National Health Care Registers Research Articles

Scraping up CHA2DS2-VASc - defining components of the acronym in a nationwide registry study

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital district Finnish foundation for cardiovascular research Introduction Atrial fibrillation (AF) is a major cause of ischemic stroke. The risk of stroke is strongly associated with age, sex and comorbidities of the patients. Therefore, it is crucial that the comorbidities are consistently recorded in medical records as well as health care registries. Purpose This study aims to evaluate the prevalence of the comorbidities related to AF stroke risk in Finnish nationwide population registries, and assess how the use and combination of these registries affect the calculated CHA2DS2-VASc risk score. The comorbidities evaluated were Hypertension, Diabetes, Stroke or TIA, Heart Failure, and Vascular Disease. Methods The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study collected data on all Finnish AF patients from 1st January 2004 to 31st December 2018. Due to the initiation of the national primary care register in 2012, this substudy uses the data of patients with a new AF diagnosis during 2012-2018 (n = 168 353). Using a unique personal identification code, individual patient data were linked from the Finnish national health care registries "AvoHILMO" (primary care) and "HILMO" (secondary and tertiary care), National Prescription Register (ATC codes of purchased medication) and the National Reimbursement Register for reimbursed medication upheld by the Social Insurance Institute (KELA). Results The average CHA2DS2-VASc risk score when entering the cohort, and including information from all registries, equaled 2.91 for men (mean age 70.0 years) and 4.42 for women (mean age 76.9 years). The highest prevalence of diabetes and hypertension were found based on the National Reimbursement Register (ATC codes). Stroke or TIA and heart failure were identified almost exclusively based on secondary and tertiary hospital records. The table represents our results. Conclusion Comprehensive registry analysis of AF patients requires the inclusion of both hospital and medication data. The role of primary care information was limited. Comorbidity and CHA2DS2-VASc weight Total Prevalence Primary care ICD-10 codes Primary care ICPC-2 codes Secondary and tertiary care ICD-10 codes ATCcodes Medication reimbursement codes Hypertension 1 82%137 317 28%47 337 13%21 427 39%66 252 77%130 400 7%10 957 Diabetes 1 24%41 017 13%22 666 13%22 547 14%23 793 21%35 942 12%20 295 Stroke or TIA 2 17%28 653 4%6 254 1%1 968 16%27 379 - - Heart Failure 1 18%29 827 5%7 630 1%1 398 16%26 366 - 1%1 908 Vascular Disease1 28%47 420 12%19 581 2%3 265 25%41 647 - 7%11 802 Average CHA2DS2-VASc contribution 1.86 0.65 0.31 1.26 0.99 0.26 The prevalence of the comorbidities and average CHA2DS2-VASc risk score contribution by registry and combined.

Integrating data from multiple Finnish biobanks and national health-care registers for retrospective studies: Practical experiences.

Aim: This case study aimed to investigate the process of integrating resources of multiple biobanks and health-care registers, especially addressing data permit application, time schedules, co-operation of stakeholders, data exchange and data quality. Methods: We investigated the process in the context of a retrospective study: Pharmacogenomics of antithrombotic drugs (PreMed study). The study involved linking the genotype data of three Finnish biobanks (Auria Biobank, Helsinki Biobank and THL Biobank) with register data on medicine dispensations, health-care encounters and laboratory results. Results: We managed to collect a cohort of 7005 genotyped individuals, thereby achieving the statistical power requirements of the study. The data collection process took 16 months, exceeding our original estimate by seven months. The main delays were caused by the congested data permit approval service to access national register data on health-care encounters. Comparison of hospital data lakes and national registers revealed differences, especially concerning medication data. Genetic variant frequencies were in line with earlier data reported for the European population. The yearly number of international normalised ratio (INR) tests showed stable behaviour over time. Conclusions: A large cohort, consisting of versatile individual-level phenotype and genotype data, can be constructed by integrating data from several biobanks and health data registers in Finland. Co-operation with biobanks is straightforward. However, long time periods need to be reserved when biobank resources are linked with national register data. There is a need for efforts to define general, harmonised co-operation practices and data exchange methods for enabling efficient collection of data from multiple sources.

Statin use and the reoperation rates in glaucoma filtration surgery - population-based cohort study.

