Outpatient Contacts Research Articles

Validity of Algorithm for Classification of In- and Outpatient Hospital Contacts in the Danish National Patient Registry.

Following the implementation of the 3rd version of the Danish National Patient Register (DNPR-3), information on whether hospitalizations were inpatient, outpatient, or emergency room (ER) contacts was no longer readily available. This study examined the positive predictive values (PPV) of a common algorithm to characterize hospitalizations as inpatient, outpatient, or emergency room (ER) contacts in both DNPR-2 and DNPR-3. All hospital contacts in North Denmark Region were identified in the DNPR within a 1-year window of the implementation of DNPR-3 in early 2019. An algorithm based upon proportion of overnight (±50%) and elective (±50%) contacts for each hospital department was developed. Next, PPVs of these categorizations were computed using manual characterization of all departments and clinics by two experienced clinicians as reference. Second, the reliability of various time intervals to join department contacts and subsequent categorization of overnight hospital stays as proxies for inpatient contacts was explored. The algorithm yielded PPVs of 91% and 89% for hospital units and related contacts categorized as inpatient in DNPR-2 and 100% for both parameters in DNPR-3. In outpatient units, the PPVs were 99% in both DNPR-2 and DNPR-3, whereas the corresponding PPVs were 99.6% and 99% on the contact level. In contrast, the PPV for ERs was 33% in DNPR-2 and 56% in DNPR-3, primarily due to misclassification of outpatient clinics. Still, the proportion of correctly categorized ER contacts was 87% in DNPR-2 and 85% in DNPR-3.Using time intervals from 0 to 12 hours to join department contacts showed that overnight hospitalizations comprised inpatient contacts in 97% in DNPR-2 and 98% in DNPR-3. However, the sensitivity was moderate at 76-78% for all inpatient hospitalizations in DNPR-2 and DNPR-3. This algorithm accurately categorized hospitalizations as inpatient, outpatient, or ER contacts in both DNPR-2 and DNPR-3.

An investigation of child health in relation to housing renovations for a disadvantaged immigrant population in Malmö, Sweden.

The aim of the study was to describe child health in relation to housing renovations in more than 800 rental units, consisting of repairs of dilapidated kitchens and bathrooms, in the disadvantaged neighbourhood of Herrgården in Rosengård, Malmö, Sweden. Data on housing conditions and self-reported health were collected during home visits to families living in Herrgården (building renovations area) and a comparison area (neighbouring Törnrosen, with generally better housing conditions). At baseline, 130 families with 359 children participated, while 51 families with 127 children participated at follow-up. All data were collected between 2010 and 2012. Additionally, regional register data on health-care usage/in- and outpatient contacts within the public health-care system between 2008 and 2013 were also collected for all 8715 children registered as living in the two areas. Self-reported health seemed to somewhat improve in both areas, with 74% versus 86% and 78% versus 88% reporting good or very good health in Herrgården and in the comparison area at baseline and follow-up, respectively. In Herrgården, crowdedness increased, while it decreased in the comparison area. The number of health-care contacts remained stable over time in Herrgården, while it decreased in the comparison area. Partial housing renovations did not seem to result in clear health improvements as measured with the indicators used in the present study. This could possibly be due to persisting health effects due to increased crowdedness or persisting poor housing conditions, as only kitchens and bathrooms were renovated.

Postoperative morbidity and mortality after adenoidectomy: A national population-based study of 51 746 surgeries.

To investigate postoperative morbidity and mortality after paediatric adenoidectomy. This was a retrospective national population-based cohort study of data from the Swedish National Patient Register (NPR) and The Swedish Cause of Death Register (CDR). All patients aged 0-18 years who underwent adenoidectomy from 2007 to 2017 (without concomitant tonsil surgery) were included in this study. To evaluate postoperative morbidity and mortality, all diagnostic and surgical codes registered in the NPR for health care contacts within 30 days of surgery were analysed. The patients retrieved from the NPR were matched with the CDR to identify any deaths occurring within 30 days of the surgery. A total of 51746 adenoidectomies were included in this study. No deaths related to adenoidectomy were identified. All types of haemorrhagic complications were rare. Only 0.1% of the surgeries resulted in an outpatient contact due to postoperative haemorrhage and only 0.1% of the adenoidectomies resulted in a readmission due to haemorrhage. The rarest haemorrhagic complication was RTT (return to theatre), with only 4 events (0.01%). Postoperative haemorrhage was most frequent on the first day after surgery. Other complications were rare as well, requiring a total of 922 (2.6%) outpatient visits and 75 (0.2%) readmissions in the adenoidectomy group, with postoperative infection being the most commonly reported. Overall, adenoidectomy should be considered a safe surgical procedure associated with few postoperative complications. No deaths related to adenoidectomy were found. Severe complications, such as late postoperative haemorrhage after adenoidectomy, were rare, and haemorrhage resulting in RTT was even rarer. The highest rate of postoperative haemorrhage was observed the first day after surgery, and most haemorrhagic complications occurred within a week. Comparisons with studies on tonsil surgery show that adenoidectomy is associated with substantially lower postoperative morbidity.

