Trends of blood pressure levels and management in Västerbotten County, Sweden, during 1990-2010

Background: Availability of longitudinal data on hypertension and blood pressure levels are important to assess changes over time at the population level. Moreover, detailed information in different population sub-groups is important to understand inequity and social determinants of blood pressure distribution in the population. Objectives: The objectives of this study are to: (1) describe the trends of population blood pressure levels in men and women between different educational levels and geographic areas in Sweden during 1990-2010; (2) identify prevalences of hypertension, awareness, treatment, and control in the population; and (3) assess the 10-year risk of developing hypertension among individuals with normal and high normal blood pressures. Methods: This study is based on data from the Vasterbotten Intervention Program (VIP) in Vasterbotten County, Sweden. The cross-sectional analysis includes 133,082 VIP health examinations among individuals aged 30, 40, 50, and 60 years from 1990 to 2010. The panel analysis includes 34,868 individuals who were re-examined 10 years after the baseline examination. Individuals completed a self-administered health questionnaire that covers demographic and socio-economic information, self-reported health, and lifestyle behaviours. Blood pressure measurement was obtained prior to the questionnaire. In the cross-sectional analysis, trends of blood pressure by sex, and between educational groups and geographic areas are presented. In the panel analysis, the 10-year risk of developing hypertension is estimated using the predicted probability from logistic regression analysis for each sex, controlling for age and educational level. Results: The prevalence of hypertension decreased from 1990 to 2010; from 43.8 to 36.0% (p<0.001) among men, and 37.6 to 27.5% among women (p<0.001). Individuals with basic education had a significantly higher prevalence of hypertension compared to those with medium or high education. Although the decreases were observed in all geographic areas, individuals in rural inland areas had a much higher prevalence compared to those who lived in Umea City. The proportion of hypertensive women who were aware of their hypertension (61.7%) was significantly higher than men (51.6%). About 34% of men and 42% of women with hypertension reported taking blood pressure medication. Over time, awareness and control of hypertension improved (from 46.5% in 1990 to 69% in 2010 and from 30 to 65%, respectively). The gaps between educational groups diminished. This study shows a significantly higher risk of developing hypertension for men and women with high normal blood pressure compared to those with normal blood pressure at baseline in all age cohorts and educational groups. The average risks of developing hypertension among men with high normal blood pressure were 21.5, 45.8, and 56.3% in the 30, 40, and 50-year cohorts, respectively. Corresponding numbers for women were 22.6, 47.4, and 57.9%. Conclusions: Levels of blood pressure and hypertension decreased significantly among the Vasterbotten population in the last 21 years. Hypertension management has improved and there is increased awareness, treatment, and control of blood pressure. Despite these achievements, the persisting social gaps in blood pressure levels and management demand further investigation and action from policy makers. Future research should attempt to identify and address the root causes of these health inequities to ensure better and equal health for the whole population

Prescription of Lipid-Lowering and Antihypertensive Drugs following Pictorial Information about Subclinical Atherosclerosis : A Secondary Outcome of a Randomized Clinical Trial

Importance: Preventive drugs are often underused. Carotid intima-media thickness and carotid plaques are associated with cardiovascular disease (CVD), and their detection could possibly improve estimation of the likelihood of CVD and prescription of preventive drugs. Objective: To evaluate whether pictorial information on participants' asymptomatic atherosclerosis based on carotid ultrasonographic examinations to participants and their physicians had an effect on prescribing of lipid-lowering or antihypertensive drugs during the following 465 days. Design, Setting, and Participants: Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention is a pragmatic randomized clinical trial nested within the Västerbotten Intervention Program, a CVD screening and prevention program in Sweden with 60% to 70% participation rates and small social selection bias. A total of 4177 individuals aged 40, 50, or 60 years participating in the Västerbotten Intervention Program who had low to moderate risk of CVD were invited to enroll in this trial from April 29, 2013, to June 7, 2016. Prescriptions for all participants were monitored for 465 days after the intervention. Data analysis was conducted from December 6, 2019, to April 2, 2020. Interventions: Participants and their family physicians were randomly assigned 1:1 to receive or not receive pictorial information from carotid ultrasonographic determination of vascular age, assessed as carotid intima-media thickness and the presence of carotid plaques, combined with a follow-up call to participants by nurses. Main Outcomes and Measures: Two outcome measures of prescriptions of antihypertensive and lipid-lowering drugs within 465 days after ultrasonography was performed. Data obtained through intention-to-treat analysis are presented as proportions of individuals with a prescription among those who had no baseline prescription for agents from these drug classes. Results: Of the 4177 individuals invited to enroll, 3532 participants were randomized and included in the analysis; 1870 (52.9%) were women, 2278 (64.5%) were aged 60 years, 978 (27.7%) were 50 years, and 276 (7.8%) were 40 years. First prescriptions of lipid-lowering drugs were higher in the intervention group vs the control group among men (118 of 639 [18.5%] vs 38 of 692 [5.5%]; P <.001) and women (126 of 804 [15.5%] vs 38 of 817 [4.7%]; P <.001). There were no significant differences in the proportion with prescription of antihypertensive drugs in the intervention vs control groups after ultrasonography among men (58 of 482 [12.0%] vs 56 of 528 [10.6%]; P =.47) and women (60 of 612 [9.8%] vs 64 of 615 [10.4%]; P =.73). Conclusions and Relevance: The findings of this trial demonstrate that provision of pictorial information on vascular age and carotid plaques based on the results of ultrasonographic examination increased physician prescription of lipid-lowering drugs but not antihypertensive drugs within the following 465 days

