Do physicians' attitudes toward prioritization predict poor-health patients' access to care?

Physicians often face tight resource constraints, meaning they have to make trade-offs between which patients they care for and the amount of care received. Studies show that patients requiring many resources disproportionately suffer a loss of care when resources are constrained. This study uncovers whether physicians' attitudes toward prioritization of healthcare predicts poor-health patients' access to care. We combine unique survey data on Danish GPs' preferred prioritization principle with register data on their patients' contacts in general practice. We consider different types of contacts as the required effort could impact the need for prioritization. Our results show variation in GPs' prioritization principles, where a majority prefers a principle that may lead to an unequal distribution of services. We further find that GPs' attitudes toward prioritization predict some poor-health patients' access to general practice. GPs who state they prefer the principle of prioritizing patients in the poorest health state when resources tightened provide more contacts to poor-health patients. The additional contacts are typically high-effort contacts such as annual status meetings and home visits, but also low-effort contacts such as emails. Our findings indicate inequity in poor-health patients' access to care across general practices.

Is there a link between health care utilisation and subjective well-being? An exploratory study among older Danes.

While extensive research has explored the influence of traditional factors such as socioeconomic position on health care utilisation, the independent role of an individual's well-being in their health care seeking behaviour remains largely uncharted territory. In this study, we delve into the role of subjective well-being (SWB) in health care utilisation. We use a unique link between survey data from a representative group of Danish citizens aged 50-80 and administrative register data containing information on health care utilisation and sociodemographics. We explore whether SWB is a predictor of health care utilisation (general practice services) over and above health (as measured by health-related quality of life (HRQoL)). We find that the association between SWB and number of services provided in general practice differs across levels of HRQoL. Among those with lower HRQoL, we find a positive association between health care utilisation and SWB. Results hold true even when controlling for previous health care utilisation, suggesting that the mechanism is not driven by reverse causality. Our findings suggest that, in particular for vulnerable individuals in poor health and with poor SWB, the propensity to seek care is inappropriately low, and there is a need for more proactive supply-driven health care.

Transitioning from hospital to home after a major lower extremity amputation: Interview study on patients' and relatives' perspectives.

INTRODUCTION: Patients often feel unprepared and concerned about their new life after a major lower extremity amputation (LEA). Therefore, we implemented an integrated care program, Safe Journey, to optimize the quality and continuity of care for patients with LEA due to vascular disease when transitioning from hospital to home. This study aims to illuminate and explore the experiences of patients with LEA and their relatives with the transition from hospital to home after implementing Safe Journey. MATERIAL AND METHODS: This qualitative, exploratory study individually interviewed six patients with a major LEA and four relatives and jointly interviewed eight patients with their relatives. RESULTS: The participants' experiences transitioning from hospital to home were centered around two major themes: (1) Going home: mixed emotions and confusion, and (2) bridging the gap. The main themes encompassed six subthemes: (1) simultaneously expectant and worried, (2) a lack of knowledge creating uncertainty, (3) an unexpressed but pending need for psychosocial support, (4) reassurance but safety comes at a price, (5) navigating the system, and (6) lack of involvement. CONCLUSION: Transitioning from hospital to home after a major LEA creates mixed emotions. Knowledge, feeling involved, and being prepared and cared for were highlighted as important during the transition. The Safe Journey program made patients and relatives feel physically reassured and safe, but all the home visits strained the families. The program's benefits are consistent with existing knowledge on patients with complex needs benefitting from integrated care models. However, a more individualized and person-centered approach is needed.

Which self-reported measures are useful to explore diabetes support needs among adults with diabetes and severe mental illness?

OBJECTIVES: To construct and test patient-reported outcome measures (PROMs) for identifying diabetes support needs of adults with co-existing diabetes and severe mental illness (SMI) provided by mental health professionals at psychiatric outpatient clinics. METHODS: Design thinking was used to identify, select, and modify PROMs in collaboration with 18 adults with type 1 or type 2 diabetes and SMI and 10 healthcare experts. The PROMs were then tested with 86 adults with diabetes and SMI recruited from eight psychiatric outpatient clinics in Denmark. Data were analysed using systematic text condensation (questionnaire construction) and descriptive statistics (testing). RESULTS: Four principles for PROMs were identified: (a) be modified to be relevant for the target group, (b) be concise and simple to complete, (c) have a clear and unambiguous wording, and (d) be designed to measure topics that are perceived as meaningful. Test of the questionnaire contained 49 items in four domains. Missing response rates in the test were 1.2-4.7% in three domains and 4.7-11.6% in a domain addressing potential sources of diabetes support. DISCUSSION: PROMs can successfully be constructed in collaboration with this vulnerable population that yield low rates of missing responses.