To examine the association of systemic statin therapy and reoperation rate after glaucoma filtration surgery (GFS). This is a population-based, historic cohort study of 2705 eyes undergoing GFS in Finland between July 2009 and December 2016. GFSs were identified from national administrative healthcare registers. Baseline sociodemographic and health characteristics were documented. Reoperation rates of GFS subgroups were analysed, with statin users compared to non-users. The outcomes were modelled using a Poisson regression model adjusted for age, sex, education, statin use, chronic comorbidities, and cataract surgery with incident rate ratios (IRR) as the main outcome measure. The cohort contained 2263 subjects with open-angle glaucoma (OAG), 823 men and 1440 women. Surgery was performed on 2705 eyes. First documented procedures: deep sclerectomy (DS) (n = 1601), trabeculectomy (TRE) (799) and glaucoma drainage device (GDD) implantation (305) respectively. In total, 438 secondary operations were performed during the 7.5-year (median 2.25 years) follow-up period. The reoperation rates were 19% after DS, 12% after TRE, and 13% after GDD. Of the surgical procedures, 32% were performed on eyes of patients receiving statin therapy. Statin users showed no difference in reoperation rates (IRR 1.06, CI 0.82-1.37). In subgroups, no difference was observed in the reoperation rates adjusted with statin use after filtration surgery (DS, TRE) (IRR 1.06, CI 0.8-1.40) or GDD implantation (0.57, CI 0.20-1.63). Systemic statin therapy among surgically treated OAG patients had no impact on secondary surgery rates following DS, TRE or GDD implantation.

Maternal health and pregnancy outcome in diagnosed and undiagnosed Marfan syndrome: A registry-based study.

In Marfan syndrome (MFS), pregnancy is considered as high risk due to the deficiency of fibrillin in the connective tissue and increased risk of aortic dissection. The objective was to demonstrate the consequences on maternal health, in women with diagnosed and undiagnosed MFS at the time of pregnancy and childbirth. By using national health care registries, we identified all pregnancy related outcomes, from women with MFS (n = 183) and an age-matched background population (n = 18,300). We found 91 pregnancies during follow-up. Significantly fewer women with MFS gave birth, compared to the background population. No women with known MFS had a pregnancy related aortic dissection but complications related to the cervix were increased (HR:19.8 [95% CI:2.2-177.5]). Fifty women with MFS were undiagnosed at the time of their first pregnancy and/or childbirth. Among these, there were more birth canal related complications HR:27.2 (95% CI: 2.3-315.0), preeclampsia (HR:2.25 [95% CI: 1.11-4.60]), fetal deaths (HR:12.3 [95% CI: 1.51-99.8]), and all delivery-related dissections came from this subgroup. In conclusion, undiagnosed women with MFS experienced more pregnancy and childbirth related complications including fetal death, birth canal issues, preeclampsia, and aortic disease, which emphasizes the need for an early MFS diagnosis and special care during pregnancy and childbirth.

Profile of Substance Misuse among Adolescent and Young Adult Gabapentinoid Users: A Register-Based Follow-up Study of Former Adolescent Psychiatric Inpatients

Aims: Our study examined characteristics of adolescent and young adult study participants using gabapentinoids (gabapentin, pregabalin), with previous history of adolescent psychiatric inpatient hospitalization. Particular focus was on temporal association of age, at first prescription for gabapentinoids, to age at tobacco smoking initiation, regular alcohol use, diagnosis of substance dependence and prescriptions for benzodiazepines and opioids. Methods: The initial study population contained 508 adolescents (300 females, 208 males) admitted to psychiatric inpatient care in Oulu University hospital between the ages 13–17 years. Register-based follow-up information on prescriptions for gabapentinoids, benzodiazepines and opioids, as well as ICD-10 diagnosis for hospital-treated substance dependence, was obtained from the Finnish national health care registers. Results: The users of gabapentinoids accounted for 9.1% of the initial study population. Of adolescence-related characteristics, suicidal ideation, suicide attempts and non-suicidal self-injury was emphasized in females using gabapentinoids. The majority of participants using gabapentinoids had benzodiazepines (80.4%) and opioids (71.7%) as comorbid drugs. Initiation of tobacco smoking and alcohol use and first prescriptions for of benzodiazepines and opioids, and a diagnosis of substance dependence commonly predated first prescriptions for gabapentinoids. Conclusions: In clinical practice, the decision to prescribe gabapentinoids to adolescents or young adults must be made with caution, particularly for those with substance use problems and/or without a clinically approved indication.

Safety of Alemtuzumab and Autologous Hematopoietic Stem Cell Transplantation Compared to Noninduction Therapies for Multiple Sclerosis.

