Revisiting the symptom iceberg based on the Danish symptom cohort - Symptom experiences and healthcare-seeking behaviour in the general Danish population in 2022.

Introduction: Healthcare-seeking behaviour may change over time, and some groups are more likely to avoid relevant help seeking, which possibly contributes to social inequity in health. Thus, we developed an expansion of and follow-up to the Danish Symptom Cohort (DaSC) from 2012 and formed the DaSC II, which encompassed a population-based questionnaire study investigating symptoms and healthcare-seeking behaviour. In this paper, we describe the conceptual framework, development and content validity of the questionnaire and a responder analysis of the participants in the DaSC II. We present the symptom iceberg in the Danish general population by estimating the prevalence of symptoms and proportion of contacts to general practitioners (GPs) in 2022. Moreover, we discuss differences in healthcare-seeking behaviour with reference to the 2012 DaSC. Methods: 100,000 randomly selected Danish citizens aged ≥20 years, along with the 44,713 respondents from the 2012 cohort, were invited to participate in a survey. The questionnaire was pilot and field tested prior to distribution. Descriptive statistics were used to estimate symptom prevalence and proportion of GP contacts, and to execute the respondent analysis. Results: Nine out of ten respondents reported at least one symptom within the preceding four weeks and reported an average of 4.6 symptoms. One in four symptoms were presented to a GP. The highest proportion of GP contacts was found for haematuria (63.3 %) and shortness of breath (51.8 %). For several symptoms, differences between the sexes were found in relation to both prevalence and GP contacts. The proportion of GP contacts was higher in 2022 than in 2012 and was most pronounced for general, frequently experienced symptoms and to a lesser extent for cancer alarm symptoms. Conclusion: Many symptoms go unreported, which may delay relevant diagnosis; more research on certain symptom categories and population subgroups is needed. Future studies based on the DaSC II form a basis for interventions targeting symptom awareness, healthcare-seeking behaviour and social equity in society and health.

Introducing Point-of-Care PCR technology in general practice: Ambiguities, experiences, and perceptions among health care professionals.

In this paper we present findings from a qualitative ethnographic study investigating the experiences and perceptions of general practitioners and other practice staff when introducing a new point of care diagnostic test technology (point of care polymerase chain reaction (POC PCR)) in general practice in Denmark. The ethnographic study was conducted in five general practice clinics, involving observations in four of the clinics and interviews with general practitioners and practice staff in all five clinics. Following an initial analytic phase in which barriers and facilitators in the implementation process of the Point-of-Care test were identified, we developed theoretically informed themes, drawing upon Hartmut Rosa's social theory of technological acceleration. These themes included ambiguous experiences and perceptions of: (i) diagnostic specification and inflation embedded in diagnostic practices; (ii) empowerment and erosion of professional judgment; (iii) strategies of security and insecurity in communication; (iv) the interdependence between professional autonomy and economic structures associated with organizational power; and (v) subjective and organizational time. We discuss how diagnostic technologies simultaneously contribute to and disrupt treatment safety, efficiency, and medical decision-making. Using Rosa's sociological concepts of alienation and resonance, this article furthermore explores how these ambiguous dynamics are experienced in general practice settings. It also examines the implications of navigating a heterogeneous socio-technical and medical landscape and what it means to be a health professional in a contemporary general practice environment that is increasingly shaped by diagnostic technologies.

Improving diagnostics using extended point-of-care testing during in-home assessments of older adults with signs of emerging acute disease: a prospective observational non-randomised pilot and feasibility study.

BACKGROUND: Delayed recognition of acute disease among older adults hinders timely management and increases the risk of hospital admission. Point-of-Care testing, including Focused Lung Ultrasound (FLUS) and in-home analysis of biological material, may support clinical decision-making in suspected acute respiratory disease. The aim of this study was to pilot test the study design for a planned randomised trial, investigate whether in-home extended use of point-of-care testing is feasible, and explore its' potential clinical impact. METHODS: A non-randomised pilot and feasibility study was conducted during September-November 2021 in Kolding Municipality, Denmark. A FLUS-trained physician accompanied an acute community nurse on home-visits to citizens aged 65 + y with signs of acute respiratory disease. The acute community nurses did a clinical assessment (vital signs, capillary C-reactive protein and haemoglobin) and gave a presumptive diagnosis. Subsequently, the physician performed FLUS, venipuncture with bedside analysis (electrolytes, creatinine, white blood cell differential count), nasopharyngeal swab (PCR for upper respiratory pathogens), and urine samples (flow-cytometry). Primary outcomes were feasibility of study design and extended point-of-care testing; secondary outcome was the potential clinical impact of extended point-of-care testing. RESULTS: One hundred consecutive individuals were included. Average age was 81.6 (SD ± 8.4). Feasibility of study design was acceptable, FLUS 100%, blood-analyses 81%, PCR for upper respiratory pathogens 79%, and urine flow-cytometry 4%. In addition to the acute community nurse's presumptive diagnosis, extended point-of-care testing identified 34 individuals with a condition in need of further evaluation by a physician. CONCLUSION: Overall, in-home assessments with extended point-of-care testing are feasible and may aid to identify and handle acute diseases in older adults.

