The durability of previous examinations for cancer: Danish nationwide cohort study

OBJECTIVE

Patients previously examined for cancer with a negative result may present in general practice with ongoing or new symptoms or signs suggestive of cancer. This paper explores the potential existence of a relatively safe period for cancer occurrence after receiving negative examination results for specific types of cancer, including lung (CT thorax), upper gastrointestinal (gastroscopy), colorectal (colonoscopy), bladder (cystoscopy), and breast (clinical mammography).

DESIGN

Register-based time-to-event analyses.

SETTING

Denmark.

SUBJECTS

All 3.3 million citizens aged 30-85 years who on January first, 2017, had not previously been diagnosed with the specific type of cancer were categorized based on the time since their most recent examination.

MAIN OUTCOME MEASURES

Using 1-year follow-up, we calculated the age- and sex-adjusted hazard ratios of being diagnosed with the related cancer, with non-examined individuals as reference. Negative examination results were defined as the absence of a cancer diagnosis within 6 months following the examination.

RESULTS

Previous negative examination results were common, also among those diagnosed with cancer during follow-up. For 10 years after a negative colonoscopy the risk of diagnosing a colorectal cancer was nearly halved. However, already 1 year after a clinical mammography and 2 years after a CT thorax the risk of diagnosing the related cancers was significantly higher among those with a previous negative result compared to non-examined individuals.

CONCLUSION

This study did not identify a post-examination period in which the cancer risk, compared to non-examined individuals, was sufficiently low to confidently rule out any of the investigated cancers.

Salutogenic health measures: Psychometric properties of the Danish versions of the Flourish Index and the Secure Flourish Index

Measurement of human flourishing represents a salutogenic approach to epidemiological and behavioral research emphasizing factors contributing to "good lives" rather than pathology. The objective of this study was to translate and psychometrically test the 10-item Flourish Index (FI) and 12-item Secure Flourish Index (SFI) in a convenience sample of Danish adults. A total of 325 participants completed a cross-sectional survey, with 148 of those participants completing the survey a second time (retest). Confirmatory factor analysis in a structural equation modelling framework was used to establish structural validity by comparing four different pre-specified models of the indexes. Additionally, internal consistency, convergent and incremental validity, and retest reliability were examined. The FI models exhibited superior structural validity compared with similar models of the SFI, although all models had good fits. Internal consistencies with McDonald's omega were 0.89 and 0.87 for the FI and SFI, respectively. The five (FI) or six (SFI) domains were happiness & life satisfaction, mental & physical health, meaning & purpose, character & virtue, close social relationships, and financial & material stability (λ4  = 0.51-0.91). Convergent and incremental validity tests supported predefined hypotheses. Retest analyses with the FI and SFI showed a high degree of retest reliability. Based on the psychometric evidence reported in this study, the Danish Flourish Index and Secure Flourish Index seem suitable for use with healthy adult Danes. The authors hope that this psychometric evaluation of the FI and SFI will stimulate research on patterns, health and economic outcomes, and predictors of human flourishing in Denmark.

Individual differences in empathy in Danish university students: A cross-sectional study

BACKGROUND

Empathy is widely recognized as a multi-dimensional construct, involving emotional and cognitive components. These may cause distinct experiences and behaviors that can be both beneficial and deleterious to individuals' well-being and mental health.

AIM

We wished to examine the association between emotional and cognitive empathy of Danish university students as measured by the multidimensional Interpersonal Reactivity Index (IRI) and study major, sex, age, and parental status. Additionally, we aimed to gauge the validity of the Jefferson Scale of Empathy - Student version (JSE-S) as a measure of primarily cognitive empathy in the context of medical majors by comparing JSE-S scores with IRI cognitive scores.

METHODS

In our national, cross-sectional study, conducted in October 2020, we used survey data from students in their first, third, and final study year. All students from University of Southern Denmark were invited to fill out IRI, and all medical students at Denmark's four medical educations were additionally invited to fill out the JSE-S. Associations were estimated by linear regression models.

RESULTS

Of 14,072 invited, 2,595 students completed the questionnaire. Health majors scored statistically significantly higher on cognitive empathy than students from other study majors. The JSE-S correlated significantly with the cognitive empathy subscales of the IRI. Furthermore, the effects found in relation to sex, age-, and parental status were significant.

CONCLUSION

Our study results show that large differences in empathy exist between university students and study majors. Overall, our results highlight (1) the relevance of investigating empathy as a multidimensional versus a global construct in young adult populations (including university students) and (2) the importance of focusing on differences in empathy across different student characteristics.

Does children's healthcare seeking change after participation in a musculoskeletal study? A register-based study

BACKGROUND

Participating in research studies often involves interactions with healthcare professionals, potentially influencing the participant's future help-seeking behaviour. We investigated whether participating in the Childhood Health Activity and Motor Performance School Study - Denmark (CHAMPS) (2008-2014), which involved telephone consultations and clinical assessments by healthcare professionals with participants experiencing musculoskeletal complaints, changed frequency of contacts with primary public healthcare services among participants over the subsequent five-years-period, compared to non-participating children.

METHODS

Using Danish health register data from 1998 to 2020, we compared CHAMPS participant's and two control group's contacts with private physiotherapists, chiropractors (outside hospitals), and general practitioners: a random 10% sample of children from Denmark (National Controls), and a secondary local control group (Local Controls) during three periods: Before (1998-31.10.2008), during (01.11.2008-20.06.2014), and after (21.06.2014-31.12.2019) the CHAMPS-study. Separate multivariable Poisson regression models were used to assess the differences between groups for the outcome variables: contacts with physiotherapists, chiropractors, and general practitioners, and overall contacts.

RESULTS

Compared to National Controls, the CHAMPS-Group had fewer physiotherapy contacts before the study with an estimated mean of 0.01 vs 0.02 per person-year, and after (0.13 vs 0.18 per person-year), corresponding to a crude incidence rate ratio (IRR) of 0.69 (95% confidence intervals (CI): 0.58-0.83) after the study period. However, they had more chiropractor contacts before (0.05 vs 0.03), and after (0.21 vs 0.09) the study, with a crude IRR of 2.29 (95% CI: 1.93-2.71) after the study period. General practice contacts were equal for the CHAMPS-group compared to national controls (5.84 vs 5.84) before the study but reduced during and after (3.21 vs 3.71), with a crude IRR of 0.86 (95% CI: 0.83-0.90) after the study. Comparable patterns of contacts changes from before to after the study were observed between the CHAMPS-group and the Local Controls except for physiotherapy which was equal between the two groups after the study.

CONCLUSION

Our findings suggest that research studies involving systematic engagement with participants experiencing musculoskeletal complaints can influence subsequent healthcare-seeking behaviour. Future research should address the influence of health literacy, health education, and healthcare provider recommendations on healthcare decisions during such research studies.

Variation in daytime general practice services and association with out-of-hours use for older patients: protocol for a Danish cohort study

INTRODUCTION

Out-of-hours primary care services cannot provide the same continuity and coordination of care as general practice. Thus, patients with high risk of complex care trajectories should, when possible, be treated by the general practitioner during daytime opening hours. This study aims to analyse the variation among general practices in the frequencies of daytime services for persons aged ≥75 years and how it relates to the patients' use of out-of-hours services.

METHODS AND ANALYSIS

Register-based cohort study of all Danish citizens aged ≥75 years, of whom >98% are listed with a general practice. Using Poisson regression, we will estimate each practice's excess variation in delivered daytime services compared with the expected based on the characteristics of its listed patients. Delivered daytime services will be analysed overall and separately for face-to-face, phone, email, home visit and preventive services. The association with the use of out-of-hours services will be analysed by Poisson regression.

ETHICS AND DISSEMINATION

Complying with European data protection rules, the legal services at University of Southern Denmark (Research & Innovation Organisation) approved the data processing activities regarding this project (journal number 11.593). According to section 14.2 of the Act on Research Ethics Review of Health Research Projects, because the study is based solely on register data, approval from the ethics committee and informed consent are not required. Results from the study will be disseminated as publications in peer-reviewed scientific journals and at international conferences.

Coping in the Danish general population: psychometric properties of the Danish version of the Brief Approach/Avoidance Coping Questionnaire

OBJECTIVE

To enable measurement of coping in the general Danish population the aims of this study are to 1) describe the translation and cultural adaption of the Danish Brief Approach/Avoidance Coping Questionnaire (BACQ) and 2) investigate the psychometric properties of the Danish BACQ.

DESIGN

The BACQ was translated and adapted into Danish, and the psychometric properties tested in two samples of adult Danish citizens: Sample A = 167, used for exploratory factor analysis (EFA), and Sample B = 330 persons, used for confirmatory factor analysis (CFA). Internal consistency was evaluated by Cronbach's Alpha, item-to-rest correlation, and scale-to-scale Pearson correlation.

