Increasing capitation in mixed remuneration schemes: Effects on service provision and process quality of care.

Many health systems apply mixed remuneration schemes for general practitioners, but little is known about the effects on service provision of changing the relative mix of fee for services and capitation. We apply difference-in-differences analyses to evaluate a reform that effectively reversed the mix between fee for services and capitation from 80/20 to 20/80 for patients with type 2 diabetes. Our results show reductions in provision of both the contact services that became capitated and in other non-capitated (still-billable) services. Reduced provision also occurred for guideline-recommended process quality services. We find that the effects are mainly driven by patients with co-morbidities and by general practitioners with high income, relatively many diabetes patients, and solo practitioners. Thus, increasing capitation in a mixed remuneration schemes appears to reduce service provision for patients with type 2 diabetes monitored in general practice with a risk of unwanted quality effects.

Continuity and discontinuity of care among older patients in Danish general practice: a retrospective cohort study.

BACKGROUND: Continuity of care (COC) for older adults has been associated with lower use of healthcare services, decreased risk of hospitalisation, and lower mortality. However, research on COC in older adults is limited by short time periods and small sample sizes. Long-term COC can only develop if the patient stays with the general practice for ≥10 years. Therefore, research that focuses on long duration and broader populations is needed. AIM: To measure the extent of longitudinal site-level COC in general practice and listing duration of the patient-general practice relation for all older Danish citizens. DESIGN & SETTING: Retrospective cohort study of all patients aged ≥65 years on 31 December 2021 listed with a Danish general practice (N = 1 144 941 persons). METHOD: Individual-level register data were used on start and end dates for listing with a general practice to analyse site-level COC by number of changes and listing duration of the patient-general practice relation from January 2007-December 2021. RESULTS: During the 15 years, 39.3% of older adults did not change general practice. Among the remaining 60.7%, who experienced discontinuity of care, 34.0% changed once, 16.3% changed twice, and 6.3% changed three times. Overall, <5% changed general practice >3 times. The duration of the patient-general practice relations were on average 9.5 years. Overall, 27.5% lasted 0-4 years, 33.7% lasted 5-9 years, and 38.8% lasted ≥10 years. CONCLUSION: Danish general practice provides high levels of site-level COC for their older patients. On average, patients aged ≥65 years changed general practice once and had a patient-general practice relation length of 9.5 years.

Reducing milking frequency from 3 to 2 times daily in early lactation: effects on milk production, health and body condition.

The objective of this experiment was to investigate the effect of reducing early lactation milking frequency on milk yield and persistency through lactation and early lactation fat mobilization, measured by body condition score (BCS) and BHB in milk. We hypothesized that milking cows twice per day in early lactation before milking them 3 times per day for the remaining lactation would cause less fat mobilization in early lactation, a lower peak milk yield but improved persistency throughout lactation compared with milking cows 3 times per day for the entire lactation. The experiment took place on 2 commercial dairy farms in Denmark. All cows calving in a period of nine months (n = 239) in their current first and later parities were randomly allocated at dry-off to 1 of 3 treatments based on expected calving date. The treatments were (1) cows milked 2 times per day for 1 week after calving, (2) cows milked 2 times per day for 4 weeks after calving and (3) cows milked 2 times per day for 7 weeks after calving. All cows were then milked 3 times per day for the remaining lactation. Milk yield peaked 3.3 and 3.6 d later and milk yield persistency improved with 18 and 19 g per day when cows were milked 2 times per day for 4 and 7 weeks, respectively, compared with milking 2 times per day for 1 week after calving. We found a significant highest milk BHB in treatment 2, but the underlying effect of milking cows 2 times per day for 4 weeks compared with 1 or 7 weeks was unclear. In conclusion, we did not confirm our hypothesis that milking cows 2 times per day compared to 3 times in early lactation would reduce fat mobilization and reduce peak yield. We did, however, find an improved milk yield persistency, which partially offset a numerical reduction in peak yield, and hence there was no significant effect of reducing early lactation milking frequency on total lactation (305 DIM) milk yield.

Profiles of GPs with high and low self-reported physician empathy-personal, professional, and antibiotic prescribing characteristics.

