Family wellbeing in general practice: a study protocol for a cluster-randomised trial of the web-based resilience programme on early child development

BACKGROUND

Social, emotional and behavioural problems in early childhood are associated with increased risk for a wide range of poor outcomes associated with substantial cost and impact on society as a whole. Some of these problems are rooted in the early mother-infant relationship and might be prevented. In Denmark, primary health care has a central role in preventive care during pregnancy and the first years of the child's life and general practice provides opportunities to promote a healthy mother-infant relationship in early parenthood.

OBJECTIVE

In the context of standardised antenatal and child development assessments focused on psychosocial wellbeing, we examine the impact of a complex intervention designed to improve maternal mentalisation skills, involving training of general practice clinicians and signposting towards a web-based resource. Joint main outcomes are child socio-emotional and language development at age 30 months measured by parentally reported questionnaires (Communicative Development Inventory and Strengths and Difficulties Questionnaire).

METHODS

The study is a cluster-randomised controlled trial based in general practices in the Capital Region and the Zealand Region of Denmark. Seventy practices were included. Practices were randomised by a computer algorithm in a ratio of 1:1 to intervention or control groups. Each practice was asked to recruit up to 30 women consecutively at their first scheduled antenatal assessment. Clinicians in both groups received one day of training in preventive antenatal and child development consultations with added focus on parental psychosocial well-being, social support, and parent-child interaction. These preventive consultations delivered in both trial arms require enhanced data recording about psychosocial factors. In intervention clinics, clinicians were asked to signpost a web page at three scheduled antenatal consultations and at four scheduled consultations when the child is 5 weeks, 5 months, 1 and 2 years.

DISCUSSION

We hypothesise that the intervention will increase mothers' ability to be sensitive to their child's mental state to an extent that improves the child's language and mental state at 30 months of age measured by parent-reported questionnaires.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04129359. Registered on Oct 16 2019.

The predictive value of common symptoms in early pregnancy for complications later in pregnancy and at birth

INTRODUCTION

The aim was to investigate whether common pregnancy-related symptoms-nausea, vomiting, back pain, pelvic girdle pain, pelvic cavity pain, vaginal bleeding, itching of vulva, pregnancy itching, leg cramps, uterine contractions and varicose veins-in the first trimester of pregnancy add to the identification of women at high risk of future pregnancy and birth complications.

MATERIAL AND METHODS

Survey data linked to national register data. All women booking an appointment for a first prenatal visit in one of 192 randomly selected General Practices in East Denmark in the period April 2015-August 2016. The General Practices included 1491 women to this prospective study. Two outcomes, pregnancy complications and birth complications, were collected from the Danish Medical Birth Register.

RESULTS

Among the 1413 included women, 199 (14%) experienced complications in later pregnancy. The most serious complication, miscarriage, was experienced by 65 women (4.6%). Other common pregnancy complications were gestational diabetes mellitus (n = 11, 0.8%), gestational hypertension without proteinuria (n = 34, 2.4%), mild to moderate preeclampsia (n = 34, 2.4%) and gestational itching with effect on liver (n = 17, 1.2%). Women who experienced pelvic girdle pain, pelvic cavity pain or vaginal bleeding in the first trimester of pregnancy had a higher risk of pregnancy complications later on in later pregnancy. None of the other examined symptoms showed associations to pregnancy complications. No associations were found between pregnancy-related physical symptoms in first trimester and birth complications.

CONCLUSIONS

Symptoms in early pregnancy do not add much information about the risk of pregnancy or birth complications, although pain and bleeding may give reason for some concern. This is an important message to women experiencing these common symptoms and to their caregivers.

The association of a past childbirth experience with a variety of early physical and mental symptoms in subsequent pregnancies

BACKGROUND

Some women have a perceived negative experience of childbirth due to various reasons- e.g., obstetric complications or the feeling of loss of control. We do not know enough about the effects of a perceived negative experience of a childbirth on a woman's subsequent pregnancies. The aim of this study was to investigate whether a previously perceived negative childbirth experience affects a woman's physical and mental well-being in a later pregnancy.

METHODS

A prospective cohort study in Danish general practice, based on information about women's childbirth experiences from the Pregnancy Health Record filled in by the general practitioner (GP) and data from an electronic questionnaire completed by the women.

RESULTS

A total of 1288 women were included in the analysis. Women who had given birth before were found to have a significantly higher risk of experiencing nausea, varicose veins and uterine contractions, and a lower risk of pelvic cavity pain in the current pregnancy. Women having given birth before were significantly more likely to assess their physical fitness as poor and to experience poor well-being. Women with a perceived negative experience of childbirth had more sleep problems and a higher prevalence of poor self-rated health than women with unproblematic childbirth experience.

CONCLUSION

This study showed that women with a previously perceived negative experience of childbirth are affected according to their mental health in their subsequent pregnancy.

Mental vulnerability before and depressive symptoms during pregnancy and postpartum: a prospective population-based cohort study from general practice

PURPOSE

The aim was to investigate and compare the prevalence of symptoms of depression throughout pregnancy and postpartum among women who at the first pregnancy consultation had (1) record of mental disease, (2) self-reported psychological difficulties but no record of mental disease, or (3) no mental vulnerability.

MATERIALS AND METHODS

Prospective cohort study. An electronic questionnaire containing the Major Depression Inventory (MDI) was e-mailed to 1494 pregnant women after the first, second and third prenatal care consultation and eight weeks postpartum. High depression score was considered present with MDI scores of 21 or more. Information on sociodemographic, somatic comorbidities and previous psychiatric disorders was collected. We used logistic regression to estimate odds ratios with 95% confidence intervals.

RESULTS

The overall prevalence of symptoms of depression (MDI ≥ 21) dropped throughout pregnancy. At the first prenatal care consultation the prevalence was 15.3%, 10.7% in the second trimester, 9.3% in the third trimester and 5.6% postpartum. Logistic regression showed increased risk of symptoms of depression throughout pregnancy and postpartum for both women with mental disease and psychological difficulties. For each outcome, the increase in odds for the psychological difficulties group was about one third of the increase in odds for the mental illness group.

CONCLUSIONS

Self-reported psychological difficulties may indicate higher odds of depressive symptoms. The healthcare staff meeting the pregnant women in early pregnancy have a good opportunity to identify this subgroup of vulnerable women by means of the Pregnancy Health Records and additional questions exploring women's experiences with previous psychological difficulties.

Mental well-being during stages of COVID-19 lockdown among pregnant women and new mothers

Background

Pregnancy and early motherhood are sensitive times where epidemic disease outbreaks can affect mental health negatively. Countries and health care systems handled the pandemic and lockdowns differently and knowledge about how the COVID-19 pandemic affected the mental well-being of pregnant women and new mothers is limited and points in different directions.

Aim

To investigate symptoms of anxiety and depression in a population of pregnant women and new mothers in various stages of infection pressure and lockdown during the first 15 months of the COVID-19 pandemic in Denmark.

Methods

The study population was nested an inception cohort of women recruited in their first trimester of pregnancy. Data about mental health of the woman were obtained in relation to pregnancy and child development (first trimester, 8 weeks postpartum and 5 months postpartum), and data were analysed cross-sectionally according to calendar time (periods defined by infection rate and lock-down during the COVID-19 pandemic).

Results

No differences in reported levels of depressive symptoms between the six examined time periods of the pandemic were observed. Specifically, symptoms remained unchanged after the first lock-down. No major changes in anxiety symptoms were observed in relation to increased infection pressure or lockdowns, but a small increase was observed during the second lockdown in women 8 weeks postpartum.

Conclusion

No clear change in mood among pregnant women was seen between during the stages of COVID-19 pandemic in Denmark.

Infant crying problems related to maternal depressive and anxiety symptoms during pregnancy: a prospective cohort study

Background

Infant crying may cause concerns among new parents and is a frequent reason for seeking help from their general practitioner (GP). The etiology of crying problems in infancy is not fully understood, but recent studies have found associations with maternal mental factors. It is well-established that postpartum depression is related to infant crying problems while the influence of maternal mental problems in pregnancy on infant crying is less investigated. We aimed to explore whether maternal depressive symptoms or maternal anxiety during pregnancy were related to crying problems by the newborn child.

