Switch to Lisdexamfetamine in the Treatment of Attention-Deficit Disorder at a Psychiatric Outpatient Clinic for School-Aged Children: A Danish Cohort Study.

Objectives: This study aimed to examine switch from first-line methylphenidate (MPH) to lisdexamfetamine (LDX) in school-aged children with attention-deficit/hyperactivity disorder (ADHD). Methods: This is a retrospective observational study based on systematic review of patient records of all children (7-13 years) diagnosed with ADHD and referred to a Danish specialized outpatient clinic. The study included 394 children switching from MPH to LDX as either second-line or third-line treatment (atomoxetine [ATX] as second-line treatment) during the study period from April 1, 2013, to November 5, 2019. Results: One in five children switched from MPH to LDX at some point during the study period. The most frequent reasons for switching to LDX were adverse effects (AEs; 70.0% for MPH, 68.3% for ATX) and lack of efficiency (52.0% for MPH, 72.7% for ATX). Top five AEs of LDX were decreased appetite (62.4%), insomnia (28.7%), irritability/aggression (26.1%), weight decrease (21.1%), and mood swings (13.9%). MPH and LDX had similar AE profiles, yet most AEs were less frequent after switching to LDX. At the end of the study period, the majority were prescribed LDX as second-line rather than third-line treatment (86.1% in 2019). However, the likelihood of LDX as second-line treatment decreased with the number of psychiatric comorbidities, ADHD symptom severity as assessed by parents, and if AEs were a reason for MPH discontinuation. Among children observed for at least 1 year after initiation of LDX, 41.3% continued LDX treatment for a year or longer. LDX continuation was less likely if AEs were a reason for MPH discontinuation. Similarly to MPH and ATX, the most frequent reasons for LDX discontinuation were AEs (74.4%) and lack of efficiency (34.7%). Implications: The findings support LDX as an important option in the personalized treatment of children with ADHD and may support prescribers in the clinical decision-making on switching medication.

Working memory heterogeneity from age 7 to 11 in children at familial high risk of schizophrenia or bipolar disorder- The Danish High Risk and Resilience Study.

BACKGROUND: Despite the genetic overlap between bipolar disorder and schizophrenia, working memory impairments are mainly found in children of parents with schizophrenia. However, working memory impairments are characterized by substantial heterogeneity, and it is unknown how this heterogeneity develops over time. We used a data-driven approach to assess working memory heterogeneity and longitudinal stability in children at familial high risk of schizophrenia (FHR-SZ) or bipolar disorder (FHR-BP). METHODS: Based on the performances on four working memory tasks by 319 children (FHR-SZ, N = 202, FHR-BP, N = 118) measured at age 7 and 11, latent profile transition analysis was used to test for the presence of subgroups, and the stability of subgroup membership over time. Population-based controls (VIA 7, N = 200, VIA 11, N = 173) were included as a reference group. The working memory subgroups were compared based on caregiver- and teacher ratings of everyday working memory function, and dimensional psychopathology. RESULTS: A model with three subgroups characterized by different levels of working memory function (an impaired subgroup, a mixed subgroup, and an above average subgroup) best fitted the data. The impaired subgroup had the highest ratings of everyday working memory impairments and psychopathology. Overall, 98 % (N = 314) stayed in the same subgroup from age 7 to 11. CONCLUSION: Persistent working memory impairments are present in a subset of children at FHR-SZ and FHR-BP throughout middle childhood. Attention should be given to these children, as working memory impairments influence daily life, and may serve as a vulnerability marker of transition to severe mental illness.

Affective lability in parents with schizophrenia or bipolar disorder and their co-parents - The Danish High Risk and Resilience Study VIA 7.

