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1.  Health care agreements as a tool for coordinating health and social services 
Introduction
In 2007, a substantial reform changed the administrative boundaries of the Danish health care system and introduced health care agreements to be signed between municipal and regional authorities. To assess the health care agreements as a tool for coordinating health and social services, a survey was conducted before (2005–2006) and after the reform (2011).
Theory and methods
The study was designed on the basis of a modified version of Alter and Hage's framework for conceptualising coordination. Both surveys addressed all municipal level units (n = 271/98) and a random sample of general practitioners (n = 700/853).
Results
The health care agreements were considered more useful for coordinating care than the previous health plans. The power relationship between the regional and municipal authorities in drawing up the agreements was described as more equal. Familiarity with the agreements among general practitioners was higher, as was the perceived influence of the health care agreements on their work.
Discussion
Health care agreements with specific content and with regular follow-up and systematic mechanisms for organising feedback between collaborative partners exemplify a useful tool for the coordination of health and social services.
Conclusion
There are substantial improvements with the new health agreements in terms of formalising a better coordination of the health care system.
PMCID: PMC4276032  PMID: 25550691
integrated care; coordinated care; health planning; National Health System; Denmark
2.  Patient Experienced Continuity of Care in the Psychiatric Healthcare System—A Study Including Immigrants, Refugees and Ethnic Danes 
Aim: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. Method: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. Results: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. Conclusions: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.
doi:10.3390/ijerph110909739
PMCID: PMC4199047  PMID: 25233017
psychiatry; mental illness; migration; immigrants; refugees; health care system; continuity of care; illness narratives
3.  Issues to Consider When Measuring and Applying Socioeconomic Position Quantitatively in Immigrant Health Research 
The relationship between migration and health is complex, yet, immigrant-related inequalities in health are largely influenced by socioeconomic position. Drawing upon previous findings, this paper discusses issues to consider when measuring and applying socioeconomic position in quantitative immigrant health research. When measuring socioeconomic position, it is important to be aware of four aspects: (1) there is a lack of clarity about how socioeconomic position should be measured; (2) different types of socioeconomic position may be relevant to immigrants compared with the native-born population; (3) choices of measures of socioeconomic position in quantitative analyses often rely on data availability; and (4) different measures of socioeconomic position have different effects in population groups. Therefore, caution should be used in the collection, presentation, analyses, and interpretation of data and researchers need to display their proposed conceptual models and data limitations as well as apply different approaches for analyses.
doi:10.3390/ijerph10126354
PMCID: PMC3881118  PMID: 24287857
migrant; ethnic minority; socioeconomic position; socioeconomic status; health; measurement; quantitative; causal mechanisms; inequality; inequity
4.  How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark 
BMC Family Practice  2013;14:17.
Background
Refugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems.
Methods
The study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis.
Results
One of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms.
Conclusion
General practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.
doi:10.1186/1471-2296-14-17
PMCID: PMC3568406  PMID: 23356401
Primary care; Refugees; Migration; Trans-cultural psychiatry; Mental health; Categorisation
5.  Use of cross-border healthcare services among ethnic Danes, Turkish immigrants and Turkish descendants in Denmark: a combined survey and registry study 
Background
Healthcare obtained abroad may conflict with care received in the country of residence. A special concern for immigrants has been raised as they may have stronger links to healthcare services abroad. Our objective was to investigate use of healthcare in a foreign country in Turkish immigrants, their descendants, and ethnic Danes.
Methods
The study was based on a nationwide survey in 2007 with 372 Turkish immigrants, 496 descendants, and 1,131 ethnic Danes aged 18–66. Data were linked to registry data on socioeconomic factors. Using logistic regression models, use of doctor, specialist doctor, hospital, dentist in a foreign country as well as medicine from abroad were estimated. Analyses were adjusted for socioeconomic factors and health symptoms.
