Abstract Context Complicated grief and depressive symptoms in bereaved caregivers have been associated with female gender, spousal relation and pre-loss psychological distress, but population-based, ...prospective studies are scarce. Objectives We aimed to investigate whether severe pre-loss grief and depressive symptoms, caregiver burden, preparedness for death, communication about dying and socio-economic factors predicted complicated grief and post-loss depressive symptoms. Methods We conducted a population-based, prospective Danish survey of caregivers. Questionnaires for their closest caregiver were mailed to patients registered with drug reimbursement for terminal illness. Of the 3,635 (38%) responding caregivers, 2,420 were bereaved within six months. Of these, 2,215 (88%) completed a post-loss follow-up questionnaire. Associations between complicated grief (PG-13), post-loss depressive symptoms (BDI-II) and predictive factors were analyzed with mutually adjusted multivariable logistic regression models. Results At six-month follow-up, 7.6% reported complicated grief and 12.1% reported post-loss depressive symptoms, whereas the levels of grief and depressive symptoms were higher pre-loss. Complicated grief and post-loss depressive symptoms were predicted by severe pre-loss grief symptoms (adjusted OR=3.8, 95% CI: 2.4-6.1), pre-loss depressive symptoms (adjusted OR=5.6, 95% CI: 3.5-9.0), being a partner (adjusted OR=2.2, 95% CI: 1.2-3.7) and low educational level (adjusted OR=2.0, 95% CI: 1.2-3.7). Complicated grief was not predicted by age and gender, whereas post-loss depressive symptoms were predicted by young age, female gender and low preparedness for death. Conclusion Severe pre-loss grief and depressive symptoms were key predictors of post-loss complicated grief and depressive symptoms. Systematic assessment may identify caregivers with a high risk profile who need targeted support.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
ObjectiveWork pressure remains an issue among general practitioners (GPs). Nevertheless, GPs rarely seek help for symptoms of burnout. The aim of this study was to examine whether burnout level was ...associated with coping strategies and help-seeking behaviour during time pressure.DesignA two-wave nationwide survey (2016 and 2019) based on questionnaire data from 1059 GPs.SettingPrimary care in Denmark.MethodsBurnout was measured by the Maslach Burnout Inventory (MBI), whereas coping strategies and help-seeking behaviour were measured by questions developed for the study. A composite score of quartile points was calculated for the three subscales of the MBI subscales. A score ≥9 was categorised as high level of burnout, and the composite score of 2019 was used as outcome. Data were analysed with logistic regression adjusted for sex, age and composite burnout score in 2016.ResultsHigh scores in 2016 on four key factors were associated with increased risk of high composite burnout score in 2019. These factors were compromising work (ORadjusted=2.27, 95% CI=1.45 to 3.56), postponing decisions (ORadjusted=1.53, 95% CI=1.04 to 2.24), delaying tasks (ORadjusted=1.61, 95% CI=1.16 to 2.25) and reducing breaks (ORadjusted=1.46, 95% CI=1.01 to 2.11) during time pressure. A lower risk of high composite burnout score was seen in 2019 in GPs who had sought help compared with GPs who did not seek help despite a perceived need (ORadjusted=0.59, 95% CI=0.35 to 0.97).ConclusionCertain coping strategies used in 2016 were associated with increased risk of high burnout score in 2019, whereas lower risk of high burnout was seen in the GPs seeking help. These findings are relevant to reduce burnout rates among GPs.
Patient multimorbidity and GP burnout are increasing problems in primary care and are potentially related.
To examine whether patient multimorbidity was associated with GP burnout in a Danish primary ...care setting.
Questionnaire data from 1676 Danish GPs and register data on their patients.
GPs completed the Maslach Burnout Inventory. Patients listed in a national registry with ≥2 chronic physical diseases from a list of 10 were classified with multimorbidity. For each practice, crude and sex- and age-standardised rates of multimorbidity were calculated, the latter computed as a weighted average with the weights taken from a reference population (5 646 976 Danish citizens). Data were analysed with logistic regression and adjusted analyses included GPs' age and sex, number of GPs in practice, and socioeconomic deprivation among patients as covariates.
