Oral anticoagulation therapy initiation in patients with atrial fibrillation in relation to world region of origin: a register-based nationwide study.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia and results in a high risk of stroke. The number of immigrants is increasing globally, but little is known about potential differences in AF care across migrant populations. AIM: To investigate if initiation of oral anticoagulation therapy (OAC) differs for patients with incident AF in relation to country of origin. METHODS: A nationwide register-based study covering 1999-2017. AF was defined as a first-time diagnosis of AF and a high risk of stroke. Stroke risk was defined according to guidelines from the European Society of Cardiology (ESC). Poisson regression adjusted for sex, age, socioeconomic position and comorbidity was made to compute incidence rate ratios (IRR) for initiation of OAC. RESULTS: The AF population included 254 586 individuals of Danish origin, 6673 of Western origin and 3757 of non-Western origin. Overall, OAC was initiated within -30/+90 days relative to the AF diagnosis in 50.3% of individuals of Danish origin initiated OAC, 49.6% of Western origin and 44.5% of non-Western origin. Immigrants from non-Western countries had significantly lower adjusted IRR of initiating OAC according to all ESC guidelines compared with patients of Danish origin. The adjusted IRRs ranged from 0.73 (95% CI: 0.66 to 0.80) following the launch of the 2010 ESC guideline to 0.89 (95% CI: 0.82 to 0.97) following the launch of the 2001 ESC guideline. CONCLUSION: Patients with AF with a high risk of stroke of non-Western origin have persistently experienced a lower chance of initiating OAC compared with patients of Danish origin during the last decades.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients.

BACKGROUND: Mobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability. METHOD: Following a pilot study, we developed a 4-level prehospital mobility score based of the question"How much help did the patient need to be mobilized to the ambulance trolley". Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020-May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics. RESULTS: We included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1). Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86). CONCLUSION: We developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers.

Incidence of atrial fibrillation and flutter in Denmark in relation to country of origin: a nationwide register-based study.

BACKGROUND: Atrial fibrillation and flutter (AF) is the most common sustained arrhythmia with an increasing prevalence in Western countries. However, little is known about AF among immigrants compared to non-immigrants. AIM: To examine the incidence of hospital-diagnosed AF according to country of origin. METHOD: Immigrants were defined as individuals born outside Denmark by parents born outside Denmark. AF was defined as first-time diagnosis of AF. All individuals were followed from the age of 45 years from 1998 to 2017. The analyses were adjusted for sex, age, comorbidity, contact with the general practitioner and socioeconomic variables. Adjustment was conducted using standardised morbidity ratio weights, standardised to the Danish population in a marginal structural model. RESULTS: The study population consisted of 3,489,730 Danish individuals free of AF and 108,914 immigrants free of AF who had emigrated from the 10 most represented countries. A total of 323,005 individuals of Danish origin had an incident hospital diagnosis of AF, among the immigrants 7,300 developed AF. Adjusted hazard rate ratios (HRRs) of AF for immigrants from Iran (0.48 [95%CI:0.35;0.64]), Turkey (0.74 [95%CI:0.67;0.82]) and Bosnia-Herzegovina (0.42 [95%CI:0.22;0.79]) were low compared with Danish individuals. Immigrants from Sweden, Germany and Norway had an adjusted HRR of 1.13 [95%CI:1.03;1.23], 1.12 [95%CI:1.05;1.18] and 1.11 [95%CI:1.03;1.21], respectively (Danish individuals as reference). CONCLUSIONS: Substantial variation in the incidence of hospital-diagnosed AF according to country of origin was observed. The results may reflect true biological differences but could also reflect barriers to AF diagnosis for immigrants. Further efforts are warranted to determine the underlying mechanisms.

Implication of Inflammatory Bowel Disease Diagnosed Before the Age of 18 for Achieving an Upper Secondary Education: A Nationwide Population-Based Cohort Study.