Prescription of Lipid-Lowering and Antihypertensive Drugs following Pictorial Information about Subclinical Atherosclerosis : A Secondary Outcome of a Randomized Clinical Trial

Importance: Preventive drugs are often underused. Carotid intima-media thickness and carotid plaques are associated with cardiovascular disease (CVD), and their detection could possibly improve estimation of the likelihood of CVD and prescription of preventive drugs. Objective: To evaluate whether pictorial information on participants' asymptomatic atherosclerosis based on carotid ultrasonographic examinations to participants and their physicians had an effect on prescribing of lipid-lowering or antihypertensive drugs during the following 465 days. Design, Setting, and Participants: Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention is a pragmatic randomized clinical trial nested within the Västerbotten Intervention Program, a CVD screening and prevention program in Sweden with 60% to 70% participation rates and small social selection bias. A total of 4177 individuals aged 40, 50, or 60 years participating in the Västerbotten Intervention Program who had low to moderate risk of CVD were invited to enroll in this trial from April 29, 2013, to June 7, 2016. Prescriptions for all participants were monitored for 465 days after the intervention. Data analysis was conducted from December 6, 2019, to April 2, 2020. Interventions: Participants and their family physicians were randomly assigned 1:1 to receive or not receive pictorial information from carotid ultrasonographic determination of vascular age, assessed as carotid intima-media thickness and the presence of carotid plaques, combined with a follow-up call to participants by nurses. Main Outcomes and Measures: Two outcome measures of prescriptions of antihypertensive and lipid-lowering drugs within 465 days after ultrasonography was performed. Data obtained through intention-to-treat analysis are presented as proportions of individuals with a prescription among those who had no baseline prescription for agents from these drug classes. Results: Of the 4177 individuals invited to enroll, 3532 participants were randomized and included in the analysis; 1870 (52.9%) were women, 2278 (64.5%) were aged 60 years, 978 (27.7%) were 50 years, and 276 (7.8%) were 40 years. First prescriptions of lipid-lowering drugs were higher in the intervention group vs the control group among men (118 of 639 [18.5%] vs 38 of 692 [5.5%]; P <.001) and women (126 of 804 [15.5%] vs 38 of 817 [4.7%]; P <.001). There were no significant differences in the proportion with prescription of antihypertensive drugs in the intervention vs control groups after ultrasonography among men (58 of 482 [12.0%] vs 56 of 528 [10.6%]; P =.47) and women (60 of 612 [9.8%] vs 64 of 615 [10.4%]; P =.73). Conclusions and Relevance: The findings of this trial demonstrate that provision of pictorial information on vascular age and carotid plaques based on the results of ultrasonographic examination increased physician prescription of lipid-lowering drugs but not antihypertensive drugs within the following 465 days

Prescription of Lipid-Lowering and Antihypertensive Drugs following Pictorial Information about Subclinical Atherosclerosis : A Secondary Outcome of a Randomized Clinical Trial