Results
Overall, 26.6% among Turkish immigrants made use of cross-border healthcare, followed by 19.4% among their descendants to 6.7% among ethnic Danes. Using logistic regression models with ethnic Danes as the reference group, Turkish immigrants were seen to have made increased use of general practitioners, specialist doctors, hospitals, and dentists in a foreign country (odds ratio (OR), 5.20-6.74), while Turkish descendants had made increased use of specialist doctors (OR, 4.97) and borderline statistically significant increased use of hospital (OR, 2.48) and dentist (OR, 2.17) but not general practitioners. For medicine, we found no differences among the men, but women with an immigrant background made considerably greater use, compared with ethnic Danish women. Socioeconomic position and health symptoms had a fairly explanatory effect on the use in the different groups.
Conclusions
Use of cross-border healthcare may have consequences for the continuity of care, including conflicts in the medical treatment, for the patient. Nonetheless, it may be aligned with the patient’s preferences and thereby beneficial for the patient. We need more information about reasons for obtaining cross-border healthcare among immigrants residing in European countries, and the consequences for the patient and the healthcare systems, including the quality of care. The Danish healthcare system needs to be aware of the significant healthcare consumption by immigrants, especially medicine among women, outside Denmark’s borders.
doi:10.1186/1472-6963-12-390
PMCID: PMC3536574  PMID: 23148550
Healthcare utilization; Medicine; Cross-border; Medical tourism; Migrant; Descendant; Continuity of care; Turkey; Denmark; Patient safety
6.  Inequalities in mortality among refugees and immigrants compared to native Danes – a historical prospective cohort study 
BMC Public Health  2012;12:757.
Background
Comparisons of mortality patterns between different migrant groups, and between migrants and natives, are relevant to understanding, and ultimately reducing, inequalities in health. To date, European studies on migrants’ mortality patterns are scarce and are based solely on country of birth, rather than migrant status. However, mortality patterns may be affected by implications in relation to migrant status, such as health hazards related to life circumstances before and during migration, and factors related to ethnic origin. Consequently, we investigated differences in both all-cause and cause-specific mortality from cancer and cardiovascular disease among refugees and immigrants, compared with the mortality among native Danes.
Methods
A register-based, historical prospective cohort design. All refugees (n = 29,139) and family-reunited immigrants (n = 27,134) who, between 1 January1993 and 31 December1999, were granted right of residence in Denmark were included and matched 1:4 on age and sex with native Danes. To identify deaths, civil registration numbers were cross-linked to the Register of Causes of Death (01.01.1994–31.12.2007) and the Danish Civil Registration System (01.01.1994–31.12.2008). Mortality rate ratios were estimated separately for men and women by migrant status and region of birth, adjusting for age and income and using a Cox regression model, after a median follow-up of 10–13 years after arrival.
Results
Compared with native Danes, all-cause mortality was significantly lower among female (RR = 0.78; 95%CI: 0.71;0.85) and male (RR = 0.64; 95%CI: 0.59-0.69;) refugees. The rates were also significantly lower for immigrants: women (RR = 0.44; 95%CI: 0.38;0.51) and men (RR = 0.43; 95%CI: 0.37;0.51). Both migrant groups also had lower cause-specific mortality from cancer and cardiovascular diseases. For both all-cause and cause-specific mortality, immigrants generally had lower mortality than refugees, and differences were observed according to ethnic origin.
Conclusions
Mortality patterns were overall advantageous for refugees and immigrants compared with native Danes. Research should concentrate on disentangling the reasons behind migrants’ health advantages, in order to enlighten future preventive public-health efforts, for the benefit of the entire population.
doi:10.1186/1471-2458-12-757
PMCID: PMC3575278  PMID: 22963550
Immigrants; Refugees; Migration; Ethnicity; Inequity; Mortality
7.  Social organization of self-management support of persons with diabetes: A health systems comparison 
Objective
Identify important organizational elements for providing self-management support (SMS).
Design
Semi-structured qualitative interviews conducted in two healthcare systems.
Setting
Kaiser Permanente Northern California and the Danish Health Care System.
Subjects
36 managers and healthcare professionals in the two healthcare systems.
Main outcome measures
Elements important to providing self-management support to persons with diabetes.
