Denmark: health system review

This analysis of the Danish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Population health in Denmark isgood and improving, with life expectancy above the European Union average but is, however, lagging behind the other Nordic countries. Denmark has a universal and tax-financed health system, providing coverage for acomprehensive package of health services. Notable exclusions to the benefits package include outpatient prescription drugs and adult dental care, which require co-payment and are the main causes of out-of-pocket spending. The hospital sector has been transformed during the past 15 years through a process of consolidating hospitals and the centralization of medical specialties. However, in recent years, there has been a move towards decentralization to increase the volume and quality of care provided outside hospitals in primary and local care settings. The Danish health care system is, to a very high degree, based on digital solutions that health care providers, citizens and institutions all use. Ensuring the availability of health care in all parts of Denmark is increasingly seen as a priority issue.Ensuring sufficient health workers, especially nurses, poses a significant challenge to the Danish health system’s sustainability and resilience. While a comprehensive package of policies has been put in place to increase thenumber of nurses being trained and retain those already working in the system, such measures need time to work. Addressing staffing shortages requires long-term action. Profound changes in working practices and workingenvironments will be required to ensure the sustainability of the health workforce and, by extension, the health system into the future.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Nordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic.

This paper explores and compares health system responses to the COVID-19 pandemic in Denmark, Finland, Iceland, Norway and Sweden, in the context of existing governance features. Content compiled in the Covid-19 Health System Response Monitor combined with other publicly available country information serve as the foundation for this analysis. The analysis mainly covers early response until August 2020, but includes some key policy and epidemiological developments up until December 2020. Our findings suggest that despite the many similarities in adopted policy measures, the five countries display differences in implementation as well as outcomes. Declaration of state of emergency has differed in the Nordic region, whereas the emphasis on specialist advisory agencies in the decision-making process is a common feature. There may be differences in how respective populations complied with the recommended measures, and we suggest that other structural and circumstantial factors may have an important role in variations in outcomes across the Nordic countries. The high incidence rates among migrant populations and temporary migrant workers, as well as differences in working conditions are important factors to explore further. An important question for future research is how the COVID-19 epidemic will influence legislation and key principles of governance in the Nordic countries.

Inter-professional agreement and collaboration between extended scope physiotherapists and orthopaedic surgeons in an orthopaedic outpatient shoulder clinic - a mixed methods study.

BACKGROUND: Extended scope physiotherapists (ESP) are increasingly supplementing orthopaedic surgeons (OS) in diagnosing patients with musculoskeletal disorders. Studies have reported satisfactory diagnostic and treatment agreement between ESPs and OSs, but methodological study quality is generally low, and only few studies have evaluated inter-professional collaboration. Our aims were: 1) to evaluate agreement on diagnosis and treatment plan between ESPs and OSs examining patients with shoulder disorders, 2) to explore and evaluate their inter-professional collaboration. METHODS: 1) In an orthopaedic outpatient shoulder clinic, 69 patients were examined independently twice on the same day by an ESP and an OS in random order. Primary and secondary diagnoses (nine categories) and treatment plan (five categories, combinations allowed) were registered by each professional and compared. Percentage of agreement and kappa-values were calculated. 2) Two semi-structured focus-group interviews were performed with ESPs and OSs, respectively. Interviews were based on the theoretical concept of Relational Coordination, encompassing seven dimensions of communication and relationship among professionals. A thematic analysis was conducted. RESULTS: 1) Agreement on primary diagnosis was 62% (95% CI: [50; 73]). ESPs and OSs agreed on the combination of diagnoses in 79% (95% CI: [70; 89]) of the cases. Partial diagnostic agreement (one professional's primary diagnosis was also registered as either primary or secondary diagnosis by the other) was 96% (95% CI: [91; 100]). Across treatment categories, agreement varied between 68% (95% CI: [57; 79]) and 100%. In 43% (95% CI: [31; 54]) of the cases, ESP and OS had full concordance between treatment categories chosen, while they agreed on at least one recommendation in 96% (95% CI: [91; 100]). 2) Positive statements of all dimensions of relational coordination were found. Three themes especially important in the inter-professional collaboration emerged: Close communication, equal and respectful relationship and professional skills. CONCLUSIONS: In the majority of cases, the ESP and OS registered the same or partly the same diagnosis and treatment plan. Indications of a high relational coordination implying a good inter-professional collaboration were found. Our results support that ESPs and OSs can share the task of examining selected patients with shoulder disorders in an orthopaedic clinic. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03343951 . Registered 10 November 2017.