Methods

In this prospective cohort study, 1290 pregnant women and their newborn children were followed throughout pregnancy until 8 weeks postpartum. Depressive symptoms and anxiety symptoms were assessed three times during pregnancy and again 8 weeks postpartum with the Major Depressive Inventory (MDI) and the Anxiety Symptoms Scale (ASS). Eight weeks postpartum the mothers were also asked whether their child cried in a way they found problematic. Multivariable regression was used to assess the association between depressive and anxiety symptoms during pregnancy and crying problems, and to adjust for potential confounders.

Results

We found statistically significant associations between high scores of depressive symptoms and anxiety symptoms in pregnancy and infant crying problems. Previously reported strong associations postpartum between depressive symptoms, anxiety symptoms and infant crying problems were also observed in the present data.

Conclusion

These results indicate that mental problems during pregnancy are associated with having a child with crying problems after birth. If more focus is given to maternal mental problems during pregnancy, the healthcare system might be able to detect and help these women, which would be beneficial for both mother and child.

Depression and anxiety symptoms in pregnant women in Denmark during COVID-19

AIMS

Maternal mental distress in pregnancy can be damaging to the mother's and child's physical and mental health. This study aimed to provide an insight into mental well-being of pregnant women in Denmark during COVID-19 by assessing symptoms of depression and anxiety.

METHODS

Data from two cohorts of pregnant women recruited from Danish general practice were compared. A COVID-19 lockdown cohort (N=330) completed questionnaires between 8 April and 6 May. Responses were compared to those from a control cohort of women from 2016 (N=1428). Mental well-being was measured with the Major Depression Inventory (MDI) and the Anxiety Symptom Scale (ASS).

RESULTS

Questionnaires were returned by 83% of the COVID-19 lockdown cohort and by 93% of the control cohort. Multivariable analysis controlling for age, cohabitation status, occupation, smoking, alcohol use, chronic disease, fertility treatment, parity and children living at home showed no difference in depressive symptoms (MDI). Anxiety symptoms (ASS) were slightly worse in the COVID-19 lockdown cohort (mean difference=1.4 points), mainly driven by questions concerning general anxiety. The largest differences in anxiety were seen in first trimester (adjusted mean difference=4.0 points).

CONCLUSIONS

Pregnant women questioned during the COVID-19 pandemic showed no change in symptoms of depression and only a modest elevation of anxiety when compared to pregnant women questioned during a non-pandemic period in 2016.

What factors are most important for the development of the maternal-fetal relationship? A prospective study among pregnant women in Danish general practice

Background

Development of the maternal antenatal attachment (MAA) constitutes an important aspect of the transition into motherhood. Early identification of women at risk of developing a poor MAA provides possibilities for preventive interventions targeting maternal mental health and the emerging mother-infant relationship. In this study, we investigate the relative importance of an extensive set of psychosocial, pregnancy-related, and physiological factors measured in the first trimester of pregnancy for MAA measured in third trimester.

Methods

A prospective study was conducted among pregnant women in Danish general practice (GP). Data were obtained in the first and the third trimester from pregnancy health records and electronic questionnaires associated with routine GP antenatal care visits. The Maternal Antenatal Attachment Scale (MAAS) was used to assess maternal antenatal attachment. The relative importance of potential determinants of maternal antenatal attachment was assessed by the relative contribution of each factor to the fit (R²) calculated from multivariable regression models.

Results

The sample consisted of 1328 women. Low antenatal attachment (Total MAAS ≤ 75) was observed for 513 (38.6%) women. Perceived social support (having someone to talk to and having access to practical help when needed) emerged as the most important determinant. Furthermore, scores on the MAAS decreased with worse self-rated health, poor physical fitness, depression, increasing age, having given birth previously, and higher education.

Conclusion

Pregnant women reporting lack of social support and general low physical and mental well-being early in pregnancy may be at risk for developing a poor MAA. An approach targeting both psychosocial and physiological well-being may positively influence expectant mothers’ successful adaptation to motherhood.

Selection bias in general practice research: analysis in a cohort of pregnant Danish women

OBJECTIVE

The aim of the present study was to examine selection in a general practice-based pregnancy cohort.

DESIGN

Survey linked to administrative register data.

SETTING AND SUBJECTS

In spring 2015, GPs were recruited from two Danish regions. They were asked to invite all pregnant women in their practice who had their first prenatal care visit before 15 August 2016 to participate in the survey.

OUTCOME MEASURES

The characteristics of GPs and the pregnant women were compared at each step in the recruitment process - the GP's invitation, their agreement to participate, actual GP participation, and the women's participation - with an uncertainty coefficient to quantify the step where the largest selection occurs.

RESULTS

Significant differences were found between participating and non-participating practices with regards to practice characteristics such as the number of patients registered with the practice, the age and sex of doctors, and the type of practice. Despite these differences, the characteristics of the eligible patients differed little between participating and non-participating practices. In participating practices significant differences were, however, observed between recruited and non-recruited patients.

CONCLUSION

The skewed selection of patients was mainly caused by a high number of non-participants within practices that actively took part in the study. We recommend that a focus on the sampling within participating practices be the most important factor in representative sampling of patient populations in general practice. Key points Selection among general practitioners (GPs) is often unavoidable in practice-based studies, and we found significant differences between participating and non-participating practices. These include practice characteristics such as the number of GPs, the number of patients registered with the GP practice, as well as the sex and age of the GPs. •Despite this, only small differences in the characteristics of the eligible patients were observed between participating and non-participating practices. •In participating practices, however, significant differences were observed between recruited and non-recruited patients. •Comprehensive sampling within participating practices may be the best way to generate representative samples of patients.

Pregnant women's concerns and antenatal care during COVID-19 lock-down of the Danish society

INTRODUCTION

Pandemics are known to cause stress and anxiety in pregnant women. During the coronavirus disease 2019 (COVID-19) lockdown of the Danish society, pregnant women were considered to be at increased risk, and access to antenatal care changed.

METHODS

On 8 April 2020A, a questionnaire was sent to 332 pregnant women previously sampled by general practitioners in two Danish regions. The women were contacted via secured e-mail (e-Boks), and questionnaires were returned until 6 May.

RESULTS

The questionnaire was returned by 257 women (77%). More than half believed that they were at a high risk of infection with COVID-19, and a third of the women were concerned about the risk of serious disease - especially for their unborn child. Almost 90% isolated at home most of the time. The majority were worried about possible consequences of the pandemic for antenatal care, but very few had actually missed a scheduled preventive consultation with their general practitioner, and only 15% had missed an appointment with their midwife. The majority of the women preferred normal consultations and found no added safety in shifting the consultation from the normal clinical setting.

CONCLUSIONS

The COVID-19 pandemic and lockdown have had a major impact on Danish pregnant women. Even so, concerns were more focused on access to care than on the risk of COVID-19 infection. Contacts with the antenatal healthcare system have only been moderately affected.

FUNDING

TRYG Foundation and KEU, Region Copenhagen.

TRIAL REGISTRATION

not relevant.

Sleep complaints in early pregnancy. A cross-sectional study among women attending prenatal care in general practice

BACKGROUND

Sleep problems in late pregnancy are common, but sleep in early pregnancy is less well described. The aim of this study was to describe the occurrence and severity of sleep complaints in early pregnancy. We asked the women about worries due to sleep problems. Furthermore, we investigated the associations between sleep complaints and pregnancy-related symptoms. This association was studied taking into account physical and mental health, sociodemographic characteristics, and reproductive history of the women.

METHODS

Cross-sectional study in Danish general practice based on an electronic questionnaire completed by pregnant women and a Pregnancy Health Record filled in by the general practitioner (GP). The questionnaire measured three sleep complaints and 11 common physical pregnancy-related symptoms. The sleep complaints were measured as mild, moderate or severe, and it was recorded how much they worried the women. The associations between the physical pregnancy-related symptoms and sleep complaints were assessed by odds ratios from multivariable logistic regression models.