Follow-up cancer care in Danish general practice - a questionnaire study.

BACKGROUND: Increasing longevity and improved cancer treatment have increased the prevalence of cancer survivors substantially and reinforced the need for effective strategies for follow-up cancer care in general practice. AIM: To investigate the organisation of follow-up cancer care in Danish general practice and to analyse the General Practitioners' (GPs) self-assessment of competences regarding cancer survivors and late effects. DESIGN & SETTING: A total of 500 Danish GPs were invited to a web-based survey. METHOD: Questions comprised organisation of follow-up cancer care, and the GPs' self-assessment of their competences in follow-up care and evaluation of late effects. Covariates considered included gender, age, seniority, and practice type. Analyses were conducted using descriptive statistics and multivariable logistic regression models. RESULTS: Some 29% of the GPs reported systematic organisation of follow-up cancer care in their clinic. Over half of the GPs assessed themselves as competent in evaluating mental sequelae, existential considerations, and the impact on co-morbidities. In contrast, only 19% and 33% of GPs reported competences in sexual and physical sequelae, respectively. Female GPs were less likely to report competences regarding physical and mental sequelae as well as sexual disturbances, and GPs from partnership practices were more likely to report competence in assessing mental sequelae. CONCLUSION: Less than one of three general practices have organised systematic follow-up cancer care and GPs assess their competence as low with respect to physical sequelae and sexual challenges. This emphasises the need for more systematic organisation and focus on knowledge of late effects in general practice.

Extended use of point-of-care technology versus usual care for in-home assessment by acute community nurses in older adults with signs of potential acute respiratory disease: an open-label randomised controlled trial protocol.

BACKGROUND: Due to ageing-related physiological changes, diagnosing older adults is challenging. Delayed disease recognition may lead to adverse health outcomes and increased hospitalisation, necessitating the development of new initiatives for timely diagnosis and treatment of older adults. Point-of-care technology, such as focused lung ultrasound scan and bedside analysis of blood samples (leucocytes with differential count, electrolytes, and creatinine) conducted in the patients' home, may support clinical decision-making, and potentially reduce acute hospital admissions. We present the protocol for a randomized controlled trial, which aims at assessing the effect of focused lung ultrasound scan and bedside blood analysis during in-home assessments among older adults with signs of potential acute respiratory disease on hospital admissions. METHOD: We will use a parallel open-label, individually randomised controlled trial design in an acute community healthcare setting. The trial will initiate on October 2022 and is expected to end one year later. The study population will include older adults (65 + year), with at least one of the following inclusion criteria: Cough, dyspnoea, fever, fall, or rapid functional decline. Expected study sample will comprise 632 participants. Participants in the control group will receive usual care, while the intervention group will undergo extended point-of-care technology (focused lung ultrasound scan and bedside venous blood analysis), in addition to usual care. The primary outcome is acute hospital admission within 30 days follow-up. Secondary outcomes include readmissions, mortality, length of hospital stay, hospital-free days, complications during hospital admission, treatment initiations or changes, functional level, re-referrals to the acute community healthcare service, and contacts to the primary care physician. A tertiary outcome is the diagnostic accuracy of Acute Community Nurses for conducting focused lung ultrasound compared with a specialist. Outcomes will be analysed as intention-to-treat. DISCUSSION: To our knowledge, this is the first randomised controlled trial examining the effect of extended use of point-of-care technology conducted in an in-home setting. We expect that the results may contribute to the development of new interventions aiming to improve timely diagnostics, treatment decisions, and reduce acute hospital admissions. TRIAL REGISTRATION: www. CLINICALTRIALS: org NCT05546073 (Date of registration: September 19th, 2022).