RESULTS

The EFA suggested reasonable fits for both a three-factor and four-factor model, confirmed by the CFA with acceptable goodness-of-fit indices for both models. Using the four-factor-model would require a re-evaluation of the scale. The three-factor model had admissible internal consistency with an overall Cronbach's alpha of 0.66. Individuals with low self-rated health, extreme concern about current health and poor physical fitness, respectively, had lower Approach and higher Diversion and Resignation scores.

CONCLUSION

The psychometric properties showed that the Danish BACQ could be used as a three-factor model. With some limitations, the Danish version had acceptable construct validity, internal consistency, and content validity.

Coping strategies among individuals with multiple physical symptoms: A general population-based cross-sectional study

OBJECTIVE

Coping has been suggested as a perpetuating factor for physical symptoms. The aim of this study was to examine the use of the coping strategies approach, resignation, and diversion in individuals with multiple physical symptoms according to the construct of Bodily Distress Syndrome (BDS).

METHODS

This cross-sectional study was part of the nationwide web-based survey Danish Symptom Cohort (DaSC). In total, 100,000 individuals were invited to participate, and individuals eligible for the present study were respondents aged 20-64 years without a current or recent pregnancy. Multiple physical symptoms were identified using the BDS checklist, and coping was assessed by the Brief Approach/Avoidance Coping Questionnaire. Statistical analyses included descriptive statistics and multinomial and logistic regression.

RESULTS

A total of 35,810 respondents were included in the study, of which 8512 (23.8%) fulfilled the criteria for having multiple physical symptoms. This group of respondents had lower coping scores on approach and higher coping scores on resignation and diversion compared with the non-BDS group. The regression analyses showed that high scores on approach were associated with a lower probability of having multiple symptoms (adjusted OR 0.92, 95% CI: 0.91-0.92), whereas high scores on diversion and resignation were associated with a higher probability of having multiple symptoms (adjusted OR 1.10; 95% CI: 1.09-1.11 and adjusted OR 1.19; 95% CI: 1.18-1.20, respectively).

CONCLUSION

The study supports the hypothesis that experiencing multiple physical symptoms is associated with certain coping strategies. This is relevant knowledge for health care professionals who will be treating this patient group.

GPs' prescription patterns, experience, and attitudes towards medicinal cannabis-a nationwide survey at the early stage of the Danish test scheme

BACKGROUND

On 1 January 2018 a four-year test scheme concerning use of medicinal cannabis (MC) was enacted. It has recently been extended for four more years by the Danish Parliament permitting all Danish physicians to prescribe MC to their patients. Previous studies have shown that general practitioners (GPs) have varying prescription experience, little knowledge, and mixed attitudes about MC. However, the present evidence is still limited, and no studies exist about Danish GPs' prescription experience, knowledge, and attitudes towards MC. Therefore, our aim was to examine Danish GPs' prescription experience, knowledge, and attitudes towards MC.

METHODS

A national online survey-based study addressing Danish GPs was performed from September 2018 to July 2019. We performed separate multivariable logistic regression analyses including GPs' prescription experience, knowledge, and attitudes towards MC as outcome variables.

RESULTS

A total of 427 (38.4%) of 1112 GPs completed the questionnaire. Of these, 37 (8.7%) had experience in prescribing MC. The majority had little or no knowledge about MC (80.6%) as well as a negative view on prescription of MC (71.4%) to patients. Factors associated with prescribing MC to patients were: Single-handed practices (OR = 1.6, 95% CI 1.1;1.8) and perception of having quite some knowledge about MC (OR = 4.8, 95% CI 2.2;10.4). Factors associated with having quite some knowledge about MC were: having a positive attitude towards prescribing MC (OR = 5.2, 95% CI 1.9;14.0), being male (OR = 1.7, 95% CI 1.4;1.8), and being at least 60 years of age (OR = 2.8, 95% CI 1.3;6.0). Factors associated with having a positive attitude towards prescribing MC were: having quite some knowledge about MC (OR = 5.2, 95% CI 2.2;12.5) and GPs being male (OR = 1.7, 95% CI 1.1;1.9).

CONCLUSION

In this first study on prescription experience, knowledge, and attitudes about MC among Danish GPs, conducted one year after the Danish test scheme was enacted, we find a very low proportion of prescribers, little knowledge, and an overall negative attitude towards MC. Among the prescribing GPs, four in ten have little to no knowledge and a negative attitude towards MC. We stress that prescribing patterns, knowledge, and attitudes may change throughout the remaining time of the test scheme.

Developing and Validating a Lung Cancer Risk Prediction Model: A Nationwide Population-Based Study

Lung cancer can be challenging to diagnose in the early stages, where treatment options are optimal. We aimed to develop 1-year prediction models for the individual risk of incident lung cancer for all individuals aged 40 or above living in Denmark on 1 January 2017. The study was conducted using population-based registers on health and sociodemographics from 2007-2016. We applied backward selection on all variables by logistic regression to develop a risk model for lung cancer and applied the models to the validation cohort, calculated receiver-operating characteristic curves, and estimated the corresponding areas under the curve (AUC). In the populations without and with previously confirmed cancer, 4274/2,826,249 (0.15%) and 482/172,513 (0.3%) individuals received a lung cancer diagnosis in 2017, respectively. For both populations, older age was a relevant predictor, and the most complex models, containing variables related to diagnoses, medication, general practitioner, and specialist contacts, as well as baseline sociodemographic characteristics, had the highest AUC. These models achieved a positive predictive value (PPV) of 0.0127 (0.006) and a negative predictive value (NPV) of 0.989 (0.997) with a 1% cut-off in the population without (with) previous cancer. This corresponds to 1.2% of the screened population experiencing a positive prediction, of which 1.3% would be incident with lung cancer. We have developed and tested a prediction model with a reasonable potential to support clinicians and healthcare planners in identifying patients at risk of lung cancer.

Sex differences in the course of implantable cardioverter defibrillator concerns (Results from the Danish national DEFIB-WOMEN study)

OBJECTIVE

The implantable cardioverter defibrillator (ICD) is used to treat malignant ventricular arrhythmias. Since 33% of patients experience ICD-related concerns, we examined sex differences in ICD concerns and correlates of ICD concerns during 24 months of follow-up after implantation of an ICD.

METHODS

Patients from the DEFIB-WOMEN study (n = 1515; 81.6% male patients) completed questionnaires on ICD concerns, anxiety, depression, and Type D personality at five measure points (baseline, 3-, 6-, 12- and 24-months post-implantation).

RESULTS

Male patients scored on average 7.0 (6.8) points on ICD concerns at the time of implantation and female patients scored on average 10.5 (8.2) points. We found statistically significant sex differences in ICD concerns at all measurement points, with female patients scoring 2.77 points (8.7% of the maximum score of 32) higher than male patients. ICD concerns decreased in both sexes the first 6 months and then levelled out. For both sexes, ICD concerns at baseline were significantly correlated with ICD concerns at 24-months follow-up. Anxiety at baseline was correlated with ICD concerns in female patients, while depression at baseline and at least one experienced shock correlated with ICD concerns in male patients.

CONCLUSION

Female patients reported more ICD concerns at all measurement points compared to male patients, but for both sexes ICD concerns decreased in the first 6 months. ICD shock, anxiety, depression, and ICD concerns at baseline were correlates of ICD concerns at 24-months follow-up.

Patients with an implantable cardioverter defibrillator at risk of poorer psychological health during 24 months of follow-up (results from the Danish national DEFIB-WOMEN study)

OBJECTIVE

Identify implantable cardioverter defibrillator (ICD) patients at risk of distress (i.e., depression, anxiety, and ICD concerns) and associated risk factors.

METHOD

First-time ICD patients (n = 1503) from the Danish national DEFIB-WOMEN study completed questionnaires at baseline, 3, 6, 12 and 24 months.

RESULTS

Of patients with low scores on distress, only 4%-7.2% experienced an increase in distress during 24 months of follow-up (FU), while 30.5%-52.5% with increased levels were likely to maintain increased levels at FU. Higher education, higher age, female sex, and good physical functioning at baseline were associated with less depression, anxiety and ICD concerns at FU. Previous psychological problems, smoking, Type D personality, NYHA class III-IV - all assessed at baseline - and shocks during FU were associated with depression, anxiety and ICD concerns.

CONCLUSIONS

Generally, patients' psychological health improved, but patients with increased baseline scores were more likely to have increased scores at FU. We need to be vigilant if patients report elevated distress, particularly if they have depression at baseline, as depression seems more persistent. Given the impact of depression on health-related quality of life and prognosis, they should be screened and monitored closely.

Adaptation of a Danish online version of the Oxford Physical Activity Questionnaire (OPAQ) for secondary school students—a pilot study

Objective

To adapt and partly validate a Danish online version of the patient-reported outcome measure (PROM) Oxford Physical Activity Questionnaire (“OPAQ”) and evaluate mobile phones and tablets as data capturing tool to identify potential problems and deficiencies in the PROM prior to implementation in the full study.

Methods

The OPAQ was translated into Danish by a formalised forward-backward translation procedure. Face validity was examined by interviewing 12 school students aged 10–15, recruited from two Danish public schools. After modifications, the online version of the Danish OPAQ was pilot tested in a convenience sample of seven school students for 1 week. Simultaneous objective accelerometer data were captured during the registration period.

