Practice In Denmark Research Articles

Cost–consequence analysis of cause of death investigation in Finland and in Denmark

The 1990s 12–16% total autopsy rate in Denmark has until now declined to 4%, while in Finland, it has remained between 25 and 30%. The decision to proceed with a forensic autopsy is based on national legislation, but it can be assumed that the financing of autopsies influences the decision process. Only little is known about the possible differences between health economics of Finnish and Danish cause of death investigation systems.The aims of this article were to analyse costs and consequences of Finnish and Danish cause of death investigations, and to develop an alternative autopsy practice in Denmark with another cost profile.Data on cause of death investigation systems and costs were derived from Departments of Forensic Medicine, Departments of Pathology, and the National Police. Finnish and Danish autopsy rates were calculated in unnatural (accident, suicide, homicide and undetermined intent) and natural (disease) deaths, and used to develop an alternative autopsy practice in Denmark. Consequences for society were analysed.The estimated unit cost (€) for one forensic autopsy is 3.2 times lower in Finland than in Denmark (€1400 versus €4420), but in Finland the salaries for forensic pathologists working at the National Institute for Health and Welfare are not included in the unit cost. The unit cost for one medical autopsy is also lower in Finland than in Denmark; €700 versus €1070. In our alternative practice in Denmark, the forensic autopsy rate was increased from 2.2% to 8.5%, and the medical autopsy rate from 2.4% to 5.8%. Costs per 10,000 deaths were estimated to be 50% (±25%) higher than now; i.e. €3,678,724 (2,759,112–4,598,336), but would result in a lower unit cost for forensic autopsies €3,094 (2,320–3,868) and for medical autopsies €749 (562–936). This practice would produce a higher accuracy of national mortality statistics, which, consequently, would entail higher quality in public health, an accurate basis for decision-making in health politics, and better legislative safety in society.The implementation of this alternative practice in Denmark requires that legislation demands that forensic autopsy be performed if causality between unnatural death and cause of death cannot be clarified or if cause of death remains unknown. The Danish Health and Medicines Authority should provide guidelines that request a medical autopsy in natural deaths where more information about disease as a cause of death is needed. Our study results warrant similar health economic analyses of different cause of death investigations in other countries.

Relational coordination and organisational social capital association with characteristics of general practice.

Background. Relational coordination (RC) and organisational social capital (OSC) are measures of novel aspects of an organisation's performance, which have not previously been analysed together, in general practice. Objectives. The aim of this study was to analyse the associations between RC and OSC, and characteristics of general practice. Methods. Questionnaire survey study comprising 2074 practices in Denmark. Results. General practitioners (GPs) rated both RC and OSC in their general practice higher than their secretaries and nurses. The practice form was statistically significantly associated with high RC and OSC. RC was positively associated with the number of patients listed with a practice per staff, where staff is defined as all members of a practice including both owners and employees. Conclusion. The study showed that RC and OSC were significantly associated with type of profession and practice type. RC was also found to be significantly positively associated with number of patients per staff. However, the low response rate must be taken into consideration when interpreting the self-reported results of this study.

Introducing out-of-pocket payment for General Practice in Denmark: Feasibility and support

AimsThe financing of General Practice (GP) is a much-debated topic. In spite of out-of-pocket (OOP) payment for other primary health care provided by self-employed professionals, there is no OOP payment for the use of GP in Denmark. This article aims to explore the arguments, the actors and the decision-making context. Methods and materialsAn analysis of the healthcare-policy debate in Parliament and the media from 1990 until September 2012. The materials are parliamentary hearings/discussions and newspaper articles. Kingdon's model on Policy Windows and the Advocacy Coalition framework by Sabatier and Jenkins are used to investigate explanations. ResultsThe arguments from the proponents are: that OOP payment for GP will reduce pressure on the primary sector; that the current allocation of OOP payment in the sector is historically conditioned; and that resistance towards OOP payment is based on emotions. The main argument from the opponents is that OOP payment will increase social inequality in health. ConclusionsThere is little connection between the attitudes and ideological backgrounds of the political parties. Despite factors such as perceived expert/scientific evidence for OOP payment, changes of government, financial crisis and a market-based reform wave, no government has introduced OOP payment for GP. This article suggests that governmental positions, public- and especially health-professional support are important factors in the decision-making context.