RESULTS

The questionnaire was completed by 1338 out of 1508 eligible women before the end of gestation week 16. The gestational age ranged from 5 to 16 weeks (median 11 weeks) among the included women. On average, more than one third of the women reported to have at least one of the three sleep complaints in the questionnaire. Problems "taking a long time to fall asleep" was reported by 312 women (23%), "waking up too early" was reported by 629 (47%), and 183 (14%) had been "lying awake most of the night". One sleep complaint was reported by 38%, two by 16, and 4% had all three symptoms. The majority were not at all or only mildly worried because of their sleep disturbances, but moderate or severe worries were found among 46% of those" taking a long time to fall asleep" and among 40% of those "lying awake most of the night". "Moderate or severe complaints" were reported by 277 (21%) women "Moderate or severe complaints" were associated with pregnancy-related physical symptoms, such as back pain, pelvic girdle pain and pelvic cavity pain, but only the association with pelvic cavity pain stayed significant after adjustment for depression.

CONCLUSION

This study showed that sleep complaints in early pregnancy are common, and sleep complaints showed association with physical as well as mental symptoms. It may be important for pregnant patients that clinicians address depression, and mood in relation to sleep problems during pregnancy.

Examining to what extent pregnancy-related physical symptoms worry women in the first trimester of pregnancy: a cross-sectional study in general practice

BACKGROUND

Women often wish to discuss their pregnancy symptoms with their GP. However, the two parties' understanding of symptoms may not be aligned.

AIM

To examine to what degree a specific pregnancy-related symptom worried women in the first trimester and analyse the characteristics of the most worried women.

DESIGN & SETTING

A cross-sectional study was performed in general practice in Denmark from 1 March 2015-15 August 2016.

METHOD

Women attending the first prenatal care visit completed a questionnaire about pregnancy-related physical symptoms and worries. Women were recruited from 125 GP practices and 294 GPs participated in the study. Further data were obtained from their pregnancy health record. Multivariable logistic regression analysis was used to assess the associations between the women's worries and the severity of the symptoms, which were adjusted for age and parity.

RESULTS

A total of 1508 women, aged 16-45 years, were included and 1455 completed the questionnaire. Nausea, vomiting, pelvic cavity pain, and back pain were the most common symptoms, and 88% reported having two or more symptoms simultaneously. Among the 1278 women reporting nausea, only 21% were worried, while 88% of the 252 women reporting vaginal bleeding were worried. Primigravidae (those pregnant for the first time) were significantly more worried about vomiting and nausea than multigravidae (those who have experienced pregnancy previously). Those aged >35 years were more worried about pelvic girdle pain and pelvic cavity pain than younger women.

CONCLUSION

Pregnancy-related physical symptoms are frequent in the first trimester. The severity of worries depends on the symptom. Vaginal bleeding and pain give rise to the majority of severe worries, especially among young women.

Premorbid risk factors influencing labour market attachment after mild traumatic brain injury: a national register study with long-term follow-up

OBJECTIVES

Some patients with mild traumatic brain injury (mTBI) experience persistent postconcussive symptoms, influencing the ability to work. This study assessed associations between mTBI and labour market attachment (up to 5 years postinjury) in patients with different premorbid characteristics.

DESIGN AND SETTING

Danish national cohort study with 5-year register follow-up.

PARTICIPANTS

We included hospital admitted patients between 18 and 60 years diagnosed with mTBI (International Classification of Diseases, version 10 diagnosis S06.0) (n=19 732). For each patient, one control was selected matched on age, gender and municipality (n=18 640).

PRIMARY OUTCOME MEASURE

Primary outcome was 'not attending ordinary work', and premorbid risk factors were cohabitation status, education, ethnicity, gender, age and comorbidities.

RESULTS

The odds of not attending ordinary work increased from 6 months to 5 years. The highest increased odds (approximately twice as high for patients) of not attending ordinary work at 5 years were found in the highest educational group (OR 2.15, 95% CI 1.78 to 2.59), for patients of non-Danish origin (OR 1.98, 95% CI 1.52 to 2.57), for patients between 30 and 39 years (OR 1.93, 95% CI 1.68 to 1.23) and for patients with somatic comorbidities (OR 1.81, 95% CI 1.38 to 2.37). Contrary to expectations, we did not find higher odds in patients with psychiatric diagnoses (OR 1.12, 95% CI 0.76 to 1.60).

CONCLUSIONS

Important premorbid characteristics for lower labour market participation after mTBI were higher education, non-Danish origin, age 30-39 years and having somatic comorbidities. Demographic and health-related variables should be considered when assessing patients with mTBI at risk of long-term sickness absence.

TRIAL REGISTRATION NUMBER

NCT03214432; Results.

Labour market attachment after mild traumatic brain injury: nationwide cohort study with 5-year register follow-up in Denmark

OBJECTIVES

Sickness absence after mild traumatic brain injury (mTBI) is frequent due to postconcussive symptoms. We examined labour market attachment following mTBI up to 5 years postinjury.

DESIGN AND SETTING

Nationwide cohort study with register follow-up.

PARTICIPANTS

Patients between 18 and 60 years with mTBI (International Classification of Diseases, version 10 diagnosis S06.0) were extracted from the Danish National Patient Register (n=19 732). Controls were matched on sex, age and municipality (n=18 640). Patients with spinal cord and column injuries, traumatic brain injury and concussions 5 years preinjury or as secondary diagnosis to the concussion in the inclusion period were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted from the Danish Register for Evaluation of Marginalization. Primary outcome was 'not attending ordinary work' defined as receiving any social transfer payment. Secondary outcomes were health-related benefits, limited attachment to the labour market, permanent lack of attachment to the labour market and death.

RESULTS

5 years after diagnosis, 43% of patients were not attending ordinary work. The odds increased from 6 months (OR 1.30, 95% CI 1.24 to 1.36) to 5 years (OR 1.54, 95% CI 1.45 to 1.63). The odds of health-related benefits were 32% (OR 1.32, 95% CI 1.22 to 1.42) at 6 months and 22% (OR 1.22, 95% CI 1.12 to 1.33) at 5 years. Limited attachment to the labour market showed increased odds at 5 years (OR 1.38, 95% CI 1.27 to 1.51) and the odds of permanent lack of attachment to the labour market were higher for patients compared with controls (OR 2.59, 95% CI 2.30 to 2.92). Death was more than two times higher at 5 years postinjury (OR 2.62, 95% CI 2.10 to 3.26).

CONCLUSIONS

43% of concussed patients were not attending ordinary work 5 years postinjury and received health and social transfer benefits. We conclude that mTBI has a long-term impact on labour market attachment. Prevention and treatment of persisting postconcussive symptoms should be considered.

TRIAL REGISTRATION NUMBER

NCT03214432; Results.

Physical discomfort in early pregnancy and postpartum depressive symptoms

PURPOSE

Pregnancy examinations conducted in general practice focus mainly on identifying high-risk pregnancies and pregnancy complications. The pregnancy health record has a biomedical focus, and consequently the woman's mental well-being may receive less attention. The aim of this study was to evaluate the extent to which early pregnancy-related symptoms should be considered as indicators of an increased risk of postpartum depression.

MATERIALS AND METHODS

For a prospective cohort of 1508 pregnant women, the presence of 11 pregnancy-related symptoms was recorded at the first prenatal care consultation together with background information about socio-demography and health. Depression was assessed 8 weeks postpartum with the major depression inventory (MDI) and depression was considered present if MDI > 20. Multivariable logistic regression was used to assess the association between pregnancy-related symptoms and postpartum depressive symptoms, and to adjust for potential confounders.

RESULTS

A high depression score (MDI score >20) 8 weeks postpartum was found among 6.6% of the women and showed apparent associations with physical discomfort in early pregnancy, such as back pain and pelvic cavity pain. Analysis of confounding revealed, however, that signs of vulnerable mental health, present in early pregnancy, explained most of these associations.

CONCLUSIONS

Indicators of an increased risk of postpartum depressive symptoms may be found in early pregnancy. Pregnancy-related pain in the first trimester may be a sign of psychological vulnerability or an aspect of an existing depressive state that calls for attention.

Predictors of undiagnosed prevalent type 2 diabetes - The Danish General Suburban Population Study

AIMS

To investigate how self-reported risk factors (including socioeconomic status) predict undiagnosed, prevalent type 2 diabetes mellitus (T2DM). To externally validate Leicester Risk Assessment Score (LRAS), Finnish Diabetes Risk Score (FINDRISC) and Danish Diabetes Risk Score (DDRS), and to investigate how these predict a European Heart SCORE≥5% in a Danish population study.