BACKGROUND: Educational achievement may be adversely affected by chronic conditions in childhood and adolescence. This study aimed to examine the effect of being diagnosed with IBD on achievement of an upper secondary education and the influence of disease severity and psychiatric comorbidity. METHODS: This cohort study was based on nationwide Danish administrative registries. We compared a cohort of patients with IBD with a matched population-based cohort. The IBD cohort included patients born between 1970 and 1994 who were diagnosed with IBD (age <18 years). The outcome was achieving an upper secondary education and was analyzed using Cox regression. The impact of disease severity (expressed by surgery or corticosteroid prescriptions) or psychiatric comorbidity within the IBD cohort was assessed using Poisson regression. RESULTS: We identified 3178 patients with IBD (Crohn's disease [CD] n = 1344, ulcerative colitis [UC] n = 1834) and matched them with 28 204 references. The hazard ratio of achieving an upper secondary education was 1.14 (95% confidence interval, 1.07-1.21) for CD and 1.16 (95% confidence interval, 1.10-1.23) for UC. In the IBD cohort, having surgery, a steroid prescription, or a comorbid psychiatric condition was associated with a lower chance of achieving an upper secondary education. CONCLUSION: Being diagnosed with IBD before 18 years of age increased the chance of achieving an upper secondary education. However, patients with more severe disease or psychiatric comorbidity were at higher risk of not achieving an upper secondary education than patients with milder disease.

A classification system for identifying patients dead on ambulance arrival: a prehospital medical record review.

BACKGROUND: Patients dead before arrival of the ambulance or before arrival at hospital may be in- or excluded in mortality analyses, making comparison of mortality difficult. Often only physicians are allowed to declare death, thereby impeding uniform registration of prehospital death. Many studies do not report detailed definitions of prehospital mortality. Our aim was to define criteria to identify and categorize prehospital patients' vital status, and to estimate the proportion of these groups, primarily the proportion of patients dead on ambulance arrival. METHODS: Prehospital medical records review for patients receiving an ambulance in the North Denmark Region from 2019 to 2021 and registered dead on the same or the following day. We defined three vital status categories: (1) Dead on Ambulance Arrival (DOAA), (2) Out-of-Hospital Cardiac Arrest (OHCA) divided into OHCA Basic Life Support (OHCA BLS) and OHCA Advanced treatment, and 3) Alive on Ambulance Arrival. RESULTS: Among 3 174 dead patients, DOAA constituted 28.8%, OHCA BLS 13.4%, OHCA Advanced treatment 31.3%, and Alive on Ambulance Arrival 26.6%. CONCLUSION: We defined exhaustive and mutually exclusive criteria to define vital status, DOAA, OHCA, and Alive on Ambulance Arrival based on prehospital medical records. More than one out of four patients receiving an ambulance and registered dead on the same or the following day were dead already at ambulance arrival. Adding OHCA BLS where resuscitation was terminated without defibrillation or other treatment, increased the proportion of patients dead on ambulance arrival to 42%. We recommend reporting similar categories of vital status to improve valid comparisons of prehospital mortality rates.

Long-Term Quality of Life After Out-of-Hospital Cardiac Arrest.

Importance: Allocating resources to increase survival after cardiac arrest requires survivors to have a good quality of life, but long-term data are lacking. Objective: To determine the quality of life of survivors of out-of-hospital cardiac arrest from 2001 to 2019. Design, Setting, and Participants: This survey study used the EuroQol Health Questionnaire, 12-Item Short Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) to assess the health-related quality of life of all adult survivors of out-of-hospital cardiac arrest included in the Danish Cardiac Arrest Registry between June 1, 2001, and August 31, 2019, who were alive in October 2020 (follow-up periods, 0-1, >1-2, >2-4, >4-6, >6-8, >8-10, >10-15, and >15-20 years since arrest). The survey was conducted from October 1, 2020, through May 31, 2021. Exposure: All patients who experienced an out-of-hospital cardiac arrest. Main Outcome and Measures: Self-reported health was measured using the EuroQol Health Questionnaire index (EQ index) score and EQ visual analog scale. Physical and mental health were measured using the SF-12, and anxiety and depression were measured using the HADS. Descriptive statistics were used for the analysis. Results: Of 4545 survivors, 2552 (56.1%) completed the survey, with a median follow-up since their event of 5.5 years (IQR, 2.9-8.9 years). Age was comparable between responders and nonresponders (median [IQR], 67 [58-74] years vs 68 [56-78] years), and 2075 responders (81.3%) were men and 477 (18.7%) women (vs 1473 male [73.9%] and 520 female [26.1%] nonresponders). For the shortest follow-up (0-1 year) and longest follow-up (>15-20 years) groups, the median EQ index score was 0.9 (IQR, 0.7-1.0) and 0.9 (0.8-1.0), respectively. For all responders, the mean (SD) SF-12 physical health score was 43.3 (12.3) and SF-12 mental health score, 52.9 (8.3). All 3 scores were comparable to a general Danish reference population. Based on HADS scores, a low risk for anxiety was reported by 73.0% (54 of 74) of 0- to 1-year survivors vs 89.3% (100 of 112) of greater than 15- to 20-year survivors; for symptoms of depression, these proportions were 79.7% (n = 59) and 87.5% (n = 98), respectively. Health-related quality of life was similar in survivor groups across all follow-up periods. Conclusions and Relevance: Among this survey study's responders, who comprised more than 50% of survivors of out-of-hospital cardiac arrest in Denmark, long-term health-related quality of life up to 20 years after their event was consistently high and comparable to that of the general population. These findings support resource allocation and efforts targeted to increasing survival after out-of-hospital cardiac arrest.

