Swedish Social Insurance Agency Research Articles

Further Interventions after Root Canal Treatment Are Most Common in Molars and Teeth Restored with Direct Restorations: A 10–11-Year Follow-Up of the Adult Swedish Population

IntroductionThe aims were to investigate 1) the frequency of nonsurgical retreatment, root-end surgery, extraction, and further restorative treatment during a follow-up of 10–11 years after root filling and compare the frequencies according to tooth group and type of coronal restoration and 2) the timing of nonsurgical retreatment, root-end surgery, and extraction. MethodsData were collected from the Swedish Social Insurance Agency's register. A search for treatment codes identified teeth root filled in 2009 and the type of coronal restoration (direct, indirect, and unspecified) registered within 6 months of root filling. The root-filled teeth were followed 10–11 years, and further interventions were recorded. Descriptive statistics and chi-square tests were used for statistical analysis. ResultsIn 2009, root fillings were registered for 215,611 individuals/teeth. Nonsurgical retreatment, root-end surgery, and extraction were undertaken in 3.5%, 1.4%, and 20% teeth, respectively. The frequency of further interventions varied with respect to tooth group and type of coronal restoration, but only slightly for endodontic retreatments. Further interventions, except for root-end surgery, were registered more often for molars and directly restored teeth (P < .001). The majority of endodontic retreatments were undertaken within 4 years, while extractions were evenly distributed over 10–11 years. ConclusionsThe frequency numbers of nonsurgical retreatment and root-end surgery were low, despite 1 in 5 root-filled teeth registered as extracted. Further interventions were most common in molars and directly restored teeth. Endodontic retreatments were performed more often during the first 4 years.

Social Insurance Literacy Among the Sick-listed-A Study of Clients' Comprehension and Self-Rated System Comprehensibility of the Sickness Insurance System.

Sickness insurance systems and their processes have been studied in terms of transparency, comprehensibility and fairness, highlighting the importance of just procedures that make sense to clients. Related research demonstrates differences between groups of clients, pointing towards a social gradient. The concept of social insurance literacy and the Social Insurance Literacy Questionnaire (SILQ) was recently developed and serves as a measure for client's ability to obtain, understand and act on information in a sickness insurance system, relating to the comprehensibility of the information that the system provides. The purpose of this study was to investigate social insurance literacy among clients on sick leave and its associations with perceived justice, being granted sickness benefits and background factors. This was a questionnaire study with clients on sick leave in Sweden. In the selection process 3993 clients were invited, of which 1173 recently had their sickness benefits withdrawn. Those who answered the SILQ (n = 1152) also answered a perceived justice measure and accepted sharing register data from the Swedish Social Insurance Agency. Data were analyzed through regression analysis. The findings demonstrate that clients' perceptions of system comprehensibility and the status of their sick leave case was significantly associated with perceived justice, and being granted sickness benefits, while their individual abilities to obtain, understand, and act on information had lesser influence. The system's ability to provide understandable information seems more important than clients' abilities to comprehend it. From a client perspective, a just system seems to be related to their experiences of the sick leave process (i,e., whether they had an ongoing or closed case) rather than their skills to obtain the correct information.

The practical realization of the feminist welfare state: Equal sharing and gender equality in institutional interaction about parental leave in Sweden

Talk about gender equality in relation to parental leave is pervasive in Sweden. The state encourages families to share parental leave and has recurrently tasked the Swedish Social Insurance Agency (SSIA) to promote gender equality. As theories and applications of street-level bureaucracy have emphasized, how policy is practically realized in social interaction with clients is an important question, specifically whether gender equality discourse also permeates such encounters. We use conversation analysis to examine how equal sharing of parental leave is raised in interactions between parents and practitioners at the SSIA. The data consist of 300 telephone calls, 378 email exchanges, and 642 Facebook exchanges. Our analysis indicates that the talk of equal sharing is not as omnipresent as previous research might suggest. When parents orient to equal sharing, they tend to describe parental responsibilities, while practitioners connect equality to regulations that in themselves work to promote equal sharing. Equal sharing is also a resource for negotiating the citizen–state relationship, as parents complain about state interference while practitioners in response must balance provision of personalized support with the state imperative to promote sharing. The study highlights the complex work of practitioners in the “feminist welfare state” and sheds light on nuanced notions of equality promotion.

