Accreditation and clinical outcomes: shorter length of stay after first-time hospital accreditation in the Faroe Islands.

BACKGROUND: The aim of accreditation is to improve quality of care and patient safety. However, studies on the effectiveness of accreditation on clinical outcomes are limited and inconsistent. Comparative studies have contrasted accredited with non-accredited hospitals or hospitals without a benchmark, but assessments of clinical outcomes of patients treated at hospitals undergoing accreditation are sparse. The Faroe Islands hospitals were accredited for the first time in 2017, making them an ideal place to study the impact of accreditation. OBJECTIVE: We aimed to investigate the association between first-time hospital accreditation and length of stay (LOS), acute readmission (AR) and 30-day mortality in the unique situation of the Faroe Islands. METHODS: We conducted a before and after study based on medical record reviews in relation to first-time accreditation. All three Faroese hospitals were voluntarily accredited using a modified second version of the Danish Healthcare Quality Programme encompassing 76 standards. We included inpatients 18 years or older treated at a Faroese hospital with one of six clinical conditions (stroke/transient ischemic attack (TIA), bleeding gastic ulcer, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture) in 2012-2013 designated 'before accreditation'or 2017-2018' after accreditation'. The main outcome measures were LOS, all-cause AR and all-cause 30-day mortality. We computed adjusted cause-specific hazard rate (HR) ratios using Cox Proportional Hazard regression with before accreditation as reference. The analyses were controlled for age, sex, cohabitant status, in-hospital rehabilitation, type of admission, diagnosis and cluster effect at patient and hospital levels. RESULTS: The mean LOS was 13.4 days [95% confidence interval (95% CI): 10.8, 15.9] before accreditation and 7.5 days (95% CI: 6.10, 8.89) after accreditation. LOS of patients hospitalized after accreditation was significantly shorter [overall, adjusted HR = 1.23 (95% CI: 1.04, 1.46)]. By medical condition, only women in childbirth had a significantly shorter LOS [adjusted HR = 1.30 (95% CI: 1.04, 1.62)]. In total, 12.3% of inpatients before and 9.5% after accreditation were readmitted acutely within 30 days of discharge, and 30-day mortality was 3.3% among inpatients before and 2.8% after accreditation, respectively. No associations were found overall or by medical condition for AR [overall, adjusted HR = 1.34 (95% CI: 0.82, 2.18)] or 30-day mortality [overall, adjusted HR = 1.33 (95% CI: 0.55, 3.21)]) after adjustment for potential confounding factors. CONCLUSION: First-time hospital accreditation in the Faroe Islands was associated with a significant reduction in LOS, especially of women in childbirth. Notably, shorter LOS was not followed by increased AR. There was no evidence that first-time accreditation lowered the risk of AR or 30-day mortality.

The association between first-time accreditation and the delivery of recommended care: a before and after study in the Faroe Islands.

BACKGROUND: Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives. METHODS: We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012-2013 (before accreditation) or 2017-2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score. RESULTS: We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: - 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10). CONCLUSION: Hospitals were in general more likely to provide recommended care after first-time accreditation.

Consecutive cycles of accreditation and quality of in-hospital care: a Danish population-based study.

BACKGROUND: Little is known about whether repeated cycles of hospital accreditation are a robust method to improve quality of care continuously. OBJECTIVE: We aimed to examine the association between compliance with consecutive cycles of accreditation and quality of in-hospital care. METHODS: We conducted a Danish nationwide population-based study including patients aged 18 years treated for acute stroke, chronic obstructive pulmonary disease, diabetes, heart failure or hip fracture at public, non-psychiatric hospitals. From 2012 to 2015, two cycles of national hospital accreditation were completed, resulting in 12 high and 14 low compliant hospitals (Low = partially accredited in both cycles). Our outcome measure was quality of in-hospital care measured by 39 process performance measures (PPMs), reflecting recommendations from the national clinical guidelines by adherence to (i) individual PPMs and (ii) the full bundle of PPMs (all-or-none). We computed adjusted odds ratios (ORs) using logistic regression based on robust standard error estimation for cluster sampling of data at hospital level. RESULTS: In total, 78 387 patient pathways covering 508 816 processes were included, of which 47% had been delivered at high compliant hospitals and 53% at low compliant hospitals, respectively. Compliance with consecutive cycles was not associated with improved quality of in-hospital care (individual: OR = 0.92, 95% confidence interval (CI): 0.77-1.10; All-or-none: OR = 0.87, 95% CI: 0.66-1.15). However, in the second cycle alone, patients treated at partially accredited hospitals had a lower adherence than patients treated at fully accredited hospitals (Individual: OR = 0.84, 95% CI: 0.71-0.99; All-or-none: OR = 0.78, 95% CI: 0.59-1.03). The association was particularly strong among patients treated at partially accredited hospitals required to submit additional documentation. CONCLUSION: Compliance with consecutive cycles of hospital accreditation in Denmark was not associated with improved quality of in-hospital care. However, compliance with the second cycle alone was associated with improved quality of in-hospital care.

