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Are suicide deaths under-reported? Nationwide re-evaluations of 1800 deaths in Scandinavia.

https://arctichealth.org/en/permalink/ahliterature275766
Source
BMJ Open. 2015;5(11):e009120
Publication Type
Article
Date
2015
Author
Ingvild Maria Tøllefsen
Karin Helweg-Larsen
Ingemar Thiblin
Erlend Hem
Marianne C Kastrup
Ullakarin Nyberg
Sidsel Rogde
Per-Henrik Zahl
Gunvor Østevold
Øivind Ekeberg
Source
BMJ Open. 2015;5(11):e009120
Date
2015
Language
English
Publication Type
Article
Keywords
Accidents - mortality
Adult
Aged
Autopsy
Cause of Death
Datasets as Topic
Death Certificates
Denmark - epidemiology
Female
Humans
Male
Middle Aged
Norway - epidemiology
Reproducibility of Results
Suicide - statistics & numerical data
Sweden - epidemiology
Abstract
Valid mortality statistics are important for healthcare planning and research. Suicides and accidents often present a challenge in the classification of the manner of death. The aim of this study was to analyse the reliability of the national suicide statistics by comparing the classification of suicide in the Scandinavian cause of death registers with a reclassification by 8 persons with different medical expertise (psychiatry, forensic pathology and public health) from each of the 3 Scandinavian countries.
The cause of death registers in Norway, Sweden and Denmark retrieved available information on a sample of 600 deaths in 2008 from each country. 200 were classified in the registers as suicides, 200 as accidents or undetermined and 200 as natural deaths. The reclassification comprised an assessment of the manner and cause of death as well as the level of certainty.
In total, 81%, 88% and 90% of deaths registered as suicide in the official mortality statistics were confirmed by experts using the Swedish, Norwegian and Danish data sets, respectively. About 3% of deaths classified as accidents or natural deaths in the cause of death registers were reclassified as suicides. However, after a second reclassification based on additional information, 9% of the natural deaths and accidents were reclassified as suicides in the Norwegian data set, and 21% of the undetermined deaths were reclassified as suicides in the Swedish data set. In total, the levels of certainty of the experts were 87% of suicides in the Norwegian data set, 77% in the Swedish data set and 92% in Danish data set; the uncertainty was highest in poisoning suicides.
A high percentage of reported suicides were confirmed as being suicides. Few accidents and natural deaths were reclassified as suicides. Hence, reclassification did not increase the overall official suicide statistics of the 3 Scandinavian countries.
Notes
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PubMed ID
26608638 View in PubMed
Less detail

Benefits and harms of screening men for abdominal aortic aneurysm in Sweden: a registry-based cohort study.

