Supporting breastfeeding for women with low education levels, psychosocial problems, and/or socioeconomic constraints: a scoping review protocol.

OBJECTIVE: This scoping review aims to identify and map interventions and/or strategies used to support the initiation and continuation of breastfeeding for women at risk of delaying initiation, early cessation, or not breastfeeding due to low levels of education, psychosocial problems, and/or socioeconomic challenges in high-income countries. INTRODUCTION: While breastfeeding has lifelong beneficial health effects for women and infants, there is a risk of delaying initiation, early cessation, or not initiating breastfeeding at all due to factors related to health inequalities, such as low levels of education, psychosocial problems, and/or socioeconomic constraints. INCLUSION CRITERIA: This review will include eligible quantitative, qualitative, and mixed methods studies, as well as systematic reviews and gray literature. We will encompass studies conducted in high-income countries, focusing on interventions and/or strategies to support women with low levels of education, psychosocial problems, and/or socioeconomic constraints in the initiation and continuation of breastfeeding for up to 6 months postpartum. METHODS: This review will follow the JBI methodology for scoping reviews, using the Participants, Concept, and Context framework. The primary search will be performed in the following databases: MEDLINE (PubMed), PsycINFO (EBSCOhost), Embase (Ovid), and CINAHL (EBSCOhost). We will include publications in English, Swedish, Norwegian, Danish, German, Bulgarian, Arabic, and Spanish, published from 1991 until the present. A data charting form will be developed and applied to all the included articles. REVIEW REGISTRATION: The study is registered in Open Science Framework, DOI 10.17605/OSF.IO/TMP4V.

Healthcare professionals' experiences with the use of antipsychotics in dementia.

Background: Antipsychotics are commonly administered to nursing home residents with dementia, despite the associated risk of severe adverse events. Objective: This study aimed to explore healthcare professionals' experiences in caring for nursing home residents with dementia, with a focus on rationales behind the use of antipsychotics. Method: Twelve semi-structured interviews with healthcare professionals' from Danish nursing homes were conducted and analyzed using the method Systematic Text Condensation. Results: Nonpharmacological interventions were reported as the primary approach to care and the first-choice treatment for behavioral and psychological symptoms of dementia (BPSD). Use of antipsychotics was considered to serve as a last resort, reserved for residents with severe symptoms. However, most informants preferred a more limited use. The study identified four main barriers to reduce the use of antipsychotics: "Scarcity of resources", "Perceiving antipsychotic use to provide relieve", "Reluctance towards deprescribing" and "Limited access to medical counseling", and three potential enablers: "Updating knowledge and nonpharmacological competencies", "Management support and clear procedures" and "Regularity in interdisciplinary collaboration". Conclusion: The treatment and care were reported as primarily following guidelines in BPSD. Several barriers were perceived to challenge the healthcare professionals' preference of limited use of antipsychotics. To further reduce the use, this study highlights the importance of understanding the adverse effects caused by limited resources, enhancing employee knowledge and competencies and ensuring regular interprofessional collaboration for assessing and reassessing the need to use antipsychotics.

Combining the Antenatal Risk Questionnaire and the Edinburgh Postnatal Depression Scale in Early Pregnancy in Danish Antenatal Care-A Qualitative Descriptive Study.

Pregnant women with a history of mental disorders, neglect, or low social support are at increased risk of mental health problems. It is crucial to identify psychosocial risk factors in early pregnancy to reduce the risk of short- and long-term health consequences for mother and child. The Antenatal Risk Questionnaire has been found acceptable as a psychosocial screening tool among pregnant women in Australia, but it has not been tested in a Scandinavian context. The aim of this study was to explore the experiences of pregnant women when using the Antenatal Risk Questionnaire and the Edinburgh Postnatal Depression Scale as part of a model to identify psychosocial vulnerabilities in pregnancy in Denmark. We conducted individual interviews (n = 18) and used thematic analysis. We identified two main themes: (1) Feeling heard and (2) An occasion for self-reflection. Overall, the pregnant women deemed the online ANRQ/EPDS acceptable as a screening tool. The screening model provided a feeling of being heard and provided an occasion for self-reflection about mental health challenges related to pregnancy and motherhood. However, some women expressed that the screening raised concerns and fear of the consequences of answering honestly. A non-judgmental, open, emphatic, and reassuring approach by clinicians may help reduce stigma.