Patients experience more support, information and involvement after first-time hospital accreditation: a before and after study in the Faroe Islands.

BACKGROUND: The impact of hospital accreditation on the experiences of patients remains a weak point in quality improvement research. This is surprising given the time and cost of accreditation and the fact that patient experiences influence outcomes. We investigated the impact of first-time hospital accreditation on patients' experience of support from health-care professionals, information and involvement in decisions. OBJECTIVE: We aimed to examine the association between first-time hospital accreditation and patient experiences. METHODS: We conducted a longitudinal study in the three Faroese hospitals that, unlike hospitals on the Danish mainland and elsewhere internationally, had no prior exposure to systematic quality improvement. The hospitals were accredited in 2017 according to a modified second version of the Danish Healthcare Quality program. Study participants were 18 years or older and hospitalized for at least 24 h in 2016 before or 2018 after accreditation. We administered the National Danish Survey of Patient Experiences for acute and scheduled hospitalization. Patients rated their experiences of support, information and involvement in decision-making on a 5-point Likert scale. We calculated individual and grouped mean item scores, the percentages of scores ≥4, the mean score difference, the relative risk (RR) for high/very high scores (≥4) using Poisson regression and the risk difference. Patient experience ratings were compared using mixed effects linear regression. RESULTS: In total, 400 patients before and 400 after accreditation completed the survey. After accreditation patients reported increased support from health professionals; adjusted mean score difference (adj. mean diff.) = 1.99 (95% confidence interval (CI): 1.89, 2.10), feeling better informed before and during the hospitalization; adj. mean diff. = 1.14 (95% CI: 1.07; 1.20) and more involved in decision-making; adj. mean diff. = 1.79 (95% CI: 1.76; 1.82). Additionally, the RR for a high/very high score (≥4) was significantly greater on 15 of the 16 questionnaire items. The greatest RR for a high/very high score (≥4) after accreditation, was found for the item 'Have you had a dialogue with the staff about the advantages and disadvantages of the examination/treatment options available?'; RR= 5.73 (95% CI: 4.51, 7.27). CONCLUSION: Hospitalized patients experienced significantly more support from health professionals, information and involvement in decision-making after accreditation. Future research on accreditation should include the patients' perspective.

Incidence of hypothyroidism after treatment for breast cancer-a Danish matched cohort study.

BACKGROUND: Breast cancer survivors (BCS) may have increased risk of hypothyroidism, but risk according to treatment modality is unclear. We estimated the incidence of hypothyroidism in women with breast cancer, and according to cancer treatment. METHODS: Using nationwide registries, we identified all Danish women aged ≥ 35 years diagnosed with non-metastatic breast cancer (1996-2009). We matched up to five cancer-free women (controls) for each BCS. We excluded women with prevalent thyroid disease. Cancer treatment was chemotherapy with or without radiotherapy (RT) targeting the breast/chest wall only, or also the lymph nodes (RTn). We identified hypothyroidism using diagnostic codes, and/or levothyroxine prescriptions. We calculated the cumulative incidence, incidence rates (IR) per 1000 person-years, and used Cox regression to estimate hazard ratios (HR) and associated 95% confidence intervals (CIs) of hypothyroidism, adjusting for comorbidities. RESULTS: We included 44,574 BCS and 203,306 matched controls with 2,631,488 person-years of follow-up. BCS had a slightly higher incidence of hypothyroidism than controls [5-year cumulative incidence, 1.8% (95%CI = 1.7-1.9) and 1.6% (95%CI = 1.5-1.6), respectively]. The overall IR was 4.45 (95%CI = 4.25-4.67) and 3.81 (95%CI = 3.73-3.90), corresponding to an adjusted HR = 1.17 (95%CI = 1.11-1.24). BCS who received RTn with chemotherapy (HR = 1.74, 95%CI = 1.50-2.02) or without chemotherapy (HR = 1.31, 95%CI = 1.14-1.51) had an elevated risk of hypothyroidism compared with matched controls and compared with BCS who underwent surgery alone [HR = 1.71, 95%CI = 1.45-2.01 and HR = 1.36, 95%CI = 1.17-1.58, respectively]. CONCLUSIONS: BCS have an excess risk of hypothyroidism compared with age-matched controls. BCS and those working in cancer survivorship settings ought to be aware that this risk is highest in women treated with radiation therapy to the lymph nodes and chemotherapy.

