Equal access to end-of-life care is important. However, social inequality has been found in relation to place-of-death. The question is whether social and economic factors play a role in access to specialist palliative care services.
The study analyzed the association between access to outreach specialist palliative care teams (SPCTs) and socioeconomic characteristics of Danish cancer patients who died of their cancer.
The study was a population-based, cross-sectional register study. We identified 599 adults who had died of cancer from March 1 to November 30, 2006, in Aarhus County, Denmark. Data from health registers were retrieved and linked based on the unique personal identifier number.
Multivariate analysis with adjustment for age, gender, and general practitioner (GP) involvement showed a higher probability of contact with an SPCT among immigrants and descendants of immigrants than among people of Danish origin (prevalence ratio [PR]: 1.55; 95% confidence interval (CI): 1.04;2.31) and among married compared to unmarried patients (PR: 1.25; 95% CI: 1.01;1.54). The trends were most marked among women.
We found an association between females, married patients, and female immigrants and their descendants and access to an SPCT in Denmark. However, no association with the examined economic factor was found. Need for specialized health care, which is supposed to be the main reason for access to an SPCT, may be related to economic imbalance; and despite the relative equality found, SPCT access may not be equal for all Danish residents. Further research into social and economic consequences in palliative care services is warranted.
The narrow ICD-10 and DSM-IV definition of hypochondriasis makes it a rarely used diagnosis. Based on a latent class analysis of the symptoms exhibited by 701 patients (ages 18-65) in general practice, a new and more valid hypochondriasis diagnosis was defined in this study. The main symptom is "obsessive rumination about illnesses", and the patient must also have at least one of five other symptoms. The prevalence was 9.5 for both genders. There was a good agreement between the diagnoses made during the psychiatric interview and the physicians' assessments.
OBJECTIVE: General practitioner (GP) involvement may be instrumental in obtaining successful palliative cancer trajectories. The aim of the study was to examine associations between bereaved relatives' evaluation of palliative cancer trajectories, place of death, and GP involvement. DESIGN: Population-based, cross-sectional combined register and questionnaire study. SETTING: The former Aarhus County, Denmark. SUBJECTS: Questionnaire data on GPs' palliative efforts and relatives' evaluations of the palliative trajectories were obtained for 153 cases of deceased cancer patients. MAIN OUTCOME MEASURES: A successful palliative trajectory as evaluated retrospectively by the relatives. RESULTS: Successful palliative trajectories were statistically significantly associated with home death (PR 1.48 (95% CI 1.04; 2.12)). No significant associations were identified between the evaluations of the palliative trajectory at home and GP involvement. "Relative living with patient" (PR 1.75 (95% CI: 0.87; 3.53)) and "GP having contact with relatives" (PR 1.69 (95% CI 0.55; 5.19)) were not significantly associated, but this may be due to the poor number of cases included in the final analysis. CONCLUSION: This study indicates that home death is positively associated with a higher likelihood that bereaved relatives will evaluate the palliative trajectory at home as successful. No specific GP services that were statistically significantly associated with higher satisfaction among relatives could be identified, but contact between GPs and relatives seems important and the impact needs further investigation.
The loss of a loved person may lead to complicated grief (CG). General practitioners (GPs) consider bereavement care to be important but find training for this task to be insufficient. We hypothesized that improvement in skills that facilitate early identification of CG and enhance GPs' clinical care may reduce adverse health outcomes. Aim. To test whether implementation of a bereavement management program in general practice could improve the GPs' ability to identify CG and provide clinical care.
A cluster-randomized controlled trial allocating GPs and their listed patients suffering from bereavement to either a intervention or a control group.
Close relatives of patients who had died from cancer in Denmark were recruited (N = 402).
The primary outcomes were defined as the bereaved relatives' score on the Beck's Depression Inventory II and the Inventory of Complicated Grief-Revised (ICG-R), the GP's clinical assessment of the relative's grief reaction and the relative's number of contacts with general practice.
Larger improvements in ICG-R scores were found in the intervention group than in the control group. In the intervention group, patients exhibiting CG symptoms were more likely to receive supportive care and to be referred to mental health practitioners, whereas GP's in the control group more often prescribed psychotropic drugs for patients with symptoms of CG. The GP's ability to identify CG at 13 months did not seem to be better in the intervention group than in the control group.
While only statistically near significant, we found some indications of an effect of the intervention compared with usual care. Our results underscore the need for improving GPs' clinical skills in identifying patients with CG.
OBJECTIVES: The aim of the study was to validate a new case-finding instrument for common mental disorders (CMDQ). METHODS: A cross-sectional, stratified, two-phase study was carried out in 28 general practices in Aarhus County, Denmark. 1785 consecutive patients, 18-65 years old, consulting 38 GPs with a new health problem participated. Patients were screened before consultation using a one-page screening questionnaire including subscales for somatisation (SCL-SOM and Whiteley-7), anxiety (SCL-ANX4), depression (SCL-DEP6) and alcohol abuse (CAGE). A stratified subsample of 701 patients was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. We tested the external validity of the scales using the SCAN interview as gold standard. All data were analysed using appropriate weighted procedures to control for the two-phase sampling design and non-response bias. RESULTS: Estimates of sensitivity and specificity for relevant ICD-10 diagnoses at theoretical optimal cut-off points on subscales: Depressive disorder: 78/86 (SCL-DEP6); Alcohol abuse or dependence: 78/97 (CAGE); Severe anxiety disorder: 77/85 (SCL-ANX4); Somatisation disorder: 83/56 (SCL-SOM); and 75/52 (Whiteley-7); any mental disorder: 72/72 (SCL-8). At the theoretical optimal cut-off points the CMDQ demonstrated higher diagnostic accuracy than GPs on any diagnosis evaluated. CONCLUSION: The study results suggest that the CMDQ has excellent external validity for use as a diagnostic aid in primary care settings.