Protocol for DEprescribing and Care to reduce Antipsychotics in Dementia (DECADE)-A hybrid effectiveness-implementation pilot study.

INTRODUCTION: Behavioural and psychological symptoms of dementia (BPSD) should only rarely and briefly be treated with antipsychotics. Despite recommendations to the contrary, the use of antipsychotics in nursing home residents with dementia is widespread and followed by serious adverse effects. Intervention studies on methods to reduce the use of antipsychotics in persons with dementia are few and needed. The aim of this protocol is to describe the rationale and content of the intervention DEprescribing and Care to reduce Antipsychotics in DEmentia (DECADE)-a hybrid effectiveness-implementation pilot study. MATERIALS AND METHODS: This is a protocol of a prospective hybrid effectiveness-implementation pilot study. The primary aim of DECADE is to reduce the use of antipsychotic drugs by 50% in 50% of nursing home residents with dementia while maintaining or improving BPSD. The intervention is implemented in six nursing homes including approximately 190 residents with dementia and consists of Academic Detailing, medication review, education of nursing home staff, and care plans. The evaluation of feasibility and potential effectiveness is an overall assessment of all clinical and process outcomes. Logistic regression analyses will be used to investigate factors characterizing situations with prescription of antipsychotics. BPSD is analysed with a before- and after design using self-controlled case series methods and the use of antipsychotics is analysed as interrupted time series. DISCUSSION: This protocol describes a study that will provide an indication of DECADE effectiveness and a model for upscaling and further evaluation in a controlled design.

The patients' perspective on multimorbidity and polypharmacy and how do we accommodate it in the healthcare system.

Patients living with multimorbidity, and polypharmacy can have difficulties handling the treatment burden they face daily. They often experience disjointed treatment courses and demand a more holistic approach to their multimorbidity and to be involved in decisions about their treatments. In the healthcare system, there are examples of new initiatives that go beyond the classic diagnostic silo thinking. However, this review finds that further development of new structures, approaches, and collaboration models in the healthcare system, as well as research, is still necessary to meet the needs of these patients.

Reaching the Frail Elderly for the Diagnosis and Management of Atrial Fibrillation-REAFEL.

BACKGROUND: Frail elderly patients are exposed to suffering strokes if they do not receive timely anticoagulation to prevent stroke associated to atrial fibrillation (AF). Evaluation in the cardiological ambulatory can be cumbersome as it often requires repeated visits. AIM: To develop and implement CardioShare, a shared-care model where primary care leads patient management, using a compact Holter monitor device with asynchronous remote support from cardiologists. METHODS: CardioShare was developed in a feasibility phase, tested in a pragmatic cluster randomization trial (primary care clinics as clusters), and its implementation potential was evaluated with an escalation test. Mixed methods were used to evaluate the impact of this complex intervention, comprising quantitative observations, semi-structured interviews, and workshops. RESULTS: Between February 2020 and December 2021, 314 patients (30% frail) were included, of whom 75% had AF diagnosed/not found within 13 days; 80% in both groups avoided referral to cardiologists. Patients felt safe and primary care clinicians satisfied. In an escalation test, 58 primary-care doctors evaluated 93 patients over three months, with remote support from four hospitals in the Capital Region of Denmark. CONCLUSIONS: CardioShare was successfully implemented for AF evaluation in primary care.

The Feasibility of the Adverse Childhood Experiences Questionnaire among Women in Danish Antenatal Care: A Mixed-Methods Study.

A traumatic upbringing increases the risks of antenatal health problems, unfavourable pregnancy outcomes, and mental disorders. Such childhood experiences may affect women's pa-renting skills and the social-emotional functioning of their children. Research on screening for adverse childhood experiences in antenatal care is limited. The objective of this study was to explore pregnant women's attitudes towards and experiences of an adverse childhood experiences questionnaire, and to assess the relevance of the questionnaire among a population of pregnant women referred to antenatal care levels one and two, targeting women who are generally not perceived to be vulnerable. Data were collected at three maternity wards and consisted of quantitative data on 1352 women's adverse childhood experience scores, structured observations of 18 midwifery visits, and in-depth interviews with 15 pregnant women. Quantitative data were analysed by descriptive statistics, and qualitative data were analysed using systematic text condensation. The qualitative analysis revealed two main categories: "Being screened for childhood adversities" and "Having adverse childhood experiences". In the study population, the prevalence of adverse childhood experiences was high. The women assessed the adverse childhood experiences questionnaire to be a relevant and acceptable screening method. Furthermore, women's perceptions of their relationship with their midwife greatly impacted their attitudes towards and experiences of the questionnaire.