Time trends in income-related disparity in incidence of acute coronary syndrome.

BACKGROUND: Higher incidence of acute coronary syndrome (ACS), among those with lower income, has been recognized in the most recent decades. Still, there is a paucity of data on temporal changes. This study aims to investigate 20-year time trends in income-related disparity in the incidence of ACS in Denmark. METHODS: This Population-based repeated cross-sectional study included all patients with first-time ACS, aged ≥20 years, registered in the Danish National Patient Registry 1998-2017. Aggregated sociodemographic data for the Danish population was accessed from Statistics Denmark. Yearly incidence rates (IR) and incidence rate ratios (IRR), with the highest-income quartile as a reference, were standardized using cell-specific personal equivalent income according to year, sex and age group with 95% confidence intervals. Interaction analysis was executed for differences in IR of ACS between the lowest- and highest-income quartile over time. RESULTS: A total of 220 070 patients hospitalized with ACS from 1998 to 2017 were identified. The yearly standardized ACS IRs decreased in all income quartiles. However, the IR remained higher in the lowest-income quartile compared to the highest for both men [1998: IRR 1.45 (95% confidence interval, CI 1.39-1.52) and 2017: 1.47 (1.40-1.54)] and women [1998: IRR 1.73 (1.64-1.82) and 2017: 1.76 (1.65-1.88)]. Interaction analysis showed that over the period the difference in IR between the lower- and the highest-income quartile decreased with 1-5 ACS cases per 100 000 person-year. CONCLUSION: Income-related disparity in the incidence of ACS was present in Denmark between 1998 and 2017. Despite a marked overall decrease in the yearly ACS incidence, the extent of income-related disparity remained unchanged.

Increasing use of computed tomography scans in the North Denmark Region raises patient safety concern.

PURPOSE: Use of computed tomography (CT) scans raises safety concern as lifetime cumulative ionising radiation exposure is associated with risk of developing malignancies. This study aimed to investigate use of abdominal CT scans in the Danish health care sector. METHODS: Data on abdominal CT scans performed annually in the North Denmark Region between 2005 and 2018 were extracted from the regional registry with emphasis on patients with a medical history of a repeated abdominal CT scan within 28 days. An audit of the medical files was subsequently conducted in 100 randomly selected patient cases to evaluate clinical information being provided, in addition to justification for a repeated abdominal CT scan, and finally if other radiology modalities could have been applied. RESULTS: Number of annually performed abdominal CT scans in this demographically stable regional population increased by a factor 4.3 from 15 in 2005 to 65 in 2018 per 1,000 inhabitants. The audit revealed that 31% of the secondabdominal CT scans within a 28 days period were categorized as either doubtful whether justified or not justified. Moreover, 20% of theCT scans were considered replaceable by ultrasonography. CONCLUSIONS: Annual performance of abdominal CT scans increased fourfold during the 14 years period. This tendency is probably attributable to changes in the Danish health care sector by which CT scan examination are used more frequently aiming at more accelerated patient investigation flow in conjunction with shorter length of hospitalization stay. Alertness is strongly warranted towards the associated risk of cancer due to life-time cumulative ionising radiation exposure by this strategy.

Socioeconomic differences in expected discomfort from colonoscopy and colon capsule endoscopy.