Patients experiences of their relationships with relatives and their collaboration with nurses during contact in non-COVID-19 hospital wards – A qualitative study

COVID-19 restrictions prevented relatives from visiting and accompanying patients to hospital and required that nurses wore personal protective equipment. These changes affected patients’ relationships with relatives and challenged their ability to connect with nurses. Individual, semi-structured interviews with 15 patients were carried out to explore patients’ experiences of their relationships with relatives and their collaboration with nurses during in- and outpatient contacts in non-COVID-19 hospital wards. The analysis of data was guided by phenomenological hermeneutic frame of reference and the study was reported according to the COREQ checklist. The findings illustrated that patients felt lonely and insecure when separated from relatives, caught between relatives and professionals during information exchange, and experienced the absence of relatives as both beneficial and burdening. Visitor restrictions provided patients with time to heal but prevented provision of informal care. Patients had to take responsibility for maintaining contact with relatives independent of their health condition. COVID-19 restrictions created distance with nurses, which potentially led to insufficient physical and psychosocial care.

Mapping diagnostic trajectories from the first hospital diagnosis of a psychiatric disorder: a Danish nationwide cohort study using sequence analysis

A key clinical problem in psychiatry is predicting the diagnostic future of patients presenting with psychopathology for the first time. The objective of this study was to establish a comprehensive map of subsequent diagnoses after a first psychiatric hospital diagnosis. Through the Danish National Patient Registry, we identified patients aged 18 years or older with an inpatient or outpatient psychiatric hospital contact and who had received one of the 20 most common first-time psychiatric diagnoses (defined at the ICD-10 two-cipher level, F00-F99) between Jan 1, 1995, and Dec 31, 2008. For each first-time diagnosis, the 20 most frequent subsequent psychiatric diagnoses (F00-F99), and death, occurring during 10 years of follow-up were identified as outcomes. To assess diagnostic stability, we used social sequence analyses, assigning a subsequent diagnosis to each state with a length of 6 months following each first-time diagnosis. The subsequent diagnosis was defined as the last diagnosis given within each 6-month period. We calculated the normalised entropy of each sequence to show the uncertainty of predicting the states in a given sequence. Cox proportional hazards models were used to assess the risk of receiving a subsequent diagnosis (at the one-cipher level, F0-F9) after each first-time diagnosis. The cohort consisted of 184 949 adult patients (77 129 [41·7%] men and 107 820 [58·3%] women, mean age 42·5 years [SD 18·5; range 18 to >100). Ethnicity data were not recorded. Over 10 years of follow-up, 86 804 (46·9%) patients had at least one subsequent diagnosis that differed from their first-time diagnosis. Measured by mean normalised entropy values, persistent delusional disorders (ICD-10 code F22), mental and behavioural disorders due to multiple drug use and use of other psychoactive substances (F19), and acute and transient psychotic disorders (F23) had the highest diagnostic variability, whereas eating disorders (F50) and non-organic sexual dysfunction (F52) had the lowest. The risk of receiving a subsequent diagnosis with a psychiatric disorder from an ICD-10 group different from that of the first-time diagnosis varied substantially among first-time diagnoses. These data provide detailed information on possible diagnostic outcomes after a first-time presentation in a psychiatric hospital. This information could help clinicians to plan relevant follow-up and inform patients and families on the degree of diagnostic uncertainty associated with receiving a first psychiatric hospital diagnosis, as well as likely and unlikely trajectories of diagnostic progression. Mental Health Services, Capital region of Denmark. For the Danish translation of the abstract see Supplementary Materials section.

Multirefractory Primary Immune Thrombocytopenia in Adults: Prevalence and Burden. Results from the Carmen-France Registry

