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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 [ABSTRACT FROM AUTHOR]

Background: Around 50% of individuals with colorectal cancer (CRC) initially present with non-alarm symptoms.Methods: We investigated the value of using the faecal immunochemical test (FIT) in the diagnostic process of CRC and other serious bowel disease in individuals presenting with non-alarm symptoms in general practice. The study was conducted in the Central Denmark Region from 1 September 2015 to 30 August 2016. The FIT was used as a rule-in test on patients aged ≥30 years with non-alarm symptoms of CRC. The cut-off value was set to 10 µg Hb/g faeces.Results: A total of 3462 valid FITs were performed. Of these, 540 (15.6%) were positive. Three months after FIT performance, 51 (PPV: 9.4% (95% CI: 7.0;11.9)) individuals with a positive FIT were diagnosed with CRC and 73 (PPV: 13.5% (95%CI: 10.6;16.4)) with other serious bowel disease. Of CRCs, 66.7% were diagnosed in UICC stage I & II and 19.6% in stage IV. The false negative rate for CRC was <0.1% for the initial 3 months after FIT performance.Conclusion: The FIT may be used as a supplementary diagnostic test in the diagnostic process of CRC and other serious bowel disease in individuals with non-alarm symptoms of CRC in general practice. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective:The objective of this study is to identify points of agreement and disagreements among general practitioners (GPs) in Denmark concerning how the existential dimension is understood, and when and how it is integrated in the GP–patient encounter. Design:A qualitative methodology with semi-structured focus group interviews was employed. Setting:General practice setting in Denmark. Subjects:Thirty-one GPs from two Danish regions between 38 and 68 years of age participated in seven focus group interviews. Results:Although understood to involve broad life conditions such as present and future being and identity, connectedness to a society and to other people, the existential dimension was primarily reported integrated in connection with life-threatening diseases and death. Furthermore, integration of the existential dimension was characterized as unsystematic and intuitive. Communication about religious or spiritual questions was mostly avoided by GPs due to shyness and perceived lack of expertise. GPs also reported infrequent referrals of patients to chaplains. Conclusion:GPs integrate issues related to the existential dimension in implicit and non-standardized ways and are hindered by cultural barriers. As a way to enhance a practice culture in which GPs pay more explicit attention to the patients’ multidimensional concerns, opportunities for professional development could be offered (courses or seminars) that focus on mutual sharing of existential reflections, ideas and communication competencies. Key pointsAlthough integration of the existential dimension is recommended for patient care in general practice, little is known about GPs’ understanding and integration of this dimension in the GP–patient encounter.The existential dimension is understood to involve broad and universal life conditions having no explicit reference to spiritual or religious aspects.The integration of the existential dimension is delimited to patient cases where life-threatening diseases, life crises and unexplainable patient symptoms occur. Integration of the existential dimension happens in unsystematic and intuitive ways.Cultural barriers such as shyness and lack of existential self-awareness seem to hinder GPs in communicating about issues related to the existential dimension. Educational initiatives might be needed in order to lessen barriers and enhance a more natural integration of communication about existential issues. [ABSTRACT FROM PUBLISHER]

Background: Colorectal cancer is a common malignancy and a leading cause of cancer-related death. Half of patients with colorectal cancer initially present with non-specific or vague symptoms. In the need for a safe low-cost test, the immunochemical faecal occult blood test (iFOBT) may be part of the evaluation of such patients in primary care. Currently, Danish general practitioners have limited access to this test. The aim of this article is to describe a study that will assess the uptake and clinical use of iFOBT in general practice. Furthermore, it will investigate the diagnostic value and the clinical implications of using iFOBT in general practice on patients presenting with non-alarm symptoms of colorectal cancer.Methods/design: The study uses a cluster-randomised stepped-wedge design and is conducted in the Central Denmark Region among 836 GPs in 381 general practices. The municipalities of the Region and their appertaining general practitioners will be included sequentially in the study during the first 7 months of the 1-year study period. The following intervention has been developed for the study: a mandatory intervention providing all general practitioners with a starting package of 10 iFOBTs, a clinical instruction on iFOBT use in general practice and online information material from the date of inclusion, and an optional intervention consisting of a continuous medical education on colorectal cancer diagnostics and use of iFOBT.Discussion: This study is among the first and largest trials to investigate the diagnostic use and the clinical value of iFOBT on patients presenting with non-alarm symptoms of colorectal cancer. The findings will be of national and international importance for the future planning of colorectal cancer diagnostics, particularly for 'low-risk-but-not-no-risk' patients with non-alarm symptoms of colorectal cancer.Trial Registration: A Trial of the Implementation of iFOBT in General Practice NCT02308384 . Date of registration: 26 November 2014. [ABSTRACT FROM AUTHOR]

Background: Some European countries have introduced standardised cancer patient pathways (CPPs), including urgent referrals, with the aim of diagnosing cancer at an earlier stage. This is despite a lack of evidence, particularly in patients with symptomatic cancer diagnosed via general practice.Aim: To compare tumour stages in patients with incident cancer diagnosed via general practice before, during, and after CPP implementation in Denmark in 2008-2009.Design and Setting: A comparative cohort study of data from GPs and registries on patients with incident cancer listed with a GP before (n = 1420), during (n = 5272), and after (n = 2988) CPP implementation.Method: χ(2) test was used to compare stage distributions and logistic regression to estimate odds ratios (OR) of having local cancer after versus before CPP implementation.Results: Distribution of tumour stages did not differ statistically significantly across time (P = 0.494) or between CPP use (P = 0.202). For all cancers combined, the OR of having local cancer after CPP implementation was 0.88 (95% confidence interval [CI] = 0.73 to 1.06) compared with before. For CPP-referred patients, the OR of having local cancer was 0.77 (95% CI = 0.62 to 0.94) compared with all patients before CPP implementation; the corresponding OR for non-CPP-referred patients was 0.96 (95% CI = 0.80 to 1.14).Conclusion: No clear tendencies were observed confirming earlier detection of cancer after rather than before CPP implementation. CPP-referred patients had lower odds of having local cancer after CPP implementation than all patients before CPP implementation; this could be because the GPs refer patients who are 'more ill' as urgent referrals. [ABSTRACT FROM AUTHOR]

Background:Sexually transmitted infections (STIs) continue to be highly prevalent in young people. New understanding of sexual risk behaviour is essential for future preventive initiatives. Studies based on self-reported STI history indicate that gap length between sexual partnerships is an important determinant in STI transmission, but little is known about the impact of concurrent partnerships and short gap length. This study aimed to examine the significance of concurrent partnerships and short gap length between serially monogamous partnerships inChlamydia trachomatis-infected individuals compared to the general population.Methods:A Danish cross-sectional study was conducted among individuals aged 15–29 years with a verifiedC. trachomatisinfection and a sample of the background population. Participants answered a web-based questionnaire on sexual behaviour. Associations were identified in multivariate analyses.Results:In total, 36% of the included young adults reported that they had two or more partners within the last year. Concurrent partnerships were frequent (46%), and the gap length between serially monogamous partnerships tended to be short (median gap length, 64 days, interquartile interval (IQI) = 31, 122). A strong association was found between concurrent partnerships (odds ratio (OR) = 12.5, 95% confidence interval (CI) = 7.7–20.4), short gap length between serially monogamous partnerships (OR = 10.0, 95% CI = 5.7–17.4) and having a verifiedC. trachomatisinfection.Conclusions: C. trachomatisinfection was strongly associated with concurrent partnerships or short gap length between serially monogamous partnerships. These findings have considerable implications for public health policy. Both types of risk factors should be considered in future preventive interventions aiming to reduce the spread ofC. trachomatisinfections. [ABSTRACT FROM AUTHOR]

