To Örebro University

PURPOSE: Arthroscopy remains the gold standard to diagnose ligamentous lesions in the wrist. The coronavirus disease (COVID)-19 pandemic put a strain on resources, prompting an increase in procedures performed under local anesthesia. Dry needle arthroscopy of the wrist has previously been used in the operating room. The purpose of this study was to assess the results and patient satisfaction of wrist arthroscopy under local anesthesia in an office setting.

METHODS: A prospective series of 15 patients presenting with wrist trauma and a suspected ligamentous injury to the wrist were included. All patients underwent radiography and magnetic resonance imaging (MRI) before the procedure. Dry needle arthroscopy was performed by a surgeon with a nurse assistant, in the office under local anesthesia, using a traction device for distraction of the wrist. Patient satisfaction was assessed with the Picker Patient Experience-15 (PPE-15) questionnaire.

RESULTS: The patient's mean age was 34 years (range: 18-51). There were no intraoperative complications or postoperative infections. The median PPE-15 score was 90 of 100. Visualization of the intraarticular structures was excellent.

CONCLUSIONS: Dry needle arthroscopy of the wrist under local anesthesia in an office setting seems to be a feasible method to diagnose ligament injuries of the wrist. Patient satisfaction with the procedure was high.

CLINICAL RELEVANCE: Dry needle arthroscopy of the wrist under local anesthesia in-office could facilitate and expedite diagnosis of wrist injuries.

Background: Data on direct and indirect annual costs for inflammatory bowel disease (IBD) patients treated with vedolizumab are limited.

Objectives: To evaluate the total annual direct healthcare costs and indirect costs among IBD patients treated with vedolizumab.

Design: A prospective observational multicentre study involving 286 patients with Crohn's disease (CD; n = 169) or ulcerative colitis (UC; n = 117) who started vedolizumab therapy during 2015-2017 at 21 hospitals across Sweden.

Methods: Data on direct and indirect costs were collected during a 3-year follow-up period. Direct costs were measured as healthcare resource utilization including medication, hospital admissions and hospital-based outpatient visits. Indirect societal costs were measured as production losses from sick leave and disability pension. Data were obtained from the Swedish Quality Register for IBD and through linkage with national registers. Data are presented both for patients who continued treatment throughout the follow-up period and for patients who discontinued treatment (CD: n = 83; UC: n = 48).

Results: The mean annual direct follow-up cost was <euro>24,305 for all IBD patients, <euro>24,873 for CD patients and <euro>23,484 for UC patients (p = 0.24). No difference was observed between men and women (<euro>24,506 vs <euro>24,080; p = 0.87). Direct costs were similar in patients who continued vedolizumab for the entire study period (<euro>24,401) and those who discontinued treatment (<euro>24,192; p = 0.12). Medication was the primary driver of direct costs (64%), followed by hospital admissions (19%) and outpatient care (17%). Mean indirect costs were lower among patients who continued vedolizumab (<euro>3044) than among those who stopped the treatment (<euro>8927; p < 0.01). Increased direct costs were associated with perianal disease and high baseline disease activity in CD, and concurrent use of immunomodulators in UC.

Conclusion: Patients treated with vedolizumab in Swedish clinical practice represent a group with high direct costs, primarily due to medication expenses. However, indirect costs were significantly lower than in previous reports.

OBJECTIVE: To estimate the effect on healthcare resource use after introducing the World Health Organization diagnostic criteria (WHO-2013) for gestational diabetes mellitus (GDM) compared to former criteria in Sweden (SWE-GDM). DESIGN: A cost-analysis alongside the Changing Diagnostic Criteria for Gestational Diabetes (CDC4G) randomised controlled trial.

SETTING: Sweden, with risk-factor based screening for GDM. POPULATION: 47 080 pregnant women and their infants. METHODS: A register-based cost-analysis from a healthcare perspective alongside a stepped-wedge cluster RCT of switching from SWE-GDM to WHO-2013 criteria in 2018. Analyses were made on the population level and repeated in the subgroup affected by the intervention, that is, those with plasma glucose values between SWE-GDM and WHO-2013 criteria. Sensitivity analysis by bootstrapping was performed.

MAIN OUTCOME MEASURES: Estimated costs for obstetric surveillance (including GDM-management), delivery and neonatal healthcare until 28 days postpartum. RESULTS: On a population level, the WHO-2013 criteria were associated with increased costs of obstetric surveillance (adjusted mean [bootstrap confidence interval]) €94.0 [24.5-169.1], delivery care €20.4 [-33.5 to 75.4] and neonatal care €331.0 [75.1-589.0] per pregnancy, and in the affected subgroup €606.9 [377.7-872.4], €348.5 [126.0-542.0] and €129.3 [-559.0 to 980.9] respectively.

