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.

Worth the trip? The effect of hospital clinic closures for patients undergoing scheduled surgery.

Recent decades' hospital closures and consolidations have been rationalized with reference to arguments of efficiency and quality returns to scale and scope. However, closures are met with public outcry from patients living in areas affected by such closures if accompanying increases in travel time are not offset by a higher quality of care. It is broadly established that increases in patients' travel time to acute care lower the probability of survival, but in non-acute and scheduled care we lack knowledge about the quality of care that patients living in closure-affected areas receive. In the non-acute setting of scheduled breast cancer surgery, this study examines how hospital clinic closures affect the quality of care that closure-affected patients receive. The effects are identified using closures of breast cancer clinics in Denmark from 2000 to 2011, during which time the number of clinics was more than halved. Using event study designs on population-wide Danish register data from 1996 to 2014, this study examine changes in surgical outcomes for 9790 patients living in municipalities where the nearest clinic has been closed. The results show that closures have reduced the number of hospitalization days and shifted surgical procedures to state-of-the-art breast-conserving techniques without generating adverse health effects and without causing crowding in non-closing clinics. An examination of the mechanisms suggests that added volume returns at non-closing clinics were of less importance than simply reallocating patients to higher-quality clinics. Closures of clinics performing scheduled surgery may be an effective policy instrument if the goal is to reduce variation in the delivery of hospital care. Increased access to state-of-the-art care may counterbalance patients' concerns of losing their local clinic. However, if the clinics to be closed are small compared to non-closing clinics then there is no potential for added economies of scale or scope in non-closing clinics.

National clinical guidelines and treatment centralization do not guarantee consistency in healthcare delivery. A mixed-methods study of wet age-related macular degeneration treatment in Denmark.

As clinical practice variation has been problematized as a symptom of suboptimal care and inefficient resource spending, consistency in the delivery of healthcare is a recurring policy goal. We examine a case where the introduction of a new treatment is most likely to provide consistency in healthcare delivery because it was introduced with a national clinical practice guideline representing consensus about best clinical practice among leading clinicians, and because care delivery was highly centralized to few high-volume treatment units. Despite the consensus on best clinical practice and care centralization, this study shows pronounced regional variation in patient outcomes and treatment costs that increased over time. Using a mixed-methods design, we find that the lack of consistency in care was largely unrelated to patient-specific characteristics, but seemed to reflect structural differences in the regional organization and financing of healthcare delivery. We conclude that the value of clinical practice guidelines is undermined when structural barriers limit the ability of clinicians and clinical managers to scale up treatment, and that some degree of decentralization may be a tool to maintain treatment intensity when the treatment effect is dependent on a high treatment intensity.

Ageing and health care expenditures: the importance of age per se, steepening of the individual-level expenditure curve, and the role of morbidity.

The demographic change towards a larger proportion of older individuals challenges universal health care systems in sustaining high-quality care and universal coverage without budget expansions. To build valuable predictions of the economic burden from population ageing, it is crucial to understand the determinants of individual-level health care expenditures. Often, the focus has been on the relative importance of an individual's age and time to death, while only a few newer studies highlight that individual-level health care expenditures are increasing faster for the elderly-i.e., creating a steepening of the individual-level health care expenditure curve over time. Applying individual-level administrative data for the entire Danish population, our study is the first to use a single data set to examine whether age, time to death, and a steepening of the individual-level health care expenditure curve all contributed to individual-level health care expenditures over a 12 year observation period (2006-2018). We find that individual-level expenditures are associated with an individual's age, an individual's time to death, and a steepening of the expenditure curve, with the steepening driven by individuals above age 75. We observe heterogeneity in the extent and age distribution of steepening across disease groups. The threefold combination of an ageing population, the correlation between expenditures and age per se, and a steepening of the expenditure curve make establishing financially sustainable universal health care systems increasingly difficult. To mitigate budgetary pressure, policy-makers should stimulate cost-effective medical advances and health care utilization in the treatment of elderly. Moreover, steepening scenarios should be added to future health care expenditure forecasts.

The importance of workplace accommodation for cancer survivors - The role of flexible work schedules and psychological help in returning to work.

We investigate whether accommodating job attributes influence the probability of returning to work three years after a cancer diagnosis. Using a combination of Danish administrative data and a survey carried out among Danish breast, colon, and melanoma skin cancer survivors, we find that the probability of returning to work is significantly and positively correlated with a flexible work schedule during and after cancer treatment. The result is robust when controlling for pre-cancer work experience, job seniority, pre-cancer job dissatisfaction, and post-cancer ability to work. Furthermore, we show that the influence of a flexible schedule varies with respect to cancer survivors' ability to work, level of education, and type of cancer.