The durability of previous examinations for cancer: Danish nationwide cohort study.

OBJECTIVE: Patients previously examined for cancer with a negative result may present in general practice with ongoing or new symptoms or signs suggestive of cancer. This paper explores the potential existence of a relatively safe period for cancer occurrence after receiving negative examination results for specific types of cancer, including lung (CT thorax), upper gastrointestinal (gastroscopy), colorectal (colonoscopy), bladder (cystoscopy), and breast (clinical mammography). DESIGN: Register-based time-to-event analyses. SETTING: Denmark. SUBJECTS: All 3.3 million citizens aged 30-85 years who on January first, 2017, had not previously been diagnosed with the specific type of cancer were categorized based on the time since their most recent examination. MAIN OUTCOME MEASURES: Using 1-year follow-up, we calculated the age- and sex-adjusted hazard ratios of being diagnosed with the related cancer, with non-examined individuals as reference. Negative examination results were defined as the absence of a cancer diagnosis within 6 months following the examination. RESULTS: Previous negative examination results were common, also among those diagnosed with cancer during follow-up. For 10 years after a negative colonoscopy the risk of diagnosing a colorectal cancer was nearly halved. However, already 1 year after a clinical mammography and 2 years after a CT thorax the risk of diagnosing the related cancers was significantly higher among those with a previous negative result compared to non-examined individuals. CONCLUSION: This study did not identify a post-examination period in which the cancer risk, compared to non-examined individuals, was sufficiently low to confidently rule out any of the investigated cancers.

What should one expect when considering re-examining a patient with a negative result of a previous examination for cancer? We found that previous negative examination results are common in the general population and among those subsequently diagnosed with cancer. We did not find a safe period after any of the examinations in which a negative result alone could safely rule out the presence of cancer.

Exploring GPs' assessments of their patients' cancer diagnostic processes: a questionnaire study.

BACKGROUND: Most cancer diagnostic pathways start from primary care and several factors affect the diagnostic processes. AIM: To analyse the associations between patient characteristics, symptom presentation, and cancer type and the GP's assessment of the diagnostic processes. DESIGN AND SETTING: General practices in the North, Central, and Southern regions of Denmark were invited to participate in a questionnaire survey. METHOD: Participating GPs received a list of patients with incident cases of cancer in the period between 1 March 2019 and 28 February 2021 based on administrative hospital data. A questionnaire was completed for each patient, addressing symptom presentation and the GP's assessment of the diagnostic process both overall and in four subcategories (the patient's role, the GP's role, the transition between primary and secondary care, and the secondary sector's role). RESULTS: A total of 187 general practices informed on 8240 patients. For 5868 patients, diagnostic pathways started in general practice. Almost half (48.3%, 2837/5868) presented with specific cancer symptoms. GPs assessed 55.6% (3263) and 32.3% (1897) of the diagnostic processes as 'very good' and 'predominantly good', respectively; 11.9% (700) were 'predominantly poor' or 'very poor' for these 5868 patients. Long symptom duration of ≥2 months prior to GP contact and presenting with non-specific or a combination of non-specific and specific symptoms were associated with a poor overall assessment of the diagnostic process. Assessment in the four subcategories showed that the patient's role was assessed less positively than the other three categories. CONCLUSION: A longer symptom duration and presenting without cancer-specific symptoms were associated with GPs assessing the diagnostic process as poor.

Coping strategies among individuals with multiple physical symptoms: A general population-based cross-sectional study.

OBJECTIVE: Coping has been suggested as a perpetuating factor for physical symptoms. The aim of this study was to examine the use of the coping strategies approach, resignation, and diversion in individuals with multiple physical symptoms according to the construct of Bodily Distress Syndrome (BDS). METHODS: This cross-sectional study was part of the nationwide web-based survey Danish Symptom Cohort (DaSC). In total, 100,000 individuals were invited to participate, and individuals eligible for the present study were respondents aged 20-64 years without a current or recent pregnancy. Multiple physical symptoms were identified using the BDS checklist, and coping was assessed by the Brief Approach/Avoidance Coping Questionnaire. Statistical analyses included descriptive statistics and multinomial and logistic regression. RESULTS: A total of 35,810 respondents were included in the study, of which 8512 (23.8%) fulfilled the criteria for having multiple physical symptoms. This group of respondents had lower coping scores on approach and higher coping scores on resignation and diversion compared with the non-BDS group. The regression analyses showed that high scores on approach were associated with a lower probability of having multiple symptoms (adjusted OR 0.92, 95% CI: 0.91-0.92), whereas high scores on diversion and resignation were associated with a higher probability of having multiple symptoms (adjusted OR 1.10; 95% CI: 1.09-1.11 and adjusted OR 1.19; 95% CI: 1.18-1.20, respectively). CONCLUSION: The study supports the hypothesis that experiencing multiple physical symptoms is associated with certain coping strategies. This is relevant knowledge for health care professionals who will be treating this patient group.

