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Marie Haase Juhl,1,2 Anne Estrup Olesen,1,2 Ellen Tveter Deilkås,3 Niels Henrik Bruun,4 Kirsten Høgh Obling,5 Nikoline Rytter,6 Maya Damgaard Larsen,6 Solvejg Kristensen7 1Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark; 2Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; 3Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway; 4Research Data and Biostatistics, Aalborg University Hospital, Aalborg, Denmark; 5Care and Rehabilitation, Department of Health and Care Services (Danish: “pleje Og Rehabilitering, Staben Sundhed Og Omsorg”), the Municipality of Aarhus, Aarhus, Denmark; 6Digitalization and Quality, Department of Health and Care Services (Danish: “digitalisering og Kvalitet, Sundhed og Omsorg”), The Municipality of Aarhus, Aarhus, Denmark; 7Aalborg University Hospital, Psychiatry, Aalborg, DenmarkCorrespondence: Anne Estrup Olesen, Department of Clinical Pharmacology, Aalborg University Hospital, Gartnerboligen, Ground Floor, Mølleparkvej 8a, Aalborg, 9000, Denmark, Tel +45 97664376, Email aneso@rn.dkBackground: A lack of instruments to assess patient safety climate within primary care exists. The objectives of this study were as follows: 1) To adapt the Danish hospital version of the Safety Attitudes Questionnaire (SAQ-DK) for use in primary care; 2) Test the internal consistency and the construct validity of this version; 3) Present benchmark data; and 4) Analyze variance.Methods: The SAQ-DK was adapted for use in Danish primary care settings (SAQ-DK-PRIM) and distributed to healthcare staff members from nursing homes (N = 11), homecare units (N = 4) and healthcare units (N = 2), within the municipality of Aarhus, Central Denmark Region, Denmark. Face- and content validity were assessed. The construct validity was evaluated by a set of goodness-of-fit indices. The internal reliability was evaluated using the item-rest correlations, the inter-item correlations, and Cronbach’s alpha (α).Results: The adaptation process resulted in a questionnaire of 10 items. Eight hundred and thirty healthcare staffs participated (78% of the eligible respondents). In total 586 (70.6%) responses were complete and were included in the analysis. Goodness-of-fit indices from the confirmatory factor analysis showed: Chi2=46.90CFI=0.97, RMSEA = 0.063 (90% CI: 0.044– 0.084), Probability RMSEA (p close)=0.12. Internal reliability was high (Cronbach’s α=0.76). Proportions of participants with a positive attitude was 41.1% and did not differ between the healthcare services. Scale mean score was 70.19 (SD: 18.05) and differed between healthcare services. The safety climate scale scores did not vary according to healthcare service type. ICC was 0.68% indicating no clustering of scores by healthcare service type.Conclusion: Considering the questionnaire’s applicability, short length, strengthened focus on one area of interest and validity, the SAQ-DK-PRIM can serve as a valuable tool for measuring patient safety climate within primary care settings in Denmark.Keywords: primary care, patient safety culture, patient safety climate, questionnaire, validity, reliability, Denmark

This article is a systematic review of studies that explore the use of game-based learning (GBL) in dermatology education. The review found that GBL can be an effective approach to teaching dermatology, with positive attitudes and favorable learning outcomes reported. However, the study quality of the reviewed articles was generally low, and there is a need for high-quality studies with objective outcomes. The authors suggest that GBL could play an important role in future dermatology training, but more research is needed to support its effectiveness. The study was funded by the Copenhagen Capital Region Postdoctorate Research Fund and the authors declare no conflicts of interest. [Extracted from the article]

The ocean plays an important role in modulating the mass balance of the polar ice sheets by interacting with the ice shelves in Antarctica and with the marine-terminating outlet glaciers in Greenland. Given that the flux of warm water onto the continental shelf and into the sub-ice cavities is steered by complex bathymetry, a detailed topography data set is an essential ingredient for models that address ice-ocean interaction.We followed the spirit of the global RTopo-1 data set and compiled consistent maps of global ocean bathymetry, upper and lower ice surface topographies, and global surface height on a spherical grid with now 30 arcsec grid spacing. For this new data set, called RTopo-2, we used the General Bathymetric Chart of the Oceans (GEBCO-2014) as the backbone and added the International Bathymetric Chart of the Arctic Ocean version 3 (IBCAOv3) and the International Bathymetric Chart of the Southern Ocean (IBCSO) version 1. While RTopo-1 primarily aimed at a good and consistent representation of the Antarctic ice sheet, ice shelves, and sub-ice cavities, RTopo-2 now also contains ice topographies of the Greenland ice sheet and outlet glaciers. In particular, we aimed at a good representation of the fjord and shelf bathymetry surrounding the Greenland continent. We modified data from earlier gridded products in the areas of Petermann Glacier, Hagen Bræ, and Sermilik Fjord, assuming that sub-ice and fjord bathymetries roughly follow plausible Last Glacial Maximum ice flow patterns. For the continental shelf off Northeast Greenland and the floating ice tongue of Nioghalvfjerdsfjorden Glacier at about 79° N, we incorporated a high-resolution digital bathymetry model considering original multibeam survey data for the region. Radar data for surface topographies of the floating ice tongues of Nioghalvfjerdsfjorden Glacier and Zachariæ Isstrøm have been obtained from the data centres of Technical University of Denmark (DTU), Operation Icebridge (NASA/NSF), and Alfred Wegener Institute (AWI). For the Antarctic ice sheet/ice shelves, RTopo-2 largely relies on the Bedmap-2 product but applies corrections for the geometry of Getz, Abbot, and Fimbul ice shelf cavities. The data set is available in full and in regional subsets in NetCDF format from the PANGAEA database at doi:10.1594/PANGAEA.856844.

