Publications by authors named "Juan Merlo"

178 Publications

Antidepressant use in Sweden: an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

Scand J Public Health 2021 Feb 23:1403494821993723. Epub 2021 Feb 23.

Unit for Social Epidemiology, Lund University, Sweden.

Introduction: Antidepressants are among the most commonly prescribed drugs in Sweden. However, we lack detailed knowledge on the socioeconomic and demographic distribution of antidepressant use in the population. To fill this gap, we performed an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy.

Methods: Analysing all Swedish residents older than 10 years (=8,190,990), we measured the absolute risk of antidepressant use across 144 intersectional strata defined by combinations of age, gender, income, country of birth and psychiatric diagnosis. We calculated the strata-specific absolute risk of antidepressant use in a series of multilevel logistic regression models. By means of the variance partitioning coefficient and the area under the receiver operating characteristic curve, we quantified the discriminatory accuracy of the intersectional contexts (i.e. strata) for discerning those who use antidepressants from those who do not.

Results: The absolute risk of antidepressant use ranged between 0.93% and 24.78% among those without a psychiatric diagnosis, and between 21.41% and 77.56% among those with a psychiatric diagnosis. Both the variance partitioning coefficient of 41.88% and the area under the receiver operating characteristic curve of 0.81 were considerable.

Conclusions: Besides overt psychiatric diagnoses, our study shows that antidepressant use is mainly conditioned by age, which might express the embodiment of socioeconomic conditions across the individual life course. Our analysis provides a detailed and highly discriminatory mapping of the heterogeneous distribution of antidepressant use in the Swedish population, which may be useful in public health management.
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http://dx.doi.org/10.1177/1403494821993723DOI Listing
February 2021

Understanding the complexity of socioeconomic disparities in smoking prevalence in Sweden: a cross-sectional study applying intersectionality theory.

BMJ Open 2021 02 11;11(2):e042323. Epub 2021 Feb 11.

Unit for Social Epidemiology, Department of Clinical Sciences, Lund University, Malmö, Sweden.

Objectives: Socioeconomic disparities in smoking prevalence remain a challenge to public health. The objective of this study was to present a simple methodology that displays intersectional patterns of smoking and quantify heterogeneities within groups to avoid inappropriate and potentially stigmatising conclusions exclusively based on group averages.

Setting: This is a cross-sectional observational study based on data from the National Health Surveys for Sweden (2004-2016 and 2018) including 136 301 individuals. We excluded people under 30 years of age, or missing information on education, household composition or smoking habits. The final sample consisted on 110 044 individuals or 80.7% of the original sample.

Outcome: Applying intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA), we investigated the risk of self-reported smoking across 72 intersectional strata defined by age, gender, educational achievement, migration status and household composition.

Results: The distribution of smoking habit risk in the population was very heterogeneous. For instance, immigrant men aged 30-44 with low educational achievement that lived alone had a prevalence of smoking of 54% (95% CI 44% to 64%), around nine times higher than native women aged 65-84 with high educational achievement and living with other(s) that had a prevalence of 6% (95% CI 5% to 7%). The discriminatory accuracy of the information was moderate.

Conclusion: A more detailed, intersectional mapping of the socioeconomic and demographic disparities of smoking can assist in public health management aiming to eliminate this unhealthy habit from the community. Intersectionality theory together with AIHDA provides information that can guide resource allocation according to the concept proportionate universalism.
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http://dx.doi.org/10.1136/bmjopen-2020-042323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880088PMC
February 2021

An intersectional analysis providing more precise information on inequities in self-rated health.

Int J Equity Health 2021 Feb 3;20(1):54. Epub 2021 Feb 3.

Unit for Social Epidemiology, Department of Clinical Sciences Malmö, Lund University, Jan Waldenströms Street 35, 205 02, Malmö, Sweden.

Background: Intersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables the application of proportionate universalism for resource allocation in public health. Analyzing self-rated health (SRH) in Sweden, we show how an intersectional perspective allows for a detailed mapping of health inequalities while avoiding simplification and stigmatization based on indiscriminate interpretations of differences between group averages.

Methods: We analyzed participants (n=133,244) in 14 consecutive National Public Health Surveys conducted in Sweden in 2004-2016 and 2018. Applying AIHDA, we investigated the risk of bad SRH across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated odds ratios (with 95% confidence intervals) to evaluate between-strata differences, using native-born men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AU-ROC) to evaluate the discriminatory accuracy of the intersectional strata for identifying individuals according to their SRH status.

Results: The analysis of intersectional strata showed clear average differences in the risk of bad SRH. For instance, the risk was seven times higher for immigrated women with low income (OR 7.00 [95% CI 6.14-7.97]) than for native men with high income. However, the discriminatory accuracy of the intersectional strata was small (AU-ROC=0.67).

Conclusions: The intersectional AIHDA approach provides more precise information on the existence (or the absence) of health inequalities, and can guide public health interventions according to the principle of proportionate universalism. The low discriminatory accuracy of the intersectional strata found in this study warrants universal interventions rather than interventions exclusively focused on strata with a higher average risk of bad SRH.
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http://dx.doi.org/10.1186/s12939-020-01368-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856780PMC
February 2021

Socio-economic disparities in the dispensation of antibiotics in Sweden 2016-2017: An intersectional analysis of individual heterogeneity and discriminatory accuracy.

Scand J Public Health 2021 Jan 18:1403494820981496. Epub 2021 Jan 18.

Unit for Social Epidemiology, Department of Clinical Sciences in Malmö, Lund University, Sweden.

