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.

Does systematic analysis of patient complaints and compensation cases at hospitals provide useful information to guide quality improvement? Experience from Denmark.

BACKGROUND: Patient complaints and compensation cases are analysed individually and do not allow for organisational learning. Systematic information on complaint patterns needs evidence-based measures. The Healthcare Complaints Analysis Tool (HCAT) can systematically code and analyse complaints and compensation claims, but whether this information is useful for quality improvement is underexplored. We aim to explore if and how HCAT information is perceived useful to inform healthcare quality gaps. METHODS: To explore the HCAT's usefulness for quality improvement purposes, we used an iterative process. We accessed all complaints relating to a large university hospital. Trained HCAT raters systematically coded all cases, using the Danish version of HCAT. INTERVENTION: The intervention had four phases: (1) coding of cases, (2) education, (3) selection of HCAT analyses for dissemination, (4) 'dashboard' development and delivery of targeted HCAT reports. To study the interventions and phases, we used quantitative and qualitative approaches. The coding patterns were descriptively displayed on department and hospital level. The educational programme was monitored using passing rates, coding reliability checks and rater feedback. Online interviews recorded dissemination feedback. We used a phenomenological approach with thematised quotations from the interviews to analyse the usefulness of the information from cases coded. RESULTS: We coded 5217 complaint cases (11 056 complaint points). The average case coding time was 8.5 min (95% CI 8.2 to 8.7). All four raters passed the online test with >80% correct answers. Using rater feedback, we handled 25 cases of doubt. None affected the HCAT structure or categories. Interviews verified the usefulness of analyses after expert group dissemination. Three themes were important: 'overview of complaints', 'learning from complaints' and 'listening to the patients'. Stakeholders perceived the 'dashboard' development as highly relevant. CONCLUSION: Through the development process with several adjustments, stakeholders found the systematic approach useful for quality improvement. The hospital management evaluated the approach as promising and decided to test the approach in clinical practice.