The Feasibility and Acceptability of the Adverse Childhood Experiences Questionnaire in Danish Antenatal Care-A Qualitative Study of Midwives' Implementation Experiences.

Adverse childhood experiences have a potential lifelong impact on health. A traumatic upbringing may increase antenatal health risks in mothers-to-be and impact child development in their offspring. Yet, little is known about the identification of adverse childhood experiences in antenatal care. The objective of this study was to explore the feasibility and acceptability of the adverse childhood experiences questionnaire among midwives and factors affecting its implementation. Three Danish maternity wards participated in the study. The data consisted of observations of midwifery visits and informal conversations with midwives, as well as mini group interviews and dialogue meetings with midwives. The data were analysed using systematic text condensation. Analysis of the data revealed three main categories; "Relevance of the adverse childhood experiences questionnaire", "Challenges related to use of the adverse childhood experiences questionnaire" and "Apprehensions, emotional strain, and professional support". The findings showed that the adverse childhood experiences questionnaire was feasible to implement in Danish antenatal care. Midwives' acceptability of the questionnaire was high. Training courses and dialogue meetings motivated the midwives to work with the questionnaire in practice. The main factors affecting the implementation process were time restrictions, worries of overstepping women's boundaries, and a lack of a specific intervention for women affected by their traumatic upbringing circumstances.

Efficacy of a randomized controlled trial of a perinatal adaptation of COS-P in promoting maternal sensitivity and mental wellbeing among women with psychosocial vulnerabilities.

Pregnant women with psychosocial vulnerabilities should be offered perinatal interventions that include a parenting component to ameliorate the potential negative effects of maternal mental health problems and/or poor social network on parenting. One such intervention program is the Circle of Security-Parenting intervention (COS-P). The COS-P is a manualized video-based intervention that based on attachment theory seek to enhance maternal sensitivity and decrease the risk on insecure and disorganized attachment. We carried out a randomized controlled trial examining the efficacy of a perinatal adapted version of COS-P for women with psychosocial vulnerabilities (e.g. histories of mental health problems and/or poor social networks). Eligible participants (N = 78) were recruited to the study by midwives during regular prenatal sessions. Interventions were delivered individually at home by trained health nurses both pre and post birth. The primary outcome was maternal sensitivity assessed with the Coding Interactive Behavior Manual by blinded coders from video-recordings of mother-infant free play interactions. Secondary outcomes were mother-reported depressive symptoms, parental reflective functioning, parental stress, infant socio-emotional functioning, and maternal wellbeing. All outcomes were assessed at nine months infant age. We did not find an effect of the intervention on the primary outcome of maternal sensitivity (ß = -0.08; 95% CI [-0.41, 0.26], p = .66). Neither did we find intervention effects on the secondary outcomes of depressive symptoms, parental reflective functioning, maternal well-being, or infant socio-emotional functioning. We did however find that the intervention decreased parental stress (ß = -8.51; 95% CI [-16.6;-0.41], p = .04). The results are discussed in light of existing findings on the effect of COS-P and sample heterogeneity. Furthermore, we discuss the challenges of adapting the COS-P for pregnant women, some without prior experiences with caregiving. Future research with larger at-risk samples examining moderation factors (e.g. adult attachment, depression maternal-fetal attachment) are recommended.

Reaching Frail Elderly Patients to Optimize Diagnosis and Management of Atrial Fibrillation (REAFEL): A Feasibility Study of a Cross-Sectoral Shared-Care Model.

