A comparison of the original major depression inventory with a modified version: A Danish validation study.

BACKGROUND: The Major Depression Inventory (MDI) is a patient-reported outcome measure used by general practitioners to assist with diagnosing and evaluation of the severity of a patient's depression. However, recent studies have questioned the structural validity of the MDI. OBJECTIVES: We proposed a modified version (mMDI) of the MDI with fewer response categories and four rephrased items and aimed to compare the psychometric properties of the changes in a joint cohort of patients from general practice and mental health associations. METHODS: We used Rasch analysis, confirmatory factor analysis, and the area under the receiver operating curve (AUROC) to assess the validity and reliability of the two versions. Equipercentile linking was used to compute cut-off points for the mMDI. RESULTS: For both versions, local dependence was found between the three item pairs (loss of interest, lack of energy), (lack of self-confidence, feelings of guilt), and (concentration problems, feeling restless/slowed down). The mMDI displayed lower measurement error in the upper end of the scale and better item level fit for three of the four reformulated items compared to the MDI. For the MDI, 5.3% of the respondents gave improbable responses; the corresponding number was 3.4% for the mMDI. The mMDI displayed better fit to a one-factor model compared to the MDI. When comparing the correlation of the scales with the WHO-5 instrument, the corresponding AUROC estimates for the mMDI and MDI were found to be 0.93 (0.92; 0.96) and 0.91 (0.87; 0.94), respectively. The cut-off points for mild, moderate, and severe depression in the mMDI were found to be 17, 20, and 23, respectively. CONCLUSION: The proposed changes of the MDI are psychometrically sound upgrades of the original.

Psychiatric disorders and the cancer diagnostic process in general practice: a combined questionnaire and register study exploring the patients' experiences in Denmark.

OBJECTIVE: Patients with psychiatric disorders are at risk of experiencing suboptimal cancer diagnostics and treatment. This study investigates how this patient group perceives the cancer diagnostic process in general practice. DESIGN: Cross-sectional study using questionnaire and register data. SETTING: General practice in Denmark. SUBJECTS: Patients diagnosed with cancer in late 2016 completed a questionnaire about their experiences with their general practitioner (GP) in the cancer diagnostic process (n = 3411). Information on pre-existing psychiatric disorders was obtained from register data on psychiatric hospital contacts and primary care treated psychiatric disorders through psychotropic medications. Logistic regression was used to analyse the association between psychiatric disorders and the patients' experiences. MAIN OUTCOME MEASURES: Patients' experiences, including cancer worry, feeling being taken seriously, and the perceived time between booking an appointment and the first GP consultation.[Box: see text]. RESULTS: A total of 13% of patients had an indication of a psychiatric disorder. This group more often perceived the time interval as too short between the first booking of a consultation and the first GP consultation. Patients with primary care treated psychiatric disorders were more likely to worry about cancer at the first presentation and to share this concern with their GP compared with patients without psychiatric disorders. We observed no statistically significant association between patients with psychiatric disorders and perceiving the waiting time to referral from general practice, being taken seriously, trust in the GP's abilities, and the patients' knowledge of the process following the GP referral. CONCLUSION: The patients' experiences with the cancer diagnostic process in general practice did not vary largely between patients with and without psychiatric disorders. Worrying about cancer may be a particular concern for patients with primary care treated psychiatric disorders.

It is unknown how patients with psychiatric disorders perceive the cancer diagnostic process in general practice.This study found an association between having a psychiatric disorder and more often perceiving the time interval as too short between the first booking of a consultation and the first GP consultation.An association was found between having a primary care treated psychiatric disorder and being worried about cancer and more often sharing these concerns with the GP.Experiences with the cancer diagnostic process in general practice did not differ between patients with a hospital treated psychiatric disorder and patients with no indication of psychiatric disorders.

Association between Mental Disorders and Subsequent Medical Conditions.

