Interorganisational Integration: Healthcare Professionals' Perspectives on Barriers and Facilitators within the Danish Healthcare System.

INTRODUCTION: Despite many initiatives to improve coordination of patient pathways and intersectoral cooperation, Danish health care is still fragmented, lacking intra- and interorganisational integration. This study explores barriers to and facilitators of interorganisational integration as perceived by healthcare professionals caring for patients with chronic obstructive pulmonary disease within the Danish healthcare system. METHODS: Seven focus groups were conducted in January through July 2014 with 21 informants from general practice, local healthcare centres and a pulmonary department at a university hospital in the Capital Region of Denmark. RESULTS AND DISCUSSION: Our results can be grouped into five influencing areas for interorganisational integration: communication/information transfer, committed leadership, patient engagement, the role and competencies of the general practitioner and organisational culture. Proposed solutions to barriers in each area hold the potential to improve care integration as experienced by individuals responsible for supporting and facilitating it. Barriers and facilitators to integrating care relate to clinical, professional, functional and normative integration. Especially, clinical, functional and normative integration seems fundamental to developing integrated care in practice from the perspective of healthcare professionals.

The use of COPD maintenance therapy following spirometry in General Practice.

BACKGROUND: Several studies have shown that the use of pulmonary medication is widespread and often initiated without initial spirometry. Early detection of chronic obstructive pulmonary disease (COPD) by spirometry in General Practice is essential for an early and correct implementation of medical treatment. AIM: The aim of the present study was to evaluate the use of regular therapy following diagnostic spirometry for COPD in General Practice from February 2008 to February 2009. METHOD: Spirometry data and results were linked through Statistics Denmark with information from the Register of Medicinal Product Statistics using the unique personal identification code. Data were analysed to evaluate the impact of screening on use of regular COPD therapy. Primary outcome was initiation of regular therapy following COPD diagnosis with spirometry. RESULTS: In a population of 3,376 individuals at risk, 1,458 underwent spirometric assessment with 631 being diagnosed with COPD; 110 of those received regular therapy before assessment with this figure increasing to 161 after spirometry. Of 827 participants not receiving a COPD diagnosis, 36 received regular therapy prior to assessment and 42 received regular therapy after spirometry despite no established COPD diagnosis. CONCLUSION: There is a significant chance of receiving regular therapy after being diagnosed with COPD. However, a large proportion of subjects diagnosed with COPD did not receive regular therapy following diagnosis. Efforts should be made to ensure correct diagnosis and correct medical treatment according to guidelines in individuals with COPD.

Instruments to assess integrated care: a systematic review.

INTRODUCTION: Although several measurement instruments have been developed to measure the level of integrated health care delivery, no standardised, validated instrument exists covering all aspects of integrated care. The purpose of this review is to identify the instruments concerning how to measure the level of integration across health-care sectors and to assess and evaluate the organisational elements within the instruments identified. METHODS: An extensive, systematic literature review in PubMed, CINAHL, PsycINFO, Cochrane Library, Web of Science for the years 1980-2011. Selected abstracts were independently reviewed by two investigators. RESULTS: We identified 23 measurement instruments and, within these, eight organisational elements were found. No measurement instrument covered all organisational elements, but almost all studies include well-defined structural and process aspects and six include cultural aspects; 14 explicitly stated using a theoretical framework. CONCLUSION AND DISCUSSION: This review did not identify any measurement instrument covering all aspects of integrated care. Further, a lack of uniform use of the eight organisational elements across the studies was prevalent. It is uncertain whether development of a single 'all-inclusive' model for assessing integrated care is desirable. We emphasise the continuing need for validated instruments embedded in theoretical contexts.

Early detection of COPD in primary care: the Copenhagen COPD screening project.

OBJECTIVE: To evaluate the effectiveness of a screening programme for COPD in primary care. MATERIAL/METHODS: Subjects aged 65 years or older registered with a general practitioner in Copenhagen were asked to complete a questionnaire on smoking status and symptoms of COPD. If they were smokers or former smokers or if morning cough with sputum and/or dyspnoea was present, subjects were defined as "at risk of COPD" and were invited to undergo spirometric examination. RESULTS: Of the 7103 subjects who met the study criteria, 81.2% responded to the questionnaire. Of these, 58.5% were at risk of COPD. Of those at risk, 40% underwent a spirometric examination. COPD was classified as mild in 252 (42.3%), moderate in 258 (43.3%) and severe-very severe in 86 subjects (14.4%). The participation rate was significantly higher among subjects invited for spirometry at a healthcare centre compared to general practice. CONCLUSIONS: Our findings suggest that a questionnaire can be used as a screening tool to identify subjects at risk of COPD. Furthermore, the study shows that more than half the subjects aged 65 years and above were at risk of COPD and required clinical assessment. Willingness to undergo spirometric examination depends on the location of the screening.

Pulmonary rehabilitation for moderate COPD (GOLD 2)--does it have an effect?

BACKGROUND: Although pulmonary rehabilitation is an integrated part of standard care in patients with severe COPD, it is uncertain whether those with less severe COPD benefit from such treatment. The aim of the present survey was to evaluate the effect of rehabilitation in patients with moderate COPD and to determine their willingness to participate in rehabilitation. MATERIAL AND METHODS: In a single-centre, randomized, placebo-controlled, unblinded clinical trial, participants comprised 61 of 133 referred subjects with moderate COPD. Of the 61 participants, 35 were randomized to receive rehabilitation and 26 subjects to receive standard COPD care from their GP. After randomization 19 subjects dropped out. RESULTS: Effects of physical training were seen during the period of intervention. Compared with those receiving standard GP care, those receiving rehabilitation showed improvements in walking distance and leg strength as well as improvements in quality of life; however, the effect was temporary, and at 18 months' follow-up there was no significant difference between the groups. Only 61 subjects of the referred group of 133 with moderate COPD accepted the offer of rehabilitation. CONCLUSION: Although an effect was found of pulmonary rehabilitation in subjects with moderate COPD, it disappeared over 18 months. Only a minority of patients with moderate COPD referred for rehabilitation accepted and completed the treatment offer.

Early detection of COPD in primary care--the Copenhagen COPD Screening Project.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is among the leading causes of death in the world, and further increases in the prevalence and mortality are predicted. Delay in diagnosing COPD appears frequently even though current consensus guidelines emphasize the importance of early detection of the disease. The aim of the present study is to evaluate the effectiveness of a screening programme in general practice. METHODS/DESIGN: Subjects aged 65 years and older registered with a General Practitioner (GP) in the eastern Copenhagen will receive a written invitation and a simple questionnaire focusing on risk factors and symptoms of COPD. Subjects who meet the following criteria will be encouraged to undergo spirometric testing at their GP: current smokers, former smokers, and subjects with no smoking history but who have dyspnea and/or chronic cough with sputum. DISCUSSION: The Copenhagen COPD Screening Project evaluates the effectiveness of a two-stage screening program for COPD in general practice and provides important information on how to organize early detection of COPD in general practice in the future.