https://arctichealth.org/en/permalink/ahliterature296578
Source
Lancet. 2018 06 16; 391(10138):2441-2447
Publication Type
Journal Article
Research Support, Non-U.S. Gov't
Date
06-16-2018
Author
Minna Johansson
Per Henrik Zahl
Volkert Siersma
Karsten Juhl Jørgensen
Bertil Marklund
John Brodersen
Author Affiliation
Department of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Cochrane Sweden, Skåne University Hospital, Lund, Sweden. Electronic address: minna.johansson@vgregion.se.
Source
Lancet. 2018 06 16; 391(10138):2441-2447
Date
06-16-2018
Language
English
Publication Type
Journal Article
Research Support, Non-U.S. Gov't
Keywords
Adult
Aged
Aged, 80 and over
Aortic Aneurysm, Abdominal - diagnosis - epidemiology - mortality - surgery
Humans
Incidence
Male
Mass Screening
Medical Overuse - statistics & numerical data
Middle Aged
Registries
Risk assessment
Sweden
Unnecessary Procedures - statistics & numerical data
Abstract
Large reductions in the incidence of abdominal aortic aneurysm (AAA) and AAA-related mortality mean that results from randomised trials of screening for the disorder might be out-dated. The aim of this study was to estimate the effect of AAA screening in Sweden on disease-specific mortality, incidence, and surgery.
Individual data on the incidence of AAA, AAA mortality, and surgery for AAA in a cohort of men aged 65 years who were invited to screening between 2006 and 2009, were compared with data from an age-matched contemporaneous cohort of men who were not invited for AAA screening. We also analysed national data for all men aged 40-99 years between Jan 1, 1987, and Dec 31, 2015, to explore background trends. Adjustment for confounding was done by weighting the analyses with a propensity score obtained from a logistic regression model on cohort year, marital status, educational level, income, and whether the patient already had an AAA diagnosis at baseline. Adjustment for differential attrition was also done by weighting the analyses with the inverse probability of still being in the cohort 6 years after screening. Generalised estimating equations were used to adjust the variance for repeated measurement and in response to the weighting.
AAA mortality in Swedish men has decreased from 36 to ten deaths per 100?000 men aged 65-74 years between the early 2000s and 2015. Mortality decreased at similar rates in all Swedish counties, irrespective of whether AAA screening was offered. After 6 years with screening, we found a non-significant reduction in AAA mortality associated with screening (adjusted odds ratio [aOR] 0·76, 95% CI 0·38-1·51), which means that two men (95% CI -3 to 7) avoid death from AAA for every 10?000 men offered screening. Screening was associated with increased odds of AAA diagnosis (aOR 1·52, 95% CI 1·16-1·99; p=0·002) and an increased risk of elective surgery (aOR 1·59, 95% CI 1·20-2·10; p=0·001), such that for every 10?000 men offered screening, 49 men (95% CI 25-73) were likely to be overdiagnosed, 19 of whom (95% CI 1-37) had avoidable surgery that increased their risk of mortality and morbidity.
AAA screening in Sweden did not contribute substantially to the large observed reductions in AAA mortality. The reductions were mostly caused by other factors, probably reduced smoking. The small benefit and substantially less favourable benefit-to-harm balance call the continued justification of the intervention into question.
Research Unit and Section for General Practice, FoUU-centrum Fyrbodal, Sweden, and the region of Västra Götaland, Sweden.
Notes
CommentIn: Lancet. 2018 Jun 16;391(10138):2394-2395 PMID 29916370
CommentIn: Lakartidningen. 2018 Sep 5;115: PMID 30204225
CommentIn: Lakartidningen. 2018 Sep 5;115: PMID 30204226
PubMed ID
29916384 View in PubMed
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Bias when calculating breast cancer mortality after screening mammography in British Colombia.

https://arctichealth.org/en/permalink/ahliterature165067
Source
Int J Cancer. 2007 Jun 1;120(11):2521; author reply 2522
Publication Type
Article
Date
Jun-1-2007
Author
Per-Henrik Zahl
Source
Int J Cancer. 2007 Jun 1;120(11):2521; author reply 2522
Date
Jun-1-2007
Language
English
Publication Type
Article
Keywords
Breast Neoplasms - mortality
British Columbia - epidemiology
Female
Humans
Mammography - utilization
Observer Variation
Notes
Comment On: Int J Cancer. 2007 Mar 1;120(5):1076-8017149701
Erratum In: Int J Cancer. 2008 Aug 1;123(3):738
PubMed ID
17311262 View in PubMed
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Breast cancer incidence and menopausal hormone therapy in Norway from 2004 to 2009: a register-based cohort study.

https://arctichealth.org/en/permalink/ahliterature272579
Source
Cancer Med. 2015 Aug;4(8):1303-8
Publication Type
Article
Date
Aug-2015
Author
Pål Suhrke
Per-Henrik Zahl
Source
Cancer Med. 2015 Aug;4(8):1303-8
Date
Aug-2015
Language
English
Publication Type
Article
Keywords
Breast Neoplasms - diagnosis - epidemiology - etiology - history
Female
History, 21st Century
Hormone Replacement Therapy
Humans
Incidence
Mammography
Menopause
Middle Aged
Neoplasm Staging
Norway - epidemiology
Public Health Surveillance
Registries
Risk
Abstract
In Norway, the breast cancer incidence increased by 50% in the 1990 s, during a period with initiation of mammography screening as well as a fourfold increase in use of menopausal hormone therapy (HT). After 2002, the HT use has dropped substantially; however, the breast cancer incidence has declined only marginally. How much mammography screening contributed to the breast cancer incidence increase in the 1990 s compared with HT use and specifically different types of HT use, has thus been discussed. Whether HT affects the incidence of subtypes of breast cancer differently has also been questioned. We have linked individual data from several national registries from 2004 to 2009 on 449,717 women aged 50-65 years. 4597 cases of invasive cancer and 681 cases of ductal carcinoma in situ (DCIS) were included in the analysis. We used Cox regression to estimate hazard ratio (HR) as a measure of the relative risk of breast cancer associated with use of HT. The HRs associated with prescriptions of HT for more than 1 year were 2.06 (1.90-2.24) for estrogen and progesterone combinations, 1.03 (0.85-1.25) for systemic estrogens, and 1.23 (1.01-1.51) for tibolone. Invasive lobular carcinoma was more strongly associated with use of estrogen and progesterone combinations, HR = 3.10 (2.51-3.81), than nonlobular carcinoma, HR = 1.94 (1.78-2.12). The corresponding value for DCIS was 1.61 (1.28-2.02). We estimated the population attributable fraction to 8.2%, corresponding to 90 breast cancer cases in 2006 indicating that HT use still caused a major number of breast cancer cases.
Notes
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PubMed ID
25991514 View in PubMed
Less detail