In bipolar disorder, dysregulation of affect is a core feature while knowledge on affective lability in schizophrenia is sparse. Research on affective lability in partners to individuals with schizophrenia or bipolar disorder is also lacking. The objective of this study was to investigate affective lability in parents with schizophrenia or bipolar disorder, and their co-parents without these disorders. The Danish High Risk and Resilience Study - VIA 7 is a population-based cohort study. This study focuses on parents diagnosed with schizophrenia (n = 148), their co-parents (n = 157), parents with bipolar disorder (n = 98), their co-parents (n = 89) and control parents (n = 359). The Affective Lability Scale - short form (ALS-SF) was used to measure affective lability. We found significantly higher levels of affective lability in parents with schizophrenia and bipolar disorder compared with controls, but no significant differences between bipolar disorder and schizophrenia. Co-parents to parents with schizophrenia had significantly higher levels of affective lability compared to controls. Our results add to the existing knowledge concerning underlying transdiagnostic factors and nonrandom mating in schizophrenia and bipolar disorder and highlight the need for studies of parental affective lability as a potential risk factor for offspring in families with parental schizophrenia or bipolar disorder.

Neurocognitive Subgroups in Children at Familial High-risk of Schizophrenia or Bipolar disorder: Subgroup Membership Stability or Change From Age 7 to 11-The Danish High Risk and Resilience Study.

BACKGROUND AND HYPOTHESIS: Subgroups with distinct levels of neurocognitive functioning exist in children of parents with schizophrenia or bipolar disorder. However, studies investigating the temporal stability of subgroup membership are currently lacking. We hypothesized that a minority of children at familial high-risk of schizophrenia (FHR-SZ) or bipolar disorder (FHR-BP) would transition to a different neurocognitive subgroup from age 7 to 11 and that most transitions would be to a more impaired subgroup. STUDY DESIGN: Latent profile analysis was used to identify subgroups at two assessments (age 7 and 11) based on the performance of 320 children at FHR-SZ or FHR-BP across eight neurocognitive functions. Temporal stability in subgroup membership was evaluated with latent profile transition analysis. Population-based controls (age 7, n = 199; age 11, n = 178) were included as a reference group. Children transitioning to a more impaired subgroup were compared with nontransitioning children on sex, FHR-status, global functioning, and psychopathology. STUDY RESULTS: At both assessment points, we identified three subgroups based on neurocognitive performance: a moderately-severely impaired, a mildly impaired, and an above-average subgroup. A total of 12.8% of children transitioned to a different subgroup, of which the majority (85.2%) moved to a more impaired subgroup. Parental diagnosis of schizophrenia, but neither parental diagnosis of bipolar disorder, global functioning at age 7, psychopathology, nor sex significantly differentiated children transitioning to a more impaired subgroup from nontransitioning children. CONCLUSIONS: During pre-adolescence, neurocognitive developmental lag is associated with being at FHR-SZ. Close attention to these children's neurocognitive development is indicated.

Association Between Early Risk Factors and Level of Functioning at Age Seven in Children at Familial Risk for Schizophrenia Or Bipolar Disorder - the Danish High Risk and Resilience Study VIA 7.

Background: Facing multiple risk factors, relative to single risk factor exposure early in life can have great implications for negative child development. Objective: We aim to examine whether the prevalence of early risk factors is higher among children with familial high risk for schizophrenia or bipolar disorder compared to controls. Further, to investigate the association between number of early risk factors and level of functioning at age seven, and whether this possible association is different in children with familial high risk compared to controls. Method: The Danish High Risk and Resilience Study VIA 7 is a population-based cohort study of children of parents diagnosed with schizophrenia (N = 202), bipolar disorder (N = 120) and controls (N = 200). We conducted a semi-structured anamnestic interview with the child's primary caregiver to assess early risk factors from pregnancy to age four. We used the Children's Global Assessment Scale to measure level of functioning at age seven. Results: 13 out of 17 risk factors were more prevalent in children at familial high risk for schizophrenia and 7 out of 17 risk factors were more prevalent in children at familial high risk for bipolar disorder compared to controls. Level of functioning decreased 2.7 (95% CI, 2.2; 3.3)-points per risk factor, but the association was not significantly different across the three groups (p = 0.09). Conclusions: Our results showed that children at age seven with familial high risk for schizophrenia or bipolar disorder experience a greater number of early risk factors. A higher number of early risk factors were associated with lower level of functioning at age seven. However, the association is not different for children with familial high risk or controls.

Do improved structural surroundings reduce restrictive practices in psychiatry?