Peer support for adults with type 2 diabetes starting continuous glucose monitoring-An exploratory randomised controlled trial.

AIMS: To explore the feasibility and potential benefits of a peer support programme for adults with insulin-treated type 2 diabetes (T2D) starting continuous glucose monitoring (CGM). METHODS: This part of the Steno2tech study is an exploratory, single-centre, open-labelled, prospective, randomised controlled trial (RCT). A total of 60 participants were randomised 2:1 to 12 months of CGM with or without peer support. All participants received a 3-h diabetes self-management education course including a CGM part on how to use the CGM and interpret the CGM-derived data. Peer support consisted of three 3-h peer support meetings over the first 6 months of the study period with groups of three to six people. The exploratory outcomes included the acceptability and feasibility of the peer support intervention, and the between-group difference in change in several glycaemic, metabolic and participant-reported outcomes measured at baseline, 6 and 12 months. RESULTS: The peer support intervention was found acceptable and feasible. Participants shared their experiences of using and interpreting CGM data and its association with health behaviour. While both groups had improvements in glycaemic, metabolic and participant-reported outcomes, there were no significant between-group differences. CONCLUSIONS: Although feasible, we found no measured additional benefits when adding a peer support programme after starting CGM in this exploratory RCT including adults with insulin-treated T2D. Understanding the perceived effect of and preferences for a peer support intervention from the participants' points of view, including why individuals declined to participate, would be of value for future research.

Comparing Continuous Glucose Monitoring and Blood Glucose Monitoring in Adults With Inadequately Controlled, Insulin-Treated Type 2 Diabetes (Steno2tech Study): A 12-Month, Single-Center, Randomized Controlled Trial.

OBJECTIVE: To compare the 12-month effects of continuous glucose monitoring (CGM) versus blood glucose monitoring (BGM) in adults with insulin-treated type 2 diabetes. RESEARCH DESIGN AND METHODS: This is a single-center, parallel, open-label, randomized controlled trial including adults with inadequately controlled, insulin-treated type 2 diabetes from the outpatient clinic at Steno Diabetes Center Copenhagen, Denmark. Inclusion criteria were ≥18 years of age, insulin-treated type 2 diabetes, and HbA1c ≥7.5% (58 mmol/mol). Participants were randomly assigned (1:1) to 12 months of either CGM or BGM. All participants received a diabetes self-management education course and were followed by their usual health care providers. Primary outcome was between-group differences in change in time in range (TIR) 3.9-10.0 mmol/L, assessed at baseline, after 6 and 12 months by blinded CGM. The prespecified secondary outcomes were differences in change in several other glycemic, metabolic, and participant-reported outcomes. RESULTS: The 76 participants had a median baseline HbA1c of 8.3 (7.8, 9.1)% (67 [62-76] mmol/mol), and 61.8% were male. Compared with BGM, CGM usage was associated with significantly greater improvements in TIR (between-group difference 15.2%, 95% CI 4.6; 25.9), HbA1c (-0.9%, -1.4; -0.3 [-9.4 mmol/mol, -15.2; -3.5]), total daily insulin dose (-10.6 units/day, -19.9; -1.3), weight (-3.3 kg, -5.5; -1.1), and BMI (-1.1 kg/m2, -1.8; -0.3) and greater self-rated diabetes-related health, well-being, satisfaction, and health behavior. CONCLUSIONS: In adults with inadequately controlled insulin-treated type 2 diabetes, the 12-month impact of CGM was superior to BGM in improving glucose control and other crucial health parameters. The findings support the use of CGM in the insulin-treated subgroup of type 2 diabetes.

Girls with idiopathic central precocious puberty did not display substatial changes in body mass index after treatment with gonadotropin-releasing hormone analogues.