METHODS

We included 21,205 adults from the Danish General Suburban Population Study. We used relative importance calculations of self-reported variables in prediction of undiagnosed T2DM. We externally validated established prediction models reporting ROC-curves for undiagnosed T2DM, pre-diabetes and SCORE.

RESULTS

More than 20% of people with T2DM were undiagnosed. The 7 most important self-rated predictors in sequential order were high BMI, antihypertensive-therapy, age, cardiovascular disease, waist-circumference, fitness compared to peers and family disposition for T2DM. The Area Under the Curve for prediction of undiagnosed T2DM was 77.1 for LRAS; 75.4 for DDRS and 67.9 for FINDRISC. AUCs for SCORE was 75.1 for LRAS; 62.3 for DDRS and 54.3 for FINDRISC.

CONCLUSIONS

BMI and self-reported cardiovascular disease are important risk factors for undiagnosed T2DM. LRAS performed better than DDRS and FINDRISC in prediction of undiagnosed T2DM and SCORE≥5%. SCORE performed best in predicting pre-diabetes.

Socio-demographic determinants and effect of structured personal diabetes care: a 19-year follow-up of the randomized controlled study diabetes Care in General Practice (DCGP)

BACKGROUND

We investigated how four aspects of socio-demography influence the effectiveness of an intervention with structured personal diabetes care on long-term outcomes.

METHODS

The Diabetes Care in General Practice (DCGP) study is a cluster-randomized trial involving a population-based sample of 1381 patients with newly diagnosed type 2-diabetes mellitus. We investigated how education, employment, cohabitation status and residence influenced the effectiveness of 6 years of intervention with structured personal diabetes care, resembling present day recommendations. Outcomes were incidence of any diabetes-related endpoint and death during 19 years after diagnosis, and cardiovascular risk factors, behaviour, attitudes and process-of-care variables 6 years after diagnosis.

RESULTS

Structured personal care reduced the risk of any diabetes-related endpoint and the effect of the intervention was modified by geographical area (interaction p = 0.034) with HR of 0.71 (95%CI: 0.60-0.85) and of 1.07 (95%CI: 0.77-1.48), for patients in urban and rural areas, respectively. Otherwise, there was no effect modification of education, employment and civil status on the intervention for the final endpoints. There were no noticeable socio-demographic differences in the effect of the intervention on cardiovascular risk factors, behaviour, attitudes, and process-of-care.

CONCLUSION

Structured personal care reduced the aggregate outcome of any diabetes-related endpoint and independent of socio-demographic factors similar effect on cardiovascular risk factors, behaviour, attitudes and process of care, but the intervention did not change the existing inequity in mortality and morbidity. Residence modified the uptake of the intervention with patients living in urban areas having more to gain of the intervention than rural patients, further investigations is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov registration no. NCT01074762 (February 24, 2010).

Exploring the concurrent validity of the nationwide assessment of permanent nursing home residence in Denmark - A cross-sectional data analysis using two administrative registries

BACKGROUND

Many register studies make use of information about permanent nursing home residents. Statistics Denmark (StatD) identifies nursing home residents by two different indirect methods, one based on reports from the municipalities regarding home care in taken place in a nursing home, and the other based on an algorithm created by StatD. The aim of the present study was to validate StatD's nursing home register using dedicated administrative municipality records on individual nursing home residents as gold standard.

METHODS

In total, ten Danish municipalities were selected. Within each Danish Region, we randomly selected one municipality reporting to Stat D (Method 1) and one not reporting where instead an algorithm created by StatD was used to discover nursing home residents (Method 2). Method 1 means that municipalities reported to Stat D whether home care has taken place in a nursing home or in a private home. Method 2 is based on an algorithm created by Stat D for the municipalities where Method 1 is not applicable. Our gold standard was the information from the local administrative system in all ten selected municipalities. Each municipality provided a list with all individuals > 65 years living in a nursing home on January 1st, 2013 as well as the central personal number. This was compared to the list of individuals >65 living in nursing home facilities in the same ten municipalities on January 1st, 2013 retrieved from StatD.

RESULTS

According to the data received directly from the municipalities, which was used as our gold Standard 3821 individuals were identified as nursing home residents. The StatD register identified 6,141 individuals as residents. Additionally, 556 of the individuals identified by the municipalities were not identified in the StatD register. Overall sensitivity for the ten municipalities in the StatD nursing home register was 0.85 (95% CI 0.84-0.87) and the PPV was 0.53 (95% CI 0.52-0.54). The municipalities for which nursing home status was based on the StatD algorithm (method 2) had a sensitivity of 0.84 (95% CI 0.82-0.86) and PPV of 0.48 (95% CI 0.46-0.50). Both slightly lower than the reporting municipalities (method 1) where the sensitivity was 0.87(95% CI 0.85-0.88) and the PPV was 0.57 (95% CI 0.56-0.59). Additionally, the sensitivity and PPV of the Stat D register varied heavily among the ten municipalities from 0.51 (95% CI 0.43-0.59) to 0.96 (95% CI 0.95-0.98) and PPV correspondingly, from 0.14 (95% CI: 0.11-0.17) to 0.73 (95% CI 0.69-0.77).

CONCLUSIONS

The overall PPV of StatD nursing home register was low and differences between municipalities existed. Even in countries with extensive nation-wide registers, validating studies should be conducted for outcomes based on these registers.

Social disparities in diabetes care: a general population study in Denmark

OBJECTIVE

We investigated the association between socioeconomic factors and the attainment of treatment goals and pharmacotherapy in patients with type 2 diabetes in Denmark.

DESIGN

A cross-sectional population study.

SETTING

The municipality of Naestved, Denmark.

SUBJECTS

We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens.

MAIN OUTCOME MEASURES

The proportion of patients who were not achieving goals for diabetes care based on their HbA_1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication.

METHODS

We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease.

RESULTS

Middle age (40-65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES.

CONCLUSIONS

In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care. KEY POINTS Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Association of socioeconomic factors with pharmacotherapy was inconsistent.

Effects of numerical information on intention to participate in cervical screening among women offered HPV vaccination: a randomised study

OBJECTIVES

To investigate the effects of different types of information about benefits and harms of cervical screening on intention to participate in screening among women in the first cohorts offered human papilloma virus (HPV) vaccination.

DESIGN

Randomised survey study.

SETTING

Denmark.

SUBJECTS

A random sample of women from the birth cohorts 1993, 1994 and 1995 drawn from the general population.

INTERVENTIONS

A web-based questionnaire and information intervention. We randomised potential respondents to one of the following four different information modules about benefits and harms of cervical screening: no information; non-numerical information; and two numerical information modules. Moreover, we provided HPV-vaccinated women in one of the arms with numerical information about benefits and harms in two steps: firstly, information without consideration of HPV vaccination and subsequently information conditional on HPV vaccination.

MAIN OUTCOME MEASURE

Self-reported intention to participate in cervical screening.

RESULTS

A significantly lower proportion intended to participate in screening in the two groups of women receiving numerical information compared to controls with absolute differences of 10.5 (95% CI: 3.3-17.6) and 7.7 (95% CI: 0.4-14.9) percentage points, respectively. Among HPV-vaccinated women, we found a significantly lower intention to participate in screening after numerical information specific to vaccinated women (OR of 0.38).

CONCLUSIONS

Women are sensitive to numerical information about the benefits and harms of cervical screening. Specifically, our results suggest that HPV-vaccinated women are sensitive to information about the expected changes in benefits and harms of cervical screening after implementation of HPV vaccination. KEY POINTS Women were less likely to participate in cervical screening when they received numerical information about benefits and harms compared to non-numerical or no information. Specifically, numerical information about the potential impact of the reduced risk of cervical cancer among HPV-vaccinated women reduced the intention to participate among vaccinated women.

How does HPV vaccination status relate to risk perceptions and intention to participate in cervical screening? a survey study

BACKGROUND

Women in several countries will soon be covered by two preventive programmes targeting cervical cancer: HPV vaccination and cervical screening. The HPV vaccines are expected to prevent approximately 70 % of cervical cancers. It has been speculated, that HPV vaccinated women will not attend screening because they falsely think that the vaccine has eliminated their cervical cancer risk. The aim of this study was to investigate the association between HPV vaccination status and perceptions of cervical cancer risk; perceptions of vaccine effect; and intention to participate in cervical screening. Furthermore, to investigate associations between perceptions of cervical cancer risk and intention to participate in cervical screening.

