In Denmark the number of cataract extractions has increased 350% from 1980 to 1991. During the same period the elderly population at risk has only increased 17%, and thus cannot account for the large increase in the number of extractions. In order to investigate whether more comprehensive clinical indications could be a possible explanation, we compared pre-operative visual acuity and visual impairment in two consecutive samples of Danish cataract surgery patients obtained in 1980 (n = 73) and in 1992 (n = 290). Criteria for inclusion were similar and both samples were representative for the whole country. During the period mean pre-operative visual acuity increased from 0.04 to 0.16 in the eye enlisted for surgery (p
We studied complications after hysterectomy among all women in the Danish population who had a simple hysterectomy in the period 1978-81 based on data obtained from the Danish National Hospital Registry. Among patients, with neither diagnosed cancer nor major co-surgery (n = 23,386), we identified all the complications which occurred during hospital admission from the time of surgery up to six years from that point. Within 30 days of hysterectomy 2.6% of the patients had been diagnosed in hospitals as having complications according to our definition. The corresponding figures at 90 days and two years after the operation were 3.7% and 9.4%. The most frequently observed complications were post operative wound infections and bleeding, each affecting about 2% of all operated women. Logistic regression and Cox regression were used to identify prognostic indicators of readmission with complications. The probability of readmission with complications within six years after hysterectomy was estimated at 8% among low risk patients. The most pronounced increase in risk of readmission with complication occurred among women who had been admitted to psychiatric or somatic hospitals 0-12 months before they had their uterus removed (OR in the range 1.59 to 1.83). We discuss the prevailing difficulties of comparing observational evidence from different clinical settings reported in the literature, and emphasize the importance of developing a coordinated international strategy for non-experimental assessment of medical technology.
This article examines some of the key research and policy issues that are emerging as a result of recent analyses of regional variations in health care. The article presents a historical background to this important new field of health services' research, and indicates, using some Danish examples of research on hysterectomy, cholecystectomy, and prostatectomy, the relevance of this research to management and policy planning. Regional variations are not yet fully explained in terms of what causes them. What is clear and what is the primary focus of this article is that their very existence, whatever their explanation, creates a major challenge for the management and planning of future health services.
OBJECTIVES: Patient-based health status measures have an important role to play in the assessment of health care outcomes. Among these measures, global assessments increasingly have been used, although the understanding of the performance of these indicators and the determinants of patients responses is underdeveloped. In this study, the performance of a single-item global indicator of visual function in cataract patients of four international settings was compared. METHODS: Visual acuity and ocular comorbidity was assessed by patients' ophthalmologist using Snellen-type charts in patients referred for a first cataract surgery in the United States, Manitoba (Canada), Denmark, and Barcelona (Spain). Patients also were interviewed by telephone and asked to report overall trouble with vision on a single-item indicator ("great deal," "moderate," "a little," "none") and to complete the Visual Functioning Index (VF-14), a scale of visual function ranging from 0 (worst function) to 100 (best level of function), along with other questions including the degree the patient was bothered by symptoms as measured by the Cataract Symptom Score (CSS). A total of 1,407 patients completed the clinical examination and the preoperative interview. RESULTS: Distribution of overall trouble with vision varied across the sites, with the proportion of patients reporting a great deal of trouble ranging from 21.7% to 37.9%. In all sites, patients reporting more trouble with vision tended to show a poorer age-adjusted and sex-adjusted visual acuity. The proportion of patients reporting great deal of trouble with vision was higher in the groups with worse visual acuity (P
The Danish National Hospital Register (LPR) has collected nationwide data on all somatic hospital admissions since 1977, and since 1995 data on outpatients and emergency patients have been included as well. Numerous research projects have been undertaken in the national Danish context as well as in collaboration with international teams, and the LPR is truly a valuable source of data for health sciences, especially in epidemiology, health services research and clinical research. Nearly complete registration of somatic hospital events in Denmark is combined with ideal conditions for longterm follow-up due to the existence of a national system of unique person identification in a population of relative demographic stability. Examples of studies are provided for illustration within three main areas: I: Using LPR for surveillance of the occurrence of diseases and of surgical procedures, II: Using the Register as a sampling frame for longitudinal population based and clinical research, and III: Using the Register as a data source for monitoring outcomes. Data available from the Register as well as studies of the validity of the data are mentioned, and it is described how researchers may get access to the Register. The Danish National Hospital Register is well suited to contribute to international comparative studies with relevance for evidence-based medicine.