Results
Healthcare professionals’ provision of SMS was influenced by healthcare system organization and their perceptions of SMS, the capability and responsibility of healthcare systems, and their roles in the healthcare organization. Enabling factors for providing SMS included: strong leadership; aligned incentives; use of an integrated health information technology (HIT) system; multidisciplinary healthcare provider teams; ongoing training for healthcare professionals; outreach; and quality goals. Barriers to providing SMS included lack of collaboration between providers and skeptical attitudes towards prevention and outreach.
Conclusions and implications
Implementation of SMS can be improved by an understanding of the elements that enhance its provision: (1) initiatives seeking to improve collaboration and integration between providers; (2) implementation of an integrated HIT system; and (3) ongoing training of healthcare professionals.
doi:10.3109/02813432.2012.704810
PMCID: PMC3443944  PMID: 22839353
Denmark; diabetes mellitus; general practice; health system; international comparison; patient education; self-management support
8.  The relationship between changes in health behaviour and initiation of lipid-lowering and antihypertensive medications in individuals at high risk of ischaemic heart disease 
BMC Public Health  2012;12:626.
Background
It has been hypothesised that health conscious individuals tend to take better care of themselves by greater adherence to preventive medications. We examined, whether long-term changes in dietary habits and physical activity were associated with initiation of lipid-lowering and antihypertensive medications.
Methods
The study population consisted of two subsamples from the population-based cohort Inter99 study (1999-2006) in Copenhagen, Denmark: one with systolic blood pressure > 140 mmHg (N = 557) and one with total cholesterol > 7 mmol/L (N = 314). At a health examination, individuals completed a questionnaire about health behaviour and had their blood pressure and cholesterol measured at baseline and after five years. Data on medications were obtained through linkage to the Registry of Medical Product Statistics.
Results
Positive changes in physical activity (odds ratio =3.50; 95% CI 1.23-7.54) and in dietary habits (odds ratio = 2.08; 95% CI 1.03-4.21) were associated with an increased initiation of lipid-lowering medications. With respect to antihypertensives, no association was observed in terms of physical activity, but for diet, a positive trend in terms of initiation was observed among those with positive changes in dietary habits (odds ratio = 1.58; 95% CI 0.96-2.59).
Conclusion
Generally, we observed health conscious behaviour in terms of increased initiation of preventive medications among those who reported positive changes in health behaviour. This study therefore suggests that more attention should be given to identifying individuals and groups, who are less health conscious and thereby less likely to engage in either preventive medications or changes in health behaviours.
doi:10.1186/1471-2458-12-626
PMCID: PMC3538631  PMID: 22873800
9.  Is the high-risk strategy to prevent cardiovascular disease equitable? A pharmacoepidemiological cohort study 
BMC Public Health  2012;12:610.
Background
Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk – i.e. individuals in lower socio-economic position (SEP) – are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups.
Methods
Design: Cohort study.
Setting and participants: Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002–2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill).
Main outcome measures: Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups.
Results
MI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40–64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65–84.
Conclusion
The high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.
doi:10.1186/1471-2458-12-610
PMCID: PMC3444315  PMID: 22863326
Statins to prevent cardiovascular disease; The high-risk strategy; Socioeconomic gradient; Horizontal equity
10.  Self-Management Support to People with Type 2 Diabetes - A comparative study of Kaiser Permanente and the Danish Healthcare System 
Background
Self-management support is considered to be an essential part of diabetes care. However, the implementation of self-management support within healthcare settings has appeared to be challenging and there is increased interest in “real world” best practice examples to guide policy efforts. In order to explore how different approaches to diabetes care and differences in management structure influence the provision of SMS we selected two healthcare systems that have shown to be comparable in terms of budget, benefits and entitlements. We compared the extent of SMS provided and the self-management behaviors of people living with diabetes in Kaiser Permanente (KP) and the Danish Healthcare System (DHS).
Methods
Self-administered questionnaires were used to collect data from a random sample of 2,536 individuals with DM from KP and the DHS in 2006–2007 to compare the level of SMS provided in the two systems and identify disparities associated with educational attainment. The response rates were 75 % in the DHS and 56 % in KP. After adjusting for gender, age, educational level, and HbA1c level, multiple linear regression analyses determined the level of SMS provided and identified disparities associated with educational attainment.
