BACKGROUND:Chronic kidney disease (CKD) increases cardiovascular and mortality risk. Guidelines recommend statins for primary prevention in individuals aged ≥50 years with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, but implementation and outcomes remain unclear. This study examined statin use and its association with all-cause mortality in individuals with CKD and no other indication for statin therapy. METHODS:A retrospective cohort study was conducted using healthcare data derived from Region Halland, Sweden. Adults aged 50-89 years with ≥2 eGFR measurements <60 mL/min/1.73 m2 during 2018-2021 were included, excluding those with prior cardiovascular disease, diabetes, primary hyperlipidemia, dialysis, or kidney transplantation. Follow-up from January 2021 to December 2023 included prevalence of statin use and all-cause mortality. Cox regression estimated adjusted hazard ratios (HR) for mortality, accounting for age, sex, CKD stage, albuminuria, hypertension, and use of statins, renin-angiotensin-aldosterone system (RAASi) inhibitors, and sodium-glucose-cotransporter-2 (SGLT2i) inhibitors. RESULTS:Among 7,177 individuals (50% women), 38% received statins. Statin use was associated with lower three-year mortality (14% vs. 19%, p < 0.001). Crude mortality rates were 42 vs. 57 deaths per 1,000 person-years. Statin use was associated with reduced mortality risk (HR 0.82, 95% CI:0.72-0.92). Higher age, advanced CKD stage, and hypertension were independently associated with increased mortality. RAASi use was protective (HR 0.31, 95% CI:0.27-0.35). CONCLUSION:Statin therapy was associated with lower all-cause mortality but was underutilized in adults ≥50 years with CKD. These findings have supported broader implementation of guideline-recommended statin therapy.

Assess healthcare utilization and direct costs for heart failure (HF) during the first two years post-diagnosis across HF subgroups. This retrospective population-based study included patients with HF aged 40–90 years in Region Halland. HF subgroups were defined based on echocardiographic ejection fraction, including HF with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF), preserved ejection fraction (HFpEF), and no defined phenotype (HF-NDP). NT-proBNP and comorbidities were analyzed as clinical features. HF phenotypes were identified via algorithmic electronic medical records analysis. Data included primary and hospital care (inpatient and outpatient) healthcare utilization and costs during a two-year post-diagnosis during 2015–2017. Utilization covered visits to physicians, nurses, paramedical staff, and inpatient days. Costs were estimated using the Patient Encounter Costing model. HF phenotypes, differentiated by ejection fraction, were identified via algorithmic analysis of electronic medical records. ANOVA with Bonferroni correction compared subgroups; Poisson regression assessed factors associated with longer hospital stays. A total of 1769 patients were included: 472 (27

BACKGROUND:Heart failure (HF) is a common disease among older individuals and is associated with poor quality of life and prognosis. Individuals at risk of developing HF are usually already patients in primary healthcare, but diagnosing HF at an early stage can be challenging. Identifying patients at risk of HF and initiating early treatment is crucial for their outcomes. Using the variables gender, age, multimorbidity (MM) level, and socioeconomic status (SES), we aimed to study the possibility of identifying individuals at high risk of HF diagnosis within two years. METHODS:A longitudinal registry-based study, including 961,190 inhabitants aged from 20 years onwards without a HF diagnosis living in southern Sweden during 2015. Logistic regression was applied to estimate the OR of HF diagnosis within two years by adjusting for the variables gender, age, MM level, and SES. Linear predictions were made based on models by adding these variables in steps. Each model was compared with the previous model using a likelihood-ratio test. The optimal cutoff point for sensitivity and specificity was calculated using the Youden method. RESULTS:Age had the highest OR of HF diagnosis within two years, followed by MM level, gender, and SES. ROC (Receiver Operating Characteristic) analysis, including these variables in steps, generated an increasing AUC (area under the curve), from 0.5144 to 0.9379. When all four variables were included in the model, an optimal cutoff point according to Youden was established at 1.15%, which predicted the probability with a sensitivity of 87.69% and specificity of 78.48%. The positive predictive value was 4.78%, and the negative predictive value was 99.81% for the whole adult population; for those aged 70 years and older, it was 21.02% and 98.99%; and for those aged 80 years and older, it was 33.62% and 98.09%, respectively. CONCLUSIONS:Age was the most important factor for predicting the probability of HF diagnosis within two years in our study, followed by MM level, gender, and SES. These findings may help identify population groups at increased risk of HF in whom targeted case-finding strategies could be evaluated in future studies.