A high crude rate of patient multimorbidity increased GPs' likelihood of burnout (odds ratio OR 1.79, 95% confidence interval CI = 1.13 to 2.82), and when adjusting for covariates the association remained significant when comparing GPs in the third highest quartile of the multimorbidity rate against GPs in the lowest quartile (OR 1.64, 95% CI = 1.02 to 2.64). The sex- and age-standardised patient multimorbidity rate was not associated with GPs' likelihood of burnout.
A high crude rate of patient physical multimorbidity increased the likelihood of burnout among GPs. The sex- and age-standardised rate of multimorbidity was not related to GPs' likelihood of burnout. Thus, the absolute amount of multimorbidity, and not the relative, affects the GP's burnout risk. GPs with high numbers of patients with complex needs should be supported to prevent suboptimal care and GP burnout.
Tuberculosis (TB) is a persistent health issue in Greenland. While rapid diagnosis is crucial to reducing transmission of the disease, remote settlements have limited access to healthcare services. ...We aimed to assess and compare the time intervals from first contact to diagnosis and treatment for patients with active TB in the cities and settlements of Greenland. A total of 153 cases were included and divided according to place of residence and whether the diagnosis was based on symptomatic presentation or contact tracing. The median time from first contact to diagnosis was 19 days for the total population. The symptomatic settlement population waited longer (median = 88.5 days) than the symptomatic city population (median = 19 days) (p = 0.018). The system interval was longer for the symptomatic settlement population than for the symptomatic city population with a median of 49.5 days vs. 3 days for chest imaging (p < 0.001) and 66.5 days vs. 10 days for expectorate sample (p = 0.008). The diagnostic, system, and total intervals were significantly longer for symptomatic patients in settlements than in cities. This may explain a higher TB incidence in the settlements and calls for the development of better diagnostic pathways.
Cancer Patient Pathways (CPPs) were introduced in 2000-2015 in several European countries, including Denmark, to reduce the time to diagnosis and treatment initiation and ultimately improve patient ...survival. Yet, the prognostic consequences of implementing CPPs remain unknown for symptomatic cancer patients diagnosed through primary care. We aimed to compare survival and mortality among symptomatic patients diagnosed through a primary care route before, during and after the CPP implementation in Denmark.
Based on data from the Danish Cancer in Primary Care (CaP) Cohort, we compared one- and three-year standardised relative survival (RS) and excess hazard ratios (EHRs) before, during and after CPP implementation for seven types of cancer and all combined (n = 7725) by using life-table estimation and Poisson regression. RS estimates were standardised according to the International Cancer Survival Standard (ICSS) weights. In addition, we compared RS and EHRs for CPP and non-CPP referred patients to consider potential issues of confounding by indication.
In total, 7725 cases were analysed: 1202 before, 4187 during and 2336 after CPP implementation. For all cancers combined, the RS
rose from 45% (95% confidence interval (CI): 42;47) before to 54% (95% CI: 52;56) after CPP implementation. The excess mortality was higher before than after CPP implementation (EHR
before vs. after CPP = 1.35 (95% CI: 1.21;1.51)). When comparing CPP against non-CPP referred patients, we found no statistically significant differences in RS, but we found lower excess mortality among the CPP referred (EHR
CPP vs. non-CPP = 0.86 (95% CI: 0.73;1.01)).
We found higher relative survival and lower mortality among symptomatic cancer patients diagnosed through primary care after the implementation of CPPs in Denmark. The observed changes in cancer prognosis could be the intended consequences of finding and treating cancer at an early stage, but they may also reflect lead-time bias and selection bias. The finding of a lower excess mortality among CPP referred compared to non-CPP referred patients indicates that CPPs may have improved the cancer prognosis independently.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
Severe grief symptoms in family caregivers during end‐of‐life cancer trajectories are associated with complicated grief and depression after the loss. Nevertheless, severe grief symptoms ...during end‐of‐life caregiving in caregivers to cancer patients have been scarcely studied. We aimed to explore associations between severe preloss grief symptoms in caregivers and modifiable factors such as depressive symptoms, caregiver burden, preparedness for death, and end‐of‐life communication.