Results
Receipt of SMS varied substantially between the two systems. More people with diabetes in KP reported receiving all types of SMS and use of SMS tools compared to the DHS (p < .0001). Less than half of all respondents reported taking diabetes medication as prescribed and following national guidelines for exercise.
Conclusions
Despite better SMS support in KP compared to the DHS, self-management remains an under-supported area of care for people receiving care for diabetes in the two health systems. Our study thereby suggests opportunity for improvements especially within the Danish healthcare system and systems adopting similar SMS support strategies.
doi:10.1186/1472-6963-12-160
PMCID: PMC3441680  PMID: 22697597
Self-management support; Type 2 diabetes mellitus; Health system; International comparison
11.  Something is amiss in Denmark: A comparison of preventable hospitalisations and readmissions for chronic medical conditions in the Danish Healthcare system and Kaiser Permanente 
Background
As many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas for improvement. Prior work indicates that chronic care coordination is poor in the DHS, especially in comparison with care in Kaiser Permanente (KP), an integrated delivery system based in the United States. We investigated population rates of hospitalisation and readmission rates for ambulatory care sensitive, chronic medical conditions in the two systems.
Methods
Using a historical cohort study design, age and gender adjusted population rates of hospitalisations for angina, heart failure, chronic obstructive pulmonary disease, and hypertension, plus rates of 30-day readmission and mortality were investigated for all individuals aged 65+ in the DHS and KP.
Results
DHS had substantially higher rates of hospitalisations, readmissions, and mean lengths of stay per hospitalisation, than KP had. For example, the adjusted angina hospitalisation rates in 2007 for the DHS and KP respectively were 1.01/100 persons (95%CI: 0.98-1.03) vs. 0.11/100 persons (95%CI: 0.10-0.13/100 persons); 21.6% vs. 9.9% readmission within 30 days (OR = 2.53; 95% CI: 1.84-3.47); and mean length of stay was 2.52 vs. 1.80 hospital days. Mortality up through 30 days post-discharge was not consistently different in the two systems.
Conclusions
There are substantial differences between the DHS and KP in the rates of preventable hospitalisations and subsequent readmissions associated with chronic conditions, which suggest much opportunity for improvement within the Danish healthcare system. Reductions in hospitalisations also could improve patient welfare and free considerable resources for use towards preventing disease exacerbations. These conclusions may also apply for similar public systems such as the US Medicare system, the NHS and other systems striving to improve the integration of care for persons with chronic conditions.
doi:10.1186/1472-6963-11-347
PMCID: PMC3258291  PMID: 22192270
12.  Access to healthcare and alternative health-seeking strategies among undocumented migrants in Denmark 
BMC Public Health  2011;11:560.
Background
As in many European countries, undocumented migrants in Denmark have restricted access to healthcare. The aim of this study is to describe and analyse undocumented migrants' experiences of access to healthcare, use of alternative health-seeking strategies; and ER nurses' experiences in encounters with undocumented migrants.
Methods
Qualitative design using semi-structured interviews and observations. The participants included ten undocumented South Asian migrants and eight ER nurses.
Results
Undocumented migrants reported difficulties accessing healthcare. The barriers to healthcare were: limited medical rights, arbitrariness in healthcare professionals' attitudes, fear of being reported to the police, poor language skills, lack of network with Danish citizens, lack of knowledge about the healthcare system and lack of knowledge about informal networks of healthcare professionals. These barriers induced alternative health-seeking strategies, such as self-medication, contacting doctors in home countries and borrowing health insurance cards from Danish citizens. ER nurses expressed willingness to treat all patients regardless of their migratory status, but also reported challenges in the encounters with undocumented migrants. The challenges for ER nurses were: language barriers, issues of false identification, insecurities about the correct standard procedures and not always being able to provide appropriate care.