Studies of cancer survivors' rehabilitation needs have mostly addressed specific areas of needs, e.g. physical aspects and/or rehabilitation needs in relation to specific cancer types.
To assess cancer survivors' perceived need for physical and psychosocial rehabilitation, whether these needs have been presented to and discussed with their GP.
A survey among a cohort of cancer survivors approximately 15 months after diagnosis. The questionnaire consisted of an ad hoc questionnaire on rehabilitation needs and the two validated questionnaires, the SF-12 and the Research and Treatment of Cancer quality of life questionnaire, the QLQ C-30 version 3.
Among 534 eligible patients, we received 353 (66.1%) answers. Two-thirds of the cancer survivors had discussed physical rehabilitation needs with their GPs. Many (51%) feared cancer relapse, but they rarely presented this fear to the GP or the hospital staff. The same applied to social problems and problems within the family. Good physical and mental condition and low confidence in the GP were associated with no contact to the GP after hospital discharge.
Cancer survivors have many psychosocial rehabilitation needs and intervention should effectively target these needs. If this task is assigned to the GPs, they need to be proactive when assessing psychosocial aspects.
Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP's suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis.
We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients' chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP's symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression.
5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient's symptoms as 'alarm' symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as 'vague' had a lower chance of being referred to a CPP than when interpreted as 'alarm' symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with 'vague' symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with 'alarm' symptoms.
GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP's choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP's symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval.
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Care coordination is a superordinate term for terms related to the optimization of care for people suffering from chronic diseases and cancer. In this article, we present Danish terms for "disease management programme" and "case management" among others, and effects are summarized. The central Danish terms explored are "forløbskoordinering", "forløbsprogram", "forløbskoordinator", and "tovholder".
OBJECTIVE. Central health organizations suggest routine screening for depression in high-risk categories of primary care patients. This study compares the effectiveness of high-risk screening versus case-finding in identifying depression in primary care. DESIGN. Using an observational design, participating GPs included patients from 13 predefined risk groups and/or suspected of being depressed. Patients were assessed by the Major Depression Inventory (MDI) and ICD-10 criteria. Setting. Thirty-seven primary care practices in Mainland Denmark. Main outcome measures. Prevalence of depression, diagnostic agreement, effectiveness of screening methods, risk groups requiring special attention. RESULTS. A total of 37 (8.4%) of 440 invited GP practices participated. We found high-risk prevalence of depression in 672 patients for the following traits: (1) previous history of depression, (2) familial predisposition to depression, (3) chronic pain, (4) other mental disorders, and (5) refugee or immigrant. In the total sample, GPs demonstrated a depression diagnostic sensitivity of 87% and a specificity of 67% using a case-finding strategy. GP diagnoses of depression agreed well with the MDI (AUC values of 0.91-0.99). The potential added value of high-risk screening was 4.6% (31/672). Patients with other mental disorders were at increased risk of having an unrecognized depression (PR 3.15, 95% CI 1.91-5.20). If patients with other mental disorders were routinely tested, then 42% more depressed patients (14/31) would be recognized. CONCLUSIONS. A broad case-finding approach including a short validation test can help GPs identify depressed patients, particularly by including patients with other mental disorders in this strategy. This exploratory study cannot support the screening strategy proposed by central health organizations.
Sexually transmitted infections (STIs) continue to be highly prevalent in young people. New understanding of sexual risk behaviour is essential for future preventive initiatives. Studies based on self-reported STI history indicate that gap length between sexual partnerships is an important determinant in STI transmission, but little is known about the impact of concurrent partnerships and short gap length. This study aimed to examine the significance of concurrent partnerships and short gap length between serially monogamous partnerships in Chlamydia trachomatis-infected individuals compared to the general population.
A Danish cross-sectional study was conducted among individuals aged 15-29 years with a verified C. trachomatis infection and a sample of the background population. Participants answered a web-based questionnaire on sexual behaviour. Associations were identified in multivariate analyses.
In total, 36% of the included young adults reported that they had two or more partners within the last year. Concurrent partnerships were frequent (46%), and the gap length between serially monogamous partnerships tended to be short (median gap length, 64 days, interquartile interval (IQI) = 31, 122). A strong association was found between concurrent partnerships (odds ratio (OR) = 12.5, 95% confidence interval (CI) = 7.7-20.4), short gap length between serially monogamous partnerships (OR = 10.0, 95% CI = 5.7-17.4) and having a verified C. trachomatis infection.
C. trachomatis infection was strongly associated with concurrent partnerships or short gap length between serially monogamous partnerships. These findings have considerable implications for public health policy. Both types of risk factors should be considered in future preventive interventions aiming to reduce the spread of C. trachomatis infections.