Objectives Sexually transmitted infections and unwanted pregnancies occur at high rates among youth. Understanding sexual behaviour is essential for planning and implementing future effective preventive interventions. The present study examines the sexual behaviour in the general Danish population aged 15-29 years using the core indicators recommended by the European Centre for Disease Prevention and Control. Methods A nationwide cross-sectional study was conducted in Denmark among a random sample of 20 000 men and women in 2012. Respondents completed a web-based sexual behaviour questionnaire and data were linked to a nationally held demographic database. Core indicators for sexual behaviour frequency stratified by gender are presented as unweighted and weighted data after consideration of sociodemographic differences between respondents and non-respondents. Results Response rate was 20.4%. Condoms were used at sexual debut by 69.9% of women and 62.3% of men, while 14.3% of women and 15.1% of men used no contraceptives at sexual debut. Half of the respondents used condom alone at the latest sexual encounter with a steady partner (women 51.8%, men 55.2%), while 10% used no contraceptives. Having a sexual encounter with a casual partner decreased the likelihood of using condoms (women 43.7%, men 49.5%) and increased the likelihood of using no contraceptives (women 14.8%, men 20.9%). Data on sexual behaviour characteristics showed only minor changes when weighted for non-response. Conclusions The findings call for interventions addressing the use of appropriate contraception at sexual debut and at last sexual encounter; this seems particularly important when the sexual partner is a casual partner. [ABSTRACT FROM AUTHOR]

Background: From 2008, Danish general practitioners could refer patients suspected of having cancer to standardised cancer patient pathways (CPPs). We aimed to compare the length of the diagnostic interval in 2010 with the length of the diagnostic interval before (2004/05) and during (2007/08) the implementation of CPPs in Denmark for all incident cancer patients who attended general practice prior to the cancer diagnosis. Methods: General practitioner questionnaires and register data on 12,558 patients were used to compare adjusted diagnostic interval across time by quantile regression. Results: The median diagnostic interval was 14 (95% CI: 11;16) days shorter during and 17 (95% CI: 15;19) days shorter after the implementation of CPPs than before. The diagnostic interval was 15 (95% CI: 12;17) days shorter for patients referred to a CPP in 2010 than during the implementation, whereas patients not referred to a CPP in 2010 had a 4 (95% CI: 1;7) days longer median diagnostic interval; the pattern was similar, but larger at the 75th and 90th percentiles. Conclusion: The diagnostic interval was significantly lower after CPP implementation. Yet, patients not referred to a CPP in 2010 tended to have a longer diagnostic interval compared to during the implementation. CPPs may thus only seem to expedite the diagnostic process for some cancer patients. [ABSTRACT FROM AUTHOR]

Objective. Little is known about the prognosis of patients with chronic disease who contact the out-of-hours (OOH) service in primary care. The characteristics of contacts with the Danish out-of-hours service and daytime general practice, hospitalization, and death were studied during a 30-day follow-up period in patients with chronic heart diseases. Design. Cohort study. Setting and subjects. The study was based on data from 11 897 adults aged 18 + years from a Danish survey of OOH contacts, including information on consultation type. Reason for encounter (RFE) was categorized by OOH GPs at triage as either 'exacerbation' or 'new health problem'. Registry data were used to identify eligible patients, and the cohort was followed for 30 days after OOH contact through nationwide registries on healthcare use and mortality. Main outcome measures. The 30-day prognosis of chronic-disease patients after OOH contact. Results. Included patients with chronic disease had a higher risk of new OOH contact, daytime GP contact, and hospitalization than other patients during the 30-day follow-up period. OOH use was particularly high among patients with severe mental illness. A strong association was seen between chronic disease and risk of dying during follow-up. Conclusion. Patients with chronic disease used both daytime general practice and the out-of-hours service more often than others during the 30-day follow-up period; they were more often hospitalized and had higher risk of dying. The findings call for a proactive approach to future preventive day care and closer follow-up of this group, especially patients with psychiatric disease. [ABSTRACT FROM AUTHOR]

Background: The importance of proactive chronic care has become increasingly evident. Yet, it is unknown whether the use of general practice (GP) during daytime may affect the use of Out-of-Hours (OOH) Primary Care Service for people with chronic disease. We aimed to analyse the association between use of daytime general practice (GP) and use of OOH services for heart disease, lung disease, diabetes, psychiatric disease, or cancer. In particular, we intended to study the association between OOH contacts due to chronic disease exacerbation and recent use of daytime GP. Methods: Data comprised a random sample of contacts to the OOH services ('LV-KOS2011'). Included patients were categorised into the following chronic diseases: heart disease, lung disease, diabetes, psychiatric disease, or cancer. Information on face-to-face contacts to daytime GP was obtained from the Danish National Health Insurance Service Registry and information about exacerbation or new episodes from the LVKOS2011 survey. Associations between number of regular daytime consultations and annual follow-up consultations during one, three, six, and 12 months prior to index contacts, and outcomes of interest were estimated by using logistic regression. Results: In total, 11,897 patients aged ≥ 18 years were included. Of these, 2,665 patients (22.4%) were identified with one of the five selected chronic diseases; 673 patients (5.7%) had two or more. A higher odds ratio (OR) for exacerbation as reason for encounter (RFE) at the index contact was observed among patients with psychiatric disease (OR = 2.15) and cancer (OR = 2.17) than among other patients for ≥2 daytime recent contacts. When receiving an annual follow-up, exacerbation OR at index contact lowered for patients with lung disease (OR = 0.68), psychiatric disease (OR = 0.42), or ≥2 diseases (OR = 0.61). Conclusion: Recent and frequent use of daytime GP for patients with the selected chronic diseases was associated with contacts to the OOH services due to exacerbation. These findings indicate that the most severely chronically ill patients tend to make more use of general practice. The provision of an annual follow-up daytime GP consultation may indicate a lower risk of contacting OOH due to exacerbation. [ABSTRACT FROM AUTHOR]

Background: Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP's suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis. Methods: We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients' chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP's symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression. Results: 5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient's symptoms as 'alarm' symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as 'vague' had a lower chance of being referred to a CPP than when interpreted as 'alarm' symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with 'vague' symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with 'alarm' symptoms. Conclusions: GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP's choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP's symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval. [ABSTRACT FROM AUTHOR]

Background The general practitioner (GP) plays an important role for chronic disease care. Continuous and close contact with daytime general practice is intended to prevent medical problems arising outside office hours due to already diagnosed chronic disease. However, previous studies indicate that patients with chronic diseases are frequent users of out-of-hours primary care services (OOH), but knowledge is limited on reasons for encounter (RFE), severity of symptoms, and OOH patient handling. We aimed to describe contacts to the OOH services from patients with chronic heart disease, lung disease, severe psychiatric disorders, diabetes, and cancer in terms of RFE, OOH GP diagnosis, assessed severity of symptoms, and actions taken by the GP. Methods Eligible patients (aged 18 years and older) were randomly sampled from a one-year crosssectional study comprising 15,229 contacts to the OOH services in the Central Denmark Region. A cohort of patients with one or more of the five selected chronic diseases were identified by linking data on the Danish civil registration number (CPR) through specific nationwide Danish health registers. Results Out of 13,930 identified unique patients, 4,912 had at least one of the five chronic diseases. In total, 25.9% of all calls to the OOH services came from this chronic disease patient group due to an acute exacerbation; 32.6% of these calls came from patients with psychiatric diagnoses. Patients with chronic disease were more likely to receive a face-to-face contact than the remaining group of patients, except for calls from patients with a psychiatric disorder who were more often completed through a telephone consultation. Patients with heart disease calling due to a new health problem formed the largest proportion of all OOH referrals to hospital (13.3%) compared to calls from the other groups with chronic disease (3.4-6.7%). Conclusions A third of the patients randomly sampled by their OOH call had one or more of the five selected chronic diseases (i.e. chronic lung disease, heart disease, diabetes, psychiatric disease, or cancer). Patients with chronic disease were more often managed by OOH GPs than other patients. [ABSTRACT FROM AUTHOR]