BACKGROUND: Persons with mental disorders are at a higher risk than the general population for the subsequent development of certain medical conditions. METHODS: We used a population-based cohort from Danish national registries that included data on more than 5.9 million persons born in Denmark from 1900 through 2015 and followed them from 2000 through 2016, for a total of 83.9 million person-years. We assessed 10 broad types of mental disorders and 9 broad categories of medical conditions (which encompassed 31 specific conditions). We used Cox regression models to calculate overall hazard ratios and time-dependent hazard ratios for pairs of mental disorders and medical conditions, after adjustment for age, sex, calendar time, and previous mental disorders. Absolute risks were estimated with the use of competing-risks survival analyses. RESULTS: A total of 698,874 of 5,940,299 persons (11.8%) were identified as having a mental disorder. The median age of the total population was 32.1 years at entry into the cohort and 48.7 years at the time of the last follow-up. Persons with a mental disorder had a higher risk than those without such disorders with respect to 76 of 90 pairs of mental disorders and medical conditions. The median hazard ratio for an association between a mental disorder and a medical condition was 1.37. The lowest hazard ratio was 0.82 for organic mental disorders and the broad category of cancer (95% confidence interval [CI], 0.80 to 0.84), and the highest was 3.62 for eating disorders and urogenital conditions (95% CI, 3.11 to 4.22). Several specific pairs showed a reduced risk (e.g., schizophrenia and musculoskeletal conditions). Risks varied according to the time since the diagnosis of a mental disorder. The absolute risk of a medical condition within 15 years after a mental disorder was diagnosed varied from 0.6% for a urogenital condition among persons with a developmental disorder to 54.1% for a circulatory disorder among those with an organic mental disorder. CONCLUSIONS: Most mental disorders were associated with an increased risk of a subsequent medical condition; hazard ratios ranged from 0.82 to 3.62 and varied according to the time since the diagnosis of the mental disorder. (Funded by the Danish National Research Foundation and others; COMO-GMC ClinicalTrials.gov number, NCT03847753.).

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study.

BACKGROUND: Patients with multimorbidity are frequent users of healthcare, but fragmented care may lead to suboptimal treatment. Yet, this has never been examined across healthcare sectors on a national scale. We aimed to quantify care fragmentation using various measures and to analyze the associations with patient outcomes. METHODS: We conducted a register-based nationwide cohort study with 4.7 million Danish adult citizens. All healthcare contacts to primary care and hospitals during 2018 were recorded. Clinical fragmentation indicators included number of healthcare contacts, involved providers, provider transitions, and hospital trajectories. Formal fragmentation indices assessed care concentration, dispersion, and contact sequence. The patient outcomes were potentially inappropriate medication and all-cause mortality adjusted for demographics, socioeconomic factors, and morbidity level. RESULTS: The number of involved healthcare providers, provider transitions, and hospital trajectories rose with increasing morbidity levels. Patients with 3 versus 6 conditions had a mean of 4.0 versus 6.9 involved providers and 6.6 versus 13.7 provider transitions. The proportion of contacts to the patient's own general practice remained stable across morbidity levels. High levels of care fragmentation were associated with higher rates of potentially inappropriate medication and increased mortality on all fragmentation measures after adjusting for demographic characteristics, socioeconomic factors, and morbidity. The strongest associations with potentially inappropriate medication and mortality were found for ≥ 20 contacts versus none (incidence rate ratio 2.83, 95% CI 2.77-2.90) and ≥ 20 hospital trajectories versus none (hazard ratio 10.8, 95% CI 9.48-12.4), respectively. Having less than 25% of contacts with your usual provider was associated with an incidence rate ratio of potentially inappropriate medication of 1.49 (95% CI 1.40-1.58) and a mortality hazard ratio of 2.59 (95% CI 2.36-2.84) compared with full continuity. For the associations between fragmentation measures and patient outcomes, there were no clear interactions with number of conditions. CONCLUSIONS: Several clinical indicators of care fragmentation were associated with morbidity level. Care fragmentation was associated with higher rates of potentially inappropriate medication and increased mortality even when adjusting for the most important confounders. Frequent contact to the usual provider, fewer transitions, and better coordination were associated with better patient outcomes regardless of morbidity level.

Multimorbidity and determinants for initiating outpatient trajectories: A population-based study.