Background Older adults aged ≥ 75 years with type 2 diabetes (T2D) experience high healthcare utilization, yet evidence on treatment patterns and outcomes in this age group is limited. Objective To assess associations between glycemic control, kidney function, and hospitalization among individuals aged ≥ 75 years with T2D. Methods Individuals aged ≥ 75 years with T2D were identified in 2018 using data from a population‑based healthcare database covering all levels of care in Region Halland. Healthcare utilization, including hospital admissions, hospital days, primary care encounters and mortality, was evaluated during 2019. Inclusion required at least one measurement of glycated hemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR). Kidney function was classified by eGFR ≥ 60; 30–59; <30 mL/min/1.73 m², and HbA1c as < 52, 52–70, or > 70 mmol/mol. Associations with hospital days were analyzed using Poisson regression adjusted for demographic, clinical, and treatment variables. Results The cohort comprised 1,446 individuals (49% women); 88 patients (6%) died during follow‑up. HbA1c was < 52 mmol/mol in 43%, 52–70 mmol/mol in 45%, and > 70 mmol/mol in 12%. CKD was common, with 56% classified as stage 3 and 10% as stage 4–5. Hospital days were higher among individuals with CKD stage 4–5 (RR 1.93, 95% CI:1.71–2.17) and HbA1c > 70 mmol/mol (RR 1.44, 95% CI:1.28–1.61). Primary care encounters were frequent (physician visits: 4.6 [SD 3.7]; nurse visits: 9.0 [SD 9.3]) and associated with CKD but not with glucose dysregulation. Insulin use was associated with more hospital days, whereas metformin and incretin‑based therapy were associated with fewer. Conclusion In adults aged ≥ 75 years with T2D, hospitalization burden was substantial and was associated with advanced CKD and poor glycemic control, while primary care encounters were frequent. These findings highlight CKD and glycemic control as key targets to reduce hospital utilization in old adults with T2D.

Primary healthcare providers are increasingly challenged in supporting patients with psychosocial needs. Arts on Prescription (AoP) has been shown to improve primary healthcare patients’ mental health wellbeing. The aim of the current study is to understand the psychosocial effect of participating in an Arts on Prescription programme. A total of 112 primary healthcare patients from 18 primary healthcare centres in Scania with mental health diagnoses depression and anxiety or social isolation participated in a 10-week group-based arts programme, twice a week for 2 h. A questionnaire with the Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS), the Salutogenic Health Indicator Scale (SHIS) (for baseline and follow-up) and 14 sociodemographic and self-rated health covariates were collected as baseline. We also conducted 28 semi-structured interviews. We analysed data using paired t-test and a general linear regression model for change in SWEMWBS and SHIS. Qualitative data was analysed using a thematic approach. The paired t-test showed highly significant results (p < 0.001) for increase in both SWEMWBS and SHIS. The general linear regression. models show that women and participants with poorer self-rated health (SRH), more contacts with the healthcare system, other referrals from the primary healthcare centre, and no previous arts and culture engagement displayed significantly stronger associations with increase in SWEMWBS but not SHIS. Qualitative results highlight use of other interventions and difficulties navigating the health system. Our findings support a proportionate universalism (scale and intensity proportionate to the degree of need) approach indicating that AoP programmes could be valuable additions to healthcare pathways enhancing wellbeing for vulnerable populations. Findings should be interpreted with caution due to small sample size.

