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Summary: This paper demonstrates a large post-fracture anti-osteoporosis treatment gap in the period 2005 to 2015. The gap was stable in Denmark at around 88–90%, increased in Catalonia from 80 to 88%, and started to increase in the UK towards the end of our study. Improved post-fracture care is needed. Introduction: Patients experiencing a fragility fracture are at high risk of subsequent fractures, particularly within the first 2 years after the fracture. Previous studies have demonstrated that only a small proportion of fracture patients initiate therapy with an anti-osteoporotic medication (AOM), despite the proven fracture risk reduction of such therapies. The aim of this paper is to evaluate the changes in this post-fracture treatment gap across three different countries from 2005 to 2015. Methods: This analysis, which is part of a multinational cohort study, included men and women, aged 50 years or older, sustaining a first incident fragility fracture. Using routinely collected patient data from three administrative health databases covering Catalonia, Denmark, and the United Kingdom, we estimated the treatment gap as the proportion of patients not treated with AOM within 1 year of their first incident fracture. Results: A total of 648,369 fracture patients were included. Mean age 70.2–78.9 years; 22.2–31.7% were men. In Denmark, the treatment gap was stable at approximately 88–90% throughout the 2005 to 2015 time period. In Catalonia, the treatment gap increased from 80 to 88%. In the UK, an initially decreasing treatment gap—though never smaller than 63%—was replaced by an increasing gap towards the end of our study. The gap was more pronounced in men than in women. Conclusion: Despite repeated calls for improved secondary fracture prevention, an unacceptably large treatment gap remains, with time trends indicating that the problem may be getting worse in recent years. [ABSTRACT FROM AUTHOR]

The paper analyzed pork market in the EU and in the top 10 pork producing countries in the period 2007-2018 based on the statistical data using dynamics analysis based on fixed basis index, and trend analysis based on polynomial and linear equations. The pig number declined in the EU, accounting for 148.2 million heads in 2018. In this year, there were slaughtered 259.3 million pigs from which there were obtained 23.84 million tonnes pork, by 3.8% more than in 2007. About 64% of the EU pork output is carried out in Germany, Spain, France, Denmark and Netherlands. The EU pork exports reached 3.93 million tonnes in 2018, 2 times more than in 2007. The pork imports are not significant and declined. The EU export value was double in 2018, accounting for Euro 7.3 billion, of which 71% is due to Spain, Germany, Denmark and Netherlands. The EU-28 is the top pork exporter in the world, its trade balance reached Euro 7.2 Billion in 2018, being 2.3 times higher than in 2007. The highest trade balance is registered by Spain, Germany, Denmark, Netherlands, Italy, and France. The average pork carcass price was Euro 142.04 in 2018 at the EU level. Pork is the most consumed meat in the EU, an inhabitant consuming 35 kg per year, 3 times more than the world average. As a final conclusion, the main trends which will continue in the near future in the EU pork market are the following ones: the decline in pig livestock, the slight growth of pork production, the intensification of exports, the decrease in imports and a slight decline of consumption. [ABSTRACT FROM AUTHOR]

Animal liberation activists' visual output invites reflection on the relationships our society has with other animals who live, suffer and die as objects of human exploitation. This paper presents the results of 60 interviews with vegan animal liberation activists in Sweden, Denmark and Spain. The main goal of this research was to consider the effectiveness of different visuals and audiovisuals (particularly violent images producing moral shock) in 1) promoting change in speciesist attitudes (the adoption of veganism), 2) promoting action against speciesism (involvement in activism) and 3) sustaining both veganism and activism in the long term. A second goal was to examine how activists used visual materials in their own efforts to promote anti-speciesism. The third goal was to validate the author's classification of violent images of farmed exploited animals. The findings suggest that exposure to moral shock was decisive in the adoption of veganism and involvement in activism in most cases. They also show that activists use these visuals to sustain their moral values and practices over time. [ABSTRACT FROM AUTHOR]

