Developing quality measures for non-pharmacological prevention and rehabilitation in primary health care for chronic conditions: a consensus study.

Poor health-related behaviours are root causes of a large number of chronic conditions; however, this study is the first to develop guideline-based quality measures targeting health-related behaviours through generic non-pharmacological secondary prevention and rehabilitation in municipal primary health care for persons with chronic conditions. From January 2020 to September 2021, a consensus study was conducted in accordance with the current scientific recommendations for developing guideline-based quality measures. A clinical expert panel (n = 11) was established and included a patient representative, health care professionals, researchers, and key specialists. The process for developing quality measures was led by methodologists and encompassed a modified Research and Development/University of California at Los Angeles (RAND/UCLA) study to evaluate consensus in the expert panel. The consensus recommendations were directed to a steering group including the Danish Ministry of Health, the Danish Regions, and the Local Government Denmark. The expert panel rated 102 clinical practice recommendations. Consensus was demonstrated on 13 quality measures assessing whether the patients are offered participation in and adhere to: self-management, smoking cessation, physical exercise training, nutritional efforts, and preventive consultation on excessive alcohol consumption; whether the patients participate in a closing meeting, whether they are offered follow-up, and whether reasons for dropout are documented. The identified quality measures constitute a framework for assessing the quality of non-pharmacological prevention and rehabilitation in municipal primary health care for persons with chronic conditions. The next steps focus on field testing of the quality measures to refine measure criteria and assess implementation. A close link between clinical practice, the evidence and practice recommendations, the data infrastructure, economic considerations, and national priorities was a key to the consensus process.

Family involvement and patient-experienced improvement and satisfaction with care: a nationwide cross-sectional study in Danish psychiatric hospitals.

BACKGROUND: Randomised controlled trials suggest that family therapy has a positive effect on the course of depression, schizophrenia and anorexia nervosa. However, it is largely unknown whether a positive link also exists between caregiver involvement and patient outcome in everyday psychiatric hospital care, using information reported directly from patients, i.e. patient-reported experience measures (PREM), and their caregivers. The objective of this study is to examine whether caregiver-reported involvement is associated with PREM regarding patient improvement and overall satisfaction with care. METHODS: Using data from the National Survey of Psychiatric Patient Experiences 2018, we conducted a nationwide cross-sectional study in Danish psychiatric hospitals including patients and their caregivers who had been in contact with the hospital (n = 940 patients, n = 1008 caregivers). A unique patient identifier on the two distinct questionnaires for the patient and their caregiver enabled unambiguous linkage of data. In relation to PREM, five aspects of caregiver involvement were analysed using logistic regression with adjustment for patient age, sex and diagnosis. RESULTS: We consistently find that high caregiver-reported involvement is statistically significantly associated with high patient-reported improvement and overall satisfaction with care with odds ratios (OR) ranging from 1.69 (95% confidence interval (CI) 0.95-2.99) to 4.09 (95% CI 2.48-6.76). This applies to the following aspects of caregiver-reported involvement: support for the patient-caregiver relationship, caregiver information, consideration for caregiver experiences and the involvement of caregivers in decision making. No statistically significant association is observed regarding whether caregivers talk to the staff about their expectations for the hospital contact. CONCLUSION: This nationwide study implies that caregiver involvement focusing on the patient-caregiver relationship is positively associated with patient improvement and overall satisfaction with care in everyday psychiatric hospital care.

Comparison of Two Pediatric Early Warning Systems: A Randomized Trial.