Methods
We conducted a population‐based prospective study of caregivers to 9512 patients registered with drug reimbursement due to terminal illness, and 3635 caregivers responded. Of these, 2865 caregivers to cancer patients completed a preloss grief scale (Prolonged Grief 13, preloss version). Associations with factors measured during end‐of‐life caregiving were analyzed using logistic regression.
Results
Severe preloss grief symptoms were reported by 432 caregivers (15.2%). These symptoms were associated with depressive symptoms (adjusted odds ratio OR = 12.4; 95% CI, 9.5‐16.3), high caregiver burden (adjusted OR = 8.3; 95% CI, 6.3‐11.1), low preparedness for death (adjusted OR = 3.3; 95% CI, 2.5‐4.4), low level of communication about dying (adjusted OR = 3.2; 95% CI, 2.2‐4.4), and “too much” prognostic information (adjusted OR = 2.8; 95%, 1.7‐4.6).
Conclusions
Severe preloss grief symptoms were significantly associated with distress, low preparedness, and little communication during caregiving. Thus, severe preloss grief symptoms may be a key indicator for complications in caregivers of cancer patients in an end‐of‐life trajectory. Targeted interventions are needed to support family caregivers with severe preloss grief symptoms. Development of preloss grief assessment tools and interventions should be a priority target in future research.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Delay in diagnosis of cancer may worsen prognosis. The aim of this study is to explore patient-, general practitioner (GP)- and system-related delay in the interval from first cancer symptom to ...diagnosis and treatment, and to analyse the extent to which delays differ by cancer type.
Population-based cohort study conducted in 2004-05 in the County of Aarhus, Denmark (640,000 inhabitants). Data were collected from administrative registries and questionnaires completed by GPs on 2,212 cancer patients newly diagnosed during a 1-year period. Median delay (in days) with interquartile interval (IQI) was the main outcome measure.
Median total delay was 98 days (IQI 57-168). Most of the total delay stemmed from patient (median 21 days (7-56)) and system delay (median 55 days (32-93)). Median GP delay was 0 (0-2) days. Total delay was shortest among patients with ovarian (median 60 days (45-112)) and breast cancer (median 65 days (39-106)) and longest among patients with prostate (median 130 days (89-254)) and bladder cancer (median 134 days (93-181)).
System delay accounted for a substantial part of the total delay experienced by cancer patients. This points to a need for shortening clinical pathways if possible. A long patient delay calls for research into patient awareness of cancer. For all delay components, special focus should be given to the 4th quartile of patients with the longest time intervals and we need research into the quality of the diagnostic work-up process. We found large variations in delay for different types of cancer. Improvements should therefore target both the population at large and the specific needs associated with individual cancer types and their symptoms.
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CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
A population-based breast cancer screening programme was implemented in the Central Denmark Region in 2008-09. The objective of this registry-based study was to examine the association between ...socio-demographic characteristics and screening participation and to examine whether the group of non-participants can be regarded as a homogeneous group of women.
Participation status was obtained from a regional database for all women invited to the first screening round in the Central Denmark Region in 2008-2009 (n=149,234). Participation data was linked to registries containing socio-demographic information. Distance to screening site was calculated using ArcGIS. Participation was divided into 'participants' and 'non-participants', and non-participants were further stratified into 'active non-participants' and 'passive non-participants' based on whether the woman called and cancelled her participation or was a 'no-show'.
The screening participation rate was 78.9%. In multivariate analyses, non-participation was associated with older age, immigrant status, low OECD-adjusted household income, high and low level education compared with middle level education, unemployment, being unmarried, distance to screening site >20 km, being a tenant and no access to a vehicle. Active and passive non-participants comprised two distinct groups with different socio-demographic characteristics, with passive non-participants being more socially deprived compared with active non-participants.