Introduction: Multirefractory primary immune thrombocytopenia (ITP) is a rare but challenging disease. There is no standard definition of multirefractory ITP, however it is usually defined by the need of several lines of treatments, including thrombopoietin receptor agonists (TPO-RAs). However, the prevalence of multirefractory patients is not known. Data about the clinical burden of these patients are scarce and stem from historical retrospective series. The aim of this study was to assess the prevalence of multirefractory ITP among adults with primary ITP and the burden of these patients in terms of bleeding, infection, thrombosis and hospital contact. Methods: The data source was the CARMEN-France registry. The CARMEN (Cytopénies Auto-immunes : Registre Midi-PyréneEN) registry is aimed at the prospective, real-world follow-up of all incident ITP adults in the French Midi-Pyrénées region (South-West of France, 3 million inhabitants) since June 2013, and has been implemented in other centers of the French Autoimmune cytopenia referral center network since 2016, taking the name of CARMEN-France. Inclusion criteria are adult patients (aged ≥18 years) newly diagnosed with ITP (platelet count <100 x 109/L and exclusion of other causes of thrombocytopenia). The study population was selected in the CARMEN-France registry up to December 2021. Two definitions of multirefractory ITP were used: the need of ITP treatment after exposure to both TPO-RAs marketed in France, eltrombopag and romiplostim (definition 1) and the need of ITP treatment after exposure to eltrombopag, romiplostim and rituximab (definition 2). We assessed the prevalence of multirefractory ITP among all adult patients with primary ITP included in the registry, and the frequency of bleeding, infection, venous thrombosis, arterial thrombosis and hospital contact due to ITP during the follow-up. Results: Out of 1080 adult patients with incident primary ITP included in the registry during the study period, 845 (78.2%) were treated for ITP, and 448 (41.5%) with a second-line treatment. Multirefractory ITP accounted for 32 (3.0%) patients according to definition 1, and for 24 (2.2%) patients according to definition 2. At ITP diagnosis, median age was 62.5 years (min-max: 25-90) and 66.5 years (min-max: 30-90) respectively; 18 (56.3%) and 12 (50.0%) were men; the median platelet count at ITP diagnosis was 6.0 x 109/L and 6.5 x 109/L; 29 (90.6%) and 21 (87.5%) had bleeding at ITP diagnosis, respectively. With a median follow-up of 30.3 months (min-max: 3.2-93.1), all patients with multirefractory primary ITP according to definition 1 had experienced bleeding, 8 (25.0%) an infection, 3 (9.4%) a venous thrombosis and 1 (3.1%) an arterial thrombosis. The median number of hospital stays for ITP was 6.5 (min-max: 1-17), the median number of outpatient hospital contacts was 9 (min-max: 3-30) with a median cumulative duration of hospital stays for ITP of 32 days (min-max: 6-142). With a median follow-up of 30.3 months (min-max: 6.4-93.1), all patients with multirefractory primary ITP according to definition 2 had experienced bleeding, 7 (29.2%) an infection, 2 (8.3%) a venous thrombosis and 1 (4.2%) an arterial thrombosis. The median number of hospital stays for ITP was 7 (min-max: 2-17), the median number of outpatient hospital contacts was 10 (min-max: 4-30) with a median cumulative duration of hospital stays for ITP of 32 days (min-max: 10-142). Conclusion: The prevalence of multirefractory ITP among adult patients with primary ITP is low (<5%) despite dynamic inclusions in the registry that may result in a slight underestimation of cases due to a short follow-up in some patients. However, this population has a heavy clinical burden.

The incidence of depressive episodes is different before, during, and after pregnancy: A population-based study

BackgroundDepressive episodes during pregnancy are widely investigated but it is still unknown whether pregnancy is a high-risk period compared to the pre-pregnancy period. Therefore, we aimed to investigate the incidence and recurrence of depressive episodes before, during, and after pregnancy. MethodsIn the current population-based registry study, we calculated monthly incidence and recurrence of psychiatric inpatient admissions and outpatient psychiatric contact for depressive episodes. We identified a population consisting of all first childbirths in Denmark from 1999 through 2015 (N = 392,287). ResultsIncidence of inpatient admission during pregnancy was lower than before pregnancy. After childbirth, a significant increase in first-time and recurrent psychiatric inpatient admissions was observed, especially in the first months. In contrast, outpatient psychiatric treatment incidence and recurrence were increased both during pregnancy as well as in the postpartum period, as compared to pre-pregnancy. LimitationsAnalyses were performed on depressive episodes representing the severe end of the spectrum, questioning generalizability to milder forms of depression treated outside psychiatric specialist treatment facilities. ConclusionWe found a different pattern of severe episodes of depression compared to moderate episodes before, during, and after pregnancy. In light of our findings and those of others, we suggest distinguishing between timing of onset in the classification of depression in the perinatal period: Depression with pregnancy onset OR with postpartum onset (instead of the current DSM classifier “with perinatal onset”), as well as severity of depression, which is important for both clinical and future research endeavors.