Conclusions
Undocumented migrants face formal and informal barriers to the Danish healthcare system, which lead to alternative health-seeking strategies that may have adverse effects on their health. This study shows the need for policies and guidelines, which in accordance with international human rights law, ensure access to healthcare for undocumented migrants and give clarity to healthcare professionals.
doi:10.1186/1471-2458-11-560
PMCID: PMC3163547  PMID: 21752296
13.  Providing medical care for undocumented migrants in Denmark: what are the challenges for health professionals? 
Background
The rights of undocumented migrants are frequently overlooked. Denmark has ratified several international conventions recognizing the right to health care for all human beings, but has very scanty legislation and no existing policies for providing health care to undocumented migrants. This study focuses on how health professionals navigate and how they experience providing treatment for undocumented migrants in the Danish health care system.
Methods
The study was carried out as part of an EU-project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). This presentation is based on 12 semi-structured interviews with general practitioners (9) and emergency room physicians (3) in Denmark.
Results
The emergency room physicians express that treatment of undocumented migrants is no different from the treatment of any other person. However, care may become more complicated due to lack of previous medical records and contact persons. Contrary to this, general practitioners explain that undocumented migrants will encounter formal barriers when trying to obtain treatment. Additional problems in the treatment of undocumented migrants include language issues, financial aspects for general practitioners, concerns about how to handle the situation including possibilities of further referrals, and an uncertainty as to whether to involve the police.
Conclusions
The health professionals in our study describe that undocumented migrants experience an unequal access to primary care facilities and that great uncertainties exist amongst health professionals as how to respond in such situations. The lack of official policies concerning the right to health care for undocumented migrants continue to pass on the responsibility to health professionals and, thereby, leaves it up to the individual to decide whether treatment can be obtained or not.
doi:10.1186/1472-6963-11-154
PMCID: PMC3150245  PMID: 21711562
14.  Good practice in health care for migrants: views and experiences of care professionals in 16 European countries 
BMC Public Health  2011;11:187.
Background
Health services across Europe provide health care for migrant patients every day. However, little systematic research has explored the views and experiences of health care professionals in different European countries. The aim of this study was to assess the difficulties professionals experience in their service when providing such care and what they consider constitutes good practice to overcome these problems or limit their negative impact on the quality of care.
Methods
Structured interviews with open questions and case vignettes were conducted with health care professionals working in areas with high proportion of migrant populations in 16 countries. In each country, professionals in nine primary care practices, three accident and emergency hospital departments, and three community mental health services (total sample = 240) were interviewed about their views and experiences in providing care for migrant patients, i.e. from first generation immigrant populations. Answers were analysed using thematic content analysis.
Results
Eight types of problems and seven components of good practice were identified representing all statements in the interviews. The eight problems were: language barriers, difficulties in arranging care for migrants without health care coverage, social deprivation and traumatic experiences, lack of familiarity with the health care system, cultural differences, different understandings of illness and treatment, negative attitudes among staff and patients, and lack of access to medical history. The components of good practice to overcome these problems or limit their impact were: organisational flexibility with sufficient time and resources, good interpreting services, working with families and social services, cultural awareness of staff, educational programmes and information material for migrants, positive and stable relationships with staff, and clear guidelines on the care entitlements of different migrant groups. Problems and good care components were similar across the three types of services.
Conclusions
Health care professionals in different services experience similar difficulties when providing care to migrants. They also have relatively consistent views on what constitutes good practice. The degree to which these components already are part of routine practice varies. Implementing good practice requires sufficient resources and organisational flexibility, positive attitudes, training for staff and the provision of information.
doi:10.1186/1471-2458-11-187
PMCID: PMC3071322  PMID: 21439059
15.  Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system 
Background
Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system.
Methods
Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models.
Results
More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration.
Conclusions
More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.
doi:10.1186/1472-6963-10-91
PMCID: PMC2907761  PMID: 20374667
16.  A qualitative assessment of implementing a cross-cultural survey on cancer wards in Denmark - a description of barriers 
Background
Research into migration and health is often confronted with methodological challenges related to the identification of migrants in various settings. Furthermore, it is often difficult to reach an acceptable level of participation among migrant groups in quantitative research. The aim of this study is to conduct a qualitative assessment of the barriers encountered during the implementation of a cross-cultural survey on cancer wards in Copenhagen, Denmark.