Antimicrobial resistance presents an increasingly serious threat to global public health, which is directly related to how antibiotic medication is used in society. Actions aimed towards the optimised use of antibiotics should be implemented on equal terms and according to the needs of the population. Previous research results on differences in antibiotic use between socio-economic and demographic groups in Sweden are not entirely coherent, and have typically focused on the effects of singular socio-economic variables. Using an intersectional approach, this study provides a more precise analysis of how the dispensation of antibiotic medication was distributed across socio-economic and demographic groups in Sweden in 2016-2017. Using register data from a nationwide cohort and adopting an intersectional analysis of individual heterogeneity and discriminatory accuracy, we map the dispensation of antibiotics according to age, sex, country of birth and income. While women and high-income earners had the highest antibiotic dispensation prevalence, no large differences in the dispensation of antibiotics were identified between socio-economic groups.
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http://dx.doi.org/10.1177/1403494820981496DOI Listing
January 2021

Small area influences on the individual unhealthy lifestyle behaviors: A multilevel analysis of discriminatory accuracy.

Health Place 2021 01 15;67:102506. Epub 2021 Jan 15.

Research Unit of Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden; Centre for Primary Health Care Research, Region Skåne, Malmö, Sweden.

We estimated the discriminatory power of area of residence (census tract) on the prevalence of main risk factors for chronic diseases. Results, based on a sample of 21,007 participants from the 2011-2012 National Health Survey of Spain, show a differential influence of the geosocial environment on the four health risk factors. Accounting for census tracts substantially increases the discriminatory power regarding at-risk alcohol consumption, unbalanced diet, and leisure-time sedentarism but not tobacco consumption. However, the socioeconomic characteristics of the tracts played a minor role. Further research on the specific geosocial contextual variables explaining variability in these risk factors is necessary.
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http://dx.doi.org/10.1016/j.healthplace.2021.102506DOI Listing
January 2021

Optical confinement in the nanocoax: coupling to the fundamental TEM-like mode.

Opt Express 2020 Oct;28(21):32152-32164

The nanoscale coaxial cable (nanocoax) has demonstrated optical confinement in the visible and the near infrared. We report on a novel nanofabrication process which yields optically addressable, sub-µm diameter, and high aspect ratio metal-insulator-metal nanocoaxes made by atomic layer deposition of Pt and AlO. We observe sub-diffraction-limited optical transmission via the fundamental, TEM-like mode by excitation with a radially polarized optical vortex beam. Our experimental results are based on interrogation with a polarimetric imager. Finite element method numerical simulations support these results, and their uniaxial symmetry was exploited to model taper geometries with both an electrically large volume, (15λ), and a nanoscopic exit aperture, (λ/200).
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http://dx.doi.org/10.1364/OE.402723DOI Listing
October 2020

Cross-classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance: the case of hospital differences in patient survival after acute myocardial infarction.

BMJ Open 2020 10 23;10(10):e036130. Epub 2020 Oct 23.

Centre for Multilevel Modelling, University of Bristol, Bristol, UK.

Objective: To describe a novel strategy, Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance, by analysing differences in 30-day mortality after a first-ever acute myocardial infarction (AMI) in Sweden.

Design: Cross-classified study.

Setting: 68 Swedish hospitals.

Participants: 43 247 patients admitted between 2007 and 2009, with a first-ever AMI.

Primary And Secondary Outcome Measures: We evaluate hospital performance by analysing differences in 30-day mortality after a first-ever AMI using a cross-classified multilevel analysis. We classified the patients into 10 categories according to a risk score (RS) for 30-day mortality and created 680 strata defined by combining hospital and RS categories.

Results: In the cross-classified multilevel analysis the overall RS adjusted hospital 30-day mortality in Sweden was 4.78% and the between-hospital variation was very small (variance partition coefficient (VPC)=0.70%, area under the curve (AUC)=0.54). The benchmark value was therefore achieved by all hospitals. However, as expected, there were large differences between the RS categories (VPC=34.13%, AUC=0.77) CONCLUSIONS: MAIHDA is a useful tool to evaluate hospital performance. The benefit of this novel approach to adjusting for patient RS is that it allowed one to estimate separate VPCs and AUC statistics to simultaneously evaluate the influence of RS categories and hospital differences on mortality. At the time of our analysis, all hospitals in Sweden were performing homogeneously well. That is, the benchmark target for 30-day mortality was fully achieved and there were not relevant hospital differences. Therefore, possible quality interventions should be universal and oriented to maintain the high hospital quality of care.
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http://dx.doi.org/10.1136/bmjopen-2019-036130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590346PMC
October 2020

Individual and Contextual Factors Associated With Hazardous Drinking in Spain: Evidence From a National Population-Based Study.

Alcohol Clin Exp Res 2020 11 15;44(11):2247-2256. Epub 2020 Oct 15.

Research Unit of Social Epidemiology, (JM), Faculty of Medicine, Lund University, Malmö, Sweden.

Background: Heavy drinking (HD) and binge drinking (BD) exhibit marked differences in their relationships with contextual-level factors imbedded in geographical areas of residence. The objective is to identify sociodemographic factors, both at the individual and at the contextual level, associated with these 2 main hazardous consumption patterns.

Methods: Cross-sectional study using data from the 2011 to 2012 National Health Survey in Spain. The sample included 21,007 individuals ≥15 years of age. HD was defined as an alcohol intake of ≥40 g/d in men and ≥24 g/d in women. BD was defined as the consumption in the previous month of ≥6 alcoholic drinks (men) or ≥5 drinks (women) within 4 to 6 hours. Individual-level variables included sociodemographic factors, urban/rural residence, smoking, and perceived social support. Contextual-level variables covered percentage of population with no schooling, unemployment rate, and hospitality industry-related economic activity, all at the census tract level. We analyzed data using multilevel logistic regression and calculated areas under the curve (AUC).

Results: Being male, smoking, high-income, and low perceived social support were associated with both hazardous drinking patterns. Younger individuals were at higher risk for BD but at lower risk for HD. BD was more common among rural than urban dwellers (odds ratios [OR] = 1.35; 95% CI: 1.05 to 1.72), whereas HD was less likely in participants residing in areas with high unemployment rates (OR = 0.62; 95% CI: 0.41 to 0.93). HD was more likely in census tracts with higher levels of hospitality industry activity (OR = 1.74; 95% CI: 1.20 to 2.54). The AUC increased substantially for both HD and BD when the census tract variable was entered in the respective models (reaching 89.5 and 93.3%, respectively).