PURPOSE: Pediatric early warning systems (PEWS) are used to detect clinical deterioration in hospitalized children. Few PEWSs have been validated in multicenter studies and the performance in many single-center studies varies. We wanted to compare two PEWS in a multicenter study. DESIGN AND METHODS: Randomized multicenter unblinded trial conducted at all pediatric departments in the Central Denmark Region. A random sample of 16,213 pediatric patients (31,337 admissions) were enrolled from November 2014 to March 2017. Patients were randomized to The Bedside PEWS or CDR PEWS. The primary outcome was the sum of hospitalized children experiencing in-hospital clinical deterioration requiring transfer to a higher level of care. RESULTS: Of the 21,077 pediatric patients who met the inclusion criteria, 16,213 (from 31,337 admissions) were enrolled. 22 unplanned transfers to a higher level of care were identified: 14 in The Bedside PEWS group and 8 in the CDR PEWS group, a non-statistical difference (P = 0.20). No significant difference in predicting unplanned transfer to a higher level of care (P = 0.78) were detected and no significant difference was observed in the secondary outcomes. CONCLUSIONS: The CDR PEWS prevents as many critical events as The Bedside PEWS. Shorter median time to PEWS reassessment when CDR PEWS was used and fewer reassessments being done to late could reflect that the CDR PEWS was more acceptable to staff. PRACTICE IMPLICATIONS: The results from this study should be interpreted with caution as very few patients experiencing clinical deterioration and further studies should also focus on challenges trying to evaluate PEWS.

Labour market participation and sick leave among patients diagnosed with myasthenia gravis in Denmark 1997-2011: a Danish nationwide cohort study.

BACKGROUND: To examine labour market participation and long-term sick leave following a diagnosis with myasthenia gravis (MG) compared with the general Danish population and for specific subgroups of MG patients. METHODS: A nationwide matched cohort study from 1997 to 2011 using data from population-based medical and social registries. The study includes 330 MG patients aged 18 to 65 years old identified from hospital diagnoses and dispensed prescriptions, and twenty references from the Danish population matching each MG patient on age, gender, and profession. Main outcome measures are labour market participation (yes/no) and long-term sick leave ≥9 weeks (yes/no) with follow-up at 1- and 2 years after the time of MG diagnosis or match. Based on complete person-level information on all public transfer payments in Denmark, persons having no labour market participation are defined as individuals receiving social benefits for severely reduced workability, flexijob, and disability pension. RESULTS: MG is consistently associated with higher odds of having no labour market participation and long-term sick leave compared with the general Danish population (no labour market participation & ≥9 weeks sick leave at 2-year follow-up, adjusted OR (95% CI): 5.76 (4.13 to 8.04) & 8.60 (6.60 to 11.23)). Among MG patients, females and patients treated with both acetylcholinesterase inhibitors and immunosuppression have higher odds of lost labour market participation and long-term sick leave. CONCLUSIONS: This study suggests that MG patients have almost 6 times higher odds of no labour market participation and almost 9 times higher odds of long-term sick leave 2 years after diagnosis compared with the general Danish population. In particular female MG patients and patients treated with both acetylcholinesterase and immunosuppression have high odds of a negative labour market outcome. Future research should focus on predictors in workplace and labour market policy of labour market participation among MG patients.

Age- and sex-related differences in use of guideline-recommended care and mortality among patients with incident heart failure in Denmark.

BACKGROUND: data are sparse on age- and sex-related differences in use of guideline-recommended care and subsequent mortality among patients with heart failure (HF). METHODS: we identified 24,308 incident patients with a verified primary diagnosis of HF recorded during 2003-2010 in the Danish Heart Failure Registry. The registry monitors guideline-recommended processes of care: echocardiography, New York Heart Association Classification, treatment with angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, betablockers, physical training and patient education. RESULTS: older age was associated with lower use of recommended processes of care. Relative risk (RR) for receiving processes of care varied for men >80 years from 0.52 to 0.91 compared with men ≤65 years. Corresponding RRs among women >80 years varied from 0.55 to 0.89 compared with women ≤65 years. Older age was as expected associated with higher 1 year mortality (32.6% among men >80 years versus 5.4% among men ≤65 years and 33.8% among women >80 years versus 6.6% among women ≤65 years). The corresponding hazard ratios (HRs) were 4.54 (95% CI 3.93-5.25) and 4.08 (95% CI 3.51-4.75) for the oldest versus youngest men and women, after adjustment for patient characteristics. Adjustment for differences in care lowered HRs among the oldest age groups (adjusted HR 3.87 for men and 3.48 for women, respectively). The findings were also confirmed when stratifying the patients according to left ventricular ejection fraction ≤40% and >40%. CONCLUSION: older patients with HF were less likely to receive guideline-recommended processes of care, irrespective of sex. Lower level of care may contribute to an excess mortality observed among the older patients.

