Importance of GP contact on readmission rate following psychiatric acute care: A Danish Nationwide study.

Insufficient acute psychiatric care substantially impacts patient well-being and healthcare quality. Early readmissions after discharge from psychiatric care are common, and preventing these is important for the patients as well as appropriate resource allocation. The relationship between post-discharge general practitioner (GP) contact and readmission rates remains to be explored, as does the association between pre-hospital GP contact and post-discharge engagement. AIM: This study examines post-discharge GP contact and its association with outpatient revisits and inpatient readmissions among unplanned psychiatric hospital contacts, including the impact of pre-visit GP contact on post-discharge care within 14 days. METHODS: Utilizing data from the Danish healthcare system (2019-2023), unplanned psychiatric hospital contacts and subsequent 14-day GP encounters were analyzed. RESULTS: Of 298,085 unplanned psychiatric hospital contacts, 12.6% had a 14-day revisit as an outpatient and 13.6% had a 14-day readmission as an inpatient. During regular business hours, GP contact was associated with a decreased risk of unplanned outpatient revisits (HR 0.45, 95% CI 0.44-0.47) and inpatient readmissions (HR 0.43, 95% CI 0.41-0.44). Similarly, utilizing GP on-call services was linked to a reduced risk of unplanned revisits (HR 0.87, 95% CI 0.81-0.94) and readmissions (HR 0.81, 95% CI 0.76-0.87). Having a GP contact within two days before an unplanned psychiatric hospital contact increased the likelihood of having a GP contact within 14 days post-discharge. CONCLUSION: Post-discharge GP encounters were associated with lower rates of 14-day outpatient revisits and inpatient readmissions following unplanned psychiatric hospital contacts. GP contact before psychiatric hospital contact enhances attendance at post-discharge appointments, suggesting a potential efficacy of promoting GP appointments for mental health care.

Evaluating dynamic patterns in mortality before and after reconfiguration of the Danish emergency healthcare system.

BACKGROUND: This study explored changes in short-term mortality during a national reconfiguration of emergency care starting in 2007. METHODS: Unplanned hospital contacts at emergency departments across Denmark from 2007 to 2016. The reconfiguration was a natural experiment, resulting in individual timelines for each hospital. The outcome was in-hospital and 30-day mortality. RESULTS: Individual patient-level data included 9,745,603 unplanned hospital contacts from 2007 to 2016 at 20 hospitals with emergency departments. We observed a sharp downwards shift in in-hospital mortality and 30-day mortality in three hospitals in relation to the reconfiguration. CONCLUSION: This nationwide study identified three hospitals where the reconfiguration was closely associated with reduced in-hospital and 30-day mortality. In contrast, no major effects were identified for the remaining hospitals.

Utilisation and time to performance of diagnostic imaging in patients admitted to Danish emergency departments: a nationwide register-based study from 2007 to 2017.

OBJECTIVES: To describe the development of diagnostic imaging utilisation in Denmark from 2007 to 2017, coinciding with a major national reform of the emergency healthcare system. DESIGN: Nationwide descriptive register-based study. SETTING: All public hospitals in Denmark. PARTICIPANTS: All unplanned hospital contacts ≥18 years old at somatic hospitals in Denmark from 1 January 2007 to 31 December 2017. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the probability of having CT, X-ray, MRI or ultrasound performed during hospitalisation in 2017 compared with 2007. The secondary outcome measure was receiving diagnostic imaging within 4 hours of hospitalisation. RESULTS: The probability of having a radiological examination during unplanned hospital admission increased from 2007 to 2017 (CT: 3.5%-10.3%; MRI: 0.2%-0.8%; ultrasound: 2.3%-4.5%; X-ray: 23.8%-26.8%). For CT scan, the adjusted OR was 3.09 (95% CI: 2.73, 3.51); for MRI, the adjusted OR was 3.39 (95% CI: 1.87, 6.12) and for ultrasound, the adjusted OR was 1.93 (95% CI: 1.56, 2.38). The likelihood of having the examination within the first 4 hours in the hospital increased from 2007 to 2017. For X-ray, the adjusted OR was 1.39 (95% CI: 1.07, 1.56); for CT scan, the adjusted OR was 1.35 (95% CI: 1.16, 1.59); for MRI, the adjusted OR was 1.34 (95% CI: 1.09, 1.66) and for ultrasound, the adjusted OR was 1.38 (95% CI: 1.16, 1.64). CONCLUSION: This nationwide study describes the development of diagnostic imaging utilisation in Denmark from 2007 to 2017. The probability of receiving radiological examinations during unplanned hospitalisation increased over this period, and the time from hospital contact to performance decreased. This supports the notion that enhancement in radiological equipment will also lead to more frequent and faster utilisation.