Hypothyroidism and the risk of breast cancer recurrence and all-cause mortality - a Danish population-based study.

BACKGROUND: Hypothyroidism may occur as a late effect of breast cancer-directed treatment, particularly after radiotherapy, but little is known whether hypothyroidism affects the prognosis after breast cancer. We investigated the association between hypothyroidism and breast cancer recurrence, and all-cause mortality. METHODS: In this population-based cohort study, we used national medical registries to identify all Danish women 35 years or older diagnosed with stage I-III, operable breast cancer between 1996 and 2009. Hypothyroidism was defined as hospital diagnoses ascertained via diagnostic codes, or as prescriptions for levothyroxine. Two analytic models were used: (i) hypothyroidism present at the time of the breast cancer diagnosis (prevalent) and (ii) hypothyroidism diagnosed during follow-up as a time-varying exposure lagged by 1 year (incident). Breast cancer recurrence was defined as any local, regional, or distant recurrence or contralateral breast cancer. All-cause mortality included death from any cause in any setting. We used Cox regression models accounting for competing risks to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of breast cancer recurrence and all-cause mortality. RESULTS: The study cohort included 35,463 women with breast cancer with 212,641 person-years of follow-up. At diagnosis, 1272 women had hypothyroidism and 859 women developed hypothyroidism during follow-up. In total, 5810 patients developed recurrent breast cancer. Neither prevalent nor incident hypothyroidism was associated with breast cancer recurrence (adjusted HRprevalent 1.01, 95% CI 0.87-1.19; adjusted HRincident 0.93, 95% CI 0.75-1.16, respectively). Furthermore, no differences were seen for all-cause mortality for prevalent or incident hypothyroidism (adjusted HRprevalent 1.02, 95% CI 0.92-1.14, and HRincident 1.08, 95% CI 0.95-1.23, respectively). Stratification by menopausal status, oestrogen receptor status, chemotherapy, or radiotherapy did not alter the estimates. CONCLUSIONS: Hypothyroidism present at diagnosis or during follow-up was not associated with breast cancer recurrence or all-cause mortality in women with breast cancer. Our findings provide reassurance to patients and their physicians that hypothyroidism is unlikely to impact on the clinical course of breast cancer or survival.

Consecutive cycles of hospital accreditation: Persistent low compliance associated with higher mortality and longer length of stay.

OBJECTIVE: To examine the association between compliance with consecutive cycles of accreditation and patient-related outcomes. DESIGN: A Danish nationwide population-based study from 2012 to 2015. SETTING: In-patients admitted with one of the 80 diagnoses at public, non-psychiatric hospitals. PARTICIPANTS: In-patients admitted with one of 80 primary diagnoses which accounted for 80% of all deaths occuring within 30 dyas after admission. INTERVENTION: Admission to a hospital with high (n = 125 485 in-patients) or low compliance (n = 152 074 in-patients) in both cycles of accreditation by the Danish Healthcare Quality Programme. MAIN OUTCOME MEASURES: A 30-day mortality, length of stay (LOS) and all-cause acute readmission. We computed adjusted odds ratios (OR) and hazard ratios (HR) using logistic and Cox Proportional Hazard regression including adjustment for six potential patient-related confounders. RESULTS: The 30-day mortality risk for in-patients admitted at high compliant hospitals was 3.95% (95% confidence interval (CI): 3.84-4.06) and 4.39% (95% CI: 4.29-4.49) at low compliant hospitals. In-patients admitted at low compliant hospitals had a substantially higher risk of dying within 30-day after admission (adjusted OR: 1.26 (95% CI: 1.11-1.43) and a longer LOS (adjusted HR of discharge: 0.89 (95% CI: 0.82-0.95) than in-patients at high compliant hospitals. No difference was seen for acute readmission (adjusted HR: 0.98 (95% CI: 0.90-1.06)). Focusing on the second cycle alone, in-patients at partially accredited hospitals had a higher 30-day mortality risk and longer LOS than admissions at fully accredited hospitals (30-day: adjusted OR: 1.12 (95% CI: 1.02-1.24) and LOS: adjusted HR: 0.91 (95% CI: 0.84-0.98)). CONCLUSION: Persistent low compliance with the DDKM (in Danish: Den Danske Kvalitetsmodel) accreditation was associated with higher 30-day mortality and longer LOS.

