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1.  The effect on knee-joint load of instruction in analgesic use compared with neuromuscular exercise in patients with knee osteoarthritis: study protocol for a randomized, single-blind, controlled trial (the EXERPHARMA trial) 
Trials  2014;15(1):444.
Knee osteoarthritis (OA) is a mechanically driven disease, and it is suggested that medial tibiofemoral knee-joint load increases with pharmacologic pain relief, indicating that pharmacologic pain relief may be positively associated with disease progression. Treatment modalities that can both relieve pain and reduce knee-joint load would be preferable. The knee-joint load is influenced by functional alignment of the trunk, pelvis, and lower-limb segments with respect to the knee, as well as the ground-reaction force generated during movement. Neuromuscular exercise can influence knee load and decrease knee pain. It includes exercises to improve balance, muscle activation, functional alignment, and functional knee stability. The primary objective of this randomized controlled trial (RCT) is to investigate the efficacy of a NEuroMuscular EXercise (NEMEX) therapy program, compared with optimized analgesics and antiinflammatory drug use, on the measures of knee-joint load in people with mild to moderate medial tibiofemoral knee osteoarthritis.
One hundred men and women with mild to moderate medial knee osteoarthritis will be recruited from general medical practices and randomly allocated (1:1) to one of two 8-week treatments, either (a) NEMEX therapy twice a week or (b) information on the recommended use of analgesics and antiinflammatory drugs (acetaminophen and oral NSAIDs) via a pamphlet and video materials. The primary outcome is change in knee load during walking (the Knee Index, a composite score of the first external peak total reaction moment on the knee joint from all three planes based on 3D movement analysis) after 8 weeks of intervention. Secondary outcomes include changes in the external peak knee-adduction moment and impulse and functional performance measures, in addition to changes in self-reported pain, function, health status, and quality of life.
These findings will help determine whether 8 weeks of neuromuscular exercise is superior to optimized use of analgesics and antiinflammatory drugs regarding knee-joint load, pain and physical function in people with mild to moderate knee osteoarthritis.
Trial registration Identifier: NCT01638962 (July 3, 2012).
PMCID: PMC4240848  PMID: 25399048
Osteoarthritis; Exercise; Gait; Joint load; Knee joint; Middle-aged; Knee; Pain management
2.  Low Back Pain in Primary Care: A Description of 1250 Patients with Low Back Pain in Danish General and Chiropractic Practice 
Study Design. Baseline description of a multicenter cohort study. Objective. To describe patients with low back pain (LBP) in both chiropractic and general practice in Denmark. Background. To optimize standards of care in the primary healthcare sector, detailed knowledge of the patient populations in different settings is needed. In Denmark, most LBP-patients access primary healthcare through chiropractic or general practice. Methods. Chiropractors and general practitioners recruited adult patients seeking care for LBP. Extensive baseline questionnaires were obtained and descriptive analyses presented separately for general and chiropractic practice patients, Mann-Whitney rank sum test and Pearson's chi-square test, were used to test for differences between the two populations. Results. Questionnaires were returned from 934 patients in chiropractic practice and 319 patients from general practice. Four out of five patients had had previous episodes, one-fourth were on sick leave, and the LBP considerably limited daily activities. The general practice patients were slightly older and less educated, more often females, and generally worse on all disease-related parameters than chiropractic patients. All differences were statistically significant. Conclusions. LBP in primary care was recurrent, causing sick leave and activity limitations. There were clear differences between the chiropractic and general practice populations in this study.
PMCID: PMC4236958  PMID: 25436149
3.  The Danish Symptom Cohort: Questionnaire and Feasibility in the Nationwide Study on Symptom Experience and Healthcare-Seeking among 100 000 Individuals 
Introduction. In order to develop strategies to prevent delay in diagnosis, it is important to gain knowledge of symptoms and healthcare-seeking processes in the population. This paper describes a combined survey and register-based study with (1) focus on development of a questionnaire concerning experience of symptoms and subsequent consequences and (2) feasibility of the study. Methods. The study is a nationwide cohort study of 100 000 individuals randomly selected from the Danish general population. A comprehensive questionnaire concerning experience of symptoms and subsequent consequences was developed. The methodological framework for the development included defining the domains to be measured, identification of previous items, scales and questionnaires in the literature, and pilot and field testing. Results. A total of five domains and 16 subdomains were defined covering the area of symptom experience, symptom characteristics, reaction in response to symptom experience, external factors, and personality characteristics with potential influence on the symptom experience. In total, 49 706 questionnaires were completed, yielding a response rate of 52.2%. Conclusion. We developed a comprehensive questionnaire used in a large combined survey and register-based study concerning experience of symptoms and subsequent consequences of symptom experiences. We succeeded in conducting a large survey providing the groundwork for The Danish Symptom Cohort.