AIM: To evaluate changes in body mass index (BMI) in girls during and after treatment for idiopathic central precocious puberty (iCPP). METHODS: We studied 123 girls receiving gonadotropin-releasing hormone analogue (GnRHa)treatment for iCPP from 2009 to 2019. Pubertal and anthropometric measurements were monitored at routine clinical visits. BMI standard deviation scores (SDS) were estimated at baseline and followed in two stages from baseline to end of treatment (median 18.9 months) and from end of treatment to end of follow-up (median 18.2 months). The influence of baseline BMI SDS and the frequency and dose of treatment was evaluated using BMI trajectories and latent class mixed models. RESULTS: The median age at treatment initiation was 8.5 years. The median BMI SDS at baseline was 0.7, corresponding to a median BMI of 17.4 kg/m2. Overall, no changes in BMI SDS were observed during treatment. According to baseline BMI subgroups, an increasing trend in BMI trajectories during treatment was observed for girls in the lowest BMI group. After treatment, most girls maintained stable BMI levels. CONCLUSION: Our retrospective study did not provide evidence that GnRHa treatment for iCPP had a significant impact on BMI trajectories in girls.

The link between physician motivation and care.

Studies report an unexplained variation in physicians' care. This variation may to some extent be explained by differences in their work motivation. However, empirical evidence on the link between physician motivation and care is scarce. We estimate the associations between different types of work motivation and care. Motivation is measured using validated questions from a nation-wide survey of Danish general practices and linked to high-quality register data on their care in 2019. Using a series of regression models, we find that more financially motivated practices generate more fee-for-services per patient, whereas practices characterised by greater altruistic motivation towards the patient serve a larger share of high-need patients and issue more prescriptions for antibiotics per patient. Practices with higher altruism towards society generate lower medication costs per patient and prescribe a higher rate of narrow-spectrum penicillin, thereby reducing the risk of antimicrobial resistance in the population. Together, our results suggest that practices' motivation is associated with several dimensions of healthcare, and that both their financial motivation and altruism towards patients and society play a role. Policymakers should, therefore, consider targeting all provider motivations when introducing organisational changes and incentive schemes; for example, by paying physicians to adhere to clinical guidelines, while at the same time clearly communicating the guidelines' value from both a patient and societal perspective.

Going the extra mile? General practitioners' upcoding of fees for home visits.

General practitioners' (GPs') income often relies on self-reported activities and performances. They can therefore 'game the system' to maximize their remuneration. We investigate whether Danish GPs game their travel fees for home visits. Combining administrative and geographical data, we measure the difference between GPs' traveled and billed distances. We exploit a rise in the fees for home visits. If there is a link between the rise in fees and upcoding, we interpret this finding as indicative of gaming behavior. We find that upcoding occurs slightly more often than downcoding (16% vs. 13% of visits) for visits that can be both upcoded and downcoded. Using linear probability models with GP fixed effects, we find that the fee rise is associated with a reduction in upcoding of 0.6% of home visits (2.8% for visits where upcoding is feasible) and no change in downcoding. Importantly, we find no statistically significant differences in the reduction in upcoding across distance bands despite large differences in their fee rises. We therefore conclude that there is no causal evidence of GPs gaming their fees.

Mapping GPs' motivation ­ it's not all about the money: a nationwide cross-sectional survey study from Denmark.

BACKGROUND: Understanding physicians' motivation may be essential for policymakers if they are to design policies that cater to physicians' wellbeing, job retention, and quality of care. However, physicians' motivation remains an understudied area. AIM: To map GPs' work motivation. DESIGN AND SETTING: A cross-sectional analysis using registry and survey data from Denmark. METHOD: Survey data were used to measure four types of motivation: extrinsic motivation, intrinsic motivation, user orientation, and public service motivation. These were combined with register data on the characteristics of the GP, practice, and area. Using latent profile analysis, the heterogeneity in GPs' motivation was explored; the associations between GPs' motivation and the GP, practice, and area characteristics were estimated using linear regression analyses. RESULTS: There was substantial heterogeneity in GPs' motivations. Five classes of GPs were identified with different work motivations: class 1 'it is less about the money' - probability of class membership 53.2%; class 2 'it is about everything' - 26.5%; class 3 'it is about helping others' - 8.6%; class 4 'it is about the work' - 8.2%; and class 5 'it is about the money and the patient' - 3.5%. Linear regression analyses showed that motivation was associated with GP, practice, and area characteristics to a limited extent only. CONCLUSION: GPs differ in their work motivations. The finding that, for many GPs, 'it is not all about the money' indicated that their different motivations should be considered when designing new policies and organisational structures to retain the workforce and ensure a high quality of care.

