Danish Healthcare Sector Research Articles

Increasing use of computed tomography scans in the North Denmark Region raises patient safety concern

PurposeUse of computed tomography (CT) scans raises safety concern as lifetime cumulative ionising radiation exposure is associated with risk of developing malignancies. This study aimed to investigate use of abdominal CT scans in the Danish health care sector. MethodsData on abdominal CT scans performed annually in the North Denmark Region between 2005 and 2018 were extracted from the regional registry with emphasis on patients with a medical history of a repeated abdominal CT scan within 28 days. An audit of the medical files was subsequently conducted in 100 randomly selected patient cases to evaluate clinical information being provided, in addition to justification for a repeated abdominal CT scan, and finally if other radiology modalities could have been applied. ResultsNumber of annually performed abdominal CT scans in this demographically stable regional population increased by a factor 4.3 from 15 in 2005 to 65 in 2018 per 1,000 inhabitants. The audit revealed that 31% of the secondabdominal CT scans within a 28 days period were categorized as either doubtful whether justified or not justified. Moreover, 20% of theCT scans were considered replaceable by ultrasonography. ConclusionsAnnual performance of abdominal CT scans increased fourfold during the 14 years period. This tendency is probably attributable to changes in the Danish health care sector by which CT scan examination are used more frequently aiming at more accelerated patient investigation flow in conjunction with shorter length of hospitalization stay. Alertness is strongly warranted towards the associated risk of cancer due to life-time cumulative ionising radiation exposure by this strategy.

Sundhed.dk and MyHealth During the Corona Storm

Background The Danish eHealth portal, sundhed.dk, pioneers open access to medical records since 2003 and is, in this regard, unique worldwide. As part of the Danish health care sector, sundhed.dk supports transparency and patient empowerment and provides health professionals with the possibility to access patient health data outside of local systems and across sectors and boundaries. Sundhed.dk and the MyHealth app have played a crucial role during the COVID-19 pandemic in Denmark, not least due to the development of the corona passport. Objective The overall purpose during the COVID-19 pandemic has been to assist the health authorities handling the pandemic and to support patient empowerment. Sundhed.dk provided new digital services to support monitoring the spread of the virus and telemedicine solutions to support the Danish citizens both during isolation and as the society was gradually reopening. Methods By exploiting sundhed.dk’s known and widespread position in the society and the already existing digital building blocks, sundhed.dk and MyHealth managed to provide fast and easy access to COVID-19 laboratory responses and, on top of that, to develop the corona passport, which was the result of accelerated IT development and fast scaling of the required server with the users. Results The many digital services accessible through sundhed.dk or MyHealth made it possible for Danish citizens to continue to see their doctor or physiotherapist during lockdown. Moreover, the corona passport made the safe and efficient reopening of Denmark possible. Conclusions The story of sundhed.dk during the COVID-19 pandemic is a story of success, a result of its close interdisciplinary and cross-sectoral cooperation with Danish health authorities and private IT vendors. It illustrates what can be achieved when there is a unified blueprint and overall purpose to overcome barriers in order to ensure development and progress for both the individual and the society. This has also drawn global attention, as reflected in a report by the World Health Organization.

Cost Effectiveness of Patient Self-Managed Warfarin Compared with Direct Oral Anticoagulants in Atrial Fibrillation: An Economic Evaluation in a Danish Healthcare Sector Setting.

BackgroundPatient self-managed anticoagulant treatment with warfarin (PSM) has been proposed as an alternative to direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF); however, direct evidence on the cost effectiveness of PSM compared with DOACs is lacking. We aimed to evaluate the cost effectiveness of PSM versus DOACs for NVAF patients in the Danish healthcare setting using a model-based cost-utility analysis.MethodsA cost-utility analysis was performed using a decision-analytic model including two treatment alternatives: continuous PSM and DOACs. The analysis was performed from an extended Danish healthcare sector perspective, including patient-paid costs of medication related to the anticoagulant treatment, with a lifetime horizon. Inputs for the model comprised of probabilities of events, costs in Danish estimates, when possible, and effect in utilities. The probabilities of events are primarily based on real-life data from a direct comparison of PSM and DOACs. The results are presented as the incremental cost-effectiveness ratio (ICER) with an assumed cost-effectiveness threshold of £20,000/quality-adjusted life-year (QALY). Both deterministic and probabilistic sensitivity analyses were performed to investigate the robustness of the results.ResultsThe base-analysis showed that PSM was dominant, with a decreased cost of £8495 and an increased QALY accumulation of 0.23 per patient (ICER = −£36,935/QALY). All deterministic sensitivity analyses indicated that PSM was dominant or at least cost effective. The probabilistic sensitivity analysis showed that 95% of the iterations were cost effective.ConclusionsThe present study found that PSM is dominant (i.e., both more effective and cost saving) compared with DOACs, adding to the scarce evidence of the comparative cost effectiveness of PSM and DOACs in NVAF.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-022-00337-3.

