indirect costs did not differ between the cohorts (EUR 12342 in T2 vs EUR 13280 in T1; ns), and loss of productivity still represented the largest component of total costs.Conclusion: T2 patients were prescribed DMARDs earlier and more aggressively than T1 patients. Stable and better improvements in disease activity, function, and quality of life were achieved in T2 compared to T1. There was a shift within the components in direct costs and indirect costs, but total costs remained essentially unchanged.

Objectives

This study aimed to compare, over a 5-year period, the prospective direct healthcare costs and service utilization of persons with subsyndromal depression (SSD) and non-depressive persons (ND), in a population of very old persons. A second aim was to develop a model that predicts direct healthcare costs in very old persons with SSD.

Design and Setting

A prospective population-based study was undertaken on 85-year-old persons in Sweden.

Measurements

Depressiveness was screened with the Geriatric Depression Scale at baseline and at 1-year follow-up, and the results were classified into ND, SSD, and syndromal depression. Data on individual healthcare costs and service use from a 5-year period were derived from national database registers. Direct costs were compared between categories using Mann-Whitney U tests, and a prediction model was identified with linear regression.

Results

For persons with SSD, the direct healthcare costs per month of survival exceeded those of persons with ND by a ratio 1.45 (€634 versus €436), a difference that was significant even after controlling for somatic multimorbidity. The final regression model consisted of five independent variables predicting direct healthcare costs: male sex, activities of daily living functions, loneliness, presence of SSD, and somatic multimorbidity.

Conclusions

SSD among very old persons is associated with increased direct healthcare costs independently of somatic multimorbidity. The associations between SSD, somatic multimorbidity, and healthcare costs in the very old need to be analyzed further in order to better guide allocation of resources in health policy.

BackgroundObesity and chronic pain are common comorbidities and adversely influence each other. Advanced age is associated with more comorbidities and multi-morbidities. In this study, we investigated the burden of overweight/obesity and its comorbidities and their associations with chronic pain in a random population sample of Swedish older adults.MethodsThe cross-sectional analysis involved a random sample of a population65years in south-eastern Sweden (N=6243). Data were collected from a postal questionnaire that addressed pain aspects, body mass index (BMI), and health experiences. Chronic pain was defined as pain during the previous three months. According to the 0-10 Numeric Rating Scale, pain scored 7 corresponds to severe pain. Binary logistic regression was used to determine the variables associated to pain aspects.ResultsA total of 2633 (42%) reported chronic pain. More obese older adults (BMI 30kg/m(2)) experienced chronic pain (58%) than those who were low-normal weight (BMI amp;lt;25kg/m(2), 39%) or overweight (25BMI amp;lt;30kg/m(2), 41%). Obese elderly more frequently had pain in extremities and lower back than their peers. In the multivariate model, obesity (Odds Ratio (OR) 1.59, 95% Confidence Interval (CI) 1.33-1.91) but not overweight (OR 1.08, 95% CI 0.95-1.22) was associated with chronic pain. Obesity (OR 1.53, 95% CI 1.16-2.01) was also significantly related to severe pain. We also found other comorbidities - i.e., traumatic history (OR 2.52, 95% CI 1.99-3.19), rheumatic diseases (OR 5.21, 95% CI 4.54-5.97), age85years (OR 1.66, 95% CI 1.22-2.25), and depression or anxiety diagnosis (OR 1.83, 95% CI 1.32-2.53) - showed stronger associations with pain aspects than weight status. Conclusion: In older adults, excess weight (BMI 30 or above) is a potentially modifiable factor but not the only risk factor that is associated with chronic pain and severe pain. Future studies should investigate the effectiveness of interventions that treat comorbid pain and obesity in older adults.

Quality-adjusted life years (QALYs) measure health by combining length and quality of life. QALYs constitute the effect side of incremental cost-effectiveness ratios, describing the results of health economic evaluations. The objectives of this study were to (1) investigate the prevalence of states worse than dead (SWD) when using the EuroQol-5D UK value set, and (2) to study to what extent SWDs are reasonable with a starting point in experience-based valuations of health states. Data from a Swedish cross-sectional population survey were used. The survey was directed to 10,000 persons 65 years and older and its primary aim was to investigate the prevalence and consequences of chronic pain. The survey included questions reflecting life situation and well-being. Some of these were used in order to characterise people in SWD. SWD were found in 1.8% of the 6611 respondents. The prevalence of SWD increased with advancing age and was more common among women than men. The control questions used indicated that most of the persons being in SWD according to the EQ-5D UK value set most probably would not judge themselves to be in a SWD. Though negative QALY-weights are not very common, they constitute a non-negligible part of health states in a Swedish population 65 years and older. Prevalence of SWD is higher among women than men and increases with age. From responses to other questions on well-being and life situation, there is reason to doubt the reasonableness of experience-based negative QALY-weights in many cases.

Background: Several studies have illustrated that multisite pain is more frequent than single pain site, and it is associated with an array of negative consequences. However, there is limited knowledge available about the potential factors associated with multisite pain in the elderly general population. Objective: This cross-sectional study examines whether the number of anatomical pain sites (APSs) is related to sociodemographic and health-related factors in older adults including oldestold ages using a new method (APSs) to assess the location of pain on the body. Materials and methods: The sample came from the PainS65+ cohort, which included 6,611 older individuals (mean age = 76.0 years; standard deviation [SD] = 7.4) residing in southeastern Sweden. All the participants completed and returned a postal survey that measured sociodemographic data, total annual income, pain intensity and frequency, general well-being, and quality of life. The number of pain sites (NPS) was marked on a body manikin of 45 sections, and a total of 23 APSs were then calculated. Univariable and multivariable models of regression analysis were performed. Results: Approximately 39% of the respondents had at least two painful sites. The results of the regression analysis showed an independent association between the APSs and the age group of 75-79 years, women, married, high pain intensity and frequency, and low well-being and quality of life, after adjustments for consumption of analgesics and comorbidities. The strongest association was observed for the higher frequency of pain. Conclusion: Our results suggest that APSs are highly prevalent with strong relationships with various sociodemographic and health-related factors and concur well with the notion that multisite pain is a potential indicator of increased pain severity and impaired quality of life in the elderly. Our comprehensive method of calculating the number of sites could be an essential part of the clinical presentation, assessment, and treatment of multisite pain.