BACKGROUND: General Practitioners' (GPs) professional empathy has been hypothesized to have substantial impact on their healthcare delivery and medication prescribing patterns. This study compares profiles of personal, professional, and antibiotic prescribing characteristics of GPs with high and low empathy. METHODS: We apply an extreme group approach to a unique combined set of survey and drug register data. The survey included questions about demographic, professional, and antibiotic prescribing characteristics, as well as the Jefferson Scale of Empathy for Health Professionals (JSE-HP) to assess self-reported physician empathy. It was sent to a stratified sample of 1,196 GPs comprising 30% of the Danish GP population of whom 464 (38.8%) GPs responded. GPs in the top and bottom decile of empathy levels were identified. All intra- and inter-profile descriptive statistics and differences were bootstrapped to estimate the variability and related confidence intervals.  RESULTS: 61% of GPs in the top decile of the empathy score were female. GPs in this decile reported the following person-centered factors as more important for their job satisfaction than the bottom decile: The Patient-physician relationship, interaction with colleagues, and intellectual stimulation. High-empathy scoring GPs prescribed significantly less penicillin than the low-empathy GPs. This was true for most penicillin subcategories. There were no significant differences in age, practice setting (urban vs. rural), practice type (partnership vs. single-handed), overall job satisfaction, or GP's value of prestige and economic profit for their job satisfaction. The intra profile variation index and confidence intervals show less prescribing uncertainty among GPs with high empathy. CONCLUSIONS: This study reveals that high empathy GPs may have different personal, professional, and antibiotic prescribing characteristics than low empathy GPs and have less variable empathy levels as a group. Furthermore, person-centered high empathy GPs on average seem to prescribe less penicillins than low empathy GPs.

Spain's Hesitation at the Gates of a COVID-19 Vaccine.

(1) Background: This study aims to delineate a pattern on vaccine hesitancy in a sample of the Spanish population, considering age groups and status as healthcare workers. (2) Methods: Participants were recruited using Twitter® as a dissemination tool to reach as many respondents as possible in different parts of the Spanish territory. The participants were recruited in a cross-sectional study, which included answering an online questionnaire. Data were collected from 10 September through 23 November 2020. Respondents answered questions asking whether they intended to be vaccinated and provided the main reason for their answers. To estimate associations between vaccination hesitancy and independent variables, we fit Poisson regression models with robust variance. (3) Results: One thousand and two responses were obtained, of which only 731 were validated. One hundred and sixty-four participants stated that they would not be vaccinated (22.43%), of which 20-24% were non-health workers or unemployed, 17.5% physicians, 31.5% other health workers, and almost 35% nurses. Concerns about lack of effectiveness of the vaccination, lack of safety when vaccinating and possibly dangerous adverse effects were the main causes provided. (4) Conclusions: This study indicates that more interventions are needed to achieve better communication with the population and health professionals. Receptiveness to the message of the importance and security of the COVID-19 vaccination could be an important strategy for improving these results.

Effects of Point-Of-Care Testing in General Practice for Type 2 Diabetes Patients on Ambulatory Visits and Hospitalizations.

Point-of-care testing (POCT) of HbA1c means instant test results and more coherent counseling that is expected to improve diabetes management and affect ambulatory visits and hospitalizations. From late 2008, POCT has been implemented and adopted by a segment of the general practices in the capital region of Denmark. The aim of this study is to assess whether the introduction of POCT of HbA1c in general practice (GP) has affected patient outcomes for T2 diabetes patients in terms of hospital activity. We apply difference-in-differences models at the GP clinic level to assess the casual effects of POCT on the following hospital outcomes: (1) admissions for diabetes, (2) admissions for ambulatory care sensitive diabetes conditions (ACSCs), (3) ambulatory visits for diabetes. The use of POCT is remunerated by a fee, and registration of this fee is used to measure the GP's use of POCT. The control group includes clinics from the same region that did not use POCT. The sensitivity of our results is assessed by an event study approach and a range of robustness tests. The panel data set includes 553 GP clinics and approximately 30,000 diabetes patients from the capital region of Denmark, observed in the years 2004-2012. We find that voluntary adoption of POCT of HbA1c in GP has no effect on hospital admissions and diabetes-related hospital ambulatory visits. Event study analysis and different treatment definitions confirm the robustness of these results. If implementation of POCT of HbA1c improves other parts of diabetes management as indicated in the literature, it seems worthwhile to implement POCT of HbA1c in the capital region of Denmark. However, doubts around the quality of POCT of HbA1c testing and a desire to capture data at central labs may prevent implementation of more value based HbA1c testing.