BACKGROUND AND OBJECTIVES: There is sparse evidence that modern hospital architecture designed to prevent violence and self-harm can prevent restrictive practices (RP). We examine if the use of RPs was reduced by the structural change of relocating a 170-year-old psychiatric university hospital (UH) in Central Denmark Region (CDR) to a new modern purpose-built university hospital. METHODS: The dataset includes all admissions (N = 19.567) and RPs (N = 13.965) in the self-contained CDR one year before and after the relocation of the UH. We compare RPs at the UH a year prior to and after relocation on November 16th (November 2017, November 2019) with RPs at the other psychiatric hospitals (RH) in CDR. We applied linear regression analysis to assess the development in the monthly frequency of RPs pre- and post-relocation and examine underlying trends. RESULTS: At UH, RPs performed decreased from 4073 to 2585 after relocation, whereas they remained stable (from 3676 to 3631) at RH. Mechanical restraint and involuntary acute medication were aligned at both UH and RH. Using linear regression analysis, we found an overall significant decrease in the use of all restrictive practices at UH with an inclination of -9.1 observations (95% CI - 12.0; - 6.3 p < 0.0001) per month throughout the two-year follow-up. However, the decrease did not deviate significantly from the already downward trend observed one year before relocation. Similar analyses performed for RH showed a stable use of coercion. CONCLUSION: The naturalistic features of the design preclude any definitive conclusion whether relocation to a new purpose-built psychiatric hospital decreased the RPs. However, we argue that improving the structural environment at the UH had a sustained effect on the already declining use of RPs, particularly mechanical restraint and involuntary acute medication.

The factor structure of attention-deficit/hyperactivity disorder in schoolchildren.

BACKGROUND: Most studies support a bifactor model of childhood ADHD with two specific factors. However, several studies have not compared this model with a bifactor model with three specific factors, few have tested the actual strength of the factors, and none have examined whether "talks excessively" should be treated as a hyperactivity versus impulsivity symptom in children with ADHD. AIMS: To examine the factor structure of ADHD symptoms and evaluate the relative strength of potential factors. METHODS: Parent-reports on the ADHD-Rating Scale (ADHD-RS-IV) were collected for 2044 schoolchildren from the general population and 147 children with ADHD from a clinical sample. Single-, two- and three-(correlated and bi-)factor models were tested using confirmatory factor analysis. RESULTS: Most models had a satisfactory fit. However, a correlated three-factor model where "talks excessively" was included as an indicator of impulsivity, and especially a bifactor model with one strong, well-defined general and two/three (ICD-10 defined) weak specific factors fit the data slightly better than the remaining models. CONCLUSIONS: The factor structure is best characterized by a bifactor model with a strong general factor and two/three weaker specific factors. Therefore, we suggest emphasizing the ADHD-RS-IV total score rather than the subscale scores in clinical practice.

Quality of life in pediatric patients with obsessive-compulsive disorder during and 3 years after stepped-care treatment.

The present study aimed to investigate the long-term quality of life (QoL) in a large sample of pediatric obsessive-compulsive disorder (OCD) patients. The study included 220 pediatric OCD patients from the Nordic Long-term OCD Treatment Study (NordLOTS) who were evaluated at seven time points before, during, and after stepped-care treatment over a 3-year follow-up period. Data from three symptom severity trajectory classes formed the basis of the QoL evaluation: acute (n = 127, N = 147), slow (n = 46, N = 63), and limited responders (n = 47, N = 59). Patients' QoL was assessed using parent and child ratings of the revised Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). QoL was analyzed by trajectory class using a random mixed effects model. The association between pre-treatment factors and long-term QoL was investigated across classes in a multivariate model. Three years after treatment, the acute responder class had reached QoL levels from a general population, whereas the limited responder class had not. The slow responder class reached norm levels for the child-rated QoL only. Higher levels of co-occurring externalizing symptoms before treatment were associated with lower parent-rated QoL during follow-up, while adolescence and higher levels of co-occurring internalizing symptoms were associated with lower child-rated QoL during follow-up. For some patients, residual OCD symptoms in the years after treatment, even at levels below assumed clinical significance, are associated with compromised QoL. Co-occurring symptoms could be part of the explanation. Assessing QoL after OCD treatment, beyond the clinician-rated symptom severity, could detect patients in need of further treatment and/or assessment. Trial registry: Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com ; ISRCTN66385119.