Patient-initiated follow-up in women with early-stage endometrial cancer: A long-term follow-up of the OPAL trial.

OBJECTIVE: A long-term follow-up of the OPAL trial to compare the effect of patient-initiated (PIFU) versus hospital-based (HBFU) follow-up on fear of cancer recurrence (FCR), quality of life (QoL) and healthcare use after 34 months of follow-up. DESIGN: Pragmatic, multicentre randomised trial. SETTING: Four Danish departments of gynaecology between May 2013 and May 2016. POPULATION: 212 women diagnosed with stage I low-intermediate risk endometrial carcinoma. METHODS: The control group attended HBFU with regular outpatient visits (i.e., 8) for 3 years after primary treatment. The intervention group underwent PIFU with no prescheduled visits but with instructions about alarm symptoms and options of self-referral. MAIN OUTCOME MEASURES: The endpoints were FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) and QoL as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire C-30 (EORTC QLQ C-30), and healthcare use as measured by questionnaires and chart reviews after 34 months of follow-up. RESULTS: FCR decreased from baseline to 34 months in both groups and no difference was found between allocations (difference -6.31 [95% confidence interval -14.24 to 1.63]). QoL remained stable with no difference in any domains between the two arms at 34 months using a linear mixed model analysis. The use of healthcare was significantly lower in the PIFU group (P < 0.01). CONCLUSION: Patient-initiated follow-up is a valid alternative to hospital-based follow-up for people who have been treated for endometrial cancer and have low risk of recurrence.

Development, implementation and evaluation of patient decision aids supporting shared decision making in women with recurrent ovarian cancer.

Objective: Shared decision making (SDM) and use of patient decision aids (PtDAs) are key components in patient-centered care in relapsed ovarian cancer. This paper describes the development and implementation process of PtDAs into a clinical routine in three departments. Methods: Two PtDAs were developed in collaboration between patients and clinicians. Acceptability and usability of the PtDAs were tested on clinicians and patients using items from the internationally validated questionnaire "Preparation for Decision Making Scale". Results: Ten patients and 15 clinicians participated in the study. Most patients indicated that PtDAs would be helpful as preparation for the decision-making process with the clinicians. Ten (75%) of the clinicians responded that the PtDAs helped the patients to understand the benefits and disadvantages of each treatment option. Generally, the clinicians indicated that they would use SDM if they had a PtDA tailored to the clinical situation. Conclusions: Two PtDAs were systematically developed, tested, and implemented thereby supporting an SDM intervention. The PtDAs are still in use at the participating departments. Innovation: This study was successful in reusing a generic template for a patient decision aid (PtDA) developed at one institution and implemented in two other institutions. This was guided by a well-described systematic development process for PtDAs.

Diagnosis and Incidence of Congenital Combined Pituitary Hormone Deficiency in Denmark-A National Observational Study.

CONTEXT: Congenital combined pituitary hormone deficiency (cCPHD) is the loss of ≥2 pituitary hormones caused by congenital factors. OBJECTIVE: We aimed to estimate the national incidence of cCPHD diagnosed before age 18 years and in subgroups. METHODS: Patients with cCPHD were identified in the Danish National Patient Registry and Danish hospital registries in the period 1996-2020. Hospital files were reviewed and incidences calculated using background population data. Incidence was the main outcome measure. RESULTS: We identified 128 patients with cCPHD; 88 (68.8%) were males. The median (range) age at diagnosis was 6.2 (0.01-19.0) years. The median (25th;75th percentile) number of hormone deficiencies at diagnosis was 3 (3; 4) at <1 year vs 2 (2; 2) at 1-17 years, P < .0001. Abnormal pituitary magnetic resonance imaging findings were seen in 70.3% (83/118). For those born in Denmark aged <18 years at diagnosis (n = 116/128) the estimated national incidence (95% CI) of cCPHD was 10.34 (7.79-13.72) per 100 000 births, with an annual incidence rate of 5.74 (4.33-7.62) per million. In subgroup analysis (diagnosis <1 vs 1-17 years), the incidence was highest in the 1-17 years subgroup, 7.97 (5.77-11.00) vs 1.98 (1.39-2.84) per 100 000 births, whereas the annual incidence rate was highest at <1 year, 19.8 (13.9-28.4) vs 4.69 (3.39-6.47) per million births. CONCLUSION: cCPHD had the highest incidence rate and the most hormone deficiencies in those diagnosed at <1 year. The incidence was highest in the 1-17 years age group, underscoring the need for multiple pituitary hormone investigations throughout childhood and adolescence in children with only 1 hormone deficiency.