Factors predicting admission of psychiatric emergency contacts after presenting to the emergency department: results of a regression analysis

BackgroundPsychiatric emergency patients have great relevance in the interdisciplinary emergency department. Emergency physicians in this setting often have to make decisions under time pressure based on incomplete information regarding the patient’s further treatment. The aim of this study was to identify possible predictors associated with an increased likelihood of inpatient psychiatric admission.MethodsA retrospective cross-sectional study of all psychiatric emergency contacts in an interdisciplinary emergency department (ED) of a general hospital in a large German city was conducted for 2015. A binary regression analysis was performed to identify possible predictors.ResultsIn 2015, a total of 21421 patient contacts were reported in the emergency department, of which 1733 were psychiatric emergencies. Psychiatric emergency was the fourth most common cause presenting to the ED. The most common diagnosis given was mental and behavioral disorders due to the use of psychotropic substances (F1). Factors associated with an increased probability of inpatient psychiatric admission were previously known patients, patients under a legal care order (guardianship), and previous outpatient medical contact. No association for gender or age was found. Data demonstrated a negative relationship between a neurotic, stress-related and somatoform disorder diagnosis and admission.ConclusionsThe present study shows some significant characteristics associated with an increased likelihood of emergency admission. Independent of the health care system, the predictors found seem to be relevant with regard to the probability of admission, when compared internationally. To improve the treatment of patients in emergency units, these factors should be taken into account.

Healthcare use by children in North West London 2015-2019 by deprivation and integrated care access

Abstract Background England has a health system offering universal coverage, but disparities in healthcare use are increasing. Between 2007-2017, children living in more deprived areas had higher rates of unplanned care (Emergency Department (ED) attendance and hospital admissions), whereas children from less deprived areas had higher rates of planned care (General Practitioner (GP) contact and outpatient appointments). More detailed research to find solutions for this divergent pattern is required. Aim To assess the rates of GP contact, outpatient appointments, hospital admissions and ED attendance in North West London, by Index of Multiple Deprivation (IMD) decile of home postcode and access to an integrated care service providing linked care between multiple child health professionals ‘Connecting Care for Children (CC4C)', for children aged 0-18 years between 2015-2019. Methods Retrospective analysis of a de-identified database of integrated care records for 495,357 children. Results Children from the most deprived decile had higher rates of emergency admissions (0.070 per child per year vs. overall mean 0.040), elective admissions (0.076 vs. 0.032), ED attendances (0.754 vs. 0.358) and outpatient appointments (1.702 vs. 0.756) between 01.01.2015- 31.12.2019. Children from the least deprived decile had the second highest rates of outpatient appointments (0.911 vs. 0.756) and GP contact (8.192 vs. 5.390) between 01.01.2015- 31.12.2019. Children with access to the CC4C service, despite being from more deprived backgrounds, had lower rates of emergency admissions (0.028 vs. 0.037) compared to patients with access to usual care. P values &amp;lt;0.001 in all cases. Conclusions Greater deprivation was linked to higher rates of emergency admissions, but this was partially mitigated by access to more integrated healthcare models. Children from the least deprived decile continued to have disproportionately higher use of planned care. Key messages • Despite universal health coverage, children from more deprived areas continue to have disproportionately higher use of unplanned care. • Further research is required to explore whether integrated care solutions can reduce the burden on unplanned health services and inequalities in access to care.

High risk of cardiovascular disease in curatively treated patients with oesophageal cancer: a Danish cohort study

Abstract Background The cardiovascular disease (CVD) burden among patients with oesophageal cancer (EC) treated with curative intent is unclear. Purpose To determine CVD incidence and all-cause mortality in patients with EC. Material and methods Danish national health registries were used to identify patients diagnosed with primary EC between 2008 and 2018. Each EC patient was matched with ten individuals from the general population. The primary endpoint was a CVD hospital contact (CVD-HC), either admission or outpatient contact. Secondary endpoints were all-cause mortality and five specific CVD endpoints evaluated separately: atrial fibrillation, ischemic heart disease, heart failure, perimyocarditis, and venous thromboembolism. Using registries, all endpoints were assessed up to ten years following the EC diagnosis. Results The study included 1,525 patients with EC matched to 15,250 individuals from the general population. Patients with EC had a post-diagnosis one-year adjusted hazard ratio (HR) of CVD-HCs of 6.1 (95% CI: 5.6 to 6.8) compared with the general population. During the next nine years, the risk of CVD-HC was comparable between the two cohorts with an adjusted HR of 1.0 (95% CI: 0.9 to 1.3) (Figure 1). Patients with EC, particularly those with prevalent CVD (29%) had a high risk of ischemic heart disease with a one-year HR of 6.2 (95% CI: 3.7 to 10.4). The risk of venous thromboembolism and atrial fibrillation was 14-fold and four-fold elevated within the first year after EC diagnosis compared to the general population. After EC diagnosis, all-cause mortality was, as expected, increased in patients with EC compared with the general population. However, prevalent CVD among patients with EC did not appear to be associated with higher all-cause mortality. Conclusion CVD morbidity was transiently increased in the first year following EC diagnosis compared with the general population. All-cause mortality risks were high but did not appear to be affected by prevalent CVD. The very high risk of CVD in curatively treated patients with EC calls for healthcare initiatives to advance preventive and post-treatment strategies. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Danish Cancer SocietyCarpenter Jorgen Holm and Wife Elisa F. Hansen's Memorial Scholarship

57-Year-Old Man With Headache, Vomiting, and Gait Instability

57-Year-Old Man With Headache, Vomiting, and Gait Instability

Potential for prediction of psychosis and bipolar disorder in Child and Adolescent Mental Health Services: a longitudinal register study of all people born in Finland in 1987.