Effect of a participant‐driven health education programme in primary care for people with hyperglycaemia detected by screening: 3‐year results from the Ready to Act randomized controlled trial (nested within the ADDITION‐Denmark study)

To assess whether a 12-week participant-driven health education programme offered to individuals with screening-detected hyperglycaemia in Danish primary care would lead to improvements in cardiovascular risk factors, health behaviour and patient-reported outcomes after 3 years. We conducted a randomized controlled trial in 509 patients with screening-detected hyperglycaemia (impaired fasting glucose, impaired glucose tolerance or type 2 diabetes) from 33 general practices in Denmark. Individuals were pre-randomized to receive (i) routine care (n = 187), or (ii) an invitation to participate in the Ready to Act health education programme (n = 322). The programme was delivered over 12 weeks in primary care and focused on motivation, action experience, informed decision-making and social involvement to promote health behaviour change. The primary outcome was 10-year modelled cardiovascular risk. Of 322 individuals, 123 (38%) received the intervention and 436/509 individuals (86%) returned for follow-up assessment. There was no difference between the trial groups in modelled cardiovascular risk at 3 years (relative difference: 1.01; 95% CI: 0.84 to 1.23). Total cholesterol was lower (-0.24mmol/l, 95% CI: -0.45 to -0.03, P = 0.027), and patient activation was higher in the intervention than in the control group (5.3, 95% CI: 0.97 to 9.7). No other between-group differences were observed for any cardiovascular risk factor, health behaviour or patient-reported outcome variables. Subgroup analyses suggested that the intervention was more beneficial in those with impaired fasting glucose/impaired glucose tolerance than in those with type 2 diabetes. For patients with screening-detected hyperglycaemia, a participant-driven health education programme was not associated with improvements in most clinical, behavioural and patient-reported outcomes after 3 years of follow-up.

Change in cardiovascular risk factors following early diagnosis of type 2 diabetes: a cohort analysis of a cluster-randomised trial

BackgroundThere is little evidence to inform the targeted treatment of individuals found early in the diabetes disease trajectory.AimTo describe cardiovascular disease (CVD) risk profiles and treatment of individual CVD risk factors by modelled CVD risk at diagnosis; changes in treatment, modelled CVD risk, and CVD risk factors in the 5 years following diagnosis; and how these are patterned by socioeconomic status.Design and settingCohort analysis of a cluster-randomised trial (ADDITION-Europe) in general practices in Denmark, England, and the Netherlands.MethodA total of 2418 individuals with screen-detected diabetes were divided into quartiles of modelled 10-year CVD risk at diagnosis. Changes in treatment, modelled CVD risk, and CVD risk factors were assessed at 5 years.ResultsThe largest reductions in risk factors and modelled CVD risk were seen in participants who were in the highest quartile of modelled risk at baseline, suggesting that treatment was offered appropriately. Participants in the lowest quartile of risk at baseline had very similar levels of modelled CVD risk at 5 years and showed the least variation in change in modelled risk. No association was found between socioeconomic status and changes in CVD risk factors, suggesting that treatment was equitable.ConclusionDiabetes management requires setting of individualised attainable targets. This analysis provides a reference point for patients, clinicians, and policymakers when considering goals for changes in risk factors early in the course of the disease that account for the diverse cardiometabolic profile present in individuals who are newly diagnosed with type 2 diabetes.

Trade mark applications in bad faith: righting wrong in Denmark and why the Benelux is next

This article discusses the latest case-law from the European Court of Justice on how to deal with ‘trade mark applications in bad faith’. It briefly compares and contrasts the impact of the new MALASIA DAIRY decision with local practice in Denmark and the Benelux. The article also explains the latest developments on ‘bad faith’ in the proposed Trade Mark Directive.