Breast cancer mortality in organised mammography screening in Denmark: comparative study.

https://arctichealth.org/en/permalink/ahliterature97599
Source
BMJ. 2010;340:c1241
Publication Type
Article
Date
2010
Author
Karsten Juhl Jørgensen
Per-Henrik Zahl
Peter C Gøtzsche
Author Affiliation
The Nordic Cochrane Centre, Rigshospitalet, University of Copenhagen, Denmark. kj@cochrane.dk
Source
BMJ. 2010;340:c1241
Date
2010
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Breast Neoplasms - mortality - prevention & control - radiography
Denmark - epidemiology
Epidemiologic Methods
Female
Humans
Mammography - mortality
Middle Aged
Abstract
OBJECTIVE: To determine whether the previously observed 25% reduction in breast cancer mortality in Copenhagen following the introduction of mammography screening was indeed due to screening, by using an additional screening region and five years additional follow-up. DESIGN: We used Poisson regression analyses adjusted for changes in age distribution to compare the annual percentage change in breast cancer mortality in areas where screening was used with the change in areas where it was not used during 10 years before screening was introduced and for 10 years after screening was in practice (starting five years after introduction of screening). SETTING: Copenhagen, where mammography screening started in 1991, and Funen county, where screening was introduced in 1993. The rest of Denmark (about 80% of the population) served as an unscreened control group. PARTICIPANTS: All Danish women recorded in the Cause of Death Register and Statistics Denmark for 1971-2006. MAIN OUTCOME MEASURE: Annual percentage change in breast cancer mortality in regions offering mammography screening and those not offering screening. RESULTS: In women who could benefit from screening (ages 55-74 years), we found a mortality decline of 1% per year in the screening areas (relative risk (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.01) during the 10 year period when screening could have had an effect (1997-2006). In women of the same age in the non-screening areas, there was a decline of 2% in mortality per year (RR 0.98, 95% CI 0.97 to 0.99) in the same 10 year period. In women who were too young to benefit from screening (ages 35-55 years), breast cancer mortality during 1997-2006 declined 5% per year (RR 0.95, CI 0.92 to 0.98) in the screened areas and 6% per year (RR 0.94, CI 0.92 to 0.95) in the non-screened areas. For the older age groups (75-84 years), there was little change in breast cancer mortality over time in both screened and non-screened areas. Trends were less clear during the 10 year period before screening was introduced, with a possible increase in mortality in women aged less than 75 years in the non-screened regions. CONCLUSIONS: We were unable to find an effect of the Danish screening programme on breast cancer mortality. The reductions in breast cancer mortality we observed in screening regions were similar or less than those in non-screened areas and in age groups too young to benefit from screening, and are more likely explained by changes in risk factors and improved treatment than by screening mammography.
PubMed ID
20332505 View in PubMed
Less detail