Factors Associated with a Delayed Autism Spectrum Disorder Diagnosis in Children Previously Assessed on Suspicion of Autism.

This study aimed to investigate factors associated with a delayed autism spectrum (ASD) diagnosis when compared to children with either no or early ASD diagnosis. Among 893 children assessed for ASD before age 8, 39% had no ASD at baseline, of which 21% received a later ASD diagnosis. Autism symptoms, diagnostic history of other developmental disorders, cognitive ability, and socioeconomic factors were associated with delayed ASD. Autism Diagnostic Observation Schedule (ADOS) scores in delayed ASD fell between early and no ASD. Other developmental disorders, time and clinical trends like ADOS use and low parental education distinguished delayed and early ASD, whereas higher frequency of IQ < 70 at baseline and a diagnosis of emotional disorders during follow-up distinguished delayed and no ASD.

Lung function in adults and future burden of obstructive lung diseases in a long-term follow-up.

Spirometry is recommended in symptomatic smokers to identify obstructive lung diseases. However, it is unknown whether there are certain characteristics that can be used to identify the individual risk of developing obstructive lung diseases. The aim of this study was to examine the association between lung function in adults and burden of lung diseases throughout 27 years of follow-up. We performed a cohort study among individuals aged 30-49 years at baseline (1991). Spirometry measurements were divided into three groups: (1) FEV1/FVC < 70, (2) FEV1/FVC: 70-75, (3) FEV1/FVC > 75 (reference). Using negative binominal regression, the burden of lung diseases was measured by contacts to general practice, hospitalisations, redeemed respiratory medicine and socioeconomic parameters between 1991 and 2017. A total of 905 citizens were included; mean age of 40.3 years, 47.5% were males and 51.2% were smokers at baseline. The group with an FEV1/FVC: 70-75 received more respiratory medicine (IRR = 3.37 (95% CI: 2.69-4.23)), had lower income (IRR = 0.96 (95% CI: 0.93-0.98)), and had more contacts to general practice (IRR = 1.14 (95% CI: 1.07-1.21)) and hospitals for lung diseases (IRR = 2.39 (95% CI: 1.96-5.85)) compared to the reference group. We found an association between lung function and the future burden of lung diseases throughout 27 years of follow-up. In particular, adults with an FEV1/FVC: 70-75 need extra attention in the case finding.

Mental well-being and job satisfaction in general practitioners in Denmark and their patients' change of general practitioner: a cohort study combining survey data and register data.

OBJECTIVES: Low job satisfaction and poor well-being (eg, stress and burnout) among physicians may have negative consequences for patient experienced healthcare quality. In primary care, this could manifest in patients choosing another general practitioner (GP). The objective of this study was to examine change of GP (COGP) (unrelated to change of address) among patients in relation to their GPs' job satisfaction, well-being and self-assessed work-ability. DESIGN AND SETTING: Data from a nationwide questionnaire survey among Danish GPs in May 2016 was combined with register data on their listed patients. Associations between patients' COGP in the 6-month study period (from May 2016) and the job satisfaction/well-being of their GP were estimated as risk ratios (RRs) at the individual patient level using binomial regression analysis. Potential confounders were included for adjustment. PARTICIPANTS: The study cohort included 569 776 patients aged ≥18 years listed with 409 GPs in single-handed practices. RESULTS: COGP was significantly associated with occupational distress (burnout and low job satisfaction) in the GP. This association was seen in a dose-response like pattern. For burnout, associations were found for depersonalisation and reduced sense of personal accomplishment (but not for emotional exhaustion). The adjusted RR was 1.40 (1.10-1.72) for patients listed with a GP with the lowest level of job satisfaction and 1.24 (1.01-1.52) and 1.40 (1.14-1.72) for patients listed with a GP in the most unfavourable categories of depersonalisation and sense of personal accomplishment (the most favourable categories used as reference). COGP was not associated with self-assessed work-ability or domains of well-being related to life in general. CONCLUSIONS: Patients' likelihood of changing GP increased with GP burnout and decreasing job satisfaction. These findings indicate that patients' evaluation of care as measured by COGP may be influenced by their GPs' work conditions and occupational well-being.