Results

No major challenges were identified when translating OPAQ. Based on the interviews, the Danish version of OPAQ was perceived to be easy to understand in general, and the questions were relevant for tracking activities during the week. Five of the 12 participants had difficulties with understanding the introductory question: “what is your cultural background” in the original OPAQ. The interviews revealed that the participants recalling 7 days forgot to record some of the physical activity they had done during the week, indicating issues with the weekly recall method.

After transforming to the online version, this was reported to be easy and quick to fill in (taking 1–3 min per day), and participants reported the daily design was helpful to remember activities. There was good correspondence between the online version and objective actigraphs with a tendency to underreport. Six participants reported 10–60 min less moderate to vigorous physical activity compared to the actigraphs, while one participant reported 3 min more.

Conclusion

Participants found the online OPAQ quick and easy to complete during a 1-week period. Completing daily rather than weekly may help limit issues with recall. Overall, there was good agreement between the objective actigraphs and the OPAQ, though the OPAQ tended to slightly underreport moderate to vigorous physical activity.

The Danish online version of OPAQ may be useful for capturing school students’ physical activity when objective measures are not feasible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01108-x.

The Association Between Individualised Religiosity and Health Behaviour in Denmark: Are Social Networks a Mediating Factor?

The present study investigates whether social networks mediate the well-established positive association between religiosity and health behaviour. Most research has focused on traditional public religiosity (e.g. regular church attendance). This study, however, focuses on the Danish population in which non-traditional and private religiosity is common. We utilise data from the Danish population-based project, Early Detection and Prevention. Our results suggest that religiosity is linked to health behaviour; however, this association is not mediated by social network.

Quality clusters in general practice: associations between cluster organization and general practitioners' self-reported benefits

BACKGROUND

Quality clusters were introduced as a quality improvement concept in Danish general practice in 2018. This new concept anchored quality improvement in local clusters managed by general practitioners (GPs).

OBJECTIVES

To describe the cluster organization and GPs' self-reported benefits of participating in them and explore the associations between cluster organization and self-reported benefits.

METHODS

A national survey in Danish general practice gathering information about cluster organization (cluster size, cluster meetings, participants, and content) and GPs' self-reported benefits (overall benefit, internal changes in the clinic, and improved external collaboration).

RESULTS

One hundred and eight (95%) clusters and 1,219 GPs (36%) were included. Cluster size varied from 10 to 68 GPs (34 GPs on average). Approximately 70% of GPs reported moderate to very high overall benefit from cluster participation. Most GPs experienced changes in their clinic organization (68%), drug prescriptions (78%), and patient care (77%). Collaboration was reported improved between the GPs (86%), municipality (50%), and hospital (36.2%). GPs in clusters with 3-6 planned meetings per year (odds ratio [OR] 1.9; confidence interval [CI] 1.3-2.9), mixed meeting types (OR 1.7; CI 1.2-2.4), group work (OR 1.7; CI 1.1-2.5), and use of guidelines in their meetings (OR 1.8; CI 1.3-2.4) had statistically significantly higher odds for reporting overall benefit of participating in clusters compared with GPs in clusters without these characteristics.

CONCLUSIONS

Frequent and active meetings with a relevant meeting content are positively related to GPs' perceived benefits and with improved collaboration between GPs in the clusters. There seems to be a potential for developing collaboration with other healthcare providers.

Can National Registries Contribute to Predict the Risk of Cancer? The Cancer Risk Assessment Model (CRAM)

Simple Summary

Early identification of individuals with an increased risk of cancer is an important challenge. Danish administrative registers may be useful in this respect because they cover the entire population and include comprehensive and consistently coded long-term data. We aimed to develop a predictive model based on Danish administrative registers to facilitate the automated identification of individuals at risk of any type of cancer. In addition to age, almost all the included factors contributed statistically significantly, but also only marginally, to the prediction models, which means that we have not overlooked obvious information available in the register. Future prediction studies should focus on specific cancer types where more precise risk estimations might be expected. It is our ultimate ambition that an effective model can be used at the point of care, integrated into electronic patient record systems to alert physicians of patients at a high risk of cancer.

Abstract

Purpose: To develop a predictive model based on Danish administrative registers to facilitate automated identification of individuals at risk of any type of cancer. Methods: A nationwide register-based cohort study covering all individuals in Denmark aged +20 years. The outcome was all-type cancer during 2017 excluding nonmelanoma skin cancer. Diagnoses, medication, and contact with general practitioners in the exposure period (2007–2016) were considered for the predictive model. We applied backward selection to all variables by logistic regression to develop a risk model for cancer. We applied the models to the validation cohort, calculated the receiver operating characteristic curves, and estimated the corresponding areas under the curve (AUC). Results: The study population consisted of 4.2 million persons; 32,447 (0.76%) were diagnosed with cancer in 2017. We identified 39 predictive risk factors in women and 42 in men, with age above 30 as the strongest predictor for cancer. Testing the model for cancer risk showed modest accuracy, with an AUC of 0.82 (95% CI 0.81–0.82) for men and 0.75 (95% CI 0.74–0.75) for women. Conclusion: We have developed and tested a model for identifying the individual risk of cancer through the use of administrative data. The models need to be further investigated before being applied to clinical practice.

Measuring Spiritual Needs in a Secular Society: Validation and Clinimetric Properties of the Danish 20-Item Spiritual Needs Questionnaire

In secular cultures, such as Denmark, tools to measure spiritual needs are warranted to guide existential and spiritual care. We examined the clinimetric properties of the Danish version of the Spiritual Needs Questionnaire (DA-SpNQ-20) based on a digital survey in a test-retest setup. A convenience sample was reached via social media and student platforms. A total of 325 (148 for retest) respondents were included in the analysis. The sample was randomly split into two groups (A and B) and used for exploratory (EFA) and confirmatory factor analysis (CFA) by structural equation modeling, respectively. SpNQ dimensions had an internal consistency with Cronbach's alpha between 0.73 and 0.93. The four factors of the SpNQ were supported by both EFA and CFA as follows: religious needs, existential needs, inner peace needs, and generativity needs. The instrument showed good internal consistency, good test-retest reliability, and acceptable structural validity in the sample of relatively young and healthy persons.

Protocol for EXICODE: the EXIstential health COhort DEnmark-a register and survey study of adult Danes

INTRODUCTION

We established the EXIstential health COhort DEnmark (EXICODE) to examine how existential and spiritual needs, practices and orientations in a secular culture are linked to health outcomes, illness trajectory and overall cost of care in patients. Substantial literature demonstrates that existential and spiritual well-being has positive effects on health. While people turn to existential and spiritual orientations and practices during ageing, struggle with illness and approaching death, patients with severe illnesses like, for example, cancer similarly experience existential and spiritual needs. These needs are often unmet in secular societies leading to spiritual pain, unnecessary suffering, worse quality of life and higher medical costs of care.

METHODS AND ANALYSIS

EXICODE is a national cohort comprising a 10% random sample of the adult Danish population with individual-level register and survey data. Specific patient subgroups are oversampled to ensure diseased respondents. The questionnaire used in the survey consists of a collection of validated instruments on existential and spiritual constructs suited for secular culture as well as some ad hoc questions compiled in the comprehensive EXICODE Questionnaire.

ETHICS AND DISSEMINATION

The project is registered for legal and GDPR concerns by the University of Southern Denmark, journal number: 10.367. Ethical approval was not required by Danish law since EXICODE collects only interview, survey and register data, but due to institutional best-practice policy an ethical evaluation and approval were nevertheless obtained from the University of Southern Denmark Research Ethics Committee (institutional review board), journal number: 20/39546. The project follows The Danish Code of Conduct for Research Integrity and is carried out in accordance with the Helsinki Declaration. Results will be disseminated widely through publications in peer-reviewed scientific journals, international conferences, patient societies as well as mass and social media.

A cross-sectional study of student empathy across four medical schools in Denmark-associations between empathy level and age, sex, specialty preferences and motivation

BACKGROUND

Professional empathy has been associated with a range of positive patient- and clinician outcomes and is therefore considered important to develop for future physicians. Measuring changes in empathy scores among medical students by using the Jefferson Scale of Empathy (Student version) (JSE-S) has led to mixed results. So far, no investigation of Danish medical students' empathy development has been conducted. The aim of this study was therefore to examine the associations between empathy scores among Danish medical students and medical school, year of curriculum, age, sex, co-habitation, and parental status, specialty preferences and motivations for choosing medicine as a future profession.

METHODS

This was a cross-sectional questionnaire study. All medical students from four medical schools in Denmark in their first, third and sixth year (N = 4,178) were invited to participate in the study in October 2020. The associations between JSE-S sum score and the above explanatory factors were analysed by uni- and multivariable linear regression models.