Integrating Climate Change into Governance at the Municipal Scale: An Institutional Perspective on Practices in Denmark

Climate change (CC) is a new and, up to 2013, voluntary planning area in Denmark, and it is perceived as an interdisciplinary field affecting several professions. CC is integrated into bureaucratised municipal organisations characterised by a fragmented organisational structure and strong institutional traditions and perceptions. With this paper I examine different approaches to CC governance and the institutional dynamics that occur in the integration process within eight Danish municipalities in the initial phase of integrating CC. The results show three different governance approaches related to CC planning: experimental, negotiation, and standardisation. This paper contributes insights into the intrainstitutional dynamics at the local level when climate plans are to be implemented in practice, and it adds perspectives on the role of local established networks rather than international networks for less affluent municipalities to act on CC.

Use of tympanometry in general practice in Denmark

ObjectivesOtitis media has been a serious disease and can be that even today. The diagnosis of otitis media is often difficult. Pneumatic otoscopy, otomicroscopy, and tympanometry can improve the diagnostic quality by indication of fluid in the middle ear and thereby improve the quality of treatment. The aim of this ongoing study is to analyze the use of tympanometry in Denmark after reimbursement for doing tympanometry (November 2006) when clinically indicated. Our research questions were: How many clinics were using tympanometry? How frequent was it used? Is the use increasing? Has the number of GPs in the clinic any relation to the use of tympanometry? MethodWe used information in The Danish National Health Service in three Regions to analyze the use of tympanometry in general practice during the years 2007–2009. The coverage of the GPs is 100% in the regions. ResultsThe three regions counted about half of Danish population. In 2009 the material was 902 different clinics with more than 1700 GPs. In 2007 55% of the clinics did tympanometry, in 2009 the figure was 60%. In the clinics doing tympanometry the median value was 28 tympanometries per year (inter-quartile range 13–53) per GP. The variation in the use of tympanometry was surprisingly high, from none or a few per GP per year to a maximum of more than 500 tympanometric examinations per GP a year. This huge variation has to be discussed. DiscussionMany answers can be given. Some of the explanation was problems in doing correct tympanometry, and problems understand the clinical implications of curves and the figures.

I can never be normal: A conversation about race, daily life practices, food and power

This article focuses on the doing and undoing of race in daily life practices in Denmark. It takes the form of a dialogue between two women, a heterosexual Muslim woman of colour and a lesbian white woman, who discuss and analyze how their daily life, e.g. interactions with their children’s schools and daycare institutions, shape their racial and gendered experiences. Drawing upon black feminist theory, postcolonial theory, critical race and whiteness studies, the two women illustrate inclusions and exclusions in their society based on gender, race, class and sexuality – and especially pinpoint to how these categories intersect in processes of inclusion and exclusion. The article argues that the lack of a Nordic vocabulary for the term ‘race’ – as ‘race’ is associated with biological racism which dominated in the nineteenth and first half of the twentieth century, and hence is viewed as a historical phenomenon left behind – prevents contemporary people from addressing existing patterns of racial discrimination, inclusion and exclusion in their daily lives, as well as from connecting their contemporary struggles to historical struggles and inequalities. Furthermore, they illustrate how food, class and race intersect with an analysis of the so-called New Nordic Kitchen, exemplified by the world famous Copenhagen restaurant NOMA. The article interprets the New Nordic Kitchen, which has become very popular in the Nordic countries in recent years, as a culinary project performing whiteness, and connects the New Nordic Kitchen’s obsession with ‘the authentic Nordic’ with historical race science in the nineteenth century and early twentieth century.

Introducing out-of-pocket payment for General Practice in Denmark: Political majority and public support

Aims The financing of General Practice (GP) is a much-debated topic. In spite of out-ofpocket payment (OOP) for other primary healthcare provided by self-employed professionals, there is no OOP payment for the use of GP in Denmark. This article aims to explore the arguments, the actors and the …

Effect of early intensive multifactorial therapy compared with routine care on self-reported health status, general well-being, diabetes-specific quality of life and treatment satisfaction in screen-detected type 2 diabetes mellitus patients (ADDITION-Europe): a cluster-randomised trial.