Compliance with accreditation and recommended hospital care-a Danish nationwide population-based study.

OBJECTIVE: To examine the association between compliance with accreditation and recommended hospital care. DESIGN: A Danish nationwide population-based follow-up study based on data from six national, clinical quality registries between November 2009 and December 2012. SETTING: Public, non-psychiatric Danish hospitals. PARTICIPANTS: Patients with acute stroke, chronic obstructive pulmonary disease, diabetes, heart failure, hip fracture and bleeding/perforated ulcers. INTERVENTIONS: All hospitals were accredited by the first version of The Danish Healthcare Quality Programme. Compliance with accreditation was defined by level of accreditation awarded the hospital after an announced onsite survey; hence, hospitals were either fully (n = 11) or partially accredited (n = 20). MAIN OUTCOME MEASURES: Recommended hospital care included 48 process performance measures reflecting recommendations from clinical guidelines. We assessed recommended hospital care as fulfilment of the measures individually and as an all-or-none composite score. RESULTS: In total 449 248 processes of care were included corresponding to 68 780 patient pathways. Patients at fully accredited hospitals had a significantly higher probability of receiving care according to clinical guideline recommendations than patients at partially accredited hospitals across conditions (individual measure: adjusted odds ratio (OR) = 1.20, 95% CI: 1.01-1.43, all-or-none: adjusted OR = 1.27, 95% CI: 1.02-1.58). For five of the six included conditions there were an association; the pattern appeared particular strong among patients with acute stroke and hip fracture (all-or-none; acute stroke: adjusted OR = 1.39, 95% CI: 1.05-1.83, hip fracture: adjusted OR = 1.57, 95% CI: 1.00-2.49). CONCLUSION: High compliance with accreditation standards was associated with a higher level of evidence-based hospital care in Danish hospitals.

Predictors of the effectiveness of accreditation on hospital performance: A nationwide stepped-wedge study.

OBJECTIVE: To identify predictors of the effectiveness of hospital accreditation on process performance measures. DESIGN: A multi-level, longitudinal, stepped-wedge, nationwide study. PARTICIPANTS: All patients admitted for acute stroke, heart failure, ulcers, diabetes, breast cancer and lung cancer at Danish hospitals. INTERVENTION: The Danish Healthcare Quality Programme that was designed to create a framework for continuous quality improvement. MAIN OUTCOME MEASURE(S): Changes in week-by-week trends of hospitals' process performance measures during the study period of 269 weeks prior to, during and post-accreditations. Process performance measures were based on 43 different processes of care obtained from national clinical quality registries. Analyses were stratified according to condition, type of care (i.e. treatment, diagnostics, secondary prevention and patient monitoring) and hospital characteristics (i.e. university affiliation, location, size, experience with accreditation and accreditation compliance). RESULTS: A total of 1 624 518 processes of care were included. The impact of accreditation differed across the conditions. During accreditation, heart failure and breast cancer showed less improvement than other disease areas. Across all conditions, diagnostic processes improved less rapidly than other types of processes. However, after stratifying the data by hospital characteristics, process performance measures improved more uniformly. In respect of the measures that had an unsatisfactory level of quality, the processes related to diabetes, diagnostics and patient monitoring all responded to accreditation and showed an increased improvement during the preparatory work. CONCLUSION: Hospital characteristics were not found to be predictors for the effects of accreditation, whereas conditions and types of care to some extent predicted the effectiveness.

Improvement in quality of hospital care during accreditation: A nationwide stepped-wedge study.

