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Background 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. Methods 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. Results 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. Conclusions 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.

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.

Introduction Patients with multimorbidity who frequently require healthcare may experience a higher treatment burden. In this study, we investigated whether high perceived treatment burden and low perceived health-related quality of life (HRQoL) were associated with healthcare utilisation among patients who attended at least two medical outpatient hospital clinics. Methods Patients who underwent medical treatment in two or more outpatient medical clinics at Silkeborg Regional Hospital in Denmark in August 2018 were included. The patients received a questionnaire containing the Multimorbidity Treatment Burden Questionnaire and the Short Form-12 questionnaire measuring HRQoL in terms of physical and mental health. Information on healthcare utilisation was collected from electronic registers one year prior to receiving the questionnaire. Logistic regression was applied to estimate the odds of 'no/low' and 'high' perceptions of treatment burden and 'low' self-rated HRQoL in relation to healthcare utilisation. Results In total, 930 patients (59.8%) answered the questionnaire. The degree of patient-assessed treatment burden was not associated with the number of outpatient contacts, hospital admissions or admission days. A high perceived treatment burden was associated with a high number of general practice contacts, whereas a low treatment burden was associated with fewer contacts in general practice, indicating a dose‒response pattern. The same pattern of associations was observed for perceived physical and mental health. Conclusion Patients with high perceived treatment burden and low HRQoL seemed to consult their general practitioner primarily despite hospital involvement. These patients may require frequent primary care attention due to other factors than those being treated at the hospital. However, further research is warranted to explore the mechanisms underlying these associations and strategies for reducing treatment burden and enhancing HRQoL in patients with multiple medical conditions.

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.

Background 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. Methods 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. Results 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)). Conclusion 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 4 th 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.

Background 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. Methods 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. Results 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. Conclusion 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.

Background Differences in cancer awareness between individuals may explain variations in healthcare seeking behaviour and ultimately also variations in cancer survival. It is therefore important to examine cancer awareness and to investigate possible differences in cancer awareness among specific population subgroups. The aim of this study is to assess awareness of cancer symptoms, risk factors and perceived 5-year survival from bowel, breast, ovarian, and lung cancer in a Danish population sample and to analyse the association between these factors and socio-economic position indicators. Methods A population-based telephone survey was carried out among 1,000 respondents aged 30–49 years and 2,000 respondents aged 50 years and older using the Awareness and Beliefs about Cancer measure. Information on socio-economic position was obtained by data linkage through Statistics Denmark. Prevalence ratios were used to determine the association between socio-economic position and cancer awareness. Results A strong socio-economic gradient in cancer awareness was found. People with a low educational level and a low household income were more likely to have a lower awareness of cancer symptoms, cancer risk factors and the growing risk of cancer with age. Furthermore, men and people outside the labour force tended to be less aware of these factors than women and people within the labour force. However, women were more likely than men to lack awareness of the relationship between age and cancer risk. No clear associations were found between socio-economic position and lack of awareness of 5-year survival from bowel, breast, ovarian, and lung cancers. Conclusions As cancer awareness has shown to be positively associated with cancer-related behaviour, e.g. healthcare seeking, consideration must be given to tackle inequalities in cancer awareness and to address this issue in future public health strategies, which should be targeted at and tailored to the intended recipient groups.

Background Multiple myeloma often presents with vague and non-specific symptoms. Many patients are diagnosed in unplanned rather than elective (planned) diagnostic pathways. This study investigates the diagnosis of multiple myeloma in unplanned pathways and the association with patient characteristics, disease profile, and survival. Methods We conducted a nationwide register-based study, including all patients diagnosed with multiple myeloma in Denmark in 2014–2018. Patients were categorised as diagnosed in an unplanned pathway if registered with an acute admission within 30 days prior to the multiple myeloma diagnosis and no other previously registered pathway to this diagnosis. Unplanned pathways were compared to all other pathways combined. Results We included 2,213 patients diagnosed with multiple myeloma, hereof 32% diagnosed in an unplanned pathway. Comorbidity, no prior cancer diagnosis, a history of few visits to the general practitioner (GP), multiple myeloma complications at diagnosis, high-risk cytogenetics, and advanced cancer stage were associated with a higher probability of being diagnosed in an unplanned pathway. For example, 24.4% (95% confidence interval (CI): 21.8–27.0) of patients with low comorbidity (Charlson Comorbidity Index (CCI) score 0) were diagnosed in an unplanned pathway as were 50.9% (95% CI: 45.6–56.1) of patients with high comorbidity (CCI score 3+). For patients with dialysis need at the time of diagnosis the probability was 66.0% (95% CI 54.2–77.8) and 30.9% (95% CI: 28.9–32.9) for patients with no dialysis need. Patients diagnosed in an unplanned pathway had inferior survival (hazard ratio 1.44 (95% CI: 1.26–1.64)). However, this association was not seen in analyses restricted to patients surviving for more than three years. Conclusions High comorbidity level, few usual GP visits, advanced disease status at diagnosis, and complications were associated with diagnosis in an unplanned pathway. Further, patients diagnosed in an unplanned pathway had inferior survival. Promoting earlier diagnosis and preventing unplanned pathways may help improve survival in multiple myeloma.

Background 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. Methods 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. Results In total, 7725 cases were analysed: 1202 before, 4187 during and 2336 after CPP implementation. For all cancers combined, the RS 3years 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 3years 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 1year CPP vs. non-CPP = 0.86 (95% CI: 0.73;1.01)). Conclusion 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.

Background During the early part of the COVID-19 pandemic, travel restrictions were implemented in Greenland to contain SARS-CoV-2 transmission. Despite their widespread use, empirical evidence supporting the effectiveness of travel restrictions is scarce. Greenland was in a unique position to maintain pre-departure testing among travellers, and we aimed to describe the effectiveness of pre-departure testing to inform the implementation of travel restrictions in future outbreaks. Methods Our analysis included SARS-Cov-2 PCR test results from travellers, including children, arriving in Greenland from Denmark between June 15, 2020, and January 26, 2022. Additionally, we identified positive tests performed within 14 days post-arrival to Greenland in this population. We estimated the sensitivity of pre-departure screening by dividing the number of positive cases identified pre-departure by the sum of cases identified pre-departure and within 14 days post-arrival in Greenland. Results Our analysis covered around 43% of all travellers who underwent pre-departure screening. Out of 26,406 SARS-CoV-2 PCR tests, the proportion of positive tests was 0.6%, which varied over time according to the incidence in Denmark. Overall sensitivity of pre-departure screening was 59% and decreased over time, reaching a minimum of 36% in January 2022. The overall proportion of positive PCR post-arrival tests among all travellers was 0.4%. Conclusions Implementing pre-departure PCR testing for SARS-CoV-2 among travellers can be effective in the early stages of outbreaks, particularly in geographical regions like Greenland where community transmission had not yet occurred. Our findings suggest that pre-departure screening of travellers contributed to delaying community transmission in Greenland compared to most other countries, thereby reducing the COVID-19 disease burden.