Objective. To study the quantitative consumption in out-of-hours (OOH) primary care in Denmark and the Netherlands, in the context of OOH care services. Design. A retrospective observational study describing contacts with OOH care services, using registration data. Setting. OOH care services (i.e. OOH primary care, emergency department, and ambulance care) in one Danish and one Dutch region. Subjects. All patients contacting the OOH care services in September and October 2011. Main outcome measures. Consumption as number of contacts per 1000 inhabitants in total and per age group per contact type. Results. For the two-month period the Danes had 80/1000 contacts with OOH primary care compared with 50/1000 for the Dutch. The number of contacts per 1000 inhabitants per age group varied between the regions, with the largest difference in the 0-5 years age group and a considerable difference in the young-adult groups (20-35 years). The difference was largest for telephone consultations (47/1000 vs. 20/1000), particularly in the youngest age group (154/1000 vs. 39/1000). The Danes also had more home visits than the Dutch (10/1000 vs. 5/1000), while the Dutch had slightly more clinic consultations per 1000 inhabitants than the Danes (25/1000 vs. 23/1000). Conclusion. The Danish population has more contacts with OOH primary care, particularly telephone consultations, especially concerning young patients. Future research should focus on the relevance of contacts and identification of factors related to consumption in OOH primary care. [ABSTRACT FROM AUTHOR]

Background: Specialized palliative care teams are typically based in larger hospitals, from where home visits, telephone consultations, and support are given directly to patients and relatives, but also to professionals working on the frontline. One of the challenges is the long distances to the patients' homes. Modern telecommunication may help overcome this, but little is known about the perceived advantages and barriers to palliative care. This study analyzed the views on modern telecommunication from specialized palliative care professionals' perspective. Materials and Methods: This descriptive study is based on four semistructured group interviews where 17 health professionals from three different palliative care teams in the Central Denmark Region were interviewed from November 2009 to March 2010. Results: We found that face-to-face communication is essential. The participants perceived a potentially added communicative value in visual telecommunication but would never let it replace face-to-face communication. Ethical and practical concerns were expressed on the implementation of 'modern telecommunication' and in particular strong reservations against permanent telemonitoring in the patient's home. Conclusions: Our study underlines the necessity of face-to-face contact in optimal palliative care and that home visits were favored. The participants were generally positive toward telecommunication, although reservations and prerequisites were voiced. [ABSTRACT FROM AUTHOR]

Background: The growing population living with chronic conditions calls for efficient healthcare-planning and effective care. Implementing disease-management-programmes is one option for responding to this demand. Knowledge is scarce about the effect of implementation processes and their effect on patients; only few studies have reported the effectiveness of disease-management-programmes targeting patients with chronic obstructive pulmonary disease (COPD). The objective of this paper was to determine the effect on healthcare-utilization of an active implementation model for a disease-management-programme for patients with one of the major multimorbidity diseases, COPD. Methods: The standard implementation of a new disease-management-programme for COPD was ongoing during the study-period from November 2008 to November 2010 in the Central Denmark Region. We wanted to test a strategy using Breakthrough Series, academic detailing and lists of patients with COPD. It targeted GPs and three hospitals serving approx. 60,000 inhabitants aged 35 or older and included interventions directed at professionals, organisations and patients. The study was a non-blinded block- and cluster-randomised controlled trial with GP-practices as the unit of randomisation. In Ringkoebing-Skjern Municipality, Denmark, 16 GP-practices involving 38 GPs were randomised to either the intervention-group or the control-group. A comparable neighbouring municipality acted as an external-control-group which included nine GP-practices with 25 GPs. An algorithm based on health-registry-data on lung-related contacts to the healthcare-system identified 2,736 patients who were alive at the end of the study-period. The population included in this study counted 1,372 (69.2%) patients who responded to the baseline questionnaire and confirmed their COPD diagnosis; 458 (33.4%) patients were from the intervention-group, 376 (27.4%) from the control-group and 538(39.2%) from the external-control-group. The primary outcome was adherence to the disease-management-programme measured at patient-level by use of specific services from general practice. Secondary outcomes were use of out-of-hours-services, outpatient-clinic, and emergency-department and hospital-admissions. Results: The intervention practices provided more planned preventive consultations, additional preventive consultations and spirometries than non-intervention practices. A comparison of the development in the intervention practices with the development in the control-practices showed that the intervention resulted in more planned preventive-consultations, fewer conventional consultations and fewer patients admitted without a lung-related- diagnosis. Conclusions: Use of the active implementation model for the disease-management-programme for COPD changed the healthcare utilization in accordance with the programme. [ABSTRACT FROM AUTHOR]

Background: Urgent referral for suspected cancer was implemented in Denmark on 1 April 2008 to reduce the secondary care interval (i.e. the time interval from the general practitioner's first referral of a patient to secondary health care until treatment is initiated). However, knowledge about the association between the secondary care interval and urgent referral remains scarce. The aim of this study was to analyse how the secondary care interval changed after the introduction of urgent referral. Methods: This was a retrospective population-based study of 6,518 incident cancer patients based on questionnaire data from the patients' GPs. Analyses were stratified with patients discharged from Vejle Hospital in one stratum and patients from other hospitals in another because Vejle Hospital initiated urgent referrals several years prior to the national implementation. Further, analyses were stratified according to symptom presentation and whether or not the GP referred the patient on suspicion of cancer. Symptom presentation was defined as with or without alarm symptoms based on GP interpretation of early symptoms. Results: The median secondary care interval decreased after the introduction of urgent referral. Patients discharged from Vejle Hospital tended to have shorter secondary care intervals than patients discharged from other hospitals. The strongest effect was seen in patients with alarm symptoms and those who were referred by their GP on suspicion of cancer. Breast cancer patients from Vejle Hospital experienced an even shorter secondary care interval after the national introduction of urgent referrals. Conclusion: Urgent referral had a positive effect on the secondary care interval, and Vejle Hospital remarkably managed to shorten the intervals even further. This finding indicates that the shorter secondary care intervals not only result from the urgent referral guidelines, but also involve other factors. Keywords: Denmark, Early detection of cancer, Family practice, Health services administration [ABSTRACT FROM AUTHOR]

Background: Equal access to end-of-life care is important. However, social inequality has been found in relation to place-of-death. The question is whether social and economic factors play a role in access to specialist palliative care services. Objective: The study analyzed the association between access to outreach specialist palliative care teams (SPCTs) and socioeconomic characteristics of Danish cancer patients who died of their cancer. Methods: The study was a population-based, cross-sectional register study. We identified 599 adults who had died of cancer from March 1 to November 30, 2006, in Aarhus County, Denmark. Data from health registers were retrieved and linked based on the unique personal identifier number. Results: Multivariate analysis with adjustment for age, gender, and general practitioner (GP) involvement showed a higher probability of contact with an SPCT among immigrants and descendants of immigrants than among people of Danish origin (prevalence ratio [PR]: 1.55; 95% confidence interval (CI): 1.04;2.31) and among married compared to unmarried patients (PR: 1.25; 95% CI: 1.01;1.54). The trends were most marked among women. Conclusion: We found an association between females, married patients, and female immigrants and their descendants and access to an SPCT in Denmark. However, no association with the examined economic factor was found. Need for specialized health care, which is supposed to be the main reason for access to an SPCT, may be related to economic imbalance; and despite the relative equality found, SPCT access may not be equal for all Danish residents. Further research into social and economic consequences in palliative care services is warranted. [ABSTRACT FROM AUTHOR]