Importance: Preventive drugs are often underused. Carotid intima-media thickness and carotid plaques are associated with cardiovascular disease (CVD), and their detection could possibly improve estimation of the likelihood of CVD and prescription of preventive drugs. Objective: To evaluate whether pictorial information on participants' asymptomatic atherosclerosis based on carotid ultrasonographic examinations to participants and their physicians had an effect on prescribing of lipid-lowering or antihypertensive drugs during the following 465 days. Design, Setting, and Participants: Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention is a pragmatic randomized clinical trial nested within the Västerbotten Intervention Program, a CVD screening and prevention program in Sweden with 60% to 70% participation rates and small social selection bias. A total of 4177 individuals aged 40, 50, or 60 years participating in the Västerbotten Intervention Program who had low to moderate risk of CVD were invited to enroll in this trial from April 29, 2013, to June 7, 2016. Prescriptions for all participants were monitored for 465 days after the intervention. Data analysis was conducted from December 6, 2019, to April 2, 2020. Interventions: Participants and their family physicians were randomly assigned 1:1 to receive or not receive pictorial information from carotid ultrasonographic determination of vascular age, assessed as carotid intima-media thickness and the presence of carotid plaques, combined with a follow-up call to participants by nurses. Main Outcomes and Measures: Two outcome measures of prescriptions of antihypertensive and lipid-lowering drugs within 465 days after ultrasonography was performed. Data obtained through intention-to-treat analysis are presented as proportions of individuals with a prescription among those who had no baseline prescription for agents from these drug classes. Results: Of the 4177 individuals invited to enroll, 3532 participants were randomized and included in the analysis; 1870 (52.9%) were women, 2278 (64.5%) were aged 60 years, 978 (27.7%) were 50 years, and 276 (7.8%) were 40 years. First prescriptions of lipid-lowering drugs were higher in the intervention group vs the control group among men (118 of 639 [18.5%] vs 38 of 692 [5.5%]; P <.001) and women (126 of 804 [15.5%] vs 38 of 817 [4.7%]; P <.001). There were no significant differences in the proportion with prescription of antihypertensive drugs in the intervention vs control groups after ultrasonography among men (58 of 482 [12.0%] vs 56 of 528 [10.6%]; P =.47) and women (60 of 612 [9.8%] vs 64 of 615 [10.4%]; P =.73). Conclusions and Relevance: The findings of this trial demonstrate that provision of pictorial information on vascular age and carotid plaques based on the results of ultrasonographic examination increased physician prescription of lipid-lowering drugs but not antihypertensive drugs within the following 465 days

Adolescent Sexual Offenders: A Total Survey of Referrals To Social Services in Sweden and Subgroup Characteristics

Sampling methodology (e.g. population-based vs. clinical samples, anonymous self-reports vs. data collected as part of mandated treatment) affects the validity of conclusions drawn from research addressing the etiology of adolescent sexual offending. Studies of unselected samples allow testing of the generalizability of etiological models suggested from investigation of selected clinical or forensic populations. Further, representative epidemiological data on adolescent sexual offending is needed for policy-making and the planning of services. We conducted a national survey of all adolescent sexual offenders (ASOs, 12-17 years) referred to Social Services during 2000. Social workers at all child and adolescent units in Social Service authorities throughout Sweden (N=285, 99% response rate) completed a questionnaire about new ASO referrals in 2000. The National Board of Health and Welfare commissioned the survey and questionnaire items tapped offender, offence, and victim characteristics. A total of 197 boys and 2 girls aged 12-17 years were referred to Social Services because of sexually abusive behavior in 2000. Focusing specifically on males, this yielded a one-year incidence of .060% (95% confidence interval = .052-.068). Forty-six percent of male ASOs abused at least one child younger than age 12 years (child offenders) whereas the rest had abused peer or adult victims (peer offenders). Forty-two percent of male ASOs had ever committed sexual offences together with at least one other offender (group offenders). Child- vs. peer offenders and group vs. single offenders, suggested typologies in the literature, were compared to explore potential subtype-specific risk factors and correlates. The results suggested a higher proportion of group ASOs than previously reported and stronger support for subdividing ASOs into child vs. peer offenders than into group vs. single ASOs

Improved adherence to statin treatment and differences in results between men and women after pictorial risk communication : a sub-study of the VIPVIZA RCT