INTRODUCTION: Individuals with multimorbidity often receive high numbers of hospital outpatient services in concurrent trajectories. Nevertheless, little is known about factors associated with initiating new hospital outpatient trajectories; identified as the continued use of outpatient contacts for the same medical condition. PURPOSE: To investigate whether the number of chronic conditions and sociodemographic characteristics in adults with multimorbidity is associated with entering a hospital outpatient trajectory in this population. METHODS: This population-based register study included all adults in Denmark with multimorbidity on January 1, 2018. The exposures were number of chronic conditions and sociodemographic characteristics, and the outcome was the rate of starting a new outpatient trajectory during 2018. Analyses were stratified by the number of existing outpatient trajectories. We used Poisson regression analysis, and results were expressed as incidence rates and incidence rate ratios with 95% confidence intervals. We followed the individuals during the entire year of 2018, accounting for person-time by hospitalization, emigration, and death. RESULTS: Incidence rates for new outpatient trajectories were highest for individuals with low household income and ≥3 existing trajectories and for individuals with ≥3 chronic conditions and in no already established outpatient trajectory. A high number of chronic conditions and male gender were found to be determinants for initiating a new outpatient trajectory, regardless of the number of existing trajectories. Low educational level was a determinant when combined with 1, 2, and ≥3 existing trajectories, and increasing age, western ethnicity, and unemployment when combined with 0, 1, and 2 existing trajectories. CONCLUSION: A high number of chronic conditions, male gender, high age, low educational level and unemployment were determinants for initiation of an outpatient trajectory. The rate was modified by the existing number of outpatient trajectories. The results may help identify those with multimorbidity at greatest risk of having a new hospital outpatient trajectory initiated.

Analysis of mortality metrics associated with a comprehensive range of disorders in Denmark, 2000 to 2018: A population-based cohort study.

BACKGROUND: The provision of different types of mortality metrics (e.g., mortality rate ratios [MRRs] and life expectancy) allows the research community to access a more informative set of health metrics. The aim of this study was to provide a panel of mortality metrics associated with a comprehensive range of disorders and to design a web page to visualize all results. METHODS AND FINDINGS: In a population-based cohort of all 7,378,598 persons living in Denmark at some point between 2000 and 2018, we identified individuals diagnosed at hospitals with 1,803 specific categories of disorders through the International Classification of Diseases-10th Revision (ICD-10) in the National Patient Register. Information on date and cause of death was obtained from the Registry of Causes of Death. For each of the disorders, a panel of epidemiological and mortality metrics was estimated, including incidence rates, age-of-onset distributions, MRRs, and differences in life expectancy (estimated as life years lost [LYLs]). Additionally, we examined models that adjusted for measures of air pollution to explore potential associations with MRRs. We focus on 39 general medical conditions to simplify the presentation of results, which cover 10 broad categories: circulatory, endocrine, pulmonary, gastrointestinal, urogenital, musculoskeletal, hematologic, mental, and neurologic conditions and cancer. A total of 3,676,694 males and 3,701,904 females were followed up for 101.7 million person-years. During the 19-year follow-up period, 1,034,273 persons (14.0%) died. For 37 of the 39 selected medical conditions, mortality rates were larger and life expectancy shorter compared to the Danish general population. For these 37 disorders, MRRs ranged from 1.09 (95% confidence interval [CI]: 1.09 to 1.10) for vision problems to 7.85 (7.77 to 7.93) for chronic liver disease, while LYLs ranged from 0.31 (0.14 to 0.47) years (approximately 16 weeks) for allergy to 17.05 (16.95 to 17.15) years for chronic liver disease. Adjustment for air pollution had very little impact on the estimates; however, a limitation of the study is the possibility that the association between the different disorders and mortality could be explained by other underlying factors associated with both the disorder and mortality. CONCLUSIONS: In this study, we show estimates of incidence, age of onset, age of death, and mortality metrics (both MRRs and LYLs) for a comprehensive range of disorders. The interactive data visualization site (https://nbepi.com/atlas) allows more fine-grained analysis of the link between a range of disorders and key mortality estimates.

Routes to cancer diagnosis for patients with pre-existing psychiatric disorders: a nationwide register-based cohort study.