CONCLUSIONS: Implementation of the WHO-2013 criteria in Sweden was associated with increased costs for obstetric surveillance and delivery on a population level, driven by the affected subgroup. The increased costs for neonatal care were associated with large uncertainty. A detailed understanding of the changes in resource use can guide decisions to mitigate cost increases.

BACKGROUND: Since 2022, self-sampling has been recommended in Sweden's cervical screening program. Despite still being used primarily for long-term non-attendees, its expected increase in use raises interest in molecular triage methods applicable to self-collected samples. Postmenopausal women face screening challenges due to physiological changes, making this group particularly relevant for evaluating alternative strategies. This study models the cost-effectiveness of different sampling and triage methods in identifying histological high-grade squamous intraepithelial lesions (HSIL) in women aged 60-69 years.

METHODS: Using real-world data, this study compares the cost-effectiveness of currently implemented strategy based on professional HPV sampling and combination triage with genotyping and cytology, with modelled strategies based on self-sampling and various molecular triage. The comparison evaluates healthcare resource use and the number of identified histological HSIL cases. The analysis focuses on a single screening cycle, re-testing of invalid samples or screening-positive/triage-negative women are not addressed.

RESULTS: Screening with molecular triage either leads to decreases in effect, i.e. fewer histological HSIL identified, or significant cost increases due to higher rate of HPV-positive screening samples and higher number of colposcopy follow-ups.

CONCLUSIONS: Molecular triage, whether used with self-sampling or professional sampling, does not appear cost-effective for identifying HSIL in this age group compared to the current screening strategy.

BACKGROUND: The World Health Organisation (WHO) 2013 diagnostic criteria for gestational diabetes mellitus (GDM) has been criticised due to the limited evidence of benefits on pregnancy outcomes in different populations when switching from previously higher glycemic thresholds to the lower WHO-2013 diagnostic criteria. The aim of this study was to determine whether the switch from previous Swedish (SWE-GDM) to the WHO-2013 GDM criteria in Sweden following risk factor-based screening improves pregnancy outcomes.

METHODS AND FINDINGS: A stepped wedge cluster randomised trial was performed between January 1 and December 31, 2018 in 11 clusters (17 delivery units) across Sweden, including all pregnancies under care and excluding preexisting diabetes, gastric bypass surgery, or multifetal pregnancies from the analysis. After implementation of uniform clinical and laboratory guidelines, a number of clusters were randomised to intervention (switch to WHO-2013 GDM criteria) each month from February to November 2018. The primary outcome was large for gestational age (LGA, defined as birth weight >90th percentile). Other secondary and prespecified outcomes included maternal and neonatal birth complications. Primary analysis was by modified intention to treat (mITT), excluding 3 clusters that were randomised before study start but were unable to implement the intervention. Prespecified subgroup analysis was undertaken among those discordant for the definition of GDM. Multilevel mixed regression models were used to compare outcome LGA between WHO-2013 and SWE-GDM groups adjusted for clusters, time periods, and potential confounders. Multiple imputation was used for missing potential confounding variables. In the mITT analysis, 47 080 pregnancies were included with 6 882 (14.6%) oral glucose tolerance tests (OGTTs) performed. The GDM prevalence increased from 595/22 797 (2.6%) to 1 591/24 283 (6.6%) after the intervention. In the mITT population, the switch was associated with no change in primary outcome LGA (2 790/24 209 (11.5%) versus 2 584/22 707 (11.4%)) producing an adjusted risk ratio (aRR) of 0.97 (95% confidence interval 0.91 to 1.02, p = 0.26). In the subgroup, the prevalence of LGA was 273/956 (28.8%) before and 278/1 239 (22.5%) after the switch, aRR 0.87 (95% CI 0.75 to 1.01, p = 0.076). No serious events were reported. Potential limitations of this trial are mainly due to the trial design, including failure to adhere to guidelines within and between the clusters and influences of unidentified temporal variations.

CONCLUSIONS: In this study, implementing the WHO-2013 criteria in Sweden with risk factor-based screening did not significantly reduce LGA prevalence defined as birth weight >90th percentile, in the total population, or in the subgroup discordant for the definition of GDM. Future studies are needed to evaluate the effects of treating different glucose thresholds during pregnancy in different populations, with different screening strategies and clinical management guidelines, to optimise women's and children's health in the short and long term.

TRIAL REGISTRATION: The trial is registered with ISRCTN (41918550).

Background: Pediatric atopic dermatitis (AD) is a common chronic disease. For assessing treatment outcomes, the concept of controlled and uncontrolled AD has been introduced.

Objectives: The aim of the study was to estimate healthcare resource use in terms of visits, treatments and costs in children with controlled and uncontrolled AD.

Materials & Methods: The study utilised administrative data and hospital patient records. An algorithm for the identification of patients with controlled and uncontrolled AD was developed, and an assessment of content validity was performed. The study included 8,922 children, aged 0-17 years, diagnosed with AD between 2015 and 2018 in three Swedish regions, treated in primary and specialist care, at regional and university hospitals.