Variation in suspected cancer referral pathways in primary care: comparative analysis across the International Benchmarking Cancer Partnership.

BACKGROUND: International variations in cancer outcomes persist and may be influenced by differences in the accessibility and organisation of cancer patient pathways. More evidence is needed to understand to what extent variations in the structure of primary care referral pathways for cancer investigation contribute to differences in the timeliness of diagnoses and cancer outcomes in different countries. AIM: To explore the variation in primary care referral pathways for the management of suspected cancer across different countries. DESIGN AND SETTING: Descriptive comparative analysis using mixed methods across the International Cancer Benchmarking Partnership (ICBP) countries. METHOD: Schematics of primary care referral pathways were developed across 10 ICBP jurisdictions. The schematics were initially developed using the Aarhus statement (a resource providing greater insight and precision into early cancer diagnosis research) and were further supplemented with expert insights through consulting leading experts in primary care and cancer, existing ICBP data, a focused review of existing evidence on the management of suspected cancer, published primary care cancer guidelines, and evaluations of referral tools and initiatives in primary care. RESULTS: Referral pathway schematics for 10 ICBP jurisdictions were presented alongside a descriptive comparison of the organisation of primary care management of suspected cancer. Several key areas of variation across countries were identified: inflexibility of referral pathways, lack of a managed route for non-specific symptoms, primary care practitioner decision-making autonomy, direct access to investigations, and use of emergency routes. CONCLUSION: Analysing the differences in referral processes can prompt further research to better understand the impact of variation on the timeliness of diagnoses and cancer outcomes. Studying these schematics in local contexts may help to identify opportunities to improve care and facilitate discussions on what may constitute best referral practice.

Associations between smoking status and involvement of personal and professional relations among individuals reporting symptoms related to a diagnosis of lung cancer: a population-based study.

BACKGROUND: Smoking is the leading cause of lung cancer, but individuals who currently smoke seek healthcare less frequently. This study of individuals reporting symptoms related to diagnosis of lung cancer has the following aims: 1) to explore the involvement of personal and professional relations; 2) to analyse whether age, sex and smoking status are associated with involving personal and professional relations; and 3) to analyse whether involving a personal relation is associated with healthcare-seeking. METHODS: Data was extracted from a Danish population-based survey from 2012 with 100,000 randomly selected invitees 20 years or older. We describe the involvement of personal and professional relations among individuals experiencing four predefined symptoms indicative of lung cancer: prolonged coughing, prolonged hoarseness, shortness of breath and haemoptysis, either alone or in combination. Using multivariate logistic regression, we analyse the associations between involving personal or professional relations and various covariates (sex, age, smoking status). Moreover, we analyse the association between involving a personal relation and healthcare-seeking. RESULTS: A total of 35,958 individuals over 40 years old completed the questionnaire. Of these, 5,869 individuals reported at least one lung cancer symptom. A higher percentage of participants with prolonged hoarseness and prolonged coughing reported no involvement of personal and professional relations (27.6% and 22.7%, respectively) compared to shortness of breath (12.4%). The most involved personal and professional relations were the spouse (46.2-62.5%) and the general practitioner (GP) (31.3-54.5%), respectively. Women and individuals in the oldest age group had higher odds of involving personal and professional relations. Individuals who currently smoke involved all relations less frequently than individuals who formerly,- and never smoked. Odds of contacting the GP or another doctor were three to seven-fold higher when a personal relation was also involved. CONCLUSION: Women and the oldest age group had higher odds of involving relations, whereas individuals who currently smoked tended to be less likely to contact any personal or professional relations. Involving a personal relation was associated with higher odds of healthcare-seeking. The findings could be useful for GPs in terms of identifying patients at risk of postponing relevant healthcare-seeking with potential lung cancer symptoms.

A population-based study on social inequality and barriers to healthcare-seeking with lung cancer symptoms.