OBJECTIVE: To assess changes over time in quality of hospital care in relation to the first accreditation cycle in Denmark. DESIGN, SETTING AND PARTICIPANTS: We performed a multi-level, longitudinal, stepped-wedge, nationwide study of process performance measures to evaluate the impact of a mandatory accreditation programme in all Danish public hospitals. Patient-level data (n = 1 624 518 processes of care) on stroke, heart failure, ulcer, diabetes, breast cancer and lung cancer care were obtained from national clinical quality registries. INTERVENTION: The Danish Healthcare Quality Programme was introduced in 2009, aiming to create a framework for continuous quality improvement. MAIN OUTCOME: Changes in week-by-week trends of hospital care during the study period of 269 weeks prior to, during and post-accreditation. RESULTS: The quality of hospital care improved over time throughout the study period. The overall positive change in trend odds ratio (OR) = 1.002 per week; 95% confidence interval (CI: 0.997-1.006) observed when comparing the period during accreditation with the period prior to accreditation was not significant. However, when restricting the analyses to processes of care where the performance did not meet target values for satisfactory quality prior to accreditation, we found a significant positive change in trend (OR = 1.006 per week; 95% CI: 1.001-1.011). When comparing the post-accreditation period with the period during accreditation, we found a significantly reduced trend (OR = 0.994 per week; 95% CI: 0.988-0.999), indicating the improvement in quality of care continued but at a lower rate than during accreditation. CONCLUSION: These findings support the hypothesis that hospital accreditation leads to improvements in patient care.

Is compliance with hospital accreditation associated with length of stay and acute readmission? A Danish nationwide population-based study.

OBJECTIVE: To examine the association between compliance with hospital accreditation and length of stay (LOS) and acute readmission (AR). DESIGN: A nationwide population-based follow-up study from November 2009 to December 2012. SETTING: Public, non-psychiatric Danish hospitals. PARTICIPANTS: In-patients admitted with one of 80 diagnoses. INTERVENTION: Accreditation by the first version of The Danish Healthcare Quality Programme. Using an on-site survey, surveyors assessed the level of compliance with the standards. The hospital was awarded either fully (n = 11) or partially accredited (n = 20). MAIN OUTCOME MEASURES: LOS including transfers between hospitals and all-cause AR within 30 days after discharge. The Cox Proportional Hazard regression was used to compute hazard ratios (HRs) adjusted for potential confounding factors and cluster effect at hospital level. RESULTS: For analyses of LOS, 275 589 in-patients were included of whom 266 532 were discharged alive and included in the AR analyses. The mean LOS was 4.51 days (95% confidence interval (CI): 4.46-4.57) at fully and 4.54 days (95% CI: 4.50-4.57) at partially accredited hospitals, respectively. After adjusting for confounding factors, the adjusted HR for time to discharge was 1.07 (95% CI: 1.01-1.14). AR within 30 days after discharge was 13.70% (95% CI: 13.45-13.95) at fully and 12.72% (95% CI: 12.57-12.86) at partially accredited hospitals, respectively, corresponding to an adjusted HR of 1.01 (95% CI: 0.92-1.10). CONCLUSION: Admissions at fully accredited hospitals were associated with a shorter LOS compared with admissions at partially accredited hospitals, although the difference was modest. No difference was observed in AR within 30 days after discharge.

Accreditation and improvement in process quality of care: a nationwide study.

OBJECTIVE: To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital. DESIGN AND SETTING: A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs. PARTICIPANTS: All patients admitted for acute stroke, heart failure or ulcer at Danish hospitals. INTERVENTION: Hospital accreditation by either The Joint Commission International or The Health Quality Service. MEASUREMENTS: The primary outcome was a change in opportunity-based composite score and the secondary outcome was a change in all-or-none scores, both measures were based on the individual processes of care. These processes included seven processes related to stroke, six processes to heart failure, four to bleeding ulcer and four to perforated ulcer. RESULTS: A total of 27 273 patients were included. The overall opportunity-based composite score improved for both non-accredited and accredited hospitals (13.7% [95% CI 10.6; 16.8] and 9.9% [95% 5.4; 14.4], respectively), but the improvements were significantly higher for non-accredited hospitals (absolute difference: 3.8% [95% 0.8; 8.3]). No significant differences were found at disease level. The overall all-or-none score increased significantly for non-accredited hospitals, but not for accredited hospitals. The absolute difference between improvements in the all-or-none score at non-accredited and accredited hospitals was not significant (3.2% [95% -3.6:9.9]). CONCLUSIONS: Participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer.