Objectives: To compute a set of atypicality indices based on combined first‐trimester screening (cFTS) markers and second‐trimester estimated fetal weight (EFW), and to demonstrate their potential in identifying pregnancies at reduced or increased risk of chromosomal aberrations following a low‐risk cFTS result. Methods: The atypicality index quantifies the unusualness of an individual set of measurements relative to a reference distribution and can be computed from any variables or measurements available. A score of 0% on the atypicality index represents the most typical profiles, while a score of 100% indicates the highest level of atypicality. From the Danish Fetal Medicine Database, we retrieved data on all pregnant women seen for cFTS in the Central Denmark Region between January 2008 and December 2018. All pregnancies with a cytogenetic or molecular analysis obtained prenatally, postnatally or following pregnancy loss or termination were identified. A first‐trimester atypicality index (AcFTS) was computed based on nuchal translucency (NT) thickness, maternal serum free β‐human chorionic gonadotropin (β‐hCG) and pregnancy‐associated plasma protein‐A (PAPP‐A). Furthermore, a second‐trimester index (AcFTS + EFW) was computed from cFTS markers and EFW from a routine second‐trimester anomaly scan. All pregnancies were stratified into subgroups based on their atypicality levels and their cFTS risk estimates. The risk of chromosomal aberrations in each subgroup was then compared with the overall prevalence, and a graphical presentation of the multivariate measurement profiles was developed. Results: We retrieved data on 145 955 singleton pregnancies, of which 9824 (6.7%) were genetically examined. Overall, 1 in 122 (0.82% (95% CI, 0.77–0.87%)) of all pregnancies seen for cFTS were affected by a fetal chromosomal aberration, and in screen‐negative pregnancies (cFTS trisomy 21 risk < 1 in 100 and/or trisomy 18/13 risk < 1 in 50), 0.41% (95% CI, 0.38–0.44%) were affected. In screen‐negative pregnancies with a typical first‐trimester profile (AcFTS< 80%), the risk of chromosomal aberrations was significantly reduced (0.28%) compared with the overall risk. The risk of chromosomal aberrations increased with higher atypicality index to 0.49% (AcFTS[80–90%)), 1.52% (AcFTS[90–99%)) and 4.44% (AcFTS≥ 99%) and was significantly increased in the two most atypical subgroups. The same applied for the second‐trimester atypicality index, with risks of chromosomal aberrations of 0.76% and 4.16% in the two most atypical subgroups (AcFTS + EFW[90–99%) and AcFTS + EFW≥ 99%, respectively). Conclusions: As an add‐on to cFTS, the atypicality index identifies women with typical measurement profiles, which may provide reassurance, whereas atypical profiles may warrant specialist referral and further investigation. In pregnancies identified as low risk on cFTS but with a highly atypical distribution of NT, PAPP‐A and β‐hCG, the risk of a chromosomal aberration is substantially increased. The atypicality index optimizes the interpretation of pre‐existing prenatal screening profiles and is not limited to cFTS markers or EFW. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

ObjectiveClinical management is hypothesized to be critical for hospital management and hospital performance. The aims of this study were to develop and validate professional involvement scales for measuring the level of clinical management by physicians and nurses in European hospitals.DesignTesting of validity and reliability of scales derived from a questionnaire of 21 items was developed on the basis of a previous study and expert opinion and administered in a cross-sectional seven-country research project 'Deepening our Understanding of Quality improvement in Europe' (DUQuE).Setting and participantsA sample of 3386 leading physicians and nurses working in 188 hospitals located in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey.Main outcome measuresValidity and reliability of professional involvement scales and subscales.ResultsPsychometric analysis yielded four subscales for leading physicians: (i) Administration and budgeting, (ii) Managing medical practice, (iii) Strategic management and (iv) Managing nursing practice. Only the first three factors applied well to the nurses. Cronbach's alpha for internal consistency ranged from 0.74 to 0.86 for the physicians, and from 0.61 to 0.81 for the nurses. Except for the 0.74 correlation between 'Administration and budgeting' and 'Managing medical practice' among physicians, all inter-scale correlations were