Non-participation was associated with low social status e.g. low income, unemployment, no access to vehicle and status as tenant. Non-participants were also more likely than participants to be older, single, and of non-Danish origin. Compared to active non-participants, passive non-participants were characterized by e.g. lower income and lower educational level. Different interventions might be warranted to increase participation in the two non-participant groups.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Poor cancer prognosis has been observed in patients with pre-existing psychiatric disorders. Therefore, we need better knowledge about the diagnosis of cancer in this patient group. The aim of the ...study was to describe the routes to cancer diagnosis in patients with pre-existing psychiatric disorders and to analyse how cancer type modified the routes.
A register-based cohort study was conducted by including patients diagnosed with incident cancer in 2014-2018 (n = 155,851). Information on pre-existing psychiatric disorders was obtained from register data on hospital contacts and prescription medication. Multinomial regression models with marginal means expressed as probabilities were used to assess the association between pre-existing psychiatric disorders and routes to diagnosis.
Compared to patients with no psychiatric disorders, the population with a psychiatric disorder had an 8.0% lower probability of being diagnosed through cancer patient pathways initiated in primary care and a 7.6% higher probability of being diagnosed through unplanned admissions. Patients with pre-existing psychiatric disorders diagnosed with rectal, colon, pancreatic, liver or lung cancer and patients with schizophrenia and organic disorders were less often diagnosed through cancer patient pathways initiated in primary care.
Patients with pre-existing psychiatric disorders were less likely to be diagnosed through Cancer Patient Pathways from primary care. To some extent, this was more pronounced among patients with cancer types that often present with vague or unspecific symptoms and among patients with severe psychiatric disorders. Targeting the routes by which patients with psychiatric disorders are diagnosed, may be one way to improve the prognosis among this group of patients.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Patients with multimorbidity are frequent users of healthcare, but fragmented care may lead to suboptimal treatment. Yet, this has never been examined across healthcare sectors on a national scale. ...We aimed to quantify care fragmentation using various measures and to analyze the associations with patient outcomes.
We conducted a register-based nationwide cohort study with 4.7 million Danish adult citizens. All healthcare contacts to primary care and hospitals during 2018 were recorded. Clinical fragmentation indicators included number of healthcare contacts, involved providers, provider transitions, and hospital trajectories. Formal fragmentation indices assessed care concentration, dispersion, and contact sequence. The patient outcomes were potentially inappropriate medication and all-cause mortality adjusted for demographics, socioeconomic factors, and morbidity level.
The number of involved healthcare providers, provider transitions, and hospital trajectories rose with increasing morbidity levels. Patients with 3 versus 6 conditions had a mean of 4.0 versus 6.9 involved providers and 6.6 versus 13.7 provider transitions. The proportion of contacts to the patient's own general practice remained stable across morbidity levels. High levels of care fragmentation were associated with higher rates of potentially inappropriate medication and increased mortality on all fragmentation measures after adjusting for demographic characteristics, socioeconomic factors, and morbidity. The strongest associations with potentially inappropriate medication and mortality were found for ≥ 20 contacts versus none (incidence rate ratio 2.83, 95% CI 2.77-2.90) and ≥ 20 hospital trajectories versus none (hazard ratio 10.8, 95% CI 9.48-12.4), respectively. Having less than 25% of contacts with your usual provider was associated with an incidence rate ratio of potentially inappropriate medication of 1.49 (95% CI 1.40-1.58) and a mortality hazard ratio of 2.59 (95% CI 2.36-2.84) compared with full continuity. For the associations between fragmentation measures and patient outcomes, there were no clear interactions with number of conditions.
Several clinical indicators of care fragmentation were associated with morbidity level. Care fragmentation was associated with higher rates of potentially inappropriate medication and increased mortality even when adjusting for the most important confounders. Frequent contact to the usual provider, fewer transitions, and better coordination were associated with better patient outcomes regardless of morbidity level.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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