Compliance with hospital accreditation and patient mortality: a Danish nationwide population-based study.

OBJECTIVE: To examine the association between compliance with hospital accreditation and 30-day mortality. DESIGN: A nationwide population-based, follow-up study with data from national, public registries. SETTING: Public, non-psychiatric Danish hospitals. PARTICIPANTS: In-patients diagnosed with one of the 80 primary diagnoses. INTERVENTION: Accreditation by the first version of The Danish Healthcare Quality Programme for hospitals from 2010 to 2012. Compliance were assessed by surveyors on an on-site survey and awarded the hospital as a whole; fully (n = 11) or partially accredited (n = 20). A follow-up activity was requested for partially accredited hospitals; submitting additional documentation (n = 11) or by having a return-visit (n = 9). MAIN OUTCOME MEASURES: All-cause mortality within 30-days after admission. Multivariable logistic regression was used to compute odds ratios (ORs) for 30-day mortality adjusted for six confounding factors and for cluster effect at hospital level. RESULTS: A total of 276 980 in-patients were identified. Thirty-day mortality risk for in-patients at fully (n = 76 518) and partially accredited hospitals (n = 200 462) was 4.14% (95% confidence interval (CI):4.00-4.28) and 4.28% (95% CI: 4.20-4.37), respectively. In-patients at fully accredited hospitals had a lower risk of dying within 30-days after admission than in-patients at partially accredited hospitals (adjusted OR of 0.83; 95% CI: 0.72-0.96). A lower risk of 30-day mortality was observed among in-patients at partially accredited hospitals required to submit additional documentation compared with in-patients at partially accredited hospitals requiring a return-visit (adjusted OR 0.83; 95% CI: 0.67-1.02). CONCLUSION: Admissions at fully accredited hospitals were associated with a lower 30-day mortality risk than admissions at partially accredited hospitals.

Preadmission oral anticoagulant treatment and clinical outcome among patients hospitalized with acute stroke and atrial fibrillation: a nationwide study.

BACKGROUND AND PURPOSE: Preadmission oral anticoagulant treatment (OAT) has been linked with less severe stroke and a better outcome in patients with atrial fibrillation. However, the existing studies have methodological limitations and have, with one exception, not included hemorrhagic strokes. We performed a nationwide historic follow-up study using data from population-based healthcare registries to assess the effect of preadmission OAT on stroke outcomes further. METHODS: We identified 11 356 patients with atrial fibrillation admitted to hospital with acute stroke (including ischemic stroke and intracerebral hemorrhage) between 2003 and 2009. Propensity score-matched analyses were used to compare stroke severity (Scandinavian Stroke Scale score) and mortality among 2175 patients with preadmission OAT and 2175 patients without preadmission OAT. RESULTS: A total of 2492 (21.9%) patients received OAT at the time of their stroke. Preadmission OAT was associated with a lower risk of severe stroke (Scandinavian Stroke Scale score at time of admission, <30 point; propensity score-matched odds ratio, 0.74; 95% confidence interval, 0.63-0.86) and lower 30-day mortality rate (propensity score-matched adjusted odds ratio, 0.83; 95% confidence interval, 0.71-0.98). CONCLUSIONS: Only a minority of hospitalized patients with acute stroke with atrial fibrillation received OAT at the time of stroke. Preadmission OAT was associated with less severe stroke and lower 30-day mortality rate in a propensity score-matched analysis.

Are cardiac rehabilitation pathways influenced by diabetes: A cohort study.

