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The opioid epidemic in the U.S has gotten payers, prescribers, and policymakers alike interested in trends in opioid use. Despite no recognized opioid crisis in Europe, several countries have reported an increase in opioid-related deaths, which has further prompted discussion on the need of monitoring of opioid prescriptions. This study was conducted to offer information on opioid use during the escalation of the U.S. opioid epidemic in Finland, a Nordic country with universal tax-based health care. This is a nationwide retrospective register-based cohort study on all individuals in Finland who were dispensed opioids in 2009–2017 (n of unique patients = 1,761,584). By using the unique personal identification code assigned to every Finnish resident, we linked data from nationwide registers on dispensed drugs, medical history, and socio-demographic parameters. We report a wide set of patient demographics, dispensing trends for all opioid Anatomical Therapeutic Chemical (ATC) classes, and reasons for opioid initiation based on diagnostic coding for the most recent health care visit. For a cohort of incident opioid users with a four-year wash-out period (n = 1 370 057), we also present opioid use patterns in a three-year follow-up: the likelihood of becoming a persistent user or escalating from weak to strong opioids. A steady 7% of the Finnish population were dispensed opioids annually in 2009-2017. The mean annual quantity of dispensed opioids per opioid patient increased between 2009 and 2017 by 33%, reaching 2 583 oral morphine equivalent mg (OMEQ)/patient/year in 2017. The median quantity of dispensed opioids was lower: 315 OMEQ/year/patient. Depending on the opioid ATC class, there were either increasing or decreasing numbers of patients who had been dispensed said opioid class, and also in the mean quantity. The most common reason for opioid initiation was post-surgical pain (20%), followed by musculoskeletal pain (15%), injury (8.3%), and non-postsurgical dental pain (6.2%). 94% of new opioid initiators started with a weak opioid, i.e. codeine or tramadol. 85% of the patients who had been dispensed a weak opioid were not dispensed an opioid subsequently 3–6 months after the first one, and 95% of them had not escalated to a strong opioid in a 3-year follow-up. The number of patients dispensed opioids in Finland did not change during the escalation of the opioid epidemic in the U.S., but there were changes in the quantity of opioids dispensed per patient. Opioid therapy was typically initiated with weak opioid, the initial dispensed prescription was relatively small, and escalation to strong opioids was rare. A considerable share of patients had been prescribed opioids for chronic non-cancer pain - a type of pain where the risk-benefit ratio of opioids is controversial.

The health economic evidence about the value and optimal targeting of genetic testing in the prevention of coronary heart disease (CHD) events has remained limited and ambiguous. The objective of this study is to optimize the population-level use and targeting of genetic testing alongside traditional risk factors in the prevention of CHD events and, thereby, to assess the cost-benefit of genetic testing. We compare several strategies for using traditional and genetic testing in the prevention of CHD through statin therapy. The targeting of tests to different patient segments within these strategies is optimized by using a decision-analytic model, in which a patient's estimated risk of CHD is updated based on test results using Bayesian methods. We adopt the perspective of healthcare sector. The data for the model is exceptionally wide and combined from national healthcare registers, the Finnish Institute for Molecular Medicine, and published literature. Our results suggest that targeting genetic testing in an optimal way to those patients about which traditional risk factors do not provide sufficiently accurate information results in the highest expected net benefit. In particular, compared to the use of traditional risk factors only, the optimal use of genetic testing would decrease the expected costs of an average patient aged 45 years or more by 2.54€ in a 10-year follow-up period while maintaining the level of the expected health outcome. Thus, genetic testing is found to be a part of a cost-beneficial testing strategy alongside traditional risk factors. This conclusion is robust to reasonable changes in model inputs. If targeted optimally, the use of genetic testing alongside traditional risk factors is cost-beneficial in the prevention of CHD.