Aims/hypothesisThe study aimed to examine the effects of intensive treatment (IT) vs routine care (RC) on patient-reported outcomes after 5 years in screen-detected diabetic patients.MethodsIn a pragmatic, cluster-randomised, parallel-group trial, 343 general practices in Denmark, Cambridge and Leicester (UK) and the Netherlands were randomised to screening for type 2 diabetes mellitus plus IT of multiple risk factors in people 40–69 years without known diabetes (n = 1,678 patients) or screening plus RC (n = 1,379 patients). Practices were randomised in a 1:1 ratio according to a computer-generated list. Diabetes mellitus was diagnosed according to WHO criteria. Exclusions were: life expectancy <1 year, housebound, pregnant or lactating, or psychological or psychiatric problems. Treatment targets for IT were: HbA1c <7.0% (53 mmol/mol), BP ≤135/85 mmHg, cholesterol <5 mmol/l in the absence of a history of coronary heart disease and <4.5 mmol/l in patients with cardiovascular (CV) disease; prescription of aspirin to people taking antihypertensive medication and, in cases of CV disease or BP >120/80 mmHg, ACE inhibitors were recommended. After 2003, the treatment algorithm recommended statins to all patients with cholesterol of ≥3.5 mmol/l. Outcome measures were: health status (Euroqol 5 Dimensions [EQ-5D]) at baseline and at follow-up; and health status (36-item Short Form Health Survey [SF-36] and Euroquol Visual Analogue Scale [EQ-VAS]), well-being (12-item Short Form of the Well-Being Questionnaire), diabetes-specific quality of life (Audit of Diabetes-Dependent Quality of Life) and satisfaction with diabetes treatment (Diabetes Treatment Satisfaction Questionnaire) at follow-up. At baseline, standardised self-report questionnaires were used to collect information. Questionnaires were completed at the same health assessment visit as the anthropometric and biochemical measurements. The patients and the staff assessing the outcomes were unaware of the group assignments. Participants were followed for a mean of 5.7 years. Outcome data were available for 1,250 participants in the intensive treatment group (74%) and 967 participants in the routine care group (70%). The estimated differences in means from the four centres were pooled using random effects meta-analysis. Baseline EQ-5D level was used as a covariate in all analyses.ResultsEQ-5D values did not change between diagnosis and follow-up, with a median (interquartile range) of 0.85 (0.73–1.00) at baseline and 0.85 (0.73–1.00) at 5 year follow-up. Health status, well-being, diabetes-specific quality of life and treatment satisfaction did not differ between the intensive treatment and routine care groups. There was some heterogeneity between centres (I 2 being between 13% [SF-36 physical functioning] and 73% [EQ-VAS]).Conclusions/interpretationThere were no differences in health status, well-being, quality of life and treatment satisfaction between screen-detected type 2 diabetes mellitus patients receiving intensive treatment and those receiving routine care. These results suggest that intensive treatment does not adversely affect patient-reported outcomes.Trial registration numberClinicalTrials.gov NCT00237549FundingADDITION-Denmark was supported by the National Health Services, the Danish Council for Strategic Research, the Danish Research Foundation for General Practice, Novo Nordisk Foundation, the Danish Centre for Evaluation and Health Technology Assessment, the Diabetes Fund of the National Board of Health, the Danish Medical Research Council and the Aarhus University Research Foundation. In addition, unrestricted grants from pharmaceutical companies were received. ADDITION-Cambridge was supported by the Wellcome Trust, the Medical Research Council, the NIHR Health Technology Assessment Programme, National Health Service R&D support funding and the National Institute for Health Research. SJG received support from the Department of Health NIHR grant funding scheme. ADDITION-Leicester was supported by Department of Health, the NIHR Health Technology Assessment Programme, National Health Service R&D support funding and the National Institute for Health Research. ADDITION-Netherlands was supported by unrestricted grants from Novo Nordisk, Glaxo Smith Kline and Merck, and by the Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht.Electronic supplementary materialThe online version of this article (doi:10.1007/s00125-013-3011-0) contains peer-reviewed but unedited supplementary material, which is available to authorised users.