This paper assesses the risk of dying within 30 days of admission among 13,854 women who had a cholecystectomy performed as the principal operation from 1977 to 1981. The overall crude mortality rate was 1.2%. Women who had a simple elective cholecystectomy performed had a mortality rate similar to women who had a simple hysterectomy. The mortality was significantly higher than in the general female population (p less than 0.05). Increased age, acute admission, admissions to hospital within 3 months prior to the index admission, the number of discharge diagnoses, and the geographical region were significantly associated with increased mortality. Exploration of the common bile duct was associated with higher mortality in the bivariate analysis, but the association disappeared when the number of discharge diagnoses was taken into account. Type of hospital and the population based cholecystectomy rate of the patient's residential area was not associated with mortality. As regards early mortality, it is concluded that simple elective cholecystectomy is a safe procedure before the age of 50 to 60 years. Acute admissions and more than one diagnosis at discharge were associated with an increased mortality, whereas exploration of the common bile duct may not be as important an independent factor as previously assumed.
The main objective of this cohort study was to analyse the early postoperative mortality after 'simple' hysterectomy for benign indications and to compare it with that of a randomly selected reference group of women matched for age. Registry data covering the entire Danish female population were used. Included in the study were all patients operated in the period 1977-1981. Patients were only included if no cancer was diagnosed and if no major co-surgery was performed (29,192 patients). Cancer patients were also excluded in the reference group (16,182 women). Mortality was studied according to characteristics of patients, their residential area, the surgical approach and operating hospital. Overall 47 patients died within 30 days of admission for hysterectomy (overall mortality 16.1 per 10,000). Only seven deaths were expected on the basis of the population sample, and adjusted for age, the relative risk (RR) for hysterectomy patients was 6.38 (95% CI 4.33-9.39). Early postoperative mortality increased with age, and the risk was elevated among emergency patients (RR = 3.22; 1.72-6.04). Patients with more than one diagnosis at discharge (RR = 4.53; 2.12-9.70) were at high risk, but early postoperative mortality was independent of surgical approach. Causes of death are discussed. Compared to the general population, patients who undergo 'simple' hysterectomy are faced with a sixfold risk of dying within 30 days, but a complete assessment of the risks and benefits of hysterectomy requires prospective studies of survival and morbidity, including quality of life for longer periods of time following operations.
This paper reevaluates the recently reported excess mortality following transurethral resection of the prostate (TURP) for benign hypertrophy as compared with traditional open resection (OPEN). We studied survival through linkage of hospital discharge data with mortality data for the entire male population of Denmark (1977-85). For a maximum of 10.5 years 38,067 prostatectomy patients were followed. Adjusting for age and health status before surgery, TURP patients were subject to significantly higher levels of mortality than OPEN patients (RR = 1.19, 95% confidence interval (1.15-1.24). The extent to which this difference is attributable to the surgical intervention itself remains an open question. The two groups of patients are quite different with regard to age and preoperative health status, and available data may not be sufficient to control such differences through statistical analysis. On the other hand, the difference in mortality persisted over calendar time, even during periods when the pattern of utilization for the two procedures changed significantly (constant RR = 1.19, adjusting for age and comorbidity). The most important causes of death among Danish TURP patients differ from the causes suggested on the basis of previously reported Canadian data. The current evidence is thus ambiguous with regard to hypothetical biologic mechanisms behind the excess mortality over TURP patients. Further investigations are needed to evaluate the safety and effectiveness of prostate surgery.
Comment In: Med Care. 1990 Oct;28(10):867-92232918
Fragrances are the first or second most common cause of contact allergy in dermatitis patients.
The aim of this study was to identify risk products for fragrance contact allergy.
The design was a case-control study with a case group of 78 fragrance-mix-positive eczema patients and two control groups, one consisting of 1,279 subjects selected as a random sample of the general population and the other consisting of 806 fragrance-mix-negative eczema patients. The identification of risk products was based on the patients' histories of rash to scented products. Analysis of the associations between first-time rash caused by different specified product categories and fragrance mix sensitivity was performed using logistic regression.
It was found that first-time rash caused by deodorant sprays and/or perfumes were related to fragrance contact allergy in a comparison with both control groups. The risk (odds ratio) of being diagnosed as fragrance allergic was 2.3 to 2.9 greater in cases of a history of first-time rash to deodorant sprays and 3.3 to 3.4 greater in cases of a history of rash to perfumes than if no such history were present. First-time rash to cleansing agents, deodorant sticks, or hand lotions was also statistically significant but only in comparison with one of the control groups.
Safety evaluation of fragrance materials used in perfumes and deodorant sprays should be performed with special attention.
In Denmark the number of cataract extractions has increased to 350% from 1980 to 1991. During the same period the elderly population at risk has only increased to 117%, and thus cannot account for the large increase in the number of extractions. In order to investigate whether more comprehensive clinical indications could be a possible explanation, we compared pre-operative visual acuity and visual impairment in two consecutive samples of Danish cataract surgery patients obtained in 1980 (n = 73) and in 1992 (n = 270). Criteria for inclusion were similar and both samples were representative for the whole country. During the period mean pre-operative visual acuity increased from 0.04 to 0.16 in the eye enlisted for surgery (p