METHODS

A random sample of Danish women from the birth cohorts 1993-1995 was invited to complete a web-based questionnaire concerning risk perceptions and intentions to participate in cervical screening. Main outcomes were: perceived lifetime-risk of cervical cancer; perceived HPV vaccine effect; and intention to participate in cervical screening.

RESULTS

HPV vaccinated women more often than unvaccinated women intended to participate in screening: adjusted odds ratio (OR) for being HPV vaccinated when intending to participate in screening of 3.89 (95 % CI: 2.50-6.06). HPV vaccinated women perceived cervical cancer risk to be higher than unvaccinated women did: adjusted OR of 0.11 (95 % CI: 0.03-0.39) and 0.51 (95 % CI: 0.33-0.78) for being HPV vaccinated while having the lowest perception of risk (in two different pre-specified dichotomisations). HPV vaccinated women perceived the vaccine effect to be larger than unvaccinated women did: adjusted OR of 0.31 (95 % CI: 0.18-0.51) and 0.37 (95 % CI: 0.25-0.53) for being HPV vaccinated while having the lowest perception of vaccine effect (in two different pre-specified dichotomisations). There were no associations between perceived cervical cancer risk and intention to participate in screening.

CONCLUSIONS

HPV vaccinated women more often than unvaccinated women intended to participate in screening and they perceived cervical cancer risk to be higher and the vaccine effect to be larger than unvaccinated women did. However, in our analyses, risk perceptions could not explain screening intentions neither among vaccinated nor among unvaccinated women.

Alcohol consumption and mortality in patients with mild Alzheimer's disease: a prospective cohort study

OBJECTIVE

To investigate the association between alcohol consumption and mortality in patients recently diagnosed with mild Alzheimer's disease (AD).

DESIGN

A post hoc analysis study based on a clinical trial population.

SETTING

The data reported were collected as part of the Danish Alzheimer's Intervention Study (DAISY), a longitudinal multicentre randomised controlled study on the efficacy of psychosocial intervention in patients with mild AD across five county districts in Denmark.

PARTICIPANTS

321 patients with mild AD (Mini-Mental State Examination ≥ 20) were included. Data regarding current daily alcohol consumption were obtained from the patient's primary caregivers at inclusion.

MAIN OUTCOME

All-cause mortality retrieved from The Danish Civil Registration System over a period of 36 months after baseline.

RESULTS

Information about alcohol consumption was obtained from all 321 study participants: 8% were abstinent, 71% only had alcohol occasionally (1 or <1 unit/day), 17% had 2-3 units/day and 4% had more than 3 units/day. An analysis adjusted for a range of potential confounders demonstrated a reduced mortality for patients with moderate alcohol consumption (2-3 units/day): HR 0.23 (95% CI (0.08 to 0.69)) compared with patients who had 1 or <1 unit/day. Mortality was not significantly different in abstinent patients or in patients with an alcohol consumption of more than 3 units/day, compared with patients drinking 1 or <1 unit/day.

CONCLUSIONS

In this cohort of patients with mild AD, moderate alcohol consumption (2-3 units/day) was associated with a significantly lower mortality over a period of 36 months. Further studies are needed in this area. These may especially focus on the association between alcohol consumption and cognitive decline in patients with AD.

The impact of HPV vaccination on future cervical screening: a simulation study of two birth cohorts in Denmark

OBJECTIVES

To explore the interplay between primary and secondary prevention of cervical cancer by estimating future screening outcomes in women offered human papillomavirus (HPV) vaccination when they were sexually naïve.

DESIGN

Estimation of outcome of liquid-based cytology screening for a post-HPV vaccination cohort using pre-vaccination screening data combined with HPV vaccination efficacy data reported in the literature.

SETTING

Denmark.

DATA

The number of screening diagnoses at first screen in a pre-vaccination birth cohort was multiplied by reported risk reductions expected for women who were vaccinated for HPV before sexual debut. All identified studies were reviewed by two authors, and weighted pooled estimates of vaccine efficacies were used.

MAIN OUTCOME MEASURES

Proportions of positive and false-positive cervical cytologies and positive predictive value (PPV) were calculated using cervical intraepithelial neoplasia (CIN) grade 2+ and 3+ as cut-off values.

RESULTS

The proportion of positive screening tests was reduced from 8.7% before vaccination to 6.5% after vaccination, and the proportion of false-positive screening tests using CIN2+ as a cut-off was reduced from 5.5% pre-vaccination to 4.3% post-vaccination, and using CIN3+ as a cut-off from 6.2% to 4.7%. PPVs were reduced from 23% to 19% (cut-off CIN2+), and from 14% to 12% (cut-off CIN3+).

CONCLUSIONS

In our calculations, the proportion of positive screening results with liquid-based cytology will be reduced as a consequence of HPV vaccination, but the reduction is small, and the expected decline in PPV is very limited. In this situation, the information general practitioners will have to provide to their patients will be largely unchanged.

Increased health-care utilisation in international adoptees

INTRODUCTION

Several studies have documented that international adoptees have an increased occurrence of health problems and contacts to the health-care system after arriving to their new country of residence. This may be explained by pre-adoption adversities, especially for the period immediately after adoption. Our study aimed to the assess health-care utilisation of international adoptees in primary and secondary care for somatic and psychiatric diagnoses in a late post-adoption period. Is there an increased use of the health-care system in this period, even when increased morbidity in the group of international adoptees is taken into consideration?

METHODS

This was a Danish register-based cohort study examining health-care utilisation in a multivariable two-part model. The prevalence of selected outcomes and the quantity of use were assessed in a late (year three, four and five) post-adoption period. The cohort comprised internationally adopted children (n = 6,820), adopted between 1994 and 2005, and all non-adopted children (n = 492,374) who could be matched with the adopted children on sex, age, municipality and family constellation at the time of adoption.

RESULTS

International adoption increased the use of all services in primary care, while in secondary care only few areas showed an increased long-term morbidity.

CONCLUSION

International adoptees use medical services in primary care at a higher rate than non-adoptees some years after adoption. Excess use of services in secondary care is also present, but only exists in selected areas.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Placebo-Controlled Discontinuation of Long-Term Acid-Suppressant Therapy: A Randomised Trial in General Practice

Objective. To investigate whether patients on long-term antisecretory medication need to continue treatment to control symptoms. Methods. A double-blinded randomised placebo-controlled trial in general practices in Denmark. Patients aged 18-90 who were treated with antisecretory drugs on a long-term basis were randomized to esomeprazole 40 mg or identical placebo. Outcome measures were time to discontinuation with trial medication due to failed symptom control analysed as survival data. The proportion of patients stopping trial medication during the one-year follow-up was estimated. Results. A total of 171 patients were included with a median prior duration of antisecretory treatment of four years (range: 0.5 to 14.6 years). 86 patients received esomeprazole 40 mg and 85 patients received placebo. At 12 months, statistically significantly more patients in the placebo group had discontinued (73% (62/85)) compared with the esomeprazole group (21% (18/86); p < 0.001). Conclusions. Long-term users of antisecretory drugs showed a preference for the active drug compared to placebo. However, 27% of patients continued on placebo throughout the study and did not need to reinstitute usual treatment. One in five patients treated with esomeprazole discontinued trial medication due to unsatisfactory symptom control. Discontinuation of antisecretory treatment should be considered in long-term users of antisecretory drugs. This trial is registered with Trial registration ClinicalTrials.gov ID: NCT00120315.

[Clinical and ethical differences between diagnosing and screening]

Screening is often defined as systematic examinations of healthy citizens to identify those with asymptomatic disease. In our modern society many persons have chronic conditions and it is not so easy to draw the line between healthy and unhealthy citizens. Today, many health-care activities aim at detecting conditions at an early non-symptomatic stage of the disease process in order to be able to avoid possible progression to the next stage. On this basis, we suggest to broaden the definition of screening to reflect the realities of modern health care.

Influence of comorbidity on cancer patients' rehabilitation needs, participation in rehabilitation activities and unmet needs: a population-based cohort study

PURPOSE

This study aims to investigate possible associations between cancer survivors' comorbidity status and their (1) need for rehabilitation, (2) participation in rehabilitation activities and (3) unmet needs for rehabilitation in a 14-month period following date of diagnosis.