Opoziční smlouvy „za kopečky“ I.: Byl pakt ČSSD a ODS z let 1998–2002 demokratickou deviací?

After the 1998 general elections to the Chamber of Deputies of the Czech Republic, the largest party, the Social Democratic Party (ČSSD), formed a minority government. The origin and existence of this government was enabled by an agreement with the second largest formation, the Civic Democratic Party (ODS). What was then known as the Opposition Agreement became the subject of considerable debate. The paper analyses the Opposition Agreement in comparison with other minority governments with external support, be they governments formed on the basis of ad hoc agreements or complex ones. The text looks in detail at government practice in Denmark, Sweden, New Zealand, and Italy at the time of the Historic Compromise; this is then used as a context for outlining the specifics of the Czech case. The paper highlights not only the Opposition Agreement between the Social Democrats and the Civic Democratic Party and the later Toleration Patent, which even deepened the cooperation between these two parties, but also the frequent ad hoc legislative coalitions which the minority government was able to form. An additional aim of the paper is to outline foreign analogies to the potential future single-party minority government of the Czech Social Democrats supported by the Communists. Because of its considerable length, the text is divided into two parts; the first part is printed in this volume.

A randomised controlled trial to improve the role of the general practitioner in cancer rehabilitation: effect on patients’ satisfaction with their general practitioners

ObjectiveTo test whether a complex intervention facilitating early cancer rehabilitation by involvement of the general practitioner (GP) soon after diagnosis improves patients’ satisfaction with their GPs.DesignA cluster randomised controlled trial....

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark

BackgroundRefugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems.MethodsThe study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis.ResultsOne of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms.ConclusionGeneral practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

Multimorbidity and Blood Pressure Control in 37 651 Hypertensive Patients From Danish General Practice

BackgroundPatients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices.Methods and ResultsUsing the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men.ConclusionIn Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.

Between Rescue and Research: An Evaluation after 30 Years of Liberal Metal Detecting in Archaeological Research and Heritage Practice in Denmark

Since the early 1980s, metal detector surveying conducted by amateur archaeologists has contributed significantly to archaeological research and heritage practice in Denmark. Here, metal detecting has always been legal, and official stakeholders pursue a liberal model, focusing on cooperation and inclusion rather than confrontation and criminalization. Like no other surveying method since the invention of the shovel, the metal detector has contributed to increasing enormously the amount of data and sites from metal-rich periods. Virtually all of the spectacular and ground-breaking discoveries of the past decades are owed to metal detectors in the hands of amateur archaeologists. And it is these finds and sites that today constitute one of the very foci of archaeological research. This article provides an overview of the current status of liberal metal detector archaeology in Denmark 30 years after its inception, and attempts to identify the reasons why this popular hobby never developed into the problem it has become in other parts of the world. It concludes that the success of the liberal model in Denmark is the result of a very complex interplay of legislative, historical, cultural, and social factors. On this basis, it is discussed whether the Danish experience can be used as a source of inspiration in the necessary progression towards a new legal agenda for responsible metal detector archaeology.

A randomised controlled trial to improve general practitioners’ services in cancer rehabilitation: Effects on general practitioners’ proactivity and on patients’ participation in rehabilitation activities