ObjectiveTo describe hospitals' organizational arrangements relevant to the abstraction of administrative data, to report on the completeness of administrative data collected and to assess associations between organizational arrangements and completeness of data submission.DesignA cross-sectionalStudy designutilizing administrative data.Setting and participantsRandomly selected hospitals from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey).Main outcome measuresCompleteness of data submission for four quality indicators: mortality after acute myocardial infarction, stroke and hip fractures and complications after normal delivery.ResultsIn general, hospitals were able to produce data on the four indicators required for this research study. A substantial proportion had missing data on one or more data items. The proportion of hospitals that was able to produce more detailed indicators of relevance for quality monitoring and improvement was low and ranged from 40.1% for thrombolysis performed on patients with acute ischemic stroke to 63.8% for hip-fracture operations performed within 48 h after admission for patients aged 65 or older. National factors were strong predictors of data completeness on the studied indicators.ConclusionsAt present, hospital administrative databases do not seem to be an appropriate source of information for comparison of hospital performance across the countries of the EU. However, given that this is a dynamic field, changes to administrative databases may make this possible in the near future. Such changes could be accelerated by an in-depth comparative analysis of the issues of using administrative data for comparisons of hospital performances in EU countries.

ObjectiveTo define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals.DesignWe developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors.Setting and participantsA sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated.Main outcome measuresFour measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR).ResultsParticipating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0-4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level.ConclusionThe newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).

ObjectiveThe aim of this study was to develop and validate an index to assess the implementation of quality management systems (QMSs) in European countries.DesignQuestionnaire development was facilitated through expert opinion, literature review and earlier empirical research. A cross-sectional online survey utilizing the questionnaire was undertaken between May 2011 and February 2012. We used psychometric methods to explore the factor structure, reliability and validity of the instrument.Setting and participantsAs part of the Deepening our Understanding of Quality improvement in Europe (DUQuE) project, we invited a random sample of 188 hospitals in 7 countries. The quality managers of these hospitals were the main respondents.Main outcome measureThe extent of implementation of QMSs.ResultsFactor analysis yielded nine scales, which were combined to build the Quality Management Systems Index. Cronbach's reliability coefficients were satisfactory (ranging from 0.72 to 0.82) for eight scales and low for one scale (0.48). Corrected item-total correlations provided adequate evidence of factor homogeneity. Inter-scale correlations showed that every factor was related, but also distinct, and added to the index. Construct validity testing showed that the index was related to recent measures of quality. Participating hospitals attained a mean value of 19.7 (standard deviation of 4.7) on the index that theoretically ranged from 0 to 27.ConclusionAssessing QMSs across Europe has the potential to help policy-makers and other stakeholders to compare hospitals and focus on the most important areas for improvement.

ObjectiveTo investigate the relationship between ISO 9001 certification, healthcare accreditation and quality management in European hospitals.DesignA mixed method multi-level cross-sectional design in seven countries. External teams assessed clinical services on the use of quality management systems, illustrated by four clinical pathways.Setting and participantsSeventy-three acute care hospitals with a total of 291 services managing acute myocardial infarction (AMI), hip fracture, stroke and obstetric deliveries, in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey.Main outcome measureFour composite measures of quality and safety [specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies (PSS) and clinical review (CR)] applied to four pathways.ResultsAccreditation in isolation showed benefits in AMI and stroke more than in deliveries and hip fracture; the greatest significant association was with CR in stroke. Certification in isolation showed little benefit in AMI but had more positive association with the other conditions; greatest significant association was in PSS with stroke. The combination of accreditation and certification showed least benefit in EBOP, but significant benefits in SER (AMI), in PSS (AMI, hip fracture and stroke) and in CR (AMI and stroke).ConclusionsAccreditation and certification are positively associated with clinical leadership, systems for patient safety and clinical review, but not with clinical practice. Both systems promote structures and processes, which support patient safety and clinical organization but have limited effect on the delivery of evidence-based patient care. Further analysis of DUQuE data will explore the association of certification and accreditation with clinical outcomes.