RESULTS

The JSE-S was completed by 672 medical students. The overall mean score was 112.7. There were no statistically significant differences in empathy between medical schools, first, third- and sixth- year medical students, age groups or parental status. Female students and students living with a spouse or partner scored higher on JSE-S than male students or students living alone, and the sex difference remained statistically significant in the multivariable regression. In both the univariable and multivariable setting, preference for future medical specialty was statistically significant, with a decrease in scores for students choosing surgery-specialties. Motivational factors were not statistically significantly associated with empathy, although there was a slight upwards trend for one of the motivational categories, named "personal experiences".

CONCLUSIONS

Overall, our results showed neither decrease nor increase but instead rather stable empathy scores across years of curriculum of medical students in Denmark, adding to the mixed picture of empathy development among medical students. Our findings are consistent with positive associations found in international studies between empathy scores and higher age, female sex, specialty preferences for psychiatry and general practice and altruistic motivations for choosing to enroll. Although specialty preferences are changing during medical education, they may be used meaningfully as predictors of individual student empathy levels.

The responsiveness of the Danish version of the Canadian Occupational Performance Measure

Introduction

To establish the responsiveness of the Danish version of the Canadian Occupational Performance Measure (COPM-DK).

Method

A cross-sectional study was performed in three Danish settings, including 88 clients, 40 men, aged 16–90 years, with a variety of diagnoses. To determine construct responsiveness, the mean changes of the COPM performance and satisfaction score (COPM-P/S) were compared and correlated with the mean changes in the five-item World Health Organization (WHO) Well-Being Index (WHO-5) and the EuroQol–five domains–five levels questionnaire (EQ-5D-5L). To determine the responsiveness, data were analysed with ROC curves to establish the optimal cut-point values for the COPM-DK scores. Minimal important change (MIC) was assessed in relation to anchor-based questions.

Results

The mean change for COPM-P/S was 3.1 and 3.0, respectively. Small positive correlations were found between the COPM-DK scores and the WHO-5 and EQ-5D-5L scores. The AUC were 0.76 and 0.75, respectively. The optimal cut-point values for the COPM-P/S-scores based on either all positive answers or to the two highest, were 1.2 or 4.20 (COPM-P) and 1.67 or 5.80 (COPM-S), respectively

Conclusions

The capability of the COPM to detect changes in perceived occupational performance issues is supported. We recommend an MIC on 3.5 points on both scales.

Factors associated with C-reactive protein testing when prescribing antibiotics in general practice: a register-based study

BACKGROUND

The use of C-reactive protein (CRP) tests has been shown to safely reduce antibiotic prescribing for acute respiratory tract infections (RTIs). The aim of this study was to explore patient and clinical factors associated with the use of CRP testing when prescribing antibiotics recommended for RTIs.

METHODS

A nation-wide retrospective cross-sectional register-based study based on first redeemed antibiotic prescriptions issued to adults in Danish general practice between July 2015 and June 2017. Only antibiotics recommended for treatment of RTIs were included in the analysis (penicillin-V, amoxicillin, co-amoxicillin or roxithromycin/clarithromycin). Logistic regression models were used to estimate odds ratios for patient-related and clinical factors on performing a CRP test in relation to antibiotic prescribing.

RESULTS

A total of 984,149 patients redeemed at least one antibiotic prescription during the two-year period. About half of these prescriptions (49.6%) had an RTI stated as the indication, and a CRP test was performed in relation to 45.2% of these scripts. Lower odds of having a CRP test performed in relation to an antibiotic prescription was found for patients aged 75 years and above (OR 0.82, 95CI 0.79-0.86), with a Charlson Comorbidity Index of more than one (OR 0.93, 95CI 0.91-0.95), unemployed or on disability pension (OR 0.84, 95CI 0.83-0.85) and immigrants (OR 0.91, 95CI 0.88-0.95) or descendants of immigrants (OR 0.90, 95CI 0.84-0.96). Living with a partner (OR 1.08, 95CI 1.07-1.10), being followed in practice for a chronic condition (OR 1.22, 95CI 1.18-1.26) and having CRP tests performed in the previous year (OR 1.78, 95CI 1.73-1.84) were associated with higher odds of CRP testing in relation to antibiotic prescribing.

CONCLUSIONS

Differences were observed in the use of CRP tests among subgroups of patients indicating that both sociodemographic factors and comorbidity influence the decision to use a CRP test in relation to antibiotic prescriptions in general practice. Potentially, this means that the use of CRP tests could be optimised to increase diagnostic certainty and further promote rational prescribing of antibiotics. The rationale behind the observed differences could be further explored in future qualitative studies.

Prescribing antibiotics: the use of diagnostic tests in general practice. A register-based study

OBJECTIVE

To assess (i) the pattern of antibiotic prescribing in Danish general practice, (ii) the use of diagnostic tests [point-of-care (POC) and tests analysed at the hospital laboratory (laboratory tests)], and (iii) the frequency of diagnostic testing in relation to antibiotic prescriptions.

DESIGN

Retrospective cross-sectional register-based study.

SETTING

General practice in a geographical area of Denmark covering 455,956 inhabitants.

SUBJECTS

We studied redeemed antibiotic prescriptions and performed diagnostic tests in general practice from 2013 to 2017 among inhabitants in nine selected municipalities.

MAIN OUTCOME MEASURES

Frequency of antibiotic courses. Frequency and type of diagnostic testing performed in relation to types of antibiotics.

RESULTS

A total of 783,252 antibiotic courses were redeemed from general practice with an overall decrease of 19% during 2013-2017. Diagnostic testing increased by 6% during this period. POC tests comprised the majority of performed diagnostic tests (83%) with C-reactive protein (CRP) as the most frequently used test. A 27% increase in the use of laboratory tests was observed. Tests were performed in relation to 43% of all antibiotic courses; most in relation to prescriptions for sulphonamide and trimethoprim (57%) and rarely when prescribing tetracyclines (10%). Conflicting with national guidelines, Danish GPs prescribed fluoroquinolones without performing any kind of diagnostic testing in 48% of the cases.

CONCLUSIONS

This study provides an overview of the use of diagnostic tests in relation to antibiotics and creates basis for further research into the variability between types of antibiotics. The study indicates that there is room for improvement to use diagnostic tests as an aid to promote prudent antibiotic use.KEY POINTSDiagnostic tests (point-of-care or tests analysed at the hospital laboratory), can increase diagnostic certainty and lead to a reduction in antibiotic use in general practice.A decrease in antibiotic courses in general practice in Denmark was observed during 2013-2017, while the use of diagnostic tests increased.A diagnostic test was performed in relation to 43% of antibiotic courses.Only 52% of prescribed fluoroquinolones was related to a diagnostic test, conflicting with national guidelines.

Predictors of health-related quality of life in patients with Crohn's disease receiving biological therapy

BACKGROUND AND AIM

Health-related quality of life (HRQoL) is impaired in patients with Crohn's disease (CD). This study aimed to identify the impact of clinical disease activity on HRQoL in CD patients treated with biological agents.

METHODS

Patients with moderate to severe active CD treated with biological agents in Denmark were included from 2016-2018. Disease related symptoms were assessed via the Harvey Bradshaw Index. HRQoL was measured on the Short Health Scale (SHS). Multivariable linear regression models were conducted separately for each SHS item and average SHS score stratified for sex, adjusting for clinical manifestation and age.

RESULTS

In total, 1,181 CD patients were included. The mean age was 33 years and 56% were women. Abdominal pain (range of regression coefficients 1.18-1.42), number of liquid stools (0.33-0.58), and the appearance of a new rectal fistula (0.91-1.32) affected all domains in the SHS negatively for men and women. Arthralgia (0.47-0.67) and abdominal mass (0.54-0.62) affected 4 out of 5 items on SHS negatively for women and men, respectively. Female sex was found a predictor of lower HRQoL across all SHS items, whereas age and fistulizing disease, as phenotype, were not associated with lower HRQoL.

CONCLUSIONS

Abdominal pain, number of liquid stools, a new rectal fistula, arthralgia for women, clinically assessed abdominal mass for men as well as female sex, were all found to be predictors of decreased HRQoL.

The reliability of the Danish version of the Canadian Occupational Performance Measure

Introduction

This study aims to assess the reliability of the Danish version of the Canadian Occupational Performance Measure (COPM).

Method

151 clients, 42.4% male, mean age 66.9 years ( SD: 14.4, range: 16–90), from two hospitals and two rehabilitation centres were interviewed twice with the COPM over a ten-day mean interval ( SD: 4.9, range: 2–27) either by the same (intra-rater) or two different occupational therapists (inter-rater). Data were analysed with intra-class correlation coefficients, coefficient of repeatability, and Bland–Altman plots.