Introduction: Atrial fibrillation (AF) management in primary care often requires a referral to cardiology clinics, which can be strenuous for frail patients. We developed "cardio-share" (CS), a new cross-sector collaboration model, to ease this process. General practitioners (GPs) can use a compact Holter monitor (C3 from Cortrium) to receive remote advice from the cardiologist. Objective: To test the feasibility and acceptability of the CS model to manage suspected AF in frail elderly patients. Methods: We used a mixed methods design, including the preparation of qualitative semistructured interviews of GPs and nurses. Results: Between MAR-2019 and FEB-2020, 54 patients were consulted through the CS model, of whom 35 underwent C3 Holter monitoring. The time from referral to a final Holter report was shortened from a mean (SD) of 117 (45) days in usual care to 30 days (13) with the CS model. Furthermore, 90% of the patients did not need to attend visits at the cardiology clinic. The GPs and nurses highlighted the ease of using the C3 monitor. Their perception was that patients were confident in the GPs' collaboration with cardiologists. Conclusions: The CS model using a C3 monitor for AF is both feasible and seems acceptable to GPs. The elapsed time from referral to the Holter report performed for the diagnosis was significantly reduced.

Intersectoral Ward Rounds on Patients Admitted to Temporary Twenty-Four-Hour Accommodations in Denmark: Case Study.

INTRODUCTION: Temporary twenty-four-hour accommodations (TTAs) are municipal beds for elderly patients discharged from the hospital with acute treatment, care and/or rehabilitation needs that cannot be met in their own homes. TTAs are staffed by nurses and nursing assistants who are not authorized to prescribe or modify medications. At North Zealand Hospital one third of the many readmissions from a TTA within eight days after discharge have been assessed as preventable. DESCRIPTION: A hospital-based team rounded on 268 patients at TTAs from May 2017 to October 2019 to promote integrated care. This study aimed to assess the efficacy of the rounding by auditing patient cases. A physician, a nurse, and a pharmacist from the hospital; a general practitioner; and one or two TTA nurses audited 17 cases. DISCUSSION: Obtaining access to all electronic patient records and reconstructing information shared across sectors were not feasible in all cases. CONCLUSION: An overview of the course of treatment was provided in most casesThe patient's health was enhanced in most cases and to a considerable or determining degree in half of casesMedication was optimized in most casesThe succeeding course of treatment was enhanced in more than half of the casesReadmission was prevented in some cases.

Protocol for a cluster-randomized non-inferiority trial of the effect of direct access to publicly subsidized physiotherapy for adults with musculoskeletal pain.

BACKGROUND: In the Danish healthcare system, direct access to physiotherapy is an option, but public subsidy for treatment requires referral from a general practitioner. To relieve general practice of unnecessary consultations and provide patients with easier access to relevant treatment, direct access to publicly subsidized physiotherapy has been suggested. METHODS: Direct access to subsidized physiotherapy will be evaluated in a controlled design and has a duration of one year. Physiotherapy clinics invite eligible patients to participate in the evaluation. Participants complete questionnaires at baseline and six weeks and six months after baseline. Physical health status (ShortForm-12v2) is the primary outcome. In addition, the evaluation will assess the use of services in general practice, physiotherapy, specialists in private practice and hospitals and referrals to diagnostic imaging. A process evaluation will assess the attitude to and implementation of direct access to subsidized physiotherapy through the experiences and attitudes of local general practitioners, secretaries and physiotherapists in participating clinics. DISCUSSION: This intervention may affect the point of entry to health care services. For the intervention group the physiotherapists assume responsibility in symptom assessment. During recruitment registration of red flags in physiotherapy is closely monitored. The results of the study may be used to assess if direct access to subsidized physiotherapy is a way to relieve the workload in general practice while maintaining or improving patient level outcomes. TRIAL REGISTRATION: The project was reported to The Committee on Health Research Ethics of the Capital Region of Denmark with protocol number J.nr.: H-19074802. The Committee assessed the project as not registrable and therefore can be implemented without further permission. This trial has been registered at the Danish Data Protection Agency (J.nr.: P-2019-672). The trial has been registered at ClinicalTrials.gov (identifiers: NCT04900480).

Maternal-fetal bonding among pregnant women at psychosocial risk: The roles of adult attachment style, prenatal parental reflective functioning, and depressive symptoms.