PMCID: PMC4132324  PMID: 25147736
4.  Relational Coordination and Organisational Social Capital Association with Characteristics of General Practice 
Background. Relational coordination (RC) and organisational social capital (OSC) are measures of novel aspects of an organisation's performance, which have not previously been analysed together, in general practice. Objectives. The aim of this study was to analyse the associations between RC and OSC, and characteristics of general practice. Methods. Questionnaire survey study comprising 2074 practices in Denmark. Results. General practitioners (GPs) rated both RC and OSC in their general practice higher than their secretaries and nurses. The practice form was statistically significantly associated with high RC and OSC. RC was positively associated with the number of patients listed with a practice per staff, where staff is defined as all members of a practice including both owners and employees. Conclusion. The study showed that RC and OSC were significantly associated with type of profession and practice type. RC was also found to be significantly positively associated with number of patients per staff. However, the low response rate must be taken into consideration when interpreting the self-reported results of this study.
PMCID: PMC4089202  PMID: 25045537
5.  The PROTECCT-M study: a cohort study investigating associations between novel specific biomarkers, patient-related, healthcare system markers and the trajectory of COPD patients treated in primary care 
Chronic Obstructive Pulmonary Disease (COPD) is the most common severe chronic disease in primary care. It is typically diagnosed at a late stage, and it is also difficult to predict its trajectory and hence to tailor treatment and rehabilitation. The overall aim is to study determinants of exacerbations of COPD treated in primary care and to study, if the prognosis is related to patient-related, healthcare system markers or levels of the potential biomarkers such as microfibrillar-associated protein 4 (MFAP4) and surfactant protein D (SP-D). Furthermore, we aim to establish a cohort of COPD patients treated in Danish primary care comprising register data, data captured from the GPs’ electronic patient record system (EPR) and a biobank in order to make analyses on factors associated with different tractories of COPD treated in primary care.
A cohort study of incident and prevalent COPD patients treated and followed by their GPs using data capture, which is a computer system collecting data from the GPs’ own EPR and transferring them to the Danish General Practice Research Database. The participating COPD patients were investigated at a baseline consultation by their own GP, and the results were registered using a pop-up menu by the GP. During the consultation blood samples were taken and the patients were given a questionnaire. The patients will then be followed prospectively at yearly consultations and in between these consultations by means of the data capture system. The collected data will also be combined with register data from other sources. The data collection started in December 2012, and so far 30 practices with 77 GPs have included about 350 patients. The study aims to include 2000 patients till the end of 2016, and after that to continue to collect data on these patients using the data capture system.
The GP currently lacks tools to predict trajectory of their COPD patients. The measurement of lung function only reflects loss of lung capacity and not disease activity. Use of biomarkers for detection of early COPD could be a possible way of predicting trajectory to aid both the GP and his/her patients. This study aims to provide evidence of determinants of a COPD trajectory, including novel specific biomarkers and other patient- and healthcare system-related markers.
Trial registration Protocol Registration System, Identifier: NCT01698151
PMCID: PMC4049396  PMID: 24886233
6.  Evaluation of a complex intervention to improve activities of daily living of disabled cancer patients: protocol for a randomised controlled study and feasibility of recruitment and intervention 
Many cancer patients have problems performing activities of daily living (ADL). A randomised controlled trial was designed to examine the effects of an ADL intervention in addition to standard treatment and care in a hospital setting. The objective of this article was to present the study and to analyse the feasibility of the recruitment process and the intervention.
Adult disabled cancer patients at Næstved Hospital in Denmark were enrolled between 1 March 2010 and 30 June 2011 and randomised into an ADL intervention or to a control group. The intervention was performed by occupational therapists. The feasibility of the recruitment was analysed with regard to success in achieving the estimated number of participants and identification of barriers, and feasibility of the intervention was based on calculations of patient attendance and patient acceptability. The primary outcome of the randomised controlled trial was patients’ health-related quality of life 2 and 8 weeks after baseline.
A total of 118 disabled cancer patients were enrolled in the study over a time span of 16 months. Very few meetings between occupational therapist and patient were cancelled. Time spent on the intervention varied considerably, but for the majority of patients, time consumption was between 1–3 hours.
Despite difficulties with recruitment, participation was considered feasible and the intervention was accepted among patients. Missing data in the follow-up period were mostly due to death among participants. Very few participants declined to complete questionnaires during follow-up.
PMCID: PMC4045894  PMID: 24779438
Cancer rehabilitation; Occupational therapy; Activities of daily living; Intervention studies; Feasibility studies
7.  Long-Term Effect of Interactive Online Dietician Weight Loss Advice in General Practice (LIVA) Protocol for a Randomized Controlled Trial 
Background. Internet-based complex interventions aiming to promote weight loss and optimize healthy behaviors have attracted much attention. However, evidence for effect is lacking. Obesity is a growing problem, resulting in an increasing demand for cost efficient weight loss programs suitable for use on a large scale, for example, as part of standard primary care. In a previous pilot project by Brandt et al. (2011) without a control group, we examined the effects of online dietician counseling and found an average weight loss of 7.0 kg (95% CI: 4.6 to 9.3 kg) after 20 months. Aims and Methods. To analyze the effects of a complex intervention using trained dieticians in a general practice setting combined with internet-based interactive and personalized weight management support compared with conventional advice with a noninteractive internet support as placebo treatment in 340 overweight patients during a 2-year period. Primary endpoints are weight loss and lowering of cholesterol (LDL). We will also explore patients' sociodemographics and use of the intervention as well as the health professionals' views and perceptions of the intervention (their role and the advice and support that they provide). Perspective. The project will generate knowledge on the cost-effectiveness of a complex internet-based intervention in a general practice setting and on barriers and acceptability among professionals and patients.