Organisational determinants and consequences of diagnostic discrepancy in two large patient groups in the emergency departments: a national study of consecutive episodes between 2008 and 2016

BackgroundDiagnostic discrepancy (DD) is a common phenomenon in healthcare, but little is known about its organisational determinants and consequences. Thus, the aim of the study was to evaluate this among selected emergency department (ED) patients.MethodWe conducted an observational study including all consecutive ED patients (hip fracture or erysipelas) in the Danish healthcare sector admitted between 2008 and 2016. DD was defined as a discrepancy between discharge and admission diagnoses. Episode and department statistics were retrieved from Danish registers. We conducted a survey among all 21 Danish EDs to gather information about organisational determinants. To estimate the results while adjusting for episode- and department-level heterogeneity, we used mixed effect models of ED organisational determinants and 30-day readmission, 30-day mortality and episode costs (2018-DKK) of DDs.ResultsDD was observed in 2308 (3.3%) of 69,928 hip fracture episodes and 3206 (8.5%) of 37,558 erysipelas episodes. The main organisational determinant of DD was senior physicians (nonspecific medical specialty) being employed at the ED (hip fracture: odds ratio (OR) 2.74, 95% confidence interval (CI) 2.15–3.51; erysipelas: OR 3.29, 95% CI 2.65–4.07). However, 24-h presence of senior physicians (nonspecific medical specialty) (hip fracture) and availability of external senior physicians (specific medical specialty) (both groups) were negatively associated with DD. DD was associated with increased 30-day readmission (hip fracture, mean 9.45% vs 13.76%, OR 1.46, 95% CI 1.28–1.66, p < 0.001) and episode costs (hip fracture, 61,681 DKK vs 109,860 DKK, log cost 0.58, 95% CI 0.53–0.63, p < 0.001; erysipelas, mean 20,818 DKK vs 56,329 DKK, log cost 0.97, 95% CI 0.92–1.02, p < 0.001) compared with episodes without DD.ConclusionDD was found to have a negative impact on two out of three study outcomes, and particular organisational characteristics seem to be associated with DD. Yet, the complexity of organisations and settings warrant further studies into these associations.

Ethnic minority patients in healthcare from a Scandinavian welfare perspective: The case of Denmark.

The Scandinavian welfare states are known for their universal access to healthcare; however, health inequalities affecting ethnic minority patients are prevalent. Ethnic minority patients' encounters with healthcare systems are often portrayed as part of a system that represents objectivity and neutrality. However, the Danish healthcare sector is a political apparatus that is affected by policies and conceptualisations. Health policies towards ethnic minorities are analysed using Bacchi's policy analysis, to show how implicit problem representations are translated from political and societal discourses into the Danish healthcare system. Our analysis shows that health policies are based on different ideas of who ethnic minority patients are and what kinds of challenges they entail. Two main issues are raised: First, ethnic minorities are positioned as bearers of 'culture' and 'ethnicity'. These concepts of 'othering' become both explanations for and the cause of inappropriate healthcare behaviour. Second, the Scandinavian welfare states are known for their solidarity, collectivism, equality and tolerance, also grounded in a postracial, colour-blind and noncolonial past ideology that forms the societal self-image. Combined with the ethical and legal responsibility of healthcare professionals to treat all patients equally, our findings indicate little leeway for addressing the discrimination experienced by ethnic minority patients.

The dark side of data ecosystems: A longitudinal study of the DAMD project

ABSTRACT Data are often vividly depicted as strategic assets that organisations can (re)use to create value for myriad purposes. However, the same qualities that make data so appreciated – that is, their volume, their value for a plurality of stakeholders and their indefinite reuse capacity – also have a dark side: data reuse can lead to deviant data use that undermines the legitimacy of data analytics initiatives. To investigate this dynamic, we build on the notion of data ecosystems and provide empirical evidence from a longitudinal, 15-year case study of the emergence, expansion and eventual collapse of a large-scale data analytics project – called DAMD – in the Danish health care sector. We demonstrate that data reuse in the evolving data ecosystem elicited a data reuse dark side that was so dominant that it eventually resulted in the project’s demise. We conceptualise the reuse dark side’s three major mechanisms as function creep, stakeholder creep and data creep. Based on these insights, we develop an empirically grounded Data Analytics Ecosystem Model that extends the current understanding of data ecosystems and provides a view of these ecosystems as having both a bright and a dark side.