BACKGROUND: Cardiac rehabilitation (CR) is recommended following acute coronary syndrome (ACS). Diabetes is a common long-term condition associated with ACS, and the inclusion of these patients in CR has been less studied. This study examines the referral, uptake, and completion rates in the CR pathway for ACS patients with and without diabetes to identify potential barriers in the CR pathway. METHODS: The study included patients aged 18 or above who were discharged after a diagnosis of ACS in the Central Denmark Region between 1 September 2017 and 31 August 2018. Diabetes information was obtained from three sources. Logistic regression models were used to examine the associations between having diabetes and the three outcomes: non-referral, non-uptake and non-completion. Results were reported as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: A total of 2447 patients were eligible for the study, of which 457 (18.7%) had diabetes. Only non-uptake was found to be significantly associated with diabetes after adjustment for prespecified variables (OR = 1.38, 95% CI 1.01-1.90). Associations for non-referral (OR = 1.11, 95% CI 0.87-1.41) and non-completion (OR = 1.06, 95 %CI 0.73-1.53) were not found to be statistically significant between ACS patients with diabetes and those without diabetes. CONCLUSION: This study highlights a significant disparity in the uptake of CR between patients with and without diabetes following ACS, demonstrating that patients with diabetes require early promotion and increased assistance to enrol in CR.

Trends in quality of care among patients with incident heart failure in Denmark 2003-2010: a nationwide cohort study.

BACKGROUND: The treatment of heart failure (HF) is complex and the prognosis remains serious. A range of strategies is used across health care systems to improve the quality of care for HF patients. We present results from a nationwide multidisciplinary initiative to monitor and improve the quality of care and clinical outcome of HF patients using indicator monitoring combined with systematic auditing. METHODS: We conducted a nationwide, population-based prospective study using data from the Danish Heart Failure Registry. The registry systematically monitors and audits the use of guideline recommended processes of care at Danish hospital departments treating incident HF patients. We identified patients registered between 2003 and 2010 (n = 24,504) and examined changes in use of recommended processes of care and 1-year mortality. RESULTS: The use of the majority of the recommended processes of care increased substantially from 2003 to 2010: echocardiography (from 62.7% to 90.5%; Relative Risk (RR) 1.45 (95% CI, 1.39-1.50)), New York Heart Association classification (from 29.4% to 85.5%; RR 2.91 (95% CI, 2.69-3.14)), betablockers (from 72.6% to 88.3%; RR 1.23 (95% CI, 1.15-1.29)), physical training (from 5.6% to 22.8%; RR 4.04 (95% CI, 2.96-4.52)), and patient education (from 49.3% to 81.4%; RR 1.65 (95% CI, 1.52-1.80)). Use of ACE/ATII inhibitors remained stable (from 92.0% to 93.2%; RR 1.01 (95% CI, 0.99-1.04)). During the same period, 1-year mortality dropped from 20.5% to 12.8% (adjusted Hazard Ratio 0.79 (95% CI, 0.65-0.96). CONCLUSIONS: Use of guideline recommended processes of care has improved among patients with incident HF included in the Danish Heart Failure Registry between 2003 and 2010. During the same period, a decrease in mortality was observed.

Higher stroke unit volume associated with improved quality of early stroke care and reduced length of stay.

BACKGROUND AND PURPOSE: Specialized stroke unit care improves outcome among patients with stroke, but it is unclear whether there are any scale advantages in costs and clinical outcome from treating a larger number of patients. We examined whether the case volume in stroke units was associated with quality of early stroke care, mortality, and hospital bed-day use. METHODS: In a nationwide population-based cohort study, we identified 63 995 patients admitted to stroke units in Denmark between 2003 and 2009. Data on exposure, outcome, and covariates were collected prospectively. Comparisons were clustered within stroke units and adjusted for patient and hospital characteristics. RESULTS: Patients in high-volume stroke units overall had a better prognostic profile than patients in low-volume stroke units. Patients in high-volume stroke units also received more processes of care in the early phase of stroke compared with patients in low-volume stroke units (unadjusted difference, 9.84 percentage points; 95% CI, 3.98-15.70). High stroke unit volume was associated with shorter length of the initial hospital stay (adjusted ratio, 0.49; 95% CI, 0.41-0.59) and reduced bed-day use in the first year after stroke (adjusted ratio, 0.79; 95% CI, 0.70-0.87). No association between volume and mortality was found. CONCLUSIONS: Patients admitted to high-volume stroke units received a higher quality of early stroke care and spent fewer days in the hospital compared with patients in low-volume units. We observed no association between volume and mortality.