Introduction: Spain is one of the leading countries in the application of proactive and personalised telecare to help support frail and vulnerable service users to live independently in their own homes for longer*. Concern was however noted regarding potential impacts on ambulance mobilisations as time in the service, and mean age at cessation, increased by 1.3 years. Aims, Objectives, Theory and Methods: The purpose of this study was to investigate these impacts. A longitudinal study of a telecare service user population in Spain (n=202.1k to 247.9k) was undertaken using anonymised operational data collected in the delivery of proactive and personalised telecare services by Televida Servicios Sociosanitarios over the period 2014-18. The population was subject to change over time as new service users became eligible to register for the service, and others ceased the service. Each of these factors were also studied to assess potential confounding or covariate factors in the population also influencing the mobilisation of ambulances. Key Findings: For the studied population, ambulance mobilisation on a per-person/per-annum (pp/pa) basis reduced over the period despite the increasing age profile at cessation and with the characteristics of the population at registration remaining otherwise similar over the period. Overall mobilisations reduced by 27.9% (0.665 to 0.479 pp/pa) over the period whilst for ambulances there was a reduction of 33.3% (0.461 to 0.307 pp/pa). There were also smaller reductions in the number for family and state security mobilisations. The study identified the positive correlation coefficient between ambulance mobilisations and service user's dependency levels, and marginal negative correlation in older age bands. We are aware of no other studies which have investigated the impact on ambulance mobilisations of advanced proactive telecare and the increasing age of the services users supported to continue living independently. We believe this paper, therefore, contributes new insight which extends the existing research literature. Conclusions: The increasing age at cessation has not correlated with an increased proportion of higher dependency service users. The share of those over 85 years in the high dependency level decreased. This indicates that the changes in the telecare service contributing to increased time living independently may also have helped service users remain in lower risk bands. Limitations: There is a risk that use of mean annual measures may obscure important variations within the data. Changes in levels of proactivity, personalisation and increased use of sophisticated monitoring sensors of the telecare services are not the subject of this paper, but addressed in part in allied research. [ABSTRACT FROM AUTHOR]

Finding alternative phosphorus sources is imperative to address negative environmental and societal impacts caused by its current inefficient use. However, the direct use of phosphorus in sewage sludge in agriculture is controversial. This paper uses Denmark, Germany, and Spain as case examples to assess relevant legislation and boundary conditions in agricultural production to identify opportunities and barriers for the utilisation of recycled phosphorus from wastewater in agriculture on a regional level. Only five out of 22 phosphorus recycling technologies considered were in full compliance with legislation across all three countries, and these five were then assessed for their potential to supply phosphorus to major crops within countries. We considered the application of technologies across four scenarios: 1) struvite; 2) vivianite as iron supply; 3) vivianite for calcium phosphate precipitation; and 4) ashes for calcium phosphate precipitation. The most suitable scenario identified for Denmark was vivianite for calcium phosphate precipitation, whereas in Spain vivianite as iron supply was identified as most suitable, and ashes for calcium phosphate in Germany. We found that in 2018, the potential phosphorus supply from recycling technologies was on average 0.38, 0.29 and 0.05 kg of phosphorus per capita for Danish, German, and Spanish regions. These quantities could meet 9.1, 21.7, and 10.0 percent of the phosphorus required to produce major cereals in each country (specifically wheat, barley, and rye). Given current legal constraints, wastewater treatment plant connections and agronomic context, the potential contribution of recycled phosphorus is non-negligible in many sub-national regions. Still, to access the full potential of phosphorus circularity clear product specifications and transport and logistics among regions will be necessary. [ABSTRACT FROM AUTHOR]

• Feasibility of estimating pertussis vaccination covering using 7 European healthcare databases. • The majority of children were vaccinated at the recommended age of vaccination. • Two estimation methods provided comparable coverage estimates. • Benchmarking using national coverage estimates showed comparable results. • The approached used provided reliable estimates for pertussis vaccination coverage. The Accelerated Development of VAccine beNefit-risk Collaboration in Europe (ADVANCE) is a public-private collaboration aiming to develop and test a system for rapid benefit-risk (B/R) monitoring of vaccines, using existing healthcare databases in Europe. The objective of this paper was to assess the feasibility of using electronic healthcare databases to estimate dose-specific acellular pertussis (aP) and whole cell pertussis (wP) vaccine coverage. Seven electronic healthcare databases in four European countries (Denmark (n = 2), UK (n = 2), Spain (n = 2) and Italy (n = 1)) participated in this study. Children were included from birth and followed up to age six years. Vaccination exposure was obtained from the databases and classified by type (aP or wP), and dose 1, 2 or 3. Coverage was estimated using period prevalence. For the 2006 birth cohort, two estimation methods for pertussis vaccine coverage, period prevalence and cumulative incidence were compared for each database. The majority of the 2,575,576 children included had been vaccinated at the country-specific recommended ages. Overall, the estimated dose 3 coverage was 88–97% in Denmark (birth cohorts from 2003 to 2014), 96–100% in the UK (2003–2014), 95–98% in Spain (2004–2014) and 94% in Italy (2006–2007). The estimated dose 3 coverage per birth cohort in Denmark and the UK differed by 1–6% compared with national estimates, with our estimates mostly higher. The estimated dose 3 coverage in Spain differed by 0–2% with no consistent over- or underestimation. In Italy, the estimates were 3% lower compared with the national estimates. Except for Italy, for which the two coverage estimation methods generated the same results, the estimated cumulative incidence coverages were consistently 1–10% lower than period prevalence estimates. This study showed that it was possible to provide consistent estimates of pertussis immunisation coverage from the electronic healthcare databases included, and that the estimates were comparable with the national estimates. [ABSTRACT FROM AUTHOR]