The Cost-Effectiveness of a COVID-19 Vaccine in a Danish Context

Vaccines against COVID-19 are under development. As a scarce resource, the health authorities have to decide how to prioritise the vaccine in the target population. The aim of this paper is to explore the cost-effectiveness of a COVID-19 vaccine and to analyse how the vaccine price, and the cost of administrating it, influence its cost-effectiveness. We consider an epidemiological model developed by Statens Serum Institut (SSI) to determine the possible effects of a vaccine in terms of the number of life-years gained and hospital cost saved. The model allows us to differentiate between two populations groups, those above and below 60 years of age, respectively. We used the model to consider four scenarios: 1) vaccination of 1.5 million persons 60 years of age or older, none below that age, 2) vaccination of 1.5 million persons below the age of 60 years, none above that age, 3) vaccination of 900.000 persons below 60 years of age and 1.5 million person 60 years of age or older, and 4) 2.4 million persons below the age of 60 years. The time horizon of the analysis is six months, and the perspective is that of the Danish healthcare sector. The results show that inclusion of the elderly population 60 years of age or older is more cost-effective than a vaccination strategy targeted a population which is younger than 60 years old only. Furthermore, the results show that an extension of the target group from the elderly population only, to also include the younger population comes with an increasing cost per life-year gained. These findings are independent of the specification of the cost of hospitalization for treating COVID-19 infections and the costs of the vaccine. However, the incremental cost-effectiveness ratio depends on the price of the vaccine, hereunder also the administration costs, and the discount rate used for the estimation of life-years gained from a vaccine.

Public-private partnerships in the healthcare sector: limited policy guidelines, but active project development in Denmark

ABSTRACT How and why has the formal policy development on PPPs in Denmark evolved? How and why do PPP projects develop in Danish healthcare sector? Despite limited policy guidelines and no PPP Act, a regional approach to PPPs has occurred in the healthcare sector. There are active projects in five hospital cases that use the PPP model. PPP projects in the Danish healthcare sector develop from a mixture of reasons, which include strategic interventions from finance institutions, change in specific formal rules on financing, and necessity for regional governments to find alternatives to public financing.

‘Meaningless work’: How the datafication of health reconfigures knowledge about work and erodes professional judgement

How do digital tools for datafication interact with contemporary ideas about what counts as knowledge about work? Based on a study of the thoroughly digitalized and data-intensive Danish healthcare sector, we argue that as digital datafication creates new forms of inspection and control, it also reconfigures perceptions of work throughout the healthcare system, and thereby potentially erodes goal orientation and the room for professional judgement. Although policy papers justify the accumulation of data with the aim of making decisions more evidence-based and rational, we now hear clinical staff and data analysts complaining about a ‘yoke of Kafkaesque idiocy’ and ‘meaningless’ data practices. When is something seen as ‘meaningless work’? Through which dynamics does such work emerge? And what are the implications of such work?

Discrepancies Between the Medication List in Electronic Prescribing Systems and Patients' Actual Use of Medicines

Discrepancies between electronic prescribing systems and patients' actual use of medicines can result in adverse events and medication errors and have serious consequences for the patients. The discrepancies can be identified when performing a thorough medication reconciliation. Computerized health care systems throughout the Danish health care sector are integrated with the Shared Medication Record (SMR). In the SMR, current medication and medication prescriptions are registered. The aim of this study was to evaluate the number and types of discrepancies between medications listed in the SMR and an updated medication list, obtained through a thorough medication reconciliation, for patients admitted in Danish hospitals. Pharmacists listed the number and type of discrepancies for 412 patients. A total of 1,004 discrepancies were registered, with a mean number of 2.4 medication discrepancies per patient. For 25% (n = 101) of the patients, no discrepancies were found, 20% (n = 86) had one discrepancy, and 16% (n = 66) had five or more discrepancies. More than 50% of the patients had one or more medications in the SMR that the patient did not administer, and 12.6% used medications that were not listed in the SMR. This shows that the SMR should not be used as the only source of information when recording medication history.

Negotiating Professional Knowledge and Responsibility in Cross-sectoral Telemedicine

In ongoing efforts of rationalization and retrenchment in the Danish health care sector, tasks are increasingly moved from costly specialized hospital departments to the primary health care sec- tor, where less specialized personnel take on these tasks. Telemedicine plays an important role in facilitating local access to specialized competences at central hospitals through ICT systems and establishes new virtual spaces for cross-sectoral cooperation between hospital and municipal health care workers. In an explorative ethnographic study, comprising interviews and participant observation, of telemedicine-based interaction between community nurses and specialized hospi- tal nurses, we show how the ‘tele-ulcer’ system becomes a site for professional development for community nurses, although a hierarchization of professional knowledge also takes place. Further- more, extensive articulation work is necessary to make the tele-ulcer system work.We illuminate how contradictory divisions of responsibility may result from the design of the sociotechnical sys- tem, leaving professionals to deal with risks and insecurity.