How to Facilitate Adherence to Cardiac Rehabilitation in Primary Health Settings for Ischaemic Heart Disease Patients. The Perspectives of Health Professionals.

Background: Cardiac rehabilitation (CR) is a class 1A recommendation and an integrated part of standard treatment for patients with cardiac disease. In Denmark, CR adheres to European guidelines, it is group-based and partly conducted in primary health settings. Despite high evidence for the benefits of CR, it remains underutilized. How to facilitate CR adherence in primary health settings is poorly understood. Aim: This study explores health professional's perspectives on how to facilitate CR adherence for patients with ischaemic heart disease in primary health settings. Methods: Data were collected through focus group discussions. Respondents were health professionals specialized in and working with CR in primary health settings. Data were analyzed using thematic analysis. Results: Eleven health professionals participated in two focus group discussions. Five themes emerged as facilitators of CR; (1) placing the person at the center, (2) coherent programme, (3) flow of information, (4) contextual factors, and (5) feeling of belonging. Conclusion: This study illuminates the complexity of facilitating adherence to CR in primary health settings and provides ways in which health professionals may facilitate adherence. Placing the person at the center is pivotal and may be done by adapting CR offers to patients' social context, culture and life circumstances and ensuring a feeling of belonging. The rhetoric related to CR should be positive and throughout the entire course of treatment health professionals should possess a generic and collective approach to and view of CR. Perceiving these elements as potential facilitators is of vital importance and addressing them may facilitate adherence.

Why Do Patients With Ischaemic Heart Disease Drop Out From Cardiac Rehabilitation in Primary Health Settings. A Qualitative Audit of Patient Charts.

Background: Cardiac rehabilitation (CR) and medical treatment are integrated parts of the intervention for cardiac patients and are a class 1A recommendation. However, CR dropout is reported to be relatively high and little is known about the reasons for CR dropout in primary health settings. Aim: This study investigates causes for CR dropout through a qualitative audit of medical charts among patients with ischaemic heart disease. Methods: This was a qualitative retrospective audit of patient's medical charts. Patients who dropped out from CR between 1 January and 31 December 2018 in five primary health settings were included. Local patient charts provided information related to causes and formed the basis of the analysis. Data were analyzed using thematic analysis. Results: A total of 690 patients were referred for and commenced CR and 199 (29%) dropped out. Twenty-five (12.6%) patients finished CR but were excluded due to standards of ≥180 days between CR meetings, leaving 118 patients included. Four themes as causes for patient's dropout were identified: (1) CR-programmes, (2) logistical, (3) intrapersonal and (4) clinical factors. Conclusion: This study identified new focus areas to which health professionals may attend in reducing drop-out from CR. Organisation of CR, challenges with combining labor market attachment and CR, focus on patient education and comorbidities. The results underline the importance of health professionals emphasizing the benefits of CR and explains that CR enhances long-term labor market attachment. Furthermore, health professionals should encourage participation in patient education and adapt exercise to the individual patient's potential.

To what extend is socioeconomic status associated with not taking up and dropout from cardiac rehabilitation: a population-based follow-up study.