ObjectiveTo assess safety outcomes for the induction therapies alemtuzumab and autologous hematopoietic stem cell transplantation (AHSCT) compared to noninduction disease-modifying therapies.MethodsWe performed a population-based cohort study linking the Swedish Multiple Sclerosis Register to national health care registers. Alemtuzumab, AHSCT, and a matched reference group of noninduction therapies (natalizumab, dimethyl fumarate, rituximab, fingolimod) were included if started between 2008 and 2017. Main outcomes were death, thyroid disease, nonthyroid autoimmune disease, and infection.ResultsWe identified 132 alemtuzumab-treated and 139 AHSCT-treated (68% high-dose cyclophosphamide and anti-thymocyte globulin [ATG], 32% BCNU, etoposide, cytosine-arabinoside, and melphalan/ATG) patients, together with 2,486 matched patients treated with noninduction therapies. Four patients in the alemtuzumab group died (incidence rate [IR] per 1,000 person-years 8.6, 95% confidence interval [CI] 2.3–22.0) compared to 1 patient in the AHSCT group (IR 1.7, 95% CI 0.0–9.6), and the mortality rate in the reference group was 0.7 (95% CI 0.3–1.3). Thyroid disease was most frequent in the alemtuzumab group (IR 109, 95% CI 75–154) but also occurred more often for AHSCT (IR 34, 95% CI 18–56) compared to the reference (IR 5.3 95% CI 3.9–7.1). The incidence of nonthyroid autoimmune disease was similar in all groups. IR for infection diagnosed ≥6 months from therapy initiation was 53 (95% CI 30–87) for alemtuzumab, 108 (95% CI 75–150) for AHSCT, and 51 (95% CI 46–57) for the reference.ConclusionWe confirmed a high incidence of thyroid disease in alemtuzumab- and, to a smaller extent, AHSCT-treated patients and found a higher incidence of infection for AHSCT compared to both alemtuzumab and noninduction therapies. The incidence of nonthyroid autoimmune disease was low for both therapies.Classification of EvidenceThis study provides Class III evidence of an increased risk of thyroid disease with alemtuzumab and an increased risk of infection with AHSCT treatment.

Early Start of Anti-Dementia Medication Delays Transition to 24-Hour Care in Alzheimer's Disease Patients: A Finnish Nationwide Cohort Study.

Dementia is one of the strongest predictors of admission to a 24-hour care facility among older people, and 24-hour care is the major cost of Alzheimer's disease (AD). The aim of this study was to evaluate the association of early start of anti-dementia medication and other predisposing factors with 2-year risk of transition to 24-hour care in the nationwide cohort of Finnish AD patients. This was a retrospective, non-interventional study based on individual-level data from Finnish national health and social care registers. The incident cohort included 7,454 AD patients (ICD-10, G30) comprised of two subgroups: those living unassisted at home (n = 5,002), and those receiving professional home care (n = 2,452). The primary outcome was admission to a 24-hour care facility. Exploratory variables were early versus late anti-dementia medication start, sociodemographic variables, care intensity level, and comorbidities. Early anti-dementia medication reduced the risk of admission to 24-hour care both in patients living unassisted at home, with a hazard ratio (HR) of 0.58 (p < 0.001), and those receiving professional home care (HR, 0.84; p = 0.039). Being unmarried (HR, 1.69; p < 0.001), having an informal caregiver (HR, 1.69; p = 0.003), or having a diagnosis of additional neurological disorder (HR, 1.68; p = 0.006) or hip fracture (HR, 1.61; p = 0.004) were associated with higher risk of admission to 24-hour care in patients living unassisted at home. To support living at home, early start of anti-dementia medication should be a high priority in newly diagnosed AD patients.

Comparison of data sources on alcohol problems: An exploratory exercise using surveys vs. national healthcare registers.

Aims:Both survey and healthcare register data struggle as data sources to capture the phenomenon of alcohol problems. We study a large group of people for whom survey data and two types of register data are available, and examine the overlaps of similar or related measures in the different data sources to learn about potential weaknesses in each. We also examine how register-based data on the prevalence of alcohol problems change depending on which register data are used.Design:We use data from the Regional Health and Wellbeing Study (ATH) of the adult Finnish population collected in 2013 and 2014 (n = 69,441), individually linked with data on two national healthcare registers (Care Register for Health Care; Register of Primary Health Care visits) for the survey year and previous year.Results:The prevalence of substance-abuse-related healthcare was almost two-fold if data on outpatient primary care visits were included in addition to hospitalisations. Forty-six per cent of the survey respondents self-reporting substance-abuse-related healthcare service use were identified in the registers, and 22% of all respondents with such service use according to registers reported this in the survey. Records of substance-abuse-related healthcare service use, controlled for self-reported alcohol use and self-reported substance-abuse-related service use, were found more often for men, the middle-aged, people with basic education only, and the non-employed.Conclusions:The results are suggestive of underreporting in both data sources. There is an evident need to develop recording practices in the healthcare registers regarding substance use disorders.