Individual income and educational level are associated with participation rates in colorectal cancer screening. We aimed to investigate the expected discomfort from the endoscopic diagnostic modalities of colonoscopy and colon capsule endoscopy in different socioeconomic groups as a potential barrier for participation. In a randomized clinical trial within the Danish colorectal cancer screening program, we distributed questionnaires to 2031 individuals between August 2020 and December 2022 to investigate the expected procedural and overall discomfort from investigations using visual analogue scales. Socioeconomic status was determined by household income and educational level. Multivariate continuous ordinal regressions were performed to estimate the odds of higher expected discomfort. The expected procedural and overall discomfort from both modalities were significantly higher with increasing educational levels and income, except for procedural discomfort from colon capsule endoscopy between income quartiles. The odds ratios for higher expected discomfort increased significantly with increasing educational level, whereas the differences between income groups were less substantial. Bowel preparation contributed most to expected discomfort in colon capsule endoscopy, whereas in colonoscopy, the procedure itself was the largest contributor. Individuals with prior experiences of colonoscopy reported significantly lower expected overall but not procedural discomfort from colonoscopy. The threshold for acceptable discomfort between subgroups is unknown, but the expected discomfort in colon capsule endoscopy and colonoscopy was higher in higher socioeconomic subgroups, suggesting that expected discomfort is not a significant contributor to the inequalities in screening uptake.

Decision on non-conveyance of patients suspected of COVID-19 in a novel arrangement with assessment visits by paramedics at home.

BACKGROUND: During the first weeks of the outbreak of the coronavirus disease 2019 (COVID-19), the North Denmark emergency medical services authorised paramedics to assess patients suspected of COVID-19 at home, and then decide if conveyance to a hospital was required. The aim of this study was to describe the cohort of patients who were assessed at home and their outcomes in terms of subsequent hospital visits and short-term mortality. METHODS: This was a historical cohort study in the North Denmark Region with consecutive inclusion of patients suspected of COVID-19 who were referred to a paramedic's assessment visit by their general practitioner or an out-of-hours general practitioner. The study was conducted from 16 March to 20 May 2020. The outcomes were the proportion of non-conveyed patients who subsequently visited a hospital within 72 hours of the paramedic's assessment visit and mortality at 3, 7 and 30 days. Mortality was estimated using a Poisson regression model with robust variance estimation. RESULTS: During the study period, 587 patients with a median age of 75 (IQR 59-84) years were referred to a paramedic's assessment visit. Three of four patients (76.5%, 95% CI 72.8;79.9) were non-conveyed, and 13.1% (95% CI 10.2;16.6) of the non-conveyed patients were subsequently referred to a hospital within 72 hours of the paramedic's assessment visit. Within 30 days from the paramedic's assessment visit, mortality was 11.1% [95% CI 6.9;17.9] among patients directly conveyed to a hospital and 5.8% [95% CI 4.0;8.5] among non-conveyed patients. Medical record review revealed that deaths in the non-conveyed group had happened among patients with 'do-not-resuscitate' orders, palliative care plans, severe comorbidities, age ≥ 90 years or nursing home residents. CONCLUSIONS: The majority (87%) of the non-conveyed patients did not visit a hospital for the following three days after a paramedic's assessment visit. The study implies that this newly established prehospital arrangement served as a kind of gatekeeper for the region's hospitals in regard to patients suspected of COVID-19. The study also demonstrates that implementation of non-conveyance protocols should be accompanied by careful and regular evaluation to ensure patient safety.

Temporal trends in socioeconomic disparity in clinical outcomes for patients with acute coronary syndrome.

AIMS: Socioeconomic factors are well-established determinants of clinical outcomes among patients with acute coronary syndrome (ACS) although quality of care has improved the last decades. This study aims to investigate 20-years temporal trends of socioeconomic disparity in 1-year incidence of major adverse cardiac events (MACE) among ACS patients in Denmark. METHODS: This population-based cohort study included all incident ACS patients in the Danish National Patient Registry during 1998-2017. Socioeconomic disparity was assessed by income and educational level. Patients were followed 1-year for MACE; defined as all-cause mortality, recurrent ACS, revascularization, stroke, or cardiac arrest. Adjusted MACE incidence rates (aIR) and hazard rate ratios (aHR) were computed with 95 % confidence intervals (CI) for five-year-periods. Changes in trends were examined from interaction analyses between the HR for five-year-periods and income and education, respectively. RESULTS: The study included 220,887 patients with first-time ACS. The incidence of MACE decreased within all income and education levels. In 1998-2002 the MACE aIR among patients with low income was 885[95%CI:863-907] versus 733[711-756]/1000-person-year among those with high income (aHR: 1.19[95%CI:1.15-1.23]). The aIRs decreased to 506[489-522] and 405[388-423]/1000-person-year, respectively, in 2013-2017 (aHR: 1.23[1.17-1.29]). The aIRs of MACE decreased correspondingly within all educational levels from 1998 to 2002 to 2013-2017. However, the socioeconomic disparity according to the interaction analyses persisted both according to income and educational level. CONCLUSION: Although 1-year clinical outcomes following ACS has improved substantially over the last decades, socioeconomic disparity persisted both according to income and education level.