Chronic low-grade inflammation is a well-known risk factor for coronary heart disease (CHD) and future cardiovascular events. Anti-inflammatory therapy can reduce the risk of ischemic cardiovascular disease (CVD) events following myocardial infarction (MI). However, it remains unknown to what extent inflammation at the time of an acute event predicts long-term outcomes. We explored whether routine blood measurements of inflammatory markers during an acute coronary syndrome (ACS) are predictive of long-term mortality. In a cohort of 5292 consecutive patients admitted to a coronary intensive care unit with suspected ACS over a four-year period in the Carlscrona Heart Attack Prognosis Study (CHAPS), 908 patients aged 30–74 years (644 men, 264 women) were diagnosed with MI (527) or unstable angina (UA) (381). A 10-year follow-up study was conducted using Swedish national registries, with total mortality and cardiac mortality as primary outcomes. Long-term total and cardiac mortality were significantly associated with higher leukocyte counts (e.g., neutrophils, monocytes, p ≤ 0.001), higher levels of inflammatory biomarkers (e.g., C-reactive protein, Serum Amyloid A, fibrinogen, p ≤ 0.001), and elevated neutrophil–lymphocyte ratio (NLR) (p < 0.001) and monocyte-lymphocyte ratio (MLR) (p = 0.002), all measured at ACS admission. These associations were independent of ACS diagnosis. Our results suggest that level of inflammation at ACS presentation—beyond its established role as a major CHD risk factor—also predicts long-term mortality following ACS. Notably, inflammation at the time of the event was a stronger predictor of long-term mortality than the acute event outcome itself. However, limitations include the observational study design, moderate sample size, and absence of modern high-sensitivity cardiac biomarkers and contemporary ACS management strategies in this cohort. The results should therefore be interpreted in the context of historical clinical practice. While our model-wise complete-case approach ensured consistency, missing data remains a potential source of bias. Future studies in larger, more contemporary cohorts are needed to validate these findings and refine risk stratification strategies.

Background Individuals with type 2 diabetes (T2D) are at increased risk of developing cardiovascular disease (CVD) which necessitates monitoring of risk factors and appropriate pharmacotherapy. This study aimed to identify factors predicting emergency department visits, hospitalizations, and mortality among T2D patients after being newly diagnosed with CVD. Methods In a retrospective observational study conducted in Region Halland, individuals aged > 40 years with T2D diagnosed between 2011 and 2019, and a new diagnosis of CVD between 2016 and 2019, were followed for one year from the date of CVD diagnosis. The first encounter for CVD diagnosis was categorized as inpatient-, outpatient-, primary-, or emergency department care. Follow-up included laboratory tests, blood pressure, pharmacotherapies, and healthcare utilization. Hazard ratios (HR) in two Cox regression analyses determined relative risks for emergency visits/hospitalization and mortality, adjusting for age, sex, glucose regulation, lipid levels, kidney function, blood pressure, pharmacotherapy, and healthcare utilization. Results The study included a total of 1759 T2D individuals who received a new CVD diagnosis, with 67% diagnosed during inpatient care. The average hospitalization stay was 6.5 days, and primary care follow-up averaged 10.1 visits. Patients with CVD diagnosed in primary care had a HR 0.52 (confidence interval [CI] 0.35-0.77) for emergency department visits/hospitalization, but age had a HR 1.02 (CI 1.00-1.03). Pharmacotherapy with insulin, DPP4-inhibitors, aldosterone antagonists, and beta-blockers had a raised HR. Highest mortality risk was observed when CVD was diagnosed inpatient care, systolic blood pressure < 100 mm Hg and elevated HbA1c. Age had a HR 1.05 (CI 1.03-1.08), eGFR < 30 ml/min HR 1.46 (CI 1.01-2.11), and LDL-Cholesterol > 2,5 h 1.46 (CI 1.01-2.11) and associated with increased mortality risk. Pharmacotherapy with metformin had a HR 0.41 (CI 0.28-0.62), statins a HR 0.39 (CI 0.27-0.57), and a primary care follow-up < 30 days a HR 0.53 (CI 0.37-0.77) and associated with lower mortality risk. Conclusions T2D individuals who had a new diagnosis of CVD were predominantly diagnosed when hospitalized, while follow-up typically occurred in primary care. Identifying factors that predict risks of mortality and hospitalization should be a focus of follow-up care, underscoring the critical role of primary care in the effective management of T2D and CVD.