Background Sleep apnea is associated with chronic comorbidities and acute complications. Existing data suggest that sleep apnea may predispose to an increased risk and severity of respiratory tract infections. Methods We investigated the incidence of lower respiratory tract infections in the first and second year before and after diagnosis of sleep apnea in a Finnish nationwide, population-based, retrospective case–control study based on linking data from the national health care registers for primary and secondary care from 2015–2019. Controls were matched for age, sex, hospital district, and multimorbidity status. We furthermore analysed the independent effect of comorbidities and other patient characteristics on the risk of lower respiratory tract infections, and their recurrence. Results Sleep apnea patients had a higher incidence of lower respiratory tract infections than their matched controls within one year before (hazard ratio 1.35, 95% confidence interval 1.16–1.57) and one year after (hazard ratio1.39, 95% confidence interval1.22–1.58) diagnosis of sleep apnea. However, we found no difference in the incidence of lower respiratory tract infections within the second year before or after diagnosis of sleep apnea in comparison with matched controls. In sleep apnea, history of lower respiratory tract infection prior to sleep apnea, multimorbidity, COPD, asthma, and age greater than 65 years increased the risk of incident and recurrent lower respiratory tract infections. Conclusions Sleep apnea patients are at increased risk of being diagnosed with a lower respiratory tract infection within but not beyond one year before and after diagnosis of sleep apnea. Among sleep apnea patients, chronic comorbidities had a significant impact on the risk of lower respiratory tract infections and their recurrence.

Background The study aim was to analyse how mental health services are used in different parts of the Kainuu region in Finland and whether travel time to primary health care services is associated with the use of different contact types (in-person visits, remote contacts, home visits). Methods The study population included adults who had used mental health services under primary health care ( N  = 7643) between 2015 and 2019. The travel times to the nearest health centre in a municipality were estimated as the population-weighted average drive time in postal code areas. The Kruskal–Wallis test and pairwise comparisons with Dunn-Bonferroni post hoc tests were used to assess the differences in mental health service use between health centre areas. A negative binomial regression was performed for the travel time categories using different contact types of mental health service use as outcomes. Models were adjusted for gender, age, number of mental health diseases and the nearest health centre in the municipality. Results Distance was negatively associated with mental health service use in health centre in-person visits and in home visits. In the adjusted models, there were 36% fewer in-person visits and 83% fewer home visits in distances further than 30 min, and 67% fewer home visits in a travel time distance of 15–30 min compared with 15 min travel time distance from a health centre. In the adjusted model, in remote contacts, the incidence rate ratios increased with distance, but the association was not statistically significant. Conclusions The present study revealed significant differences in mental health service use in relation to travel time and contact type, indicating possible problems in providing services to distant areas. Long travel times can pose a barrier, especially for home care and in-person visits. Remote contacts may partly compensate for the barrier effects of long travel times in mental health services. Especially with conditions that call for the continuation and regularity of care, enabling factors, such as travel time, may be important.

Atrial fibrillation (AF) is a major cause of ischemic stroke and the number of AF patients is increasing. Thus, up-to-date multifaceted data about the characteristics of AF patients, their treatments, and outcomes are urgently needed. The Finnish anticoagulation in atrial fibrillation (FinACAF) study has collected comprehensive data on all Finnish AF patients from 1st January 2004 to 31st December 2018. The aim of this paper is to describe the study rationale, the process of integrating data from the applied resources and to define the study cohort. Using national unique personal identification number, individual patient data is linked from nationwide health care registries (primary, secondary, and tertiary care), drug purchases, education, and socio-economic status as well as places of domicile, incomes, and taxes. Six regional laboratory databases (~282,000, 77% of the patients) are also included. The study cohort comprises of a total of 411,000 patients. Since the introduction of the national primary care register in 2012, 9% of all AF patients were identified outside hospital care registers. The prevalence of AF in Finland—4.1% of whole population—is for the first time now established. The FinACAF study allows a unique possibility to investigate the epidemiology and socio-medico-economic impact of AF as well as the cost effectiveness of different AF management strategies in a completely unselected, nationwide population. This article provides the rationale and design of the study together with a summary of the characteristics of the cohort.