Centralization of emergency hospital care is not associated with increased in-hospital mortality; a population-based cohort study.

BACKGROUND: We describe changes in the distance travelled, the utilization of emergency services, and the inhospital mortality before and after the centralization of hospital emergency services in Denmark. METHODS: All unplanned non-psychiatric hospital contacts from adults (aged ≥18 years) in 2008 and 2016 are included. Analyses are age-standardized and conducted at a municipality level. The municipalities are divided into groups according to the presence of emergency hospital services. RESULTS: Municipalities where hospitals with emergency services have been closed differed by having the most significant increase in distance travelled from 2008 to 2016. All groups experienced a reduction in overall in-hospital mortality. The reduction in mortality was not present for acute myocardial infarct contacts from municipalities where hospitals with emergency services have been closed. CONCLUSION: Our data do not suggest that hospital closures, and thereby increased travel distance, have contributed significantly as a barrier to emergency-care access and changes to in-hospital mortality.

The COVID-19 pandemic has not affected the mortality for patients admitted with pneumonia in Denmark.

During the COVID-19 pandemic, several hospital systems observed a reduction in patients with respiratory complaints. Using the Danish national registers, we conducted an observational study on disease severity and 30-day all-cause mortality for acutely admitted pneumonia patients before (3/19-3/20) and during (3/20-2/21) the pandemic. We calculated mortality rate ratios and Cox regression analyses. We identified 54,405 patients and during the pandemic, patients were older, more likely to be male, had more co-morbidity and a lower albumin on admission. Crude mortality was higher during the pandemic (8.4 vs. 6.9%). Adjusted hazard ratio for 30-day all-cause mortality was 1.07 (95%CI 1.01-1.14). We showed a small but significant, increase in mortality risk for patients admitted to hospital during the COVID-19 pandemic in Denmark.

Mortality before and after reconfiguration of the Danish hospital-based emergency healthcare system: a nationwide interrupted time series analysis.

OBJECTIVES: The study aimed to investigate how the 'natural experiment' of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. DESIGN: Hospital-based cohort study. SETTING: All public hospitals in Denmark. PARTICIPANTS: Patients with an unplanned contact from 1 January 2007 until 31 December 2016. INTERVENTIONS: Stepped-wedge reconfiguration of the Danish emergency healthcare system. MAIN OUTCOME MEASURES: We determined the adjusted ORs for in-hospital mortality and HRs for 30-day mortality using logistic and Cox regression analysis adjusted for sex, age, Charlson Comorbidity Index, income, education, mandatory referral and the changes in the out of hours system in the Capital Region. The main outcomes were stratified by the time of arrival. We performed subgroup analyses on selected diagnoses: myocardial infarction, stroke, pneumonia, aortic aneurysm, bowel perforation, hip fracture and major trauma. RESULTS: We included 11 367 655 unplanned hospital contacts. The adjusted OR for overall in-hospital mortality after reconfiguration of the emergency healthcare system was 0.998 (95% CI 0.968 to 1.010; p=0.285), and the adjusted OR for 30-day mortality was 1.004 (95% CI 1.000 to 1.008; p=0.045)). Subgroup analyses showed some possible benefits of the reconfiguration such as a reduction in-hospital and 30-day mortality for myocardial infarction, stroke, aortic aneurysm and major trauma. CONCLUSIONS: The Danish emergency care reconfiguration programme was not associated with an improvement in overall in-hospital mortality trends and was associated with a slight slowing of prior improvements in 30-day mortality trends.