Pregnancy offers a unique period for initiating preventive parenting interventions. Disturbances in maternal-fetal bonding may indicate suboptimal parenting and a need for intervention. However, more knowledge is needed on the development of maternal-fetal bonding among at-risk groups. The study aim was to examine psychosocial correlates of maternal-fetal bonding among pregnant women identified to be at risk socially and regarding their mental health. The sample consisted of 78 at-risk pregnant women participating in a perinatal intervention study: Godt på Vej Sammen [A Good Start to Life-an Early Cross-sectorial Intervention]. This study was cross-sectional reporting on the baseline characteristics of the participants. In the beginning of the second trimester, participants completed questionnaires assessing maternal-fetal bonding (the Maternal Antenatal Attachment Scale [MAAS]), prenatal parental reflective functioning, adult attachment style, and depressive symptoms. We compared the distribution of MAAS styles with norms from a recent Dutch community sample. In addition, we tested associations between psychosocial variables and the quality and intensity of MAAS scores in regression models and performed Chi-square analyses to assess the association of MAAS styles with psychosocial variables. First, compared to women from a community sample, approximately half of the women in our sample presented lower and suboptimal MAAS scores. Second, insecure avoidant adult attachment style was negatively associated with MAAS intensity, and depressive symptoms were negatively associated with MAAS quality. Third, prenatal parental reflective functioning positively correlated with both quality and intensity of MAAS. Fourth, we found no association between insecure anxious adult attachment style and MAAS scores. Fifth, women with a negative disinterested MAAS style demonstrated the highest avoidant attachment scores, while women with a positively preoccupied MAAS style demonstrated the highest prenatal parental reflective functioning scores. The results suggest that there is a need to differentiate among at-risk pregnant woman and that prenatal screening using the MAAS may help identify those who need preventive parenting interventions and what those interventions should focus on. A main limitation of the study is the lack of a representative group of at-risk pregnant women which limits the generalizability of the study results to all risk groups.

An early intervention to promote maternal sensitivity in the perinatal period for women with psychosocial vulnerabilities: study protocol of a randomized controlled trial.

BACKGROUND: Maternal mental well-being and social circumstances during pregnancy and early childhood impact the child's well-being and development. Supportive and sensitive parenting is one of the strongest predictors of positive emotional, social and behavioral outcomes for the child. Knowledge is needed about how to detect and support vulnerable families already during pregnancy and in the postnatal period. The aim of this study is to assemble and evaluate an interdisciplinary cross-sectoral intervention to promote maternal sensitivity among women with psychological or social vulnerabilities. METHODS/DESIGN: This randomized controlled trial tests the efficacy of an intervention program in the perinatal period compared to care as usual in enhancing maternal sensitivity in a group of psychologically or socially vulnerable women in the Capital Region of Denmark. The intervention consists of four components: 1) detecting symptoms of mental illness in vulnerable pregnant women and initiating treatment if indicated, 2) strengthening parenting skills using the Circle of Security Parenting program, 3) supporting breastfeeding, and 4) sharing knowledge and organizing treatment pathways for families across sectors. Seventy-six families will be randomly assigned to the intervention or care-as-usual. Data will be obtained at study inclusion at 3-5 months of pregnancy, eight weeks after childbirth, and nine months after childbirth. The primary outcome is maternal sensitivity. Secondary outcomes include infant's socio-emotional development, parents' mentalization, parental stress, depressive symptoms, and parental wellbeing. Qualitative data will provide insight into the implementation process. DISCUSSION: This paper presents the rational and background for developing the intervention. Furthermore, the design and protocol of the randomized controlled trial. It is hypothesized that the intervention will be associated with positive changes in primary and secondary outcomes. If effective, the intervention will provide insights into prenatal risk profiles among an identified group of psychosocial vulnerable women important for early screening and point to effective preventive interventions that can support women in the perinatal period, increase maternal sensitivity and promote positive child development -starting before the child is born. TRIAL REGISTRATION: ClinicalTrials.gov: ID: NCT03190707. Registered June 16, 2017.

Multimorbidity, healthcare utilization and socioeconomic status: A register-based study in Denmark.