Healthcare-seeking with lung cancer symptoms is a prerequisite for improving timely diagnosis of lung cancer. In this study we aimed to explore barriers towards contacting the general practitioner (GP) with lung cancer symptoms, and to analyse the impact of social inequality. The study is based on a nationwide survey with 69,060 individuals aged ≥40 years, randomly selected from the Danish population. The survey included information on lung cancer symptoms, GP contacts, barriers to healthcare-seeking and smoking status. Information about socioeconomics was obtained by linkage to Danish Registers. Descriptive statistics and multivariate logistic regression model were used to analyse the data. "Being too busy" and "Being worried about wasting the doctor's time" were the most frequent barriers to healthcare-seeking with lung cancer symptoms. Individuals out of workforce and individuals who smoked more often reported "Being worried about what the doctor might find" and "Being too embarrassed" about the symptoms. The social inequality in barriers to healthcare-seeking with lung cancer symptoms is noticeable, which emphasises the necessity of focus on vulnerable groups at risk of postponing relevant healthcare-seeking.

Barriers to assessing vulnerability in pregnant women. A cross-sectional survey in Danish general practice.

BACKGROUND: Undetected vulnerability in pregnancy contributes to inequality in maternal and perinatal health and is associated with negative birth outcomes and adverse child outcomes. Nationwide reports indicate important barriers to assessing vulnerability among Danish general practitioners. OBJECTIVE: To explore general practitioners perceived barriers to vulnerability assessment in pregnant women and whether the barriers are associated with practice organization of antenatal care, general practitioner, and practice characteristics. METHODS: The questionnaire was sent to all Danish general practitioners (N = 3,465). Descriptive statistics described the barriers to assessing vulnerability in pregnant women. Analytical statistics with ordered logistic regression models were used to describe the association between selected barriers to vulnerability assessment and antenatal care organization, and general practitioner and practice characteristics. RESULTS: 760 general practitioners (22%) answered. Barriers to vulnerability assessment were related to lacking routines for addressing vulnerability, lacking attention to and record-keeping on vulnerability indicators, an insufficient overview of vulnerable pregnant women, and perceived insufficient remuneration for antenatal care consultations. Not prioritizing extra time when caring for vulnerable pregnant women was associated with experiencing more barriers. Always prioritizing continuity of care was associated with experiencing fewer barriers. General practitioners of either young age, male gender, or who did not prioritize extra time to care for vulnerable pregnant women experienced more barriers. CONCLUSION: Barriers to vulnerability assessment among pregnant women do exist in general practice and are associated with organizational characteristics such as lacking prioritization of extra time and continuity in antenatal care consultations. Also, general practitioner characteristics like male gender and relatively young age are associated with barriers to vulnerability assessment.

Identifying vulnerability in pregnant women is essential to prevent pregnancy-related depression or problems of mother-child attachment, and these women need extra support during pregnancy. In Denmark, all pregnant women are offered pregnancy care by their general practitioner (GP). However, identifying vulnerable pregnant women is challenging for the GPs. This questionnaire study among 760 GPs explores whether the GPs perceived barriers to identifying vulnerable pregnant women are lack of attention to and overview of vulnerable women in their clinic, insufficient record-keeping of vulnerability indicators, and insufficient communicative routines in addressing vulnerability. Additionally, lack of monetary incentives, i.e. not getting paid for spending extra time to talk about vulnerability, was perceived as a barrier. These barriers to identifying vulnerable pregnant women are related to e.g. characteristics of the GP, the practice, and the antenatal care organization in general practice. Young GPs, male GPs, and GPs who did not spend as much time caring for vulnerable pregnant women experienced the most barriers. Contrary, GPs who always prioritized continuity of care experienced fewer barriers. Continuity of care and extra time is important for improving the care of vulnerable pregnant women. Health commissioners may consider supporting the GPs in mobilizing extra time and resources to enhance their care for vulnerable pregnant women.

Prescribing antibiotics: Factors driving decision-making in general practice. A discrete choice experiment.