ObjectiveThe objective of this study was to describe the involvement of patients or their representatives in quality management (QM) functions and to assess associations between levels of involvement and the implementation of patient-centred care strategies.DesignA cross-sectional, multilevelStudy designthat surveyed quality managers and department heads and data from an organizational audit.SettingRandomly selected hospitals (n = 74) from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).ParticipantsHospital quality managers (n = 74) and heads of clinical departments (n = 262) in charge of four patient pathways (acute myocardial infarction, stroke, hip fracture and deliveries) participated in the data collection between May 2011 and February 2012.Main outcome measuresFour items reflecting essential patient-centred care strategies based on an on-site hospital visit: (1) formal survey seeking views of patients and carers, (2) written policies on patients' rights, (3) patient information literature including guidelines and (4) fact sheets for post-discharge care. The main predictors were patient involvement in QM at the (i) hospital level and (ii) pathway level.ResultsCurrent levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level (mean score 1.6 on a scale of 0 to 5, SD 0.7), but even lower at departmental level (mean 0.6, SD 0.7). We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies; however, the smallest hospitals were more likely to have implemented patient-centred care strategies.ConclusionsThere is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care; however, lack of evidence should not be interpreted as evidence of no effect.

ObjectiveThe assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures.DesignIt is a multi-level, cross-sectional, mixed-method study.Setting and participantsAs part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used.Main outcome measuresThree measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR).ResultsPositive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments.ConclusionBy using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.

Objective: To compare morbidity, as measured by length of stay in the neonatal intensive care unit (NICU), in twin and singleton gestations classified as small‐for‐gestational age (SGA) according to estimated fetal weight < 10th percentile on twin or singleton growth charts. Methods: NICU length of stay was compared in 1150 twins and 29 035 singletons that underwent ultrasound assessment between 35 + 0 and 36 + 6 weeks' gestation. Estimated fetal weight was obtained from measurements of head circumference, abdominal circumference and femur length using the Hadlock formula. Gestational age was derived from the first‐trimester crown–rump length measurement, using the larger of the two twins. Singletons and twins were compared in terms of NICU admission rate and length of stay according to classification as SGA by the Fetal Medicine Foundation singleton and twin reference distributions. Results: The overall proportions of twins and singletons admitted to NICU were similar (7.3% vs 7.4%), but twins tended to have longer lengths of stay in NICU (≥ 7 days: 2.4% vs 0.8%; relative risk (RR), 3.0 (95% CI, 1.6–4.4)). Using the singleton chart, a higher proportion of twins were classified as SGA compared with singletons (37.6% vs 7.0%). However, the proportion of SGA neonates entering NICU was similar (10.2% for twins and 10.1% for singletons) and the proportion of SGA neonates spending ≥ 7 days in NICU was substantially higher for twins compared with singletons (3.7% vs 1.4%; RR, 2.6 (95% CI, 1.4–4.7)). Conclusions: When singleton charts are used to define SGA in twins and in singletons, there is a greater degree of growth‐related neonatal morbidity amongst SGA twins compared with SGA singletons. Consequently, singleton charts do not inappropriately overdiagnose fetal growth restriction in twins and they should be used for monitoring fetal growth in both twins and singletons. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Background: Chronic pain is the hallmark symptom of joint diseases. This study examined the differences in quantitative sensory testing between patients with psoriatic arthritis (PsA), hand osteoarthritis (hand‐OA) and a pain‐free control group and differences between patients with and without concomitant fibromyalgia (cFM). Methods: All patients and pain‐free controls were assessed using pressure pain thresholds (PPT), temporal summation of pain (TSP), conditioned pain modulation (CPM) and clinical pain intensities. Psychological distress was assessed with the Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and Pittsburgh Sleep Quality Index. Disability was assessed with the Health Assessment Questionnaire and pain quality with the painDETECT questionnaire. cFM was identified using the revised 2016 American College of Rheumatology diagnostic criteria. Results: Patients with hand‐OA (n = 75) or PsA (n = 58) had statistically significant lower PPTs and CPM, greater TSP, and higher scores of psychological distress (p < 0.05) than controls (n = 20). Patients with cFM (58%) had higher scores of depression (p = 0.001), anxiety (p = 0.004), catastrophizing (p = 0.012), disability (p < 0.001), higher painDETECT score (p = 0.001), TSP (p = 0.027), and reduced sleep quality (p = 0.021) when compared to patients without cFM. Conclusion: Patients with hand‐OA and PsA exhibited signs of pain sensitization and a higher degree of psychological distress and disability than pain‐free individuals. Patients with cFM had greater TSP, painDETECT score, disability, catastrophizing, and reduced sleep quality, than patients without, indicating greater degree of pain sensitization, psychological burden, and disability. Statement of Significance: This paper shows that a significant proportion of patients with hand osteoarthritis and psoriatic arthritis with moderate pain intensity have significantly increased signs of pain sensitization and markers of psychological distress. A large proportion of these patients fulfil the criteria for concomitant fibromyalgia and these patients show even greater propensity towards pain sensitization and psychological distress. [ABSTRACT FROM AUTHOR]