Conclusions: Except for age, both drinking patterns have similar associations with individual-level variables but disparate links to contextual-level indicators. In both cases, accounting for area of residence substantially increased the ability to discriminate between high-risk drinkers from nonhazardous alcohol consumers.
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http://dx.doi.org/10.1111/acer.14451DOI Listing
November 2020

Complex sociodemographic inequalities in consultations for low back pain: lessons from multilevel intersectional analysis.

Pain 2021 04;162(4):1135-1143

Clinical Epidemiology Unit, Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden.

Abstract: Sociodemographic inequalities in the occurrence of low back pain (LBP) are well-studied. This study aimed to examine complex sociodemographic inequalities in the risk of LBP consultation in the population from a socioeconomical intersectional perspective. Using register data, we identified 458,852 individuals aged 35 to 75 years residing in Skåne in 2013, with no previous LBP consultation since 2006. We created 108 strata using categories of age, sex, education, income, and nativity. With individuals nested within strata, we modelled the absolute risk of LBP consultation during 2014 in a series of multilevel logistic regression models. We quantified discriminatory accuracy (DA) of these variables by computing the variance partition coefficient and area under the receiver operating characteristic curve (AUC). We identified 13,657 (3.0%) people with an LBP consultation. The absolute risk ranged from 2.1% (95% credible interval: 1.9%-2.3%) among young native men with high education and high income to 4.8% (4.3%-5.5%) among young foreign-born women with medium education and low income (2.3-fold relative difference). Discriminatory accuracy of intersectional strata was very low (variance partition coefficient 1.1% (0.7-1.6); and AUC 0.56 [0.55-0.56]). Sex (35.6%) and nativity (19.2%) had the largest contributions in explaining the initially small between-strata variation in risk of LBP. The low DA of the intersectional strata indicates the existence of limited intersectional inequalities in LBP consultation. Therefore, interventions to reduce LBP risk should be universal rather than targeted to specific socioeconomic groups with a higher average risk. Before planning targeted intervention, other risk factors with higher DA need to be identified.
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http://dx.doi.org/10.1097/j.pain.0000000000002081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977617PMC
April 2021

Geographical and sociodemographic differences in discontinuation of medication for Chronic Obstructive Pulmonary Disease - A Cross-Classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA).

Clin Epidemiol 2020 20;12:783-796. Epub 2020 Jul 20.

Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden.

Background: While discontinuation of COPD maintenance medication is a known problem, the proportion of patients with discontinuation and its geographical and sociodemographic distribution are so far unknown in Sweden. Therefore, we analyse this question by applying an innovative approach called multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

Patients And Methods: We analysed 49,019 patients categorized into 18 sociodemographic contexts and 21 counties of residence. All patients had a hospital COPD diagnosis and had been on inhaled maintenance medication during the 5 years before the study baseline in 2010. We defined "discontinuation" as the absolute lack of retrieval from a pharmacy of any inhaled maintenance medication during 2011. We performed a cross-classified MAIHDA and obtained the average proportion of discontinuation, as well as county and sociodemographic absolute risks, and compared them with a proposed benchmark value of 10%. We calculated the variance partition coefficient (VPC) and the area under the receiver operating characteristics curve (AUC) to quantify county and sociodemographic differences. To summarize the results, we used a framework with 15 scenarios defined by the size of the differences and the level of achievement in relation to the benchmark value.

Results: Around 18% of COPD patients in Sweden discontinued maintenance medication, so the benchmark value was not achieved. There were very small county differences (VPC=0.35%, AUC=0.54). The sociodemographic differences were small (VPC=4.98%, AUC=0.57).

Conclusion: Continuity of maintenance medication among COPD patients in Sweden could be improved by reducing the unjustifiably high prevalence of discontinuation. The very small county and small sociodemographic differences should motivate universal interventions across all counties and sociodemographic groups. Geographical analyses should be combined with sociodemographic analyses, and the cross-classified MAIHDA is an appropriate tool to assess health-care quality.
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http://dx.doi.org/10.2147/CLEP.S247368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381094PMC
July 2020

Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture: A cross-classified multilevel analysis in Sweden.

PLoS One 2020 3;15(6):e0234041. Epub 2020 Jun 3.

Research Unit of Social Epidemiology, Clinical Research Centre, Faculty of Medicine, Lund University, Malmö, Sweden.

Background: One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively.

Methods: We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC).

Results: The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718).

Conclusions: Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234041PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269247PMC
August 2020

Partitioning variation in multilevel models for count data.

Psychol Methods 2020 Dec 20;25(6):787-801. Epub 2020 Apr 20.

Institute of Health Management, Policy and Evaluation.

A first step when fitting multilevel models to continuous responses is to explore the degree of clustering in the data. Researchers fit variance-component models and then report the proportion of variation in the response that is due to systematic differences between clusters. Equally they report the response correlation between units within a cluster. These statistics are popularly referred to as variance partition coefficients (VPCs) and intraclass correlation coefficients (ICCs). When fitting multilevel models to categorical (binary, ordinal, or nominal) and count responses, these statistics prove more challenging to calculate. For categorical response models, researchers appeal to their latent response formulations and report VPCs/ICCs in terms of latent continuous responses envisaged to underly the observed categorical responses. For standard count response models, however, there are no corresponding latent response formulations. More generally, there is a paucity of guidance on how to partition the variation. As a result, applied researchers are likely to avoid or inadequately report and discuss the substantive importance of clustering and cluster effects in their studies. A recent article drew attention to a little-known exact algebraic expression for the VPC/ICC for the special case of the two-level random-intercept Poisson model. In this article, we make a substantial new contribution. First, we derive exact VPC/ICC expressions for more flexible negative binomial models that allows for overdispersion, a phenomenon which often occurs in practice. Then we derive exact VPC/ICC expressions for three-level and random-coefficient extensions to these models. We illustrate our work with an application to student absenteeism. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/met0000265DOI Listing
December 2020

Low adherence to statin treatment during the 1st year after an acute myocardial infarction is associated with increased 2nd-year mortality risk-an inverse probability of treatment weighted study on 54 872 patients.