Current strategies to predict psychosis identify only a small proportion of individuals at risk. Additional strategies are needed to increase capacity forpre-diction and prevention of serious mental illness, ideally during childhood and adolescence. One possible approach would be to investigate systems in which psychosis risk factors are concentrated during childhood. One notable such system is represented by Child and Adolescent Mental Health Services (CAMHS). Although psychotic disorders are uncommon in CAMHS, many risk factors for psychosis are highly prevalent in young people who enter this system. We hypothesized, therefore, that youth attending CAMHS would be a high-risk group for psychosis if followed into adulthood and, furthermore, that CAMHS systems would capture a substantial proportion of future psychosis cases. We constructed a total population cohort study of all Finns born in 1987 (N=55,875), linking together extensive register data on health care contacts from birth through age 28years. We identified all individuals diagnosed with a psychotic or bipolar disorder by age 28 (N=1,785). The risk of psychosis/bipolar disorder by age 28years was 1.8% for individuals who had not attended CAMHS during childhood or adolescence, whereas it was 12.8% for those with a history of any outpatient CAMHS contact (odds ratio, OR=7.9, 95% CI: 7.2-8.7). Furthermore, the risk of psychosis/bipolar disorder by age 28years was 2.3% for individuals without a history of inpatient CAMHS admission, whereas it was 24.0% for those with a history of inpatient CAMHS admission (OR=13.3, 95% CI: 11.9-14.9), and 36.5% for those with a history of inpatient CAMHS admission in adolescence (age 13-17years) (OR=24.2, 95% CI: 21.2-27.6). Individuals who attended CAMHS but received no mental disorder diagnosis had an equally high risk of subsequently developing a psychosis/bipolar disorder as individuals who did receive a diagnosis (OR=0.9, 99.5% CI: 0.7-1.1). Compared to other CAMHS attendees, individuals who developed psychosis or bipolar disorder were more likely to have had an initial CAMHS diagnosis of depressive or other mood disorder (OR=2.3, 99.5% CI: 1.6-3.0) and disruptive behaviour disorder (OR=1.7, 99.5% CI: 1.2-2.5). Of all psychosis/bipolar diagnoses by age 28years, 50.2% occurred in individuals who had, at some point in childhood or adolescence, attended CAMHS, indicating that CAMHS represent not only a high-risk but also a high-capacity system for prediction of psychosis/bipolar disorder. These findings suggest an enormous, untapped potential for large-scale psychosis/bipolar disorder prediction and prevention research within existing specialist CAMHS.

The Rising Burden of Inflammatory Bowel Disease in Denmark Over Two Decades: A Nationwide Cohort Study

Shifts in epidemiological stages of inflammatory bowel disease (IBD) carry implications toward understanding IBD etiology and managing clinical care. We conducted a temporal analysis of the epidemiology of IBD between 1995 and 2016 in the Danish nationwide cohort. We used the Danish registers to obtain data on demographics and IBD-related outpatient and inpatient contacts between 1995 and 2016. IBD diagnosis was defined as having ≥2 registrations related to Crohn's disease (CD) or ulcerative colitis (UC) within a 2-year period. We estimated overall and annual incidence rates and prevalence of CD and UC standardized with respect to age and sex. A total of 47,830 individuals met the criteria for IBD diagnosis, of which 33% were diagnosed with CD and 67% with UC. Between 1995 and 2016, the incidence rate (95% confidence interval) per 100,000 person-years rose from 9.1 (8.3-10.0) to 17.8 (16.8-19.0) for CD, and from 21.0 (19.8-22.3) to 28.4 (27.0-29.8) for UC. The highest increase in CD and UC incidence rates occurred in children and young adults, respectively. The prevalence of IBD doubled from 1995 to 2016; the greatest increase (2.5-fold) was in UC prevalence among individuals aged >40 years. During this period, the median age of the IBD population increased by 6 to 7 years. In Denmark, the incidence and prevalence of IBD have increased during the last 2 decades. The IBD population is shifting toward an older age. These findings have implications towards understanding environmental shifts as well as preparing health care systems for an aging IBD population.