Enteric methane emission from Jersey cows during the spring transition from indoor feeding to grazing.

Organic dairy cows in Denmark are often kept indoors during the winter and outside at least part time in the summer. Consequently, their diet changes by the season. We hypothesized that grazing might affect enteric CH4 emissions due to changes in the nutrition, maintenance, and activity of the cows, and they might differentially respond to these factors. This study assessed the repeatability of enteric CH4 emission measurements for Jersey cattle in a commercial organic dairy herd in Denmark. It also evaluated the effects of a gradual transition from indoor winter feeding to outdoor spring grazing. Further, it assessed the individual-level correlations between measurements during the consecutive feeding periods (phenotype × environment, P × E) as neither pedigrees nor genotypes were available to estimate a genotype by environment effect. Ninety-six mixed-parity lactating Jersey cows were monitored for 30 d before grazing and for 24 d while grazing. The cows spent 8 to 11 h grazing each day and had free access to an in-barn automatic milking system (AMS). For each visit to the AMS, milk yield was recorded and logged along with date and time. Monitoring equipment installed in the AMS feed bins continuously measured enteric CH4 and CO2 concentrations (ppm) using a noninvasive "sniffer" method. Raw enteric CH4 and CO2 concentrations and their ratio (CH4:CO2) were derived from average concentrations measured during milking and per day for each cow. We used mixed models equations to estimate variance components and adjust for the fixed and random effects influencing the analyzed gas concentrations. Univariate models were used to precorrect the gas measurements for diurnal variation and to estimate the direct effect of grazing on the analyzed concentrations. A bivariate model was used to assess the correlation between the 2 periods (in-barn vs. grazing) for each gas concentration. Grazing had a weak P × E interaction for daily average CH4 and CO2 gas concentrations. Bivariate repeatability estimates for average CH4 and CO2 concentrations and CH4:CO2 were 0.77 to 0.78, 0.73 to 0.80, and 0.26, respectively. Repeatability for CH4:CO2 was low (0.26) but indicated some between-animal variation. In conclusion, grazing does not create significant shifts compared with indoor feeding in how animals rank for average CH4 and CO2 concentrations and CH4:CO2. We found no evidence that separate evaluation is needed to quantify enteric CH4 and CO2 emissions from Jersey cows during in-barn and grazing periods.

Use of preventive home visits by general practitioners in patients diagnosed with dementia.

INTRODUCTION: The prevalence of dementia is estimated to increase due to a growing elderly population. Patients with dementia are vulnerable as they are less likely to consult their general practitioner (GP). According to Danish guidelines, they are considered frail and in need of a proactive approach in the form of an annual preventive home visit (PHV). The aim of this study was to describe and analyse the use of PHVs among patients with dementia in general practice. METHODS: This was a quantitative descriptive quality assurance study of elderly patients (≥ 75 years) identified with dementia by their GP. During a four-week audit in 2015, 40 general practices registered all elderly patients who saw their GP or received a home visit, using a registration form addressing frailty characteristics. RESULTS: The study included 3,098 elderly patients among whom 214 had been identified with dementia. Patients with dementia received more PHVs than dementia-free patients. Even so, more than 60% of the patients with dementia had not received the recommended PHV within the past year. Walking distance < 100 m and > 1 chronic disease alongside dementia were associated with receiving a PHV. Substantial variation was found among the general practices with regard to conducting PHVs. CONCLUSIONS: GP's adherence to guidelines for patients identified with dementia leaves room for improvement as a significant part of the patients had not received the annual PHV as recommended in the guidelines. Furthermore, substantial variation between general practices indicates that not all GPs need to improve to the same extent. FUNDING: The study was supported by the Quality Improvement Committee for General Practice in the Region of Southern Denmark, Audit Project Odense and the University of Southern Denmark. TRIAL REGISTRATION: not relevant.