Studien syftade till att undersöka vilka åtgärder arbetsgivare gör för sjukskrivna medarbetare och vilka kostnader arbetsgivare och samhället har i samband med sjuknärvaro och sjukfrånvaro.

Totalt 3000 sjukskrivna personer i AFA Försäkrings register med diagnoserna psykiska besvär eller besvär i rörelseorganen fick ett informationsbrev och förfrågan om samtycke till att forskarna skulle få skicka en enkät till deras arbetsledare; 393 sjukskrivna gav samtycke. En  webbenkät skickades till dessa arbetsledare. Totalt 198 arbetsledare (50 %) till sjukskrivna personer besvarade enkäten.

Resultaten visar att arbetsgivare genomför en rad olika åtgärder och anpassningar när en medarbetare blir sjukskriven. Analyserna visade att dessa åtgärder och anpassningar i viss mån beror på vem den sjukskrivne medarbetaren är. Åtgärder och anpassningar var vanligare för sjukskrivna med psykiska diagnoser, för högutbildade och för sjukskrivna i högkvalificerade yrken. Kvinnor fick i högre grad anpassningar och åtgärder såsom ändrade arbetsuppgifter och psykosocialt stöd jämfört med män.

Demografiska faktorer visade sig ha mindre betydelse för om den sjukskrivne återgick i arbete eller ej. Multipla logistiska regressionsanalyser visade att åtgärder och anpassningar på arbetsplatsen hade signifikanta samband med en ökad chans för återgång i arbete. Resultaten visade också att för sjukskrivna medarbetare vars arbetsledare hade tagit många kontakter med andra aktörer, som HR-avdelningen, företagshälsan och/eller Försäkringskassan var sannolikheten lägre att den sjukskrivne medarbetaren återgick i arbete. Arbetsledare tog fler kontakter, om den sjukskrivne medarbetaren hade en psykisk diagnos.

Sjuknärvaro och produktionsförlust före, under och efter sjukskrivningen skattades av arbetsledarna. Sammanlagt beräknades produktionsförlusterna till cirka SEK 100 000 per sjukskrivningsfall. Härutöver lägger arbetsgivare tid på att ta kontakter, genomföra åtgärder och anpassningar och organisera om arbetet. Arbetsledare hade mycket oklar eller saknade helt uppfattning om vad tid, åtgärder och anpassningar kostar, varför detta inte har kunnat analyseras närmare. De beräknade genomsnittliga kostnaderna till följd av produktivitetsförluster är således en underskattning av de faktiska kostnaderna för arbetsgivare.

Studien visar att arbetsledares kunskap om vad sjuknärvaro och sjukfrånvaro kostar för verksamheten och för samhället är begränsad. En ökad kostnadsmedvetenhet skulle kunna stimulera till att större resurser läggs på att implementera policys för hälsofrämjande åtgärder och att utbilda arbetsledare i att hantera frågor om hälsa och arbetsförmåga på arbetsplatsen.

Background: Fifty percent of people injured by whiplash still report neck pain after 1 year and costs associated with whiplash associated disorders (WAD) are mostly attributed to health service and sick-leave costs in chronic conditions. With increasing health care expenditures the economic impact of interventions needs to be considered. Objective: To analyze the cost-effectiveness of physiotherapist-led neck-specific exercise without (NSE) or with a behavioral approach (NSEB), or prescription of physical activity (PPA) in chronic WAD, grade 2 to 3. Methods: This is a secondary cost-effectiveness analysis of a multicenter randomized clinical trial of 216 participants with chronic WAD grade 2 to 3. The interventions were physiotherapist-led neck-specific exercise without or with a behavioral approach, or prescription of physical activity for 12 weeks. Incremental cost-effectiveness ratios (ICERs) were determined after 1 year and bootstrapped cost-effectiveness planes and sensitivity analyses of physiotherapy visits were performed. Health care and production loss costs were included and quality-adjusted life years (QALYs) were estimated, using the Euroqol-5D questionnaire. Comparisons with the Short Form-6D, and neck disability index (NDI) were also made. Results: The 1-year follow-up was completed by 170 participants (79%). Both physiotherapist-led groups improved in health related quality of life. The intervention cost alone, per quality-adjusted life year (QALY) gain in the NSE group was US$12,067. A trend for higher QALY gains were observed in the NSEB group but the costs were also higher. The ICERs varied depending on questionnaire used, but the addition of a behavioral approach to neck-specific exercise alone was not cost-effective from a societal perspective (ICER primary outcome $127,800 [95% confidence interval [CI], 37,816-711,302]). The sensitivity analyses confirmed the results. The prescription of physical activity did not result in any QALY gain and the societal costs were not lower. Conclusion: Neck-specific exercise was cost-effective from a societal perspective in the treatment of chronic WAD compared with the other exercise interventions. ICERS varied depending on health-related quality of life questionnaires used, but the addition of a behavioral approach was not cost-effective from a societal perspective. The prescription of physical activity did not result in any QALY gain and was thus not considered a relevant option.