Objectives To study the association between risk for hospitalisation in an elderly population related to renal function, number of chronic diseases and number of prescribed drugs.Design A case–control study. Persons hospitalised were included and their controls were obtained from electronic hospital medical records. If data were lacking on creatinine levels, multiple imputation was used.Setting Blekinge County in southwestern Sweden.Participants Study of individuals aged 75 years or older in 2013. We identified a total of 2,941 patients with a first hospitalisation. Of these, 81 were excluded, 78 due to incomplete data and 3 because of lack of control persons. Controls were matched to the same sex and birth year, which resulted in 5720 persons.Primary and secondary outcome measures To analyse the OR for hospitalisation conditional logistic regression was used.Results A total of 695 persons lacked creatinine value. Using imputation values comparing persons with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 with ≥30 univariate analyses showed an increased OR 2.35 (95% CI 1.83 to 3.03). Adjusted analyses demonstrated an OR of 1.90 (95% CI 1.46 to 2.47). Comparing eGFR<45 mL/min/1.73 m2 against ≥45 univariate analyses showed OR 1.38 (95% CI 1.22 to 1.57). Adjusted analyses OR for the same group were 1.17 (95% CI 1.03 to 1.33). In both models, the OR for five or more chronic conditions and five or more medications showed a statistically increased risk for hospitalisation.Conclusions There is a need for systems using data collected in routine care to follow elderly patients to minimise avoidable hospitalisations that can cause adverse effects. Renal function, number of chronic conditions and medications are factors that are of significant importance. This study demonstrates the complexity of this patient group.

Background: It is well-known that urate is a risk factor for gout but hyperuricemia is also a condition associated with common diseases such as hypertension, obesity and diabetes mellitus. Case presentation: A caucasian male in his late 50’s who had developed a moderate drinking habit over 10 years (2-3 glasses of wine at weekends) from a previous habit of almost no alcohol use and no previous past medical history developed extreme general fatigue, which made movement increasingly difficult. This resulted in weight gain for 1.5 years before he developed numbness and about 4 years later ulcerating tophi in both of his heels. After the condition of his heels got worse, he consulted a private orthopedic surgeon who referred him to his GP where he was diagnosed with hyperuricemia, hypertension, diabetes mellitus, and obesity. Both heel tophi were removed surgically. After both the large heel tophi were surgically removed, lifestyle changes were made and medical treatment by his General Practitioner (GP) was initiated for his hyperuricemia, hypertension, and diabetes mellitus. Most of his laboratory tests and clinical symptoms such as fatigue and being overweight quickly improved, however it has been taking a longer time for inflammation to get normalized. Conclusion: Hyperuricemia is a condition that is often untreated or undertreated, but it has been shown that hyperuricemia itself has a relationship in the development of diseases such as hypertension, diabetes mellitus and cardiovascular diseases, which could eventually be life-threatening. However, hyperuricemia can induce unexplainable extreme fatigue, which results in less movement and the development of weight gain and other lifestyle-related diseases e.g. hypertension and diabetes mellitus. Treatment for hyperuricemia should be considered even if the patient has not developed gout exacerbations, because hyperuricemia may not only cause gout, which reduces patients’ quality of life, but also has a relationship with life-threatening diseases.

ObjectiveTo investigate the prevalence of diabetes retinopathy and evaluate the factors influencing its occurrence both at the onset of type 2 diabetes (T2D) and three years into its duration.DesignRetrospective population-based study.SettingData was retrieved from Regional Healthcare Information Platform in Region Halland 2016-2020.SubjectsPatients 35-75 years old in Region Halland receiving first-time diabetes diagnosis according to ICD-code E11-14 in 2016-17. The total cohort consisted of 1659 patients.Main outcome measuresThe main outcome measure of the study was the occurrence of diabetes retinopathy at onset and within three years from the diabetes diagnosis. Multivariate logistic regression analysis was conducted for diabetes retinopathy at onset and within three years, adjusted for age, gender, comorbidities, levels of HbA1c, cholesterol, kidney functional and blood pressure.ResultsAt onset, there were 12% with diabetes retinopathy and after three years, 32% of the patients had developed diabetes retinopathy. In the study cohort, 71 of patients who were examined with fundus photography within three years after onset, and 8% had had dietary recommendation without pharmacotherapy. High HbA1c levels, blood pressure values and impaired renal function already at onset were associated with development of diabetes retinopathy at onset and this association persisted after three years. The odds ratio for diabetes retinopathy was increased adjusted for HbA1c elevations, renal impairment, and increased blood pressure at index and when adjusted for these variables three years from index.ConclusionThese findings indicate that the risk of developing diabetes retinopathy is present early on at onset and within the first three years of diabetes diagnosis. This highlights the importance of promptly regulating glucose- and blood-pressure levels and follow up kidney dysfunction to mitigate the risk of diabetes retinopathy. Among patients with type 2 diabetes, 12% had developed diabetes retinopathy already at onset.Among patients with type 2 diabetes, one-third had developed diabetes retinopathy after three years from onset.The presence of diabetes retinopathy already at diabetes onset, was associated with elevated HbA1c levels, renal impairment and elevated blood pressure.Diabetes retinopathy three years after the onset of the disease, was associated with increased HbA1c levels, high blood pressure, and renal dysfunction.