General dental practitioners' fees for root canal treatment, coronal restorationand follow-on treatment in the adult population in Sweden: A 10-year follow-up of data from the Swedish Dental Register.

To analyze the accumulated fees connected with root filling, permanent coronal restoration and follow-on treatment charged by Swedish dentists over a 10-11-year follow-up period. Furthermore, analyzing these fees with reference to the type of restoration, tooth group, and the root-filled teeth which survived compared to those requiring extraction. In 2009, the data register of the Swedish Social Insurance Agency recorded a total of 215,611 teeth as root-filled. The accumulated fees for each tooth encompassed the following interventions: initial root filling, coronal restorations, and follow-up treatments during the designated period. The outcomes were analyzed using descriptive and analytic statistics, including ttests and one-way analysis of variance. The fees are presented in Euros (€1 = SEK 8.94). The total accumulated fees for root fillings amounted to 72 million Euros: the mean fee per root filled tooth was €333.6. The total mean fee over a 10-11-year period, comprising root canal treatment, coronal restorations, and any follow-up treatments, was €923.4. Root-filled teeth with indirect restorations presented a higher mean fee (€1 279.3) compared to those with direct restorations (€829.4) or those without specified restorations (€832.7; p < .001). Moreover, molars presented a significantly higher mean fee (€966.4) compared to premolars (€882.8) and anterior teeth (€891.3; p < .001). Lastly, the mean fee for extracted teeth was €1225.3, which was higher compared to those who survived the follow-up period (€848.0; p < .001). Fees charged by general dental practitioners for root-filled teeth accumulate over time, probably due to the need for further treatment of the tooth. The total mean fee was significantly higher for molars and root-filled teeth with indirect restorations. However, an analysis of the total costs would require prospective clinical cost-effectiveness studies.

Periradicular surgery: a longitudinal registry study of ten-year outcomes and factors predictive of post-surgical extraction.

This historical prospective cohort study of the adult population of Sweden is based on data from a national registry: the primary aim was to evaluate the long-term survival of teeth after periradicular surgery. A secondary aim was to identify factors predictive of extraction within 10 years of registration of periradicular surgery. The cohort consisted of all individuals who had undergone periradicular surgery to treat apical periodontitis, as reported to the Swedish Social Insurance Agency (SSIA) during 2009. The cohort was followed until December 31, 2020. Subsequent registrations of extractions were collected for Kaplan-Meier survival analyses and survival tables. The patients' sex, age, dental service provider and tooth group were also retrieved from SSIA. Only one tooth per individual was included in the analyses. Multivariable regression analysis was used and P < 0.05 was considered statistically significant. The reporting guidelines STROBE and PROBE were followed. After data cleaning, and exclusion of 157 teeth, 5 622 teeth/individuals remained for analysis. The mean age of the individuals at the time of the periradicular surgery was 60.5 years (range 20-97, standard deviation 13.31); 55% were women. At the end of the follow-up, that is, up to 12 years, a total of 34.1% of the teeth had been reported as extracted. The multivariate logistic regression analysis, based on follow-up data at 10 years after registration of the periradicular surgery, included 5 548 teeth, of which 1 461 (26.3%) had been extracted. Significant associations between the independent variables tooth group and dental care setting (both P < 0.001) and the dependent variable extraction were found. The highest odds ratio (OR) for extraction applied to tooth group: compared to maxillary incisors and canines, mandibular molars were at greatest risk of extraction (OR 2.429, confidence interval 1.975-2.987, P < 0.001). After periradicular surgery in predominantly elderly people in Sweden, approximately three quarters of the teeth are retained over a 10-year period. The type of tooth is associated with extraction: mandibular molars are at greater risk of extraction than maxillary incisors and canines.

"He Won't Pay": The Entanglement of Financial Abuse and Negligence in Swedish Child Maintenance Processes.

Since 2016, separated parents in Sweden are expected to pay child maintenance directly to each other unless special reasons, such as intimate partner violence (IPV), can be invoked. Problems with maintenance payments, which may involve expressions of financial abuse, have become a common topic in interactions between parents and the Swedish Social Insurance Agency (SSIA) that handles these cases. This article examines 132 phone calls to the SSIA, and the results show that payment problems are typically framed as relating to inability or negligence and not as possible indications of abuse. This highlights the need for training and capacity building regarding IPV in the Swedish welfare state.