Background: Improved knowledge based on clinical features of chronic pain in older adults would be valuable in terms of patient-orientated approaches and would provide support for health care systems in optimizing health care resources. This study identifies subgroups based on pain and psychological symptoms among Swedish older adults in the general population and compares derived subgroups with respect to socio-demographics, health aspects, and health care costs. Methods: This cross-sectional study uses data collected from four registers and one survey. The total sample comprised 2415 individuals amp;gt;= 65 years old. A two-step cluster analysis was performed. Data on pain intensity, number of pain sites, anxiety, depression, and pain catastrophizing were used as classification variables. Differences in socio-demographics, quality of life, general health, insomnia, and health care costs among the clusters were investigated. Association of the clusters with the above parameters was further evaluated using multinomial logistic regression. Results: Four major clusters were identified: Subgroup 1 (n = 325; 15%) - moderate pain and high psychological symptoms; Subgroup 2 (n = 516; 22%) - high pain and moderate psychological symptoms; Subgroup 3 (n = 686; 30%) - low pain and moderate psychological symptoms; and Subgroup 4 (n = 767; 33%) - low pain and low psychological symptoms. Significant differences were found between the four clusters with regard to age, sex, educational level, family status, quality of life, general health, insomnia, and health care costs. The multinomial logistic regression analysis revealed that Subgroups 1 and 2, compared to Subgroup 4, were significantly associated with decreased quality of life, decreased general health, and increased insomnia. Subgroup 3, compared to Subgroup 4, was associated with decreased general health and increased insomnia. In addition, compared to Subgroup 4, Subgroups 1 and 2 were significantly associated with higher health care costs. Conclusions: Two high risk clusters of older adults suffering from chronic pain; one mainly based on psychological symptoms and one mainly on pain intensity and pain spread, associated with decreased quality of life and health and increased health care costs were identified. Our findings indicate that subgroup-specific treatment will improve pain management and reduce health care costs.

Background: Hepatitis C (HCV) infection causes an asymptomatic chronic hepatitis in most affected individuals, which often remains undetected until cirrhosis and cirrhosis-related complications occur. Screening of high-risk subjects in Northern Norway has revealed a relatively low prevalence in the general population (0.24%). Despite this, late complications of HCV infection are increasing. Our object was to estimate the future prevalence and complications of chronic HCV infection in the period 2013-2050 in a low-risk area. Methods: We have entered available data into a prognostic Markov model to project future complications to HCV infection. Results: The model extrapolates the prevalence in the present cohort of HCV-infected individuals, and assumes a stable low incidence in the projection period. We predict an almost three-fold increase in the incidence of cirrhosis (68 per 100,000), of decompensated cirrhosis (21 per 100,000) and of hepatocellular carcinoma (4 per 100,000) by 2050, as well as a six-fold increase in the cumulated number of deaths from HCV-related liver disease (170 per 100,000 inhabitants). All estimates are made assuming an unchanged treatment coverage of approximately 15%. The estimated numbers can be reduced by approximately 50% for cirrhosis, and by approximately one third for the other endpoints if treatment coverage is raised to 50%. Conclusion: These projections from a low-prevalence area indicate a substantial rise in HCV-related morbidity and mortality in the coming years. The global HCV epidemic is of great concern and increased treatment coverage is necessary to reduce the burden of the disease.

Background: Insomnia is a major cause of concern in the elderly with and without pain. This study set out to examine the insomnia and its correlates in a large sample of community adults aged amp;gt;= 65 years. Methods: A cross-sectional postal survey was completed by 6205 older individuals (53.8% women; mean age = 76.2 years; SD = 7.5). The participants also completed the Insomnia Severity Index (ISI) and questionnaires assessing pain intensity, pain spreading, anxiety, depression, and basic demographic information. The sample was divided into three groups based on the presence and duration of pain: chronic pain (CP; n = 2790), subacute pain (SP; n = 510), and no pain (NP; n = 2905). Results: A proportion of each of the groups had an ISI score of 15 or greater (i.e., clinical insomnia): CP = 24.6%; SP = 21.3%; and NP = 13.0%. The average scores of ISI differed significantly among CP, SP, and NP groups (p amp;lt; 0.001). Stratified regression analyses showed that pain intensity, pain spreading, anxiety, and depression were independently related to insomnia in the CP group. Anxiety and depression were independently related to insomnia in the SP group, but only anxiety was significantly associated with insomnia in the NP group. Age and sex were not associated with insomnia. Conclusions: This study confirms that insomnia is not associated with chronological aging per se within the elderly population. Although the possible associations of insomnia with pain are complex, ensuing from pain intensity, pain spreading, anxiety, and depression, our results highlighted that anxiety was more strongly associated with insomnia in all groups than the depression and pain characteristics. Therapeutic plans should consider these relations during the course of pain, and a comprehensive assessment including both pain and psychological features is essential when older people are seeking primary health care for insomnia complaints.

INTRODUCTION: The objective of this study was to calculate costs associated with severe fear of childbirth (FOC) during pregnancy and peripartum by comparing two groups of women expecting their first child and attending an ordinary antenatal program; one with low FOC and one with severe FOC.

MATERIAL AND METHODS: In a prospective case-control cohort study one group with low FOC [Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) sum score ≤60, n = 107] and one with severe FOC (W-DEQ ≥85, n = 43) were followed up till 3 months postpartum and included in the analysis. Medical records were assessed and medical parameters were mapped. Mean costs for healthcare consumption and sick leave during pregnancy were calculated and compared.

RESULTS: When means were compared between the groups, the group with severe FOC had more visits for psychosocial reasons (p = 0.001) and more hours on sick leave (p = 0.03) during pregnancy, and stayed longer at the maternity ward (p = 0.04). They also more seldom had normal spontaneous deliveries (p = 0.03), and more often had an elective cesarean section on maternal request (p = 0.02). Postpartum, they more often than the group with low FOC paid visits to the maternity clinic because of complications (p = 0.001) and to the antenatal unit because of adverse childbirth experiences (p = 0.001). The costs for handling women with severe FOC was 38% higher than those for women with low FOC.