Methods
Participant observation at the involved wards was combined with qualitative interviews with selected nurses and informal talks with a wider group of nurses at the wards involved in the survey.
Results
One possible way to increase the participation of migrant patients in research is through the involvement of the hospital staff in contact with patients. Involvement of nurses on cancer wards in the delivery of questionnaires to patients was challenging, despite a general willingness to participate in psychosocial research. The main difficulties were found to be both external (policy changes, general strike among nurses) and internal on the wards (heavy workload, lack of time, focus on medical aspects of cancer rather than psychosocial aspects). These factors interacted and resulted in a lower priority being given to psychosocial research. Further, nurses expressed a feeling that researchers in general did not recognize their contribution in research, making it more difficult to engage fully in studies.
Conclusions
Involving hospital staff in research is feasible but not straightforward. Awareness of the influence of possible external and internal factors and efforts to deal with these factors are fundamental to the successful implementation of psychosocial cancer research in a hospital setting.
doi:10.1186/1471-2288-10-4
PMCID: PMC2820029  PMID: 20067615
17.  Registry data for cross-country comparisons of migrants' healthcare utilization in the EU: a survey study of availability and content 
Background
Cross-national comparable data on migrants' use of healthcare services are important to address problems in access to healthcare; to identify high risk groups for prevention efforts; and to evaluate healthcare systems comparatively. Some of the main obstacles limiting analyses of health care utilization are lack of sufficient coverage and availability of reliable and valid healthcare data which includes information allowing for identification of migrants. The objective of this paper was to reveal which registry data on healthcare utilization were available in the EU countries in which migrants can be identified; and to determine to what extent data were comparable between the EU countries.
Methods
A questionnaire survey on availability of healthcare utilization registries in which migrants can be identified was carried out among all national statistic agencies and other relevant national health authorities in the 27 EU countries in 2008-9 as part of the Migrant and Ethnic Minority Health Observatory-project (MEHO). The information received was compared with information from a general survey on availability of survey and registry data on migrants conducted by Agency of Public Health, Lazio Region, Italy within the MEHO-project; thus, the information on registries was double-checked to assure accuracy and verification.
Results
Available registry data on healthcare utilization which allow for identification on migrants on a national/regional basis were only reported in 11 EU countries: Austria, Belgium, Denmark, Finland, Greece, Italy, Luxembourg, the Netherlands, Poland, Slovenia, and Sweden. Data on hospital care, including surgical procedures, were most frequently available whereas only few countries had data on care outside the hospital. Regarding identification of migrants, five countries reported having information on both citizenship and country of birth, one reported availability of information on country of birth, and five countries reported availability of information on citizenship.
Conclusion
Lack of registry data in 16 EU countries, shortage of data on healthcare utilization, and the diversity in the definition of migrant status hampers cross-national comparisons and calls for an urgent establishment of registries, expansion of the existing registry information, and adoption of a common, generally acceptable definition and identification method of migrants across the EU.
doi:10.1186/1472-6963-9-210
PMCID: PMC2788548  PMID: 19922657
18.  Measurement of integrated healthcare delivery: a systematic review of methods and future research directions 
Background
Integrated healthcare delivery is a policy goal of healthcare systems. There is no consensus on how to measure the concept, which makes it difficult to monitor progress.
Purpose
To identify the different types of methods used to measure integrated healthcare delivery with emphasis on structural, cultural and process aspects.
Methods
Medline/Pubmed, EMBASE, Web of Science, Cochrane Library, WHOLIS, and conventional internet search engines were systematically searched for methods to measure integrated healthcare delivery (published – April 2008).
Results
Twenty-four published scientific papers and documents met the inclusion criteria. In the 24 references we identified 24 different measurement methods; however, 5 methods shared theoretical framework. The methods can be categorized according to type of data source: a) questionnaire survey data, b) automated register data, or c) mixed data sources. The variety of concepts measured reflects the significant conceptual diversity within the field, and most methods lack information regarding validity and reliability.