Indicators of quality of diabetes care in persons with type 2 diabetes with and without severe mental illness: a Danish nationwide register-based cohort study.

Background: This study aims to examine quality of diabetes care in persons with type 2 diabetes with and without severe mental illness (SMI). Methods: In a nationwide prospective register-based study, we followed persons with type 2 diabetes in Denmark with and without SMI including schizophrenia, bipolar disorder, or major depression. Quality of care was measured as receipt of care (hemoglobin A1c, low-density lipoprotein-cholesterol and urine albumin creatinine ratio assessment and eye and foot screening) and achievement of treatment targets between 2015 and 2019. Quality of care was compared in persons with and without SMI using generalized linear mixed models adjusted for key confounders. Findings: We included 216,537 persons with type 2 diabetes. At entry 16,874 (8%) had SMI. SMI was associated with lower odds of receiving care, with the most pronounced difference in urine albumin creatinine ratio assessment and eye screening (OR: 0.55, 95% CI: 0.53-0.58 and OR: 0.37 95% CI: 0.32-0.42, respectively). Among those with an assessment, we found that SMI was associated with higher achievement of recommended hemoglobin A1c levels and lower achievement of recommended low-density lipoprotein-cholesterol levels. Achievement of recommended low-density lipoprotein-cholesterol levels was similar in persons with versus without schizophrenia. Interpretation: Compared to persons without SMI, persons with SMI were less likely to receive process of care, with the most pronounced differences in urine albumin creatinine ratio assessment and eye screening. Funding: This study was funded by Steno Diabetes Center Copenhagen through an unrestricted grant from Novo Nordisk Foundation.

Epidemiology and diagnostic trends of congenital adrenal hyperplasia in Denmark: a retrospective, population-based study.

Background: The prevalence of newborns with congenital adrenal hyperplasia (CAH) detected by neonatal screening is well-described, but data including patients diagnosed later in life are extremely limited. This study aimed to describe diagnostic trends for all patients with CAH in Denmark. Methods: A nationwide population-based registry study including medical record review. Findings: We identified 462 patients (290 females) with any form of CAH. The prevalence of CAH combined was 15.1 (95% confidence interval [CI]: 12.3-16.1) and 9.0 (CI: 7.6-10.4) per 100,000 newborn females and males. There was a prevalence of salt-wasting (SW), simple-virilizing (SV), and non-classic (NC) CAH due to 21-hydroxylase deficiency of: SW-CAH: 6.4 (CI: 5.3-7.6) and 5.6 (CI: 4.6-6.8); SV-CAH: 2.0 (CI: 1.4-2.8) and 1.6 (CI: 1.0-2.7); and NC-CAH: 5.5 (CI: 4.4-6.9) and 2.5 (CI: 1.7-3.7) per 100,000 newborn females and males, respectively. Diagnosis of NC-CAH increased significantly during the course of the study. There was a female preponderance for SV-CAH (ratio: 1.8) and NC-CAH (ratio: 3.2). Median age at diagnosis, females and males respectively: SW-CAH: 4 (interquartile range [IQR]: 0-11) and 14 (IQR: 8-24) days, SV-CAH: 3.1 (IQR: 1.2-6.6) and 4.8 (IQR: 3.2-6.9) years, and NC-CAH: 15.5 (IQR: 7.9-22.5) and 9.4 (IQR: 7.2-23.2) years. Interpretation: The combined prevalence of CAH was 15.1 and 9.0 per 100,000 newborn females and males, respectively. The female preponderance was primarily due to diagnosis of more females than males with NC-CAH. Funding: International Fund of Congenital Adrenal Hyperplasia, Health Research Fund of Central Denmark Region, Aase and Einar Danielsen Fund, and "Fonden til Lægevidenskabens Fremme".