Eur Heart J Cardiovasc Pharmacother 2021 Mar;7(2):141-147

Unit for Social Epidemiology, Department of Clinical Sciences, Faculty of Medicine, Lund University, Jan Waldenströms gata 35, 20502 Malmö, Sweden.

Aims: Experiencing an acute myocardial infarction (AMI) is a life-threatening event and use of statins can reduce the probability of recurrence and improve long-term survival. However, the effectiveness of statins in the real-world setting may be lower than the reported efficacy in randomized clinical trials. Therefore, we aimed to investigate whether low statin treatment adherence during the year following an AMI episode is associated with increased 2nd-year mortality.

Methods And Results: We analysed all 54 872 AMI patients aged ≥45 years, admitted to Swedish hospitals between 2010 and 2012, and who survive at least 1 year after the AMI episode. We defined low adherence as a medication possession ratio <50% or non-use of statins. Applying inverse probability of treatment weighting (IPTW), we investigated the association between low adherence and all-cause, cardiovascular disease (CVD), and non-CVD mortality during the 2nd year. Overall, 20% of the patients had low adherence during the 1st year and 8% died during the 2nd year. In the IPTW analysis, low adherence was associated with an increased risk of all-cause [absolute risk difference (ARD) = 0.048, number needed to harm (NNH) = 21, relative risk (RR) = 1.71], CVD (ARD = 0.035, NNH = 29, RR = 1.62), and non-CVD mortality (ARD = 0.013, NNH = 77, RR = 2.17).

Conclusion: In the real-world setting, low statin adherence during the 1st year after an AMI episode is associated with increased mortality during the 2nd year. Our results reaffirm the importance of achieving a high adherence to statin treatment after suffering from an AMI.
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http://dx.doi.org/10.1093/ehjcvp/pvaa010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957903PMC
March 2021

Acknowledging the role of patient heterogeneity in hospital outcome reporting: Mortality after acute myocardial infarction in five European countries.

PLoS One 2020 6;15(2):e0228425. Epub 2020 Feb 6.

Health Services and Policy Research Group, Institute for Health Sciences in Aragon (IACS), Zaragoza, Spain.

Background: Hospital performance, presented as the comparison of average measurements, dismisses that hospital outcomes may vary across types of patients. We aim at drawing out the relevance of accounting for patient heterogeneity when reporting on hospital performance.

Methods: An observational study on administrative data from virtually all 2009 hospital admissions for Acute Myocardial Infarction (AMI) discharged in Denmark, Portugal, Slovenia, Spain, and Sweden. Hospital performance was proxied using in-hospital risk-adjusted mortality. Multilevel Regression Modelling (MLRM) was used to assess differences in hospital performance, comparing the estimates of random intercept modelling (capturing hospital general contextual effects (GCE)), and random slope modelling (capturing hospital contextual effects for patients with and without congestive heart failure -CHF). The weighted Kappa Index (KI) was used to assess the agreement between performance estimates.

Results: We analysed 46,875 admissions of AMI, 6,314 with coexistent CHF, discharged from 107 hospitals. The overall in-hospital mortality rate was 5.2%, ranging from 4% in Sweden to 6.9% in Portugal. The MLRM with random slope outperformed the model with only random intercept, highlighting a much higher GCE in CHF patients [VPC = 8.34 (CI95% 4.94 to 13.03) and MOR = 1.69 (CI95% 1.62 to 2.21) vs. VPC = 3.9 (CI95% 2.4 to 5.9), MOR of 1.42 (CI95% 1.31 to 1.54) without CHF]. No agreement was observed between estimates [KI = -0,02 (CI95% -0,08 to 0.04].

Conclusions: The different GCE in AMI patients with and without CHF, along with the lack of agreement in estimates, suggests that accounting for patient heterogeneity is required to adequately characterize and report on hospital performance.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228425PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004308PMC
April 2020

Understanding the complexity of socioeconomic disparities in type 2 diabetes risk: a study of 4.3 million people in Sweden.

BMJ Open Diabetes Res Care 2019 7;7(1):e000749. Epub 2019 Nov 7.

Unit for Social Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.

Objective: Investigating demographic and socioeconomic factors as intersecting rather than as separate dimensions may improve our understanding of the heterogeneous distribution of type 2 diabetes in the population. However, this complexity has scarcely been investigated and we still do not know the accuracy of these factors for predicting type 2 diabetes. Improved understanding of the demographic and socioeconomic disparities predicting type 2 diabetes risk in the population would contribute to more precise and effective public health interventions.

Research Design And Methods: We analyzed the risk of type 2 diabetes among 4 334 030 individuals aged 40-84 years who by 2010 had resided in Sweden for at least 5 years. We stratified the study population into 120 strata defined by categories of age, gender, income, education, and immigration status. We calculated measures of absolute risk (prevalence) and relative risk (prevalence ratio), and quantified the discriminatory accuracy of the information for predicting type 2 diabetes in the population.

Results: The distribution of type 2 diabetes risk in the population was highly heterogeneous. For instance, immigrated men aged 70-79 years with low educational achievement and low income had a risk around 32 times higher than native women aged 40-49 years with high income and high educational achievement (ie, 17.6% vs 0.5%). The discriminatory accuracy of the information was acceptable.

Conclusion: A more detailed, intersectional mapping of socioeconomic and demographic distribution of type 2 diabetes can assist in public health management aiming to reduce the prevalence of the disease.
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http://dx.doi.org/10.1136/bmjdrc-2019-000749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861116PMC
August 2020

Does country-level gender equality explain individual risk of intimate partner violence against women? A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) in the European Union.

Eur J Public Health 2020 04;30(2):293-299

Research Unit of Social Epidemiology, CRC, Faculty of Medicine, Lund University, Malmö, Sweden.