Readmission trends before and after a national reconfiguration of emergency departments in Denmark.

OBJECTIVE: In order to achieve better and more efficient emergency health care, the Danish public hospital system has been reconfigured, with hospital emergency care being centralised into extensive and specialised emergency departments. This article examines how this reconfiguration has affected patient readmission rates. METHODS: We included all unplanned hospital admissions (aged ≥18 years) at public, non-psychiatric hospitals in four geographical regions in Denmark between 1 January 2007 and 24 December 2017. Using an interrupted time-series design, we examined trend changes in the readmission rates. In addition to analysing the overall effect, analyses stratified according to admission time of day and weekdays/weekends were conducted. The analyses were adjusted for patient characteristics and other system changes. RESULTS: The seven-day readmission rate increased from 2.6% in 2007 to 3.8% in 2017, and the 30-day rate increased from 8.1% to 11.5%. However, the rates were less than what they would have been had the reconfiguration not been introduced. The reconfiguration reduced the seven-day readmission rate by 1.4% annually (hazard ratio [CI 95%] 0.986 [0.981-0.991]) and the 30-day rate by 1% annually (hazard ratio [CI 95%] 0.99 [0.987-0.993]). CONCLUSIONS: Reconfiguration reduced the rate of increase in readmissions, but nevertheless readmissions still increased across the study period. It seems hospitals and policymakers will need to identify further ways to reduce patient loads.

Are 5-level triage systems improved by using a symptom based approach?-a Danish cohort study.

BACKGROUND: Five-level triage systems are being utilized in Danish emergency departments with and without the use of presenting symptoms. The aim of this study was to validate and compare two 5-level triage systems used in Danish emergency departments: "Danish Emergency Process Triage" (DEPT) based on a combination of vital signs and presenting symptoms and a locally adapted version of DEPT (VITAL-TRIAGE) using vital signs only. METHODS: This was a retrospective cohort using data from five Danish emergency departments. All patients attending an emergency department during the period of 1 April 2012 until 31 December 2015 were included. Validity of the two triage systems was assessed by comparing urgency categories determined by each triage system with critical outcomes: admission to Intensive care unit (ICU) within 24 h, 2-day mortality, diagnosis of critical illness, surgery within 48 h, discharge within 4 h and length of hospital stay. RESULTS: We included 632,196 ED contacts. Sensitivity for 24-h ICU admission was 0.79 (95% confidence interval 0.78-0.80) for DEPT and 0.44 (0.41-0.47) for VITAL-TRIAGE. The sensitivity for 2-day mortality was 0.69 (0.67-0.70) for DEPT and 0.37 (0.34-0.41) for VITAL-TRIAGE. The sensitivity to detect diagnoses of critical illness was 0.48 (0.47-0.50) for DEPT and 0.09 (0.08-0.10) for VITAL-TRIAGE. The sensitivity for predicting surgery within 48 h was 0.30 (0.30-0.31) in DEPT and 0.04 (0.04-0.04) in VITAL-TRIAGE. Length of stay was longer in VITAL-TRIAGE than DEPT. The sensitivity of DEPT to predict patients discharged within 4 h was 0.91 (0.91-0.92) while VITAL-TRIAGE was higher at 0.99 (0.99-0.99). The odds ratio for 24-h ICU admission and 2-day mortality was increased in high-urgency categories of both triage systems compared to low-urgency categories. CONCLUSIONS: High urgency categories in both triage systems are correlated with adverse outcomes. The inclusion of presenting symptoms in a modern 5-level triage system led to significantly higher sensitivity measures for the ability to predict outcomes related to patient urgency. DEPT achieves equal prognostic performance as other widespread 5-level triage systems.

Arterial blood gas analysis: as safe as we think? A multicentre historical cohort study.