Results: The proposed algorithm demonstrated adequate content validity. About 13% of children had uncontrolled AD. In dermatology clinics, most patients with uncontrolled disease were 12-17 years old (39%) and 17% had moderate-to-severe AD; 2% had systemic drug treatment and 7% received UVB treatment. Uncontrolled AD was associated with treatment changes and frequent visits in specialist care over several years compared to controlled disease. The mean annual healthcare cost of a child with AD aged 0-17 years in Sweden was estimated at 4,479.5. There was a statistically significant cost difference (around 4000 annually) between patients with uncontrolled AD and those with controlled disease.

Conclusion: AD was associated with high healthcare utilization, especially for children with uncontrolled disease. A high proportion of children with AD might be undertreated, and risk groups, such as adolescents with uncontrolled AD, should be treated more effectively.

In Sweden, physical activity on prescription (PAP) is used to support patients in increasing their levels of physical activity (PA). The role of healthcare professionals in supporting PA behavior change requires optimization in terms of knowledge, quality and organization. This study aims to evaluate the cost-effectiveness of support from a physiotherapist (PT) compared to continued PAP at a healthcare center (HCC) for patients who remained insufficiently active after 6-month PAP treatment at the HCC. The PT strategy was constituted by a higher follow-up frequency as well as by aerobic physical fitness tests. The analysis was based on an RCT with a three-year time horizon, including 190 patients aged 27-77 with metabolic risk factors. The cost per QALY for the PT strategy compared to the HCC strategy was USD 16,771 with a societal perspective (including individual PA expenses, production loss and time cost for exercise, as well as healthcare resource use) and USD 33,450 with a healthcare perspective (including only costs related to healthcare resource use). Assuming a willingness-to-pay of USD 57,000 for a QALY, the probability of cost-effectiveness for the PT strategy was 0.5 for the societal perspective and 0.6 for the healthcare perspective. Subgroup analyses on cost-effectiveness based on individual characteristics regarding enjoyment, expectations and confidence indicated potential in identifying cost-effective strategies based on mediating factors. However, this needs to be further explored. In conclusion, both PT and HCC interventions are similar from a cost-effectiveness perspective, indicating that both strategies are equally valuable in healthcare's range of treatments.

Background: In Sweden, suicide is the most common external cause of death and is accounting for a growing share of potential years of life lost due to injuries. To help policymakers in how to prioritize interventions to reduce the number of the suicides, there is a need for economic evaluations. However, the number of economic evaluations of suicide prevention is scarce. One reason for this can be an insecurity about how to include a reduction in the suicide rate.

Aims of the Study: The aim of this paper is to review the literature of economic evaluations for suicide prevention, with a specific focus on the methods used to value the benefits from the intervention.

Methods: A literature review based on searches in the electronic bibliographic databases: PubMed, Web of Science and Google Scholar, from 2000 until October 2022. The search was independently conducted by two separate researchers. The goal was to identify papers which contained an original economic evaluation of an intervention aimed at preventing suicides that was published in a peer-reviewed journal.

Results: Our final search resulted in 515 hits, including duplicates. Most studies were excluded after the first screening of the abstracts and titles. The most common reason for exclusion was that the study did not evaluate an intervention for suicide prevention. A total of 13 papers was included in the final analysis.

Discussion and Conclusion: We find that there is a lack of economic evaluations of interventions to reduce the number of suicides. Furthermore, the ones that do exist varies both in quality and in which methods that are being used to measure and value the outcome.

Implications for Further Research: For the economic evaluations to be comparable and thereby helping policymakers to answer the question which intervention that is most cost-effective to reduce the number of suicides there is a need for standardization and methodological improvements.

Background/Objective: The aim of this study was to assess whether home phototherapy is a safe alternative to hospital treatment.

Method: This was a randomised controlled, multicentre, trial in which term newborns with a total serum bilirubin of 300-400 μmol/ were randomized to either home phototherapy or conventional in-hospital phototherapy.The outcome measurements were parent-infant bonding, stress and measurements of safety and feasibility. A descriptive qualitative study based on interviews was performed as well as a health economic analysis.

Result: 147 patients were recruited from 6 hospitals, Results showed no difference between groups in the safety and feasibility outcomes. Parents in the intervention group had better scores on bonding and lower levels of stress. The interviews showed that parents felt secure at home. The cost per patient was €337 for home phototherapy compared with €1156 for the hospital alternative indicating average cost savings of €819 or 71% per patient.

Conclusion: Home phototherapy can be considered a safe and feasible alternative to hospital care for well selected patients. It improves bonding and stress for parents and reduces health care costs. Since the first publication from this study was published home phototherapy is now recommended by the American Academy of Pediatrics as an alternative to hospital care for patients with uncomplicated hyperbilirubinemia.