BACKGROUND: Poor cancer prognosis has been observed in patients with pre-existing psychiatric disorders. Therefore, we need better knowledge about the diagnosis of cancer in this patient group. The aim of the study was to describe the routes to cancer diagnosis in patients with pre-existing psychiatric disorders and to analyse how cancer type modified the routes. METHODS: A register-based cohort study was conducted by including patients diagnosed with incident cancer in 2014-2018 (n = 155,851). Information on pre-existing psychiatric disorders was obtained from register data on hospital contacts and prescription medication. Multinomial regression models with marginal means expressed as probabilities were used to assess the association between pre-existing psychiatric disorders and routes to diagnosis. RESULTS: Compared to patients with no psychiatric disorders, the population with a psychiatric disorder had an 8.0% lower probability of being diagnosed through cancer patient pathways initiated in primary care and a 7.6% higher probability of being diagnosed through unplanned admissions. Patients with pre-existing psychiatric disorders diagnosed with rectal, colon, pancreatic, liver or lung cancer and patients with schizophrenia and organic disorders were less often diagnosed through cancer patient pathways initiated in primary care. CONCLUSION: Patients with pre-existing psychiatric disorders were less likely to be diagnosed through Cancer Patient Pathways from primary care. To some extent, this was more pronounced among patients with cancer types that often present with vague or unspecific symptoms and among patients with severe psychiatric disorders. Targeting the routes by which patients with psychiatric disorders are diagnosed, may be one way to improve the prognosis among this group of patients.

Statins and Risk of Intracerebral Hemorrhage in Individuals With a History of Stroke.

Background and Purpose- It has been suggested that statins increase the risk of intracerebral hemorrhage in individuals with a history of stroke, which has led to a precautionary principle of avoiding statins in patients with prior intracerebral hemorrhage. However, such prescribing reticence may be unfounded and potentially harmful when considering the well-established benefits of statins. This study is so far the largest to explore the statin-associated risk of intracerebral hemorrhage in individuals with prior stroke. Methods- We conducted a population-based, propensity score-matched cohort study using information from Danish national registers. We included all individuals initiating statin treatment after a first-time stroke diagnosis (intracerebral hemorrhage, N=2728 or ischemic stroke, N=52 964) during 2002 to 2016. For up to 10 years of follow-up, they were compared with a 1:5 propensity score-matched group of statin nonusers with the same type of first-time stroke. The difference between groups was measured by adjusted hazard ratios for intracerebral hemorrhage calculated by type of first-time stroke as a function of time since statin initiation. Results- Within the study period, 118 new intracerebral hemorrhages occurred among statin users with prior intracerebral hemorrhage and 319 new intracerebral hemorrhages in users with prior ischemic stroke. The risk of intracerebral hemorrhage was similar for statin users and nonusers when evaluated among those with prior intracerebral hemorrhage, and it was reduced by half in those with prior ischemic stroke. These findings were consistent over time since statin initiation and could not be explained by concomitant initiation of other medications, by dilution of treatment effect (due to changes in exposure status over time), or by healthy initiator bias. Conclusions- This large study found no evidence that statins increase the risk of intracerebral hemorrhage in individuals with prior stroke; perhaps the risk is even lower in the subgroup of individuals with prior ischemic stroke.

General practitioners' management of patients with psychological stress: audit results from Denmark.

BACKGROUND: In western countries, psychological stress is among the most common causes of long-lasting sick leave and a frequent reason to consult the general practitioner (GP). This study aimed to investigate how GPs manage patients with psychological stress and how the management is associated with the patient's sex, the GP's assessment of causality, and coexisting mental disorders. METHODS: We conducted an audit of consecutive cases in Danish general practice. The GPs used electronic medical records to fill in a registration form for each 18-65-year-old patient with whom they had had at least one consultation regarding stress during the past 6 months. Only patients initially in the workforce were included. Age- and sex-adjusted binary regression was applied. RESULTS: Fifty-six GPs (61% women) identified 785 cases. The patients' mean age was 44 years and 70% were women. The cause of stress was considered at least partially work-related in 69% of the cases and multifactorial in a third of cases. The management included sick leave (54%), counselling (47%), pharmaceutical treatment (37%), and referral to psychologist (38%). Compared to women, stress in men was less often considered work-related (RR: 0.84, CI95%: 0.77-0.92) and men were less often sick-listed (RR: 0.83 CI95%: 0.73-0.96) but were more often prescribed tranquilizers (RR: 1.72 CI95%: 1.08-2.74). CONCLUSIONS: GPs' management of patients with stress usually involve elements of counselling, sick leave, referral to psychologist, and medication. Women and men with stress are perceived of and managed differently.