METHODS

We performed a population-based cohort study including incident cancer patients diagnosed from 1 October 2007 to 30 September 2008 in two regions in Denmark. Fourteen months after diagnosis, participants completed a questionnaire measuring different aspects and dimensions of rehabilitation. Individual information on comorbidity was based on hospital contacts from 1994 and until diagnosis, subsequently classified according to the Charlson comorbidity index. Logistic regression analyses were used to explore the association between comorbidity and outcomes for rehabilitation. Analyses were conducted overall and stratified for gender, age and cancer type.

RESULTS

A total of 3,439 patients responded (70%). Comorbidity at all levels was statistically significant associated with a physical rehabilitation need, and moderate to severe comorbidity was statistically significant associated with a need in the emotional, family-oriented and financial areas as well as participation in physical-related rehabilitation activities. Stratified analyses showed that significant results in most cases were related to being older than 65 years or having colorectal or prostate cancer.

CONCLUSIONS

Comorbidity at all levels was significantly associated with needs for physical rehabilitation. Moderate to severe comorbidity was further associated with other areas of need and participation in physical area activities. This should be taken into account when planning rehabilitation interventions for cancer survivors. Differences among subgroups could help target interventions and should be explored further.

Characteristics of complaints resulting in disciplinary actions against Danish GPs

OBJECTIVE

The risk of being disciplined in connection with a complaint case causes distress to most general practitioners. The present study examined the characteristics of complaint cases resulting in disciplinary action.

MATERIAL AND METHODS

The Danish Patients' Complaints Board's decisions concerning general practice in 2007 were examined. Information on the motives for complaining, as well as patient and general practitioner characteristics, was extracted and the association with case outcome (disciplinary or no disciplinary action) was analysed. Variables included complaint motives, patient gender and age, urgency of illness, cancer diagnosis, healthcare settings (daytime or out-of-hours services), and general practitioner gender and professional seniority.

RESULTS

Cases where the complaint motives involved a wish for placement of responsibility (OR = 2.35, p = 0.01) or a wish for a review of the general practitioner's competence (OR = 1.95, p = 0.02) were associated with increased odds of the general practitioner being disciplined. The odds of discipline decreased when the complaint was motivated by a feeling of being devalued (OR = 0.39, p = 0.02) or a request for an explanation (OR = 0.46, p = 0.01). With regard to patient and general practitioner characteristics, higher general practitioner professional seniority was associated with increased odds of discipline (OR = 1.97 per 20 additional years of professional seniority, p = 0.01). None of the other characteristics was statistically significantly associated with discipline in the multiple logistic regression model.

CONCLUSION

Complaint motives and professional seniority were associated with decision outcomes. Further research is needed on the impact of professional seniority on performance.

A randomised controlled trial to improve general practitioners' services in cancer rehabilitation: effects on general practitioners' proactivity and on patients' participation in rehabilitation activities

Few studies have evaluated initiatives targeting implementation of cancer rehabilitation. In this study we aim to test the effects of a complex intervention designed to improve general practitioners' (GPs) involvement in cancer rehabilitation. Outcomes were proactive contacts to patients by their GP reported by the patients and GPs, respectively, and patients' participation in rehabilitation activities.

METHODS

Cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention group or to a control group (usual procedures). Patients were subsequently allocated to the intervention or the control group based on randomisation status of their GP. Between May 2008 and February 2009, adult patients treated for incident cancer at Vejle Hospital, Denmark, were assessed for eligibility. A total of 323 general practices were included, allocating 486 patients to an intervention and 469 to a control group. The intervention included a patient interview about rehabilitation with a rehabilitation coordinator at the hospital, comprehensive information to the GP about individual needs for rehabilitation, and an encouragement to the GP to contact the patient proactively. Questionnaires were administered to patients and GPs at 14 months after inclusion.

RESULTS

At baseline average age of patients was 63 years and 72% were female. The most frequent cancer localisations were breast (43%), lung (15%), and malignant melanoma (8%). The intervention had no effect on either patient- or GP-reported extent of GP proactivity. Further, no effect was observed on patient participation in rehabilitation activities during the 14-month follow-up period.

DISCUSSION

The intervention had no effect on GP proactivity or on patient participation in rehabilitation activities. However, analyses showed a significant association between proactivity and participation and we, therefore, conclude that increased GP proactivity may facilitate patient participation in rehabilitation activities.

Social inequality in cancer rehabilitation: a population-based cohort study

OBJECTIVES

In a healthcare system with equal access we analysed possible associations between cancer survivors' socioeconomic status (SES) and their: 1) need for rehabilitation; 2) participation in rehabilitation activities; and 3) unmet needs for rehabilitation in a 14-month period following date of diagnosis.

METHODS

A population-based cohort study including incident cancer patients diagnosed from 1 October 2007 to 30 September 2008 in Denmark. Fourteen months after diagnosis participants completed a mailed out questionnaire developed to measure different aspects and dimensions of rehabilitation. Individual information on cohabitation status, education, income and labour market status was retrieved from national registers. Logistic regression analyses were used to explore associations between socioeconomic status and rehabilitation outcomes.

RESULTS

A total of 3439 patients responded (70%). Significant interactions between SES and sex were demonstrated and further analyses were therefore stratified for gender. In general, women and to a lesser extent men with short education and low income participated less often in activities and had in some areas more unmet needs. Women living alone more often expressed a rehabilitation need in the physical, emotional and financial area and had to a higher extent unmet needs in a number of areas. Men living alone and men outside the workforce had increased odds of unmet needs in the physical area.

CONCLUSIONS

Despite equal access to care, SES had a significant impact on cancer survivors' rehabilitation. In general, the associations were most pronounced for female cancer patients. We suggest that special attention should be paid to socioeconomically disadvantaged groups by taking into account differences in SES in a clinical setting and when developing targeted rehabilitation programmes.

Process-related factors associated with disciplinary board decisions

BACKGROUND

In most health care systems disciplinary boards have been organised in order to process patients' complaints about health professionals. Although, the safe-guarding of the legal rights of the involved parties is a crucial concern, there is limited knowledge about what role the complaint process plays with regard to board decision outcomes. Using complaint cases towards general practitioners, the aim of this study was to identify what process factors are statistically associated with disciplinary actions as seen from the party of the complainant and the defendant general practitioner, respectively.

METHODS

Danish Patient Complaints Board decisions concerning general practitioners completed in 2007 were examined. Information on process factors was extracted from the case files and included complaint delay, complainant's lawyer involvement, the number of general practitioners involved, event duration, expert witness involvement, case management duration and decision outcome (discipline or no discipline). Multiple logistic regression analyses were performed on compound case decisions eventually involving more general practitioners (as seen from the complainant's side) and on separated decisions (as seen from the defendant general practitioner's side).

RESULTS

From the general practitioner's side, when the number of general practitioners involved in a complaint case increased, odds of being disciplined significantly decreased (OR=0.661 per additional general practitioner involved, p<0.001). Contrarily, from the complainant's side, no association could be detected between complaining against a plurality of general practitioners and the odds of at least one general practitioner being disciplined. From both sides, longer case management duration was associated with higher odds of discipline (OR=1.038 per additional month, p=0.010). No association could be demonstrated with regard to complaint delay, lawyer involvement, event duration, or expert witness involvement. There was lawyer involvement in 5% of cases and expert witness involvement in 92% of cases. The mean complaint delay was 3 months and 18 days and the mean case management duration was 14 months and 7 days.

CONCLUSIONS

Certain complaint process factors might be statistically associated with decision outcomes. However, the impact diverges as seen from the different parties. Future studies are merited in order to uncover the judicial mechanisms lying behind.

A randomised controlled trial to improve the role of the general practitioner in cancer rehabilitation: effect on patients' satisfaction with their general practitioners

OBJECTIVE

To test whether a complex intervention facilitating early cancer rehabilitation by involvement of the general practitioner (GP) soon after diagnosis improves patients' satisfaction with their GPs.

DESIGN

A cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention or a control group before the start of the study. Patients included those with cancer who were subsequently allocated to either group based on the randomisation status of their GP.