PURPOSE: Arterial punctures (APs) for arterial blood gas (ABG) analyses are much-used medical procedures. To date, no large studies have been conducted on the major complication rate of APs. We aimed to describe the risk of major complications within 7 days after puncture and investigate whether using antithrombotic medication affected this. METHODS: We included all APs performed for ABG analysis at three Danish hospitals from January 1, 1993 to February 25, 2013. We excluded APs ordered by the anaesthesiology department, intensive care unit (ICU) or in patients <18 years old. Data on the patient level were extracted from the Danish National Patient Registry, Danish Civil Registration System and Odense Pharmaco-Epidemiologic Database (OPED), the latter providing us with information on antithrombotic medication. Initially, two clinicians compiled a list with all procedures and diagnoses that could possibly be a consequence of APs. The selected procedures and diagnoses were further categorised independently by three surgeons and used to indicate the complication rate. RESULTS: We analysed 473 327 APs and found 669 (0.14%, 95% CI 0.13-0.15) APs led to major complications: embolisms or thrombosis (49.0%), aneurysms (15.4%), nerve damage (1.5%), arteriovenous fistulas (0.6%) or of another kind (33.5%). The identified major complication rates in patients on antithrombotic medication were increased (OR 1.31, 95% CI 1.07-1.61). CONCLUSION: APs for ABG analyses are safe procedures. The major complication rate within 7 days was 0.14% (95% CI 0.13-0.15). Patients on antithrombotic medication carry an increased risk of developing major complications.

The effect of the March 2020 COVID-19 lockdown on national psychiatric contacts in Denmark: An interrupted time series analysis.

The COVID-19 pandemic resulted in national lockdowns in several countries. Previous global epidemics led to an increase in the number of psychiatric patients presenting symptoms of anxiety or depression. Knowledge about the impact of early lockdown initiatives during the COVID-19 pandemic on the number of healthcare interactions is sparse. Contacts in this study include all recorded face-to-face (FTF) and virtual treatment interactions between patients and healthcare systems. AIM: To investigate both the impact of the Danish lockdown event on psychiatric patients' contact with the healthcare system, stratified by type of contact (FTF or virtual) and ICD-10 diagnosis, and how acute contacts were impacted in the five regions in Denmark. METHODS: An interrupted time series analysis was applied to determine the effect of the COVID-19 lockdown event on the number of contacts with psychiatric hospitals in Denmark, from February 25, 2019 to May 3, 2020. The analyses took a Box-Jenkins approach to fit an autoregressive integrated moving average (ARIMA) model. RESULTS: Virtual contacts replaced most FTF contacts during the lockdown. For most patient groups, the total number of contacts did not decrease significantly. However, for adult patients diagnosed with ICD-10 F 0-10, 10-19, and 60-69 and child and adolescent patients diagnosed with F 10-19, 70-79, and 80-89, the number of contacts decreased during lockdown. The number of acute contacts with the psychiatric system decreased significantly in all regions in Denmark during lockdown. DISCUSSION: The Danish healthcare system was forced to introduce innovative tele-psychiatry to mental health care during the lockdown. Disruption to service delivery was minimized because the resources were in place to sustain the transition from FTF to virtual contacts.

Nationwide study on trends in unplanned hospital attendance and deaths during the 7 weeks after the onset of the COVID-19 pandemic in Denmark.

BACKGROUND: The impact of a pandemic on unplanned hospital attendance has not been extensively examined. The aim of this study is to report the nationwide consequences of the COVID-19 pandemic on unplanned hospital attendances in Denmark for 7 weeks after a 'shelter at home' order was issued. METHODS: We merged data from national registries (Civil Registration System and Patient Registry) to conduct a study of unplanned (excluding outpatient visits and elective surgery) hospital-based healthcare and mortality of all Danes. Using data for 7 weeks after the 'shelter at home' order, the incidence rate of unplanned hospital attendances per week in 2020 was compared with corresponding weeks in 2017-2019. The main outcome was hospital attendances per week as incidence rate ratios. Secondary outcomes were general population mortality and risk of death in-hospital, reported as weekly mortality rate ratios (MRRs). RESULTS: From 2 438 286 attendances in the study period, overall unplanned attendances decreased by up to 21%; attendances excluding COVID-19 were reduced by 31%; non-psychiatric by 31% and psychiatric by 30%. Out of the five most common diagnoses expected to remain stable, only schizophrenia and myocardial infarction remained stable, while chronic obstructive pulmonary disease exacerbation, hip fracture and urinary tract infection fell significantly. The nationwide general population MRR rose in six of the recorded weeks, while MRR excluding patients who were COVID-19 positive only increased in two. CONCLUSION: The COVID-19 pandemic and a governmental national 'shelter at home' order was associated with a marked reduction in unplanned hospital attendances with an increase in MRR for the general population in two of 7 weeks, despite exclusion of patients with COVID-19. The findings should be taken into consideration when planning for public information campaigns.