Socioeconomic inequalities in interval colorectal cancer are explained by differences in faecal haemoglobin concentration and age: a register-based cohort study.

OBJECTIVE: To estimate the risk of interval colorectal cancer (CRC) in faecal immunochemical test (FIT) negative screening participants according to socioeconomic status. DESIGN: In this register-based study, first round FIT negative (<20 µg hb/g faeces) screening participants (biennial FIT, citizens aged 50-74) were followed to estimate interval CRC risk. Multivariate Cox proportional hazard regression models estimated HRs based on socioeconomic status defined by educational level and income. Models were adjusted for age, sex and FIT concentration. RESULTS: We identified 829 (0.7‰) interval CRC in 1 160 902 individuals. Interval CRC was more common in lower socioeconomic strata with 0.7‰ for medium-long higher education compared with 1.0‰ for elementary school and 0.4‰ in the highest income quartile compared with 1.2‰ in the lowest. These differences did not translate into significant differences in HR in the multivariate analysis, as they were explained by FIT concentration and age. HR for interval CRC was 7.09 (95% CI) for FIT concentrations 11.9-19.8 µg hb/g faeces, and 3.37 (95% CI) for FIT between 7.2 and 11.8 compared with those <7.2. The HR rose with increasing age ranging from 2.06 (95% CI 1.45 to 2.93) to 7.60 (95% CI 5.63 to 10.25) compared with those under 55 years. CONCLUSION: Interval CRC risk increased with decreasing income, heavily influenced by lower income individuals more often being older and having increased FIT concentrations. Individualising screening interval based on age and FIT result, may decrease interval CRC rates, reduce the social gradient and thereby increase the screening efficiency.

Our Healthy Community Conceptual Framework and Intervention Model for Health Promotion and Disease Prevention in Municipalities.

This paper introduces the conceptual framework and intervention model of Our Healthy Community (OHC), a new, coordinated, and integrated approach towards health promotion and disease prevention in municipalities. The model is inspired by systems-based approaches and employs a supersetting approach for engaging stakeholders across sectors in the development and implementation of interventions to increase health and well-being among citizens. The conceptual model includes a combination of a bottom-up approach emphasizing involvement of citizens and other community-based stakeholders combined with a top-down approach emphasizing political, legal, administrative, and technical support from a variety of councils and departments in local municipality government. The model operates bidirectionally: (1) by pushing political and administrative processes to promote the establishment of conducive structural environments for making healthy choices, and (2) by involving citizens and professional stakeholders at all levels in co-creating processes of shaping their own community and municipality. An operational intervention model was further developed by the OHC project while working with the OHC in two Danish municipalities. The operational intervention model of OHC comprises three main phases and key actions to be implemented at the levels of local government and community: (1) Local government: Situational analysis, dialogue, and political priorities; (2) Community: Thematic co-creation among professional stakeholders; and (3) Target area: Intervention development and implementation. The OHC model will provide municipalities with new tools to improve the citizens' health and well-being with available resources. Health promotion and disease prevention interventions are developed, implemented, and anchored in the local community by citizens and local stakeholders at municipal and local community levels using collaboration and partnerships as leverage points.

The impact of single nucleotide polymorphisms on return-to-work after taxane-based chemotherapy in breast cancer.