PARTICIPANTS

Adult patients with cancer treated for incident cancer at the public regional hospital (Vejle Hospital, Denmark) were included between May 2008 and February 2009. A total of 955 patients registered with 323 practices were included, of which 486 patients were allocated to the intervention group and 469 to the control group.

INTERVENTION

The intervention included a patient interview assessing the need for rehabilitation, improved information from the hospital to GPs including information on the patients' current needs along with information about needs of patients with cancer in general. Further, GPs were encouraged to proactively contact the patients and facilitate the patients' rehabilitation course.

OUTCOME MEASURES

6 months after inclusion of the patient, patient satisfaction with their GP during the last 12 months in five different dimensions of GP care was assessed using the Danish version of the EuroPEP (European Patients Evaluate General Practice Care) questionnaire (DanPEP). 14 months after inclusion, patient satisfaction with the GP regarding the cancer course and GP's satisfaction with own contribution to the patients' rehabilitation course were assessed using ad hoc questions specifically designed for this study.

RESULTS

No overall effect of the intervention was observed. Subgroup analysis of the patients with breast cancer showed statistically significant improvement of satisfaction with the GP in two of the five DanPEP dimensions.

CONCLUSIONS

This complex intervention aiming at improving GPs' services in cancer rehabilitation had no impact on patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov, registration ID number NCT01021371.

Postpartum infections: occurrence, healthcare contacts and association with breastfeeding

OBJECTIVE

To investigate the following: (i) the occurrence of postpartum infections; (ii) the frequency of contact with either a general practitioner or a hospital due to postpartum infections; and (iii) the association of postpartum infections with continuation of breastfeeding.

DESIGN

Cross-sectional study.

SETTING

Department of Gynecology and Obstetrics Horsens Hospital, Horsens, Denmark.

POPULATION

A total of 1871 women who gave birth at a regional hospital in Denmark over a one-year period (2007-2008).

METHODS

Data were collected by a questionnaire given to the women and combined with data from general practitioner and hospital records.

MAIN OUTCOME MEASURES

The distribution of different infections, as well as the overall occurrence of any infection, was evaluated according to mode of delivery and breastfeeding status (stopped/continued).

RESULTS

Within four weeks after delivery, 24% of all women had experienced one or more self-reported episode of infection. Breast infections (12%) were most frequent, followed by wound (3%), airway (3%), vaginal (3%) and urinary tract infections (3%), endometritis (2%) and "other infections" (2%). Of the women with an infection, 66% (265 of 395) contacted their general practitioner, while 9% (37 of 395) had contact with a hospital. A significantly larger proportion of women with a postpartum infection stopped breastfeeding (21%) within the first four weeks after delivery compared with women without infection (12%; p < 0.001).

CONCLUSIONS

Postpartum infections were common, and the occurrence is likely to be underestimated if based on hospital medical records only. Infection was associated with higher rates of discontinuation of breastfeeding.

Gynecological cancer patients' differentiated use of help from a nurse navigator: a qualitative study

Background

Fragmentation in healthcare can present challenges for patients with suspected cancer. It can add to existing anxiety, fear, despair and confusion during disease trajectory. In some circumstances patients are offered help from an extra contact person, a Nurse Navigator (NN). Scientific studies showing who will benefit from the extra help offered are missing. This study aims to explore who could benefit from the help on offer from a nurse appointed as NN in the early part of a cancer trajectory, and what would be meaningful experiences in this context.

Methods

A longitudinal study with a basis in phenomenology and hermeneutics was performed among Danish women with gynecological cancer. Semi-structured interviews provided data for the analysis, and comprehensive understanding was arrived at by first adopting an open-minded approach to the transcripts and by working at three analytical levels.

Results

Prior experience of trust, guarded trust or distrust of physicians in advance of encountering the NN was of importance in determining whether or not to accept help from the NN. For those lacking trust in physicians and without a close relationship to a healthcare professional, the NN offered a new trusting relationship and they felt reassured by her help.

Conclusions

Not everyone could use the help offered by the NN. This knowledge is vital both to healthcare practitioners and to administrators, who want to do their best for cancer patients but who are obliged to consider financial consequences. Moreover patients’ guarded trust or distrust in physicians established prior to meeting the NN showed possible importance for choosing extra help from the NN. These findings suggest increased focus on patients’ trust in healthcare professionals. How to find the most reliable method to identify those who can use the help is still a question for further debate and research.

Do general practitioners know patients' preferences? An empirical study on the agency relationship at an aggregate level using a discrete choice experiment

OBJECTIVES

This study investigated whether general practitioners (GPs) know patients' preferences regarding a number of organizational characteristics in general practice (i.e., waiting time on the telephone, opening hours, waiting time to the appointment, distance to the general practice, waiting time in the waiting room, consultation time, and whether the GP or assisting personnel performs routine tasks) to examine whether there is a basis for improving the agency relationship at an aggregate level.

DATA

A total of 698 respondents from the Danish population and 969 GPs answered the questionnaire in May and September 2010.

METHODS

In a discrete choice experiment, GPs and patients made both forced and unforced choices, allowing us to explore the congruence of preferences 1) when patients must choose a new GP and 2) when they can stay with their current GP.

RESULTS

Results show that in the forced choice, preferences are seen to differ. In the unforced choice also, preferences differ--mainly because GPs overestimate their own importance to the patients. Rank orders, however, are similar for both GPs and patients.

CONCLUSIONS

It is concluded that GPs do not have a precise knowledge of patients' preferences. However, in the unforced choice, GPs do know on which attributes to compete although they underestimate the necessity of competition. The overall conclusion is that there is room for improving the agency relationship in the organization of general practice.

Participation in cancer rehabilitation and unmet needs: a population-based cohort study

Purpose

To investigate associations between cancer survivors’ sex, age, and diagnosis in relation to their (1) need for rehabilitation, (2) participation in rehabilitation activities, and (3) unmet needs for rehabilitation in a 14-month period following date of diagnosis.

Methods

A population-based cohort study was performed on incident cancer patients diagnosed from 1 October 2007 to 30 September 2008. Fourteen months after diagnosis, participants completed a questionnaire developed to measure the aspects of rehabilitation. Logistic regression analyses were used to explore the association between sex, age, and diagnosis, and the outcome variables for rehabilitation.

Results

A total of 3,439 patients participated, yielding an overall response rate of 70%. One third of the cancer patients reported a need for physical rehabilitation and one third for psychological rehabilitation. Half of the patients participated in at least one activity. Unmet needs were most often reported in psychological, sexual, and financial areas. Women expressed more needs, participated more often in rehabilitation activities, and had, to a higher extent, their emotional needs fulfilled. Breast cancer patients participated more often in physical rehabilitation. Elderly who expressed rehabilitation needs more often had them unresolved.

Conclusions

A substantial variation in rehabilitation needs, participation in activities, and unmet needs in relation to sex, age, and cancer type was observed. Cancer care ought to systematically address the wide range of needs in all groups through integration of systematic needs assessment and targeted supply of offers.

Enhanced involvement of general practitioners in cancer rehabilitation: a randomised controlled trial

OBJECTIVE

To test the hypothesis that a multimodal intervention giving the general practitioner (GP) an enhanced role in cancer rehabilitation improves patients' health-related quality of life and psychological distress.

DESIGN

Cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention group or to a control group. Patients were subsequently allocated to intervention or control (usual procedures) based on the randomisation status of their GP.

SETTING

All clinical departments at a public regional hospital treating cancer patients and all general practices in Denmark.

PARTICIPANTS

Adult patients treated for incident cancer at Vejle Hospital, Denmark, between 12 May 2008 and 28 February 2009. A total of 955 patients (486 to the intervention group and 469 to the control group) registered with 323 general practices were included.

INTERVENTION

The intervention included an interview about rehabilitation needs with a rehabilitation coordinator at the regional hospital, information from the hospital to the GP about individual needs for rehabilitation and an encouragement of the GP to contact the patient to offer his support with rehabilitation.

MAIN OUTCOME MEASURES

The primary outcome was health-related quality of life measured 6 months after inclusion using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Secondary outcomes included quality of life at 14 months and additional subscales of the EORTC QLQ-C30 at 6 and 14 months and psychological distress at 14 months using the Profile of Mood States Scale.

RESULTS

No effect of the intervention was observed on primary and/or secondary outcomes after 6 and 14 months.