Intended and unintended changes in length of stay following reconfiguration of emergency care departments.

BACKGROUND: The Danish health-care system has witnessed noticeable changes in the acute hospital care organization. The reconfiguration includes closing hospitals, centralizing acute care functions and investing in new buildings and equipment. OBJECTIVE: To examine the impact on the length of stay (LOS) and the proportion of overnight stays for hospitalized acute care patients. METHODS: This nationwide interrupted time series examined trend changes in LOS and overnight stay. Admissions were stratified based on admission time (weekdays/weekends and time of day), age and the level of co-morbidity. RESULTS: In 2007-2016, the global average LOS declined 2.9% per year (adjusted time ratio [CI (confidence interval) 95%] 0.971 [0.970-0.971]). The reconfiguration was overall not associated with change in trend of LOS (time ratio [CI 95%] 1.001 [1.000-1.002]). When admissions were stratified for either weekdays or weekends, the reconfiguration was associated with reduction of the underlying downward trend for weekdays (time ratio [CI 95%] 1.004 [1.003-1.005]) and increased downward trend for weekend admissions (time ratio [CI 95%] 0.996 [0.094-0.098]). Admissions at night were associated with a 0.7% trend change in LOS (time ratio [CI 95%] 0.993 [0.991-0.996]). The reconfiguration was not associated with trend changes for overnight stays. CONCLUSION: The nationwide reconfiguration of acute hospital care was overall not associated with change in trend for the registered LOS and no change in trend for overnight stays. However, the results varied according to hospitalization time, where admissions during weekends and nights after the reconfiguration were associated with shortened LOS.

Healthcare inequality in compensation claims concerning acute hospital services: a Danish register-based study.

OBJECTIVE: Although citizens' equal right to acute healthcare of appropriate quality is an oft-cited goal for modern societies, healthcare disparities may persist. We aimed to investigate inequality in compensation claims and compensation payments regarding acute healthcare services. DESIGN AND SETTING: We conducted a cross-sectional study of compensation claim patterns using the Danish Patient Compensation Association (DPCA) registries. PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES: We used register data on all cases managed by DPCA relating to acute hospital healthcare for adults (aged > 18 years) from 2007 to 2017. RESULTS: In total, the DPCA had 5556 compensation claims for injuries caused by acute care services during the years 2007-2017. Age group of 50-64 years (odds ratio (OR) = 1.37 compared with those aged 18-49 years; P < 0.001), marriage (OR = 1.14; P < 0.001), higher income (OR = 1.55; P < 0.001) and Danish origin (OR = 1.49; P < 0.001) were statistically associated with higher odds for filing a compensation claim; men (OR = 0.83; P < 0.001) and those with many co-morbidities were much less represented (OR = 0.24; P < 0.001). Male gender (OR = 1.25; P < 0.001) and higher age (OR = 2.55 (80+ years); P < 0.001) were associated with higher odds for a compensation award. Failed diagnosis was also more often at stake in men (OR = 1.38; P < 0.001) and in patients aged 50-64 years (OR = 1.17; P < 0.001) but occurred less often in patients with multiple morbidities (OR = 0.68; P < 0.001). CONCLUSIONS: Findings from our Danish material suggest some inequality in compensation claims and compensation payments regarding acute healthcare services.

Increasing emergency hospital activity in Denmark, 2005-2016: a nationwide descriptive study.