OBJECTIVES: High socioeconomic status (SES) has been linked to high referral for cardiac rehabilitation (CR). However, the impact of SES on CR utilisation from enrolment to completion is unclear. The objective of this study was to examine whether indicators of SES are associated with not taking up and dropout from CR. DESIGN: A population-based, follow-up study. SETTING: Hospitals and primary healthcare centres in the Central Denmark Region. PARTICIPANT: Patients diagnosed with ischaemic heart disease (IHD) in the hospital and referred for rehabilitation in the primary healthcare setting from 1 September 2017 to 31 August 2018 (n=2018). VARIABLES: Four SES indicators (education, disposable family income, occupation and cohabitant status) were selected because of their established association with cardiovascular health and CR utilisation. Patients were followed up regarding no uptake of or dropout from CR in the primary healthcare setting. STATISTICAL METHODS: The associations between the four SES indicators and either no uptake or dropout from CR were analysed using logistic regression with adjustment for age, sex, nationality and comorbidity. RESULTS: Overall, 25% (n=507) of the referred patients did not take up CR and 24% (n=377) of the participators dropped out the CR. All adjusted ORs, except one (education/dropout) demonstrated that low SES compared with high are statistically significantly associated with higher odds of not taking up CR and dropout from CR. The ORs ranged from 1.52, 95% CI 1.13 to 2.04 (education/no uptake) to 2.36, 95% CI 1.60 to 3.46 (occupation/dropout). CONCLUSIONS: This study highlights that indicators of SES are important markers of CR utilisation following hospitalisation for IHD.

Quality of care and patient outcome in stroke units: is medical specialty of importance?

BACKGROUND: Specialized stroke unit care improves outcome in stroke patients. However, it is uncertain whether the units should be placed in a neurological or non-neurological (eg, internal medicine or geriatric) setting. OBJECTIVES: To assess whether stroke unit setting (neurological/non-neurological) is associated with quality of care and outcome among patients with stroke, and whether these associations depend on the severity of comorbidity. METHODS: In a nationwide population-based follow-up study, we identified 45,521 patients admitted to stroke units in Denmark between 2003 and 2008. Outcomes were quality of care (whether patients received evidence-based processes of acute stroke care), mortality, length of stay, and readmission. Charlson comorbidity index was used to assess comorbidity, and comparisons were adjusted for patient and hospital characteristics. RESULTS: Patients admitted to stroke units in neurological settings had higher odds for early antiplatelet therapy (odds ratio, 1.68; 95% confidence interval, 1.10-2.56) and early computed tomographic scan or magnetic resonance imaging (odds ratio, 1.77; 95% confidence interval, 1.29-2.45) compared with patients in non-neurological settings. No other differences were found when studying quality of care and patient outcomes. However, patients with moderate comorbidity admitted to stroke units in neurological settings had higher odds for 1-year mortality, but comparisons across strata of comorbidity were not statistical significant. CONCLUSIONS: Except for early antiplatelet therapy and early computed tomographic scan or magnetic resonance imaging, the medical setting was not associated with differences in processes of acute stroke care and patient outcome. No medical setting related differences were found according to comorbidity, although indications of a worse outcome in patients with moderate comorbidity in neurological settings warrant further investigation.

Quality of care and length of hospital stay among patients with stroke.

BACKGROUND: The relationship between quality of care and economic outcome measures, including length of stay (LOS), among patients with stroke remains to be clarified. OBJECTIVES: To determine whether quality of care is associated with LOS among patients with stroke. METHODS: In this population-based follow-up study, we included 2636 patients with stroke who had been admitted to dedicated stroke units in Aarhus County, Denmark, from 2003 to 2005. Quality of care was measured as fulfillment of 12 criteria: early admission to a stroke unit, early antiplatelet therapy, early anticoagulant therapy, early computed tomography/magnetic resonance imaging scan, early water swallowing test, early mobilization, early intermittent catheterization, early deep venous thromboembolism prophylaxis, early assessment by a physiotherapist and an occupational therapist, and early assessment of nutritional and constipation risk. Data were analyzed by linear regression clustered at the stroke units by multilevel modeling. RESULTS: Median LOS was 13 days (25th and 75th percentiles: 7, 33). Meeting each quality of care criteria was associated with shorter LOS. Adjusted relative LOS ranged from 0.67 (95% confidence interval (CI): 0.61-0.73) to 0.87 (95% CI: 0.81-0.93). The association between meeting more quality of care criteria and LOS followed a dose-response effect, that is, patients who fulfilled between 75% and 100% of the quality of care criteria were hospitalized about one-half as long as patients who fulfilled between 0% and 24% of the criteria (adjusted relative LOS: 0.53, 95% CI: 0.48-0.59). CONCLUSIONS: Higher quality of care during the early phase of stroke was associated with shorter LOS among patients with stroke.