Centralization, Specialization, and Outpatient Care for Head and Neck Tumor Patients

Demographically, the German population is aging and becoming more morbid. At the same time, urbanization trends, medical overcapacities, and increasing care costs are being observed in association with a tight healthcare budget. Centralization, specialization, and outpatient care are intended to provide a remedy and can be controlled by modifications to remuneration. This upheaval poses new challenges for patients and physicians, which were analyzed exemplarily at the Head and Neck Tumor (HNC) Center of the University Hospital Ulm. This is a retrospective, monocentric cohort study on the development of patient volume, catchment area, treatment modality, and demographics including 2070 HNC patients at the ENT clinic between the years 2011 and 2020. It was observed that the number (new diagnoses 2011: 134 vs. 2020: 204) and the average age (2011: 61.5 years vs. 2020: 65.8 years; p < 0.0001) of HNC patients increased over time. In addition, patients tended to travel longer distances (2011: 54.4 km vs. 2020: 64.4 km; p = 0.05). At the same time, the mean number of consultations and treatments per patient per 5-year follow-up interval grew (at initial diagnosis in 2011: 7.8 vs. 2016: 10.4; p = 0.0003), with the proportion of outpatient contacts increasing from 58.9 % to 62.4 % (p = 0.09) from 2011 to 2020. Accordingly, clinical centers are expected to become more important in the care of HNC patients as the healthcare system becomes more specialized, and centralized with a growing outpatient setting. The following consequences for patient care should be considered in restructuring strategies.

Trajectories in Outpatient Care for People with Multimorbidity: A Population-Based Register Study in Denmark.

BackgroundMultimorbidity is a global health challenge. Individuals with multimorbidity are frequent users of healthcare services, and many experience fragmented healthcare. We assessed the number of outpatient trajectories and contacts with hospital outpatient clinics for individuals with multimorbidity and explored different time intervals for the occurrence of concurrent outpatient trajectories.MethodsA population-based cohort of 1.3 million residents, ≥18 years, with multimorbidity was identified through Danish national health registries. Multimorbidity was defined as having two or more of 39 specific chronic conditions. Nine disease system categories were used to categorize outpatient contacts in 2018 into outpatient trajectories and trajectory-related contacts. We defined an “outpatient trajectory” as two contacts within 12 consecutive months for the same medical condition. All outpatient contacts and trajectories with related contacts were counted for 2018. The impact of different time intervals on the number of concurrent trajectories was analyzed.ResultsOn 1 January 2019, 29% of the adult Danish population was classified as multimorbid. During 2018, 68% of them had ≥1 outpatient contact (median: 2 (IQI: 0–4)). Twenty-six percent had ≥1 outpatient trajectory. The median number of trajectory contacts was 3 (IQI: 2–5). The 4% of individuals with ≥2 outpatient trajectories accounted for 28% of trajectory contacts. During the 6-week period from the latest outpatient contact, 33% of all patients with ≥2 trajectories in 2018 experienced concurrent trajectories with outpatient contact.ConclusionTwo-thirds of adult Danes with multimorbidity attended an outpatient clinic in 2018, and one-fourth had at least one outpatient trajectory. Individuals with two or more trajectories represented 4% and comprised 28% of the trajectory contacts; 33% had concurrent trajectories within a 6-week period. It appears that a small proportion place demands on outpatient clinics because of frequent attendance. A more uniform way of organizing outpatient trajectories for these patients merits consideration.

Clinical impact of functional CYP2C19 and CYP2D6 gene variants on treatment outcomes in patients with depression: a Danish cohort study

IntroductionPharmacogenetic (PGx) targets to optimize drug therapy, but its implementation is rare.ObjectivesWe evaluate the clinical utility of PGx testing in psychiatry by investigating the one-year risks of clinical outcomes in patients with depression taking sertraline, (es)citalopram or fluoxetine by their Cytochrome P450 (CYP) 2C19/2D6 phenotypes.MethodsWe investigated 17,297 individuals born between 1981-2005 with a depression diagnosis between 1996-2012 from the iPsych2012 case-cohort. Based on array-based single-nucleotide-polymorphism genotype data, individuals were phenotyped as CYP2C19/CYP2D6 normal (NM, reference group), ultra-rapid- (UM), rapid- (RM), intermediate- (IM), or poor-metabolizer (PM). Outcomes were treatment switching or discontinuation, psychiatric in-, out-, and emergency room contacts (ER), and suicide attempt/self-harm. Incidence rate ratios (IRR) by age groups were estimated using Poisson regression analysis with 95% confidence intervals, adjusted for potential confounders.ResultsRisks of switching (IRR=1.89[1.22-2.93]), ERs (1.69 [1.01-2.81]) and suicide attempt/self-harm (2.73 [1.49-5.01]) were higher in CYP2C19 PMs &lt;19 years taking (es)citalopram. Fluoxetine users &lt;19 years had a decreased risk of discontinuation in CYP2D6 PMs (0.5 [0.27-0.95]) and decreased risk of out-patient contacts in CYP2D6 PMs and IMs (IRRIM=0.83 [0.68-1.00] and IRRPM=0.59 [ 0.37-0.96]). We observed an increased risk for ERs in CYP2D6 PMs aged 19-25 years taking fluoxetine (4.53 [1.54-13.35]). In CYP2C19 UMs &gt;25 years taking (es)citalopram the risk of suicide attempt/self-harm was more than three-fold increased (3.64 [ 1.01-13.19]). We found no significant results in users of sertraline.ConclusionsPGx variability was associated with treatment outcomes in depression in patients with CYP2C19 PM or UM status taking (es)citalopram, or CYP2D6 PM or IM status taking fluoxetine.DisclosureNo significant relationships.