BACKGROUND: Antimicrobial resistance is a threat to human health. We need to strive for a rational use of antibiotics to reduce the selection of resistant bacteria. Most antibiotics are prescribed in general practice, but little is known about factors influencing general practitioners' (GPs) decision-making when prescribing antibiotics. AIM: To 1) assess the importance of factors that influence decisions by GPs to prescribe antibiotics for acute respiratory tract infections (RTIs) and 2) identify segments of GPs influenced differently when deciding to prescribe antibiotics. METHODS: A questionnaire survey including a discrete choice experiment was conducted. Danish GPs were asked to indicate whether they would prescribe antibiotics in six hypothetical choice sets with six variables: whether the GP is behind schedule, patient's temperature, patient's general condition, lung auscultation findings, C-reactive protein (CRP) level, and whether the patient expects antibiotics. Error component and latent class models were estimated and the probabilities of prescribing in different scenarios were calculated. RESULTS: The questionnaire was distributed to every Danish GP (n = 3,336); 1,152 (35%) responded. Results showed that GPs were influenced by (in prioritised order): CRP level (Relative importance (RI) 0.54), patient's general condition (RI 0.20), crackles at auscultation (RI 0.15), and fever (RI 0.10). Being behind schedule and patient expectations had no significant impact on antibiotic prescription at the aggregate level. The latent class analysis identified five classes of GPs: generalists, CRP-guided, general condition-guided, reluctant prescribers, and stethoscopy-guided. For all classes, CRP was the most important driver, while GPs were heterogeneously affected by other drivers. CONCLUSION: The most important factor affecting Danish GPs' decision to prescribe antibiotics at the aggregate level, in subgroups of GPs, and across latent classes was the CRP value. Hence, the use of CRP testing is an important factor to consider in order to promote rational antibiotic use in the battle against antimicrobial resistance.

Involvement of personal and professional relations when experiencing colorectal cancer symptoms - a cross sectional study.

OBJECTIVE: As part of improving early diagnosis of colorectal cancer (CRC), knowledge about involvement of personal and professional relations, when experiencing CRC symptoms, is important. This study aimed to analyse involvement of personal and professional relations and whether age, sex, number of symptoms and available social network are associated with involving family, non-family and professional relations amongst individuals experiencing CRC symptoms. METHODS: Some, 100 000 Danes over 20 years were randomly selected and invited to a cross sectional survey comprising questions about involvement of relations regarding four predefined CRC symptoms (abdominal pain, rectal bleeding and change in stool texture and frequency). RESULTS: In total, 35 801 respondents over 40 years answered all relevant items and 9346 (26.1%) had experienced at least one CRC symptom in the preceding 4 weeks. Abdominal pain was more often than stool-related symptoms discussed with relations. Respondents with >1 symptom had higher odds of reporting general practitioner (GP) contact compared to respondents with single symptoms. Age ≥60 years was associated with higher odds of GP contact and involving family relations. Spouse/partner was the most frequently involved relation. Involving a personal relation increased the odds of GP contact. Having an available social network decreased GP contact for some symptoms. CONCLUSION: Odds of involving professional relations, e.g. the GP, were higher amongst individuals experiencing multiple CRC symptoms and those involving personal relations. Having an available social network was associated with lower odds of GP contact, suggesting that individuals with no available social network are more prone to use their GP.

Healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective: a scoping review.

OBJECTIVE: General practice plays an important role in cancer trajectories, and cancer patients request the continuous involvement of general practice. The objective of this scoping review was to identify healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective. DESIGN, SETTING, AND SUBJECTS: A scoping review of the literature published in Danish or English from 2010 to 2020 was conducted. Data was collected using identified keywords and indexed terms in several databases (PubMed, MEDLINE, EBSCO CINAHL, Scopus, and ProQuest), contacting key experts, searching through reference lists, and reports from selected health political, research- and interest organizations' websites. MAIN OUTCOME MEASURES: We identified healthcare practices in cancer trajectories that increase quality care. Identified healthcare practices were grouped into four contextual domains and allocated to defined phases in the cancer trajectory. The results are presented according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR). RESULTS: A total of 45 peer-reviewed and six non-peer-reviewed articles and reports were included. Quality of care increases in all phases of the cancer trajectory when GPs listen carefully to the full story and use action plans. After diagnosis, quality of care increases when GPs and practice staff have a proactive care approach, act as interpreters of diagnosis, treatment options, and its consequences, and engage in care coordination with specialists in secondary care involving the patient. CONCLUSION: This scoping review identified healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective. The results support general practice in investigating own healthcare practices and identifying possibilities for quality improvement.KEY POINTSIdentified healthcare practices in general practice that increase the quality of care in cancer trajectories:Listen carefully to the full storyUse action plans and time-out-consultationsPlan and provide proactive careAct as an interpreter of diagnosis, treatment options, and its consequences for the patientCoordinate care with specialists, patients, and caregivers with mutual respectIdentified barriers for quality of care in cancer trajectories are:Time constraints in consultationsLimited accessibility for patients and caregiversHealth practices to increase the quality of care should be effective, safe, people-centered, timely, equitable, integrated, and efficient. These distinctions of quality of care, support general practice in investigating and improving quality of care in cancer trajectories.