Background: Gender equality is widely accepted as an important explanatory factor for the occurrence of intimate partner violence (IPV) against women. However, the relationship is not straightforward, as high country-level gender equality is not always associated with lower IPV prevalence. We apply 'multilevel analysis of individual heterogeneity and discriminatory accuracy' (MAIHDA) to (i) quantify the extent to which the country of residence determines individual risk of IPV and (ii) investigate the association between country-level gender equality and individual experience of IPV, and to which extent this association explains the observed between-country differences.

Methods: Using data from the 2012 European Union Agency for Fundamental Rights survey on violence against women we applied MAIHDA to analyse experiences of physical and sexual IPV among 42 000 women living in the EU. We fitted three consecutive models, and calculated specific individual contextual effects (measures of association) as well as the general contextual effects (measures of variance) and the discriminatory accuracy (DA).

Results: Our findings show that the relationship between experiences of IPV and country-level gender equality is weak and heterogeneous. The general contextual effect is small and the DA is low, indicating that country boundaries are rather irrelevant for understanding the individual risk of IPV.

Conclusions: Findings from the present study do not imply that that gender equality is unimportant in relation to IPV, but rather that information on country of residence or country-level gender equality does not discriminate very well with regards to individual experiences of IPV in cross-national comparisons.
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http://dx.doi.org/10.1093/eurpub/ckz162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183361PMC
April 2020

Multilevel versus single-level regression for the analysis of multilevel information: The case of quantitative intersectional analysis.

Soc Sci Med 2020 01 24;245:112499. Epub 2019 Aug 24.

Research Unit of Social Epidemiology, Faculty of Medicine, University of Lund, Sweden.

Intersectional MAIHDA involves applying multilevel models in order to estimate intercategorical inequalities. The approach has been validated thus far using both simulations and empirical applications, and has numerous methodological and theoretical advantages over single-level approaches, including parsimony and reliability for analyzing high-dimensional interactions. In this issue of SSM, Lizotte, Mahendran, Churchill and Bauer (hereafter "LMCB") assert that there has been insufficient clarity on the interpretation of fixed effects regression coefficients in intersectional MAIHDA, and that stratum-level residuals in intersectional MAIHDA are not interpretable as interaction effects. We disagree with their second assertion; however, the authors are right to call for greater clarity. For this purpose, in this response we have three main objectives. (1) In their commentary, LMCB incorrectly describe model predictions based on MAIHDA fixed effects as estimates of "grand means" (or the mean of means), when they are actually "precision-weighted grand means." We clarify the differences between average predicted values obtained by different models, and argue that predictions obtained by MAIHDA are more suitable to serve as reference points for residual/interaction effects. This further enables us to clarify the interpretation of residual/interaction effects in MAIHDA and conventional models. Using simple simulations, we demonstrate conditions under which the precision-weighted grand mean resembles a grand mean, and when it resembles a population mean (or the mean of all individual observations) obtained using single-level regression, explaining the results obtained by LMCB and informing future research. (2) We construct a modification to MAIHDA that constrains the fixed effects so that the resulting model predictions provide estimates of population means, which we use to demonstrate the robustness of results reported by Evans et al. (2018). We find that stratum-specific residuals obtained using the two approaches are highly correlated (Pearson corr = 0.98, p < 0.0001) and no substantive conclusions would have been affected if the preference had been for estimating population means. However, we advise researchers to use the original, unconstrained MAIHDA. (3) Finally, we outline the extent to which single-level and MAIHDA approaches address the fundamental goals of quantitative intersectional analyses and conclude that intersectional MAIHDA remains a promising new approach for the examination of inequalities.
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http://dx.doi.org/10.1016/j.socscimed.2019.112499DOI Listing
January 2020

Precision public health: Mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA).

PLoS One 2019 27;14(8):e0220322. Epub 2019 Aug 27.

Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden.

Background: In light of the opioid epidemic in the United States, there is growing concern about the use of opioids in Sweden as it may lead to misuse and overuse and, in turn, severe public health problems. However, little is known about the distribution of opioid use across different demographic and socioeconomic dimensions in the Swedish general population. Therefore, we applied an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), to obtain an improved mapping of the risk heterogeneity of and socioeconomic inequalities in opioid prescription receipt.

Methods And Findings: Using data from 6,846,106 residents in Sweden aged 18 and above, we constructed 72 intersectional strata from combinations of gender, age, income, cohabitation status, and presence or absence of psychological distress. We modelled the absolute risk (AR) of opioid prescription receipt in a series of multilevel logistic regression models distinguishing between additive and interaction effects. By means of the Variance Partitioning Coefficient (VPC) and the area under the receiver operating characteristic curve (AUC), we quantified the discriminatory accuracy (DA) of the intersectional strata for discerning those who received opioid prescriptions from those who did not. The AR of opioid prescription receipt ranged from 2.77% (95% CI 2.69-2.86) among low-income men aged 18-34, living alone, without psychological distress, to 28.25% (95% CI 27.95-28.56) among medium-income women aged 65 and older, living alone, with psychological distress. In a model that conflated both additive and interaction effects, the intersectional strata had a fair DA for discerning opioid users from non-users (VPC = 13.2%, AUC = 0.68). However, in the model that decomposed total effects into additive and interaction effects, the VPC was very low (0.42%) indicating the existence of small interaction effects for a number of the intersectional strata.

Conclusions: The intersectional MAIHDA approach aligns with the aims of precision public health, through improving the evidence base for health policy by increasing understanding of both health inequalities and individual heterogeneity. This approach is particularly relevant for socioeconomically conditioned outcomes such as opioid prescription receipt. We have identified intersections of social position within the Swedish population at greater risk for opioid prescription receipt.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0220322PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711500PMC
March 2020

Hospital differences in mortality rates after hip fracture surgery in Denmark.

Clin Epidemiol 2019 16;11:605-614. Epub 2019 Jul 16.

Department of Clinical Medicine, Aalborg University, Aalborg DK-9000, Denmark.