CONCLUSION: Women with severe FOC generate considerably higher perinatal costs than women with low FOC when handled in care as usual.

Background

It is a great challenge to provide a sustainable health care that maintain high quality and is available on equal terms for all citizens.

Disinvestment in health care implies that existing health care services/interventions are removed from the publicly funded supply of health care or that they will be restricted in use. Quality improvements are continuously performed and unnecessary, harmful or ineffective services are replaced with new and better ones. This is generally not perceived as disinvestment. With time, however, a situation arises where it will be difficult to find "unnecessary, harmful or ineffective" care. This implies that clear priorities must be set for the provision of care and that evidence based disinvestment will be a necessary component to ensure the quality of care within limited budgets.

The aim of this report on evidence based disinvestment is to describe how this is perceived and performed in Sweden's county councils and regions. We also give a brief overview of international disinvestment initiatives. The concept of disinvestment is illustrated by a number of ongoing or completed disinvestment initiatives and through a tentative framework for disinvestment in a Swedish context. The work has four parts:

• An interview study for mapping disinvestment activities in Sweden
• Case studies of active disinvestment
• An overview of disinvestment initiatives internationally
• A description of disinvestment processes and different types of disinvestment in a schematic framework

Methods

An initial literature search was performed in 2012 as a basis for a minor pilot study and to provide an introduction to the subject. The literature search was supplemented with new search terms in 2013 and 2015. The interviews were conducted by telephone with experts at Sweden's county councils and regions. A questionnaire was constructed to be used as an interview template and to serve as an e-mail survey in case any of our informants preferred this.

Results

In Sweden, open discussions on disinvestment of health care practices began in the early 2000s, which led to several counties starting to sketch on disinvestment policies. Few policies were, however, realized in practice. Organized disinvestment occurs in some counties/regions in the context of more general improvement or prioritization efforts and the term disinvestment is not always used. The majority of our respondents still thought that disinvestment was a significant issue requiring special attention.

An evidence based disinvestment is always active, that is, it includes a conscious decision to stop using, restrict the use of, or withdraw resources from existing healthcare practices. The disinvestment work, however, was in most cases not clearly organized. The most active disinvestment work occurs where there is a priority setting committee or a group for evidence based adoption and disinvestment.

This report describes disinvestment components and sub-processes in a schematic framework. The character of these processes was in large mapped by the interviews. Interview results were then synthesized with information from the literature into a tentative description of evidence based disinvestment. Whatever the causes and goals with disinvestment, the same problems arise and the work follows in large the same steps or sub-processes. Broadly, these sub-processes are:

• identification of disinvestment objects
• choice and preparation/assessment of disinvestment proposals
• decision making
• implementation of decisions and
• follow-up and possible revision of decided disinvestments

One of the sub-processes, that so far received little attention in Sweden, is how disinvestment decisions are implemented in operational health care. We have chosen to develop this in the framework as it seems to be an area on the rise internationally. There is a range of strategies and practical measures to facilitate and accelerate a desired change. This has been thoroughly investigated regarding implementation of new methods. Such strategies are based on different mechanisms to eliminate barriers and utilize facilitators.

To illustrate the results presented in the report we present four cases of disinvestment in a little more detail. These are examples of how practices are identified as disinvestment objects, the preparation of cases, implementation of decisions, and of controversies that might arise. The cases have been selected to show the variation in types of disinvestment objects and the outcomes of disinvestment initiatives.

Disinvestment has gained increased interest internationally in recent years. The problem of rising health care costs is present everywhere in the world and disinvestment is discussed in many countries. Early on, the focus was on disinvestment for greater efficiency. Then the trend turned to re-assessment of old services to be able to make evidence-based disinvestments. This resulted in so-called "low-value-lists" and "do-notdo" recommendations. Today, the focus is on measurable outputs of different disinvestment initiatives and studies have shown that compliance with "low-value-lists" is modest.

Conclusions

There are many indications that the future will call for efficient disinvestment processes to obtain a sustainable health care financing. Our study shows that disinvestment is used both for efficiency reasons and for cost control.

• Most counties/regions are using or have used disinvestment; defined as decisions to withdraw or restrict the use of services/interventions in publicly funded health care.
• The main reasons for disinvestment is the need for: quality improvements, reallocation of resources to new practices, cost control and/or better efficiency.
• We identified two main types of organized disinvestment in Sweden: -  evidence based adoption including disinvestment as an integral part, and - proactive identification of disinvestment objects with a subsequent assessment and prioritization of the objects.

• Services that are withdrawn or restricted in use is a mixture of pharmaceuticals, non-pharmaceutical methods and organizational arrangements.
• Many withdrawn services remains available as privately funded options.
• Prioritization principles are often indicative of disinvestment work and evidence-based medicine and health technology assessment are considered as obvious components.
• Important criteria for classification as disinvestment candidates are: - the service/intervention has adverse effects or very little clinical benefit - the service/intervention is not cost effective - the service/intervention is perceived to have negative effects on the organization and/or work environment

• There are also services that have been removed due to ethical considerations on what publicly funded healthcare should cover.
• Today, disinvestment takes place without sufficient openness and citizen involvement in the processes. Documentation of the work, to the extent there is any, is usually not readily accessible.

In order to improve health care quality, and at the same time control rising costs, it will be required that disinvestment is placed on the national agenda. Ethically difficult considerations associated with disinvestment have made it a question hard to tackle for decision makers at the regional political and administrative levels. Conflicting interests may arise between the patient and the caregiver's budgetary commitment. It is not always easy to determine which interventions are medically and socially justified in the individual patient case, which induces ethical dilemmas.

Regardless of the ethical dilemmas and difficulties that arise – and at which organizational level decisions are made – a useful working model will be required for active withdrawal of services from the supply of publicly funded health care. In our study, we have outlined a framework that describes the processes, including medical and economic as well as social and ethical aspects.