Mental well-being, job satisfaction and self-rated workability in general practitioners and hospitalisations for ambulatory care sensitive conditions among listed patients: a cohort study combining survey data on GPs and register data on patients.

BACKGROUND: Physicians' work conditions and mental well-being may affect healthcare quality and efficacy. Yet the effects on objective measures of healthcare performance remain understudied. This study examined mental well-being, job satisfaction and self-rated workability in general practitioners (GPs) in relation to hospitalisations for ambulatory care sensitive conditions (ACSC-Hs), a register-based quality indicator affected by referral threshold and prevention efforts in primary care. METHODS: This is an observational study combining data from national registers and a nationwide questionnaire survey among Danish GPs. To ensure precise linkage of each patient with a specific GP, partnership practices were not included. Study cases were 461 376 adult patients listed with 392 GPs. Associations between hospitalisations in the 6-month study period and selected well-being indicators were estimated at the individual patient level and adjusted for GP gender and seniority, list size, and patient factors (comorbidity, sociodemographic characteristics). RESULTS: The median number of ACSC-Hs per 1000 listed patients was 10.2 (interquartile interval: 7.0-13.7). All well-being indicators were inversely associated with ACSC-Hs, except for perceived stress (not associated). The adjusted incidence rate ratio was 1.26 (95% CI 1.13 to 1.42) for patients listed with GPs in the least favourable category of self-rated workability, and 1.19 (95% CI 1.05 to 1.35), 1.15 (95% CI 1.04 to 1.27) and 1.14 (95% CI 1.03 to 1.27) for patients listed with GPs in the least favourable categories of burn-out, job satisfaction and general well-being (the most favourable categories used as reference). Hospitalisations for conditions not classified as ambulatory care sensitive were not equally associated. CONCLUSIONS: ACSC-H frequency increased with decreasing levels of GP mental well-being, job satisfaction and self-rated workability. These findings imply that GPs' work conditions and mental well-being may have important implications for individual patients and for healthcare expenditures.

Looking beyond the mean in grief trajectories: A prospective, population-based cohort study.

BACKGROUND: Most individuals adjust to the loss of a close person, but some experience adverse grief that challenges everyday life. No previous study has examined the development of grief symptoms in trajectories over time. We aimed to investigate trajectories of grief symptoms in bereaved partners and non-partners of severely ill patients starting before death until three years after death of the patient. METHOD: We conducted a prospective population-based cohort study including 1138 partners and 597 non-partners of terminally ill patients. Participants completed the Prolonged Grief-13 scale pre-loss, six months post-loss, and three years post-loss. On this basis, we developed semi-parametric group-based trajectory models. Multinomial logistic regression models estimated, odds ratios (ORs) with 95% confidence intervals (CIs) between selected characteristics: age, gender, educational level, the patient's survival time, and types of grief trajectories. RESULTS: We identified five specific grief trajectories for partners and four for non-partners. Low grief was identified in 34% of partners and 45% of non-partners, moderate/decreasing grief in 30% of partners and 31% of non-partners, high/decreasing grief in 20% of partners and 16% of non-partners, and high grief in 7% of partners and 8% of non-partners. In addition, a late grief trajectory was identified in 10% of partners. Low education compared to high education was associated with adverse grief trajectories (OR = 0.19 (95% CI = 0.80, 0.43) for partners following a high grief trajectory). CONCLUSIONS: This study is the first to systematically describe specific trajectories of grief based on grief symptoms. The majority had a low or decreasing grief trajectory, whereas minor groups of partners and non-partners had a high grief trajectory, and a group of partners had a late grief trajectory. A consistent vulnerability factor was low education. Bereaved individuals may benefit from information on possible patterns of grief development, including adverse grief trajectories.

Factors related to out-of-hours help-seeking for acute health problems: a survey study using case scenarios.