OBJECTIVES: To describe changes in unplanned acute activity and to identify and characterise unplanned contacts in hospitals in Denmark from 2005 to 2016, including following healthcare reform. DESIGN: Descriptive study. SETTING: Data from Danish nationwide registers. POPULATION: Adults (≥18 years). PARTICIPANTS: All adults with an unplanned acute hospital contacts (acute inpatient admissions and emergency care visits) in Denmark from 2005 to 2016. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes were annual number of contacts, length of stay, number of contacts per 1000 citizen per year, age-adjusted contacts per 1000 citizens per year, sex, age groups, country of origin, Charlson Comorbidity Index score, discharge diagnosis and time of arrival. RESULTS: We included a total of 13 524 680 contacts. The annual number of acute hospital contacts increased from 1 067 390 in 2005 to 1 221 601 in 2016. The number also increased with adjustment for age per 1000 citizens. In addition, regional differences were observed. CONCLUSIONS: Unplanned acute activity changed from 2005 to 2016. The national number of contacts increased, primarily because of changes in one of the five regions.

Risk prediction in acute medical care: the potassium story.

The increased demand for secondary healthcare services has led to overflow in emergency departments and acute medical units throughout the world. And, as all patients therefore cannot be seen at once, most departments have introduced triage by experienced nurses at arrival. Triage is meant to predict time to be seen by a qualified healthcare professional and not - necessarily - to predict outcome.

An acute hospital admission greatly increases one year mortality - Getting sick and ending up in hospital is bad for you: A multicentre retrospective cohort study.

BACKGROUND: For most of the population a serious acute illness that require an emergency admission to hospital is a rare "once in a life time" event. This paper reports the one year mortality of patients admitted to hospital as acute emergencies compared to the general population. METHOD: This is a post-hoc retrospective multicentre cohort study of acutely admitted patients from October 2008 to December 2013 aged 40 or higher. It compares the observed one-year mortality of both acute medical and surgical patients with the overall mortality in the general population at comparable age bands. RESULTS: We included 18,375 patients and 4037 (22.0%) died within one year. For all age groups the one year mortality of those admitted to hospital for acute illness was markedly greater than for the general population. Although the odds ratio of death was highest in younger patients (e.g. odds ratio >20 for 40year olds), the absolute risk of death was greatest in the elderly (e.g. 20% mortality rate for men admitted to hospital over 65years of age, compared to 1.7% for the general population). DISCUSSION: Admission to hospital for an acute illness is associated with a greatly increased risk of death within a year and for many elderly patients may be a seminal event.

Modular Neck vs Nonmodular Femoral Stems in Total Hip Arthroplasty-Clinical Outcome, Metal Ion Levels, and Radiologic Findings.

BACKGROUND: Modular neck femoral stem (MNFS) for total hip arthroplasty (THA) was introduced to optimize the outcome, but created concerns about pain, elevated blood metal ion levels, and adverse reaction to metal debris such as pseudotumors (PTs), related to corrosion between femoral neck and stem. We compared these outcomes in patients with MNFS or nonmodular femoral stem (NFS) THA. METHODS: Thirty-three patients with unilateral MNFS THA were compared with 30 patients with unilateral NFS THA. Levels of pain, serum cobalt, serum chromium were determined. Magnetic resonance imaging was performed to describe PT and fatty atrophy of muscles. RESULTS: The MNFS and NFS group had a mean follow-up of 2.3 and 3.1 years, respectively. Four and 13 patients in the MNFS and NFS group had pain, respectively (P = .005). The MNFS group had higher levels of serum cobalt (P < .0001) and chromium (P = .006). PTs were present in both the MNFS (n = 15) and NFS (n = 7) groups (P = .066). PTs were related to serum cobalt (P = .04) but not to pain or serum chromium. Fatty atrophy prevalence in the piriformis and gluteal muscles were higher in patients with MNFS (P = .009 and P = .032, respectively). CONCLUSION: More patients in the NFS group had pain. Serum cobalt and chromium levels were higher in the MNFS group. Prevalence of PTs was twice as high in the MNFS group, but the difference was insignificant.