Background and objective: There is limited knowledge about the prevalence of pain and its relation to comorbidities, medication, and certain lifestyle factors in older adults. To address this limitation, this cross-sectional study examined the spreading of pain on the body in a sample of 6611 subjects amp;gt;= 65 years old (mean age = 75.0 years; standard deviation [SD] = 7.7) living in southeastern Sweden. Methods: Sex, age, comorbidities, medication, nicotine, alcohol intake, and physical activity were analyzed in relation to the following pain categories: local pain (LP) (24.1%), regional pain medium (RP-Medium) (20.3%), regional pain heavy (RP-Heavy) (5.2%), and widespread pain (WSP) (1.7%). Results: RP-Medium, RP-Heavy, and WSP were associated more strongly with women than with men (all pamp;lt;0.01). RP-Heavy was less likely in the 80-84 and amp;gt;85 age groups compared to the 65-69 age group (both pamp;lt;0.01). Traumatic injuries, rheumatoid arthritis/osteoarthritis, and analgesics were associated with all pain categories (all pamp;lt;0.001). An association with gastrointestinal disorders was found in LP, RP-Medium, and RP-Heavy (all pamp;lt;0.01). Depressive disorders were associated with all pain categories, except for LP (all pamp;lt;0.05). Disorders of the central nervous system were associated with both RP-Heavy and WSP (all pamp;lt;0.05). Medication for peripheral vascular disorders was associated with RP-Medium (pamp;lt;0.05), and hypnotics were associated with RP-Heavy (pamp;lt;0.01). Conclusion: More than 50% of older adults suffered from different pain spread categories. Women were more likely to experience greater spreading of pain than men. A noteworthy number of common comorbidities and medications were associated with increased likelihood of pain spread from LP to RP-Medium, RP-Heavy, and WSP. Effective management plans should consider these observed associations to improve functional deficiency and decrease spreading of pain-related disability in older adults.

Sjukdomsaktivitet, funktionsförmåga samt direkta och indirekta kostnader har analyserats i två kohorter av patienter med nydebuterad (≤ 1 år) reumatoid artrit (RA).

Den första kohorten med 320 patienter (T1) rekryterades 1996–1998 och den andra med 463 patienter (T2) rekryterades 2006–2009. Patienterna har följts regelbundet avseende kliniska och laboratoriemedicinska variabler och har fortlöpande i hälsoekonomienkäter registrerat all sjukvårdskonsumtion och antal dagar med sjukskrivning/sjukersättning samt rapporterat livskvalitet med EQ-5D och EQ-VAS.

OBJECTIVES:

To calculate total costs during the first year after diagnosis in 463 patients with early rheumatoid arthritis (RA) included during 2006-09 (T2) and compare the results with a similar cohort included in 1996-98 (T1).

METHOD:

Clinical and laboratory data were collected regularly in both cohorts, and patients completed biannual questionnaires reporting health care utilization and number of days lost from work.

RESULTS:

Disease activity was similar in both cohorts T1 and T2 at inclusion. Significant improvements were seen during the first year in both cohorts but were more pronounced in T2. Outpatient care increased and hospitalization decreased in T2 compared with T1. Almost 3% of patients had surgery in both cohorts, but in T2, only women had surgery. Drug costs were higher in T2 than in T1 (EUR 689 vs. EUR 435). In T2, 12% of drug costs were direct costs and 4% were total costs. The corresponding values for T1 were 9% and 3%. In T1, 50% were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion, compared to T2, where prescription was > 90%. Direct costs were EUR 5716 in T2 and EUR 4674 in T1. Costs for sick leave were lower in T2 than in T1 (EUR 5490 vs. EUR 9055) but disability pensions were higher (EUR 4152 vs. EUR 2139), resulting in unchanged total costs. In T1, direct costs comprised 29% and indirect costs 71% of the total costs. The corresponding values for T2 were 37% and 63%.

CONCLUSIONS:

The earlier and more aggressive treatment of RA with traditional DMARDs in T2 resulted in better outcomes compared to T1. Direct costs were higher in T2, partly offset by decreased sick leave, but total costs remained unchanged.

Background: Pre-existing disease is the most important factor in the prediction of health-related quality of life (HRQoL) after intensive care. We hypothesised that the “inpatient care trajectories” in the years before admission to the ICU is a stronger predictor of HRQoL and mortality after intensive care than pre-existing disease, and that it has significant effects on overall costs.

Method:A retrospective investigation in two combined medical and surgical ICUs in Sweden. Inpatient care was assessed from the County administrative registry. HRQoL (SF-36) was measured at 6, 12, 24, and 36 months after discharge.

Results:Of 1092 patients, 459 (73%) had pre-existing diseases, and among them 360 (57%) had at least one inpatient episode less than 3 years before the ICU period, during which the group used significantly more hospital resources than the combined cost for all ICU care during the same time. The addition of episodes of inpatient care to the regression model strongly reduced the effect of pre-existing disease on HRQoL and was also a strong predictor for early mortality after ICU.