De‐gendering parents: Gender inclusion and standardised language in screen‐level bureaucracy

AbstractSwedish welfare organisations have a long history of promoting gender equality and inclusivity, involving implementation of more gender‐inclusive language (e.g., non‐gendered terminology). This study analysed the use of non/gendered expressions at the Swedish Social Insurance Agency, as state policy is realised in conjunction with personalised service in textual interaction in screen‐level bureaucracy. We drew on conversation analysis and membership categorisation analysis to analyse 378 email interactions between clients and social insurance officers, focusing on gendered institutional terminology and gendered person references. The findings suggest that social insurance officers avoided a heteronormative language, in line with Swedish official public language policy, but that a gender‐neutral language may come at the cost of formality, standardisation, and de‐personalisation. The study brings new knowledge on the ways in which street‐level bureaucrats manage responsiveness and standardisation in digital text‐based interaction with clients.

Challenges in recognizing and facilitating disclosures of intimate partner violence in customer service calls about maintenance support

Separated parents in Sweden need to sort out child maintenance themselves unless there are ‘special reasons’, such as experiences of intimate partner violence (IPV), in which case the Swedish Social Insurance Agency (SSIA) may function as an intermediary. In such cases, the parent must disclose their experiences for institutional assessment. This study uses conversation analysis (CA) to examine 132 phone calls between parents and SSIA officers, examining how parental conflict and possible violence is brought up and responded to. The analysis shows how parents describe cooperative problems in non-specific terms, incrementally adding information that makes possible violence inferentially available, rendering it difficult for case officers to distinguish IPV from post-separation conflicts. Case officers typically respond minimally and do not encourage further tellings, which means that IPV may go unnoticed. The study highlights the need for training in how to recognize possible IPV and how to facilitate such disclosures.

Sick leave and predictive factors for sick leave at 12 months after breast cancer surgery in the randomized controlled physical activity trial (PhysSURG-B)

ObjectiveTo evaluate sick leave 12 months after breast cancer surgery, to analyze the effect of adjuvant chemotherapy and to identify predictive factors for sick leave, based on a randomized controlled trial of a non-supervised physical activity intervention (PhysSURG-B). MethodsSick leave days (for patients age 18–67) were collected from the Swedish Social Insurance Agency, and compared between the intervention and control arm in the trial. A random forest model was used to analyze predictive factors for sick leave, including baseline patient and tumor characteristics as well as patient-reported outcomes measuring quality of life, personality traits, pain, anxiety and depression. ResultsA total of 203 patients were analyzed, and when comparing intervention to control, there was no differences in sick leave days (117 vs 55 days, odds ratio 1.21; 95% CI 0.75–1.96). Adjuvant chemotherapy significantly increased days of sick leave (323 vs 42 days, odds ratio 17.3; 95% CI 9.15–34.2). Factors predicting prolonged sick leave were adjuvant chemotherapy, young age, previous mental health problems and low quality of life (measured as FACT-B score) at baseline. ConclusionA non-supervised physical activity intervention had no effect on sick leave 12 months after surgery. Significantly longer sick leave was seen in patients treated by adjuvant chemotherapy. Factors predicting prolonged sick leave can be recognized at baseline and utilized when designing future interventions.

Individual realities and legal responsibilities: a study of non-resident parents who dispute child maintenance obligations in Swedish administrative courts, 2014–2019

Abstract This study is the first large-scale empirical account of child maintenance non-compliance in Sweden. The scheme explored is the guaranteed support system, i.e. when liable parents do not comply with their formal maintenance obligations as determined by the Swedish Social Insurance Agency (SSIA). The objective is to map out and describe the overall reasons why parents do not pay, as well as to explain why parents’ perceptions of their maintenance obligations diverge from those of the SSIA officials. To this end, the study utilises both quantitative descriptive analysis and qualitative thematic text analysis. The data were built on a unique body of material comprising over 700 court cases where liable parents disputed their maintenance obligations in Sweden’s 12 administrative courts, during 2014–2019. The quantitative results show that claiming economic inability and regular involvement in the care of children are the two most common arguments for non-payment. The qualitative analysis further suggests that the administrative tools and legal assessments designed to calculate payments to aid parents are in reality creating barriers, uncertainty, and distrust in the process. Consequently, the rules designed to protect children in lone-parent households are a factor contributing to non-payment by the other parent. The article concludes with reflections and public policy implications.

