To Örebro University

Prurigo nodularis (PN) is a chronic, itchy, inflammatory skin condition that negatively affects quality of life. A study was undertaken to investigate the healthcare utilization, including treatment patterns and direct costs for specialist care, for PN in Sweden. Linkage cohorts were created from national Swedish patient and prescription registers, and the cost-per-patient database of PN adults in specialist care in Sweden from 2015 to 2020. Around 875 patients were registered annually with a specialist diagnosis of PN in Sweden, with 3,548 specialist visits per year on average. In patients with severe PN with AD, the most common treatment sequence was topical treatment with corticosteroids followed by systemic prednisolone and methotrexate (32.6%). More than one-fifth of individuals with PN, and most with severe PN, had treatment for more than 1 year. For in- and outpatient care, the mean cost per visit was €458.6 and per patient per year around €1,862. The total annual cost of PN patients is estimated to be €1.6 million in Sweden. A high proportion of patients are treated for years with several, often systemic, treatment sequels. Targeted treatments for PN might improve patients' quality of life and reduce the high related costs for the healthcare system.

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.

BACKGROUND: Unpaid domestic work has been found to be negatively associated with mental health, especially among women, in previous studies but the measures of domestic work vary. The aim of this study was to elucidate the association between time spent in domestic work and mental health in the general population.

METHOD: The study is based on 14,184 women and men aged 30-69 years who responded to a survey questionnaire in Central Sweden in 2017 (overall response rate: 43%). Multivariate logistic regression models, adjusting for age group, educational level, family status, employment status, economic difficulties, and social support, were used to study the association between hours spent in domestic work and depressive symptoms and self-reported diagnosed depression, respectively.

RESULTS: In total, 26.7% of the respondents reported depressive symptoms and 8.8% reported diagnosed depression. No independent associations between hours spent in domestic work and depressive symptoms were found. Among women, the lowest prevalence of depression was found among those who spend 11-30 h per week in domestic work. Among men, the prevalence of self-reported diagnosed depression was highest among those who spend 0-2 h per week in domestic work, but no other statistically significant associations between time spent in domestic work and depression were found. In addition, a strong dose-response relationship was found between experiencing domestic work as burdensome and both depressive symptoms and self-reported diagnosed depression among women and men.

CONCLUSION: Investigating time spent in unpaid domestic work may not be sufficient to assess the association between exposure to domestic work and mental health. Conversely, strain in domestic work may be a more important factor contributing to the prevalence of poor mental health in the general population.

BACKGROUND: There is increasing evidence supporting the use of faecal immunochemical tests (FIT) in patients reporting symptoms associated with colorectal cancer (CRC), but most studies until now have focused on selected subjects already referred for investigation. We therefore set out to determine the accuracy and predictive values of FIT in a primary care population.

METHOD: A prospective, multicentre, single-gated comparative diagnostic study on quantitative FIT in patients aged 40 years and above presenting in primary care with symptoms associated with CRC will be conducted. Patients representing the whole spectrum of severity of such symptoms met with in primary care will be eligible and identified by GPs. Participants will answer a short form on symptoms during the last month. They will provide two faecal samples from two separate days. Analyses will be performed within 5 days (QuikRead go®, Aidian Oy). The analytical working range is 10-200 μg Hb/g faeces. Reference test will be linked to the Swedish Colorectal Cancer Registry up to 2 years after inclusion. Accuracy, area under ROC curves, and predictive values will be calculated for one FIT compared to the highest value of two FIT and at cutoff < 10, 10-14.9, 15-19.9 and ≥ 20 μg Hb/g faeces. Subgroup analyses will be conducted for patients with anaemia and those reporting rectal bleeding. A model-based cost-effectiveness analysis based on the clinical accuracy study will be performed. Based on previous literature, we hypothesized that the sensitivity of the highest value of two FIT at cutoff 10 μg Hb/g faeces will be 95% (95% CI + / - 15%). The prevalence of CRC in the study population was estimated to be 2%, and the rate of non-responders to be 1/6. In all, 3000 patients will be invited at 30 primary care centres.