[Breast cancer mortality versus breast cancer survival]

https://arctichealth.org/en/permalink/ahliterature98022
Source
Tidsskr Nor Laegeforen. 2010 Feb 11;130(3):261
Publication Type
Article
Date
Feb-11-2010
Author
Per-Henrik Zahl
Jan Maehlen
Author Affiliation
Nasjonalt folkehelseinstitutt.
Source
Tidsskr Nor Laegeforen. 2010 Feb 11;130(3):261
Date
Feb-11-2010
Language
Norwegian
Publication Type
Article
Keywords
Breast Neoplasms - mortality
Female
Humans
Mammography
Mass Screening
Norway - epidemiology
Survival Rate
PubMed ID
20160765 View in PubMed
Less detail
Source
Ann Intern Med. 2017 10 03;167(7):524
Publication Type
Article
Date
10-03-2017
Author
Karsten Juhl Jørgensen
Peter C Gøtzsche
Mette Kalager
Per-Henrik Zahl
Source
Ann Intern Med. 2017 10 03;167(7):524
Date
10-03-2017
Language
English
Publication Type
Article
Keywords
Breast Neoplasms
Denmark
Early Detection of Cancer
Humans
Mammography
Mass Screening
Notes
Comment On: Ann Intern Med. 2017 Mar 7;166(5):313-32328114661
Comment On: Ann Intern Med. 2017 Oct 3;167(7):52228973198
Comment On: Ann Intern Med. 2017 Oct 3;167(7):523-52428973197
Comment On: Ann Intern Med. 2017 Oct 3;167(7):52328973199
PubMed ID
28973200 View in PubMed
Less detail

Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis.

https://arctichealth.org/en/permalink/ahliterature282568
Source
Ann Intern Med. 2017 Mar 07;166(5):313-323
Publication Type
Article
Date
Mar-07-2017
Author
Karsten Juhl Jørgensen
Peter C Gøtzsche
Mette Kalager
Per-Henrik Zahl
Source
Ann Intern Med. 2017 Mar 07;166(5):313-323
Date
Mar-07-2017
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Breast Neoplasms - diagnosis - epidemiology
Carcinoma, Intraductal, Noninfiltrating - diagnosis - epidemiology
Cohort Studies
Denmark - epidemiology
Early Detection of Cancer
Female
Humans
Incidence
Mammography
Mass Screening
Medical Overuse - statistics & numerical data
Middle Aged
Abstract
Effective breast cancer screening should detect early-stage cancer and prevent advanced disease.
To assess the association between screening and the size of detected tumors and to estimate overdiagnosis (detection of tumors that would not become clinically relevant).
Cohort study.
Denmark from 1980 to 2010.
Women aged 35 to 84 years.
Screening programs offering biennial mammography for women aged 50 to 69 years beginning in different regions at different times.
Trends in the incidence of advanced (>20 mm) and nonadvanced (=20 mm) breast cancer tumors in screened and nonscreened women were measured. Two approaches were used to estimate the amount of overdiagnosis: comparing the incidence of advanced and nonadvanced tumors among women aged 50 to 84 years in screening and nonscreening areas; and comparing the incidence for nonadvanced tumors among women aged 35 to 49, 50 to 69, and 70 to 84 years in screening and nonscreening areas.
Screening was not associated with lower incidence of advanced tumors. The incidence of nonadvanced tumors increased in the screening versus prescreening periods (incidence rate ratio, 1.49 [95% CI, 1.43 to 1.54]). The first estimation approach found that 271 invasive breast cancer tumors and 179 ductal carcinoma in situ (DCIS) lesions were overdiagnosed in 2010 (overdiagnosis rate of 24.4% [including DCIS] and 14.7% [excluding DCIS]). The second approach, which accounted for regional differences in women younger than the screening age, found that 711 invasive tumors and 180 cases of DCIS were overdiagnosed in 2010 (overdiagnosis rate of 48.3% [including DCIS] and 38.6% [excluding DCIS]).
Regional differences complicate interpretation.
Breast cancer screening was not associated with a reduction in the incidence of advanced cancer. It is likely that 1 in every 3 invasive tumors and cases of DCIS diagnosed in women offered screening represent overdiagnosis (incidence increase of 48.3%).
None.
PubMed ID
28114661 View in PubMed
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Chain of care for patients who have attempted suicide: a follow-up study from Bærum, Norway.