Thromboembolic Risk in Patients With Pneumonia and New-Onset Atrial Fibrillation Not Receiving Anticoagulation Therapy

New-onset atrial fibrillation (AF) is commonly reported in patients with severe infections. However, the absolute risk of thromboembolic events without anticoagulation remains unknown. To investigate the thromboembolic risks associated with AF in patients with pneumonia, assess the risk of recurrent AF, and examine the association of initiation of anticoagulation therapy with new-onset AF. This population-based cohort study used linked Danish nationwide registries. Participants included patients hospitalized with incident community-acquired pneumonia in Denmark from 1998 to 2018. Statistical analysis was performed from August 15, 2021, to March 12, 2022. New-onset AF. Thromboembolic events, recurrent AF, and all-cause death. Estimated risks were calculated for thromboembolism without anticoagulation therapy, new hospital or outpatient clinic contact with AF, initiation of anticoagulation therapy, and all-cause death at 1 and 3 years of follow-up. Death was treated as a competing risk, and inverse probability of censoring weights was used to account for patient censoring if they initiated anticoagulation therapy conditioned on AF. Among 274 196 patients hospitalized for community-acquired pneumonia, 6553 patients (mean age [SD], 79.1 [11.0] years; 3405 women [52.0%]) developed new-onset AF. The 1-year risk of thromboembolism was 0.8% (95% CI, 0.8%-0.8%) in patients without AF vs 2.1% (95% CI, 1.8%-2.5%) in patients with new-onset AF without anticoagulation; this risk was 1.4% (95% CI, 1.0%-2.0%) among patients with AF with intermediate stroke risk and 2.8% (95% CI, 2.3%-3.4%) in patients with AF with high stroke risk. Three-year risks were 3.5% (95% CI, 2.8%-4.3%) among patients with intermediate stroke risk and 5.3% (95% CI, 4.4%-6.5%) among patients with high stroke risk. Among patients with new-onset AF, 32.9% (95% CI, 31.8%-34.1%) had a new hospital contact with AF, and 14.0% (95% CI, 13.2%-14.9%) initiated anticoagulation therapy during the 3 years after incident AF diagnosis. At 3 years, the all-cause mortality rate was 25.7% (95% CI, 25.6%-25.9%) in patients with pneumonia without AF vs 49.8% (95% CI, 48.6%-51.1%) in patients with new-onset AF. This cohort study found that new-onset AF after community-acquired pneumonia was associated with an increased risk of thromboembolism, which may warrant anticoagulation therapy. Approximately one-third of patients had a new hospital or outpatient clinic contact for AF during the 3-year follow-up, suggesting that AF triggered by acute infections is not a transient, self-terminating condition that reverses with resolution of the infection.

Effectiveness of a home telemonitoring program for patients with chronic obstructive pulmonary disease in Germany: Evidence from the first three years

IntroductionChronic obstructive pulmonary disease (COPD) affects more than 6 million people in Germany. Monitoring the vital parameters of COPD patients remotely through telemonitoring may help doctors and patients prevent and treat acute exacerbations of COPD, improving patients’ quality of life and saving costs for the statutory health insurance system.ObjectiveTo evaluate the effects from October 2012 until December 2015 of a structured home telemonitoring program implemented by a statutory health insurer in Germany.MethodsWe conducted a retrospective cohort study using administrative data. After building a balanced control group using Entropy Balancing, we calculated difference-in-difference estimators to account for time-invariant heterogeneity. We estimated differences in mortality rates using Cox regression and conducted subgroup and sensitivity analyses to check the robustness of the base case results. We observed each patient in the program for up to 3 years depending on his or her time of enrolment.ResultsAmong patients in the telemonitoring cohort, we observed significantly higher inpatient costs due to COPD (€524.2, p<0,05; €434.6, p<0.05) and outpatient costs (102.5, p<0.01; 78.8 p<0.05) during the first two years of the program. Additional cost categories were significantly increased during the first year of telemonitoring. We also observed a significantly higher number of drug prescriptions during all three years of the observation period (2.0500, p < 0.05; 0.7260, p < 0.05; 3.3170, p < 0.01) and a higher number of outpatient contacts during the first two years (0.945, p<0.01, 0.683, p<0.05). Furthermore, we found significantly improved survival rates for participants in the telemonitoring program (HR 0.68, p<0.001).ConclusionOn one hand, telemonitoring was associated with higher health care expenditures, especially in the first year of the program. For example, we were able to identify a statistically significant increase in inpatient costs due to COPD, outpatient contacts and drug prescriptions among individuals participating in the telemonitoring program. On the other hand, the telemonitoring program was accompanied by a survival benefit, which might be related to higher adherence rates, more intense treatment, or an improved understanding of COPD among these patients.