Factors influencing return to work after surgery for ulnar nerve compression at the elbow

Ulnar nerve compression at the elbow (UNE) frequently affects people of working age. Surgically treated patients may not immediately return to work (RTW) postoperatively. In 2008, the Swedish Social Insurance Agency reformed the national insurance policy. We aimed to examine RTW postoperatively for UNE, variations among surgical methods, and potential risk factors for prolonged RTW (sick leave > 6 weeks). Surgically treated cases of UNE (n = 635) from two time periods (2004–2008 and 2009–2014) and two healthcare regions (Southern and South-eastern) were studied retrospectively regarding age, sex, comorbidities, occupation, type of surgery and time to RTW. A sub-analysis of the exact number of weeks before RTW (n = 201) revealed longer RTW for unemployed cases compared to employed cases. Prolonged RTW was seen among younger, manual workers and after transposition or revision surgery. Prolonged RTW was approximately four times more likely after transposition than after simple decompression. Comparisons before and after 2008 showed occupational differences and differences in RTW, where cases operated before 2008 more often had permanent sickness benefit, but the reform of the social insurance system did not seem to influence RTW. In conclusion, unemployment, younger age at surgery, manual labour, transposition, and revision surgery were related to prolonged RTW.

Professional discretion in Swedish welfare institutions: What factors influence perceived discretion?

Abstract Discretion is a central topic in the literature on service delivery of frontline professionals, especially in the light of neoliberal transformations in all welfare states. Previous studies have focused on exploring “discretionary space” and its meaning for service delivery, but these studies have not been able to clearly identify single determinants of perceived discretion. This study aims to contribute to the discussion by investigating factors that influence perceived discretion. To this end, data were examined from a nationwide survey of Swedish frontline professionals (N = 1319) within two major welfare organizations: the Public Employment Service and the Swedish Social Insurance Agency. Hierarchical OLS regression was applied, resulting in the identification of two major influencing factors. Frontline professionals who reported higher levels of work pressure showed less perceived discretion, and frontline professionals working at the Public Employment Service showed higher levels of perceived discretion than those working at the Social Insurance Agency, highlighting the importance of organizational context for discretion. Greater work experience also proved to increase the feeling of having discretion at work. The results of this paper add to the existing literature by proposing a model of factors that are important for perceived discretion by frontline professionals.

Economic burden of atherosclerotic cardiovascular disease: costs related to healthcare and loss of productivity; a matched case-control study in more than 450,000 Swedish individuals

Abstract Introduction Atherosclerotic cardiovascular disease (ASCVD) is associated with significant morbidity and mortality. We aimed to quantify the impact of ASCVD on healthcare costs, risk of cardiovascular (CV) events and mortality. Purpose To examine the progression of direct healthcare costs, indirect costs and other outcomes over 5 years in people with ASCVD and matched controls in Sweden. Methods In this 5-year retrospective closed cohort study, adults (aged ≥18 years) living in Sweden on 1/1/2012 were identified in an existing database,1,2 and those with ASCVD (≥1 inpatient admission/outpatient visit with a main or sub-diagnosis relating to stroke, ischaemic heart disease or peripheral artery disease, or procedure codes related to revascularization or amputation, in the National Patient Register [1997–2011]) were propensity score matched to controls without ASCVD by birth year, sex and educational status. Study variables included costs of selected hospital-based care and prescription drugs, and mortality from the National Board of Health and Welfare; demographic and socioeconomic information from Statistics Sweden; and work absences from Försäkringskassan (Swedish Social Insurance Agency). We compared annual direct healthcare costs (inpatient, outpatient and drug costs) and indirect costs from lost productivity, and analysed risks of early retirement, stroke, myocardial infarction and mortality. Hazard ratios (HRs) were estimated using Cox proportional regression adjusted for baseline age, sex, comorbidities, education and marital status. Results Individuals with ASCVD (N=231,417) had similar ages, sex distribution and education to matched controls, but were more likely to have T2D or renal disease (Table). Over the 5-year study period, average annual total direct and indirect costs for people with ASCVD were 2.5 times higher than in controls; direct healthcare costs in the ASCVD group were three times those for controls (Figure). In both groups, indirect costs accounted for nearly two-thirds of total costs. In the ASCVD group, inpatient costs comprised 74% of total direct costs, whereas outpatient costs and drug costs contributed 15% and 11%. In controls, total direct costs were made up of 70% inpatient costs, 18% outpatient costs and 12% drug costs. All-cause mortality was 72% higher in people with ASCVD than in controls (HR: 1.72 [95% confidence interval: 1.69–1.75]). Individuals with ASCVD were also more likely than controls to experience stroke (HR: 1.89 [1.83–1.95]), myocardial infarction (HR: 2.33 [2.26–2.41]) and early retirement (HR: 3.04 [2.78–3.33]). Conclusions Individuals with ASCVD incurred more than 2.5 times the total costs of matched controls, and had a greater risk of death, CV events and early retirement. Effective measures to prevent ASCVD and to slow its progression could limit these substantial burdens for individuals, healthcare systems and society. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): This study was supported by a grant from Novo Nordisk A/S to the Swedish Institute for Health Economics. Medical writing support was provided by Oxford PharmaGenesis, Oxford, UK, with funding from Novo Nordisk A/S.