Background: Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council's model for complex interventions and the Chronic Care Model. Methods: We used the Medical Research Council's five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model. Results: The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council's model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere). Conclusion: The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council's model added transparency to the design phase which further facilitated the process of implementing the program. [ABSTRACT FROM AUTHOR]

Background. The loss of a loved person may lead to complicated grief (CG). General practitioners (GPs) consider bereavement care to be important but find training for this task to be insufficient. We hypothesized that improvement in skills that facilitate early identification of CG and enhance GPs’ clinical care may reduce adverse health outcomes. Aim. To test whether implementation of a bereavement management program in general practice could improve the GPs’ ability to identify CG and provide clinical care. Design. A cluster-randomized controlled trial allocating GPs and their listed patients suffering from bereavement to either a intervention or a control group. Setting. Close relatives of patients who had died from cancer in Denmark were recruited (N = 402). Method. The primary outcomes were defined as the bereaved relatives’ score on the Beck’s Depression Inventory II and the Inventory of Complicated Grief-Revised (ICG-R), the GP’s clinical assessment of the relative’s grief reaction and the relative’s number of contacts with general practice. Results. Larger improvements in ICG-R scores were found in the intervention group than in the control group. In the intervention group, patients exhibiting CG symptoms were more likely to receive supportive care and to be referred to mental health practitioners, whereas GP’s in the control group more often prescribed psychotropic drugs for patients with symptoms of CG. The GP’s ability to identify CG at 13 months did not seem to be better in the intervention group than in the control group. Conclusion. While only statistically near significant, we found some indications of an effect of the intervention compared with usual care. Our results underscore the need for improving GPs’ clinical skills in identifying patients with CG. [ABSTRACT FROM PUBLISHER]

This study examined associations between avoidance and approach coping and patient delay in cancer patients (N = 1024). Approach coping was associated with short appraisal intervals (time from symptom discovery to recognition of symptom seriousness). Avoidance coping was associated with long appraisal intervals when adjusting for covariates. Help-seeking intervals (time from recognition of symptom seriousness to contact to general practitioner) were only associated with approach coping and only when adjusting for the influence of covariates. The results revealed a complex relationship between coping and patient delay and supported that normal processing of health threats implies avoidance and approach coping strategies. [ABSTRACT FROM AUTHOR]

The article discusses the agreement between place of care (POC) and place of death (POD) among Danish cancer patients. According to the authors, in palliative care, it is important to meet patient's preference especially regarding POC and POD. Results of the study showed that terminally ill patients preferred home care and a home death with their partners beside them, and regular discussion with patients and large scaled studies are needed to focus how to meet their preferences.

Background. We assessed risk of burnout in GPs during a 7-year followup and examined whether (1) thoughts about changing medical specialty increased the risk of burnout and (2) burned out GPs had higher job turnover rates than burnout-free GPs. Methods. In 2004 and 2012, all GPs in the county of Aarhus, Denmark, were invited to participate in a survey. Retirement status of physicians who participated in 2004 was obtained through the Registry of Health Providers in 2012. Results. 216 GPs completed both surveys. The risk of developing burnout during the 7-year followup was 13.2% (8.2-19.6%). GPs who in 2004 were burnout-free and reported that they would not select general practice as medical specialty again had a statistically significant increased risk of burnout in 2012 (OR = 4.5; 95% CI = 1.2-16.5; P = 0.023). Among GPs with burnout in 2004, 25.0% had with drawn from general practice during followup compared to 28.8% of burnout-free GPs in 2004 (adj. OR = 0.99; 95% CI = 0.48-2.02; P = 0.975). Conclusion. The 7-year incidence of burnout was 13%.Thoughts about changing medical specialty were an important predictor of burnout. Burned out GPs had not higher job turnover rates than burnout-free GPs. [ABSTRACT FROM AUTHOR]

walk-in open access in general practice may influence the general practitioner's (GP's) work, but very little research has been done on the consequences. In this study from Danish general practice, we compare the prevalence of burnout between GPs with a walk-in open access and those without. In a questionnaire study (2004), we approached all 458 active GPs in the county of Aarhus, Denmark, and 376 (82.8%) GPs returned the questionnaire. walk-in open access was defined as at least 30 minutes every weekday where patients could attend practice without an appointment. Burnout was measured by the Maslach Burnout Inventory. Analyses using logistic regression were adjusted for gender, age, marital status, job satisfaction, minutes per consultation, practice organisation, working hours, number of listed patients per GP, number of contacts per GP, continuing medical education- (CME-) activities, and clusters of GPs. In all, 8% of GPs had open access and the prevalence of burnout was 24%. GPs with walk-in open access were more likely to suffer from burnout. Having open access was associated with a 3-fold increased likelihood of burnout (OR = 3.1 (95% CI: 1.1-8.8, p = 0.035)). Although the design cannot establish causality, it is recommended to closely monitor possible negative consequences of open access in general practice. [ABSTRACT FROM AUTHOR]

Background: People living with chronic disease currently account for the majority of the total healthcare costs. The Central Denmark Region implemented a disease management programme (DMP) for chronic obstructive pulmonary disease (COPD) in 2008. This presented an opportunity to examine the effect of an evidence-based, planned and proactive implementation of a DMP compared to the usual implementation strategy. Methods: We performed a block- and cluster-randomised controlled trial with two groups and an extra external control group. The primary outcome was patients' assessment of their care after using an active implementation model for a DMP for COPD measured with the Patient-Assessment-of-Chronic-Illness-Care (PACIC) instrument. At baseline, questionnaires were sent to 2,895 patients identified by an algorithm based on health registry data on lung-related contacts to the healthcare system. Patients were asked to confirm or refute their diagnosis of COPD. Of those who responded, 1,445 (72.8%) confirmed their diagnosis. PACIC data were collected at baseline and at a 12-month follow-up for 744 (51.1%) patients. Results: Comparing the three groups after the implementation of the DMP, we found a statistically significantly higher change in the PACIC score in the intervention group than in the control groups. No statistically significant differences were found between the control and the external control groups in any of the dimensions. Conclusions: Reinforcing the role of general practice as coordinator for care-and self-management-support with an active implementation of a DMP for COPD made patients score higher on the PACIC instrument, which indicates a better experience of the received healthcare. Trial registration: NCT01228708. [ABSTRACT FROM AUTHOR]