BACKGROUND: The acute out-of-hours healthcare services are challenged by increasing demand in many countries. We aimed to examine factors influencing the intended help-seeking in out-of-hours care for acute health problems during evenings, nights, and weekends. METHODS: We conducted a survey study based on data from parents of children (aged 0-4 years) and adults (aged 30-39 and 50-59 years) in Denmark, the Netherlands and Switzerland. Intended help-seeking behaviour was measured by six hypothetical case scenarios. We used Andersen's Behavioural Model to categorise potentially influential factors and applied multiple binomial regression to assess the influence of selected factors. RESULTS: A total of 1015 parents and 2942 adults participated. We identified several significant influential factors. Parents holding a low education (OR 1.56), having migrant background (western: OR 1.23; non-western: OR 1.93), having one child (OR 1.24), perceiving few barriers to using out-of-hours primary care (OR 1.59), perceiving difficulties with organising childcare (OR 1.13), and having a history of frequent contacts with out-of-hours care (OR 1.55) were more inclined to contact out-of-hours care, whereas female (OR 0.85) and non-anxious parents (OR 0.77) were less inclined. Adults who were older (OR 1.01), holding a medical education (OR 1.13), having non-western background (OR 1.28), being unemployed (OR 1.17), perceiving few barriers to using out-of-hours primary care (OR 1.37), and having a history of frequent contacts with a GP (few: OR 1.15; more: OR 1.22) and/or with out-of-hours care (one: OR 1.20; more: OR 1.49) were more inclined to contact out-of-hours care, whereas adults with no or little social support (OR 0.84) and adults with high health literacy level on health information (OR 0.91) were less inclined. Dutch parents were less inclined than Danish parents to contact out-of-hours care (OR 0.62), whereas Swiss adults were more inclined than Danish adults to contact out-of-hours care (OR 1.16). CONCLUSION: We identified several factors related to intended help-seeking in out-of-hours care. These results could be used to develop targeted interventions, but more research is needed to examine the underlying explanations for the identified differences.

Help-seeking behaviour outside office hours in Denmark, the Netherlands and Switzerland: a questionnaire study exploring responses to hypothetical cases.

OBJECTIVES: We aim to study the preferred behaviour among individuals from different age groups in three countries when acute health problems occur outside office hours and thereby to explore variations in help-seeking behaviour. DESIGN: A questionnaire study exploring responses to six hypothetical cases describing situations with a potential need for seeking medical care and questions on background characteristics. SETTING: General population in Denmark, the Netherlands and Switzerland. POPULATION: Danish, Dutch and Swiss individuals from three age groups (0-4, 30-39, 50-59 years). MAIN OUTCOME MEASURES: Distribution of intended help-seeking preferences per case per age group, compared between countries. Differences in percentage of help-seeking outside office hours per age group and country, crude and adjusted for background characteristics. RESULTS: Danish and Dutch parents of children aged 0-4 years differed in intended help-seeking behaviour for five out of six cases (abdominal pain, red eyes, rash, relapse fever, chickenpox); Danish parents significantly more often chose to contact out-of-hours (OOH) care than Dutch parents. For adults aged 30-39 years, no significant difference between the three countries was found for contacting OOH care. Swiss adults aged 50-59 years had the highest percentage of OOH contacts (38.3%), followed by the Danish (33.4%) and the Dutch (32.5%). CONCLUSION: Some differences in help-seeking behaviour outside office hours exist between Danish, Dutch and Swiss individuals, particularly for parents of young children. The question remains whether these differences result from individual preferences, cultural disparities and/or health services variations. Future research should focus on identifying explanations for these differences to reduce undesirable use of OOH care.

Differences in diagnostic activity in general practice and findings for individuals invited to the danish screening programme for colorectal cancer: a population-based cohort study.