Direct and indirect costs, early retirement, cardiovascular events and mortality in more than 50,000 adults with chronic heart failure in Sweden: a matched case-control study

Abstract Introduction Chronic heart failure (CHF) is a progressive condition that requires long-term treatment for symptom management; it is associated with reduced physical functioning and quality of life, and increased mortality. Real-world data from population-based registries can be used to quantify CHF impact on both individuals and healthcare systems. Purpose To examine the progression of direct and indirect healthcare costs, cardiovascular (CV) outcomes and mortality over 5 years in people with CHF and matched controls in Sweden. Methods In this closed cohort study, adults (aged ≥18 years) living in Sweden on 1/1/2012 were identified in an existing database,1,2 and those with CHF (≥1 inpatient admission/outpatient visit with a main or sub-diagnosis of heart failure in the National Patient Register [1997–2011]) were propensity score matched to controls without CHF by birth year, sex and educational status. Study variables included costs of selected hospital-based care and prescription drugs, and mortality from the National Board of Health and Welfare; demographic and socioeconomic information from Statistics Sweden; and work absences from Försäkringskassan (Swedish Social Insurance Agency). We compared annual and cumulative direct healthcare costs (inpatient, outpatient and drug costs) and indirect costs from lost productivity, and analysed risks of stroke, myocardial infarction (MI), early retirement, and mortality. Results After matching, there were 53,520 individuals in each cohort. Demographic characteristics were well matched (Table). Over 5 years (2012–2016), cumulative direct costs for people with CHF were four- to fivefold higher than those for controls (2012: €5477/€971; 2013: €10 074/€1986; 2014: €14,009/€2976; 2015: €17 622/€3950; 2016: €20,723/€4942); cumulative indirect costs were at least 2.5 times higher (2012: €5419/€2144; 2013: €10,524/€4047; 2014: €15,215/€5735; 2015: €19,595/€7285; 2016: €23,732/€8646). In people with CHF, inpatient costs comprised 78% of total annual mean direct costs over follow-up (€3995/€5144). Outpatient costs contributed 15% (€763) and drug costs contributed 8% (€386) of total annual direct costs. In controls, these were 71% (€808), 18% (€209) and 11% (€124), respectively, of total annual mean direct costs (€1141). People with CHF were significantly more likely than controls to experience stroke (hazard ratio [HR]: 1.61 [95% confidence interval (CI): 1.51–1.71]) or MI (1.75 [1.65–1.87]). All-cause mortality was nearly threefold higher (2.89 [2.80–2.98]) and the risk of early retirement was nearly fourfold higher (3.79 [3.16–4.53]). During follow-up, 31.3% (n=16,766) of people in the CHF cohort died, compared with 10.1% (n=5426) of controls (Figure). Conclusions This analysis demonstrates the considerable impact of CHF, in terms of risk of CV events and death, early retirement and healthcare costs. Inpatient admissions and lost productivity were major contributors to economic costs. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): This study was supported by a grant from Novo Nordisk A/S to the Swedish Institute for Health Economics. Medical writing support was provided by Oxford PharmaGenesis, Oxford, UK, with funding from Novo Nordisk A/S.