Prevalence of persons contacting general practice for psychological stress in Denmark.

OBJECTIVE: The prevalence of psychological stress has previously been estimated based on self-reported questionnaires. This study aimed to investigate the prevalence of persons who contact the general practitioner (GP) for psychological stress and to explore associations between psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. DESIGN: Cross-sectional computer assisted journal audit. SETTING: General practice in the Region of Southern Denmark. SUBJECTS: Patients aged 18-65 years with a consultation during a six-month period that was classified with a stress-related diagnosis code. MAIN OUTCOME MEASURES: Six months prevalence of GP-assessed psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. RESULTS: Fifty-six GPs (7% of the invited) identified 1066 patients considered to have psychological stress among 51,422 listed patients. Accordingly, a 2.1% six months prevalence of psychological stress was estimated; 69% of cases were women. High prevalence of psychological stress was associated with female sex, age 35-54 years, high education level and low population density in the municipality, but not with unemployment in the municipality or household income in the postal district. GP female sex and age <50 years, few GPs in the practice and few patients per GP were also associated with a higher prevalence of psychological stress. CONCLUSIONS: A total of 2% of the working-age population contacted the GP during a six-month period for psychological stress. The prevalence of psychological stress varies with age, sex and characteristics of both the regional area and the GP. Key points Psychological stress is a leading cause of days on sick leave, but its prevalence has been based on population surveys rather than on assessment by health care professionals. • This study found that during six months 2.1% of all working-age persons have at least one contact with the GP regarding psychological stress. • The six months prevalence of psychological stress was associated with patient age and sex, GP age and sex, practices' number of GPs and patients per GP, and area education and urbanization level.

Does perceived stress increase the risk of atrial fibrillation? A population-based cohort study in Denmark.

BACKGROUND: Psychological stress is associated with increased risk of acute cardiovascular diseases, as myocardial infarction. We recently found a higher risk of atrial fibrillation following an acute stressful life event, but it remains unknown whether this also applies to common and less acute stress exposures. METHODS: We investigated the risk of incident atrial fibrillation in people with high levels of perceived stress by following a population-based cohort of 114,337 participants from the Danish National Health Survey from 2010 to 2014. The survey holds information on lifestyle factors and perceived stress measured by Cohen's 10-item Perceived Stress Scale (PSS). We obtained information on atrial fibrillation, comorbidities and socioeconomic status from Danish nationwide registers. We identified 2172 persons with a first episode of atrial fibrillation during 424,839 person-years of follow-up. The hazard ratio (HR) of atrial fibrillation with 95% confidence interval (CI) was calculated with Cox proportional hazard model. RESULTS: The risk of atrial fibrillation increased with increasing PSS score; persons in the highest perceived stress quintile had 28% (95% CI, 12%-46%) higher risk of atrial fibrillation compared with persons in the lowest perceived stress quintile. However, the association disappeared when adjusting for comorbidities, socioeconomic status and lifestyle factors; HR was 1.01 (95% CI, 0.88-1.16) when comparing persons in the highest and the lowest perceived stress quintile. CONCLUSIONS: This large population-based cohort study did not reveal a higher risk of atrial fibrillation among persons with a high degree of perceived stress after adjustment for participants' baseline characteristics.

Perceived Stress, Multimorbidity, and Risk for Hospitalizations for Ambulatory Care-sensitive Conditions: A Population-based Cohort Study.