Healthcare costs of patients with chronic obstructive pulmonary disease in Denmark - specialist care versus GP care only.

BACKGROUND: Many patients with chronic obstructive pulmonary disease (COPD) are treated in general practice only and have never received specialist care for COPD. They are seldom included in COPD cost studies but may account for a substantial proportion of the total costs. OBJECTIVE: To estimate and specify the total healthcare costs of patients who are treated for COPD in Denmark comparing those who have- and have not had specialist care for COPD. SETTING: Denmark, population 5.7 million citizens. METHODS: Via national registers, we specified the total healthcare costs of all + 30-years-old current users of respiratory pharmaceuticals. We identified the patients with COPD and compared those with at least one episode of pulmonary specialist care to those with GP care only. RESULTS: Among totally 329,428 users of respiratory drugs, we identified 46,084 with specialist-care- and 68,471 with GP-care-only COPD. GP-care-only accounted for 40% of the two populations' total healthcare costs. The age- and gender-adjusted coefficient relating the individual total costs specialist-care versus GP-care-only was 2.19. The individual costs ranged widely and overlapped considerably (p25-75: specialist-care €2,175-€12,625, GP-care-only €1,110-€4,350). Hospital treatment accounted for most of the total cost (specialist-care 78%, GP-care-only 62%; coefficient 2.81), pharmaceuticals (specialist-care 16%, GP-care-only 27%; coefficient 1.28), and primary care costs (specialist-care 6%, GP-care-only 11%; coefficient 1.13). The total costs of primary care pulmonary specialists were negligible. CONCLUSION: Healthcare policy makers should consider the substantial volume of patients who are treated for COPD in general practice only and do not appear in specialist statistics.

Quality clusters in general practice: associations between cluster organization and general practitioners' self-reported benefits.

BACKGROUND: Quality clusters were introduced as a quality improvement concept in Danish general practice in 2018. This new concept anchored quality improvement in local clusters managed by general practitioners (GPs). OBJECTIVES: To describe the cluster organization and GPs' self-reported benefits of participating in them and explore the associations between cluster organization and self-reported benefits. METHODS: A national survey in Danish general practice gathering information about cluster organization (cluster size, cluster meetings, participants, and content) and GPs' self-reported benefits (overall benefit, internal changes in the clinic, and improved external collaboration). RESULTS: One hundred and eight (95%) clusters and 1,219 GPs (36%) were included. Cluster size varied from 10 to 68 GPs (34 GPs on average). Approximately 70% of GPs reported moderate to very high overall benefit from cluster participation. Most GPs experienced changes in their clinic organization (68%), drug prescriptions (78%), and patient care (77%). Collaboration was reported improved between the GPs (86%), municipality (50%), and hospital (36.2%). GPs in clusters with 3-6 planned meetings per year (odds ratio [OR] 1.9; confidence interval [CI] 1.3-2.9), mixed meeting types (OR 1.7; CI 1.2-2.4), group work (OR 1.7; CI 1.1-2.5), and use of guidelines in their meetings (OR 1.8; CI 1.3-2.4) had statistically significantly higher odds for reporting overall benefit of participating in clusters compared with GPs in clusters without these characteristics. CONCLUSIONS: Frequent and active meetings with a relevant meeting content are positively related to GPs' perceived benefits and with improved collaboration between GPs in the clusters. There seems to be a potential for developing collaboration with other healthcare providers.

Factors associated with C-reactive protein testing when prescribing antibiotics in general practice: a register-based study.