CONCLUSION

A multimodal intervention aiming to give the GP an enhanced role in cancer patients' rehabilitation did not improve quality of life or psychological distress.

TRIAL REGISTRATION

ClinicalTrials.gov, registration ID number NCT01021371.

Primary care physicians' adoption of new drugs is not associated with their clinical interests: a pharmacoepidemiologic study

OBJECTIVES. Increasing drug expenditures call for better understanding of the reasons behind individual general practitioners' (GPs') prescribing decisions. The aim was to analyse associations between GPs' clinical interests and their preference for new drugs. DESIGN. Historical cohort study using population-based prescription data and data collected by postal questionnaire. SETTING AND SUBJECTS. A total of 68 single-handed GPs in the County of Funen, Denmark. Main outcome measures. GPs' preferences for two new (2004) drug groups (selective cyclo-oxygenase-2 inhibitors and angiotensin-II antagonists) were analysed. The preference was defined as the percentage of patients receiving a new drug among first-time users of either the new drug or an older alternative. The GPs' preference proportion was modelled using linear regression analysis. Data from a questionnaire on GPs' interest in corresponding clinical areas (musculoskeletal diseases and hypertension, respectively), continuing medical education (CME) activities, and previous employment were the independent variables. RESULTS. The adjusted mean difference in preference for new drugs between GPs with high and low interest in each of the two clinical areas was 0.4% (95% CI -2.0% to 2.8%), and -2.2% (-15.0% to 10.7%), respectively. Only current CME activities in the area of hypertension were significantly associated with GPs' preference for new drugs (adjusted mean difference 17.9% (95% CI 5.8% to 30.0%). CONCLUSION. No clear association between GPs' self-rated clinical interest and their prescribing of new drugs was found.

A complex intervention to enhance the involvement of general practitioners in cancer rehabilitation. Protocol for a randomised controlled trial and feasibility study of a multimodal intervention

BACKGROUND

The effect of interventions that support rehabilitation among cancer patients has to be tested before implementation.

OBJECTIVE

A randomised controlled trial was conducted to test the hypothesis that a multimodal intervention may give the general practitioner (GP) an enhanced role and improve rehabilitation for cancer patients. The intervention included an interview about rehabilitation needs with a rehabilitation coordinator (RC), information from the hospital to the general practitioner about individual needs for rehabilitation and an incentive for the GP to contact the patient about rehabilitation. The objective of this first report from the study was to examine the acceptability and feasibility of the intervention.

MATERIAL AND METHODS

Adult patients treated for incident cancer at Vejle Hospital, Denmark were included between May 12, 2008 and February 28, 2009. All general practices in Denmark were randomised. Patients were allocated to intervention or control (usual procedures) based on the randomisation status of their GP. The feasibility of the intervention was analysed with regard to recruitment of patients, acceptability by patients and GPs and the degree to which the planned contacts between patients, RCs and GPs were implemented. The primary outcome of the randomised controlled trial (RCT) will be health-related quality of life at six months (EORTC-30).

RESULTS

Following assessment of 1 896 cancer patients, 955 patients (50%) registered with 323 general practices were included. The interview was conducted at the hospital with 50% of the patients in the intervention group, 31% were contacted by phone. Patients valued the fact that the conversation was dedicated to needs beyond the medical treatment. The GPs were generally available for information by phone and positive towards having a central role in the cancer rehabilitation.

DISCUSSION

It was feasible to conduct a RCT to evaluate a complex intervention in the healthcare system. All elements of the intervention were acceptable and feasible and may be implemented in future practice if the effect is positive.

Benefits and challenges perceived by patients with cancer when offered a nurse navigator; a qualitative study

Purpose

To explore the experiences of patients with cancer who were offered a nurse navigator in their course of illness before the in-hospital period.

Theory

Development has fragmentized healthcare systems in many countries, and coherence is now desired. Among interventions suggested to reduce the fragmentation and improve delivery of care are help from patient navigators, where patients are offered extra help in a defined area by e.g., a nurse [nurse navigator (NN)]. Patients’ experiences are of major interest, but have seldom been thoroughly investigated.

Methods

A phenomenological-hermeneutical longitudinal study was performed among Danish gynecological patients from before an in-hospital period to two months after discharge. NN offered extra information, coordination, logistic services and emotional talk. Semi-structured interviews provided data to the primarily open-minded analysis.

Results

Not all could use the help from NN. Those who could, attached affectional bonds to NN and experienced benefit from her presence as well as her help. Many had a feeling of deep-felt disappointment and felt rejected when the contact to NN stopped.

Conclusion

Resources for NN should be prioritized to patients who can use the help, and not stop prematurely. The traditional division and thinking by healthcare professionals are challenged, if all patients should be helped.

Lipid-lowering treatment to the end? A review of observational studies and RCTs on cholesterol and mortality in 80+-year olds

People aged 80 or older are the fastest growing population in high-income countries. One of the most common causes of death among the elderly is the cardiovascular disease (CVD). Lipid-lowering treatment is common, e.g. one-third of 75-84-year-old Swedes are treated with statins. The assumption that hypercholesterolaemia is a risk factor at the highest ages seems to be based on extrapolation from younger adults. A review of observational studies shows a trend where all-cause mortality was highest when total cholesterol (TC) was lowest ('a reverse J-shaped' association between TC and all-cause mortality). Low TC (<5.5 mmol/l) is associated with the highest mortality rate in 80+-year olds. No clear optimal level of TC was identified. A review of the few randomised controlled trials including 80+-year olds did not provide evidence of an effect of lipid-lowering treatment on total mortality in 80+-year-old people. There is not sufficient data to recommend anything regarding initiation or continuation of lipid-lowering treatment for the population aged 80+, with known CVD, and it is even possible that statins may increase all-cause mortality in this group of elderly individuals without CVD.

Prevalence of cancer alarm symptoms: a population-based cross-sectional study

OBJECTIVE

To estimate the prevalence of alarm symptoms for breast, colorectal, urinary tract, and lung cancer in the general population.

DESIGN

Cross-sectional questionnaire survey.

SETTING

The former County of Funen, Denmark, with 480,000 inhabitants.

PARTICIPANTS

A total of 13,777 randomly selected persons aged 20 years and older.

MAIN OUTCOME MEASURES

Prevalence estimates of having experienced cancer alarm symptoms during the past 12 months: a lump in the breast, blood in bowel movements, blood in urine, or coughing for more than six weeks. The number of alarm symptoms experienced within the past 12 months was also calculated.

RESULTS

With a response rate of 69%, 3.3% of responders (95% CI 2.9% to 3.7%) reported a lump in their breast, 5.7% (5.2% to 6.3%) reported blood in bowel movements, 2.2% (1.9% to 2.5%) reported blood in urine, and 6.5% (6.1% to 7.5%) reported coughing for more than six weeks within the past 12 months. Overall, 15.3% (95% confidence interval 14.3% to 16.3%) of the females and 12.7% (11.6% to 13.7%) of the males reported having experienced at least one cancer alarm symptom within the past 12 months.

CONCLUSION

Alarm symptoms of breast, colorectal, urinary tract, and lung cancer are common in the general population and approximately 15% of the population have experienced at least one of these cancer alarm symptom within the past 12 months.

Attachment in the doctor-patient relationship in general practice: a qualitative study

OBJECTIVE

To explore why interpersonal continuity with a regular doctor is valuable to patients.

DESIGN, SETTING, AND SUBJECTS

A qualitative study based on 22 interviews with patients, 12 who saw their regular general practitioner (GP) and 10 who saw an unfamiliar GP. The patients were selected after an observed consultation and sampled purposively according to reason for encounter, age, and sex. The research question was answered by means of psychological theory.

RESULTS

A need for attachment was a central issue for the understanding of the value of interpersonal continuity for patients. The patients explained that they preferred to create a personal relationship with their GP and the majority expressed a degree of vulnerability in the doctor-patient relationship. The more sick or worried they were the more vulnerable and the more in need of a regular GP. Furthermore, patients stated that it was difficult for them to change GP even if they had a poor relationship.

CONCLUSION

Attachment theory may provide an explanation for patients' need to see a regular GP. The vulnerability of being a patient creates a need for attachment to a caregiver. This need is fundamental and is activated in adults when they are sick or scared.