Few studies have evaluated initiatives targeting implementation of cancer rehabilitation. In this study we aim to test the effects of a complex intervention designed to improve general practitioners’ (GPs) involvement in cancer rehabilitation. Outcomes were proactive contacts to patients by their GP reported by the patients and GPs, respectively, and patients’ participation in rehabilitation activities. Methods. Cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention group or to a control group (usual procedures). Patients were subsequently allocated to the intervention or the control group based on randomisation status of their GP. Between May 2008 and February 2009, adult patients treated for incident cancer at Vejle Hospital, Denmark, were assessed for eligibility. A total of 323 general practices were included, allocating 486 patients to an intervention and 469 to a control group. The intervention included a patient interview about rehabilitation with a rehabilitation coordinator at the hospital, comprehensive information to the GP about individual needs for rehabilitation, and an encouragement to the GP to contact the patient proactively. Questionnaires were administered to patients and GPs at 14 months after inclusion. Results. At baseline average age of patients was 63 years and 72% were female. The most frequent cancer localisations were breast (43%), lung (15%), and malignant melanoma (8%). The intervention had no effect on either patient- or GP-reported extent of GP proactivity. Further, no effect was observed on patient participation in rehabilitation activities during the 14-month follow-up period. Discussion. The intervention had no effect on GP proactivity or on patient participation in rehabilitation activities. However, analyses showed a significant association between proactivity and participation and we, therefore, conclude that increased GP proactivity may facilitate patient participation in rehabilitation activities.

Time trends for alendronate prescription practices in women with chronic obstructive pulmonary disease and women exposed to systemic glucocorticoids

Chronic obstructive pulmonary disease (COPD) and systemic glucocorticoid exposure are well-known risk factors of osteoporosis. We evaluated alendronate prescription practices related to COPD and exposure to systemic corticosteroids from 1996 to 2008 and showed an increasing targeting of alendronate treatment in patients with COPD and patients with systemic corticosteroid exposure. COPD and systemic glucocorticoid exposure are well-known risk factors of osteoporosis and fragility fracture, but osteoporosis is often underdiagnosed and undertreated in these patients. This study aims to evaluate alendronate prescription practices related to COPD and/or to exposure to systemic glucocorticoids among Danish women. A total of 388,314 female subjects >50years old, 64,719 of whom initiated treatment with alendronate, and 323,595 age- and gender-matched controls were retrospectively identified between 1996 and 2008 from national health registers. Multivariate logistic regression was used for examining prescription practices, specifically if these risk factors (COPD or glucocorticoid exposure) increased or decreased the likelihood of beginning alendronate therapy. A diagnosis of COPD was associated with an increased likelihood of using alendronate (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.4-1.5, p < 0.001). Further, a diagnosis of COPD was associated with an increasing tendency of initiating alendronate treatment in the study period (OR 1.3 (95% CI 1.1-1.5, years 1996-1999) to 1.5 (95% CI 1.4-1.6, years 2006-2008), p < 0.01). Exposure to systemic glucocorticoids was associated with a significantly increasing (OR 3.6, 95% CI 3.3-3.9 to OR 5.5, 95% CI 5.3-5.8) probability of receiving alendronate treatment in the same observation period. This nationwide register-based study on alendronate prescription practices in Denmark shows an increasing targeting of alendronate treatment in patients with COPD and an even stronger trend for patients with systemic glucocorticoid exposure, perhaps indicating increased awareness of well-known and associated conditions.

Maternal smoking during pregnancy and reproductive health of daughters: a follow-up study spanning two decades