Background The purpose was to examine the prevalence of fear of recurrence (FoR) in long-term testicular cancer survivors (TCSs) and the association between FoR and causal attributions of cancer. Methods Testicular cancer survivors were sampled from a clinical register and were sent a questionnaire assessing FoR, depression using Beck Depression Inventory II (BDI-II), physical symptoms (ototoxicity, neuropathy, and Raynaud-like phenomena), and causal attributions of testicular cancer. Results There were 316 TCSs who completed the questionnaires (response rate, 65%). The mean age was 47.6 years (standard deviation ( SD) = 10.9), and the mean time since diagnosis was 12.0 years ( SD = 3.0). Among the TCSs, 27.9% reported FoR. Univariate analyses revealed that FoR was associated with a BDI-II sum score of ≥19 (odds ratio ( OR) = 7.07, p < 0.001) and attributing the cancer disease to psychological stress ( OR = 2.57, p = 0.002). A multivariate analysis revealed associations between FoR and attributing the cancer disease to psychological stress ( OR = 2.35, p = 0.010) and a BDI-II sum score ≥19 ( OR = 5.82, p = 0.002). Conclusions Fear of recurrence is prevalent in long-term TCSs. The observed relationship between FoR and a psychological causal attribution is probably complex and the direction of causality may be twofold: attributing the disease to a factor that is perceived as uncontrollable in nature could induce loss of control, and high levels of FoR may increase the need to gain control over the situation by pointing out factors that could be responsible for the disease such as psychological stress. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: There is little research on complicated grief (CG) in family caregivers in palliative care. The aim of the study was to assess the levels of complicated grief and depression in family caregivers after the death of a relative with cancer, to identify their need for support, to compare the palliative team staff's risk assessment of the relatives' grief reaction with measured levels of CG and depression, and to assess the use of bereavement support. Methods: All 114 eligible family caregivers to deceased patients treated in a palliative care unit in the year 2006 were asked to participate in the study, and 87 (77%) accepted. The participants completed a postal questionnaire 2, 6, 13, and 18 months after the loss measuring complicated grief (Inventory of Complicated Grief, Revised), depression (Beck's Depression Inventory II), and their use of bereavement services. The palliative team staff completed a form 1 month post-loss with their clinical risk assessment of the family caregivers' levels of complicated grief and need for support. Results: The prevalence of moderate to severe depression and CG was 15% and 40%, respectively, at 6 months post-loss. Professional risk assessment showed a sensitivity of 55% for CG and of 27% for depression and a specificity of 86% for depression and 63% for CG. The positive predictive value was 27% for depression and 21% for CG. Use of bereavement services was observed in 36% of the cases at 6 months after the loss. The proportion of bereaved with CG or depression at 6 months who had received bereavement services was 47% and 64%, respectively. Conclusions: The results suggest that a substantial number of family caregivers of diseased palliative care patients are at risk of developing CG and depression following their loss. While early identification of those at risk of developing CG could be helpful, the risk assessment of professionals may lack in precision. The results indicate that bereavement services could be utilized in a more targeted and perhaps more efficient manner. Guidelines for bereavement planning in palliative care are indicated. [ABSTRACT FROM AUTHOR]

Objective Most terminally ill patients and relatives prefer care and death to occur at home. However, in many cases patients die in hospital and the question arises whether social inequity in palliative care exists. The aim of this study was to analyse associations between dying at home and demographic and socioeconomic characteristics adjusted for healthcare utilisation among Danish cancer patients. Method Population-based, cross-sectional register study in Aarhus County, Denmark. 599 deceased adults who died from cancer from 1 March to 30 November 2006 in a well-defined geographical area were identified. Based on unique personal identifier numbers, socioeconomic data and healthcare utilisation from different registers were retrieved and analysed. Results Multivariate analysis showed that dying at home was negatively associated with, first, being either 50-59 (prevalence ratio (PR): 0.67 (95% CI 0.45 to 0.99)) or 70-79 years of age (PR: 0.83 (95% CI 0.70 to 0.99)) compared with being 80 years or above; second, a middle personal income compared with a high income (PR: 0.86 (95% CI 0.75 to 1.00)); and, third, being employed or having a leadership position compared with being unemployed/student/receiving social security (PR: 0.72 (95% CI 0.53 to 0.98)). Conclusion The found socioeconomic differences in whether death occurred at home or at institutions indicate that age, income and social class must be taken into account when palliative care services engage in fulfilling preferences of dying at home. This may lead to more equality in the possibility of dying at home, despite differences in socioeconomic level. [ABSTRACT FROM AUTHOR]

Aim: To determine the time intervals from symptom to treatment for childhood cancer patients. Methods: Danish national population-based study. Children (<15 years) with an incident cancer diagnosed from January 2007 to December 2010 were sampled. A total of 376 (68%) parents and 315 (87%) general practitioners (GPs) completed questionnaires on the diagnostic pathway. The time interval was categorized into, patient-, GP-, system-, diagnostic- and total intervals, and as short or long intervals. Factors associated with long time intervals were assessed in a logistic regression model using prevalence ratios (PRs). Results: Girls were almost twice as likely as boys to experience long patient intervals (adjusted PR: 1.8, 95% confidence interval (CI): 1.1-2.8). The oldest children were more likely than the youngest to experience long total intervals (adjusted PR: 1.9, 95% CI: 1.1-3.3). Cancer type was associated with all time intervals, except GP intervals. Children with bone- and CNS tumours had the longest total intervals (median: 88 days, interquartile interval (IQI): 57-132) vs. (median: 76, IQI: 28-191). Parental education showed a possible association with patient- and GP intervals. Conclusion: Time intervals varied by gender, age and cancer type. Parental education may possibly affect the patient- and GP intervals. [ABSTRACT FROM AUTHOR]

Objective. Approximately 98% of Danish citizens are listed with a general practice which they consult for medical advice. Although 85% of the population contact their general practitioner (GP) every year, little is known about these contacts. The aim of the present paper is to gain updated knowledge about patients' reasons for encounter and the GP activities and to make comparisons with a similar study from 1993. Methods. All GPs in the Central Denmark Region were invited to register all contacts during one randomly chosen day within a year. The registration included questions about patients' reasons for encounter, the types and contents of the contacts, referrals, and distribution between new episodes and follow-up contacts. Aggregated data were compared with the results from 1993. Results. A total of 404 (46%) GPs participated. The number of contacts per 1000 inhabitants had risen by 19.7%. The reasons for encounter and final diagnoses resembled those in 1993. Musculoskeletal, psychological, and respiratory problems were the most common reasons for encounter, psychological problems being the only type to increase over the period. Interestingly, the proportion of diagnoses within the ICPC 'A' chapter rose from 13.5 to 19.7%. The referral rate rose by 2% (relative: 18.7%) from 10.7% to 12.7% and the share of follow-up contacts rose from 45.9% to 50.4% (relative: 8.7%). Conclusion. Quite small changes were seen in the patterns of reasons for encounter and diagnoses from 1993 to 2009. However, an increase was found in contacts with general practice and referrals and in the proportion of follow-ups. [ABSTRACT FROM AUTHOR]

Background: Information is essential in healthcare. Recording, handling and sharing healthcare information is important in order to ensure high quality of delivered healthcare. Information and communication technology (ICT) may be a valuable tool for handling these challenges. One way of enhancing the exchange of information could be to establish a link between patient-specific and general information sent to the general practitioner (GP). The aim of the present paper is to study GPs' use of a hyperlink inserted into electronic test result communication. Methods: We inserted a hyperlink into the electronic test result communication sent to the patients' GPs who participated in a regional, systematic breast cancer screening program. The hyperlink target was a web-site with information on the breast cancer screening program and breast cancer in general. Different strategies were used to increase the GPs' use of this hyperlink. The outcome measure was the GPs' self-reported use of the link. Data were collected by means of a one-page paper-based questionnaire. Results: The response rate was 73% (n=242). In total, 108 (45%) of the GPs reported to have used the link. In all, 22% (n=53) of the GPs used the web-address from a paper letter and 37% (n=89) used the hyperlink in the electronic test result communication (δ=15%[95%confidence int erval(CI) = 8--22%P < 0.001]). We found no statistically significant associations between use of the web-address/hyperlink and the GP's gender, age, or attitude towards mammography screening. Conclusions: The results suggest that hyperlinks in electronic test result communication could be a feasible strategy for combining and sharing different types of healthcare information. [ABSTRACT FROM AUTHOR]