OBJECTIVE: To investigate the diagnostic activity in general practice and the cumulative incidence of colorectal cancer (CRC) in individuals invited to the Danish national screening programme for CRC. DESIGN: A historical population-based cohort study. SETTING: The Danish CRC screening programme and general practice. SUBJECTS: The 376,198 individuals invited to the Danish CRC screening programme from 1 March to 31 December 2014. MAIN OUTCOME MEASURES: The diagnostic activity (consultations and haemoglobin measures) in general practice in the year preceding the screening invitation and the cumulated incidence of CRC in the year following the screening invitation. RESULTS: Screening participants had significantly higher diagnostic activity than non-participants. Individuals with a positive faecal immunochemical test (FIT) had higher diagnostic activity compared to individuals with a negative FIT, and a small increase in the months leading up to the invitation. Individuals with a screen-detected CRC had lower diagnostic activity than individuals with no CRC. In total, 308 (25.3%) of CRCs diagnosed in the invited population were diagnosed outside the screening programme. Non-participants with CRC more often had low socio-economic status, high comorbidity and stage IV CRC than participants with CRC. CONCLUSIONS: There was a tendency that participants and those with a positive FIT had a higher diagnostic activity the year before the screening. This was not seen for those with CRC detected through screening. CRC must still be diagnosed in general practice in the invited population and non-participants are of special interest as they have higher risk of late stage CRC. Key Points Current awareness:Individuals with colorectal cancer (CRC) in screening may be symptomatic and CRC may still occur outside screening in the invited population. Most important points:The majority of individuals with CRC in screening cannot be expected to be diagnosed on symptomatic presentation in general practice GPs have to be aware that CRC still occurs outside screening in the invited population Non-participants with CRC are often deprived and have late stage CRC.

Data quality and factor analysis of the Danish version of the Relationship Scale Questionnaire.

BACKGROUND: The Relationship Scale Questionnaire (RSQ) is a widely-used measure of adult attachment, but whether the results obtained by the RSQ fit the attachment construct has only been examined to a limited extent. OBJECTIVE: The objectives of this study were to investigate the psychometric properties of the Danish translation of the RSQ and to test whether the results are consistent with the hypothesized model of attachment. METHODS: The study included two samples: 602 general practitioners and 611 cancer patients. The two samples were analyzed separately. Data quality was assessed by mean, median and missing values for each item, floor and ceiling effects, average inter-item correlations and Cronbach's α for each subscale. Test-retest was assessed by intra-class correlations among 76 general practitioners. A confirmatory factor analysis was conducted to establish evidence of the four proposed subscales. Due to an inadequate fit of the model, data was randomly split into two equally sized subsamples and an exploratory factor analysis was conducted for all 30 items in the first subsample comprised of 286 cancer patients and 285 general practitioners. The EFA yielded a three-factor structure which was validated through a confirmatory factor analyses in a second subsample comprised of 278 cancer patients and 289 general practitioners. RESULTS: The data quality of the RSQ was generally good, except low internal consistency and low to moderate test-retest reliability. The four subscales of the RSQ were not confirmed by the confirmatory factor analysis. An exploratory factor analysis suggested a three-factor solution for both general practitioners and patients, which accounted for 61.1% of the variance among general practitioners and 62.5% among patients. The new three-factor solution was verified in a confirmatory factor analyses. CONCLUSION: The proposed four-factor model of the RSQ could not be confirmed in this study. Similar challenges have been found by other studies validating the RSQ. An alternative three-factor structure was found for the RSQ.

Measurement properties of the Danish version of the Awareness and Beliefs about Cancer (ABC) measure.

BACKGROUND: The International Cancer Benchmarking Partnership aims to study international differences in cancer survival and the possible causes. Participating countries are Australia, Canada, Norway, Sweden, Denmark and the UK and a particular focus area is differences in awareness and beliefs about cancer. In this connection, the Awareness and Beliefs about Cancer (ABC) measure has been translated into multiple languages. The aim of this study is to appraise the translation process and measurement properties of the Danish version of the ABC measure. METHODS: The translation process included forward and backward translations and a pilot-test. Data quality was assessed using survey data from 3000 Danish respondents and content validity indexes were calculated based on judgments from ten academic researchers. Construct validity was determined by a confirmative factor analysis (CFA) and exploratory factor analyses (EFA) using survey data and a known group comparison analysis including 56 persons. Test-retest reliability was assessed based on responses from 123 person whom completed the interview twice with an interval of 2-3 weeks. RESULTS: The translation process resulted in a Danish ABC measure conceptually equivalent to the English ABC measure. Data quality was acceptable in relation to non-response to individual items which was maximum 0.3%, but the percentage of respondents answering 'don't know' was above 3% for 16 out of 48 items. Content validity indexes showed that items adequately reflected and represented the constructs to be measured (item content validity indexes: 0.9-1.0; construct content validity indexes: 0.8-1.0). The hypothesised factor structure could not be replicated by a CFA, but EFA on each individual subscale showed that six out of seven subscales were unidimensional. The ABC measure discriminated well between non-medical academics and medical academics, but had some difficulties in discriminating between educational groups. Test-retest reliability was moderate to substantial for most items. CONCLUSIONS: The Danish ABC measure is a useful measurement that is accepted and understood by the target group and with accepted measurement criteria for content validity and test-retest reliability. Future studies may further explore the factorial structure of the ABC measure and should focus on improving the response categories.