Radical cystectomy compared to intravesical BCG immunotherapy for high-risk non-muscle invasive bladder cancer – is there a long-term survival difference? A Swedish nationwide analysis

Objectives High-risk non-muscle invasive urinary bladder cancer (NMIBC) presents an increased risk of progression and cancer death. To reduce these risks, two different treatments are recommended – BCG or radical cystectomy (RC). The purpose of this study is to analyze cancer-specific survival of these two initial treatments. Materials and Methods BladderBaSe links information from the SNRUBC from 1997 to 2014, with a number of national healthcare and demographic registers. BCG was used for 3,862 patients (399 had delayed RC), while 687 had initial RC. Propensity scores were used to match the patients treated with RC and with relevant variables such as age, gender, and tumor stage with the same number treated with BCG (673 each arm). In a further comparison, an instrumental variable analysis using hospital strategy as the instrument was used. Results The 5-year cancer-specific survival chance was higher for the BCG group than it was for the initial RC group, 87 vs 71%, respectively. In the population with propensity score matching, 78 died from cancer in the BCG group during follow-up and 162 in the RC group. In the instrumental variable analysis, the multivariate adjusted risk difference of cancer-specific death 2 years after diagnosis was 32 per 100 treated patients, in favor of the BCG group. Conclusions BCG therapy had better cancer-specific survival than RC also when two different statistic methods were used to try to control for confounding. A prospective randomized trial will be necessary to rule out that selection is a major factor for the outcome.

Time spent in hormone-sensitive and castration-resistant disease states in men with advanced prostate cancer, and its health economic impact: registry-based study in Sweden

Objective To investigate time spent in hormone-sensitive and castration-resistant disease states in men with advanced prostate cancer in Sweden, and the associated health economic impact. Materials and methods Registry study (NCT03619980) of the Prostate Cancer data Base Sweden with data from the National Prostate Cancer Register, including the Patient-overview Prostate Cancer (PPC) and other national healthcare registries. The primary endpoint was time in each disease state. Secondary endpoints were co-medications, comorbidities and healthcare resource utilization (HRU) and cost in each disease state. Results In total, 1,869 men with advanced prostate cancer registered in PPC between 2014 and 2016, with data on the start of androgen deprivation therapy, were identified. Median time to progression and median survival were 4 and 11 years, respectively, for men with non-metastatic (nm) hormone-sensitive prostate cancer (HSPC); 1 and 7 years for men with metastatic (m) HSPC; and 1 and 8.5 years for men with nm castration-resistant prostate cancer (CRPC). Median survival for men with mCRPC was 4 years. Total annual mean costs for HRU per patient increased with increasing severity of disease, from 41,064 Swedish krona (SEK) for nmHSPC to 288,242 SEK for mCRPC. Conclusion Progression time from mHSPC and nmCRPC to the mCRPC state was short and survival in the mCRPC state was approximately 4 years. Survival times were longer than expected, likely due to the selection of long-term survivors among prevalent cases. Healthcare costs were high for men with mCRPC. Further studies are needed to confirm our pilot study findings.

Association between atopic dermatitis and autoimmune diseases: a population-based case-control study.

SummaryBackgroundAtopic dermatitis (AD) is a common chronic skin disorder and is well known to be associated with other atopic conditions. There is increasing evidence for an association also with nonatopic conditions, including autoimmune diseases, but data are limited about several autoimmune diagnoses.ObjectivesTo investigate the association between AD and autoimmune diseases.MethodsThis case–control study used Swedish national healthcare registers. The source population comprised the entire Swedish population aged ≥ 15 years from 1968 to 2016. Cases, including all those with an inpatient diagnosis of AD (from 1968) and/or a specialist outpatient diagnosis of AD (from 2001), were matched by sex and age to healthy controls (104 832 cases of AD, 1 022 435 controls).ResultsAD was significantly associated with one or more autoimmune diseases compared with controls – adjusted odds ratio (aOR) 1·97, 95% confidence interval (CI) 1·93–2·01 – and this association was significantly stronger in the presence of multiple autoimmune diseases compared with only one. The association was strongest for autoimmune disorders involving the skin (aOR 3·10, 95% CI 3·02–3·18), the gastrointestinal tract (aOR 1·75, 95% CI 1·69–1·82) or connective tissue (aOR 1·50, 95% CI 1·42–1·58). In the overall analysis, men with AD had a stronger association with rheumatoid arthritis and coeliac disease than did women with AD. In subanalyses, the findings remained stable in multivariable analyses after adjustment for smoking and parental autoimmune disease.ConclusionsThis large population‐based study indicates significant autoimmune comorbidity of adults with AD, especially between AD and autoimmune dermatological, gastrointestinal and rheumatological diseases. Having multiple autoimmune diseases resulted in a stronger association with AD than having only one autoimmune disease.