BACKGROUND: Psychiatric disorders are associated with an increased risk for ambulatory care-sensitive condition (ACSC)-related hospitalizations, but it remains unknown whether this holds for individuals with nonsyndromic stress that is more prevalent in the general population. OBJECTIVES: To determine whether perceived stress is associated with ACSC-related hospitalizations and rehospitalizations, and posthospitalization 30-day mortality. RESEARCH DESIGN AND MEASURES: Population-based cohort study with 118,410 participants from the Danish National Health Survey 2010, which included data on Cohen's Perceived Stress Scale, followed from 2010 to 2014, combined with individual-level national register data on hospitalizations and mortality. Multimorbidity was assessed using health register information on diagnoses and drug prescriptions within 39 condition categories. RESULTS: Being in the highest perceived stress quintile was associated with a 2.13-times higher ACSC-related hospitalization risk (95% CI, 1.91, 2.38) versus being in the lowest stress quintile after adjusting for age, sex, follow-up time, and predisposing conditions. The associated risk attenuated to 1.48 (95% CI, 1.32, 1.67) after fully adjusting for multimorbidity and socioeconomic factors. Individuals with above reference stress levels experienced 1703 excess ACSC-related hospitalizations (18% of all). A dose-response relationship was observed between perceived stress and the ACSC-related hospitalization rate regardless of multimorbidity status. Being in the highest stress quintile was associated with a 1.26-times insignificantly increased adjusted risk (95% CI, 0.79, 2.00) for ACSC rehospitalizations and a 1.43-times increased adjusted risk (95% CI, 1.13, 1.81) of mortality within 30 days of admission. CONCLUSIONS: Elevated perceived stress levels are associated with increased risk for ACSC-related hospitalization and poor short-term prognosis.

The Association Between Perceived Stress and Mortality Among People With Multimorbidity: A Prospective Population-Based Cohort Study.

Multimorbidity is common and is associated with poor mental health and high mortality. Nevertheless, no studies have evaluated whether mental health may affect the survival of people with multimorbidity. We investigated the association between perceived stress and mortality in people with multimorbidity by following a population-based cohort of 118,410 participants from the Danish National Health Survey 2010 for up to 4 years. Information on perceived stress and lifestyle was obtained from the survey. We assessed multimorbidity using nationwide register data on 39 conditions and identified 4,229 deaths for the 453,648 person-years at risk. Mortality rates rose with increasing levels of stress in a dose-response relationship (P-trend < 0.0001), independently of multimorbidity status. Mortality hazard ratios (highest stress quintile vs. lowest) were 1.51 (95% confidence interval (CI): 1.25, 1.84) among persons without multimorbidity, 1.39 (95% CI: 1.18, 1.64) among those with 2 or 3 conditions, and 1.43 (95% CI: 1.18, 1.73) among those with 4 or more conditions, when adjusted for disease severities, lifestyle, and socioeconomic status. The numbers of excess deaths associated with high stress were 69 among persons without multimorbidity, 128 among those with 2 or 3 conditions, and 255 among those with 4 or more conditions. Our findings suggested that perceived stress contributes significantly to higher mortality rates in a dose-response pattern, and more stress-associated deaths occurred in people with multimorbidity.

Contact with general practice in patients with suspected chronic coronary syndrome before and after CT angiography compared with the general population.

BACKGROUND: Most patients undergoing coronary computed tomography angiography (CCTA) to diagnose coronary artery disease (CAD) are referred from general practitioners (GPs). The burden of contacts to GP in relation to investigation of suspected CAD is unknown. METHODS AND RESULTS: All patients undergoing CCTA in Western Denmark from 2014 to 2022 were included. CCTA stenosis was defined as diameter stenosis of ≥50%. Patients with and without stenosis were matched, in each group, 1:5 to a reference population based on birth year, gender, and municipality using data from national registries. All GP visits were registered up to 5 years preceding and 1 year after the CTA and stratified by gender and age. Charlson comorbidity index (CCI) was calculated in all groups.Of the 62 512 patients included, 12 886 had a stenosis, while 49 626 did not. Patients in both groups had a substantially higher GP visit frequency compared with reference populations. In the year of coronary CTA, the median GP contacts in patients with stenosis were 11 (6-17) vs. 6 (2-11) in the reference population (P < 0.001), and in patients without stenosis, the median GP contacts were 10 (6-17) vs. 5 (2-11) (P < 0.001). These findings were consistent across age and gender. CCI was higher among both patients with and without stenosis compared with reference groups. CONCLUSION: In patients undergoing CCTA to diagnose CAD, a substantially increased frequency of contacts to GP was observed in the 5-year period prior to examination compared with the reference populations, regardless of the CCTA findings. Obtaining the CCTA result did not seem to substantially affect the GP visit frequency.