PurposeCancer survivors experience barriers to primary healthcare (PHC) services. The aim was to explore reactions to and opinions about perceived challenges associated with PHC access and quality among cancer survivors in Sweden, including how they have acted to adapt to challenges.MethodsFive semi-structured focus group interviews were conducted with cancer survivors (n = 20) from Sk & aring;ne, Sweden, diagnosed with breast, prostate, lung, or colorectal cancer or malignant melanoma. Focus groups were mixed in regard to diagnosis. Data were analysed using a descriptive template analysis approach.ResultsIn light of perceived challenges associated with access to adequate PHC, participants experienced that they had been forced to work hard to achieve functioning PHC contacts. The demands for self-sufficiency were associated with negative feelings such as loneliness and worry. Participants believed that cancer survivors who lack the ability to express themselves, or sufficient drive, risk missing out on necessary care due to the necessity of being an active patient.ConclusionsThe findings highlight negative patient experiences. They have implications for the organization of care for cancer survivors as they indicate a need for more efficient post-treatment coordination between cancer specialist care and PHC providers, as well as increased support for patients leaving primary cancer treatment.

Objective: This Swedish study aimed to assess the prevalence, associated clinical factors, and mortality rates of heart failure patients diagnosed without echocardiograms in both hospital and primary care settings.Design: We conducted a retrospective population-based study using data from the Region Halland healthcare database in Sweden covering 330,000 residents.Subjects: From 2013-2019, 3,903 patients received an incidental heart failure diagnosis without an echocardiogram and they were followed for one year.Main outcome measuresUsing logistic and Cox regression analyses, we evaluated the prevalence, clinical characteristics, and all-cause mortality at intervals of 30, 100, and 365 days post-diagnosis.Results: In this Swedish cohort, the one-year all-cause mortality rate was markedly higher for patients diagnosed in hospitals (42%) compared to those in primary care (20%, p < 0.001). Patients diagnosed in primary care were older and had fewer comorbidities and lower NT-proBNP levels. Hospital-diagnosed patients faced a significantly higher mortality rate in the initial 30 days but saw similar rates to primary care patients thereafter.Conclusion: In a Swedish region, heart failure diagnoses without echocardiograms were more common in hospitals, and these patients initially faced worse prognoses. After the first month, however, the prognosis of hospital-diagnosed patients mirrored that of those diagnosed in primary care. These findings emphasize the need for improved diagnostic and treatment approaches in both care settings to enhance outcomes.

Background:After a heart failure (HF) hospital discharge, the risk of a cardiovascular (CV) related event is highest in the following 100 days. It is important to identify factors associated with increased risk of readmission.Method:This retrospective, population-based study examined HF patients in Region Halland (RH), Sweden, hospitalized with a HF diagnosis between 2017 and 2019. Data regarding patient clinical characteristics were retrieved from the Regional healthcare Information Platform from admission until 100 days post-discharge. Primary outcome was readmission due to a CV related event within 100 days.Results:There were 5029 included patients being admitted for HF and discharged and 1966 (39%) were newly diagnosed. Echocardiography was available for 3034 (60%) patients and 1644 (33%) had their first echocardiography while admitted. The distribution of HF-phenotypes was 33% HF with reduced ejection fraction (EF), 29% HF with mildly reduced EF and 38% HF with preserved EF. Within 100 days, 1586 (33%) patients were readmitted, and 614 (12%) died. A Cox regression model showed that advanced age, longer hospital length of stay, renal impairment, high heart rate and elevated NT-proBNP were associated with an increased risk of readmission regardless of HF-phenotype. Women and increased blood pressure are associated with a reduced risk of readmission.Conclusions:One third had a CV-readmission within 100 days. This study found clinical factors already present at discharge that are associated with increased risk of readmission which should be considered at discharge.