A Cross-Sectional Study Evaluating Potential Differences in the Need for Cancer Survivorship Care in Relation to Patients' Socioeconomic Status.

BACKGROUND: There seems to be inequity within cancer survivorship care in primary care settings related to gender, shorter education, and early poor health, but there is uncertainty regarding the character of the needs in hospital and in primary care settings and whether there is inequity regarding meeting these needs. This study aims to describe potential differences in needs among patients in hospital and in primary care settings, and to assess the need for survivorship care and rehabilitation in patients with cancer in relation to socioeconomic status. METHODS: In a cross-sectional study including patients in hospital (n = 89) and primary care settings (n = 99), information from needs assessments was linked with population-based data on socioeconomic status via unique personal identification numbers. The association between socioeconomic status and stated needs was analyzed separately for patients in hospital and primary care settings, with adjustment for age and gender. RESULTS: A total of 90% patients expressed one or more needs in the physical area, 51% in the emotional area, and 40% in the practical area. Patients in primary care expressed more needs than patients in hospital. Men expressed more needs than women in primary care (adjusted odds ratio (OR) (95% confidence interval (CI)): 2.66 (1.04 - 6.79)). The results indicate that higher socioeconomic status is associated with fewer stated needs. CONCLUSIONS: This study suggests that the association between gender and stated needs may depend on healthcare setting and confirms that higher socioeconomic status in relation to civil status, educational level, income, and labor market status is associated with fewer stated needs.

Association between process performance measures and 1-year mortality among patients with incident heart failure: a Danish nationwide study.

Aims: To examine the association between fulfilment of performance measures supported by clinical guidelines recommendations and 1-year mortality among patients with incident heart failure (HF) in Denmark. Methods and results: A nationwide population-based follow-up study based on the Danish Heart Failure Registry. All Danish hospital departments caring for patients with HF. We identified 24 308 in- and outpatients diagnosed with HF from 2003 to 2010. Quality of care was defined as receiving the guideline recommended processes of care: use of echocardiography, New York Heart Association classification, treatment with angiotensin-converting-enzyme inhibitors/angiotensin-II-receptor blocker, beta blockers, physical training, and patient education. Main outcome measure is 1-year mortality. We used multiple imputation and multivariable Cox proportional hazard regression to compute hazard ratios (HRs) for 1-year mortality adjusted for potential confounding factors. Within 1 year, 17.1% of the patients died and the adjusted HRs ranged from 0.61 [95% confidence interval (CI) 0.55-0.67] for patient education to 0.99 (95% CI 0.90-1.10) for beta blocker therapy. The association between meeting more performance measures and 1-year mortality appeared to follow a dose-response pattern: using 0-25% of fulfilled measures as reference, patients who fulfilled 76-100% of the performance measures had an adjusted HR of 0.43 (95% CI 0.38-0.48), while the adjusted HR was 0.96 (95% CI 0.86-1.07) for patients who fulfilled between 26% and 50% of the performance measures. Conclusion: Meeting process performance measures, which reflect care in concordance with clinical guideline recommendations, was associated with substantially lower 1-year mortality among patients with incident HF.

Improving quality of care among patients hospitalised with schizophrenia: a nationwide initiative.