The Relationships Between Use of Quality-of-Care Feedback Reports on Chronic Diseases and Medical Engagement in General Practice.

BACKGROUND: There is a limited knowledge on how medical engagement influences quality of care provided in primary care. The extent of the use of feedback reports from a national quality-of-care database can be considered as a measure of process quality. This study explores relationships between the use of feedback reports and medical engagement among general practitioners, general practitioner demographics, clinic characteristics, and services. METHODS: A cross-sectional combined questionnaire and register study in a sample of 352 single-handed general practitioners in 2013. Logistic regression analysis was used to explore associations between the use of feedback reports for diabetes and chronic obstructive pulmonary disease and medical engagement. RESULTS: For both diabetes and chronic obstructive pulmonary disease, a higher degree of medical engagement was associated with an increased use of feedback reports. Furthermore, we identified positive associations between using feedback reports and general practitioner services (spirometry, influenza vaccinations, performing annual reviews for patients with chronic diseases) and a negative association between usage of quality-of-care feedback reports and the number of consultations per patient. CONCLUSION: Using feedback reports for chronic diseases in general practice was positively associated with medical engagement and also with the provision of services in general practice.

Empathy Variation in General Practice: A Survey among General Practitioners in Denmark.

Background: Previous studies have demonstrated that high levels of physician empathy may be correlated with improved patient health outcomes and high physician job satisfaction. Knowledge about variation in empathy and related general practitioner (GP) characteristics may allow for a more informed approach to improve empathy among GPs. Objective: Our objective is to measure and analyze variation in physician empathy and its association with GP demographic, professional, and job satisfaction characteristics. Methods: 464 Danish GPs responded to a survey containing the Danish version of the Jefferson Scale of Empathy for Health Professionals (JSE-HP) and questions related to their demographic, professional and job satisfaction characteristics. Descriptive statistics and a quantile plot of the ordered empathy scores were used to describe empathy variation. In addition, random-effect logistic regression analysis was performed to explore the association between empathy levels and the included GP characteristics. Results: Empathy scores were negatively skewed with a mean score of 117.9 and a standard deviation of 10.1 within a range from 99 (p5) to 135 (p95). GPs aged 45-54 years and GPs who are not employed outside of their practice were less likely to have high empathy scores (≥120). Neither gender, nor length of time since specialization, length of time in current practice, practice type, practice location, or job satisfaction was associated with odds of having high physician empathy. However, odds of having a high empathy score were higher for GPs who stated that the physician-patient relationship and interaction with colleagues has a high contribution to job satisfaction compared to the reference groups (low and medium contribution of these factors). This was also the trend for GPs who stated a high contribution to job satisfaction from intellectual stimulation. In contrast, high contribution of economic profit and prestige did not contribute to increased odds of having a high empathy score. Conclusions: Albeit generally high, we observed substantial variation in physician empathy levels among this population of Danish GPs. This variation is positively associated with values of interpersonal relationships and interaction with colleagues, and negatively associated with middle age (45-54 years) and lack of outside employment. There is room to increase GP physician empathy via educational and organizational interventions, and consequently, to improve healthcare quality and outcomes.

Variation in Point-of-Care Testing of HbA1c in Diabetes Care in General Practice.