BackgroundHeart failure (HF) and cancer are common diseases among the elderly population. Many chronic diseases, including diabetes mellitus (DM), share risk factors and increase the incidence of HF and cancer. The aim of this study was to investigate if there was an association between HF and the prevalence of haematologic- and solid malignancies.MethodsThe study population was comprised of almost one million adults living in southern Sweden in 2015. All participants were divided into seven age groups from 20 and onwards, and 10 percentiles according to their socioeconomic status (SES). All data concerning diagnoses from each consultation in both primary- and secondary health care were collected during 18 months. The prevalence of haematologic and solid malignancies was measured separately for men and women, age groups, SES and multimorbidity levels. Multivariable logistic regression was used to determine the associations between HF and the probability of having haematologic- and solid malignancies in more complex models including stratifying variables.ResultsPeople with HF had a higher prevalence of haematologic- and solid malignancies than the general population, but a lower prevalence of solid malignancies than the multimorbid population. The people with HF had an increased OR for haematologic malignancies, 1.69 (95% CI 1.51-1.90), and solid malignancies, OR 1.21 (95% CI 1.16-1.26), when adjusted for gender and age. In more complex multivariate models, multimorbidity explained the increased OR for haematologic- and solid malignancies in people with HF. Increasing socioeconomic deprivation was associated with a decreased risk for solid malignancies, with the lowest risk in the most socioeconomically deprived CNI-percentile.ConclusionsHF was shown to be associated with malignancies, especially haematologic malignancies. Multimorbidity, however, was an even more important factor for both haematologic- and solid malignancies than HF in our study, but not socioeconomic deprivation. Further research on the interactions between the chronic conditions in people with HF is warranted to examine the strength of association between HF and malignancies.

Objectives Venous thromboembolism (VTE) is a common worldwide disease. The burden of multimorbidity, that is, two or more chronic diseases, has increased. Whether multimorbidity is associated with VTE risk remains to be studied. Our aim was to determine any association between multimorbidity and VTE and any possible shared familial susceptibility.Design A nationwide extended cross-sectional hypothesis - generating family study between 1997 and 2015.Setting The Swedish Multigeneration Register, the National Patient Register, the Total Population Register and the Swedish cause of death register were linked.Participants 2 694 442 unique individuals were analysed for VTE and multimorbidity.Main outcomes and measures Multimorbidity was determined by a counting method using 45 non-communicable diseases. Multimorbidity was defined by the occurrence of ≥2 diseases. A multimorbidity score was constructed defined by 0, 1, 2, 3, 4 or 5 or more diseases.Results Sixteen percent (n=440 742) of the study population was multimorbid. Of the multimorbid patients, 58% were females. There was an association between multimorbidity and VTE. The adjusted odds ratio (OR) for VTE in individuals with multimorbidity (2 ≥ diagnoses) was 3.16 (95% CI: 3.06 to 3.27) compared with individuals without multimorbidity. There was an association between number of diseases and VTE. The adjusted OR was 1.94 (95% CI: 1.86 to 2.02) for one disease, 2.93 (95% CI: 2.80 to 3.08) for two diseases, 4.07 (95% CI: 3.85 to 4.31) for three diseases, 5.46 (95% CI: 5.10 to 5.85) for four diseases and 9.08 (95% CI: 8.56 to 9.64) for 5 ≥ diseases. The association between multimorbidity and VTE was stronger in males OR 3.45 (3.29 to 3.62) than in females OR 2.91 (2.77 to 3.04). There were significant but mostly weak familial associations between multimorbidity in relatives and VTE.Conclusions Increasing multimorbidity exhibits a strong and increasing association with VTE. Familial associations suggest a weak shared familial susceptibility. The association between multimorbidity and VTE suggests that future cohort studies where multimorbidity is used to predict VTE might be worthwhile.