Scand J Caring Sci; 2011; 25; 627-636 Preference for place-of-death among terminally ill cancer patients in Denmark Achieving home death is often seen as an important endpoint in palliative care, but no studies of the preferred place-of-death have yet been conducted in Scandinavia. Furthermore, we do not know if professionals' report on deceased patients' preference of place-of-death is a valid information. The aim of this study was to describe where terminally ill Danish cancer patients prefer to die and to determine if their preference changed during the palliative period, as reported retrospectively by bereaved relatives, general practitioners (GPs) and community nurses (CNs) and to assess the agreement of their accounts. The study was a population-based, cross-sectional combined register and questionnaire study in Aarhus County, Denmark. The population comprised 599 deceased adult cancer patients who had died from 1 March to 30 November 2006 and were identified through merging of health registers. Relatives returned 198 questionnaires about patients' preferred place-of-death, GPs 333 and CNs 201. The study showed that most terminally ill cancer patients preferred home death (up to 80.7%). The reported preference for home death weakened as death approached (down to 64.4%). A better congruence was seen between relatives' and GPs' accounts of preference for place of death at the end of the palliative period ( κ 0.71) than between relatives' and CNs' accounts ( κ 0.37). In conclusion, bereaved relatives (and GPs and CNs) report retrospectively that most terminally ill cancer patients wish to die at home. The preference weakened significantly as death approached. The agreement between relatives' and GPs' accounts on patients' preferences at the end of the palliative period was 'substantial', whereas the agreement between relatives' and CNs' accounts at the same time was significantly less outspoken. This indicates that CNs may be facing a problem in assessing their patients' wishes retrospectively. [ABSTRACT FROM AUTHOR]

Objective. Palliative home care involves coordination of care between the professionals involved. The NICE guideline on supportive and palliative care (UK) recommends that teams, regardless of their base, should promote continuity for patients. This may involve nomination of a coordinating 'key worker'. This study aimed to explore who acts as key worker and who ought to take on this role in the views of patients, relatives, and primary care professionals. Furthermore, it aimed to explore the level of agreement on this issue between study participants. Design. Interview and questionnaire study. Setting. Former County of Aarhus, Denmark (2008-2009). Subjects. Ninety-six terminally ill cancer patients, their relatives, general practitioners (GPs), and community nurses (CNs). Main outcome measures. Actual key worker as valued by patients, relatives, and primary care professionals; ideal key worker as valued by patients and relatives. Results. Patients, relatives, GPs, and CNs most often saw themselves as having been the key worker. When asked about the ideal key worker, most patients (29%; 95%CI: 18;42) and relatives (32%; 95%CI: 22;45) pointed to the GP. Using patients' views as reference, we found very limited agreement with relatives (47.7%; k == 0.05), with GPs (30.4%; k == 0.01) and with CNs (25.0%; k == 0.04). Agreement between patients and relatives on the identity of the ideal key worker was of a similar dimension (29.6%; k == 0.11). Conclusion. Poor agreement between patients, relatives, and professionals on actual and ideal key worker emphasizes the need for matching expectations and clear communication about task distribution in palliative home care. [ABSTRACT FROM AUTHOR]

Objective. The absence of a more significant improvement in cancer survival in countries such as the UK and Denmark may be partly rooted in delayed care-seeking among cancer patients. Past research on patient delay has mainly focused on patient characteristics (e.g. sociodemographic and psychological factors and symptom recognition) as causes of delayed care-seeking, while few studies have examined how the organizational structure of health care systems may influence patients' reflections on seeking care. The aim of this study was to explore this relationship. Design. The analysis presented is based on semi-structured interviews with 30 cancer patients and their families. Results. The article raises two hypotheses on the relationship between structural elements of a health care system and people's reflections on seeking health care: (1) Gatekeeping introduces an asymmetrical relationship between the patient and the GP which potentially results in self-restricting care-seeking, (2) Continuity in the doctor-patient relationship may negatively influence patient reflections on access to health care, as the focus shifts from the medical issues of the consultation to reflections on how to properly interact with the GP and the system in which she/he is situated. Conclusion. It is concluded that these hypotheses form a sound basis for further primary care research on how the organizational structure of health care systems influences patient reflections on access to medical care. [ABSTRACT FROM AUTHOR]

Background: It is puzzling to note that British and Danish citizens have a poorer cancer prognosis than citizens from other countries, and this study hypothesises that their low cancer survival could be partly rooted in the gatekeeper function undertaken by general practice in these two countries.Aim: To test the association between principles of gatekeeper systems and cancer survival.Design and Setting: An ecologic study with data from EUROCARE-4 and primary care structure.Method: This hypothesis was tested in an ecologic study on the association between three principles of gatekeeper systems and cancer survival in 19 European countries for which valid and full data were available.Results: It was found that healthcare systems with a gatekeeper system do have a significantly lower 1-year relative cancer survival than systems without such gatekeeper functions.Conclusion: The possible mechanisms behind this finding are discussed, and while all the positive aspects of gatekeeping are recognised, it is strongly recommended that further research be conducted to confirm or reject the study hypothesis on this possible serious adverse effect of gatekeeping. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to establish the predictive value of an ICD-10 diagnosis of depressive disorder or dysthymia (depressive patients) among 70 years ++ frail rural community living patients by measuring morbidity, mortality and use of health services. Identical measures were studied over time in general elderly populations. Methods: Outcome measures: morbidity, mortality and use of health services were registered over 13 years in: (i) a clinical cohort of frail community-living depressive patients (n == 38), a frail control group (n == 116) and non-frail elderly people (n == 575), all living in the same municipality, and (ii) register-based samples of general rural (n == 4 115) and capital living (n == 54 977) elderly populations. The outcome measures were compared using data from Danish national health registers. Results: Every one of the clinical cohort of depressive patients had died at the end of the study. Compared with both the frail control group and the non-frail elderly people, the depressive patients had significantly more psychiatric hospital days, outpatient home visits, antidepressant use, antipsychotic use, GP service use and more psychiatric diagnoses with higher morbidity. However, greater use of somatic hospital services or more somatic diagnoses among the depressive elderly patients were not observed. The general elderly population living in the capital had, compared with rural equals, significantly more somatic and psychiatric diagnoses, larger use of somatic hospital services, psychiatric hospital days, antipsychotics and anxiolytics, but less use of antidepressants, psychiatric outpatient home visits and GP services. Conclusions: An ICD-10 diagnosis of depressive disorder or dysthymia predicted increased use of psychiatric services, more psychiatric diagnoses and increased mortality, indicating poor late-life psychiatric outcome. Contrasting with other studies, depression did not predict increased use of somatic hospital services or more somatic diagnoses. The differences in health care status and use between elderly living in the capital and in rural areas elderly are novel findings. [ABSTRACT FROM AUTHOR]

Objective. Central health organizations suggest routine screening for depression in high-risk categories of primary care patients. This study compares the effectiveness of high-risk screening versus case-finding in identifying depression in primary care. Design. Using an observational design, participating GPs included patients from 13 predefined risk groups and/or suspected of being depressed. Patients were assessed by the Major Depression Inventory (MDI) and ICD-10 criteria. Setting. Thirty-seven primary care practices in Mainland Denmark. Main outcome measures. Prevalence of depression, diagnostic agreement, effectiveness of screening methods, risk groups requiring special attention. Results. A total of 37 (8.4%) of 440 invited GP practices participated. We found high-risk prevalence of depression in 672 patients for the following traits: (1) previous history of depression, (2) familial predisposition to depression, (3) chronic pain, (4) other mental disorders, and (5) refugee or immigrant. In the total sample, GPs demonstrated a depression diagnostic sensitivity of 87% and a specificity of 67% using a case-finding strategy. GP diagnoses of depression agreed well with the MDI (AUC values of 0.91--0.99). The potential added value of high-risk screening was 4.6% (31/672). Patients with other mental disorders were at increased risk of having an unrecognized depression (PR 3.15, 95% CI 1.91--5.20). If patients with other mental disorders were routinely tested, then 42% more depressed patients (14/31) would be recognized. Conclusions. A broad case-finding approach including a short validation test can help GPs identify depressed patients, particularly by including patients with other mental disorders in this strategy. This exploratory study cannot support the screening strategy proposed by central health organizations. [ABSTRACT FROM AUTHOR]