Narcolepsy is a rare neurological sleep disorder especially in children who are younger than 10 years. In the beginning of 2010, an exceptionally large number of Finnish children suffered from an abrupt onset of excessive daytime sleepiness (EDS) and cataplexy. Therefore, we carried out a systematic analysis of the incidence of narcolepsy in Finland between the years 2002-2010. All Finnish hospitals and sleep clinics were contacted to find out the incidence of narcolepsy in 2010. The national hospital discharge register from 2002 to 2009 was used as a reference. Altogether 335 cases (all ages) of narcolepsy were diagnosed in Finland during 2002-2009 giving an annual incidence of 0.79 per 100,000 inhabitants (95% confidence interval 0.62-0.96). The average annual incidence among subjects under 17 years of age was 0.31 (0.12-0.51) per 100,000 inhabitants. In 2010, 54 children under age 17 were diagnosed with narcolepsy (5.3/100,000; 17-fold increase). Among adults ≥20 years of age the incidence rate in 2010 was 0.87/100,000, which equals that in 2002-2009. Thirty-four of the 54 children were HLA-typed, and they were all positive for narcolepsy risk allele DQB1*0602/DRB1*15. 50/54 children had received Pandemrix vaccination 0 to 242 days (median 42) before onset. All 50 had EDS with abnormal multiple sleep latency test (sleep latency <8 min and ≥2 sleep onset REM periods). The symptoms started abruptly. Forty-seven (94%) had cataplexy, which started at the same time or soon after the onset of EDS. Psychiatric symptoms were common. Otherwise the clinical picture was similar to that described in childhood narcolepsy. A sudden increase in the incidence of abrupt childhood narcolepsy was observed in Finland in 2010. We consider it likely that Pandemrix vaccination contributed, perhaps together with other environmental factors, to this increase in genetically susceptible children.

Background Information about health care use and costs of cutaneous T-cell lymphoma (CTCL) patients is limited, particularly in a European setting. Methods In this population-wide study we set out to investigate prevalence, and trends in health care use in two CTCL subtypes, mycosis fungoides (MF) and Sézary syndrome (SS) over a time period of 19 years in 1998–2016 by using a nation-wide patient register containing data on all diagnosed MF and SS cases in Finland. Results The prevalence of diagnosed MF and SS rose from 2.04 to 5.38/100000, and from 0.16 to 0.36/100000 for MF and SS respectively during 1998–2016. We found a substantial decrease in inpatient treatment of MF/SS in the past two decades with a mean of 2 inpatient days/patient/year due to MF/SS in 2016, while the mean numbers of MF/SS related outpatient visits remained stable at 8 visits/year/patient. Most MF/SS-related outpatient visits occurred in the medical specialty of dermatology. In a ten-year follow-up after MF/SS diagnosis, the main causes for outpatient visits and inpatient stays were MF/SS itself, other cancers, and other skin conditions. Also cardiovascular disease and infections contributed to the number of inpatient days. Mean total hospital costs decreased from 11,600 eur/patient/year to 3600 eur/patient/year by year 4 of the follow-up, and remained at that level for the remainder of the 10-year follow-up. MF/SS accounted for approximately half of the hospital costs of these patients throughout the follow-up. Conclusions The nearly 3-fold increase in prevalence of diagnosed MF/SS during 1998–2016 puts pressure on the health care system, as this is a high-cost patient group with a heavy burden of comorbidities. The challenge can be in part answered by shifting the treatment of MF/SS to a more outpatient-based practice, and by adapting new pharmacotherapy, as has been done in Finland.

Background Opioid use is associated with increased health care service utilization but home care recipients and patients with dementia have been mostly ignored in earlier studies, although changes in their health status can have dramatic cost consequences. This study examined social and health care utilization and costs among older home care recipients before and after opioid initiation, with persons with dementia as a subgroup of interest. Methods This retrospective nationwide register-linkage study included Finnish regular home care recipients aged ≥ 65 years with opioid initiation between 1st March 2015 and 31st December 2016. Recipients with health care contacts due to cancer and palliative care were excluded. Incidence rate ratios of social and health care service use during the observation period starting one year before and ending one year after opioid initiation were calculated using nationwide register data. The utilization costs of various social and health care service categories were compared before and after the opioid initiation. Recipients with and without dementia were analysed separately. Results Home care recipients had 1.76 (95% CI 1.75 − 1.78) times more inpatient days, 1.31 (1.26 − 1.36) times more emergency care admissions, and recipients without dementia had more outpatient service use (secondary care 1.10 [1.06 − 1.13], primary care 1.06 [1.04 − 1.07]) after opioid initiation compared to the preceding year. Home care service use decreased (0.85 [0.85 − 0.85]) in recipients with dementia but increased in those without (1.08 [1.08 − 1.08]). Of the recipients, 20.8% were admitted to long-term residential care during the follow-up year. The mean annual total costs per recipient were 21% higher during the year following opioid initiation compared to the preceding year. A peak in the costs, consisting largely of inpatient costs, was observed about a month before opioid initiation, after which costs showed a declining trend but remained above the baseline level. Conclusions Recipients’ monthly health care resource use started to increase already before opioid initiation, after which monthly expenditures declined steadily, which may reflect mostly recipients’ worsened health status before opioid initiation. Most of the expenditures arose from housing services. The relationship between opioid use and utilization of residential care and home care services should be further examined. Trial registration Not applicable (a retrospective register-based study).