Referral-based transition to subsequent rehabilitation at home after stroke: one-year outcomes and use of healthcare services

BackgroundThere is a lack of knowledge about patients’ journeys across the stroke care continuum, especially regarding the transition from inpatient to outpatient care and rehabilitation. Therefore, the aim of the present study was to explore and describe patterns of healthcare use over a one-year period, health outcomes at 3 and 12 months for patients following a referral-based transition to subsequent rehabilitation in the home, and the caregiver burden on their significant others. A further aim was to explore factors associated with the use of rehabilitation and healthcare after the referral-based transition to continued rehabilitation in the home for people recovering from a stroke.MethodsData regarding healthcare use during the first 12 months post-stroke was collected from the Region Stockholm computerized register. Data on patient characteristics, disease-related data, and functioning were retrieved drawn from medical records and questionnaires. Descriptive statistics were used to present healthcare use, participants’ characteristics, disease-related data, and patient functioning. Multivariable regression models were created to explore associations between the total number of outpatient contacts, total visits with the neurorehabilitation team, and the independent variables.ResultsThe mean age for the 190 participants was 73 years for men and 78 years for women. Twenty-one participants (11%) had an acute rehospitalization within 30 days after discharge, and 41 participants (21%) were re-hospitalized within 90 days. Twenty-two (12%) of the participants had no visits with the neurorehabilitation team, 73 (39%) participants had 1–3 visits, 57 (30%) had 4–16 visits, and 38 (20%) had ≥17 visits. Female sex and length of hospital stay were associated with a higher number of visits with the neurorehabilitation team. Living alone, higher self-rated recovery, and being able to walk independently were associated with a lower number of visits with the neurorehabilitation team. Female sex, having home help services before the stroke, longer length of hospital stay, and more comorbidities were associated with a higher number of outpatient contacts.ConclusionsThe findings indicate that there is no generic pattern of healthcare use during the first-year post-stroke in patients receiving referral-based transition to continued rehabilitation in the home. The different patterns of healthcare use seemed to mirror the participants’ level of functioning. However, there is a need to further investigate how follow-up and rehabilitation correspond to the needs of patients and their significant others in the short- and long-term perspective.Trial registrationClinicalTrials.gov, registration number: NCT02925871. Date of registration: October 6, 2016.

The Impact of Social Distancing in 2020 on Admission Rates for Exacerbations in Asthma: A Nationwide Cohort Study

BackgroundSocial distancing measures introduced during the coronavirus disease 2019 pandemic have reduced admission rates for various infectious and noninfectious respiratory diseases. We hypothesized that rates of asthma exacerbations would decline following the national lockdown in Denmark.ObjectiveTo determine weekly rates of in- and out-of-hospital asthma exacerbations before and during the social distancing intervention implemented on March 12, 2020.MethodsAll individuals older than 18 years with at least 1 outpatient hospital contact with asthma as the main diagnosis from January 1, 2013, to December 31, 2017, were included. Weekly asthma exacerbation rates from January 1, 2018, to May 22, 2020, were calculated. An interrupted time-series model with the lockdown on March 12, 2020, as the point of interruption was used.ResultsA total of 38,225 patients with asthma were identified. The interrupted time-series model showed no immediate fall in exacerbation rates during the first week after March 12, 2020. However, there was a significant decline in weekly exacerbation rates in the following 10 weeks (change in trend for exacerbations requiring hospitalization: −0.75 [95% CI, −1.39 to −0.12]; P < .02 and in all asthma exacerbations: −12.2 [95% CI, −19.1 to −5.4; P < .001), amounting to a reduction of approximately 1 and 16.5 exacerbations per year per 100 patients in the cohort, respectively.ConclusionsThe introduction of the social distancing measures in Denmark did not lead to an immediate reduction in asthma exacerbation rates; however, a gradual decline in exacerbation rates during the following 10-week period was observed.