Symptoms as the main problem: a cross- sectional study of patient experience in primary care.

BACKGROUND: Symptoms are common in primary care. Besides providing thorough assessment of possible severe disease, the general practitioner (GP) must ensure good health care to all patients, irrespective of diagnoses. We aimed to explore patient satisfaction with the provided care and how well expectations in patients were met when no diagnosis was made during the consultation. METHOD: Cross-sectional study based on a questionnaire survey conducted in 2008-2009 among 377 GPs and their patients in the Central Denmark Region. A total of 2286 patients completed a questionnaire after the consultation (response rate: 54 %). The questionnaire included four satisfaction items from the EUROPEP instrument and a question about unmet expectations. For each patient, the GP answered a one-page registration form including information about the main problem in the consultation, chronic disorders and assessment of prognosis. Statistical analyses were adjusted for patient characteristics and GP clustering. RESULTS: A higher proportion of patients reported illness worry (20 vs. 17 %, p-value: 0.005), unmet expectations (17 vs. 13 %, p-value: 0.019) and dissatisfaction with their GP after the consultation when no diagnosis was made. Dissatisfaction was primarily related to the medical examination (adjusted OR 1.30; 95 % CI: 1.06-1.60) and GP explanations (adjusted OR 1.40; 95 % CI: 1.14-1.71). Exploratory analyses revealed an association between dissatisfaction with examination and the GP assessment that symptoms were unrelated to biomedical disease. This association was found both in patients with 'symptoms only' and patients given a specific diagnosis. CONCLUSION: GPs are challenged by patients presenting symptoms that do not fit the patterns of biomedical diagnoses. The current study demonstrates more illness worry, unmet expectations and dissatisfaction with the consultation in these patients compared to patients receiving a diagnosis. This trend is true for all patients assessed as having 'symptoms only' at the end of a consultation and not only for the minority group with 'medically unexplained symptoms'. As primary care is the frontline of the health-care system, symptoms are managed as the main problem in almost one in three consultations. It is about time that we take the same professional approach to symptoms as we have done for years to biomedical disease.

The prognosis of bodily distress syndrome: a cohort study in primary care.

OBJECTIVE: Bodily distress syndrome (BDS) is a newly proposed diagnosis for functional disorders. The diagnosis is based on empirical research, but little is known about the course of the disease. We aimed to study the prognosis in terms of diagnosis stability over time. METHOD: A longitudinal study of 1356 primary care patients with 2-year follow-up was conducted in the Central Denmark Region. Data were obtained from family physician registration forms, patient questionnaires (including a BDS checklist) and nationwide registries. Complete data were available for 1001 patients (73.8%). RESULTS: Overall, 146 persons [14.6%, 95% confidence interval (CI): 12.5-16.9] fulfilled the criteria for BDS at baseline and 142 persons (14.2%, CI: 12.1-16.5) at follow-up. Among study participants with BDS at baseline, 56.8% (CI: 48.4-65.0) also had BDS at follow-up. Multiorgan BDS tended to be more persistent (81.8%, CI: 48.2-97.7) than single-organ BDS (54.8%, CI: 46.0-63.4). Patients with BDS had fewer socioeconomic resources, experienced more emotional distress, and used more opioids and medical services. CONCLUSIONS: BDS is a common clinical condition being prone to chronicity; one in seven primary care patients met the criteria for BDS, and more than half of these patients still suffered from BDS 2 years later.