Background: Point-of-care testing (POCT) of HbA1c may result in improved diabetic control, better patient outcomes, and enhanced clinical efficiency with fewer patient visits and subsequent reductions in costs. In 2008, the Danish regulators created a framework agreement regarding a new fee-for-service fee for the remuneration of POCT of HbA1c in general practice. According to secondary research, only the Capital Region of Denmark has allowed GPs to use this new incentive for POCT. The aim of this study is to use patient data to characterize patients with diabetes who have received POCT of HbA1c and analyze the variation in the use of POCT of HbA1c among patients with diabetes in Danish general practice. Methods: We use register data from the Danish Drug Register, the Danish Health Service Register and the National Patient Register from the year 2011 to define a population of 44,981 patients with diabetes (type 1 and type 2 but not patients with gestational diabetes) from the Capital Region. The POCT fee is used to measure the amount of POCT of HbA1c among patients with diabetes. Next, we apply descriptive statistics and multilevel logistic regression to analyze variation in the prevalence of POCT at the patient and clinic level. We include patient characteristics such as gender, age, socioeconomic markers, health care utilization, case mix markers, and municipality classifications. Results: The proportion of patients who received POCT was 14.1% and the proportion of clinics which were "POCT clinics" was 26.9%. There were variations in the use of POCT across clinics and patients. A part of the described variation can be explained by patient characteristics. Male gender, age differences (older age), short education, and other ethnicity imply significantly higher odds for POCT. High patient costs in general practice and other parts of primary care also imply higher odds for POCT. In contrast, high patient costs for drugs and/or morbidity in terms of the Charlson Comorbidity index mean lower odds for POCT. The frequency of patients with diabetes per 1000 patients was larger in POCT clinics than Non-POCT clinics. A total of 22.5% of the unexplained variability was related to GP clinics. Conclusions: This study demonstrates variation in the use of POCT which can be explained by patient characteristics such as demographic, socioeconomic, and case mix markers. However, it appears relevant to reassess the system for POCT. Further studies are warranted in order to assess the impacts of POCT of HbA1c on health care outcomes.

Multivariate dynamic linear models for estimating the effect of experimental interventions in an evolutionary operations setup in dairy herds.

Evolutionary operations is a method to exploit the association of often small changes in process variables, planned during systematic experimentation and occurring during the normal production flow, to production characteristics to find a way to alter the production process to be more efficient. The objective of this study was to construct a tool to assess the intervention effect on milk production in an evolutionary operations setup. The method used for this purpose was a dynamic linear model (DLM) with Kalman filtering. The DLM consisted of parameters describing milk yield in a herd, individual cows from a herd, and an intervention effect on a given day. The model was constructed to handle any number of cows, experimental interventions, different data sources, or presence of control groups. In this study, data from 2 commercial Danish herds were used. In herd 1, data on 98,046 and 12,133 milkings registered from an automatic milking system (AMS) were used for model building and testing, respectively. In herd 2, data on 3,689 milkings on test days were used for estimating the initial model parameters. For model testing, data from both bulk tank milk yield (85 observations) and test-day milkings (1,471) were used. In herd 1, the manager wanted to explore the possibility of reducing the amount of concentrate provided to the cows in an AMS. In herd 2, the manager wanted to know if the milk yield could be increased by elevating the energy level provided to the cows in a total mixed ration. The experiment conducted in herd 1 was designed with a treatment and a control group, whereas in herd 2 we used a pretest/posttest design. The constructed tool provided estimates (mean and confidence intervals) for each of 3 interventions carried out in both herds. In herd 1, we concluded that the reduction in concentrate amount provided in the AMS had no negative influence on milk yield. For herd 2, the increased level of energy had a significant positive effect on milk yield but only for the first intervention. In this herd, the effect of intervention was also evaluated for cows in the first lactation and without bulk tank records. The presented model proved to be a flexible and dynamic tool, and it was successfully applied for systematic experimentation in dairy herds. The model can serve as a decision support tool for on-farm process optimization exploiting planned changes in process variables and the response of production characteristics.

Frailty characteristics and preventive home visits: an audit on elderly patients in Danish general practice.

AIM: Preventive home visits (PHVs) to frail elderly patients, provided by the GP, have been widely promoted in many health care systems, including the Danish system. This study investigates to what extent PHVs are provided to patients with characteristics of frailty. METHODS: During a four-week period, GPs and their staff in three different parts of Denmark filled in a questionnaire for each patient aged 75 years or older who attended the clinic or received a home visit. The association between 20 different frailty characteristics and the receipt of a PHV was assessed through logistic regression. RESULTS: A total of 73 GPs and 41 staff members sampled information about 3133 patients, of whom 332 patients (10.7%) had received a PHV within one year prior to their audit date. A PHV was closely associated with the patient's number of frailty characteristics. The adjusted odds ratios show that the receipt of a PHV was associated with a low walking distance 2.34 (1.65-3.31), dementia 3.35 (2.26-4.96), depression 2.24 (1.38-3.63) and a need for home care 3.40 (2.45-4.73), and increased with the GP's tendency to provide PHVs. CONCLUSION: Most PHV-receiving elderly patients have several characteristics of frailty, the most significant being impaired mobility, dementia, depression and a need for home care. PHVs are also more often provided to patients listed with a GP who has an overall high tendency to conduct these visits.