Does in utero exposure to constituents of cigarette smoke have a programming effect on daughters' age of menarche and markers of long-term reproductive health? In utero exposure to constituents of cigarette smoke was associated with earlier age of menarche and--to a lesser extent--changes in the testosterone profile of the young women. Studies observe potential effects of in utero exposure to constituents of cigarette smoke on the intrauterine formation of female gonads, but the consequences on long-term reproductive health in daughters remain unclear. A prospective cohort study was designed using data from 965 pregnant women enrolled prior to a routine 30th-week antenatal examination at a midwifery practice in Denmark from 1988 to 1989 and a follow-up of their 19-21-year-old daughters in 2008. The pregnant women provided information on lifestyle factors during pregnancy, including the exact number of cigarettes smoked per day during the first and the second trimesters. A total of 438 eligible daughters were asked to complete a web-based questionnaire on reproductive health and subsequently invited to participate in a clinical examination during 2008. Of the 367 daughters (84%) who answered the questionnaire, 267 (61%) agreed to further examination. Information on menstrual pattern was provided at examination, blood samples were drawn to be analyzed for serum levels of reproductive hormones [FSH, LH, estradiol (E(2)), sex hormone-binding globulin, anti-Müllerian hormone, dehydroepiandrosterone-sulphate (DHEAS), free testosterone and free E(2)] and number of follicles (2-9 mm) were examined by transvaginal ultrasound. The daughters were divided into three exposure groups according to the level of maternal smoking during first trimester [non-exposed (reference), low-exposed (mother smoking >0-9 cigarettes/day) and high-exposed (mother smoking ≥ 10 cigarettes/day)]. Data were analyzed by multiple regression analyses in which we adjusted for potential confounders. Both crude and adjusted test for trend were carried out using maternal smoking during the first trimester as a continuous variable. We observed an inverse association between in utero exposure to constituents of cigarette smoke and age of menarche (P = 0.001). Daughters exposed to >0-9 cigarettes/day debuted with -2.7 [95% confidence interval (CI) -5.2 to -0.1] percentage earlier age of menarche, whereas daughters exposed to ≥ 10 cigarettes/day had -4.1 (95% CI: -6.6 to -1.5) percentage earlier age of menarche corresponding to 6.5 (95% CI: -10.7 to -2.2) months. There was a non-significant tendency towards lower levels of testosterone and DHEAS with increasing in utero exposure to constituents of cigarette smoke but no associations with follicle number, cycle length or serum levels of the other reproductive hormones were observed. We collected information on age of menarche retrospectively but the recall time was relatively short (2-10 years) and the reported values were within the normal range of Caucasians. Analyses of reproductive hormones are presented only for the group of daughters who were non-users of hormonal contraceptives because users were excluded, leaving only a low number of daughters available for the analyses (n = 75), as reflected in the wide CIs. The analyses of hormones were further adjusted for menstrual phase at time of clinical examination (follicular, ovulation and luteal phase) because blood samples were not collected on a specific day of the menstrual cycle. This study supports the limited evidence of an inverse association between maternal smoking during pregnancy and age of menarche and further addresses to what extent reproductive capacity and hormones may be programmed by maternal smoking during pregnancy. A trend toward earlier maturation of females is suggested to have implications on long-term reproductive function. Supported by a scholarship from The Lundbeck Foundation (R93-A8476). No conflict of interest declared.

Cost-effectiveness of dabigatran etexilate for stroke prevention in non-valvular atrial fibrillation. Applying RE-LY to clinical practice in Denmark

Objective:To estimate the economic implications of introducing dabigatran etexilate (‘dabigatran’) for anti-coagulation therapy in Danish patients with non-valvular atrial fibrillation based on results of the RE-LY trial.Methods:The lifetime cost and outcomes of dabigatran and warfarin were estimated using a previously published cost-effectiveness model. The model utilizes the data from the RE-LY study to estimate the costs and outcomes of stroke prevention in atrial fibrillation. Cost estimates were based on official Danish tariffs and prices, and published literature on the cost of stroke. In the base-case analysis a conservative approach was adopted applying tariffs from the lowest range for the cost of International Normalized Ratio (INR) monitoring associated with warfarin. The effectiveness measure of the analysis was quality-adjusted life-years (QALY).Results:The model estimated that the mean cost per patient for the remaining life-time is €16,886 treated with warfarin and €18,752 treated with dabigatran. This was associated with mean QALYs per patient of 8.32 with warfarin and 8.59 with dabigatran. The resulting incremental cost-effectiveness ratio (ICER) of ∼€7000 per QALY gained is regarded as cost-effective by Danish standards. This conclusion was seen to be robust to realistic variations in input parameters, including adjustment for the RE-LY centres achieving the best INR monitoring quality. Threshold analysis revealed that dabigatran would be cost-saving in settings where the cost of warfarin monitoring exceeds €744 per year.Limitations:The analysis does not include all aspects of Danish clinical practice anti-coagulation that will influence cost-effectiveness of dabigatran, e.g., this study did not attempt to model quality of anticoagulation monitoring and under-utilization in clinical practice.Conclusions:Based on the outcomes observed in the RE-LY trial, dabigatran represents a cost-effective alternative to warfarin in Denmark for all patients with atrial fibrillation within the licensed indication of dabigatran.