Influence of statin-potency on the risk of kidney disease - A nationwide cohort study using laboratory data.

To estimate the risk of kidney disease in high-potency statin users compared to those treated with low-potency statins without history of kidney disease at statin initiation, linking the Swedish national healthcare registers and laboratory data. Incident users of statins, ≥40 years of age, with estimated Glomerular Filtration Rate (eGFR) >60 ml/min/1.73 m2 and no diagnosis of kidney disease at treatment initiation were identified between 2006 and 2007 and then followed for 2-years. The outcome was the incidence of kidney disease identified by the presence of the diagnostic code in the healthcare registers or eGFR <60 ml/min/1.73 m2 . We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) with adjusted and propensity score (PS)-matched Cox proportional hazards models. A total of 27 385 patients were identified, 25.2% of which treated with a high-potency statin. During the follow-up, 68 (0.25%) patients were identified with a diagnosis of kidney disease from the registers. The number increased to 2498 (9.1%) when the criteria of eGFR <60 ml/min/1.73 m2 was added. The adjusted HR of kidney disease in high-potency statin users was 1.14 (95%CI 1.03-1.25) compared to low-potency users; the result was unchanged after the PS approach. Adding information from laboratory data to those from the national health registers, a slightly increased risk for kidney disease was found in high-potency statin users without pre-existing kidney disease at treatment initiation compared to those treated with low-potency statins.

Systemic lupus erythematosus during pregnancy is not associated with school performance in offspring - A Danish population-based study.

Systemic lupus erythematosus (SLE) in pregnancy is considered a risk factor for a range of adverse outcomes in the offspring. Studies have indicated increased risk of neurodevelopmental disorders such as autism spectrum disorders, dyslexia and ADHD. However, the overall long-term cognitive development of children born to women with SLE has scarcely been examined. In this study, we compare test scores from the Danish National School Tests of children born to women SLE with children of the background population. We included all singleton children born in Denmark between 1995 and 2008, who were listed in the Danish National School Test Register (n=738,862). Children born to women with SLE were identified through linkage of national healthcare registers. We assessed the children's performance in the national school tests between 2nd and 8th grade, in reading and mathematics. Information on the mothers' redeemed prescriptions in pregnancy was included in stratified analyses. Differences of mean test scores were derived from linear regressions and compared according to maternal SLE status, and predefined categories of medication exposures. In total, 312 (0.04%) children were born to mothers with SLE. There were no differences in performance in neither reading nor mathematics tests between those born to mothers with SLE and children born to mothers without SLE. When stratifying on medication exposures among children whose mothers had SLE, there was a non-significant tendency towards poorer results among those exposed to hydroxychloroquine and/or immunosuppressants (n=31), compared to those not exposed to these medications. A similar tendency was not observed among children whose mothers received hydroxychloroquine for non-SLE reasons (n=1,235). This study indicates no major harmful effect on the child's neurocognitive development from exposure in utero to SLE, hydroxychloroquine and/or immunosuppressants, as measured by school performance.

Lyme borreliosis in Finland: a register-based linkage study

BackgroundIn Finland, the routine surveillance of Lyme borreliosis (LB) is laboratory-based. In addition, we have well established national health care registers where countrywide data from patient visits in public health care units are collected. In our previous study based on these registers, we reported an increasing incidence of both microbiologically confirmed and clinically diagnosed LB cases in Finland during the past years. Here, we evaluated our register data, refined LB incidence estimates provided in our previous study, and evaluated treatment practices considering LB in the primary health care.MethodsThree national health care registers were used. The Register for Primary Health Care Visits (Avohilmo) and the National Hospital Discharge Register (Hilmo) collect physician-recorded data from the outpatient and inpatient health care visits, respectively, whereas the National Infectious Diseases Register (NIDR) represents positive findings in LB diagnostics notified electronically by microbiological laboratories. We used a personal identification number in register-linkage to identify LB cases on an individual level in the study year 2014. In addition, antibiotic purchase data was retrieved from the Finnish Social Insurance Institution in order to evaluate the LB treatment practices in the primary health care in Finland.ResultsAvohilmo was found to be useful in monitoring clinically diagnosed LB (i.e. erythema migrans (EM) infections), whereas Hilmo did not add much value next to existing laboratory-based surveillance of disseminated LB. However, Hilmo gave valuable information about uncertainties related to physician-based surveillance of disseminated LB and the total annual number of EM infections in our country. Antibiotic purchases associated with the LB-related outpatient visits in the primary health care indicated a good compliance with the recommended treatment guidelines.ConclusionsAvohilmo and laboratory-based NIDR together are useful in monitoring LB incidence in Finland. A good compliance was observed with the recommended treatment guidelines of clinically diagnosed LB in the primary health care. In 2018, Avohilmo was introduced in the routine surveillance of LB in Finland next to laboratory-based surveillance of disseminated LB.