Exposure to work-related violence and/or threats of violence as a predictor of certified sickness absence due to mental disorders: a prospective cohort study of 16,339 Swedish men and women in paid work

ObjectivesThe aim of this prospective cohort study was to investigate if exposure to work-related violence and/or threats of violence predict certified sickness absence due to mental disorders.MethodsInformation on work-related exposure to violence and/or threats of violence were derived from the biannual Swedish Longitudinal Occupational Survey of Health (SLOSH) study 2012–2016, including individuals in paid work across Sweden and from different occupations/sectors (n = 16,339). Certified sickness absence due to mental disorders were ascertained from register data from the Swedish Social Insurance Agency. Odds ratios of certified sickness absence due to mental disorders according to exposure to work-related violence were estimated using multiple logistic regression. Several potential confounding variables, such as demographic and socio-economic factors, age, sex, cohabitation, children living at home, socio-economic status, educational level, as well as other types of psychosocial work environmental factors, were adjusted for in the analyses.ResultsIn the total study sample, 9% reported exposure to violence and/or threats of violence and the prevalence of sickness absence due to mental disorders was 5%. Exposure to work-related violence and/or threats of violence was associated prospectively with certified sickness absence due to mental disorders (odds ratio 1.46, 95% confidence interval 1.17–1.82, p < 0.01). Analysis of possible interaction showed no difference in association when comparing women to men and different age groups.ConclusionsExposure to work-related violence and/or threats of violence appear to increase the odds of certified sickness absence due to mental disorders. Preventive measures aiming to lower the risk of exposure is thus of great importance.

Risk factors for surgically treated cervical spondylosis in male construction workers: a 20-year prospective study

BACKGROUND CONTEXTDegenerative changes due to cervical spondylosis (CS) can detrimentally affect work ability and quality of life yet understanding of how physical exposure affects disease progression is limited. PURPOSETo assess the associations between occupational physical exposures and occurrence of surgically treated cervical spondylosis (ST-CS) and early exit from the labor market via disability pension. STUDY DESIGN/SETTINGProspective register study with 20 years follow-up period. PATIENT SAMPLESwedish construction workers participating in a national health surveillance project conducted between 1971 and 1993. OUTCOME MEASURESSurgically treated cervical spondylosis (ST-CS) and early labor market exit at a minimum rate of 25% time on disability pension. METHODSAssociations between occupational physical exposures (job exposure matrix) and subsequent ST-CS (National Hospital in-patient register) and early labor market exit via disability pension (Swedish Social Insurance Agency register) were assessed in a cohort of male construction workers (n=237,699). RESULTSA total of 1381 ST-CS cases were present and a 20 years incidence rate of 35.1 cases per 100,000 person years (95% confidence interval (CI) 33.2–36.9). Increased relative risk (RR) for ST-CS was found for workers exposed to non-neutral (RR 1.40, 95% CI 1.15–1.69), and awkward neck postures (1.52, 1.19–1.95), working with the hands above shoulder height (1.30, 1.06–1.60), and high upper extremity loading (1.35, 1.15–1.59). Increased risk was also present for workers who reported frequent neck (3.06, 2.18–4.30) and upper back (3.84, 2.57–5.73) pain in the 12 months prior to survey. Among workers with elevated arm exposure, higher risk was seen in those who also had more frequent neck pain. ST-CS cases took early retirement more often (41.3%) and at a younger age (53 years) than the total study cohort (14.8% and 56 years of age, respectively). CONCLUSIONSOccupational exposure to non-neutral neck postures, work with hands above shoulders and high loads born through the upper extremities increased the risk for ST-CS and early retirement due to disability. Decreasing postural and load exposure is salient for primary, secondary, and tertiary prevention of CS. Neck pain was shown to be a prognostic factor for ST-CS, which stresses the importance of acting early and taking preventative action to reduce workplace exposure, and the need for systematic medical check-ups within primary or occupational care to mitigate disease progression and early labour market exit due to disability.

Clinical outcomes and sick leave in relation to UDCA treatment in Swedish patients with primary biliary cholangitis

Objectives Primary biliary cholangitis (PBC) is an autoimmune liver disease that may progress into liver cirrhosis. Ursodeoxycholic acid (UDCA) is known to prevent or delay the disease progression, but little is known about work incapacity in PBC patients. We aimed to compare clinical outcomes (transplantation-free survival; cirrhosis development) and sick leave in patients with PBC with and without UDCA therapy. Methods The medical records of 526 patients with PBC diagnosed from 2004 to 2016 were reviewed retrospectively. Sick leave data retrieved from the Swedish Social Insurance Agency were analysed for a sub-cohort of patients and matched controls. Cox regression was used for analysis of clinical outcomes. Logistic and conditional logistic regressions were used for sick leave analysis. Results A total of 10.6% of patients died and 3.4% received liver transplantation over a median follow-up time of 5.7 years. UDCA-untreated patients (HR 3.62 (95%CI 2.02–6.49)) and UDCA non-responders (HR 3.78 (95% CI 1.87–7.66)) had higher mortality or transplantation rates than UDCA responders. Patients with PBC had higher odds of sick leave (OR 2.50; 95% CI 1.69–3.70) than matched controls. Untreated patients were more likely to be on sick leave (OR 3.22; 95% CI 1.12–9.25) two years after diagnosis than UDCA responders. Conclusion Both untreated patients and UDCA non-responders had lower liver transplantation-free survival rates than UDCA responders. Patients with PBC were more likely to be on sick leave compared to matched controls from the general population.