Conclusion
Several methods have been developed to measure integrated healthcare delivery; 24 methods are available and some are highly developed. The objective governs the method best used. Criteria for sound measures are suggested and further developments should be based on an explicit conceptual framework and focus on simplifying and validating existing methods.
PMCID: PMC2663702  PMID: 19340325
integrated healthcare delivery; methods; literature review; quality of healthcare
19.  A retrospective analysis of health systems in Denmark and Kaiser Permanente 
Background
To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy.
Methods
Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability.
Results
A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS).
Conclusion
Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.
doi:10.1186/1472-6963-8-252
PMCID: PMC2630928  PMID: 19077229
20.  Mental health among children seeking asylum in Denmark – the effect of length of stay and number of relocations: a cross-sectional study 
BMC Public Health  2008;8:293.
Background
The process of seeking asylum and the related organisational conditions in the host country may adversely affect the children's mental health. The objective of this study was to examine the mental health of children seeking asylum in relation to organisational factors of the asylum system including length of stay and number of relocations.
Methods
The population included all 260 parent-accompanied asylum-seeking children aged 4–16 years living in the asylum centres managed by the Danish Red Cross in October–December 2006. Mental health was evaluated using the Strengths and Difficulties Questionnaire. School teachers evaluated children aged 4–16; and the 11–16-year-olds completed the self-report version. To assess the association between organisational factors and mental health, binary logistic regression analyses were done using backwards elimination. We received responses for 246 children equivalent to 95% of the study population.
Results
Using teachers' reports, we found that children who had been asylum-seeking for more than one year in Denmark had an increased risk of having mental difficulties (odds ratio 5.5, 95% CI 1.8–16.3); four or more relocations in the asylum system were also associated with a higher risk (3.0, 1.4–6.7). When the self-report data were included, the associations were even stronger.
Conclusion
Protracted stays at asylum centres and multiple relocations within the asylum system appear to have an adverse effect on asylum-seeking children's mental health. A limit to the duration of the children's stay in the asylum system should be ensured. Follow-up studies with inclusion of other conditions, such as parental mental health and the children's previous trauma, are needed to clarify the influence of the different factors and their interactions.
doi:10.1186/1471-2458-8-293
PMCID: PMC2535781  PMID: 18713455
21.  Does a public single payer system deliver integrated care? A national survey study among professional stakeholders in Denmark 
Background
Integrated health care delivery is a goal of health care systems; to date there has been limited information on the integration of medical care in practice.
Purpose
To examine and compare perceptions of clinical integration and to identify associated strategic, cultural, technical and structural factors.
Design and setting
A national survey addressed to: all county administrative managers (n=15); all hospital managers (n=44); and randomized selected samples of hospital department physician managers (n=200) and general practitioners (n=700) in Denmark.
Results
Several initiatives have been implemented in Denmark to integrate care. Nevertheless, most physicians agree that only half of all patients experience well coordinated pathways. Clinical integration is a strategic priority at the managerial levels, but this is not visible at the functional levels. Financial incentives are not used to encourage coordination. The information communication technology to facilitate clinical integration is perceived to be inadequate.
Conclusion
The scope for improvement is high due to the structural composition of the system. Increased managerial stewardship, alignment of the financial incentives, and expanded use of information communication technology to link sub-organisations will be a way to move the system forward to meet its explicit goal of providing an integrated delivery of services.
PMCID: PMC2504700  PMID: 18695747
integrated health care delivery; computerized medical records system; case management; disease management; health planning; Denmark
22.  Does a public single payer system deliver integrated services? A national survey study among professional stakeholders in Denmark 
Background
Integrated health care delivery is a goal of contemporary health systems; however, the achievement of this goal is rarely quantified. The Danish health care system provides an interesting case study, as a setting with a formally integrated financing and delivery system.
Purpose
To measure the level of integration of care and conceptual sub dimensions in the Danish health system, using a major professional stakeholder (MaPS) approach. In addition, organisational and management factors associated with delivery of integrated care are investigated.
Design
A survey addressed to: all county administrative managers (N=15); all hospital managers (N=44); and randomised selected samples of hospital department physician managers (N=200) and general practitioners (N=700).