Objectives: To compare baseline sociodemographic characteristics in two rheumatoid arthritis (RA) cohorts enrolled 10 years apart, and to examine differences with respect to the general population. Method: Clinical and sociodemographic data were collected in 320 early RA patients during 1996-98 (TIRA-1) and 467 patients in 2006-09 (TIRA-2). Multivariate logistic regression tests were performed and intercohort comparisons were related to general population data, obtained from official databases. Results: TIRA-2 patients were older than TIRA-1 (58 vs. 56 years). Women (both cohorts, 67%) were younger than men in TIRA-1 (55 vs. 59 years) and in TIRA-2 (57 vs. 61 years). Disease activity was similar but TIRA-2 women scored worse pain and worse on the HAQ. Approximately 73% were cohabiting, in both cohorts and in the general population. Education was higher in TIRA-2 than in TIRA-2 but still lower than in the general population. Women had consistently higher education than men. Education was associated with age, younger patients having higher education. In both cohorts, lower education was associated with increased disability pension and increased sick leave. Sick leave was lower in TIRA-2 than in TIRA-1 (37% vs. 50%) but disability pension was higher (16% vs. 10%). In TIRA-1, 9% of women had disability pension compared with 17% in TIRA-2. A similar decrease in sick leave and an increase in disability pension were also seen in the general population. Older age and a higher HAQ score were associated with increased sick leave and being in the TIRA-2 cohort was associated with decreased sick leave. Conclusions: TIRA-2 patients were slightly older, better educated, had lower sick leave and higher disability pension than those in TIRA-1. Similar changes were seen simultaneously in the general population. Belonging to the TIRA-2 cohort was associated with decreased sick leave, indicating that societal changes are of importance.

Chronic pain among elderly people has long been a well-known problem, in terms of both societal costs and the quality of life of affected individuals. To estimate the magnitude of the problems associated with chronic pain in an elderly population, data on both costs and quality of life were gathered. A postal questionnaire was sent out to a stratified sample of 10 000 inhabitants 65 years and older in Linköping and Norrköping. The survey included questions on demographics, habits, and life situation, and different kinds of questions and instruments related to well-being (e.g., quality-of-life and pain-specific questions). In the questionnaire respondents were asked whether they were receiving any help—informal care—from a relative. If they answered yes, they were asked for permission to contact the informal caregiver and to provide contact details. The amount of informal care provided by relatives to persons with chronic pain was investigated by use of a questionnaire directed to the caregiving relatives, containing questions about time spent providing informal care.

Data on costs were collected from registers of consumption of health care, drugs, and municipal services.

The results of the study showed a very clear association between existence and severity of chronic pain and societal costs. The study population was subdivided into three groups with respect to having chronic pain or not, and a pain intensity during the last week of 0–4 (mild), 5–7 (moderate), or 8–10 (severe) on a scale of 0–10. Taking all costs (health care, drugs, municipal services, and informal care) into account, persons in the severe chronic pain group consumed on average 72% more resources than persons in the moderate chronic pain group and 143% more than those in the no or mild chronic pain group. Differences were most pronounced concerning municipal services and informal care costs.

Even more alarming are the results on the quality of life of persons in the different groups. On the EQ-5D index, the average value for persons in the no or mild chronic pain group was 0.82. For those in the moderate chronic pain group the average value was 0.64, and for those in the severe chronic pain group the average value was only 0.38. EQ-VAS resulted in less pronounced but still clearly significant differences.

It is concluded that this study, reaching a rather large part of the target population, shows that existence and severity of chronic pain among people 65 years and older affects costs to society and the quality of life of affected individuals in a massive way.

Purpose: The aim of this study was to investigate, from the perspective of society, the costs of sick leave and rehabilitation of recently sick-listed workers with musculoskeletal disorders (MSD) or mental disorders (MD). Methods: In a prospective cohort study, 812 sick-listed workers with MSD (518) or MD (294) were included. Data on consumption of health care and production loss were collected over six months from an administrative casebook system of the health care provider. Production loss was estimated based on the number of sick-leave days. Societal costs were based on the human capital approach. Results: The mean costs of production loss per person were EUR 5978 (MSD) and EUR 6381 (MD). Health care interventions accounted for 9.3% (MSD) and 8.2% (MD) of the costs of production loss. Corresponding figures for rehabilitation activities were 3.7% (MSD) and 3.1% (MD). Health care interventions were received by about 95% in both diagnostic groups. For nearly half of the cohort, no rehabilitation intervention at all was provided. Conclusions: Costs associated with sick leave were dominated by production loss. Resources invested in rehabilitation were small. By increasing investment in early rehabilitation, costs to society and the individual might be reduced. Implications for Rehabilitation Resources invested in rehabilitation for sick-listed with musculoskeletal and mental disorders in Sweden are very small in comparison with the costs of production loss. For policy makers, there may be much to gain through investments into improved rehabilitation processes for return to work. Health care professionals need to develop rehabilitative activities aiming for return to work, rather than symptoms treatment only.

Objectives The study aims to identify individual and workplace factors associated with early return to work (RTW)-defined as within 3 months-and factors associated with later RTW-between 3 and 12 months after being sick-listed-in a cohort of newly sick-listed individuals with common mental disorders. Methods In a prospective cohort study, a cross-sectional analysis was performed on baseline measures of patients granted sick leave due to common mental disorders. A total of 533 newly sick-listed individuals fulfilled the inclusion criteria and agreed to participate. A baseline questionnaire was sent by post within 3 weeks of their first day of certified medical sickness; 354 (66 %) responded. Those who were unemployed were excluded, resulting in a study population of 319 individuals. Sick leave was recorded for each individual from the Social Insurance Office during 1 year. Analyses were made with multiple Cox regression analyses. Results Early RTW was associated with lower education, better work ability at baseline, positive expectations of treatment and low perceived interactional justice with the supervisor. RTW after 3 months was associated with a need to reduce demands at work, and turnover intentions. Conclusions Early RTW among sick-listed individuals with common mental disorders seems to be associated with the individuals need to secure her/his employment situation, whereas later RTW is associated with variables reflecting dissatisfaction with work conditions. No health measures were associated with RTW. The study highlights the importance of considering not only health and functioning, but also workplace conditions and relations at the workplace in implementing RTW interventions.