Health care policy at a crossroads? A discursive study of patient agency in national health quality strategies between 1993 and 2015.

The Danish health care sector currently undergoes changes that imply a gradual transition from an evidence-based activity model to a value-based quality model centered on patient involvement and value-based governance. The patient naturally occupies a central position in health care, and the transition therefore raises important questions about health care quality and how successive national health quality strategies value quality and ascribe roles and agency to patients. To explore the complexity of these quality strategies, we analyze and discuss how political discourse moments influence the contents of the national health quality strategies and how variation in the construal of patient roles and agency indicates discursive struggle in Danish national health care policy. Underlying theoretical concepts are informed by New Public Management, the welfare state, health communication, and discourse theory. Our analytical approach is inspired by Critical Discourse Analysis and combines content analysis with linguistic analysis.

Quality Development in Health Care: Participation vs. Accreditation

For more than a decade, quality development in the Danish health care sector has been managed with an accreditation system known as the Danish quality model (DQM), shaping the strategy for how to align work organization with technology use. In this article, we introduce a participatory design approach, known as effects-driven information technology development (EDIT), and discuss how this approach may contribute to a new quality-assurance program for the Danish health care sector. Our purpose is to demonstrate how accreditation, which focuses on processes and standards, needs to be supplemented and balanced with participatory approaches that allow for local experimentation and implementation of high-quality outcomes. We describe accreditation and participatory design as two approaches to reconfiguring and aligning work organization and technology; further, we emphasize the differences in each approach’s strategy and application.

The effect of specialization on operational performance

PurposeThe purpose of this paper is to analyze how specialization in hospitals affects operational performance, measured by the length of stay and readmission rate. The authors assess a public policy change in the Danish healthcare sector from 2011 which required that some hospital services had to be centralized leading to specialization within the merged departments.Design/methodology/approachTaking an institutional theory perspective, the authors conduct a natural experiment. The data include 24,694 observations of urological patient treatments from 2010 to 2012.FindingsThe econometric difference-in-difference analysis finds that the readmission rate decreases by approximately four percentage points in the departments affected by the policy change. Contrary to expectations, the length of stay increases by 0.38 days. The authors complement the natural experiment with a mixed-methods approach that includes proprietary data from the management control system of the hospital, public documentation on the policy change, as well as interviews with key informants. These data suggest that operational deficiency is related to the fact that specialization was externally enforced through the public policy change. The authors illustrate how the hospital staff struggle for legitimacy after this policy change, and how cost savings obstructed the specialized department in achieving its goals.Originality/valueThe authors conclude that the usual economies-of-scales-based logic of (higher)volume-(better)outcome studies cannot easily be transferred to specialization in hospitals, unless one accounts for the institutional reason of the specialization.

The cost-effectiveness of introducing a vaccine for the prevention of herpes zoster and post-herpetic neuralgia in elderly Danes

Herpes Zoster is an unpleasant and painful skin condition associated with a risk of developing post-herpetic neuralgia if the pain persists. Herpes Zoster most often occurs in elderly people. This study examines the cost-effectiveness of introducing a vaccine against Herpes Zoster in the Danish health care sector. The cost-effectiveness is examined in a Markov lifetime model framework and populated with Danish data and results from the international literature. From the base case analysis, with an ICER of DKK 261,372 per QALY gained, it seems that an implementation of a vaccine against HZ in the Danish population aged 65 years or more might be cost-effective within generally accepted incremental cost-effectiveness thresholds. Furthermore, an age-specific analysis showed that although the incidence of herpes zoster generally increases with age, targeting the vaccine at persons aged 50-69 years rather than the persons aged 65 years or more, seems to be a more cost-effective strategy from the societal perspective. However, these results are very sensitive to changes in vaccine price, utility values, discount rates, and especially, to the vaccine duration of protection.Published: Online December 2016. In print December 2017.

