Social disparities in the prevalence of multimorbidity - A register-based population study.

BACKGROUND: Prevalences of multimorbidity vary between European studies and several methods and definitions are used. In this study we examine the prevalence of multimorbidity in relation to age, gender and educational attainment and the association between physical and mental health conditions and educational attainment in a Danish population. METHODS: A cross-sectional design was used to study the prevalence of multimorbidity, defined as two or more chronic conditions, and of comorbid physical and mental health conditions across age groups and educational attainment levels among 1,397,173 individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. After calculating prevalence, odds ratios for multimorbidity and mental health conditions were derived from logistic regression on gender, age, age squared, education and number of physical conditions (only for odds ratios for mental health conditions). Odds ratios for having multimorbidity and mental health conditions for each variable were adjusted for all other variables. RESULTS: Multimorbidity prevalence was 21.6%. Half of the population aged 65 and above had multimorbidity, and prevalence was inversely related to educational attainment: 26.9% (95% CI, 26.8-26.9) among those with lower secondary education versus 13.5% (95% CI, 13.5-13.6) among people with postgraduate education. Adjusted odds ratios for multimorbidity were 0.50 (95% CI, 0.49-0.51) for people with postgraduate education, compared to people with lower secondary education. Among all population members, 4.9% (95% CI, 4.9-4.9) had both a physical and a mental health condition, a proportion that increased to 22.6% of people with multimorbidity. Physical and mental health comorbidity was more prevalent in women (6.33%; 95% CI, 6.3-6.4) than men (3.34%; 95% CI, 3.3-3.4) and approximately 50 times more prevalent among older persons than younger ones. Physical and mental health comorbidity was also twice as prevalent among people with lower secondary education than among those with postgraduate education. The presence of a mental health condition was strongly associated with the number of physical conditions; those with five or more physical conditions had an adjusted odds ratio for a mental health condition of 3.93 (95% CI, 3.8-4.1), compared to those with no physical conditions. CONCLUSION: Multimorbidity prevalence and patterns in the Danish population are comparable to those of other European populations. The high prevalence of mental and physical health conditions highlights the need to ensure that healthcare systems deliver care that takes physical and mental comorbidity into account. Further, the higher prevalence of multimorbidity among persons with low educational attainment emphasizes the importance of having a health care system providing care that is beneficial to all regardless of socioeconomic status.

Quality of care for people with multimorbidity - a case series.

BACKGROUND: Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark. METHODS: To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients' medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records. RESULTS: The review of the patients' records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment. CONCLUSIONS: Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.

A qualitative study of integrated care from the perspectives of patients with chronic obstructive pulmonary disease and their relatives.

BACKGROUND: Disease management programmes have been developed for chronic obstructive pulmonary disease (COPD) to facilitate the integration of care across healthcare settings. The purpose of the present study was to examine the experiences of COPD patients and their relatives of integrated care after implementation of a COPD disease management programme. METHODS: Seven focus groups and five individual interviews were held with 34 patients with severe or very severe COPD and two focus groups were held with eight of their relatives. Data were analysed using inductive content analysis. RESULTS: Four main categories of experiences of integrated care emerged: 1) a flexible system that provides access to appropriate healthcare and social services and furthers patient involvement; 2) the responsibility of health professionals to both take the initiative and follow up; 3) communication and providing information to patients and relatives; 4) coordination and professional cooperation. Most patients were satisfied with their care and raised few criticisms. However, patients with more unstable and severe disease tended to experience more problems. CONCLUSIONS: Participant suggestions for optimizing the integration of healthcare included assigning patients a care coordinator, telehealth solutions for housebound patients and better information technology to support interprofessional cooperation. Further studies are needed to explore these and other possible solutions to problems with integrated care among COPD patients. A future effort in this field should be informed by detailed knowledge of the extent and relative importance of the identified problems. It should also be designed to address variable levels of severity of COPD and relevant comorbidities and to deliver care in ways appropriate to the respective healthcare setting. Future studies should also take health professionals' views into account so that interventions may be planned in the light of the experiences of all those involved in the treatment of COPD patients.

Older people's perception of and coping with falling, and their motivation for fall-prevention programmes.