https://arctichealth.org/en/permalink/ahliterature137323
Source
BMC Public Health. 2011;11:81
Publication Type
Article
Date
2011
Author
Håkon A Johannessen
Gudrun Dieserud
Diego De Leo
Bjørgulf Claussen
Per-Henrik Zahl
Author Affiliation
Department of Suicide Research and Prevention, Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway. hajn@fhi.no
Source
BMC Public Health. 2011;11:81
Date
2011
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Female
Follow-Up Studies
Humans
Logistic Models
Male
Medical Audit
Middle Aged
Norway - epidemiology
Patient care team
Program Evaluation
Proportional Hazards Models
Registries
Risk
Risk factors
Risk Management - methods
Social Support
Suicide, Attempted - prevention & control - statistics & numerical data
Young Adult
Abstract
Individuals who have attempted suicide are at increased risk of subsequent suicidal behavior. Since 1983, a community-based suicide prevention team has been operating in the municipality of Bærum, Norway. This study aimed to test the effectiveness of the team's interventions in preventing repeated suicide attempts and suicide deaths, as part of a chain of care model for all general hospital treated suicide attempters.
Data has been collected consecutively since 1984 and a follow-up was conducted on all individuals admitted to the general hospital after a suicide attempt. The risk of repeated suicide attempt and suicide were comparatively examined in subjects who received assistance from the suicide prevention team in addition to treatment as usual versus those who received treatment as usual only. Logistic regression and Cox regression were used to analyze the data.
Between January 1984 and December 2007, 1,616 subjects were registered as having attempted suicide; 197 of them (12%) made another attempt within 12 months. Compared to subjects who did not receive assistance from the suicide prevention team, individuals involved in the prevention program did not have a significantly different risk of repeated attempt within 6 months (adjusted OR = 1.08; 95% CI = 0.66-1.74), 12 months (adjusted OR = 0.86; 95% CI = 0.57-1.30), or 5 years (adjusted RR = 0.90; 95% CI = 0.67-1.22) after their first recorded attempt. There was also no difference in risk of suicide (adjusted RR = 0.85; 95% CI = 0.46-1.57). Previous suicide attempts, marital status, and employment status were significantly associated with a repeated suicide attempt within 6 and 12 months (p 0.05). With each year of age, the risk of suicide increased by 3% (p
Notes
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PubMed ID
21294876 View in PubMed
Less detail

Changes in mental health services and suicide mortality in Norway: an ecological study.

https://arctichealth.org/en/permalink/ahliterature135830
Source
BMC Health Serv Res. 2011;11:68
Publication Type
Article
Date
2011
Author
Håkon A Johannessen
Gudrun Dieserud
Bjørgulf Claussen
Per-Henrik Zahl
Author Affiliation
Division of Mental Health, Department of Suicide Research and Prevention, Norwegian Institute of Public Health, Oslo, Norway. hajn@fhi.no
Source
BMC Health Serv Res. 2011;11:68
Date
2011
Language
English
Publication Type
Article
Keywords
Female
Health Resources - supply & distribution
Humans
Male
Mental Health Services - organization & administration - supply & distribution
Mortality - trends
Norway - epidemiology
Suicide - statistics & numerical data - trends
Abstract
Mental disorders are strongly associated with excess suicide risk, and successful treatment might prevent suicide. Since 1990, and particularly after 1998, there has been a substantial increase in mental health service resources in Norway. This study aimed to investigate whether these changes have had an impact on suicide mortality.
We used Poisson regression analyses to assess the effect of changes in five mental health services variables on suicide mortality in five Norwegian health regions during the period 1990-2006. These variables included: number of man-labour years by all personnel, number of discharges, number of outpatient consultations, number of inpatient days, and number of hospital beds. Adjustments were made for sales of alcohol, sales of antidepressants, education, and unemployment.
In the period 1990-2006, we observed a total of 9480 suicides and the total suicide rate declined by 26%. None of the mental health services variables were significantly associated with female or male suicide mortality in the adjusted analyses (p > 0.05). Sales of antidepressants (adjusted Incidence Rate Ratio = 0.98; 95% CI = 0.97-1.00) and sales of alcohol (adjusted IRR = 1.41; 95% CI = 1.18-1.72) were significantly associated with female suicide mortality; education (adjusted IRR = 0.86; 95% CI = 0.79-0.94) and unemployment (adjusted IRR = 0.91; 95% CI = 0.85-0.97) were significantly associated with male suicide mortality.
The adjusted analyses in the present study indicate that increased resources in Norwegian mental health services in the period 1990-2006 were statistically unrelated to suicide mortality.
Notes
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PubMed ID
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