Results

823 occupational performance issues were prioritized of which 41%, 338 occupational performance issues (95% CI: 37.7–44.5), were mentioned in both interviews. The intra-class correlation coefficients were 59.8 (95% CI-intra-class correlation coefficients: 49.3–69.5) (COPM), 73.5 (95% CI intra-class correlation coefficients: 65.5-80.2) (COPM-Performance), and 71.8 (95% CI intra-class correlation coefficients: 63.4–78.8) (COPM-Satisfaction). The limits of agreement were −2.83 to 3.05 for the COPM-Performance and −3.50–3.53 for the COPM-Satisfaction. The COPM-Importance scores were highest when obtained by two raters, but opposite for the scores of the COPM-Performance and COPM-Satisfaction. The coefficient of repeatability roughly showed a change in +/- three points (COPM-Importance: 2.67; COPM-Performance: 2.94; and COPM-Satisfaction: 3.52). Correspondingly, Bland–Altman plots showed limits of agreement for the mean values of −2.71 and 3.53, respectively.

Conclusions

The intra-rater and inter-rater reliability of the COPM were moderate across settings, clients and rater experiences.

New onset anxiety and depression in patients with an implantable cardioverter defibrillator during 24 months of follow-up (data from the national DEFIB-WOMEN study)

OBJECTIVE

To examine the cumulative incidence of and covariates' association with new onset anxiety and depression in implantable cardioverter defibrillator (ICD) patients during 24 months of follow-up in patients without depression and anxiety at implant.

METHODS

Patients (n = 1040; 155 (14.9%) women; mean age: 64.2 ± 10.6) with a first-time ICD enrolled in the national, multi-center prospective observational DEFIB-WOMEN study comprised the study cohort. We obtained information on demographic and clinical data from the Danish Pacemaker and ICD Register.

RESULTS

During 24 months of follow-up, 138 (14.5%) patients developed new onset anxiety and 109 (11.3%) new onset depression. Age ≥ 60 [HR:0.60;95%CI:0.40-0.90] and an anxiety score between 3 and 4 [HR:2.85; 95%CI:1.71-4.75] and 5-7 [HR:5.97; 95%CI:3.77-9.45] on the Hospital Anxiety and Depression Scale (HADS) were associated with different hazards of new onset anxiety during follow-up. Age ≥ 60 [HR:0.62;95%CI:0.42-0.93] and a HADS depression score between 3 and 4 [HR:2.99;95%CI:1.80-4.95] and 5-7 [HR:6.45; 95%CI:4.12-10.10] were associated with different hazards of new onset depression.

CONCLUSION

During 24 months of follow-up, respectively 14.5% and 11.3% of patients developed new onset anxiety and depression, suggesting that screening patients at several timepoints, and in particular those with even minimally elevated HADS scores at baseline, may be warranted to identify patients at risk for poor health outcomes.

Anxiety and depression symptoms in Danish patients with an implantable cardioverter-defibrillator: prevalence and association with indication and sex up to 2 years of follow-up (data from the national DEFIB-WOMEN study)

AIMS

To investigate (i) the prevalence of anxiety and depression and (ii) the association between indication for implantable cardioverter-defibrillator (ICD) implantation and sex in relation to anxiety and depression up to 24 months' follow-up.

METHODS AND RESULTS

Patients with a first-time ICD, participating in the national, multi-centre, prospective DEFIB-WOMEN study (n = 1496; 18% women) completed the Hospital Anxiety and Depression Scale at baseline, 3, 6, 12, and 24 months. Data were analysed using linear mixed modelling for longitudinal data. Patients with a secondary prophylactic indication (SPI) had higher mean anxiety scores than patients with a primary prophylactic indication (PPI) at baseline, 3, and 12 months and higher mean depression scores at all-time points, except at 24 months. Women had higher mean anxiety scores as compared to men at all-time points; however, only higher mean depression scores at baseline. Overall, women with SPI had higher anxiety and depression symptom scores than men with SPI. Symptoms decreased over time in both women and men. From baseline to follow-up, the prevalence of anxiety (score ≥8) was highest in patients with SPI (13.3-20.2%) as compared to patients with PPI (range 10.0-14.7%). The prevalence of depression was stable over the follow-up period in both groups (range 8.5-11.1%).

CONCLUSION

Patients with a SPI reported higher anxiety and depression scores as compared to patients with PPI. Women reported higher anxiety scores than men, but only higher depression scores at baseline. Women with SPI reported the highest anxiety and depression scores overall.

Association of Socioeconomic Status With Dementia Diagnosis Among Older Adults in Denmark

IMPORTANCE

Low socioeconomic status (SES) has been identified as a risk factor for the development of dementia. However, few studies have focused on the association between SES and dementia diagnostic evaluation on a population level.

OBJECTIVE

To investigate whether household income (HHI) is associated with dementia diagnosis and cognitive severity at the time of diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This population- and register-based cross-sectional study analyzed health, social, and economic data obtained from various Danish national registers. The study population comprised individuals who received a first-time referral for a diagnostic evaluation for dementia to the secondary health care sector of Denmark between January 1, 2017, and December 17, 2018. Dementia-related health data were retrieved from the Danish Quality Database for Dementia. Data analysis was conducted from October 2019 to December 2020.

EXPOSURES

Annual HHI (used as a proxy for SES) for 2015 and 2016 was obtained from Statistics Denmark and categorized into upper, middle, and lower tertiles within 5-year interval age groups.

MAIN OUTCOMES AND MEASURES

Dementia diagnoses (Alzheimer disease, vascular dementia, mixed dementia, dementia with Lewy bodies, Parkinson disease dementia, or other) and cognitive stages at diagnosis (cognitively intact; mild cognitive impairment but not dementia; or mild, moderate, or severe dementia) were retrieved from the database. Univariable and multivariable logistic and linear regressions adjusted for age group, sex, region of residence, household type, period (2017 and 2018), medication type, and medical conditions were analyzed for a possible association between HHI and receipt of dementia diagnosis.

RESULTS

Among the 10 191 individuals (mean [SD] age, 75 [10] years; 5476 women [53.7%]) included in the study, 8844 (86.8%) were diagnosed with dementia. Individuals with HHI in the upper tertile compared with those with lower-tertile HHI were less likely to receive a dementia diagnosis after referral (odds ratio, 0.65; 95% CI, 0.55-0.78) and, if diagnosed with dementia, had less severe cognitive stage (β, -0.16; 95% CI, -0.21 to -0.10). Individuals with middle-tertile HHI did not significantly differ from those with lower-tertile HHI in terms of dementia diagnosis (odds ratio, 0.92; 95% CI, 0.77-1.09) and cognitive stage at diagnosis (β, 0.01; 95% CI, -0.04 to 0.06).

CONCLUSIONS AND RELEVANCE

The results of this study revealed a social inequality in dementia diagnostic evaluation: in Denmark, people with higher income seem to receive an earlier diagnosis. Public health strategies should target people with lower SES for earlier dementia detection and intervention.

Socioeconomic position and mental health care use before and after first redeemed antidepressant and time until subsequent contact to psychologist or psychiatrists: a nationwide Danish follow-up study

PURPOSE

The purpose was to investigate inequalities in access to care among people with possible depression.

METHOD

In this nationwide register-based cohort study of 30,593 persons, we observed the association between socioeconomic position (SEP, education/income) and mental health care use (MHCU) four months before the date of first redeemed antidepressant (Index Date/ID) and 12 months afterwards-and time to contact to psychologist/psychiatrist (PP). Logistic, Poisson, and Cox regression models were used, adjusted for sex, age, cohabitation, and psychiatric comorbidity.

RESULTS

Before ID, high SEP was associated with less GP contact (general practitioner), higher odds ratios for GP-Mental Health Counseling (GP-MHC), psychologist contact, and admissions to hospital. This disparity decreased the following 12 months for GP-MHC but increased for contact to psychologist; same pattern was seen for rate of visits. However, the low-income group had more contact to private psychiatrist. For the 25,217 individuals with no MHCU before ID, higher educational level was associated with almost twice the rate of contact to PP the following 12 months; for the high-income group, the rate was 40% higher. 10% had contact to PP within 40 days after ID in the group with higher education; whereas, 10% of those with a short education would reach PP by day 120. High-income group had faster access as well.

CONCLUSION

Being in high SEP was positively associated with MHCU, before and after ID, and more rapid PP contact, most explicit when measured by education. Co-payment for psychologist may divert care towards private psychiatrist for low-income groups.

Clinical management of hip fractures in elderly patients with dementia and postoperative 30-day mortality: A population-based cohort study

OBJECTIVES

Patients with dementia have an increased 30-day mortality after hip fracture. We investigated clinical management including time to surgery, out-of-hours admission and surgery, surgery on weekends, surgery volume per ward, and anesthesia technique for this excess mortality risk.

METHOD

This register- and population-based study comprised 12,309 older adults (age 70+) admitted to hospital for a first-time hip fracture in 2013-2014, of whom 11,318 underwent hip fracture surgery. Cox proportional hazards regression models were applied for the analysis.

RESULTS

The overall postoperative 30-day mortality was 11.4%. Patients with dementia had a 1.5 times increased mortality risk than those without (HR = 1.50 [95% CI 1.31-1.72]). We observed no time-to-surgery difference by patient dementia status; additionally, the excess mortality risk in patients with dementia could not be explained by the clinical management factors we examined.