Evaluation of a policy to strengthen case management and quality of diabetes care in general practice in Denmark.

OBJECTIVES: To evaluate the utilization of a policy for strengthening general practitioner's case management and quality of care of diabetes patients in Denmark incentivized by a novel payment mode. We also want to elucidate any geographical variation or variation on the basis of practice features such as solo- or group practice, size of practice and age of the GP. METHODS: On the basis registers encompassing reimbursement data from GPs and practice specific information about geographical location (region), type of practice (solo- or group-practice), size of practice (number of patients listed) and age of the GP were are able to determine differences in use of the policy in relation to the practice-specific information. RESULTS: At the end of the study period (2007-2012) approximately 30% of practices have enrolled extending services to approximately 10% of the diabetes population. There is regional--as well as organizational differences between GPs who have enrolled and the national averages with enrolees being younger, from larger practices and with more patients listed. CONCLUSIONS: Our study documents an organizationally and regionally varied and limited utilization with the overall incentive structure defined in the policy not strong enough to move the majority of GPs to change their way of delivering and financing care for patients with diabetes within a period of more than 5 years.

Polypharmacy in general practice.

INTRODUCTION: Polypharmacy increases the risk of side effects and interactions. We quantified the prevalence of major polypharmacy (MPP) in a Danish county with 236,000 inhabitants, invited general practitioners (GPs) to participate in a quality improvement project and discussed the medication of 10-20 MPP patients selected by the participating GPs. MATERIAL AND METHODS: This was a prospective registry study of all prescriptions of subsidized drugs in the third quarter of 2005 for all inhabitants living in Roskilde County, Denmark. An audit was performed of the prescriptions of 220 MPP patients selected by the GPs based on a list of each MPP patient's medications. RESULTS: MPP patients constituted 2.1% of the county's population. GPs demonstrated a strong interest in auditing prescriptions. A large share of the patients selected by the GPs was treated with drugs which were no longer indicated, or with drugs with a doubtful indication. CONCLUSIONS: MPP compromises the GP's ability to manage medication of individual patients. Systematic audit of the total medication of patients should be introduced.

[Influencing the prescriptions of general practitioners via guidelines and feedback--secondary publication]. / Påvirkning af praktiserende laegers ordinationer via kliniske retningslinjer og feedback--sekundaerpublikation.

We investigated the effects of a multi-dimensional intervention on practice prescription patterns in five drug groups. The number of prescribed defined daily doses (DDDs) increased after the intervention, while potential savings/DDD decreased. The county's average cost/DDD fell to a level below the national average. It is possible to change general practitioners' prescription patterns without interfering with their clinical freedom or patients' access to treatment.

Changing GPs' prescription patterns through guidelines and feedback. Intervention study.

PURPOSE: To investigate whether and how a multi-dimensional intervention including clinical guidelines on the choice of medical treatment in the primary and the secondary health care sector, and individual feedback to general practices about their own and other practices' prescription patterns in five Anatomical Therapeutic Chemical classification system (ATC)-groups was followed by changes in the practices' prescription pattern. METHODS: Prospective historical registry study and a questionnaire study of GPs' self-reported use of guidelines and feedback. RESULTS: In every ATC-group the number of prescribed defined daily doses (DDDs) kept growing after the intervention, while potential savings by DDD decreased. Individual practices' changes in the prescription pattern differed by ATC-group and practices with high potential savings/DDD before the intervention showed the greatest relative reduction in potential savings/DDD. The county's average cost/DDD for the five ATC-groups declined from above the Danish average before the intervention to a level below the average cost/DDD after the intervention. In the questionnaire study (response rate: 79%), 69% of respondents had read the guidelines and 78% reported that the feedback influenced their prescription of drugs. CONCLUSIONS: The observed changes in drug costs and potential savings were not due to volume effects but a combination of price effects, including generic substitution and choice of less expensive analogues, demonstrating that it is possible to change GPs' prescription patterns without interfering with patients' access to treatment or with GPs' clinical freedom.'

Patient reactions to hospital choice in Norway, Denmark, and Sweden.