Background: Thirty-day mortality after hip fracture is widely used when ranking hospital performance, but the reliability of such hospital ranking is seldom calculated. We aimed to quantify the variation in 30-day mortality across hospitals and to determine the hospital general contextual effect for understanding patient differences in 30-day mortality risk.

Methods: Patients aged ≥65 years with an incident hip fracture registered in the Danish Multidisciplinary Fracture Registry between 2007 and 2016 were identified (n=60,004). We estimated unadjusted and patient-mix adjusted risk of 30-day mortality in 32 hospitals. We performed a multilevel analysis of individual heterogeneity and discriminatory accuracy with patients nested within hospitals. We expressed the hospital general contextual effect by the median odds ratio (MOR), the area under the receiver operating characteristics curve and the variance partition coefficient (VPC).

Results: The overall 30-day mortality rate was 10%. Patient characteristics including high sociodemographic risk score, underweight, comorbidity, a subtrochanteric fracture, and living at a nursing home were strong predictors of 30-day mortality (area under the curve=0.728). The adjusted differences between hospital averages in 30-day mortality varied from 5% to 9% across the 32 hospitals, which correspond to a MOR of 1.18 (95% CI: 1.12-1.25). However, the hospital general context effect was low, as the VPC was below 1% and adding the hospital level to a single-level model with adjustment for patient-mix increased the area under the receiver operating characteristics curve by only 0.004 units.

Conclusions: Only minor hospital differences were found in 30-day mortality after hip fracture. Mortality after hip fracture needs to be lowered in Denmark but possible interventions should be patient oriented and universal rather than focused on specific hospitals.
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http://dx.doi.org/10.2147/CLEP.S213898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6643065PMC
July 2019

A simple multilevel approach for analysing geographical inequalities in public health reports: The case of municipality differences in obesity.

Health Place 2019 07 10;58:102145. Epub 2019 Jun 10.

Research Unit of Social Epidemiology, Faculty of Medicine, University of Lund, Jan Waldenströms Street 35, SE-20502 Malmö, Sweden; Centre for Multilevel Modelling, University of Bristol, 35 Berkeley Square, Bristol, BS8 1JA, UK.

The epidemiological analysis of geographical inequalities in individual outcomes is a fundamental theme in public health research. However, many traditional studies focus on analysing area differences in averages outcomes, disregarding individual variation around such averages. In doing so, these studies may produce misleading information and lead researchers to draw incorrect conclusions. Analysing individual and municipality differences in body mass index (BMI) and overweight/obesity status, we apply an analytical approach based on the multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). This analytical approach may be viewed as a reorganization of existing multilevel modelling concepts in order to provide a systematic approach to simultaneously considering both differences between area averages and individual heterogeneity around those averages. In doing so, MAIHDA provides an improved approach to the quantification and understanding of geographical inequalities as compared with traditional approaches.
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http://dx.doi.org/10.1016/j.healthplace.2019.102145DOI Listing
July 2019

Prevalence of intimate partner violence against women in Sweden and Spain: A psychometric study of the 'Nordic paradox'.

PLoS One 2019 16;14(5):e0217015. Epub 2019 May 16.

Unit for Social Epidemiology, University of Lund, Malmö, Sweden.

The high prevalence of intimate partner violence against women (IPVAW) in countries with high levels of gender equality has been defined as the "Nordic paradox". In this study we compared physical and sexual IPVAW prevalence data in two countries exemplifying the Nordic paradox: Sweden (N = 1483) and Spain (N = 1447). Data was drawn from the European Union Agency for Fundamental Rights Survey on violence against women. To ascertain whether differences between these two countries reflect true differences in IPVAW prevalence, and to rule out the possibility of measurement bias, we conducted a set of analyses to ensure measurement equivalence, a precondition for appropriate and valid cross-cultural comparisons. Results showed that in both countries items were measuring two separate constructs, physical and sexual IPVAW, and that these factors had high internal consistency and adequate validity. Measurement equivalence analyses (i.e., differential item functioning, and multigroup confirmatory factor analysis) supported the comparability of data across countries. Latent means comparisons between the Spanish and the Swedish samples showed that scores on both the physical and sexual IPVAW factors were significantly higher in Sweden than in Spain. The effect sizes of these differences were large: 89.1% of the Swedish sample had higher values in the physical IPVAW factor than the Spanish average, and this percentage was 99.4% for the sexual IPVAW factor as compared to the Spanish average. In terms of probability of superiority, there was an 80.7% and 96.1% probability that a Swedish woman would score higher than a Spanish woman in the physical and the sexual IPVAW factors, respectively. Our results showed that the higher prevalence of physical and sexual IPVAW in Sweden than in Spain reflects actual differences and are not the result of measurement bias, supporting the idea of the Nordic paradox.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217015PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522122PMC
February 2020

Albuminuria measurement in diabetic care: a multilevel analysis measuring the influence of accreditation on institutional performance.

BMJ Open Qual 2019 14;8(1):e000449. Epub 2019 Jan 14.

Research Unit of Chronic Conditions, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark.

Background: Studies assessing institutional performance regarding quality of care are frequently performed using single-level statistical analyses investigating differences between provider averages of various quality indicators. However, such analyses are insufficient as they do not consider patients' heterogeneity around those averages. Hence, we apply a multilevel analysis of individual-patient heterogeneity that distinguishes between 'general' ('latent quality' or measures of variance) and 'specific' (measures of association) contextual effects. We assess general contextual effects of the hospital departments and the specific contextual effect of a national accreditation programme on adherence to the standard benchmark for albuminuria measurement in Danish patients with diabetes.

Methods: From the Danish Adult Diabetes Database, we extracted data on 137 893 patient cases admitted to hospitals between 2010 and 2013. Applying multilevel logistic and probit regression models for every year, we quantified general contextual effects of hospital department by the intraclass correlation coefficient (ICC) and the area under the receiver operating characteristic curve (AUC) values. We evaluated the specific effect of hospital accreditation using the ORs and the change in the department variance.