Certain diseases cluster in families, suggesting a genetic contribution to multimorbidity, so what are the implications of this finding for clinical practice? Bengt Zöller and colleagues discuss

ObjectivesTo examine whether multimorbidity aggregates in families in Sweden.DesignNational explorative family study.SettingSwedish Multigeneration Register linked to the National Patient Register, 1997-2015. Multimorbidity was assessed with a modified counting method of 45 chronic non-communicable diseases according to ICD-10 (international classification of diseases, 10th revision) diagnoses.Participants2 694 442 Swedish born individuals (48.73% women) who could be linked to their Swedish born first, second, and third degree relatives. Twins were defined as full siblings born on the same date.Main outcome measuresMultimorbidity was defined as two or more non-communicable diseases. Familial associations for one, two, three, four, and five or more non-communicable diseases were assessed to examine risks depending on the number of non-communicable diseases. Familial adjusted odds ratios for multimorbidity were calculated for individuals with a diagnosis of multimorbidity compared with relatives of individuals unaffected by multimorbidity (reference). An initial principal component decomposition followed by a factor analysis with a principal factor method and an oblique promax rotation was used on the correlation matrix of tetrachoric correlations between 45 diagnoses in patients to identify disease clusters.ResultsThe odds ratios for multimorbidity were 2.89 in twins (95% confidence interval 2.56 to 3.25), 1.81 in full siblings (1.78 to 1.84), 1.26 in half siblings (1.24 to 1.28), and 1.13 in cousins (1.12 to 1.14) of relatives with a diagnosis of multimorbidity. The odds ratios for multimorbidity increased with the number of diseases in relatives. For example, among twins, the odds ratios for multimorbidity were 1.73, 2.84, 4.09, 4.63, and 6.66 for an increasing number of diseases in relatives, from one to five or more, respectively. Odds ratios were highest at younger ages: in twins, the odds ratio was 3.22 for those aged ≤20 years, 3.14 for those aged 21-30 years, and 2.29 for those aged >30 years at the end of follow-up. Nine disease clusters (factor clusters 1-9) were identified, of which seven aggregated in families. The first three disease clusters in the principal component decomposition were cardiometabolic disease (factor 1), mental health disorders (factor 2), and disorders of the digestive system (factor 3). Odds ratios for multimorbidity in twins, siblings, half siblings, and cousins for the factor 1 cluster were 2.79 (95% confidence interval 0.97 to 8.06), 2.62 (2.39 to 2.88), 1.52 (1.34 to 1.73), and 1.31 (1.23 to 1.39), and for the factor 2 cluster, 5.79 (4.48 to 7.48) 3.24 (3.13 to 3.36), 1.51 (1.45 to 1.57), and 1.37 (1.341.40).ConclusionsThe results of this explorative family study indicated that multimorbidity aggregated in Swedish families. The findings suggest that map clusters of diseases should be used for the genetic study of common diseases to show new genetic patterns of non-communicable diseases.

ObjectiveThe aim of this study was to compare the prevalence of heart failure (HF) in relation to age, multimorbidity and socioeconomic status of primary healthcare centres in southern Sweden.DesignA cross-sectional study.SettingThe data were collected concerning diagnoses at each consultation in all primary healthcare centres and secondary healthcare in the southernmost county of Sweden at the end of 2015.ParticipantsThe individuals living in southern Sweden in 2015 aged 20 years and older. The study population of 981 383 inhabitants was divided into different categories including HF, multimorbidity, different levels of multimorbidity and into 10 CNI (Care Need Index) groups depending on the socioeconomic status of their listed primary healthcare centre.OutcomesPrevalence of HF was presented according to age, multimorbidity level and socioeconomic status. Logistic regression was used to further analyse the associations between HF, age, multimorbidity level and socioeconomic status in more complex models.ResultsThe total prevalence of HF in the study population was 2.06%. The prevalence of HF increased with advancing age and the multimorbidity level. 99.07% of the patients with HF fulfilled the criteria for multimorbidity. The total prevalence of HF among the multimorbid patients was only 5.30%. HF had a strong correlation with the socioeconomic status of the primary healthcare centres with the most significant disparity between 40 and 80 years of age: the prevalence of HF in primary healthcare centres with the most deprived CNI percentile was approximately twice as high as in the most affluent CNI percentile.ConclusionThe patients with HF were strongly associated with having multimorbidity. HF patients was a small group of the multimorbid population associated with socioeconomic deprivation that challenges efficient preventive strategies and health policies.