PURPOSE: Breast cancer treatment is associated with adverse effects, which may delay return-to-work. Single nucleotide polymorphisms (SNPs) may influence the risk and severity of treatment toxicities, which in turn could delay return-to-work. We examined the association of 26 SNPs with return-to-work in premenopausal women with breast cancer. METHODS: Using Danish registries, we identified premenopausal women diagnosed with non-distant metastatic breast cancer during 2007‒2011, assigned adjuvant combination chemotherapy including cyclophosphamide and docetaxel. We genotyped 26 SNPs in 20 genes (ABCB1, ABCC2, ABCG2, CYP1A1, CYP1B1, CYP3A, CYP3A4, CYP3A5, GSTP1, SLCO1B1, SLCO1B3, ARHGEF10, EPHA4, EPHA5, EPHA6, EPHA8, ERCC1, ERCC2, FGD4 and TRPV1) using TaqMan assays. We computed the cumulative incidence of return-to-work (defined as 4 consecutive weeks of work) up to 10 years after surgery, treating death and retirement as competing events and fitted cause-specific Cox regression models to estimate crude hazard ratios (HRs) and 95% confidence intervals (CIs) of return-to-work. We also examined stable labor market attachment (defined as 12 consecutive weeks of work). RESULTS: We included 1,964 women. No associations were found for 25 SNPs. The cumulative incidence of return-to-work varied by CYP3A5 rs776746 genotype. From 6 months to 10 years after surgery, return-to-work increased from 25 to 94% in wildtypes (n = 1600), from 17 to 94% in heterozygotes (n = 249), and from 7 to 82% in homozygotes (n = 15). The HR showed delayed return-to-work in CYP3A5 rs776746 homozygotes throughout follow-up (0.48, 95% CI 0.26, 0.86), compared with wildtypes. Estimates were similar for stable labor market attachment. CONCLUSION: Overall, the SNPs examined in the study did not influence return-to-work or stable labor market attachment after breast cancer in premenopausal women. Our findings did suggest that the outcomes were delayed in homozygote carriers of CYP3A5 rs776746, though the number of homozygotes was low.

"I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction.

OBJECTIVES: Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers. METHODS: Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied. RESULTS: Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see". CONCLUSION: Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response. PRACTICE IMPLICATIONS: Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

Measuring Comprehensive, General Health Literacy in the General Adult Population: The Development and Validation of the HLS19-Q12 Instrument in Seventeen Countries.

BACKGROUND: For improving health literacy (HL) by national and international public health policy, measuring population HL by a comprehensive instrument is needed. A short instrument, the HLS19-Q12 based on the HLS-EU-Q47, was developed, translated, applied, and validated in 17 countries in the WHO European Region. METHODS: For factorial validity/dimensionality, Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM) were used. For discriminant validity, correlation analysis, and for concurrent predictive validity, linear regression analysis were carried out. RESULTS: The Cronbach alpha coefficients are above 0.7. The fit indices for the single-factor CFAs indicate a good model fit. Some items show differential item functioning in certain country data sets. The regression analyses demonstrate an association of the HLS19-Q12 score with social determinants and selected consequences of HL. The HLS19-Q12 score correlates sufficiently highly (r ≥ 0.897) with the equivalent score for the HLS19-Q47 long form. CONCLUSIONS: The HLS19-Q12, based on a comprehensive understanding of HL, shows acceptable psychometric and validity characteristics for different languages, country contexts, and methods of data collection, and is suitable for measuring HL in general, national, adult populations. There are also indications for further improvement of the instrument.

Prevalence and mortality among patients with COPD hospitalised by ambulance in the 2007-2018 period.

INTRODUCTION: Severe exacerbations in chronic obstructive pulmonary disease (COPD) may require acute medical attention by calling the emergency medical services (EMS) for an ambulance. The 30-day mortality for EMS patients with respiratory diseases appears to have stagnated, which may be due to changes in age, comorbidity or disease severity. We examined trends of occurrence, severity and mortality for EMS patients with COPD. METHODS: A historical population-based cohort study was conducted encompassing patients with COPD who requested an ambulance in the North Denmark Region in the 2007-2018 period. We described acute severity by oxygen saturation and respiratory rate at the arrival of the ambulance along with comorbidity and duration of hospitalisation. RESULTS: A total of 5,969 EMS patients with COPD were identified and the figure nearly doubled from 2007 to 2018. Age and comorbidity were higher in the last part of the period. Furthermore, the initial respiratory rate was higher, oxygen saturation was lower and the duration of hospitalisation was lower in the last part of the period. The 30-day mortality rose from 12.6% to 15.4%, but the odds ratio was not statistically higher and decreased after adjustment. CONCLUSIONS: COPD constituted increasing proportions of those admitted to hospital after calling the EMS. The mortality among EMS patients with COPD may be due to patients being older, having more comorbidities or being more severely acutely ill. The mortality suggests that COPD patients requesting an ambulance should be considered severely ill. FUNDING: none. TRIAL REGISTRATION: not relevant.

Symptoms reported in calls to emergency medical services within 24 hours prior to out-of-hospital cardiac arrest.