Results: In 2010, the department context had considerable influence on adherence with albuminuria measurement (ICC=21.8%, AUC=0.770), but the general effect attenuated along with the implementation of the national accreditation programme. The ICC value was 16.5% in 2013 and the rate of compliance with albuminuria measurement increased from 91.6% in 2010 to 96% in 2013.

Conclusions: Parallel to implementation of the national accreditation programme, departments' compliance with the standard benchmark for albuminuria measurement increased and the ICC values decreased, but remained high. While those results indicate an overall quality improvement, further intervention focusing on departments with the lowest compliance could be considered.
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http://dx.doi.org/10.1136/bmjoq-2018-000449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340563PMC
April 2020

Socioeconomic differences in body mass index in Spain: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy.

PLoS One 2018 10;13(12):e0208624. Epub 2018 Dec 10.

Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden.

Many studies have demonstrated the existence of simple, unidimensional socioeconomic gradients in body mass index (BMI). However, in the present paper we move beyond such traditional analyses by simultaneously considering multiple demographic and socioeconomic dimensions. Using the Spanish National Health Survey 2011-2012, we apply intersectionality theory and multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to analyze 14,190 adults nested within 108 intersectional strata defined by combining categories of gender, age, income, educational achievement and living situation. We develop two multilevel models to obtain information on stratum-specific BMI averages and the degree of clustering of BMI within strata expressed by the intra-class correlation coefficient (ICC). The first model is a simple variance components analysis that provides a detailed mapping of the BMI disparities in the population and measures the accuracy of stratum membership to predict individual BMI. The second model includes the variables used to define the intersectional strata as a way to identify stratum-specific interactions. The first model suggests moderate but meaningful clustering of individual BMI within the intersectional strata (ICC = 12.4%). Compared with the population average (BMI = 26.07 Kg/m2), the stratum of cohabiting 18-35-year-old females with medium income and high education presents the lowest BMI (-3.7 Kg/m2), while cohabiting 36-64-year-old females with low income and low education show the highest BMI (+2.6 Kg/m2). In the second model, the ICC falls to 1.9%, suggesting the existence of only very small stratum specific interaction effects. We confirm the existence of a socioeconomic gradient in BMI. Compared with traditional analyses, the intersectional MAIHDA approach provides a better mapping of socioeconomic and demographic inequalities in BMI. Because of the moderate clustering, public health policies aiming to reduce BMI in Spain should not solely focus on the intersectional strata with the highest BMI, but should also consider whole population polices.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208624PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6287827PMC
May 2019

Overuse of methylphenidate: an analysis of Swedish pharmacy dispensing data.

Clin Epidemiol 2018 9;10:1657-1665. Epub 2018 Nov 9.

Department of Clinical Sciences, Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden,

Purpose: To identify overuse of methylphenidate and to investigate patterns of overuse in relation to sociodemographic and clinical characteristics.

Patients And Methods: Swedish national, pharmacy dispensing data were analyzed for all 56,922 individuals aged 6-79 years, who filled a methylphenidate prescription between 2010 and 2011. Overuse was defined as having above 150% days covered by the dispensed amount during 365 days from the first prescription fill, assuming use at the maximum recommended daily dose.

Results: In total, 4,304 individuals (7.6% of the methylphenidate users) were categorized as overusers. The risk of overuse increased with age (OR for 46-65 years vs 6-12 years 17.5, 95% CI 14.3-21.3), and was higher in men (OR 1.4, 95% CI 1.3-1.5) and individuals with low income (OR 1.1, 95% CI 1.0-1.2), as well as in individuals with an attention deficit hyperactivity disorder (ADHD) diagnosis (OR 1.4, 95% CI 1.3-1.6), health care visits (OR 1.3, 95% CI 1.2-1.4), previous ADHD medication use (OR 2.6, 95% CI 2.4-2.8), and previous diagnosis of mental and behavioral disorders due to psychoactive substance use (OR 2.1 95% CI 2.0-2.3).

Conclusion: Among individuals using methylphenidate in Sweden, 7.6% receive amounts that are larger than what they should have a medical need for, assuming that they were using the maximum recommended daily dose 365 days per year. Notably, the prevalence of overuse was associated with previous diagnosis of alcohol and drug misuse. The prevalence was also positively associated with higher age and previous use of ADHD medication. These findings may point toward a link between exposure time and overuse. However, future studies with long-term data are needed to investigate this.
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http://dx.doi.org/10.2147/CLEP.S178638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233857PMC
November 2018

General and specific contextual effects in multilevel regression analyses and their paradoxical relationship: A conceptual tutorial.

SSM Popul Health 2018 Aug 19;5:33-37. Epub 2018 May 19.

Unit for Social Epidemiology, Department of Clinical Sciences, Faculty of Medicine, Lund University, CRC, Jan Waldenströms Street 35, SE- 214 21 Malmö, Sweden.

To be relevant for public health, a context (e.g., neighborhood, school, hospital) should influence or affect the health status of the individuals included in it. The greater the influence of the shared context, the higher the correlation of subject outcomes within that context is likely to be. This intra-context or intra-class correlation is of substantive interest and has been used to quantify the magnitude of the (GCE). Furthermore, ignoring the intra-class correlation in a regression analysis results in spuriously narrow 95% confidence intervals around the estimated regression coefficients of the specific contextual variables entered as covariates and, thereby, overestimates the precision of the estimated (SCEs). Multilevel regression analysis is an appropriate methodology for investigating both GCEs and SCEs. However, frequently researchers only report SCEs and disregard the study of the GCE, unaware that small GCEs lead to more precise estimates of SCEs so, paradoxically, the less relevant the context is, the easier it is to detect (and publish) small but "statistically significant" SCEs. We describe this paradoxical situation and encourage researchers performing multilevel regression analysis to consider simultaneously both the GCE and SCEs when interpreting contextual influences on individual health.
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http://dx.doi.org/10.1016/j.ssmph.2018.05.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993177PMC
August 2018

Chronic Obstructive Pulmonary Disease in Sweden: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy.