Background: General practice plays an important role in the cancer care pathway. The initial diagnostic phase may be crucial for the relationship between the patient and the GP.Aim: The aim was to describe whether patients' confidence in their GP changed after a cancer diagnosis, and analyse whether the change in confidence was associated with doctor delay.Design and Setting: Population-based cohort study with 1892 questionnaires sent to patients and their GPs in general practices in the former Aarhus County, Denmark.Method: Information on patients' confidence in their GP was obtained from the patient questionnaire. Information on doctor delay was obtained from the GPs and defined as a period of 14 days or more from the date of first symptom presentation to the GP until cancer-specific investigation was initiated.Results: Before the cancer diagnosis, 88.4% of the patients had confidence in their GP, which decreased to 80.0% after the diagnosis (P<0.001); 15.8% of the patients who experienced no doctor delay reported a decrease in confidence after the cancer diagnosis, compared with 29.1% of the patients with a doctor delay (P<0.001). Patients presenting with alarm symptoms and experiencing doctor delay were 3.8 times more likely to lose confidence compared with those presenting with alarm symptoms who experienced no doctor delay (P = 0.048).Conclusion: The majority of the patients had high levels of confidence in their GP before, as well as after, the cancer diagnosis. Nevertheless, a substantial amount had low confidence in the GP, especially when experiencing doctor delay in the initial phase of the pathway. [ABSTRACT FROM AUTHOR]

Background DNA amplification assays are increasingly being used to facilitate the testing of asymptomatic individuals for urogenital . The long-term clinical benefit in terms of avoided infertility and ectopic pregnancy is unknown. Methods In 1997, 15 459 women and 14 980 men aged 21–23 years were living in Aarhus County, Denmark. A random sample of 4000 women and 5000 men was contacted by mail and offered the opportunity to be tested for by means of a sample obtained at home and mailed directly to the laboratory. The remaining 11 459 women and 9980 men received usual care and constituted the control population. All men and women were subsequently followed for 9 years by the use of Danish health registers. Data were collected on pelvic inflammatory disease (PID), ectopic pregnancy (EP), infertility diagnoses, in-vitro fertilisation (IVF) treatment and births in women, and on epididymitis in men. The intervention and control groups were compared using Cox regression analyses and the intention-to-screen principle. Results Among women, no differences were found between the intervention group and the control group: HR (95% CI) for PID 1.12 (0.70 to 1.79); EP 0.97 (0.63 to 1.51); infertility 0.87 (0.71 to 1.07); IVF treatment 0.88 (0.62 to 1.26) and births 1.02 (0.95 to 1.10). In men, the HR for epididymitis was 1.25 (0.70 to 2.24). Conclusions A population-based offer to be tested for urogenital infection by the use of non-invasive samples and DNA amplification did not reduce the long-term risk of reproductive complications in women or of epididymitis in men. Trial registration number in www.clinicaltrials.gov NCT 00827970. [ABSTRACT FROM PUBLISHER]

Background: Little is known about the existing barriers to cooperation among health professionals in basic level palliative care for terminally ill patients with cancer in primary health care. Objective: The aim of this study was to analyze health professionals' views on interprofessional cooperation in basic level palliative home care for terminally ill cancer patients. Method: This study was a qualitative, descriptive study based on 7 semistructured group interviews conducted in the former Aarhus County, Denmark. Forty-three health professionals (23 family physicians, 5 chief physicians, and 15 home care nurses) were interviewed. Results: Two main categories of problems were identified: (1) the organization of palliative home care (need for proactive planning from the start of the palliative trajectory, clear distribution of tasks, advancement of more efficient communication pathways, and improved accessibility to all health professionals) and (2) interaction between health professionals (increased knowledge of and respect for the competencies of other health occupations and individuals). Conclusion: The study indicates problems with respect to both the organization of the basic level palliative home care and the working culture among health professionals. The main issues: distribution of tasks, information exchange, availability, respect, and personal acquaintance are pivotal to improve the delivery of palliative home care, to training in palliative care and warrant future research. [ABSTRACT FROM AUTHOR]

Objective. General practitioner (GP) involvement may be instrumental in obtaining successful palliative cancer trajectories. The aim of the study was to examine associations between bereaved relatives’ evaluation of palliative cancer trajectories, place of death, and GP involvement. Design. Population-based, cross-sectional combined register and questionnaire study. Setting. The former Aarhus County, Denmark. Subjects. Questionnaire data on GPs’ palliative efforts and relatives’ evaluations of the palliative trajectories were obtained for 153 cases of deceased cancer patients. Main outcome measures. A successful palliative trajectory as evaluated retrospectively by the relatives. Results. Successful palliative trajectories were statistically significantly associated with home death (PR 1.48 (95% CI 1.04; 2.12)). No significant associations were identified between the evaluations of the palliative trajectory at home and GP involvement. “Relative living with patient” (PR 1.75 (95% CI: 0.87; 3.53)) and “GP having contact with relatives” (PR 1.69 (95% CI 0.55; 5.19)) were not significantly associated, but this may be due to the poor number of cases included in the final analysis. Conclusion. This study indicates that home death is positively associated with a higher likelihood that bereaved relatives will evaluate the palliative trajectory at home as successful. No specific GP services that were statistically significantly associated with higher satisfaction among relatives could be identified, but contact between GPs and relatives seems important and the impact needs further investigation. [ABSTRACT FROM AUTHOR]

Background: Most cancer patients die at institutions despite their wish for home death. GP-related factors may be crucial in attaining home death.Aim: To describe cancer patients in palliative care at home and examine associations between home death and GP involvement in the palliative pathway.Design Of Study: Population-based, combined register and questionnaire study.Setting: Aarhus County, Denmark.Method: Patient-specific questionnaires were sent to GPs of 599 cancer patients who died during a 9-month period in 2006. The 333 cases that were included comprised information on sociodemography and GP-related issues; for example knowledge of the patient, unplanned home visits, GPs providing their private phone number, and contact with relatives. Register data were collected on patients' age, sex, cancer diagnosis, place of death, and number of GP home visits. Associations with home death were analysed in a multivariable regression model with prevalence ratios (PR) as a measure of association.Results: There was a strong association between facilitating home death and GPs making home visits (PR = 4.3, 95% confidence interval [CI] = 1.2 to 14.9) and involvement of community nurses (PR = 1.4, 95% CI = 1.0 to 1.9). No other GP-related variables were statistically significantly associated with home death.Conclusion: Active involvement of GPs providing home visits and the use of home nurses were independently associated with a higher likelihood of facilitating home death for cancer patients. The primary care team may facilitate home death, accommodating patients' wishes. Future research should examine the precise mechanisms of their involvement. [ABSTRACT FROM AUTHOR]

Background Most cancer patients die at institutions despite their wish for home death. GP-related factors may be crucial in attaining home death. Aim To describe cancer patients in palliative care at home and examine associations between home death and GP involvement in the palliative pathway. Design of study Population-based, combined register and questionnaire study. Setting Aarhus County, Denmark. Method Patient-specific questionnaires were sent to GPs of 599 cancer patients who died during a 9-month period in 2006. The 333 cases that were included comprised information on sociodemography and GP-related issues; for example knowledge of the patient, unplanned home visits, GPs providing their private phone number, and contact with relatives. Register data were collected on patients' age, sex. cancer diagnosis, place of death, and number of GP home visits. Associations with home death were analysed in a multivariable regression model with prevalence ratios (PR) as a measure of association. Results There was a strong association between facilitating home death and GPs making home visits (PR = 4.3, 95% confidence interval [Cl] = 1.2 to 14.9) and involvement of community nurses (PR - 1.4, 95% CI = 1.0 to 1.9). No other GP-related variables were statistically significantly associated with home death. Conclusion Active involvement of GPs providing home visits and the use of home nurses were independently associated with a higher likelihood of facilitating home death for cancer patients. The primary care team may facilitate home death, accommodating patients' wishes. Future research should examine the precise mechanisms of their involvement. [ABSTRACT FROM AUTHOR]