Time trends in use of cardioprotective medication in patients with peripheral artery disease between 1997 and 2016: a nationwide study

Abstract Background Peripheral artery disease (PAD) is associated with increased cardiovascular (CV) morbidity and mortality. Aggressive management of risk factors and lifestyle modification may improve outcomes for patients with PAD. The present study aims to investigate changes in use of cardioprotective medication after the incident diagnosis of PAD between 1997 and 2016. Methods By using Danish national healthcare registries, we identified all patients with first-time diagnosis of PAD between 1997 and 2016. These patients were classified into 2 main groups: PAD-all (n=167,762) that includes all PAD patients with or without a history of CVD, including myocardial infarction (MI), atrial fibrillation (AF), and stroke (n=167,761) and PAD-only (n=87,935) that comprise patients with PAD without a history of AF, MI, and stroke. We calculated temporal trends and assessed comparative use of cardioprotective medication in the first 12 months after the incident diagnosis of PAD. Results Our results showed an improved use of cardioprotective medication temporally in both groups. However, PAD-all were marginally better treated (Aspirin, 3.5% - 48.4%; Clopidogrel, 0% - 17.6%; VKA 0.9% - 7.8%; NOACs 0.0% - 10.1%; Statins, 1.9%- 58.1%; ACE-inhibitors, 1.2% - 20.6%), compared to PAD-only (Aspirin, 2.9% - 54.4%; Clopidogrel, 0% - 11.9%; VKA 0.9% - 2.4%; NOACs 0.0% - 3.4%; Statins, 1.5%- 56.9%; ACE-inhibitors, 0.9% - 17.2%), respectively. Proportion of PAD patients treated with any cardioprotective medication was greater among those with a history of MI or stroke. Whereas, PAD patients with a history of AF were substantially better treated with VKA and NOACs. Conclusion In this nationwide study, use of cardioprotective medication increased considerably with time, but there remains an underuse of guideline-recommended therapy in patients with PAD. Funding Acknowledgement Type of funding source: None

Anorectal Malformations and the Risk of Colorectal Cancer-Is Early Routine Endoscopic Screening Indicated?

Colorectal cancer (CRC) has been reported in early adulthood in patients with anorectal malformation (ARM), and therefore, the need of endoscopic controls has been discussed. The aim of this study was to assess the risk of CRC in patients with ARM. This was a nationwide population-based study with data from Swedish national health care registers. All patients diagnosed with ARM born in Sweden between 1964 and 1999 were identified in the National Patient Register. The same group was followed up in the Swedish Cancer Register from birth to December 31, 2014, for occurrences of CRC. Five age- and gender-matched individuals randomly selected from the Medical Birth Register served as controls for each ARM patient born between 1973 and 1999. A total of 817 patients (474 males) with ARM were included and followed up from birth to the end of observational period. Time of follow-up ranged from 15 to 50 years (mean: 28 years). None of the patients was diagnosed with CRC during the observational period. One case of rectal cancer and one case of sigmoid cancer were detected among the 3,760 controls. In our study, the risk of CRC in early adulthood in patients with ARM is low. Our result does not support routine endoscopic follow-up for patients with ARM during the first decade of life.

Risk factor management of type 2 diabetic patients in primary care in the Scandinavian countries between 2003 and 2015

AimsTo observe and report population demography, comorbidities, risk factor levels and risk factor treatment in a sample of individuals treated for type 2 diabetes in primary care in Norway, Sweden and Denmark. MethodsRetrospective observational cohort using extraction of data from electronic medical records linked with national health care registries. ResultsSixty primary care clinics participated with annual cross-sectional data (2003 to 2015). In 2015 the sample consisted of 31,632 individuals. Mean age (64.5–66.8 years) and proportion of women (43–45%) were similar. The prevalence of cardiovascular disease in 2015 was 40.7%, 41.6% and 38.0% for Norway, Sweden and Denmark, respectively and 84% to 89% of patients were receiving a pharmacological anti-diabetic treatment. More Danish patients reached targets for HbA1c and LDL cholesterol, while more patients in Sweden and Denmark met the blood pressure target of <130/80 mmHg as compared to Norway. ConclusionsIn three comparable public primary health care systems we found a high prevalence of cardiovascular disease and differences in risk factor treatment and attainment of risk factor goals. With recent guideline changes there is potential for further prevention of diabetes complications in primary care in the future.