SSM Popul Health 2018 Apr 20;4:334-346. Epub 2018 Mar 20.

Unit for Social Epidemiology, Faculty of Medicine, Lund University, Sweden.

Socioeconomic, ethnic and gender disparities in Chronic Obstructive Pulmonary Disease (COPD) risk are well established but no studies have applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) within an intersectional framework to study this outcome. We study individuals at the first level of analysis and combinations of multiple social and demographic categorizations (i.e., intersectional strata) at the second level of analysis. Here we used MAIHDA to assess to what extent individual differences in the propensity of developing COPD are at the intersectional strata level. We also used MAIHDA to determine the degree of similarity in COPD incidence of individuals in the same intersectional stratum. This leads to an improved understanding of risk heterogeneity and of the social dynamics driving socioeconomic and demographic disparities in COPD incidence. Using data from 2,445,501 residents in Sweden aged 45-65, we constructed 96 intersectional strata combining categories of age, gender, income, education, civil- and migration status. The incidences of COPD ranged from 0.02% for young, native males with high income and high education who cohabited to 0.98% for older native females with low income and low education who lived alone. We calculated the intra-class correlation coefficient (ICC) that informs on the discriminatory accuracy of the categorizations. In a model that conflated additive and interaction effects, the ICC was good (20.0%). In contrast, in a model that measured only interaction effects, the ICC was poor (1.1%) suggesting that most of the observed differences in COPD incidence across strata are due to the main effects of the categories used to construct the intersectional matrix while only a minor share of the differences are attributable to intersectional interactions. We found conclusive interaction effects. The intersectional MAIHDA approach offers improved information to guide public health policies in COPD prevention, and such policies should adopt an intersectional perspective.
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http://dx.doi.org/10.1016/j.ssmph.2018.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976844PMC
April 2018

Hormonal contraception increases the risk of psychotropic drug use in adolescent girls but not in adults: A pharmacoepidemiological study on 800 000 Swedish women.

PLoS One 2018 22;13(3):e0194773. Epub 2018 Mar 22.

Unit of Social Epidemiology, Department of Clinical Sciences, Lund University, Clinical Research Center, Malmö, Sweden.

The burden of depression and anxiety disorders is greater in women, and female sex hormones have been shown to affect mood. Psychological side effects of hormonal contraception (HC) are also a common complaint in the clinic, but few previous studies have investigated this subject. We therefore wanted to investigate whether use of HC was associated with adverse psychological health outcomes, and whether this association was modified by age. All women aged 12-30 years on 31 December 2010, residing in Sweden for at least four years and with no previous psychiatric morbidity (n = 815 662), were included. We followed the women from their first HC use (or 31 December 2010, if they were non-users) at baseline, until a prescription fill of psychotropic drugs or the end of the one-year follow-up. We performed age-stratified logistic regression models and estimated odds ratios (OR) to measure the association between different HC methods and psychotropic drug use, as well as the area under the receiver operating curve to estimate discriminatory accuracy of HC in relation to psychotropic drugs. Overall, we found an association between HC and psychotropic drugs (adjusted OR 1.34, 95% confidence interval [CI] 1.30-1.37). In the age-stratified analysis, the strongest association was found in adolescent girls (adjusted OR 3.46, 95% CI 3.04-4.94 for age 12 to 14 years), while it was non-existent for adult women. We conclude that hormonal contraception is associated with psychotropic drug use among adolescent girls, suggesting an adverse effect of HC on psychological health in this population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194773PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5864056PMC
July 2018

Psychotropic drug use as indicator of mental health in adolescents affected by a plexus injury at birth: A large population-based study in Sweden.

PLoS One 2018 21;13(3):e0193635. Epub 2018 Mar 21.

Unit for Social Epidemiology, Department of Clinical Sciences (Malmö), Faculty of Medicine, Lund University, Malmö, Sweden.

Chronic handicap in early life may have a long-term impact on children's psychosocial well-being. Here, we investigated whether Brachialis Plexus Birth Injury (BPBI)-an unpredictable injury at birth-is associated with worse mental health later on, as indicated by prescription and use of psychotropic drugs in adolescence. We explored further whether this association is different depending on socioeconomic characteristics of the child's family, as well as sex. Of the 641 151 children born to native parents in Sweden 1987-1993 (alive and still living in Sweden at the end of 2008), identified in the Swedish Medical Birth Registry, 1587 had suffered a BPBI. Logistic regression analysis was performed to assess the impact of socioeconomic characteristics and associations with later psychosocial health. Results show that beyond the known increased risks for females as compared to males, BPBI, but also lower family income, further increased the risk of burdened mental health requiring psychotropic drug use in adolescence. The effects were additive. Thus, compared to unaffected peers, teenagers who suffered a BPBI at birth are at higher risk of suffering poor mental health during adolescence, independently of surgical intervention and its outcome. Girls growing up in families with lower socioeconomic status have this risk added to their already increased risk of poor mental health during adolescence.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193635PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862449PMC
June 2018

Natural frequencies improved diagnostic inference among medical students i Sweden

Lakartidningen 2018 03 16;115. Epub 2018 Mar 16.

Lunds Universitet Institutionen for psykologi - Department of Psychology Lund, Sweden Lunds Universitet Institutionen for psykologi - Department of Psychology Lund, Sweden.

The ability to draw statistical inferences from test results may be generally limited among physicians. A new way of presenting statistics, called natural frequencies, has been shown to improve this ability. The current study is the first to investigate this effect in Sweden, involving senior medical students. An intra-individual cross-over design was used in which participants answered a statistical inference task presented with natural frequencies and another with percentages, which has been the customary format. A total of 74% made a correct inference on the natural frequencies task, as compared to 54% on the percentages task, with an odds ratio of 3.2, p = 0.002, 95% CI 1.52-6.81. The findings indicate that the effect of using natural frequencies arises also in a Swedish context.
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March 2018
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