Objective. This study explores former cancer patients' psychosocial rehabilitation needs after hospital discharge. Method. Three focus-group interviews with 15 patients. Results. Five main areas were identified: (1) Need for continuous support and information about rehabilitation opportunities; (2) Support to the family; (3) Psychological help also addressing fear of relapse of cancer; (4) Needs for social support; (5) Needs pertaining to how friends and acquaintances relate to the patients. Conclusion. Each of these aspects should be carefully considered for each patient, preferably by one assigned healthcare provider. Fear of cancer relapse prevails among the patients, the family and the social network and it is important in relation to psychosocial rehabilitation. [ABSTRACT FROM AUTHOR]

The study aims to establish the predictive value of a diagnosis of depression among elderly according to the 10th revision of the International Statistical Classification of Diseases (ICD-10) by measuring morbidity, medication usage, health service utilization and mortality during an 8-year follow-up of depressed elderly inpatients (n=76) and community-living depressed patients (n=38) compared with controls (n=116). The data were taken from GPs' medical records and health statistics registers. At baseline, no significant differences were observed between the two cohorts of depressed patients and the controls in terms of prevalence of cardiovascular, respiratory or cerebrovascular morbidity. During follow-up, both cohorts of depressed patients had significantly increased rates of recurrent depressions, consumption of antidepressants, psychiatric in- and outpatient admissions, and home visits; inpatients used more psychiatric hospital days. Health service utilization in somatic hospitals and somatic diagnoses was not significantly increased. Inpatients used significantly fewer GP office-hour services but more out-of-hours services than the control group. Community-living depressed patients experienced no significant increase in use of GP services. Survival was unaffected in both cohorts. In agreement with other studies, especially inpatient depression predicted increased rates of recurrent depressions and increased use of psychiatric hospital services, indicating poor long-term outcome. Inpatients consumed fewer GP office-hour services but more out-of-hours services, possibly due to less office-hour contact. Contrasting with other studies, ICD-10 depression among elderly predicted no increase in the use of somatic hospital facilities. [ABSTRACT FROM AUTHOR]

Background: Delay in cancer diagnosis may be important for cancer prognosis. Large individual variations in the duration of delay have been observed. This study examines whether patients' socioeconomic characteristics are predictors of long patient-, doctor- and system-related delay in cancer diagnosis. Methods: Danish population-based cohort study. From September 2004 to September 2005, newly diagnosed cancer patients were enrolled from administrative registries. A total of 467 general practitioners in the County of Aarhus, Denmark, completed questionnaires on 2,212 cancer patients' diagnostic pathways. A total of 1,252 cancer patients filled in questionnaires on their socioeconomic characteristics (e.g. marital status, education, occupation, household income and fortune). Delay was categorised as short or long based on quartiles. Predictors of long delay were assessed in a logistic regression model using odds ratios (ORs) as a proxy of relative risks. Results: In regard to patient delay, retired female patients experienced shorter delays (OR 0.35, 95% confidence interval (95%CI) 0.13 to 0.98) than employed female patients, while female smokers experienced longer delays (OR 2.42, 95%CI 1.21 to 4.85) than female non-smokers. In regard to doctor delay, female patients with a large household fortune experienced shorter delays (OR 0.07, 95%CI 0.01 to 0.45) than economically less privileged female patients. Well-educated men experienced shorter delays (OR 0.40, 95%CI 0.16 to 1.00) than men with short education. Male patients experienced longer doctor delays (OR 2.11, 95%CI 1.11 to 4.02) than women when gender-specific cancers were excluded. In regard to system delay, female patients with a large household fortune experienced shorter delays (OR 0.46, 95%CI 0.21 to 0.99) than economically less privileged women, while female patients with a high alcohol intake experienced longer delays (OR 2.82, 95%CI 1.18 to 6.72) than women with an average intake. Conclusion: We found socioeconomic predictors of delay that allow us to hypothesize social inequalities in the distribution of delay, but, in general, only a few socioeconomic variables predicted delay in cancer diagnosis. Future research should examine a broader array of patients' personal characteristics. [ABSTRACT FROM AUTHOR]

Background: Knowledge of the extent to which patient characteristics are systematically associated with variation in patient evaluations will enable us to adjust for differences between practice populations and thereby compare GPs. Whether this is appropriate depends on the purpose for which the patient evaluation was conducted. Associations between evaluations and patient characteristics may reflect gaps in the quality of care or may be due to inherent characteristics of the patients. This study aimed to determine such associations in a setting with a comprehensive list system and gate-keeping. Methods: A nationwide Danish patient evaluation survey among voluntarily participating GPs using the EUROPEP questionnaire, which produced 28,260 patient evaluations (response rate 77.3%) of 365 GPs. In our analyses we compared the prevalence of positive evaluations in groups of patients. Results: We found a positive GP assessment to be strongly associated with increasing patient age and increasing frequency of attendance. Patients reporting a chronic condition were more positive, whereas a low self-rated health was strongly associated with less positive scores also after adjustment. The association between patient gender and assessment was weak and inconsistent and depended on the focus. We found no association either with the patients' educational level or with the duration of listing with the GP even after adjusting for patient characteristics. Conclusion: Adjustment for patient differences may produce a more fair comparison between GPs, but may also blur the assessment of GPs' ability to meet the needs of the populations actually served. On the other hand, adjusted results will enable us to describe the significance of specific patient characteristics to patients' experience of care. [ABSTRACT FROM AUTHOR]

This study aims to analyze whether the rehabilitation of cancer surviving patients (CSPs) can be better organized. The data for this paper consists of focus group interviews (FGIs) with CSPs, general practitioners (GPs) and hospital physicians. The analysis draws on the theoretical framework of Jürgen Habermas, utilizing his notions of 'the system and the life world' and 'communicative and strategic action'. In Habermas' terminology, the social security system and the healthcare system are subsystems that belong to what he calls the 'system', where actions are based on strategic actions activated by the means of media such as money and power which provide the basis for other actors' actions. The social life, on the other hand, in Habermas' terminology, belongs to what he calls the 'life world', where communicative action is based on consensual coordination among individuals. Our material suggests that, within the hospital world, the strategic actions related to diagnosis, treatment and cure in the biomedical discourse dominate. They function as inclusion/exclusion criteria for further treatment. However, the GPs appear to accept the CSPs' previous cancer diagnosis as a precondition sufficient for providing assistance. Although the GPs use the biomedical discourse and often give biomedical examples to exemplify rehabilitation needs, they find psychosocial aspects, so-called lifeworld aspects, to be an important component of their job when helping CSPs. In this way, they appear more open to communicative action in relation to the CSPs' lifeworld than do the hospital physicians. Our data also suggests that the CSPs' lifeworld can be partly colonized by the system during hospitalization, making it difficult for CSPs when they are discharged at the end of treatment. This situation seems to be crucial to our understanding of why CSPs often feel left in limbo after discharge. We conclude that the distinction between the system and the lifeworld and the implications of a possible colonization during hospitalization offers an important theoretical framework for determining and addressing different types of rehabilitation needs. [ABSTRACT FROM AUTHOR]