Background: People with intermediate CVD risk constitute most of the population. Within this group, the proportion of events is lower compared to the high-risk group, but they contribute with the largest absolute number of events. Atherosclerosis is a dynamic process and progression can be slowed or even reversed with medication and lifestyle changes, but adherence to prescribed treatment is crucial. Aim: To investigate the long-term effects of interventions with pictorial risk communication of cardiovascular (CVD) risk on average adherence in a group of statin users. Compare response in adherence over time between men and women after intervention. Methods: Participants on active statin treatment were followed up to 5 years after being randomly assigned to an intervention program aimed at raising CVD risk awareness among participants and their physicians. Merging prescribed medication databases with VIPVIZA study to study adherence over time. A moving average adherence was used to compare groups. Results: Generally, the average adherence to statins among the 512 participants was high. Men had a higher average adherence over time, while women had a sharper increase in adherence in conjuncture with the intervention program. Conclusions: Both men and women were receptive to pictorial information regarding CVD risk, but the intervention effect was more pronounced in women. Sex differences are important when considering risk communication strategies. Periodically repeating the intervention was beneficial for maintaining the intervention effect over time. Trial registration: The VIPVIZA study is registered with ClinicalTrials.gov, May 8, 2013, number NCT01849575

Time to initiation of lipid-lowering drugs for subclinical atherosclerosis : sub-study of VIPVIZA randomized controlled trial, with single-arm cross-over

AIMS: Visual information about subclinical atherosclerosis was provided to physicians and participants in the VIPVIZA trial, inclusion 2013-16 in northern Sweden, aiming to improve adherence to cardiovascular disease (CVD) prevention guidelines. Pictorial risk information may be more actionable. The aim of this study was to investigate the effect of intervention with pictorial risk information on time to first dispensing of statins. METHODS AND RESULTS: Asymptomatic atherosclerotic disease was screened for by carotid ultrasound examination in 3532 participants enrolled in VIPVIZA, of those 3000 met the criteria for this study. Participants were randomly assigned to receive pictorial risk information consisting of graphical representation of atherosclerosis as compared to a control group without intervention. Time to initiation of statins was assessed during 5 years of follow-up through the National prescribed drug register. After 3 years, both groups were re-examined and received the intervention information. In the intervention group, initiation of statins increased considerably for the first 3 years and a smaller increase was also seen after re-intervention. After the cross-over, the control group showed a sharp increase in initiation of statins, almost reaching the same proportion treated at 5 years. The propensity to initiate statin treatment increased over the study period and there was no difference between men and women. CONCLUSIONS: The pictorial information had an effect on time to initiation of statins, both as original and repeated intervention and also in the control group after single-arm cross-over. The current study supports pictorial information as a tool to shorten time to initiation of statins for CVD prevention.The VIPVIZA study is registered with ClinicalTrials.gov, number NCT01849575

Association of education and feedback on hypertension management with risk for stroke and cardiovascular disease

PURPOSE: Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS: Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS: A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS: This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution

Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control

Importance: Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal. Objective: To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates. Design, Setting, and Participants: This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019. Exposures: An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group). Main Outcomes and Measures: Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up. Results: A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups. Conclusions and Relevance: This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management

The beneficial effect over 3 years by pictorial information to patients and their physician about subclinical atherosclerosis and cardiovascular risk : Results from the VIPVIZA randomized clinical trial.

Objective: Non-adherence to guidelines and preventive measures is a major challenge, particularly so to obtain long-term adherence to lifestyle changes and recommended medication. The objective was to investigate if pictorial information regarding subclinical carotid atherosclerosis provided to individuals and physicians gave sustained effects on cardiovascular risk beyond the previously reported effect after 1 year and up to 3 years. Methods: A Prospective Randomized Open Blinded End-point (PROBE) trial. Within a CVD prevention program in Västerbotten County, Sweden, 3532 healthy individuals aged 40, 50 or 60 years were enrolled and 1:1 randomized to intervention (n = 1749; pictorial information with additional prevention materials to participants and physicians) or control group (n = 1783; no pictorial information to participants and physicians). Preventive measures were managed within primary care. Participants were investigated at baseline during 2013-2016 and at follow-up after 1 and 3 years. Results: A beneficial effect on cardiovascular risk was observed at 3-year follow-up; Framingham Risk Score (FRS) was 13.38 for the intervention group and 14.08 for the control group (p = 0.047) and SCORE was 1.69 vs. 1.82 (p = 0.022). The effect observed at 1-year was sustained over 3 years after adjustment for sex and education and more pronounced among participants with a severe atherosclerotic picture at baseline. Conclusions: This study provides evidence of sustained beneficial effects on the adherence to prevention guidelines over 3 years of pictorial information about subclinical carotid atherosclerosis, resulting in lower cardiovascular risk regardless of sex and educational level. Direct visualization of the underlying still subclinical atherosclerotic disease, rather than just indirect information about risk factors and statistical risk of future myocardial infarction, stroke and death, is one way to tackle the problem of non-adherence to prevention of cardiovascular diseases