Chronic pain is associated with large societal costs, but few studies have investigated the total costs of chronic pain with respect to elderly subjects. The elderly usually require informal care, care performed by municipalities, and care for chronic diseases, all factors that can result in extensive financial burdens on elderly patients, their families, and the social services provided by the state. This study aims to quantify the societal cost of chronic pain in people of age 65 years and older and to assess the impact of chronic pain on quality of life. This study collected data from 3 registers concerning health care, drugs, and municipal services and from 2 surveys. A postal questionnaire was used to collect data from a stratified sample of the population 65 years and older in southeastern Sweden. The questionnaire addressed pain intensity and quality of life variables (EQ-5D). A second postal questionnaire was used to collect data from relatives of the elderly patients suffering from chronic pain. A total of 66.5% valid responses of the 10,000 subjects was achieved; 76.9% were categorized as having no or mild chronic pain, 18.9% as having moderate chronic pain, and 4.2% as having severe chronic pain. Consumed resources increased with the severity of chronic pain. Clear differences in EQ-5D were found with respect to the severity of pain. This study found an association between resource use and severity of chronic pain in elderly subjects: the more severe the chronic pain, the more extensive (and expensive) the use of resources.

BACKGROUND: The aim of this study was to survey minor home help services provided by Swedish municipalities with the main purpose to prevent fall injuries.

METHODS: If minor home help services were presented on the homepage of a municipality, an initial telephone contact was taken. Thereafter a questionnaire was administered, including questions about target groups, aim with the services, tasks included, costs and restrictions for users, budget, and experienced gains with the services. Municipalities not providing minor home help services were asked about the reason therefore and if the municipality had previously provided the services Results: The questionnaire response rate was 92%. In 191 of Sweden's 290 municipalities services were provided by, or in cooperation with, the municipality. Reasons for not providing the services were mainly financial and lack of demand. Services were more often provided in larger cities and in municipalities located in populous regions. In some municipalities services were performed by persons with functional disabilities or unemployed persons. CONCLUSIONS: BOTH PROVIDERS AND USERS EXPRESSED SATISFACTION WITH THE SERVICES ASPECTS EXPRESSED WERE THAT SERVICES LEAD TO GREATER SENSE OF SAFETY AND SOCIAL GAINS THE EFFECT OF THE SERVICES IN TERMS OF FALL PREVENTION IS YET TO BE PROVED WITH ONLY A SMALL FALL-PREVENTIVE EFFECT SERVICES ARE PROBABLY COST-EFFECTIVE IMPROVED QUALITY OF LIFE, SENSE OF SAFETY, AND BEING ABLE TO OFFER MEANINGFUL WORK TO OTHERWISE UNEMPLOYED PERSONS ARE IMPORTANT ASPECTS THAT MIGHT IN THEMSELVES MOTIVATE THE PROVISION OF MINOR HOME HELP SERVICES.

Objectives. The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990–2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs.

Methods. A prevalence-based cost-of-illness study was conducted based on data from national and regional registries.

Results. There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990–2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010.

Conclusion. By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment.

Objectives: To calculate total costs over 6 years after diagnosis of early rheumatoid arthritis (RA).

Method: In the longitudinal prospective multicentre TIRA study, 239 patients from seven units, diagnosed in 1996–98, reported regularly on health-care utilization and the number of days lost from work. Costs were obtained from official databases and calculated using unit costs (Swedish kronor, SEK) from 2001. Indirect costs were calculated using the human capital approach (HCA). Costs were inflation adjusted to Euro June 2012, using the Swedish Consumer Price Index and the exchange rate of June 2012. Statistical analyses were based on linear mixed models (LMMs) for changes over time.

Results: The mean total cost per patient was EUR 14 768 in year 1, increasing to EUR 18 438 in year 6. Outpatient visits and hospitalization decreased but costs for surgery increased from EUR 92/patient in year 1 to EUR 444/patient in year 6. Drug costs increased from EUR 429/patient to EUR 2214/patient, mainly because of the introduction of biologics. In year 1, drugs made up for 10% of direct costs, and increased to 49% in year 6. Sick leave decreased during the first years but disability pensions increased, resulting in unchanged indirect costs. Over the following years, disability pensions increased further and indirect costs increased from EUR 10 284 in year 1 to EUR 13 874 in year 6. LMM analyses showed that indirect costs were unchanged whereas direct costs, after an initial fall, increased over the following years, leading to increasing total costs.

Conclusions: In the 6 years after diagnosis of early RA, drug costs were partially offset by decreasing outpatient visits but indirect costs remained unchanged and total costs increased.

BACKGROUND:

Many patients with cervical disc disease require leave from work, due to long-lasting, complex symptoms, including chronic pain and reduced levels of physical and psychological function. Surgery on a few segmental levels might be expected to resolve disc-specific pain and reduce neurological deficits, but not the non-specific neck pain and the frequent illness. No study has investigated whether post-surgery physiotherapy might improve the outcome of surgery. The main purpose of this study was to evaluate whether a well-structured rehabilitation programme might add benefit to the customary post-surgical treatment for cervical disc disease, with respect to function, disability, work capability, and cost effectiveness.

METHODS/DESIGN:

This study was designed as a prospective, randomised, controlled, multi-centre study. An independent, blinded investigator will compare two alternatives of rehabilitation. We will include 200 patients of working age, with cervical disc disease confirmed by clinical findings and symptoms of cervical nerve root compression. After providing informed consent, study participants will be randomised to one of two alternative physiotherapy regimes; (A) customary treatment (information and advice on a specialist clinic); or (B) customary treatment plus active physiotherapy. Physiotherapy will follow a standardised, structured programme of neck-specific exercises combined with a behavioural approach. All patients will be evaluated both clinically and subjectively (with questionnaires) before surgery and at 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. The main outcome variable will be neck-specific disability. Cost-effectiveness will also be calculated.

DISCUSSION:

We anticipate that the results of this study will provide evidence to support physiotherapeutic rehabilitation applied after surgery for cervical radiculopathy due to cervical disc disease.

