BackgroundEarly identification of persons at risk of sickness absence due to work-related stress is a crucial problem for society in general, and primary health care in particular. Tho date, no established method to do this exists. This project’s aim is to evaluate whether systematic early identification of work-related stress can prevent sickness absence. This paper presents the study design, procedure and outcome measurements, as well as allocation and baseline characteristics of the study population.Method/designThe study is a two-armed randomized controlled trial with follow-up at 3, 6 and 12 months. Non-sick-listed employed women and men, aged 18 to 64 years, who had mental and physical health complaints and sought care at primary health care centers (PHCC) were eligible to participate. At baseline work-related stress was measured by the Work Stress Questionnaire (WSQ), combined with feedback at consultation, at PHCC. The preventive intervention included early identification of work-related stress by the WSQ, GP training in the use of WSQ, GP feedback at consultation and finding suitable preventive measures. A process evaluation was used to explore how to facilitate future implementation and structural use of the WSQ at the PHCC. The primary outcome to compare the preventive sick leave intervention by the general practitioner (GP) versus treatment as usual is sick leave data obtained from the Swedish Social Insurance Agency register.DiscussionEarly screening for sick leave due to work-related stress makes it possible not only to identify those at risk for sick leave, but also to put focus on the patient’s specific work-related stress problems, which can be helpful in finding suitable preventive measures. This study investigates if use of the WSQ by GPs at PHCCs, combined with feedback at consultation, prevents future sickness absence.Trial registrationClinicalTrials.gov. Identifier: NCT02480855. Registered 20 May 2015

Background and aims: The ReFLeCT study demonstrated that switching to insulin degludec from other basal insulins was associated with reductions in glycated hemoglobin and hypoglycemic events in type 1 (T1D) and type 2 diabetes (T2D), and reductions in insulin doses in T1D. The aim of the present analysis was to assess the short-and long-term cost-effectiveness of switching to insulin degludec in Sweden. Methods: Short-term outcomes were evaluated over 1 year in a Microsoft Excel model, while longterm outcomes were projected over patient lifetimes using the IQVIA CORE Diabetes Model. Cohort characteristics and treatment effects were sourced from the ReFLeCT study. Costs (in 2018 Swedish krona [SEK]) encompassed direct medical expenditure and indirect costs from loss of workplace productivity. In the long-term analyses, patients were assumed to receive insulin degludec or continue prior insulin therapy (primarily insulin glargine U100) for 5 years, before all patients intensified to once-daily degludec and mealtime aspart. Results: Switching to insulin degludec was associated with improved quality-adjusted life expectancy of 0.04 and 0.02 quality-adjusted life years (QALYs) over 1 year, and 0.16 and 0.08 QALYs over patient lifetimes, in T1D and T2D. Combined costs in T1D and T2D were estimated to be SEK 1,249 lower and SEK 1,181 higher over the short-term, and SEK 157,258 and SEK 2,114 lower over the long-term. Benefits were due to lower insulin doses in T1D, reduced rates of hypoglycemia, and lower incidences of diabetes-related complications. Insulin degludec was associated with an incremental cost-effectiveness ratio of SEK 64,298 per QALY gained for T2D over 1 year and considered dominant for T1D and T2D in all other comparisons. Conclusions: Insulin degludec was projected to be cost-effective or dominant versus other basal insulins for the treatment of T1D and T2D in Sweden.

ObjectiveGeneric substitution has contributed to economic savings but switching products may affect patient adherence, particularly among those using multiple medications. The aim was to analyse if use of multiple medications influenced the association between switching products and refill adherence to angiotensin-converting-enzyme (ACE) inhibitors in Sweden.Study Design and SettingNew users of ACE-inhibitors, starting between 1 July 2006 and 30 June 2007, were identified in the Swedish Prescribed Drug Register. Refill adherence was assessed using the continuous measure of medication acquisition (CMA) and analysed with linear regression and analysis of covariance.ResultsThe study population included 42735 individuals whereof 51.2% were exposed to switching ACE-inhibitor and 39.6% used multiple medications. Refill adherence was higher among those exposed to switching products than those not, but did not vary depending on the use of multiple medications or among those not. Refill adherence varied with age, educational level, household income, country of birth, previous hospitalisation and previous cardiovascular diagnosis.ConclusionThe results indicate a positive association between refill adherence and switching products, mainly due to generic substitution, among new users of ACE-inhibitors in Sweden. This association was independent of use of multiple medications.

Objectives: The 9.5 version of IQVIA-CORE-Diabetes-Model (CDM) includes a simplified foot ulcer (FU) submodel. The current study aims to explain the differences between the new and previous FU submodel and assess their impact on health economic outputs. Methods: The updated FU submodel is a five-health-state Markov Model (no history of ulcer, active ulcer, history of ulcer, history of amputation, death) with an annual cycle length, using the UKPDS82 risk equations (user defined inputs are optional). The previous FU submodel comprised nine health-states with monthly cycles and included options of screening and several treatment types. To test this update, cohorts were simulated with baseline characteristics and treatment effects from the observational EDGE study comparing metformin+vildagliptin (M+V) with metformin+sulphonylurea (M+S), with mean age of 57.8 years and time horizon of 50 years. Patients had no history of ulcer and amputation. Cumulative Incidence (CI) of FU complications, total and quality-adjusted life years (LY, QALY) were determined. The economic analysis employed UK 2018 costs and applied an annual discount rate of 3.5% on costs and outcomes. Results: The updated FU model leads to moderate differences in first ulcer CI (M+V: 2.86% to 3.45%; M+S: 2.90% to 3.64%) and amputation rate (M+V: 1.10% to 0.82%; M+S: 1.08% to 0.85%). Changes benefit the most effective arm, which also reflects in a limited difference in costs between the two arms (10 GBP). FU-related costs are reduced (M+V: -4.67%; M+S: -1.12%). The new model results in higher LY (M+V: +0.224; M+S: +0.258) and QALY (M+V: +0.038; M+S: +0.052), mainly due to the updated renal submodel, which reduces end-stage renal disease CI (M+V: 9.91% to 2.39%; M+S 10.03% to 2.41%). The Incremental Cost-Utility Ratio (ICUR) increases from 8,455 to 10,410 GBP/QALY. Conclusions: Using the simplified ulcer model of v9.5 CDM results in small differences in FU-related incidence, benefiting the most effective treatment arm.