Results
Several initiatives on administrative and functional levels have been implemented in Denmark to improve the delivery of integrated services. Still most physicians agree that only half of all patients experience well coordinated pathways. Clinical integration is a strategic priority at the managerial levels, but this is not visible at the functional levels. Financial incentives are not used to encourage coordination. The information communication technology to facilitate clinical integration is perceived to be inadequate.
Conclusion
Seen from the perspective of major stakeholders at the professional level the formally integrated health care delivery system in Denmark does not deliver fully integrated services. However, the scope for improvement is high due to the inherent structural composition of the system and the one payer system approach. The MaPS approach suggest that alignment of the financial incentives, increased managerial stewardship, structural reorganisation, and expanded use of information technology to link sub-organisations will be a way to move the system forward to its explicit goal of providing an integrated delivery of services which could ultimately benefit the recipients of the Danish health care services.
PMCID: PMC2430308
stake holders; survey; general practitioners; questionnaire; Denmark
23.  Are joint health plans effective for coordination of health services? An analysis based on theory and Danish pre-reform results 
Background
Since 1994 formal health plans have been used for coordination of health care services between the regional and local level in Denmark. From 2007 a substantial reform has changed the administrative boundaries of the system and a new tool for coordination has been introduced.
Purpose
To assess the use of the pre-reform health plans as a tool for strengthening coordination, quality and preventive efforts between the regional and local level of health care.
Methods
A survey addressed to: all counties (n=15), all municipalities (n=271) and a randomised selected sample of general practitioners (n=700).
Results
The stakeholders at the administrative level agree that health plans have not been effective as a tool for coordination. The development of health plans are dominated by the regional level. At the functional level 27 percent of the general practitioners are not familiar with health plans. Among those familiar with health plans 61 percent report that health plans influence their work to only a lesser degree or not at all.
Conclusion
Joint health planning is needed to achieve coordination of care. Efforts must be made to overcome barriers hampering efficient whole system planning. Active policies emphasising the necessity of health planning, despite involved cost, are warranted to insure delivery of care that benefits the health of the population.
PMCID: PMC2000978  PMID: 17925882
integrated care; coordinated care; health planning; National Health System; Denmark
24.  Are there differences in injury mortality among refugees and immigrants compared with native-born? 
Injury Prevention  2012;19(2):100-105.
Background
The authors studied injury mortality in Denmark among refugees and immigrants compared with that among native Danes.
Method
A register-based, historical prospective cohort design. All refugees (n=29 139) and family reunited immigrants (n=27 134) who between 1 January 1993 and 31 December 1999 received residence permission were included and matched 1:4 on age and sex with native Danes. Civil registration numbers were cross-linked to the Register of Causes of Death, and fatalities due to unintentional and intentional injuries were identified based on ICD-10 diagnosis. Sex-specific mortality ratios were estimated by migrant status and region of birth, adjusting for age and income and using a Cox regression model after a median follow-up of 11–12 years.
Results
Compared with native Danes, both female (RR=0.44; 95% CI 0.23 to 0.83) and male (RR=0.40; 95% CI 0.29 to 0.56) refugees as well as female (RR=0.40; 95% CI 0.21 to 0.76) and male (RR=0.22; 95% CI 0.12 to 0.42) immigrants had significantly lower mortality from unintentional injuries. Suicide rates were significantly lower for male refugees (RR=0.38; 95% CI 0.24 to 0.61) and male immigrants (RR=0.24; 95% CI 0.10 to 0.59), whereas their female counterparts showed no significant differences. Only immigrant women had a significantly higher homicide rate (RR=3.09; 95% CI 1.11 to 8.60) compared with native Danes.
Conclusions
Overall results were advantageous to migrant groups. Research efforts should concentrate on investigating protective factors among migrants, which may benefit injury prevention in the majority population.
doi:10.1136/injuryprev-2012-040336
PMCID: PMC3607096  PMID: 22627779
Injury; mortality; migration; ethnicity; immigrants; mental health; epidemiology; registry; suicide/self; harm; drowning; bicycle; fall

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