BACKGROUND: People with multimorbidity have reduced functional capacity, lower quality of life, higher mortality rates and use healthcare resources more intensively than healthy people or those with a single chronic condition. Multimorbidity was defined as the coexistence of two or more chronic conditions in the same person. The aim of this study was to explore associations between multimorbidity and use of healthcare services and the impact of socioeconomic status on utilization of hospitalizations and bed days. METHODS: The study population included all individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. Data on chronic conditions, use of healthcare services and demographics were obtained from Danish national administrative and health registries. Zero-inflated models were used to calculate anticipated annual use of hospitalizations and bed days. FINDINGS: The study population comprised 1,397,173 individuals; the prevalence of multimorbidity was 22%. Prevalence was inversely related to educational attainment. For people with multimorbidity, utilization of hospitalizations and bed days increased approximately linearly with the number of chronic conditions. However, a steep increase in utilization of bed days was observed between five and six or more chronic conditions. An educational gradient in hospitalization rates and use of bed days was observed regardless of the number of chronic conditions. Educational attainment was strongly associated with healthcare utilization. CONCLUSION: Multimorbidity was associated with a significant increase in utilization of all healthcare services in Denmark. In addition, a socioeconomic gradient was observed in utilization of hospitalizations and bed days.

Polypharmacy and medication deprescribing: A survey among multimorbid older adults in Denmark.

Polypharmacy is common among multimorbid adults and associated with increased morbidity and mortality. Excessive polypharmacy (ie, ≥10 medicine) is strongly associated with inappropriate medication use, but little is known about attitudes toward deprescribing in patients with excessive polypharmacy. We surveyed 100 Danish individuals aged 65 years and above with ≥10 prescribed medications, using the validated Patients' Attitudes Towards Deprescribing (PATD) instrument. Most participants (81, 81%) thought they took a large number of medications, and 79 (79%) believed that their medications were necessary. Even so, 85 (85%) reported that they would be willing to stop taking one or more of their regular medications if their doctor told them they could, and 11 (11%) felt that they took at least one regular medication that they no longer needed. When presented with visual presentation of various amounts of tablets and capsules, 62 (62%) of participants reported that they would be comfortable taking fewer medications than they did. Forty-two (42%) participants had experience with stopping a regular medication. Almost all participants (92%) wanted to receive follow-up by various means if a medication was discontinued. Forty-one (41%) participants were interested in a consultation at an outpatient clinic specializing in polypharmacy. Overall, the answers to the PATD questionnaire suggest that our cohort of Danish, multimorbid outpatients with extensive polypharmacy have a high confidence in their healthcare providers for medication-related decisions, even though some feel that they are taking more medications than they would like to and feel that some medications may be unnecessary. Our results underline the need for healthcare providers to offer medication reviews in patients with multimorbidity.

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

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

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

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

Perceived value of eHealth among people living with multimorbidity: a qualitative study.

BACKGROUND: The prevalence of multimorbidity is increasing, creating challenges for patients, healthcare professionals, and healthcare systems. Given that chronic disease management increasingly involves eHealth, it is useful to assess its perceived value among people with multimorbidity. OBJECTIVE: To explore challenges related to multimorbidity and patients' perspectives on eHealth. DESIGN: Ten semi-structured interviews with adults, living with multimorbidity in Copenhagen, Denmark. Interviews focused on patient-experienced challenges, from challenges related to self-management to challenges experienced in the healthcare sector, as well as perceptions of eHealth. During interviews, participants were presented with pictures of different eHealth technologies. Data analysis followed the systematic text condensation approach. RESULTS: Participants experienced challenges in their daily lives, e.g. when practicing self-management activities, when navigating the healthcare sector, and when interacting with healthcare professionals. Patient-perceived value of eHealth varied, depending on their burden of illness and treatment: those with a greater burden had more positive perceptions of eHealth, and expressed more intention to use it. Participants with less complex disease patterns and less burdensome treatment regimens were more likely to perceive eHealth as something worthless and undesirable. Participants stressed that eHealth should only be introduced as an optional supplement. CONCLUSIONS: eHealth can potentially address some patient-experienced challenges related to multimorbidity by promoting self-management, patient-centeredness, and access. However, patients' needs and preferences vary and eHealth cannot substitute the personal interaction between patient and healthcare professionals. Our findings point to the importance of patient assessment and stratification to ensure appropriate use of eHealth.

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

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