Treatments should be customized to patients to improve patients' health outcomes and maximize the treatment benefits. We aimed to identify meaningful data-driven trajectories of incident type 2 diabetes patients with similarities in glycated haemoglobin (HbA1c) patterns since diagnosis and to examine their clinical and economic relevance. A cohort of 1540 patients diagnosed in 2011-2012 was retrieved from electronic health records covering primary and specialized healthcare in the North Karelia region, Finland. EHRs data were compiled with medication purchase data. Average HbA1c levels, use of medications, and incidence of micro- and macrovascular complications and deaths were measured annually for seven years since T2D diagnosis. Trajectories were identified applying latent class growth models. Differences in 4-year cumulative healthcare costs with 95% confidence intervals (CIs) were estimated with non-parametric bootstrapping. Four distinct trajectories of HbA1c development during 7 years after T2D diagnosis were extracted: patients with \"Stable, adequate\" (66.1%), \"Slowly deteriorating\" (24.3%), and \"Rapidly deteriorating\" glycaemic control (6.2%) as well as \"Late diagnosed\" patients (3.4%). During the same period, 2.2 (95% CI 1.9-2.6) deaths per 100 person-years occurred in the \"Stable, adequate\" trajectory increasing to 3.2 (2.4-4.0) in the \"Slowly deteriorating\", 4.7 (3.1-6.9) in the \"Rapidly deteriorating\" and 5.2 (2.9-8.7) in the \"Late diagnosed\" trajectory. Similarly, 3.5 (95% CI 3.0-4.0) micro- and macrovascular complications per 100 person-years occurred in the \"Stable, adequate\" trajectory increasing to 5.1 (4.1-6.2) in the \"Slowly deteriorating\", 5.5 (3.6-8.1) in the \"Rapidly deteriorating\" and 7.3 (4.3-11.8) in the \"Late diagnosed\" trajectory. Patients in the \"Stable, adequate\" trajectory had lower accumulated 4-year medication costs than other patients. Data-driven patient trajectories have clinical and economic relevance and could be utilized as a step towards personalized medicine instead of the common \"one-fits-for-all\" treatment practices.

Background Anticoagulant therapies are used to prevent atrial fibrillation-related strokes, with warfarin and direct oral anticoagulant (DOAC) the most common. In this study, we incorporate direct health care costs, drug costs, travel costs, and lost working and leisure time costs to estimate the total costs of the two therapies. Methods This retrospective study used individual-level patient data from 4000 atrial fibrillation (AF) patients from North Karelia, Finland. Real-world data on healthcare use was obtained from the regional patient information system and data on reimbursed travel costs from the database of the Social Insurance Institution of Finland. The costs of the therapies were estimated between June 2017 and May 2018. Using a Geographical Information System (GIS), we estimated travel time and costs for each journey related to anticoagulant therapies. We ultimately applied therapy and travel costs to a cost model to reflect real-world expenditures. Results The costs of anticoagulant therapies were calculated from the standpoint of patient and the healthcare service when considering all costs from AF-related healthcare visits, including major complications arising from atrial fibrillation. On average, the annual cost per patient for healthcare in the form of public expenditure was higher when using DOAC therapy than warfarin therapy (average cost = € 927 vs. € 805). Additionally, the average annual cost for patients was also higher with DOAC therapy (average cost = € 406.5 vs. € 296.7). In warfarin therapy, patients had considerable more travel and time costs due the different implementation practices of therapies. Conclusion The results indicated that DOAC therapy had higher costs over warfarin from the perspectives of the patient and healthcare service in the study area on average. Currently, the cost of the DOAC drug is the largest determinator of total therapy costs from both perspectives. Despite slightly higher costs, the patients on DOAC therapy experienced less AF-related complications during the study period.