Objective To explore how cancer survivors have experienced their contacts with primary care after being diagnosed with cancer, focusing on the integration between cancer specialist and primary care, and participants' views on what could make primary care services better at catering to the needs of cancer survivors.Design A qualitative study in which data was collected through semi-structured digital focus group interviews and analyzed using a template analysis approach.Setting and subjects Adult residents of Skåne, Sweden, who had been diagnosed with and initiated treatment for either of five common cancer forms, recruited through patient advocacy groups.Main outcome measures A qualitative description of participants' experiences and perceptions as expressed in focus group interview data.Results Most participants felt that primary care services had not played a significant role for them, despite patterns of both increased and unmet health needs. Insufficient coordination and communication with specialist cancer care, low availability, lacking personal continuity, low cancer competence and lacking commitment to cancer-related needs were presented as barriers to satisfactory primary care. A strengthened bond between cancer and primary care services, privileged access, and holistic perspectives were all suggested as measures to make primary care more suitable to cancer survivors' needs.Conclusion The study suggests that cancer survivors experience a range of issues that hinders primary care services from playing a productive role in the cancer care process. The results speak for a need for interventions to remove barriers to satisfactory primary care contacts in this group of patients.KEY POINTSThe growing number of cancer survivors highlights the role of primary care services in the cancer care continuum.Despite the presence of unmet needs, few cancer survivors felt that primary care services had been significant to their care.Survivors identified a number of barriers to satisfactory primary care, including lacking coordination and communication between cancer and primary care.Strengthened links between healthcare services, privileged access, and holistic perspectives were suggested to improve primary care delivery for cancer survivors.

Purpose: Infections from the oral microbiome may lead to exacerbations of chronic obstructive pulmonary disease (COPD). We investigated whether advanced dental cleaning could reduce exacerbation frequency. Secondary outcomes were disease-specific health status, lung function, and whether the bacterial load and composition of plaque microbiome at baseline were associated with a difference in outcomes. Patients and Methods: One-hundred-one primary and secondary care patients with COPD were randomized to intervention with advanced dental cleaning or to dental examination only, repeated after six months. At baseline and at 12 months, data of exacerbations, lung function, COPD Assessment Test (CAT) score, and periodontal status were collected from questionnaires, record review, and periodontal examination. Student's t-test and Mann- Whitney-U (MWU) test compared changes in outcomes. The primary outcome variable was also assessed using multivariable linear regression with adjustment for potential confounders. Microbiome analyses of plaque samples taken at baseline were performed using Wilcoxon signed ranks tests for calculation of alpha diversity, per mutational multivariate analysis of variance for beta diversity, and receiver operating characteristic curves for prediction of outcomes based on machine learning models. Results: In the MWU test, the annual exacerbation frequency was significantly reduced in patients previously experiencing frequent exacerbations (p = 0.020) and in those with repeated advanced dental cleaning (p = 0.039) compared with the non-treated control group, but not in the total population including both patients with a single and repeated visits (p = 0.207). The result was confirmed in multivariable linear regression, where the risk of new exacerbations was significantly lower in patients both in the intention to treat analysis (regression coefficient 0.36 (95% CI 0.25-0.52), p < 0.0001) and in the population with repeated dental cleaning (0.16 (0.10-0.27), p < 0.0001). The composition of microbiome at baseline was moderately predictive of an increased risk of worsened health status at 12 months (AUC = 0.723). Conclusion: Advanced dental cleaning is associated with a reduced frequency of COPD exacerbations. Regular periodontal examination and dental cleaning may be of clinical importance to prevent COPD exacerbations.