Background: Up to 50% of chronic whiplash associated disorders (WAD) patients experience considerable pain and disability and remain on sick-leave. No evidence supports the use of physiotherapy treatment of chronic WAD, although exercise is recommended. Previous randomised controlled studies did not evaluate the value of adding a behavioural therapy intervention to neck-specific exercises, nor did they compare these treatments to prescription of general physical activity. Few exercise studies focus on patients with chronic WAD, and few have looked at patients ability to return to work and the cost-effectiveness of treatments. Thus, there is a great need to develop successful evidence-based rehabilitation models. The study aim is to investigate whether neck-specific exercise with or without a behavioural approach (facilitated by a single caregiver per patient) improves functioning compared to prescription of general physical activity for individuals with chronic WAD. less thanbrgreater than less thanbrgreater thanMethods/Design: The study is a prospective, randomised, controlled, multi-centre study with a 2-year follow-up that includes 216 patients with chronic WAD (andgt;6 months and andlt;3 years). The patients (aged 18 to 63) must be classified as WAD grade 2 or 3. Eligibility will be determined with a questionnaire, telephone interview and clinical examination. The participants will be randomised into one of three treatments: (A) neck-specific exercise followed by prescription of physical activity; (B) neck-specific exercise with a behavioural approach followed by prescription of physical activity; or (C) prescription of physical activity alone without neck-specific exercises. Treatments will be performed for 3 months. We will examine physical and psychological function, pain intensity, health care consumption, the ability to resume work and economic health benefits. An independent, blinded investigator will perform the measurements at baseline and 3, 6, 12 and 24 months after inclusion. The main study outcome will be improvement in neck-specific disability as measured with the Neck Disability Index. All treatments will be recorded in treatment diaries and medical records. less thanbrgreater than less thanbrgreater thanDiscussion: The study findings will help improve the treatment of patients with chronic WAD.

Aim To describe the types of intervention offered, to investigate the relationship between the type of intervention given, patient-reported usefulness of interventions and the effect on self-reported work ability in a cohort of sick-listed patients with musculoskeletal disorders (MSD) or mental disorders (MD).

Methods A prospective cohort study was performed including 810 newly sick-listed patients (MSD 62 % and MD 38 %). The baseline questionnaire included sociodemographic characteristics and measures of work ability. The 3-month follow-up questionnaire included measures of work ability, type of intervention received, and judgment of usefulness.

Results Twenty-five percent received medical intervention modalities (MI) only, 45 % received a combination of medical and rehabilitative intervention modalities (CRI) and 31 % received work-related interventions combined with medical or rehabilitative intervention modalities (WI). Behavioural treatments were more common for patients with MD compared with MSD and exercise therapy were more common for patients with MSD. The most prevalent workplace interventions were adjustment of work tasks or the work environment. Among patients with MD, WI was found to be useful and improved work ability significantly more compared with only MI or CRI. For patients with MSD, no significant differences in improved work ability were found between interventions.

Conclusions Patients with MD who received a combination of work-related and clinical interventions reported best usefulness and best improvement in work ability. There was no difference in improvements in work ability between rehabilitation methods in the MSD group. There seems to be a gap between scientific evidence and praxis behaviour in the rehabilitation process. Unimodal rehabilitation was widely applied in the early rehabilitation process, a multimodal treatment approach was rare and only one-third received work-related interventions. It remains a challenge to understand who needs what type of intervention.

This report deals with so called minor home help services. These services are primarily meant for older persons with the aim to prevent injuries caused by falling in domestic environments (ones home). The minor home help services are mostly provided by the municipalities in Sweden, although it is not mandatory to provide these services. The extent of the provision and use of minor home help services has previously not been studied on a national level. The aim of this study was to delineate the minor home help services run by the municipalities in Sweden and further to examine and estimate the societal costs and consequences of providing these services.

Out of the 290 municipalities in Sweden, 191 (66 %) offer minor home help services to their citizens. The tasks carried out are primarily aimed at preventing falls from furniture such as step stools or ladders, removing items that may cause falls (cords, carpets etc.) and providing an overhaul of injury risks in the home. A few municipalities also offer outdoor services such as removing snow in wintertime. In the majority of the municipalities (58 %) the services are offered free of charge but the user has to pay for the materials, in 32 % the services are completely free of charge and in 9 % of the municipalities an amount is charged for the services. The minor home help services are organized in various ways in the municipalities: the services can be completely run by the municipality where the services are carried out by one or several employed persons, by persons with disabilities (involved in daily activity programmes in the municipality) or by persons involved in work programmes; or the minor home help services can be carried out by the community rescue service or companies paid by the municipality to offer these services to the citizens. There are also organizations with volunteers that carry out minor home help services, these are however not included in the main results since the focus in this report is on municipal minor home help services. Ninety nine municipalities do not offer minor home help services to their citizens. Reasons for this are e.g. economic restraints and low demand.

Experienced gains with minor home help services from the perspectives of the municipalities are prevention of falls, facilitation of the possibility to remain living in one’s own home, contribution to social wellbeing and being able to offer meaningful work tasks for persons in work programmes or persons with disabilities. Problems that have been brought forward are low demand of the services, problems with providing the target group with information and difficulties to measure the effect on fall injuries.

A socioeconomic model was constructed for the analysis of costs and consequences of fall injuries. The model includes the large cost items as well as outcomes such as mortality and loss of quality of life when affected by a fall injury. The total direct costs in Sweden for fall injuries has previously been calculated to approximately 5 billion SEK, which includes only the direct costs during the first year of the injury. A calculation exercise was performed and applied to a hypothetical municipality with 50 000 inhabitants. This calculation exercise shows that if only a small amount of falls that lead to serious injuries (fractures) can be prevented by minor home help services, then the costs saved are approximately equivalent to the mean budget of minor home help services with one employed person. Calculations using real data including both costs and effects need to be performed.