CONCLUSIONS

Increased mortality in patients with dementia could not be explained by the measured preoperative clinical management. Suboptimal handling of postoperative complication and rehabilitation are to be investigated for their role in the witnessed increased mortality for patients with dementia.

Does socioeconomic status make a difference? A register-based study on the extent to which cardiovascular screening in patients with inflammatory arthritis leads to recommended follow-up in general practice

OBJECTIVE

To investigate to what extent patients with inflammatory arthritis (IA) follow recommendations given in a secondary care nurse-led cardiovascular (CV) risk screening consultation to consult their general practitioner (GP) to reduce their CV risk and whether their socioeconomic status (SES) affects adherence.

METHODS

Adults with IA who had participated in a secondary care screening consultation from July 2012 to July 2015, based on the EULAR recommendations, were identified. Patients were considered to have high CV risk if they had risk Systematic COronary Risk Evaluation (SCORE) ≥5%, according to the European SCORE model or systolic blood pressure ≥145 mmHg, total cholesterol ≥8 mmol/L, LDL cholesterol ≥5 mmol/L, HbA1c ≥42 mmol/mol or fasting glucose ≥6 mmol/L. The primary outcome was a consultation with their GP and at least one action focusing on CV risk factors within 6 weeks after the screening consultation.

RESULTS

The study comprised 1265 patients, aged 18-85 years. Of these, 336/447 (75%) of the high-risk patients and 580/819 (71%) of the low-risk patients had a GP consultation. 127/336 (38%) of high-risk patients and 160/580 (28%) of low-risk patients received relevant actions related to their CV risk, for example, blood pressure home measurement or prescription for statins, antihypertensives or antidiabetics. Education ≥10 years increased the odds for non-adherence (OR 0.58, 95% CI 0.0.37 to 0.92, p=0.02).

CONCLUSIONS

75% of the high-risk patients consulted their GP after the secondary care CV risk screening, and 38% of these received an action relevant for their CV risk. Higher education decreased adherence.

Predictors of health-related quality of life in patients with moderate to severely active ulcerative colitis receiving biological therapy

Background and aims: Patients with ulcerative colitis have reduced health-related quality of life compared to the general population. Current treatment strategy aims to reduce patients' symptoms and increase health-related quality of life. We investigated which symptoms of ulcerative colitis correlate to decreased health-related quality of life.Methods: Among 743 patients with moderate to severely active ulcerative colitis receiving biological therapy in a cross-sectional national study, we determined which disease-related symptoms, as measured by the Simple Clinical Colitis Activity Index, worsened health-related quality of life scores across the Short Health Scale dimensions, while adjusting for treatment, age, and clinical manifestation, and stratifying for sex, by means of multiple linear regression.Results: Patients with active disease had decreased health-related quality of life compared to those with inactive disease (median 5.8 (range 4.5-7.5) vs. 2 (0.8-3.3)). Both sexes had decreased health-related quality of life in all dimensions for the symptoms: bowel frequency during daytime (0.37-0.86 and 0.46-0.84), urgency of defecation (0.54-0.79 and 0.49-0.65) and blood in stool (0.50-0.75 and 0.36-0.54) for men and women respectively. Women were more often negatively affected by bowel frequency during night-time (4 domains vs. 1) and arthritis (5 domains vs. 3). In non-stratified analysis female sex is an independent predictor of lower health-related quality of life for 3 domains (0.38-0.53).Conclusions: Health-related quality of life was most prominently associated with bowel frequency during daytime, urgency of defecation, and blood in stool. Other symptoms associated for some health-related quality of life dimensions, and appear to vary between the sexes.

Looking into the Content of the Canadian Occupational Performance Measure (COPM): A Danish Cross-Sectional Study

PURPOSE

To examine the content validity of the Danish version of the Canadian Occupational Performance Measure (COPM-DK).

MATERIALS AND METHODS

This cross-sectional study was performed in a hospital and a community rehabilitation centre. The content validity of the COPM was assessed by relating the clients' prioritized occupational performance issues (OPIs) to the conceptual model of the Canadian Model of Occupational Performance and Engagement (CMOP-E) and the levels of the Taxonomic Code of Occupational Performance (TCOP). Six occupational therapy lecturers participated in classifying the OPIs using the TCOP.

RESULTS

A total of 112 clients from a regional and community-based rehabilitation participated. The 56% regional participants came from a hospital's hand and knee surgery department. The remaining 44% participants came from a community-based rehabilitation centre with in- and outpatient departments. There were 44% males, with a mean age of 65.2 years. They prioritized 495 OPIs, of which 40% concerned self-care, 32% productivity, and 28% leisure. The prioritized OPIs were divided into a total of 224 different OPIs. There were significant differences in which areas were prioritized in the various population groups. Of the OPIs, 64.3% could be classified into the TCOP levels of occupation and activity, i.e., 1/3 of the OPIs were related to tasks and actions, and thus beyond the scope of the COPM. The interrater agreement of the OPI classification was only fair (kappa 0.3).

CONCLUSION

The content validity of the COPM seems to depend on how and with which clients it is administered. Caution must be taken to secure OPIs on the higher levels of the TCOP, while maintaining the clients' right to nominate OPI preferences. Therefore, an introductory course and on-going support are recommendable. Bearing this in mind, the COPM seems useful to identify individual clients' prioritized OPIs in a Danish context.

The Validity of the Danish Version of the Canadian Occupational Performance Measure

PURPOSE

To establish the construct validity of the Danish version of the Canadian Occupational Performance Measure (COPM).

METHODS

A cross-sectional study was performed in two settings, a regional hospital and a rehabilitation centre in a community. Including adult clients with a variety of diagnoses, we assessed construct validity by correlating the COPM to the Occupational Self-Assessment (OSA), the five-item World Health Organization Well-Being Index (WHO-5), and the EuroQol-five domain-five level questionnaire (EQ-5D-5L). Further examination of the comparability of the OSA and the COPM was performed in two ways. First, an interrater agreement of the theoretical correlation of the 21 OSA items and the three areas of the COPM was conducted. Secondly, we examined the compliance between the prioritized occupational performance issues (OPIs) and items of the OSA prioritized for change.

RESULTS

The study included a total sample of 112 participants with more than half of the participants (56%) recruited from the hospital. 109 participants had measurements for both COPM and OSA (44% males) with a mean age of 64.7 years (range 16-96 years). All correlations, between the COPM and the OSA, the WHO-5, and the EQ-5D-5L, were low or negligible (r < 0.50). Manual examination confirmed a difference in the constructs of the OSA and the COPM. This was demonstrated by a negligible interrater agreement between the items of the OSA and the areas of the COPM, and differences in the prioritized OPIs and OSA items, even if there were some resemblances, were found.

CONCLUSIONS

This study suggests that the construct of the COPM provides data different to those obtained with the standardized measurements included for comparison. The present study supports the assumption that the COPM can detect unique OPIs that clients want to do, need to do, must do, or are not satisfied with the way they do.

Development in Danish medical students' empathy: study protocol of a cross-sectional and longitudinal mixed-methods study

BACKGROUND

Clinical empathy has been associated with positive outcomes for both physicians and patients such as: more accurate diagnosis and treatment, increased patient satisfaction and compliance, and lower levels of burnout and stress among physicians. International studies show mixed results regarding the development of empathy among future physicians associating medical education with decline, stability or increase in empathy levels. These mixed results are due to several study limitations. In Denmark, no investigation of Danish medical students' empathy trajectory has yet been conducted wherefore such a study is needed that optimizes the study design of earlier studies.

METHODS

The aim of the study is to examine and analyze empathy levels and empathy changes among Danish medical students from the four medical faculties in Denmark, employing a cross-sectional and longitudinal mixed-methods design including a control group of non-medical students. By supplementing cross-sectional and longitudinal questionnaire studies with a focus group interview study it is the aim to identify and analyze factors (including educational) that are perceived by medical students to influence the development of empathy and its expression in clinical care.

DISCUSSION

The results of the study will provide insight into the trajectory of medical students' empathy and in undergraduate and graduate students' experiences with and perceptions of empathy development. In addition, the study will provide evidence to support further research on how targeted educational programmes can best be designed to educate empathic and patient-centered physicians.

Therapeutic Use of the Human Papillomavirus Vaccine on Recurrent Respiratory Papillomatosis: A Systematic Review and Meta-Analysis

BACKGROUND

Recurrent respiratory papillomatosis is a benign condition caused by human papillomavirus (HPV). Surgery is the mainstay of treatment, but numerous adjuvant therapies have been applied to improve surgical outcome. Recently, HPV vaccination has been introduced, but only smaller studies of its effect have been published. The present meta-analysis is intended as a possible substitute for a proposed but not yet realized multicenter randomized controlled trial.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed, Embase, and Cochrane were systematically searched. All retrieved studies (n = 593) were reviewed and qualitatively assessed. In addition, 2 previously unpublished data sets were included. The systematic review included 11 studies, comprising 133 patients, of whom 63 patients from 5 studies were eligible for meta-analysis. A random-effects meta-analysis was conducted for the mean difference in number of surgical procedures per month before and after vaccination.