Resource allocation and the burden of co-morbidities among patients diagnosed with chronic obstructive pulmonary disease: an observational cohort study from Danish general practice.

BACKGROUND: Chronic obstructive pulmonary disease is a leading cause of mortality, and associated with increased healthcare utilization and healthcare expenditure. In several countries, morbidity-based systems have changed the way resources are allocated in general practice. In primary care, fee-for-services tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated expenditures for patients with chronic obstructive pulmonary disease has not previously been examined. The aim of this study is to analyze fee-for-service expenditure of patients diagnosed with chronic obstructive pulmonary disease visiting Danish general practice clinics and further to assess what proportion of fee-for-service expenditure variation was explained by patient morbidity and general practice clinic characteristics, respectively. METHODS: We used patient morbidity characteristics such as diagnostic markers and multi-morbidity adjustment based on adjusted clinical groups (ACGs) and fee-for-service expenditure for a sample of primary care patients for the year 2010. Our sample included 3,973 patients in 59 general practices. We used a multi-level approach. RESULTS: The average annual fee-for-service expenditure of caring for patients diagnosed with chronic obstructive pulmonary disease in general practice was about EUR 400 per patient. Variation in the expenditures was driven by multimorbidity characteristics up to 28% where as characteristics such as age and gender only explained 5%. Expenditures increased progressively with the degree of multimorbidity. In addition, expenditures were higher for patients who had diagnostic markers based on ICPC-2 (body systems and/or components such as infections and symptoms). Nevertheless, 9.8-15.4% of the variation in expenditure was related to the clinic in which the patient was cared for. CONCLUSION: Patient morbidity and general practice clinic characteristics are significant patient-related fee-for-service expenditure drivers in chronic obstructive pulmonary disease care.

Medical engagement and organizational characteristics in general practice.

BACKGROUND: Medical engagement is a mutual concept of the active and positive contribution of doctors to maintaining and enhancing the performance of their health care organization, which itself recognizes this commitment in supporting and encouraging high quality care. A Medical Engagement Scale (MES) was developed by Applied Research Ltd (2008) on the basis of emerging evidence that medical engagement is critical for implementing radical improvements. OBJECTIVES: To study the importance of medical engagement in general practice and to analyse patterns of association with individual and organizational characteristics. DESIGN AND SETTING: A cross-sectional study using a sampled survey questionnaire and the official register from the Danish General Practitioners' Organization comprising all registered Danish GPs. METHOD: The Danish version of the MES Questionnaire was distributed and the survey results were analysed in conjunction with the GP register data. RESULTS: Statistically adjusted analyses revealed that the GPs' medical engagement varied substantially. GPs working in collaboration with colleagues were more engaged than GPs from single-handed practices, older GPs were less engaged than younger GPs and female GPs had higher medical engagement than their male colleagues. Furthermore, GPs participating in vocational training of junior doctors were more engaged than GPs not participating in vocational training. CONCLUSION: Medical engagement in general practice varies a great deal and this is determined by a complex interaction between both individual and organizational characteristics. Working in collaboration, having staff and being engaged in vocational training of junior doctors are all associated with enhanced levels of medical engagement among GPs.

Association between fee-for-service expenditures and morbidity burden in primary care.

BACKGROUND: In primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined. OBJECTIVES: To examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures. METHODS: We applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics. RESULTS: Out of the individual expenditures, 31.6% were explained by age, gender and RUB, and around 18% were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0-RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44%; 3.8-9.4% of the variation in expenditures was related to the GP clinic in which the patient was treated. CONCLUSIONS: Morbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.

Resources allocation and health care needs in diabetes care in Danish GP clinics.