Multidisciplinary Nutritional Support for Undernutrition in Older Adults in Nursing Home and Home-Care is Cost- Effective

Few intervention studies have evaluated the cost-effectiveness of nutritional support among frail older adults and none of these have been multidisciplinary. The aim of the study was to assess the cost-effectiveness of multidisciplinary nutritional support for undernutrition in older adults in nursing home and home-care identified with the validated Eating Validation Scheme (EVS). The design was an 11 week cluster randomized trial with setting (home-care or nursing home) as the unit of randomization. Before the start of the study a train-the-trainer intervention was performed involving educated nutrition coordinators. In addition, the participants assigned to the intervention group strategy received multidisciplinary nutrition support. Focus was on treatment of the potentially modifiable nutritional risk factors identified with EVS, by involving physiotherapist, registered dietician, and occupational therapist, as relevant and independent of the municipality’s ordinary assessment and referral system. Outcome parameters used for the cost-effectiveness analysis were costs and time of the intervention, quality of life (by means of Euroquol-5D-3L); and change in weight. Respectively, 55 (46 from home-care) and 40 (18 from home-care) were identified by EVS and comprised the intervention and control group. A difference was seen after 11 weeks in quality of life (0.758 (± 0.222) vs. 0.534 (± 0.355), p = 0.001). Even though a small gain in weight was observed in the intervention group there was no difference in change in weight. The effect on quality of life, measured in terms of Quality-Adjusted Life Year (QALY) gain relatively to the control group, gave a cost-effectiveness ratio of DKK 46,000 per QALY gained which compares reasonably well to other interventions found worthwhile in the Danish healthcare sector.

Empowering patients through healthcare technology and information? The challenge of becoming a Patient 2.0

In the mid-2000s, the term Patient 2.0 began to be used to denote a new patient role: empowered patients. Transformation of the traditional healthcare system remains on the agenda, and it continues to challenge the traditional view of the patient role. Based on empirical field studies, interviews and written material, we argue that changes to socio-material assemblages may have implications beyond the immediate gains. To accurately reflect this, Mort et al. (2003) suggested using the terms remote doctors and absent patients. Likewise, Oudshoorn (2008) highlighted how the absence of face-to-face interaction implies that healthcare professionals rely more on numerical representations of illness than on observations of patients. Through ethnographic research in the Danish healthcare sector, we discuss how this healthcare vision manifests in practice. Technologies aimed at patient empowerment change how patients are framed in established networks; the emergent chronic patient frame challenges the traditional patient-doctor relationships.

0222 Night work and breast cancer risk among women in the public Danish health care sector - a short-term follow up of a large scale population

ObjectivesExperimental evidence suggest a short-term effect of light at night on breast cancer oncogenesis. We studied the short-term effect of night work on breast cancer occurence.MethodWe established a large, national...

The effectiveness of a semi-tailored facilitator-based intervention to optimise chronic care management in general practice: a stepped-wedge randomised controlled trial

BackgroundThe Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice; and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention.MethodThe study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD); changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification; sign-up for a software program for patient overview; and reduction in number of practices with few annual chronic disease check-ups.ResultsWe randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program.ConclusionThe mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care.Trial registrationClinicalTrials.gov: NCT01297075

Are labour-intensive efforts to prevent pressure ulcers cost-effective?

Background:Pressure ulcers are a major problem in Danish healthcare with a prevalence of 13–43% among hospitalized patients. The associated costs to the Danish Health Care Sector are estimated to be €174.5 million annually. In 2010, The Danish Society for Patient Safety introduced the Pressure Ulcer Bundle (PUB) in order to reduce hospital-acquired pressure ulcers by a minimum of 50% in five hospitals. The PUB consists of evidence-based preventive initiatives implemented by ward staff using the Model for Improvement.Objective:To investigate the cost-effectiveness of labour-intensive efforts to reduce pressure ulcers in the Danish Health Care Sector, comparing the PUB with standard care.Methods:A decision analytic model was constructed to assess the costs and consequences of hospital-acquired pressure ulcers during an average hospital admission in Denmark. The model inputs were based on a systematic review of clinical efficacy data combined with local cost and effectiveness data from the Thy-Mors Hospital, Denmark. A probabilistic sensitivity analysis (PSA) was conducted to assess the uncertainty.Results:Prevention of hospital-acquired pressure ulcers by implementing labour-intensive effects according to the PUB was cost-saving and resulted in an improved effect compared to standard care. The incremental cost of the PUB was −€38.62. The incremental effects were a reduction of 9.3% prevented pressure ulcers and 0.47% prevented deaths. The PSAs confirmed the incremental cost-effectiveness ratio (ICER)’s dominance for both prevented pressure ulcers and saved lives with the PUB.Conclusion:This study shows that labour-intensive efforts to reduce pressure ulcers on hospital wards can be cost-effective and lead to savings in total costs of hospital and social care.Key limitations:The data included in the study regarding costs and effects of the PUB in Denmark were based on preliminary findings from a pilot study at Thy-Mors Hospital and literature.