DISCUSSION: This study will generate important clinical real-life structured data on accuracy and predictive values of FIT in the most critical population for work-up of CRC, i.e. patients presenting with at times ambiguous symptoms in primary care. It will help establish the role of FIT in this large group.

TRIAL REGISTRATION: NCT05156307 . Registered on 14 December 2021-retrospectively registered.

Background: Atopic dermatitis (AD) is a common inflammatory skin disease while the economic burden of AD by severity is not adequately understood.

Objective: To estimate the societal economic burden and to identify cost determinants of AD.

Methods: In this population‐based, controlled cohort study in Sweden, patients with AD were identified through diagnosis codes in primary or secondary care or by dispensed medications using administrative healthcare registers. A reference cohort without AD was randomly selected from the general population. Healthcare costs (primary/secondary care visits and dispensed medication) and indirect costs (care for sick children and long‐termsick leave for adults) were calculated annually. AD patients were stratified by age (paediatric [age < 12], adolescent [12≤age < 18] or adult [age≥18]), and severity (mild‐to‐moderate [M2M] or severe AD) and matched to the reference cohort.

Results: Compared with controls, the annual mean per‐patient direct healthcare costs in the first year following diagnosis were €941 and €1259 higher in paediatric patients with M2M and severe AD, respectively. In the first year following diagnosis, the mean indirect cost for care of sick children was €69 and €78 higher per patient in M2M and severe AD, respectively. In adolescents with M2M and severe AD, direct healthcare costs were €816 and €1260 higher, respectively. In adults, healthcare costs were €1583 and €2963 higher in patients with M2M and severe AD, respectively and indirect costs were €148 and €263 higher compared with controls. Management of comorbid medical conditions was an important driver of incremental healthcare costs.Total incremental societal economic burden for AD was €351 and €96 million higher in patients with M2M and severe AD, respectively, compared to controls.

Conclusion: AD is associated with a significant societal economic burden primarily driven by the cost burden of M2M AD due to the high prevalence of this population. Regardless of severity level, management of non‐ADcomorbidities is a major driver of total costs.

Data quantifying population-based direct healthcare costs (DHCC) for atopic dermatitis (AD) by severity are limited. This study was designed to provide estimates for these costs. Patients were identified at first AD diagnosis in the National Patient Registry (secondary care) or in primary care (national coverage: 31%) (International Classification of Diseases-10 L20) or first dispensation of topical calcineurin inhibitor or topical corticosteroid (Anatomical Therapeutic Chemical code D11AH01/02 once; D07 twice in a year) in the Prescribed Drug Registry in 2007-17 (index) and followed until death, emigration, 31 Dec 2018 or adulthood. Patients without AD diagnosis with a record of diagnoses/treatment for other non-AD skin conditions were excluded. Patients were matched 1:1 on age, gender and region to controls. 1-year DHCC for secondary and primary care visits and filled prescriptions were compared with controls (2020€). Disease severity (mild-to-moderate [M2M] vs severe) using AD treatment and visits as proxies was assessed between index to 30 days after. 187,338 M2M (48% female; mean age 4) and 46,754 severe children (51%; 8), while 445,317 M2M (55%; 55) and 11,640 severe adults (57%; 53) were included. In children vs. controls, 1-year DHCC for secondary care, primary care and medications were respectively €72, €23, €33 million (mn) higher in M2M and €26, €4, €13 mn higher in severe; in adults vs. controls, €353, €68, €182 mn higher in M2M and €21, €2, €17 mn higher in severe (all comparisons significant, p<0.05). On population level, AD is associated with substantial economic burden, which is higher in M2M vs severe AD partially due to higher prevalence of M2M.

BACKGROUND: In contrast to paid work, few studies have investigated the association between unpaid domestic work and mental health. The aim of this study was to investigate the association between domestic work and self-reported diagnosed depression and to estimate related costs in a general population.