Introduction: Regular moderate‐to‐vigorous physical activity (MVPA) is associated with improved mental health, but the evidence for the effect of reducing sedentary behavior (SB) or increasing light PA (LPA) in older adults is lacking. Using isotemporal substitution (IS) models, the aim of this paper was to investigate the effect of substituting SB with LPA or MVPA on associations with mental health in older adults. Methods: Data from 1360 older adults (mean age 75.18 years) in four countries were utilized. PA and SB was measured using ActiGraph wGT3X‐BT + accelerometers worn for 7 days. Self‐rated mental health was measured using the Hospital and Anxiety Depression Scale (HADS). IS models estimated cross‐sectional associations when 30 minutes of one behavior was substituted with another. Models were adjusted for age, sex, marital status, and educational attainment. Results: Substituting 30 minutes of SB with LPA (β −.37; 95% CI −0.42, −0.32) or MVPA (β −.14; 95% CI −0.21, −0.07) and substituting LPA with MVPA (β −.11; 95% CI −0.18, −0.04) were associated with improvements in anxiety. However, substituting 30 minutes of SB with LPA (β.55; 95% CI 0.49, 0.62) was associated with increased depression. Conclusion: Replacing 30 minutes of SB with LPA or MVPA was associated with improved anxiety symptoms in older adults. Greater benefits were observed when shifting SB and LPA to MVPA. [ABSTRACT FROM AUTHOR]

Introduction: After several years of promoting integrated care pathways (ICP), in 2020 Osakidetza published the corporate document for the design, implementation and evaluation of corporate integrated care pathways (CICP) throughout its network of integrated care organisations (ICOs). This paper describes its elaboration, contrast and some reflections on its extension. Aims, Objectives: integrated care continues to be one of Osakidetza's strategic challenges, after having completed the integration of primary care and hospital care throughout the entire service in thirteen ICOs over the past decade. The ICPs are intended to be the operative space in which the various fundamental elements of integrated care come together. It is necessary to standardise the use of this tool in the ICOs as a whole, and to this end it was decided to draw up a reference guide for the entire network. Highlights: Definition of ICP: one of the first issues to be resolved was the concept of ICP, which is often confused with terms like clinical practice guideline, protocol, etc. The definition developed takes a dual perspective, from the professional-managerial point of view and from the point of view of the patient and their relatives. Differential elements of ICP: the proposed concept of ICP inherently entails: - agreement among all actors, including patients and relatives, - explicit description of the goals and key elements of treatments and care based on evidence, best practices and the expectations of patients and their relatives, - coordination of the care process - recording, monitoring and evaluation of variability and outcomes. Checklist: a tool is proposed to enable ICOs to assess their existing ARs and to guide the design of new ICPs. This checklist is composed of 18 questions with a Likert scale of 1 to 7 grouped into six domains: - ICP rationale, shared leadership and institutional momentum - Constitution, functioning, independence of the ICP Elaboration Group - Pathway design (scope, usability and external review) - Incorporation of evidence into the ICP Training, dissemination and implementation - Monitoring and evaluation. Conclusions: The checklist was piloted with the COPD care pathways that several ICOs had been working with previously. The usefulness of the corporate document and its checklist has been confirmed, with both the Corporate level and ICOs stating that they will use it for the design and implementation of new ICPs or for the adaptation of existing ICPs. Implications For Applicability And Limitations: one of the reflections provoked by this process is the as yet unresolved issue of extending the use of this guide to the whole of the Osakidetza's network of ICOs. There are two main alternatives, with intermediate possibilities between, depending on which criterion is given more weight: 1. Under a more centralised and standardising criterion for the creation of CICPs, the development of corporate ICPs to be implemented locally by the ICOs. 2. Under a criterion of greater autonomy for each organisation but based on common characteristics set out in this corporate guide, local ICP developed directly by each ICO. [ABSTRACT FROM AUTHOR]