This article is a comparative study of three Scandinavian countries--Norway, Denmark, and Sweden--all of which have provided the individual patient with extensive rights to choose the hospital where he/she wishes to receive treatment. In the paper, we present an analysis of the utilization of the opportunity to choose between hospitals in these three countries. The analysis addresses two questions: (i) How many patients are exercising the right to choose between hospitals in these countries and who is making use of this opportunity? (ii) How can we explain the observed utilization pattern? The results of the study reveal clear similarities between the three countries and suggest that few patients have actually chosen their hospital. However, a gradual increase can be observed over the years. Few formal, legislative, or economic barriers exist for patients. Instead, limited knowledge amongst patients regarding reforms, combined with insufficient support from GPs and limited information, can explain why few patients choose to receive care outside of their local region.

Why do not all hip- and knee patients facing long waiting times accept re-referral to hospitals with short waiting time? Questionnaire study.

Patients' preferences are often assumed to be homogeneous and to favour hospitals with a short waiting time and high quality. Due to long waiting times (6 months) for artificial hip or knee implantation a Danish county in 1999-2000 offered patients on a waiting list a choice between remaining on the local hospital's waiting list with the long waiting time, or re-referral to a hospital outside the county with a shorter waiting time. Fewer patients than expected took advantage of the offer of re-referral ("accepters"): 89 of 149 patients (60%). In 2003, we asked patients about the reasons for their choice: 87% of patients responded. Respondents and non-respondents were similar by decision, choice of hospital, diagnosis and age; men were significantly more likely to respond than women. Accepters and decliners were similar by age, sex, diagnosis and the presence of a car in the household. Short distance, short transport time and previous experience with the nearby hospital were the most important reasons for choosing that hospital. Some patients appeared to be willing to accept a long waiting time, if they were told exactly when they would undergo surgery. The results of this study question the validity of the conventional wisdom, that patients are willing to travel long distances in order to receive treatment with short waiting time.

[Quality monitoring of colon surgeons' volume of operations]. / Kvalitetsovervågning af colonkirurgers operationsvolumen.

INTRODUCTION: The number of operations performed by a surgeon is a predictor of the outcome of colon/rectum resection. Therefore it is relevant to monitor the surgeons' volume of work and the number of patients' complications in order to secure both an adequate number and high quality. MATERIALS AND METHODS: Using data from the Danish National Patient Registry and Danish Colon Cancer Group's database, we located hospital departments that had performed colon/rectum surgery in 2003 and asked them whether they monitored surgeons' volume of work and the number of patients' complications and whether they considered those data relevant to the patients or their GPs. RESULTS: Thirty-nine departments had performed colon/rectum resection; 27 of them responded. Eight departments (36%) had defined a standard for the number of operations per surgeon, while only four used the data to determine the surgeons' volume of work. 68% found data concerning the department's volume of operations relevant to both GPs and patients, while 23% thought that those data were not relevant to GPs or patients. 64% found the data concerning surgeons' volume to be irrelevant to both GPs and patients. None of the departments had informed the GPs or the patients about their results. DISCUSSION: It is remarkable that very few hospital departments actually collect and use data to secure adequate volume and quality. It is necessary to increase the focus on surgeons' volume of operations in order to secure high quality.

[Distribution of colonic surgery among surgeons in the city of Copenhagen]. / Fordeling af colonkirurgi på operatører i hovedstadsområdet.

INTRODUCTION: The outcome of some surgical procedures is related to the surgeon's experience. We examined how much experience surgeons in 12 hospitals in the region of Copenhagen gained in colon surgery in 1999. MATERIAL AND METHODS: The Ministry of Health identified the number of colon patients operated on in the region of Copenhagen in 1999. The departments were asked to validate the lists of patients and to fill in a questionnaire describing the surgeon's experience in that year. RESULTS: Eleven of 12 departments answered the questionnaire (92%). One hundred and two senior surgeons operated on 674 patients. Forty of the surgeons operated on one to four patients in 1999, and only five performed 15 or more operations. More than 50% of the surgical procedures were carried out by surgeons who performed fewer than 10 colon operations in 1999. Most of the low-volume surgeons' operations were performed during calls. DISCUSSION: Colon surgery in the region of Copenhagen was performed by a large number of surgeons in many hospitals in 1999. Hospital volume was not associated with surgeon volume.