METHOD: The study is based on women (N = 7981) and men (N = 6203) aged 30-69 years who responded to a survey questionnaire in Mid-Sweden in 2017 (overall response rate 43%). Multivariate logistic regression models, adjusting for age group, educational level, family status, employment status, economic difficulties, and social support, were used to study the association between domestic work and depression. The estimation of direct and indirect costs was based on the calculation of population attributable risks, the literature, and administrative data.

RESULTS: In total, 25% of the women and 14% of the men spent more than 20 h a week on domestic work, and 57% of the women and 39% of the men experienced domestic work sometimes or more often as burdensome. A strong independent association between experiencing domestic work as burdensome and depression was observed both in women and men. The total cost of depression possibly related to burdensome domestic work was estimated up to EUR 135.1 million (min EUR 20.7 million-max EUR 21.4 billion) of the total EUR 286.4 million per year in Mid-Sweden.

CONCLUSIONS: The association between experiencing domestic work as burdensome and depression was strong among both women and men and was not restricted to employed persons or to parents with children. Even though the cross-sectional design does not allow one to assess the direction of the association between domestic work and depression, and longitudinal studies are needed, the results imply that strain in domestic work should be taken into account when considering factors that contribute to the prevalence of depression in the general population and its high societal costs.

The burden of atopic dermatitis (AD) was assessed. A population-based, cross-sectional questionnaire study was performed among 34,313 Swedish adults in 2017. The prevalence of AD was 14%. Adults with mild AD had an increased relative risk ratio (RRR) of severe depression (aRRR 1.78, 95% confidence interval (95% CI) 1.50-2.12) and anxiety (aRRR 1.97, 95% CI 1.69-2.30), which was higher for severe AD (aRRR 6.22 95% CI 4.60-8.42, aRRR 5.62 95% CI 4.10-7.71, respectively). Persons with severe AD were less likely to have a university degree (aRRR 0.55, 95% CI 0.34-0.90) and more likely to have a lower annual income (238,000-324,000 SEK: aRRR 0.51, 95% CI 0.39-0.77; 325,000 SEK or more 0.36; 0.25-0.58) compared with individuals without AD. These results suggest that AD implies an increased prevalence of comorbid mental conditions and an adverse impact on academic achievement and work. These adverse associations increase substantially for patients with severe AD and comorbid asthma.

Objective: To perform a cost-effectiveness analysis of a randomised controlled trial of internet-mediated cognitive behavioural therapy (ICBT) compared with treatment as usual (TaU) for patients with mild to moderate depression in the Swedish primary care setting. In particular, the objective was to assess from a healthcare and societal perspective the incremental cost-effectiveness ratio (ICER) of ICBT versus TaU at 12 months follow-up.

Design: A cost-effectiveness analysis alongside a pragmatic effectiveness trial.

Setting: Sixteen primary care centres (PCCs) in south-west Sweden.

Participants: Ninety patients diagnosed with mild to moderate depression at the PCCs.

Main outcome measure: ICERs calculated as (CostICBT-CostTaU)/(Health outcomeICBT-Health outcomeTaU)=ΔCost/ΔHealth outcomes, the health outcomes being changes in the Beck Depression Inventory-II (BDI-II) score and quality-adjusted life-years (QALYs).

Results: The total cost per patient for ICBT was 4044 Swedish kronor (SEK) (€426) (healthcare perspective) and SEK47 679 (€5028) (societal perspective). The total cost per patient for TaU was SEK4434 (€468) and SEK50 343 (€5308). In both groups, the largest cost was associated with productivity loss. The differences in cost per patient were not statistically significant. The mean reduction in BDI-II score was 13.4 and 13.8 units in the ICBT and TaU groups, respectively. The mean QALYs per patient was 0.74 and 0.79 in the ICBT and TaU groups, respectively. The differences in BDI-II score reduction and mean QALYs were not statistically significant. The uncertainty of the study estimates when assessed by bootstrapping indicated that no firm conclusion could be drawn as to whether ICBT treatment compared with TaU was the most cost-effective use of resources.

Conclusions: ICBT was regarded to be as cost-effective as TaU as costs, health outcomes and cost-effectiveness were similar for ICBT and TaU, both from a healthcare and societal perspective.

Trial registration number: ID NR 30511.