Compliance with hospital accreditation and patient mortality: a Danish nationwide population-based study.

OBJECTIVE: To examine the association between compliance with hospital accreditation and 30-day mortality. DESIGN: A nationwide population-based, follow-up study with data from national, public registries. SETTING: Public, non-psychiatric Danish hospitals. PARTICIPANTS: In-patients diagnosed with one of the 80 primary diagnoses. INTERVENTION: Accreditation by the first version of The Danish Healthcare Quality Programme for hospitals from 2010 to 2012. Compliance were assessed by surveyors on an on-site survey and awarded the hospital as a whole; fully (n = 11) or partially accredited (n = 20). A follow-up activity was requested for partially accredited hospitals; submitting additional documentation (n = 11) or by having a return-visit (n = 9). MAIN OUTCOME MEASURES: All-cause mortality within 30-days after admission. Multivariable logistic regression was used to compute odds ratios (ORs) for 30-day mortality adjusted for six confounding factors and for cluster effect at hospital level. RESULTS: A total of 276 980 in-patients were identified. Thirty-day mortality risk for in-patients at fully (n = 76 518) and partially accredited hospitals (n = 200 462) was 4.14% (95% confidence interval (CI):4.00-4.28) and 4.28% (95% CI: 4.20-4.37), respectively. In-patients at fully accredited hospitals had a lower risk of dying within 30-days after admission than in-patients at partially accredited hospitals (adjusted OR of 0.83; 95% CI: 0.72-0.96). A lower risk of 30-day mortality was observed among in-patients at partially accredited hospitals required to submit additional documentation compared with in-patients at partially accredited hospitals requiring a return-visit (adjusted OR 0.83; 95% CI: 0.67-1.02). CONCLUSION: Admissions at fully accredited hospitals were associated with a lower 30-day mortality risk than admissions at partially accredited hospitals.

Sociodemographic Characteristics, Indicators of Quality, and Hospital Visits in Patients With COPD During COVID-19.

BACKGROUND: Evidence on quality of care and sociodemographics in patients with COPD needing care during the COVID-19 pandemic is scarce. We aimed to examine indicators of quality and clinical outcomes (eg, readmissions, death) and sociodemographics in patients with COPD in need of hospital care during the COVID-19 pandemic compared to before the pandemic. METHODS: This was a nationwide register-based study of subjects with a hospital contact due to COPD from January 1, 2015-December 15, 2021, in Denmark. A generalized linear model using Poisson distribution was used to estimate prevalence ratios (PRs) for variables of interest. RESULTS: During the pandemic, the early average of admissions was 36% lower than before the pandemic; the average number of out-patients was 23% lower. The proportion of readmissions for exacerbation within 30 d of discharge decreased during the pandemic (PR 0.93 [95% CI 0.90-0.96]). The proportion of subjects who died within 30 d of admission remained unchanged (PR 0.98 [0.94-1.03]). Among out-patients, the proportion with 2 or more exacerbations in the preceding year was lower during the pandemic (PR 0.82 [0.80-0.84]). During the pandemic, both in-patients and out-patients were less likely to be younger, to live alone, and to have a lower educational level. CONCLUSIONS: In this nationwide study of subjects with COPD, hospital contacts decreased during the pandemic due to lockdowns and isolation, which led to a decrease in infections overall in the society. Meanwhile, in-hospital care remained unaltered. However, concerns are raised about patients with COPD and low educational level and immigrants not seeking relevant health care.

Breast cancer, breast cancer-directed radiation therapy and risk of hypothyroidism: A systematic review and meta-analysis.