AIMS: This study aims to investigate older people's perceptions of and coping with falls, and what motivates them to join such programmes. METHOD: We used semi-structured interviews to collect data on 14 individuals (65 years +) who contacted an emergency department because they had fallen. Data were analyzed using a phenomenographic approach that traces older people's perception of the phenomenon of ''falling''. RESULTS: Five categories and 15 subcategories emerged from the interviews. The five main categories were: emotional perceptions of falling; falling has consequences; coping with the situation; support from the social network; motivation and demotivation. To fall was shameful and embarrassing and could be explained by old age. To some, ''fear of falling'' was the dominant feeling. These people did not see falls as a risk factor they ought to care about. Instead, to prevent future falls, they restricted their activities or stopped certain activities altogether. If demands exceeded their resources, they asked their relatives or their general practitioner for help. Elderly people were motivated by autonomy, competence, and relatedness and preferred activities that spread happiness and joy, preferably in a social atmosphere, but they encountered elements in their surroundings that curbed their motivation. CONCLUSIONS: Future fall-prevention programmes must target older people's needs and acknowledge that there are many ways of perceiving falling. Moreover, elderly individuals' coping strategies are not necessarily productive. Social networks and general practitioners can actively encourage older people to participate in fall-prevention programmes. Such programmes must support older people's need for autonomy, competence and social relations.

[Life-threatening illness and the decision to resuscitate or not].

Current Danish guidance stipulates, that the physician responsible for treatment must assess, if resuscitation is medically indicated in patients with life-threatening illness. Nevertheless, terminally ill patients without medical indication for resuscitation are still asked about preferences for resuscitation rather than informed about the decision not to resuscitate. This review describes clinical dilemmas, which may arise, if these legal rights are misinterpreted. It provides a communication guide designed to assist physicians communicating with patients about the decision to resuscitate or not.

Involving patients with multimorbidity in service planning: perspectives on continuity and care coordination.

BACKGROUND: The prevalence of multiple comorbid chronic conditions, or multimorbidity, is increasing. Care provided to people with multimorbidity is often fragmented, incomplete, inefficient, and ineffective. As part of a research and development project focusing on improving care, we sought to involve patients with multimorbidity in the planning process. OBJECTIVE: To identify opportunities for improving care by understanding how patients from a Danish University Hospital experience care coordination. DESIGN: Qualitative semi-structured interviews with 14 patients with multimorbidity. RESULTS: Patients with multimorbidity described important concerns about care that included: (1) disease-centered, rather than patient-centered, care; (2) lack of attention to comorbidities and patient preferences and needs; and (3) involvement of numerous healthcare providers with limited care coordination. Poor continuity of care resulted in lack of treatment for complex problems, such as pain and mental health issues, medication errors, adverse events, and a feeling of being lost in the system. Receiving care from generalists (e.g. general practitioners and healthcare professionals at prevention centers) and having a care coordinator seemed to improve patients' experience of continuity and coordination of care. Suggestions for service improvements when providing care for people with multimorbidity included using care coordinators, longer consultation times, consultations specifically addressing follow-up on prescribed medications, and shifting the focus of care from disease states to patients' overall health status. CONCLUSIONS: A need exists for a reorganization of care delivery for people with multimorbidity that focuses on improved care coordination and puts patient preferences at the center of care.

[Clinical communication skills training is an educational challenge]. / Klinisk kommunikationstræning er en uddannelsesmæssig udfordring.

This qualitative study presents results from a development project of clinical communication skills training for physicians in a paediatric ward. Overall, the doctors express that the training positively supports their clinical work and that it provides a model for discussing communication challenges with colleagues. Challenges, however, are time constraints and overcoming conventional hierarchical structures. Prerequisites for ward-based communication training thus are: a suitable timeframe, use of a structured feedback model, managerial backup, and support from external expertise.

[Clinical communication skills training is an educational challenge]. / Klinisk kommunikationstræning er en uddannelsesmæssig udfordring.

This qualitative study presents results from a development project of clinical communication skills training for physicians in a paediatric ward. Overall, the doctors express that the training positively supports their clinical work and that it provides a model for discussing communication challenges with colleagues. Challenges, however, are time constraints and overcoming conventional hierarchical structures. Prerequisites for ward-based communication training thus are: a suitable timeframe, use of a structured feedback model, managerial backup, and support from external expertise.

[The use of reflection as an educational tool is important to render professional competence]. / Refleksion som læringsmetode i den professionelle rolle er vigtig.