The Effect of Coordinating the Outpatient Treatment across Medical Specialities for Patients With Multimorbidity.

Introduction: Patients with multimorbidity attend multiple outpatient clinics. We assessed the effects on hospital use of scheduling several outpatient appointments to same-day visits in a multidisciplinary outpatient pathway (MOP). Methods: This study used a quasi-experimental design. Eligible patients had multimorbidity, were aged ≥18 years and attended ≥2 outpatient clinics in five different specialties. Patients were identified through forthcoming appointments from August 2018 to March 2020 and divided into intervention group (alignment of appointments) and comparison group (no alignment). We used patient questionnaires and paired analyses to study care integration and treatment burden. Using negative binomial regression, we estimated healthcare utilisation as incidence rates ratios (IRRs) at one year before and one year after baseline for both groups and compared IRR ratios (IRRRs). Results: Intervention patients had a 19% reduction in hospital visits (IRRR: 0.81, 95% CI: 0.70-0.96) and a 17% reduction in blood samples (IRRR: 0.83, 0.73-0.96) compared to comparison patients. No effects were found for care integration, treatment burden, outpatient contacts, terminated outpatient trajectories, hospital admissions, days of admission or GP contacts. Conclusion: The MOP seemed to reduce the number of hospital visits and blood samples. These results should be further investigated in studies exploring the coordination of outpatient care for multimorbidity. Research question: Can an intervention of coordinating outpatient appointments to same-day visits combined with a multidisciplinary conference influence the utilisation of healthcare services and the patient-assessed integration of healthcare services and treatment burden among patients with multimorbidity?

Effectiveness of an adaptive, multifaceted intervention to enhance care for patients with complex multimorbidity in general practice: protocol for a pragmatic cluster randomised controlled trial (the MM600 trial).

INTRODUCTION: Patients with complex multimorbidity face a high treatment burden and frequently have low quality of life. General practice is the key organisational setting in terms of offering people with complex multimorbidity integrated, longitudinal, patient-centred care. This protocol describes a pragmatic cluster randomised controlled trial to evaluate the effectiveness of an adaptive, multifaceted intervention in general practice for patients with complex multimorbidity. METHODS AND ANALYSIS: In this study, 250 recruited general practices will be randomly assigned 1:1 to either the intervention or control group. The eligible population are adult patients with two or more chronic conditions, at least one contact with secondary care within the last year, taking at least five repeat prescription drugs, living independently, who experience significant problems with their life and health due to their multimorbidity. During 2023 and 2024, intervention practices are financially incentivised to provide an extended consultation based on a patient-centred framework to eligible patients. Control practices continue care as usual. The primary outcome is need-based quality of life. Outcomes will be evaluated using linear and logistic regression models, with clustering considered. The analysis will be performed as intention to treat. In addition, a process evaluation will be carried out and reported elsewhere. ETHICS AND DISSEMINATION: The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its most recent form and good clinical practice recommendations, as well as the regulation for informed consent. The study was submitted to the Danish Capital Region Ethical Committee (ref: H-22041229). As defined by Section 2 of the Danish Act on Research Ethics in Research Projects, this project does not constitute a health research project but is considered a quality improvement project that does not require formal ethical approval. All results from the study (whether positive, negative or inconclusive) will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05676541.

Variation in Psychometric Testing in General Practice - A Nationwide Cohort Study.