A NEw MOdel of individualized and patient-centered follow-up for women with gynecological cancer (the NEMO study)-protocol and rationale of a randomized clinical trial.

BACKGROUND: Follow-up programs for gynecological cancer patients are currently under revision. There is limited evidence that traditional follow-up and clinical examinations improve survival in an early-stage gynecological setting. Further, traditional follow-up programs fail to accommodate the patient's need for psychosocial and sexual supportive care and to actively involve patients and their relatives in the follow-up process. Individualized programs may replace traditional routine follow-up with fixed intervals and length. Focusing on alarm-symptoms and self-reporting may ensure detection of recurrence while allowing a continuous attention to the patient's well-being and return to daily life. In this study, a nurse-led, individualized, and need-based intervention with a specific focus on patient empowerment is tested against a standard physician-led model primarily focusing on the detection of recurrence. METHODS: The study is designed as a clinical, randomized trial conducted in one of four national onco-gynecological centers in Denmark. Patients with early-stage cervical or endometrial cancer are eligible for inclusion. The intervention group undergoes individualized, nurse-led follow-up supporting patient empowerment including repeated use of electronic patient-reported outcome measures (ePROMs) before each contact as a dialogue support tool. The follow-up contacts are mainly conducted by telephone. All project nurses attended a special training program before project start and are all well-educated and dedicated onco-gynecological nurses. The control group receives standard, physician-led, follow-up without use of ePROMs or specific focus on empowerment. The effect of the intervention is evaluated by questionnaires completed by patients at baseline (3 months after surgery) and 12, 18, and 36 months after surgery. Outcomes include empowerment using the Skill and technique subscale of the HEI-Q questionnaire as the primary outcome while fear of cancer recurrence and health-related quality of life as well as the remaining subscales of the HEI-Q represent secondary outcomes. Data is collected by use of the REDCap technology, which also provides a customized visual support function for the dialogue tool. DISCUSSION: This study will provide new information about follow-up in early-stage gynecological cancer settings and thereby contribute to improvement of future follow-up programs. Importantly, the study will provide knowledge about the impact of specific focus on patient empowerment in follow-up programs and, further, how to facilitate empowerment among patients. TRIAL REGISTRATION: The study is registered at clinicaltrials.gov: ID no. NCT03838861. Registered on 6 February 2019. Protocol version 2, issue date 21 November 2022.

From hospital to home following a lower limb amputation: A focus group study of healthcare professionals' views and experiences with transitioning.

INTRODUCTION: Patients undergoing major lower limb amputation often have multiple comorbidities, requiring care from numerous healthcare professionals (HCPs). Furthermore, they may experience physical, medical and practical challenges post-amputation. Patients with complex needs are particularly vulnerable during care transitions and may benefit from integrated care models. AIM: This study aimed to explore HCPs' views and experiences regarding the transition process after implementing an integrated care model for patients with lower limb amputation. METHODS: We conducted two focus groups with 13 HCPs from a Danish hospital and three surrounding districts; all working in the Safe Journey programme. The interviews were analysed using thematic analysis. RESULTS: Three themes were created: 1) becoming a team across sectors, 2) continuity of care as a driver for patient safety and 3) challenges in achieving safe transitions. The Safe Journey programme facilitated the construction of an interdisciplinary team, cross-sectoral communication and professional relations, increasing HCPs' sense of improved patient safety and care continuity. However, HCPs experienced an increased workload, including coordination and at-home patient visits. CONCLUSIONS: HCPs found the Safe Journey programme to be valuable for patients undergoing major lower limb amputation and promotive of cross-sectoral professional relations, communication, continuity and patient safety. However, the programme was time- and resource-consuming compared to conventional models.

"SDM:HOSP"- a generic model for hospital-based implementation of shared decision making.