AIM: There is limited evidence regarding prodromal symptoms of out-of-hospital cardiac arrest (OHCA). We aimed to describe patient characteristics, prodromal symptoms, and prognosis of patients contacting emergency medical services (EMS) within 24 hours before OHCA. METHODS: We identified all OHCA treated by Copenhagen EMS from 2016 through 2018 using the Danish Cardiac Arrest Registry and linked them to emergency calls. We included all pre-arrest calls by patients or bystanders if they were performed 1) within 24 hours before the OHCA call or 2) during the OHCA event for EMS-witnessed OHCA. Calls were reviewed by healthcare professionals using a survey guide. RESULTS: Among 4,071 patients, 481 patients (12 %) had 539 calls within 24 hours prior to OHCA (60 % male, median age 74 years of age). The patient spoke on the phone in 25 % of calls. The most common symptoms were breathing problems (59 %), confusion (23 %), unconsciousness (20 %), chest pain (20 %), and paleness (19 %). Patients with breathing problems compared to chest pain were more likely to be ≤ 75 years of age (55 % versus 35 %), less likely to be male (52 % versus 73 %), have shockable rhythm (10 % versus 38 %), receive bystander defibrillation (6 % versus 19 %) or EMS defibrillation (15 % versus 65 %), achieve return of spontaneous circulation (37 % versus 68 %) and survive 30 days following OHCA (10 % versus 50 %). CONCLUSION: More than 10% of patients with OHCA had a call to EMS within 24 hours before OHCA. The most common symptom was breathing problems which compared to chest pain had lower 30-day survival.

Use of the least intrusive coercion at Danish psychiatric wards: A register-based cohort study of 131,632 first and subsequent coercive episodes within 35,812 admissions.

OBJECTIVE: Psychiatric legislation in Denmark implies a principle of using the least intrusive types of coercion first. The intrusiveness is not universally agreed upon. We examined the order in which coercive measures during admission were used, implying that the first used should be less intrusive than the following types. METHODS: For coercive episodes reported to the national administrative register for the period 2011-16, the order of 12 legal coercive interventions during each admission was examined. Comparing with mechanical restraint, the odds ratio (OR) and confidence interval (95%CI) of being first or subsequent used types were estimated using conditioned (96,611 episodes) and unconditioned (131,632 episodes) logistic regression models, stratified on sex. RESULTS: Totally 17,796 patients aged 18+ were subjected to at least one coercive episode. The median time between admission and the first episode was 4 days in men and 6 for women. For females, involuntary detention, forced feeding, coercive treatment of somatic disorder, locking of doors and close observations in females were used before mechanical restraint, and forced follow-up, involuntary electro convulsive therapy (ECT), forced treatment, use of gloves and straps, physical restraint and forced intramuscular medication was used later. In men, only involuntary detention was used before mechanical restraint, while involuntary ECT, close observations, administration of drugs, use of gloves and straps, physical restraint and forced intramuscular medication was used after mechanical restraint. CONCLUSION: The order of used coercive measures is not consistent with the international ranking of the least intrusive types, especially in men and in younger adults.

Validation of retail food outlet data from a Danish government inspection database.

BACKGROUND: Globally, unhealthy diet is one of the leading global risks to health, thus it is central to consider aspects of the food environment that are modifiable and may enable healthy eating. Food retail data can be used to present and facilitate analyses of food environments that in turn may direct strategies towards improving dietary patterns among populations. Though food retail data are available in many countries, their completeness and accuracy differ. METHODS: We applied a systematically name-based procedure combined with a manual procedure on Danish administrative food retailer data (i.e. the Smiley register) to identify, locate and classify food outlets. Food outlets were classified into the most commonly used classifications (i.e. fast food, restaurants, convenience stores, supermarkets, fruit and vegetable stores and miscellaneous) each divided into three commonly used definitions; narrow, moderate and broad. Classifications were based on branch code, name, and/or information on the internal and external appearance of the food outlet. From ground-truthing we validated the information in the register for its sensitivity and positive predictive value. RESULTS: In 361 randomly selected areas of the Capital region of Denmark we identified a total of 1887 food outlets compared with 1861 identified in the register. We obtained a sensitivity of 0.75 and a positive predictive value of 0.76. Across classifications, the positive predictive values varied with highest values for the moderate and broad definitions of fast food, convenience stores and supermarkets (ranging from 0.89 to 0.97). CONCLUSION: Information from the Smiley Register is considered to be representative to the Danish food environment and may be used for future research.