The role of inflammation in the relationship of self-rated health with mortality and implications for public health: Data from the English Longitudinal Study of Aging (ELSA)

Self-rated health (SRH) predicts mortality after adjustment for potential confounders, including measures of health status. Prodromal disease might lead to worsened SRH and higher mortality. But no study of SRH and mortality has focussed on inflammation. The objective of this study is to investigate the influence of inflammation upon the association between SRH and mortality in a British cohort. The English Longitudinal Study of Ageing (ELSA) involves interviewing participants aged over 50 every two years. We analysed data for 3405 men and 4139 women. Mortality for consenting members was detected by linkage with UK National Health Care registry up to March 2012. Demographic, clinical, and health behaviours at wave 2 were treated as confounders, as well as inflammation-related disease and C-reactive protein (CRP). A five-step hierarchical multivariable logistic regression was estimated. An association was observed between SRH and mortality after adjusting for all variables. In men, compared to those with excellent health, CRP only, and CRP and inflammation-related disease combined, could explain 7.03% and 24.35% of increased risk of dying associated with poor health, respectively. For women, the corresponding figures were 8.95% and 24.28%, respectively. Inflammation is associated with increased risk of death, and may help to explain approximately a quarter of the association between SRH and mortality. Individuals with relatively poor SRH may be aware of underlying inflammation that increases the risk of illness and death, and this may lead to increased use of services, for example. Identifying the cause and treating inflammation in those without a diagnosis may help to increase survival and life quality among those who perceive their health to be relatively poor.

P0397OUTCOMES OF PROTEINASE 3- AND MYELOPEROXIDASE ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY ASSOCIATED VASCULITIS IN DENMARK 2014-2017

Abstract Background and Aims Anti-neutrophil cytoplasmic antibody associated vasculitis (AAV) defines an uncommon group of autoimmune diseases with antibodies directed against proteinase 3 (PR3) or myeloperoxidase (MPO). Incidence rates of PR3- and MPO-AAV differ geographically, and current evidence based on genetic variations and cluster analyses supports discrimination of associated vasculitis based on PR3- and MPO-positivity. Such discrimination could provide insights of scope for clinical trials with ramifications for improvement of treatment. With the aim of comparing patient characteristics and outcomes between PR3- and MPO-AAV, we report on results from a nationwide retrospective cohort study. Method Incident patients positive for PR3- and MPO-anti-neutrophil cytoplasmic antibodies were identified in central laboratories of three of four administrative regions (covering 80% of the population) in Denmark between 1/1-2014 and 31/12-2017. Patient characteristics were identified by cross-referencing of data from multiple national health care registers. Baseline renal function was calculated based on the CKD-EPI equation using plasma creatinine measurements recorded 365 to 7 days prior to index. Incidences of all-cause mortality and end-stage renal disease stratified on baseline eGFR were computed using the Aalen-Johansen estimator. Hazard ratios for specific predictors including strata of baseline eGFR were calculated based on a multiple Cox proportional hazards model adjusted for relevant confounders. Results In total 770 patients were included in the study (PR3 n=399 and MPO n=371). Annual incidence rates of PR3- and MPO-AAV were 22.6 and 21.1 per million, respectively. PR3-AAV was associated with greater preponderance for male gender (54.4% vs. 42.3%, p=0.001), lower patient age (61.9 years [IQR 41.6-73.0 years] vs. 64.9 years [IQR 50.0-74.0 years], p=0.016), and greater baseline renal function (eGFR 87 ml/min [IQR 56-101 ml/min] vs. 75 ml/min [IQR 36-92 ml/min] compared with MPO-AAV. Comorbid burden was comparable; 26% of patients had history of hypertension, 15% of patients had a history of ischemic heart disease, and 12% of patients had a history of cancer. Acute dialysis was initiated in 5.3% and 6.7%, plasmapheresis in 12.8% and 13.7%, and mechanical ventilation in 4.8% and 4.3% of patients with PR3- and MPO-AAV, respectively. Median follow-up was 564 days [234 – 932]. A total of 86 deaths and 25 end-stage renal disease endpoints were recorded during follow-up. Cumulative incidences of all-cause mortality and end-stage renal disease stratified on baseline eGFR are shown in Figure 1. Adjusted hazard ratios for all-cause death and/or end-stage renal disease showed increased risk associated with PR3-AAV, HR 1.51 (95% CI 1.03 – 2.25, p=0.036), non-European descent, HR 3.63 (95% CI 1.29-10.25, p=0.015) and patient age, HR 1.05 (95% CI 1.03-1.07, p&amp;lt;0.001). In both PR3- and MPO-AAV, only baseline eGFR ≤ 20ml/min/1.73m2 was associated with poorer prognosis (ref.: baseline eGFR &amp;gt;90 ml/min/1.73m2); MPO-AAV: eGFR 51-90 ml/min/1.73m2: HR 2.34 (95% CI 0.75 – 7.34, p=0.145), eGFR 21-50 ml/min/1.73m2: HR 2.11 (95% CI 0.60 – 7.47, p=0.246), and eGFR ≤ 20ml/min/1.73m2: 5.05 (95% CI 1.55 – 16.45, p=0.007); PR3-AAV: eGFR 51-90 ml/min/1.73m2: HR 1.54 (95%CI 0.53 – 4.46, p=0.427), eGFR 21-50 ml/min/1.73m2: HR 1.70 (95% CI 0.51 – 5.64, p=0.386), and eGFR ≤ 20ml/min/1.73m2: 8.06 (95% CI 2.83 – 23.0, p=&amp;lt;0.001). Conclusion In a nationwide cohort study comparing PR3- and MPO-AAV, PR3-AAV was associated with poorer 24-month outcomes in spite of superior renal function at baseline. Overall, poor prognosis was limited to patients with severe renal insufficiency (eGFR ≤20ml/min/1.73m2) at time of diagnosis in both PR3- and MPO-AAV.