RESULTS

The number of surgical procedures per month was significantly reduced after HPV vaccination compared with before vaccination (estimated mean, 0.06 vs 0.35). The mean intersurgical interval increased from 7.02 months (range, 0.30-45 months) before to 34.45 months (2.71-82 months) after HPV vaccination.

CONCLUSION

The present study supports the continued use of the HPV vaccine as an adjuvant treatment for recurrent respiratory papillomatosis.

The Risk of Elective Abortion in Women With Crohn's Disease and Ulcerative Colitis: A Nationwide Cohort Study

BACKGROUD

Women with inflammatory bowel disease (IBD) might have an increased tendency to choose an elective abortion due to a fear that their fetus could be harmed by use of medications, disease flares during pregnancy, or for genetic reasons. We examined the risk of elective abortions in women with ulcerative colitis (UC) and Crohn's disease (CD) compared with women without IBD.

METHODS

This nationwide cohort study, based on Danish health registries, comprises all registered pregnancies from 1996 through 2015. The 2 exposed groups constituted pregnancies of women with UC or CD, and the unexposed group constituted all pregnancies of women without IBD. Our outcome was elective abortion by maternal request up until the end of the 12th completed week of gestation. We used logistic regression models and calculated the odds ratio (OR) for an elective abortion, controlling for confounders.

RESULTS

The overall prevalence rates of elective abortions in women with UC and CD and without IBD were 12.4% (898 elective abortions/7250 pregnancies), 14.9% (978 elective abortions/6559 pregnancies), and 16.9% (285,251 elective abortions/1,691,857 pregnancies), respectively. In women with UC and CD, the adjusted ORs for an elective abortion (95% confidence interval) were 0.80 (0.74-0.86) and 0.96 (0.89-1.04), respectively.

CONCLUSIONS

Pregnant women with IBD are not more likely to choose an elective abortion compared with women without IBD. These results are reassuring as they suggest that women with IBD are not so worried about a negative impact of their disease, disease activity, or medications that they would choose to terminate a pregnancy.

Socioeconomic position, symptoms of depression and subsequent mental healthcare treatment: a Danish register-based 6-month follow-up study on a population survey

OBJECTIVE

Examine whether the severity of symptoms of depression was associated with the type of mental healthcare treatment (MHCT) received, independent of socioeconomic position (SEP).

DESIGN

Register-based 6-month follow-up study on participants from the Danish General Suburban Population Study (GESUS) 2010-2013, who scored the Major Depression Inventory (MDI).

PARTICIPANTS

Nineteen thousand and eleven respondents from GESUS.

INTERVENTIONS

The MHCT of the participants was tracked in national registers 4 months prior and 6 months after their MDI scores. MHCT was graduated in levels. SEP was defined by years of formal postsecondary education and income categorised into three levels. Data were analysed using logistic and Poisson regression analyses.

OUTCOMES

MHCT included number of contacts with: general practitioner (GP), GP mental health counselling, psychologist, psychiatrist, emergency contacts, admissions to psychiatric hospitals and prescriptions of antidepressants.

RESULTS

For 547 respondents with moderate to severe symptoms of depression there was no difference across SEP in use of services, contact (y/n), frequency of contact or level of treatment, except respondents with low SEP had more frequent contact with their GP. However, of the 547 respondents , 10% had no treatment contacts at all, and 47% had no treatment beyond GP consultation. Among respondents with no/few symptoms of depression, postsecondary education ≥3 years was associated with more contact with specialised services (adjusted OR (aOR) 1.92; 95% CI 1.18 to 3.13); however, this difference did not apply for income; additionally, high SEP was associated with fewer prescriptions of antidepressants (education aOR 0.69; CI 0.50 to 0.95; income aOR 0.56, CI 0.39 to 0.80) compared with low SEP.

CONCLUSION

Participants with symptoms of depression were treated according to the severity of their symptoms, independent of SEP; however, more than half with moderate to severe symptoms received no treatment beyond GP consultation. People in low SEP and no/few symptoms of depression were more often treated with antidepressants. The study was approved by The Danish Data Protection Agency Journal number 2015-41-3984. Accessible at: https://www.datatilsynet.dk/fortegnelsen/soeg-i-fortegnelsen/.

Causes of death among full term stillbirths and early neonatal deaths in the Region of Southern Denmark

OBJECTIVE

We examined the causes of death amongst full term stillbirths and early neonatal deaths.

METHODS

Our cohort includes women in the Region of Southern Denmark, who gave birth at full term to a stillborn infant or a neonate who died within the first 7 days from 2010 through 2014. Demographic, biometric and clinical variables were analyzed to assess the causes of death using two classification systems: causes of death and associated conditions (CODAC) and a Danish system based on initial causes of fetal death (INCODE).

RESULTS

A total of 95 maternal-infant cases were included. Using the CODAC and INCODE classification systems, we found that the causes of death were unknown in 59/95 (62.1%). The second most common cause of death in CODAC was congenital anomalies in 10/95 (10.5%), similar to INCODE with fetal, genetic, structural and karyotypic anomalies in 11/95 (11.6%). The majority of the mothers were healthy, primiparous, non-smokers, aged 20-34 years and with a normal body mass index (BMI).

CONCLUSION

Based on an unselected cohort from an entire region in Denmark, the cause of stillbirth and early neonatal deaths among full term infants remained unknown for the vast majority.

Risk factors and between-hospital variation of caesarean section in Denmark: a cohort study

OBJECTIVES

The aim of this study was to estimate the effects of risk factors on elective and emergency caesarean section (CS) and to estimate the between-hospital variation of risk-adjusted CS proportions.

DESIGN

Historical registry-based cohort study.

SETTINGS AND PARTICIPANTS

The study was based on all singleton deliveries in hospital units in Denmark from January 2009 to December 2012. A total of 226 612 births by 198 590 mothers in 29 maternity units were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated (1) OR of elective and emergency CS adjusted for several risk factors, for example, body mass index, parity, age and size of maternity unit and (2) risk-adjusted proportions of elective and emergency CS to evaluate between-hospital variation.

RESULTS

The CS proportion was stable at 20%-21%, but showed wide variation between units, even in adjusted models. Large units performed significantly more elective CSs than smaller units, and the risk of emergency CS was significantly reduced compared with smaller units. Many of the included risk factors were found to influence the risk of CS. The most important risk factors were breech presentation and previous CS. Four units performed more CSs and one unit fewer CSs than expected.

CONCLUSION

The main risk factors for elective CS were breech presentation and previous CS; for emergency CS they were breech presentation and cephalopelvic disproportion. The proportions of CS were stable during the study period. We found variation in risk-adjusted CS between hospitals in Denmark. Although exhaustive models were applied, the results indicated the presence of systematic variation between hospital units, which was unexpected in a small, well-regulated country such as Denmark.

Risk of Ectopic Pregnancy in Women With Inflammatory Bowel Disease: A 22-Year Nationwide Cohort Study

BACKGROUND & AIMS

Few data are available on adverse events of pregnancy in women with inflammatory bowel diseases (IBD), such as ectopic pregnancy. We assessed the risk of ectopic pregnancy in pregnancies of women in Denmark with IBD compared with those without IBD over a 22-year period. We also examined the disease-specific risks of ectopic pregnancies in pregnancies of women with ulcerative colitis (UC) or Crohn's disease (CD) who underwent IBD-related surgical procedures.

METHODS

We performed a retrospective study of all women of child-bearing age (ages, 15-50 y) registered in the Danish National Patient Registry with at least 1 pregnancy during the period from January 1994 through December 31, 2015. We collected data on all women with an ectopic pregnancy, hydatidiform mole, miscarriages (spontaneous and other abortions, including abnormal pregnancy products, missed abortion, and pregnancy without a fetus), induced abortions, and births in women with and without IBD. Our study population included 7548 pregnancies in women with UC, 6731 pregnancies in women with CD, and 1,832,732 pregnancies in women without IBD. We controlled for multiple covariates, including pelvic and abdominal surgery.

RESULTS

Women with CD had a greater risk of ectopic pregnancy, per pregnancy, than women without IBD (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.01-1.49), whereas women with UC did not (OR, 0.98; 95% CI, 0.80-1.20). In pregnancies of women with CD and UC who underwent IBD-related surgery before pregnancy, there was a nonsignificant increase in risk of ectopic pregnancy compared with pregnancies in women with IBD who did not have surgery (OR, 1.49; 95% CI, 0.91-2.44 for CD, and OR, 1.17; 95% CI, 0.54-2.52 for UC).

CONCLUSIONS

We found a statistically significant increased risk of ectopic pregnancy in pregnancies of women with CD compared with pregnancies of women without IBD. Surgery for IBD before pregnancy increased the risk of ectopic pregnancy, although this increase was not statistically significant.