Records of personal assistance applications reveal young carers: Viewed from the rights of the child

AbstractThe aim of this article is to investigate how children's care responsibility is recognised in records of personal assistance carried out by the Swedish Social Insurance Agency (SSIA). The article consists of document analysis, examining how caring activities are made visible in the records, and professionals' views and actions regarding responsibilities placed on children. Data consist of 100 cases randomly selected from the SSIA register amongst applicants with children, focusing on parents' descriptions of their needs, the public officials' assessments, and statements from professionals. Recurring themes related to young carers were developed.

Ethical aspects of the coordination of return-to-work among employees on sick leave due to common mental disorders: a qualitative study

Purpose Identify ethical issues that arise in the coordination of return-to-work (RTW) among employees on sick leave due to common mental disorders (CMDs). Material and methods 41 semi-structured individual interviews and one focus group interview with stakeholders (n = 46) involved in RTW: employees on sick leave due to CMDs, coordinators and physicians at primary health care centres, managers, representatives of the Swedish social insurance agency and occupational health services. A six-step thematic analysis focused on the ethical values and norms related to autonomy, privacy, resources and organization, and professional values. Results Five themes were identified: (1) autonomous decision-making versus the risk of taking over, (2) employee rights versus restrictions to self-determination, (3) respect for employee privacy versus stakeholders’ interests, (4) risk of unequal inclusion due to insufficient organizational structure and resources, (5) risk of unequal support due to unclear professional roles and responsibilities. Conclusion The main ethical issues are the risks of unequal access to and unequal support for the coordination of RTW. For the fair and equal provision of coordination, it is necessary to be transparent on how to prioritize the coordination of RTW for different patient groups, provide clarity about the coordinator’s professional role, and facilitate ongoing boundary work between stakeholders. IMPLICATIONS FOR REHABILITATION Unfair and arbitrary criteria for inclusion to the coordination of RTW implicate risks of unequal access for the employee on sick leave due to CMDs. Unclear professional roles and responsibilities among stakeholders in the coordination of RTW implicate risks of unequal support for the employee on sick leave due to CMDs. Coordination of RTW should be transparently prioritized on policy and organisational levels to secure fair and equal inclusion. The coordinator’s professional role should be clearly defined to facilitate boundary work between stakeholders and improve the competence around the coordination of RTW.

“And all Hell Broke Loose”: How Child Maintenance Regulations Contribute to Re-actualizing Intimate Partner Violence between Separated Parents in Sweden

This study examines recent changes in Swedish regulations for child maintenance in relation to post-separation families with experiences of either intimate partner violence (IPV) or conflict. The reform limited the possibility to rely on the state for maintenance in cases of cooperation difficulties. For IPV cases, the Swedish Social Insurance Agency (SSIA) can function as an intermediary between parents, but such exceptions are made upon assessment and require disclosure of IPV. This study investigates consequences of the maintenance reform and the ways in which it may re-actualize conflict and IPV between separated parents. Data consist of 649 recorded phone calls (~ 55 h) to the SSIA concerning maintenance. Disclosures of post-separation conflict or IPV were found in 132 of these calls; these calls were analyzed using thematic analysis. The maintenance reform’s requirement to reinstate contact with a former partner can re-actualize experiences of parental conflict as well as IPV by (a) re-surfacing physical or psychological abuse; (b) continued or accelerated cooperative difficulties; (c) renewed financial control; and (d) ‘paper abuse’ and new possibilities to display diligence or exert camouflaged control. This can take the form of explicit acts of abuse, anxiety or concern caused by the renewed contact, or being forced to deal with difficult memories. We argue that the Swedish maintenance reform ignores the reality of parental conflicts and IPV by re-actualizing such experiences in a range of ways.