BACKGROUND: The use of C-reactive protein (CRP) tests has been shown to safely reduce antibiotic prescribing for acute respiratory tract infections (RTIs). The aim of this study was to explore patient and clinical factors associated with the use of CRP testing when prescribing antibiotics recommended for RTIs. METHODS: A nation-wide retrospective cross-sectional register-based study based on first redeemed antibiotic prescriptions issued to adults in Danish general practice between July 2015 and June 2017. Only antibiotics recommended for treatment of RTIs were included in the analysis (penicillin-V, amoxicillin, co-amoxicillin or roxithromycin/clarithromycin). Logistic regression models were used to estimate odds ratios for patient-related and clinical factors on performing a CRP test in relation to antibiotic prescribing. RESULTS: A total of 984,149 patients redeemed at least one antibiotic prescription during the two-year period. About half of these prescriptions (49.6%) had an RTI stated as the indication, and a CRP test was performed in relation to 45.2% of these scripts. Lower odds of having a CRP test performed in relation to an antibiotic prescription was found for patients aged 75 years and above (OR 0.82, 95CI 0.79-0.86), with a Charlson Comorbidity Index of more than one (OR 0.93, 95CI 0.91-0.95), unemployed or on disability pension (OR 0.84, 95CI 0.83-0.85) and immigrants (OR 0.91, 95CI 0.88-0.95) or descendants of immigrants (OR 0.90, 95CI 0.84-0.96). Living with a partner (OR 1.08, 95CI 1.07-1.10), being followed in practice for a chronic condition (OR 1.22, 95CI 1.18-1.26) and having CRP tests performed in the previous year (OR 1.78, 95CI 1.73-1.84) were associated with higher odds of CRP testing in relation to antibiotic prescribing. CONCLUSIONS: Differences were observed in the use of CRP tests among subgroups of patients indicating that both sociodemographic factors and comorbidity influence the decision to use a CRP test in relation to antibiotic prescriptions in general practice. Potentially, this means that the use of CRP tests could be optimised to increase diagnostic certainty and further promote rational prescribing of antibiotics. The rationale behind the observed differences could be further explored in future qualitative studies.

Is concern for gynaecological alarm symptoms associated with healthcare-seeking? A Danish population-based cross-sectional study.

BACKGROUND: Diagnosing cancer at an early stage increases survival, and for most gynaecological cancers the diagnostic pathway is initiated, when women seek medical attention with symptoms. As many factors influence healthcare-seeking, knowledge about these factors is important. Concern can act as a barrier or a trigger for women experiencing gynaecological alarm symptoms. This study aimed to examine whether concern for the symptom or the current health was associated with healthcare-seeking among women with gynaecological alarm symptoms. METHODS: Some 100,000 randomly selected Danish citizens were invited to a national web-based survey. The questionnaire included items regarding symptom experiences, healthcare-seeking and concern for the experienced symptoms and current health. This study included 5019 women with self-reported gynaecological alarm symptoms (pelvic pain, pain during intercourse, bleeding during intercourse and postmenopausal bleeding). Concern was reported on a 5-point Likert scale from 'not at all' to 'extremely'. Data were analysed using multivariate logistic regression models. RESULTS: Women who were 'extremely' concerned about a gynaecological alarm symptom had two to six times higher odds of reporting healthcare-seeking compared to women who were 'not at all' concerned. Symptom concern was associated with higher odds of healthcare-seeking for all four gynaecological alarm symptoms and the odds increased with increasing levels of concern. Additionally, concern for current health was associated with higher odds of healthcare-seeking. Concern for current health as expressed by others was positively associated with healthcare-seeking but had only minor influence on the association between concern for current health and healthcare-seeking. CONCLUSIONS: Concern for a gynaecological alarm symptom and for current health was positively associated with healthcare-seeking. The results can be used for future informational health campaigns targeting individuals at risk of postponing warranted healthcare-seeking.

Antibiotic treatment of community-acquired pneumonia: A questionnaire survey in Danish general practice.

BACKGROUND: Discrepancies exist in Danish guidelines for the treatment of bacterial community-acquired pneumonia (CAP). This study aimed to investigate how general practitioners (GPs) treat adults with CAP and explore associations between GP characteristics and treatment duration. METHODS: In autumn 2020, GPs in the North Denmark Region were asked to complete an electronic questionnaire on antibiotic prescribing for CAP. Information about GP gender, age, experience and type of practice was obtained. Multivariable logistic regression was used to analyse the association between GP characteristics and treatment duration. RESULTS: A total of 298 GPs were invited to participate of whom 108 completed the survey. Penicillin V was used as first line treatment for CAP by all participants. Treatment duration varied from 5 (54.6%) to 10 days (8.3%). A 5-day course of penicillin was less likely to be prescribed by male GPs (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13-0.94) and more likely to be prescribed by GPs with 5-9 years of experience in general practice (OR 5.03, 95% CI 1.09-23.21) compared to those with 10-19 years of experience. CONCLUSION: Variation in antibiotic treatment of CAP emphasises the importance of generating solid evidence about the optimal duration regarding both effectiveness and safety.