Abstract: Background: It is generally acknowledged that Denmark is one, if not the, leading country in terms of the use of information technology by its primary care physicians. Other countries, notably excluding the United States and Canada, are also advanced in terms of electronic medical records in general practitioner offices and clinics. Purpose: This paper compares the status of primary care physician office computing in Andalucía to that of Denmark by contrasting the functionality of electronic medical records (EMRs) and the ability to electronically communicate clinical information in both jurisdictions. Methods: A novel scoring system has been developed based on data gathered from databases held by the respective jurisdictional programs, and interviews with individuals involved in the deployment of the systems. The scoring methodology was applied for the first time in a comparison of the degree of automation in primary care physician offices in Denmark and the province of Alberta in Canada. It was also used to compare Denmark and New Zealand. This paper is the third offering of this method of scoring the adoption of electronic medical records in primary care office settings which hopefully may be applicable to other health jurisdictions at national, state, or provincial levels. Results: Although similar in many respects, there are significant differences between these two relatively autonomous health systems which have led to the rates of uptake of physician office computing. Particularly notable is the reality that the Danish primary care physicians have individual “Electronic Medical Records” while in Andalucía, the primary care physicians share a common record which when secondary care is fully implemented will indeed be an “Electronic Health Record”. Conclusion: It is clear that the diffusion of technology, within the primary care physician sector of the health care market, is subject to historical, financial, legal, cultural, and social factors. This tale of two places illustrates the issues, and different ways that they have been addressed. [Copyright &y& Elsevier]

Background: Variation in prescription of antibiotics in primary care can indicate poor clinical practice that contributes to the increase of resistant strains. General Practitioners (GPs), as a professional group, are expected to have a fairly homogeneous prescribing style. In this paper, we describe variation in prescribing style within and across groups of GPs from six countries. Methods: Cross-sectional study with the inclusion of 457 GPs and 6394 sore throat patients. We describe variation in prescribing antibiotics for sore throat patients across six countries and assess whether variation in “prescribing style” - understood as a subjective tendency to prescribe - has an important effect on variation in prescription of antibiotics by using the concept of prescribing style as a latent variable in a multivariable model. We report variation as a Median Odds Ratio (MOR) which is the transformation of the random effect variance onto an odds ratio; Thus, MOR = 1 means similar odds or strict homogeneity between GPs' prescribing style, while a MOR higher than 1 denotes heterogeneity in prescribing style. Results: In all countries some GPs always prescribed antibiotics to all their patients, while other GPs never did. After adjusting for patient and GP characteristics, prescribing style in the group of GPs from Russia was about three times more heterogeneous than the prescribing style in the group of GPs from Denmark - Median Odds Ratio (6.8, 95% CI 3.1;8.8) and (2.6, 95% CI 2.2;4.4) respectively. Conclusion: Prescribing style is an important source of variation in prescription of antibiotics within and across countries, even after adjusting for patient and GP characteristics. Interventions aimed at influencing the prescribing style of GPs must encompass context-specific actions at the policy-making level alongside GP-targeted interventions to enable GPs to react more objectively to the external demands that are in place when making the decision of prescribing antibiotics or not. [ABSTRACT FROM AUTHOR]

With a growing ageing population and the advent of interactive TV (iTV), understanding how older people use iTV services is a timely and important task. Working towards this end, this paper reports on in situ conversations of, and observations with, almost 400 older people, with different levels of educational attainment and experience with ICTs, while talking about and using online video portals and similar interactive systems in Spain, Brazil and Denmark. The results show more similarities than differences in their reasons for adopting online video portals and patterns of use. All our participants used these portals for keeping or remaining in touch with people they trusted. The results also show that privacy online was a common concern to all the participants. Differences in the acceptance of e-government services and the type of content that drove most of their interactions were also found. Implications for designing more accessible and meaningful iTV services are discussed. [ABSTRACT FROM AUTHOR]

Two important aspects of global environmental problems are that (1) the actions of past generations affect the opportunities of the present, and (2) both in the past and the present generations, collaboration across different countries is needed to provide global public goods. In this paper, we study how these two aspects influence public good provisions by running simultaneous intercountry laboratory experiments using a modified public goods game in Denmark, Spain and Ghana. While the theoretical predictions of the modified public goods game do not differ from that of the standard public goods game, our experimental results show otherwise. Pooling across results from our Danish, Spanish and Ghanaian participants, we find that present-generation individuals contribute a higher percentage of their endowments when they have better institutions and a lower percentage of their endowments when they have higher endowments. We also find that present-generation individuals contribute less to transnational public goods only when their initial conditions have not been affected by past-generation contributions. [ABSTRACT FROM AUTHOR]