BACKGROUND: The effectiveness of systematic quality improvement initiatives in psychiatric care remains unclear. AIMS: To examine whether quality of care has changed following implementation of a systematic monitoring programme of hospital performance measures. METHOD: In a nationwide population-based cohort study, we identified 14 228 patients admitted to psychiatric departments between 2004 and 2011 from The Danish Schizophrenia Registry. The registry systematically monitors the adherence to guideline recommended processes of care. RESULTS: The overall proportion of all relevant recommended processes of care increased from 64 to 76% between 2004 and 2011. The adherence to individual processes of care increased over time, including assessment of psychopathology using a diagnostic interview (relative risk (RR): 2.01, 95% CI: 1.51-2.68), contact with relatives (RR: 1.44, 95% CI: 1.27-1.62), psychoeducation (RR: 1.33, 95% CI: 1.19-1.48), psychiatric aftercare (RR: 1.06, 95% CI: 1.01-1.11) and suicide risk assessment (RR: 1.31, 95% CI: 1.21-1.42). CONCLUSIONS: Quality of care improved from 2004 to 2011 among patients hospitalised with schizophrenia in Denmark. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Processes of early stroke care and hospital costs.

BACKGROUND: The relationship between processes of early stroke care and hospital costs remains unclear. AIMS: We therefore examined the association in a population based cohort study. METHODS: We identified 5909 stroke patients who were admitted to stroke units in a Danish county between 2005 and 2010.The examined recommended processes of care included early admission to a stroke unit, early initiation of antiplatelet or anticoagulant therapy, early computed tomography/magnetic resonance imaging (CT/MRI) scan, early physiotherapy and occupational therapy, early assessment of nutritional risk, constipation risk and of swallowing function, early mobilization,early catheterization, and early thromboembolism prophylaxis.Hospital costs were assessed for each patient based on the number of days spent in different in-hospital facilities using local hospital charges. RESULTS: The mean costs of hospitalization were $23 352 (standard deviation 27 827). The relationship between receiving more relevant processes of early stroke care and lower hospital costs followed a dose­response relationship. The adjusted costs were $24 566 (95% confidence interval 19 364­29 769) lower for patients who received 75­100% of the relevant processes of care compared with patients receiving 0­24%. All processes of care were associated with potential cost savings, except for early catheterization and early thromboembolism prophylaxis. CONCLUSIONS: Early care in agreement with key guidelines recommendations for the management of patients with stroke may be associated with hospital savings.

Preadmission oral anticoagulant therapy and clinical outcome in patients hospitalised with acute stroke and atrial fibrillation.

INTRODUCTION: Information about the effect of preadmission oral anticoagulant therapy (OAT) on stroke outcome in patients with atrial fibrillation (AF) is scarce. A systematic review was done of the existing data on the association between preadmission OAT and stroke outcome in patients with AF. METHOD: We performed a systematic search in the PubMed Database, the Embase Database and the Cochrane Database of Systematic Reviews identifying 13 studies that met the inclusion criteria. RESULTS: The studies included a total of 18,523 patients with AF and admission with stroke. Of these, 1,169 had a haemorrhagic stroke. The proportion of patients in preadmission OAT varied from 5 to 37%, and the proportion who did not receive any antithrombotic therapy (AT) varied from 22 to 75%. The risk of having a severe stroke for patients with an international normalised ratio (INR) < 2 ranged from 26 to 43% compared with a 15-36% range for patients with an INR ≥ 2. The risk of death or disability among patients not receiving any AT ranged from 22 to 56% compared with 15-59% for those on platelet inhibitors, 16-48% for those on OAT with an INR < 2 and 6-37% among patients with an INR ≥ 2. These patterns were confirmed after adjustment for confounding factors. CONCLUSION: Only a minority of AF patients with stroke received OAT at the time of hospitalisation. Overall, preadmission OAT was associated with less severe strokes and a lower risk of death or disability. Further efforts seem warranted to ensure OAT for all eligible AF patients.