Retrospective evaluation of a national guideline to prevent neonatal hypoglycemia

BACKGROUND

Hypoglycemia is common in neonates and may cause adverse neurological outcomes. Guidelines should aim to prevent repeated hypoglycemic episodes in risk groups, but they are not usually stratified according to the severity of hypoglycemia risk, which may lead to inappropriate and redundant interventions. We evaluated the effect of a national prevention guideline stratified according to mild, moderate, and severe risks of hypoglycemia.

METHODS

From national registers, a population cohort of 22,725 neonates was identified retrospectively before and after implementation of a national guideline. Of these, 1900 had World Health Organization International Classification of Diseases 10 discharge diagnoses of hypoglycemia. Diagnoses indicating hypoglycemia risk [small/large for gestational age (SGA/LGA), asphyxia, prematurity, maternal insulin-treated diabetes mellitus] were recorded. Neonatal ward files were evaluated to validate hypoglycemia diagnoses. Adjusted odds ratios (aORs) were calculated, adjusting for sex, parity, SGA, LGA, preterm birth, and asphyxia, where relevant.

RESULTS

Primiparity and male sex were associated independently with hypoglycemia diagnosis [aORs, 1.29 (1.17-1.42) and 1.14 (1.03-1.26), respectively]. Overall incidence of hypoglycemia at discharge decreased from 9.4% to 5.5% after guideline implementation [aOR_change, 0.57 (0.50-0.64)]. Overall incidence of validated hypoglycemia decreased from 2.1% to 1.2% [aOR 0.59 (0.46-0.77), p<0.001]. By risk group, the hypoglycemia incidence decreased from 30.5% to 18.6% [aOR 0.52 (0.36-0.75)] among SGA neonates, from 25.8% to 16.4% [aOR 0.57 (0.42-0.76)] among preterm infants, and from 27.4% to 16.6% [aOR 0.63 (0.34-0.83)] among those with asphyxia. LGA neonates showed a decreased incidence in obstetric wards only. No significant change was observed for the diabetes group.

CONCLUSION

Stratification of hypoglycemia risk in a hypoglycemia prevention guideline was followed by decreased estimated hypoglycemia incidence, but no causative conclusion could be drawn. Prospective studies with risk stratification for hypoglycemia prevention are encouraged.

Impact of appropriate empirical antibiotic treatment on recurrence and mortality in patients with bacteraemia: a population-based cohort study

Background

Data on the impact of empirical antibiotic treatment (EAT) on patient outcome in a population-based setting are sparse. We assessed the association between EAT and the risk of recurrence within one year, short-term- (2–30 days) and long-term (31–365 days) mortality in a Danish cohort of bacteraemia patients.

Methods

A cohort study including all patients hospitalized with incident bacteraemia during 2007–2008 in the Copenhagen City and County areas and the North Denmark Region. EAT was defined as the antibiotic treatment given at the 1^st notification of a positive blood culture. The definition of recurrence took account of pathogen species, site of infection, and time frame and was not restricted to homologous pathogens. The vital status was determined through the civil registration system. Association estimates between EAT and the outcomes were estimated by Cox and logistic regression models.

Results

In 6483 eligible patients, 712 (11%) had a recurrent episode. A total of 3778 (58%) patients received appropriate EAT, 1290 (20%) received inappropriate EAT, while EAT status was unrecorded for 1415 (22%) patients. The 2–30 day mortality was 15.1%, 17.4% and 19.2% in patients receiving appropriate EAT, inappropriate EAT, and unknown EAT, respectively. Among patients alive on day 30, the 31–365 day mortality was 22.3% in patients given appropriate EAT compared to 30.7% in those given inappropriate EAT. Inappropriate EAT was independently associated with recurrence (HR 1.25; 95% CI = 1.03–1.52) and long-term mortality (OR 1.35; 95% CI = 1.10–1.60), but not with short-term mortality (OR 0.85; 95% CI = 0.70–1.02) after bacteraemia.

Conclusions

Our data indicate that appropriate EAT is associated with reduced incidence of recurrence and lower long-term mortality following bacteraemia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2233-z) contains supplementary material, which is available to authorized users.

Effects of lifestyle intervention in pregnancy and anthropometrics at birth on offspring metabolic profile at 2.8 years: results from the Lifestyle in Pregnancy and Offspring (LiPO) study

CONTEXT

Maternal obesity and gestational weight gain are linked to offspring adverse metabolic profiles, and lifestyle interventions during pregnancy in obese women may have long-term positive effects on their children. Furthermore, although the association between birth weight and later metabolic outcomes is well established, little is known about the predictive value of abdominal circumference at birth.

OBJECTIVES

The purpose of this study was to determine (1) the effects of lifestyle interventions during pregnancy in obese women on offspring metabolic risk factors and (2) predictive values of birth weight (BW) and birth abdominal circumference (BAC).

DESIGN

This was a follow-up of a randomized controlled trial, the Lifestyle in Pregnancy (LiP) study.

SETTING

The study was conducted in Odense and Aarhus University Hospitals, Denmark.

PARTICIPANTS

We studied the offspring of LiP study participants (n = 157) and offspring of normal-weight mothers (external reference group, n = 97).

INTERVENTION

INTERVENTIONs included dietary advice, coaching, and exercise during pregnancy.

MAIN OUTCOME MEASURES

The outcome measures were body mass index (BMI) Z-score, abdominal circumference, blood pressure, and fasting plasma glucose, insulin, high-density lipoprotein, and triglycerides at the age of 2.8 years.

RESULTS

No differences were detected in BMI Z-scores or metabolic risk factors between the LiP intervention and control groups or between the LiP and external reference groups. BAC and BW were associated (all P < .05) with BMI Z-score (0.19-0.23), abdominal circumference (0.57-0.70), plasma glucose (0.11-0.09), insulin (4.33-3.13), and triglycerides (0.07-0.07) but not with blood pressure or high-density lipoprotein (regression coefficients per increase in BAC and BW of 1 SD score).

CONCLUSIONS

Early childhood metabolic risk factors were unaffected by lifestyle interventions in obese pregnant women. Offspring of obese mothers who participated in the LiP study were comparable to offspring of normal-weight mothers, possibly indicating a general beneficial effect of trial participation. BAC and BW were both associated with later metabolic risk factors.

Relative survival of peritoneal dialysis and haemodialysis patients: effect of cohort and mode of dialysis initiation

INTRODUCTION

Epidemiological studies consistently show an initial survival advantage for PD patients compared to HD. It has recently been suggested that this is due to the fact that many HD patients are referred late, and start dialysis on an acute, in-patient basis. The present study was performed to investigate (1) whether, and if so, how, PD and HD prognosis had changed in recent years, (2) whether a potential survival advantage of PD versus HD is constant over dialysis duration, and (3) whether differences in prognosis could be explained by patient age, renal diagnosis of diabetic nephropathy, or mode of dialysis initiation.

PATIENTS AND METHODS

12095 patients starting dialysis therapy between 1990 and 2010 in Denmark were studied. Prognosis was assessed according to initial dialysis modality on an intention-to-treat basis, censored for transplantation. Results were adjusted for age, sex, renal diagnosis, Charlson Comorbidity Index (CCI), and mode of dialysis initiation.

RESULTS

Overall adjusted prognosis improved by 34% (HD 30%, PD 42%). PD prognosis relative to HD improved, and was 16% better at the end of the period. Final PD prognosis improved consistently from 1990-99 to 2000-10 in all subgroups. PD was associated with a significant initial survival advantage, both overall and for all subgroups For the latter cohort, overall PD prognosis was better than HD for the first 4 years, after which it was insignificantly worse. The initial survival advantage was also present in a subgroup analysis of patients with early & routine ESRD initiation.

CONCLUSIONS

Dialysis survival has increased during the past 20 years. PD survival since 2000 has been better than HD, overall and for all subgroups. The difference in survival is not explained by mode of dialysis initiation.

Salpingectomy as standard at hysterectomy? A Danish cohort study, 1977-2010

OBJECTIVE

To assess if the risk of first-time salpingectomy was affected by prior hysterectomy with retained fallopian tubes and by prior sterilisation.

DESIGN

A historical cohort study.

SETTING

Denmark.

PARTICIPANTS

170 000 randomly selected women born 1947-1963 (10 000/year) were followed from 1977 until the end of 2010.

MAIN OUTCOME MEASURES

Effect of hysterectomy with retained fallopian tubes or sterilisation on the risk of salpingectomy. Both were modelled in a Cox proportional hazards model as time-dependent covariates, analysing time to first salpingectomy. End of follow-up period was 31 December 2010.

RESULTS

Of 9591 hysterectomies, 6456 (67.3%) had both fallopian tubes retained. HRs for salpingectomy after hysterectomy with retained fallopian tubes and sterilisation were 2.13 (95% 1.88 to 2.42) and 2.42 (2.21 to 2.64), as compared with those for non-hysterectomised and non-sterilised women.

CONCLUSIONS

Women undergoing hysterectomy with retained fallopian tubes or sterilisation have at least a doubled risk of subsequent salpingectomy. Removal of the fallopian tubes at hysterectomy should therefore be recommended.