Professionalism can be difficult to teach and integrate in the clinical training of younger doctors. Making the professional competences visible in an educational context is a challenge for most clinical educators. This paper presents the use of reflection as an educational tool, where the use of narratives, literature and focused dialogues with a supervisor are relevant methods. These approaches make it possible to render the professional competences concrete and tangible in the supervision of professional identity development as well as in the ways of being a doctor.

Instruments to assess integrated care: a systematic review.

INTRODUCTION: Although several measurement instruments have been developed to measure the level of integrated health care delivery, no standardised, validated instrument exists covering all aspects of integrated care. The purpose of this review is to identify the instruments concerning how to measure the level of integration across health-care sectors and to assess and evaluate the organisational elements within the instruments identified. METHODS: An extensive, systematic literature review in PubMed, CINAHL, PsycINFO, Cochrane Library, Web of Science for the years 1980-2011. Selected abstracts were independently reviewed by two investigators. RESULTS: We identified 23 measurement instruments and, within these, eight organisational elements were found. No measurement instrument covered all organisational elements, but almost all studies include well-defined structural and process aspects and six include cultural aspects; 14 explicitly stated using a theoretical framework. CONCLUSION AND DISCUSSION: This review did not identify any measurement instrument covering all aspects of integrated care. Further, a lack of uniform use of the eight organisational elements across the studies was prevalent. It is uncertain whether development of a single 'all-inclusive' model for assessing integrated care is desirable. We emphasise the continuing need for validated instruments embedded in theoretical contexts.

Effects of telemedicine in the treatment of patients with type 2 diabetes--a study protocol.

INTRODUCTION: Despite rehabilitation programmes offered to all patients with newly diagnosed type 2 diabetes in Denmark, a number of patients either never accomplish good diabetes regulation or the regulation deteriorates with time. Therefore, new approaches are needed. The aim of the present study is to examine whether telemedicine conferences with a nurse can contribute to achieving good diabetes control among patients with poorly regulated type 2 diabetes. MATERIAL AND METHODS: A total of 165 patients with type 2 diabetes who have formerly undergone a rehabilitation programme are randomized to either telemedicine intervention or usual care. The intervention lasts for 32 weeks and consists of monthly videoconferences with a nurse from a health-care centre as an add-on to usual care. Blood sugar, blood pressure and weight are regularly self-monitored and measurements are automatically transferred to a database. Glycaemic control (HbA1c level) is examined at baseline, 16 weeks, 32 weeks and 58 weeks (six months post intervention). Blood pressure, weight, waist/hip ratio, quality of life, physical activity, lipids, creatinine and haemoglobin are examined at baseline and after 32 weeks. CONCLUSION: The study will examine whether telemedicine technology can contribute to achieving good diabetes regulation. FUNDING: The City of Copenhagen and the Prevention Fund of the Capital Region of Denmark funded the project. Also "Smedemester Niels Hansen og Hustru Johanne F. Frederiksens Legat" has supported the study. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT01688778.

Integration of healthcare rehabilitation in chronic conditions.

INTRODUCTION: Quality of care provided to people with chronic conditions does not often fulfil standards of care in Denmark and in other countries. Inadequate organisation of healthcare systems has been identified as one of the most important causes for observed performance inadequacies, and providing integrated healthcare has been identified as an important organisational challenge for healthcare systems. Three entities-Bispebjerg University Hospital, the City of Copenhagen, and the GPs in Copenhagen-collaborated on a quality improvement project focusing on integration and implementation of rehabilitation programmes in four conditions. DESCRIPTION OF CARE PRACTICE: FOUR MULTIDISCIPLINARY REHABILITATION INTERVENTION PROGRAMMES, ONE FOR EACH CHRONIC CONDITION: chronic obstructive pulmonary disease, type 2 diabetes, chronic heart failure, and falls in elderly people were developed and implemented during the project period. The chronic care model was used as a framework for support of implementing and integration of the four rehabilitation programmes. CONCLUSION AND DISCUSSION: The chronic care model provided support for implementing rehabilitation programmes for four chronic conditions in Bispebjerg University Hospital, the City of Copenhagen, and GPs' offices. New management practices were developed, known practices were improved to support integration, and known practices were used for implementation purposes. Several barriers to integrated care were identified.