OBJECTIVE: Breast cancer and breast cancer-directed radiation therapy (RT) may increase the risk of late effects, such as hypothyroidism. We conducted a systematic review and meta-analysis to investigate the association between breast cancer, RT, and risk of hypothyroidism in breast cancer survivors. METHODS: Through February 2022, we searched PubMed, EMBASE, and references of relevant articles, to identify papers on breast cancer and breast cancer-directed RT and subsequent risk of hypothyroidism. Articles were screened by title and abstract and reviewed for eligibility. We used a pre-formed data extraction sheet and identified key design elements that could potentially introduce bias. The main outcome was the confounder-adjusted relative risk (RR) of hypothyroidism in breast cancer survivors versus women without breast cancer, and in breast cancer survivors according to the receipt of RT to the supraclavicular lymph nodes. We used a random-effects model to calculate pooled RRs and associated 95% confidence intervals (95% CI). RESULTS: From 951 papers screened by title and abstract, 34 full-text papers were reviewed for eligibility. We included 20 studies published between 1985 and 2021-19 were cohort studies. Compared with women without breast cancer, the pooled RR of hypothyroidism in breast cancer survivors was 1.48 (95% CI: 1.17, 1.87), with highest risk associated with RT to the supraclavicular region (RR = 1.69, 95% CI: 1.16, 2.46). The most important limitations of the studies were small sample size yielding estimates with low precision, and lack of data on potential confounders. CONCLUSION: Breast cancer and radiation therapy to the supraclavicular lymph nodes is associated with an increased risk of hypothyroidism.

Patient-related healthcare disparities in the quality of acute hip fracture care: a 10-year nationwide population-based cohort study.

OBJECTIVES: To characterise and quantify possible patient-related disparities in hip fracture care including temporal changes. DESIGN: Population-based cohort study. SETTING: All Danish hospitals treating patients with hip fracture. PARTICIPANTS: 60 275 hip fracture patients from 2007 to 2016. INTERVENTIONS: Quality of care was defined as fulfilment of eligible care process measures for the individual patient recommended by an expert panel. Using yearly logistic regression models, we predicted the individual patient's probability for receiving high-quality care, resulting in a distribution of adjusted probabilities based on age, sex, comorbidity, fracture type, education, family mean income, migration status, cohabitation status, employment status, nursing home residence and type of municipality. Based on the distribution, we identified best-off patients (ie, the 10% of patients with the highest probability) and worst-off patients (ie, the 10% of patients with the lowest probability). We evaluated disparities in quality of care by measuring the distance in fulfilment of outcomes between the best-off and worst-off patients. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was fulfilment of all-or-none, defined as receiving all relevant process measures. Secondary outcomes were fulfilment of the individual process measures including preoperative optimisation, early surgery, early mobilisation, assessment of pain, basic mobility, nutritional risk and need for antiosteoporotic medication, fall prevention and a postdischarge rehabilitation programme. RESULTS: The proportion of patients receiving high-quality care varied over time for both best-off and worst-off patients. The absolute difference in percentage points between the best-off and worst-off patients for receiving all-or-none of the eligible process measures was 12 (95% CI 6 to 18) in 2007 and 23 (95% CI 19 to 28) in 2016. Disparities were consistent for a range of care processes, including assessment of pain, mobilisation within 24 hours, assessment of need for antiosteoporotic medication and nutritional risk assessment. CONCLUSIONS: Disparity of care between best-off and worst-off patients remained substantial over time.

Effectiveness and safety of oral anticoagulation treatment beyond 1 year after venous thromboembolism in patients at intermediate recurrence risk.

Effectiveness and safety of long-term anticoagulation treatment are uncertain in venous thromboembolism (VTE) patients at intermediate risk of recurrence. We examined the association between treatment beyond 1 year and outcomes in a Danish nationwide register-based study. VTE patients at intermediate risk of recurrence, that is, non-cancer patients with a first-time unprovoked VTE, who started oral anticoagulation treatment within 30 days and were alive 365 days after the index VTE were included and followed between 2007 and 2015. Exposure was extended (>365 days) or intermediate (91-365 days) treatment. Analyses were done using Cox regression on a propensity score weighted population. We included 18 609 patients with 7232 (38.9%) receiving extended treatment. Mean duration of follow-up was 2.6 years. Compared with intermediate treatment, treatment beyond 365 days was associated with a lower weighted risk of recurrent VTE (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.49-0.65) and all-cause mortality (HR 0.81, 95% CI 0.72-0.90) and an increased risk of major bleeding (HR 1.87, 95% CI 1.58-2.22). In conclusion, extended anticoagulation treatment (predominantly warfarin) beyond 1 year was in real-life settings associated with a lower risk of recurrent VTE and all-cause mortality among VTE patients with an intermediate risk of recurrence. However, an increased bleeding risk should be considered.