BACKGROUND: In several countries, morbidity burdens have prompted authorities to change the system for allocating resources among patients from a demographic-based to a morbidity-based casemix system. In Danish general practice clinics, there is no morbidity-based casemix adjustment system. AIM: The aim of this paper was to assess what proportions of the variation in fee-for-service (FFS) expenditures are explained by type 2 diabetes mellitus (T2DM) patients' co-morbidity burden and illness characteristics. METHODS AND DATA: We use patient morbidity characteristics such as diagnostic markers and co-morbidity casemix adjustments based on resource utilisation bands and FFS expenditures for a sample of 6706 T2DM patients in 59 general practices for the year 2010. We applied a fixed-effect approach. RESULTS: Average annual FFS expenditures were approximately 398 euro per T2DM patient. Expenditures increased progressively with the patients' degree of co-morbidity and were higher for patients who suffered from diagnostic markers. A total of 17-25% of the expenditure variation was explained by age, gender and patients' morbidity patterns. CONCLUSION: T2DM patient morbidity characteristics are significant patient related FFS expenditure drivers in diabetes care. To address the specific health care needs of T2DM patients in GP clinics, our study indicates that it may be advisable to introduce a morbidity based casemix adjustment system.

Chemical composition and sensory quality of bovine milk as affected by type of forage and proportion of concentrate in the feed ration.

BACKGROUND: The objective of this study was to investigate how some small changes in the forage content of maize and lucerne silage and in the ration between forage and concentrate in the diet of dairy cows affect milk quality. Milk quality was assessed by quantitative descriptive sensory analysis and by analysis of tocopherols and carotenoids as well as fatty acid composition. RESULTS: Changing the ratio between maize silage and lucerne silage from 5:1 to 2:1 increased milk fat content of carotenoids (23-27%) and C18:3 n3 (15%), and reduced stale aroma and creamy flavour. Increasing the proportion of concentrates in the feed ration from 0.2 to 0.4 increased energy corrected milk yield (26%), reduced fat content (-10%), increased C18 fatty acids (8-62%) and reduced C16 (-20%) content in milk fat. In addition, this milk type was described by the sensory panel as less oily, less saturated and less yellow. The changes in milk composition were related to differences in feed composition. CONCLUSION: The study revealed the potential to produce milk with a distinct composition and sensory quality based on even small changes in the feed composition that are straightforward to implement by farmers.

Organisational determinants of production and efficiency in general practice: a population-based study.

OBJECTIVE: Shortage of general practitioners (GPs) and an increased political focus on primary care have enforced the interest in efficiency analysis in the Danish primary care sector. This paper assesses the association between organisational factors of general practices and production and efficiency. METHODS: We assume that production and efficiency can be modelled using a behavioural production function. We apply the Battese and Coelli (Empir Econ 20:325-332, 1995) estimator to accomplish a decomposition of exogenous variables to determine the production frontier and variables determining the individual GPs distance to this frontier. Two different measures of practice outputs (number of office visits and total production) were applied and the results compared. RESULTS: The results indicate that nurses do not substitute GPs in the production. The production function exhibited constant returns to scale. The mean level of efficiency was between 0.79 and 0.84, and list size was the most important determinant of variation in efficiency levels. CONCLUSIONS: Nurses are currently undertaking other tasks than GPs, and larger practices do not lead to increased production per GP. However, a relative increase in list size increased the efficiency. This indicates that organisational changes aiming to increase capacity in general practice should be carefully designed and tested.

Content and distribution of phytanic acid diastereomers in organic milk as affected by feed composition.

Phytanic acid (PA) is a bioactive compound found in milk that is derived from the phytol chain of chlorophyll, and the content of PA in milk fat depends on the availability of phytol from feed. In this study, the content of PA diastereomers was analyzed in milk sampled from five organic herds twice during the grazing season (May and September). The total content of PA was higher in September compared to May, but was not affected by breed (Danish Holstein or Danish Jersey). Total PA could not be directly related to intake of green feed items. The distribution between diastereomers was closely related to the amount of grazed clovers, where a higher intake resulted in a higher share of the RRR isomer.