BACKGROUND: Shared decision making (SDM) is a core element in the meeting between patient and healthcare professionals, but has proved difficult to implement and sustain in routine clinical practice. One of five Danish regions set out to succeed and to develop a model that ensures lasting SDM based on learnings from large-scale real-world implementation initiatives that go beyond the 'barriers' and 'facilitators' research approach. This paper describes this process and development of a generic implementation model, SDM:HOSP. METHODS: This project was carried out in the Region of Southern Denmark with five major hospital units. Based on existing theory of SDM, SDM implementation, implementation science and improvement methodology, a process of four phases were described; development of conceptual elements, field-testing, evaluation, and development of the final implementation model. The conceptual elements developed aimed to prepare leaders, train SDM teachers, teach clinicians to perform SDM, support development of patient decision aids, and support systematic planning, execution and follow-up. Field testing was done including continuous participant evaluations and an overall evaluation after one year. RESULTS: Data from field testing and learnings from the implementation process, illustrated the need for a dynamic and easy adjustable model. The final SDM:HOSP model included four themes; i)Training of Leaders, ii) Training of Teachers and Clinicians, iii) Decision Helper, and iv) 'Process', each with details in three levels, 1) shared elements, 2) recommendations, and 3) local adaption. CONCLUSIONS: A feasible and acceptable model for implementation of SDM across hospitals and departments that accounts for different organizations and cultures was developed. The overall design can easily be adapted to other organizations and can be adjusted to fit the specific organization and culture. The results from the ongoing and overall evaluation suggest promising avenues for future work in further testing and research of the usability of the model.

Hospitalisation at Home of Patients with COVID-19: A Qualitative Study of User Experiences.

Hospitalisation at Home (HaH) is a new model providing hospital-level care at home as a substitute for traditional care. Biometric monitoring and digital communication are crucial, but little is known about user perspectives. We aim to explore how in-patients with severe COVID-19 infection and clinicians engage with and experience communication and self-monitoring activities following the HaH model. A qualitative study based on semi-structured interviews of patients and clinicians participating in the early development phase of HaH were conducted. We interviewed eight clinicians and six patients. Five themes emerged from clinicians: (1) staff fear and concerns, (2) workflow, (3) virtual closeness, (4) patient relatives, and (5) future HaH models; four themes emerged from patients: (1) transition to home, (2) joint responsibility, (3) acceptability of technologies, and (4) relatives. Despite technical problems, both patients and clinicians were enthusiastic about the conceptual HaH idea. If appropriately introduced, treatment based on self-monitoring and remote communication was perceived acceptable for the patients; however, obtaining vitals at night was an overwhelming challenge. HaH is generally acceptable, perceived patient-centred, influencing routine clinical workflow, role and job satisfaction. Therefore, it calls for educational programs including more perspective than issues related to technical devices.

Cost-effectiveness of a transdiagnostic psychotherapy program for youth with common mental health problems.

OBJECTIVES: Our objective was to evaluate the cost-effectiveness of the transdiagnostic psychotherapy program Mind My Mind (MMM) for youth with common mental health problems using a cost-utility analysis (CUA) framework and data from a randomized controlled trial. Furthermore, we analyzed the impact of the choice of informant for both quality-of-life reporting and preference weights on the Incremental Cost-Effectiveness Ratio (ICER). METHODS: A total of 396 school-aged (6-16 years) youth took part in the 6-month trial carried out in Denmark. CUAs were carried out for the trial period and four one-year extrapolation scenarios. Costs were based on a combination of budget and self-reported costs. Youths and parents were asked to report on the youth's quality-of-life three times during the trial using the Child Health Utility 9D (CHU9D). Parental-reported CHU9D was used in the base case together with preference weights of a youth population. Analyses using self-reported CHU9D and preference weights of an adult population were also carried out. RESULTS: The analysis of the trial period resulted in an ICER of €170,465. The analyses of the one-year scenarios resulted in ICERs between €23,653 and €50,480. The ICER increased by 24% and 71% compared to the base case when using self-reported CHU9D and adult preference weights, respectively. CONCLUSION: The MMM intervention has the potential to be cost-effective, but the ICER is dependent on the duration of the treatment effects. Results varied significantly with the choice of informant and the choice of preference weights indicating that both factors should be considered when assessing CUA involving youth.