P1444CHANGES IN TREATMENTS AND OUTCOMES OF PATIENTS INITIATING PERITONEAL DIALYSIS DURING THE LAST 10 YEARS: DATA FROM SWEDISH RENAL REGISTRY

Abstract Background and Aims The recent years have witnessed several therapeutic improvements regarding both peritoneal dialysis (PD) treatment itself and the prevention and management of complications. We evaluated trends in implementation of therapeutic improvements and their relationship with survival and other relevant clinical outcomes in PD patients from Sweden. Method Using the Swedish Renal Registry (SRR), clinical data from all patients initiating PD in Sweden between 2006 and 2015 were linked to other national healthcare registries to obtain information on vital status, hospitalization and diagnoses during in and out-patient care, along with information on all dispensed drugs, from inclusion to the end of 2017. We first evaluated trends in the use of PD-related treatments and of selected key medications within 2-year blocks. We then evaluated the incidence of death, major cardiovascular events (MACE), technique failure, transplantation and peritonitis episodes within one and two years from PD initiation using standardized incidence rates via logistic regression to account for differences in patient characteristics over time. In subsequent Cox regression models, we studied whether adjustment for implementation of these therapeutic changes modified observed trends in clinical outcomes. Finally, patient survival was compared against the age-sex matched general Swedish population using standardized incidence ratios (SIR). Results 3,312 patients (mean age 63±15 years; 34% women) initiated PD in Sweden during the study period. Across 2-year time blocks, there was no difference over time in the distribution of age, sex or comorbidities with the exception of an increased proportion of patients with chronic pulmonary disease. The proportion of patients undergoing automated peritoneal dialysis and using icodextrin increased over time, while mean standard Kt/V and weekly creatinine clearance did not change. The use of non-calcium phosphate binders, cinacalcet and calcium-channel blockers increased, and the use of angiotensin-converting enzyme inhibitors /angiotensin receptor blockers, erythropoietin, iron, and calcium supplements showed decreasing trends. After standardization for differences in demography and comorbidities, the one-year incidence of peritonitis decreased by 13% and the rate of kidney transplantation increased by 52% in 2014/15 compared to 2006/07. The rates of death, MACE or technique failure did not show differences over time. Similar results were observed with 2-years of follow up and when applying Cox models; Per 2-year period, the risk of peritonitis within one year decreased by 8% (HR 0.92, 95% CI 0.87-0.98) regardless of age, sex, comorbidity and the abovementioned therapeutic changes. The risk of death for PD patients was in 2006/2007 4 times higher [SIR 4.08 (3.15–5.29)] and in 2014/15 3.7 times higher [SIR 3.65 (2.70–4.94)] than the general population, corresponding to a reduction of SIR by 11%. Conclusion During the last 10 years, there has been a gradual implementation of new and established evidence-based treatments in patients starting PD in Sweden. Although survival rates are improving compared to the general population, there were no clear differences in the rates of technique failure, MACE or death across PD patients over time. We observed, however, consistent improvements in peritonitis frequency and access to transplantation.