Objective: Most mental disorders are diagnosed and treated in general practice. Psychometric tests may help the general practitioner diagnose and treat mental disorders like dementia, anxiety, and depression. However, little is known about the use of psychometric tests in general practice and their impact on further treatment. We aimed to assess the use of psychometric tests in Danish general practice and to estimate whether variation in use is associated with the provided treatment and death by suicide in patients. Methods: This nationwide cohort study included registry data on all psychometric tests performed in Danish general practice in 2007-2018. We used Poisson regression models adjusted for sex, age, and calendar time to assess predictors of use. We used fully adjusted models to estimate the standardized utilization rates for all general practices. Results: A total of 2,768,893 psychometric tests were used in the study period. Considerable variations were observed among general practices. A positive association was seen between a general practitioner's propensity to use psychometric testing and talk therapy. Patients listed with a general practitioner with low use had an increased rate of redeemed prescriptions for anxiolytics [incidence rate ratio (95% confidence interval):1.39 (1.23;1.57)]. General practitioners with high use had an increased rate of prescriptions for antidementia drugs [1.25 (1.05;1.49)] and first-time antidepressants [1.09 (1.01;1.19)]. High test use was seen for females [1.58 (1.55; 1.62)] and patients with comorbid diseases. Low use was seen for populations with high income [0.49 (0.47; 0.51)] and high educational level [0.78 (0.75; 0.81)]. Conclusion: Psychometric tests were used mostly for women, individuals with a low socioeconomic status, and individuals with comorbid conditions. The use of psychometric tests depends on general practice and is associated with talk therapy, redemptions for anxiolytics, antidementia drugs, and antidepressants. No association was found between general practice rates and other treatment outcomes.

Temporal capital and unaligned times as inequality mechanisms: A case study of chronic care in general practice.

Addressing persistent health inequality is one of the most critical challenges in public health. Structural features of 'time' may provide new perspectives on the link between social inequality and time in a healthcare context. Drawing on the case of chronic care in Danish general practice, we aim to use temporal capital as a theoretical frame to unfold how patients' social positions are interlinked with their medical treatment. We followed patients with multimorbidity and polypharmacy in general practice. Data were collected from interviews, observations, informal conversations, and medical records. We used the concept temporal capital to illuminate the mechanism of inequality in healthcare. We suggest understanding temporal capital as patients' abilities and possibilities to understand, navigate, negotiate, and manage the temporal rhythms of healthcare. Unaligned times, i.e. the mismatch between patients' temporal capital and healthcare organisations and/or professionals' rhythms, are unfolded in five themes: unaligned schedules (scheduling the consultation to fit everyday life and institutional rhythms and attending the consultation), sequences (preparing activities in a specific order to accommodate clinical linearity), agendas (timing the agenda to the clinical workflow), efficiency (ensuring efficiency in the consultation and balancing on-task and off-task content), and pace (conducting the consultation to accommodate fixed durations). Differences in temporal capital and hence abilities and possibilities for aligning with the temporal rhythms of healthcare may be facilitated or restrained by the individual patient's social position, thereby defining and establishing temporal mechanisms of social inequality in medical treatment. In conclusion, social inequality in medical treatment has several temporal references, resulting from pre-existing inequalities and causing new ones. Notions of temporal capital and temporal unalignment provide a useful lens for exploring social inequality in healthcare encounters.

Definition and delimitation of multimorbidity.

Multimorbidity is often defined as two or more long-term conditions, the definition may, however, vary. This review summarises various definitions of multimorbidity. The prevalence of multimorbidity in Denmark is between 7% and 29% depending on data sources and definition and is increasing with age; nonetheless most patients with multimorbidity are of working age. Several multimorbidity indices have been developed for research purposes, but with no clinical consensus. The concept of complex multimorbidity adds psychosocial context and health-care patterns to better describe the group of patients with multimorbidity having the highest needs.

Multi-morbid patients with co-existing mental and physical illness.

This review investigates the mortality gap that exists between people with or people without mental illness. Poor physical health is the leading cause of excess mortality among people with mental illness. Mental disorders increase the risk of developing a broad range of physical diseases and the risk of death caused by somatic diseases is increased. Also, mental disorder is associated with less optimal treatment in the somatic healthcare system, which is also evident within a broad spectrum of somatic diseases. The role of structural factors such as the design of the healthcare system and stigma are developing.