PMCID: PMC4016832  PMID: 24860666
8.  Danish General Practitioners' Use of Prostate-Specific Antigen in Opportunistic Screening for Prostate Cancer: A Survey Comprising 174 GPs 
Background. The use of prostate-specific antigen test has markedly increased in Danish general practice in the last decade. Despite the national guidelines advice against PSA screening, opportunistic screening is supposed to be the primary reason for this increased number of PSA tests performed. Aims. Based on the increase in the amount of PSA conducted, we aimed to analyse how GPs in Denmark use the PSA test. Methods. A self-administrated questionnaire concerning symptomatic and asymptomatic patient cases was developed based on the national and international guidelines and the extensive literature review, and an in-depth interview conducted with a GP was performed. Results. None of the GPs would do a PSA measurement for an asymptomatic 76-year-old man. For asymptomatic 55- and 42-year-old men, respectively, 21.9% and 18.6% of GPs would measure PSA. Patient request and concern could be potential reasons for measuring PSA for asymptomatic patients. Almost all GPs stated that a PSA measurement is indicated for symptomatic 49- and 78-year-old men, respectively, 98.9% and 93.8%. Conclusion. Opportunistic PC screening is being performed in general practice to a high degree. Hence, current guidelines are not followed, and intense focus should be on more effective implementation strategies in order to avoid overuse of PSA.
PMCID: PMC3852312  PMID: 24349779
9.  Child overweight in general practice – parents’ beliefs and expectations – a questionnaire survey study 
BMC Family Practice  2013;14:152.
Care for overweight children in general practice involves collaboration with parents. Acknowledging the parents’ frames of references is a prerequisite for successful management. We therefore aimed to analyse parental beliefs about the presumed causes and consequences of overweight in children and expectations towards the GP. Moreover, we aimed at comparing the beliefs and expectations of parents of non-overweight children (NOWC) and parents of overweight children (OWC).
A cross-sectional survey. Data were obtained from a questionnaire exploring parents’ beliefs and expectations regarding overweight in children. The questionnaires were completed by parents following their child’s participation in the five-year preventive child health examination (PCHE).
Parental agreement upon statements concerning beliefs and expectations regarding overweight in children was measured on a Likert scale. Differences in levels of agreement between parents of non-overweight children and parents of overweight children were analysed using Chi-squared test and Fisher’s exact test.
Parents of 879 children completed and returned questionnaires. Around three fourths of the parents agreed that overweight was a health problem. A majority of parents (93%) agreed that the GP should call attention to overweight in children and offer counselling on diet and exercise. Almost half of the parents expected a follow-up programme. Parents of overweight children seemed to agree less upon some of the proposed causes of overweight, e.g. inappropriate diet and lack of exercise. These parents also had stronger beliefs about overweight disappearing by itself as the child grows up.
According to parental beliefs and expectations, general practice should have an important role to play in the management of child overweight. Moreover, our findings suggest that GPs should be aware of the particular beliefs that parents of overweight children may have regarding causes of overweight in their child.
PMCID: PMC3852217  PMID: 24118920
Children; Overweight; Parents; Beliefs; Expectations; General practice
10.  Depressive Symptoms and Risk of New Cardiovascular Events or Death in Patients with Myocardial Infarction: A Population-Based Longitudinal Study Examining Health Behaviors and Health Care Interventions 
PLoS ONE  2013;8(9):e74393.
Depressive symptoms is associated with adverse cardiovascular outcomes in patients with myocardial infarction (MI), but the underlying mechanisms are unclear and it remains unknown whether subgroups of patients are at a particularly high relative risk of adverse outcomes. We examined the risk of new cardiovascular events and/or death in patients with depressive symptoms following first-time MI taking into account other secondary preventive factors. We further explored whether we could identify subgroups of patients with a particularly high relative risk of adverse outcomes.
Methods and Results
We conducted a prospective population-based cohort study of 897 patients discharged with first-time MI between 1 January 2009 and 31 December 2009, and followed up until 31 July 2012. Depressive symptoms were found in 18.6% using the Hospital Anxiety and Depression Scale (HADS-D≥8). A total of 239 new cardiovascular events, 95 deaths, and 288 composite events (239 new cardiovascular events and 49 deaths) occurred during 1,975 person-years of follow-up. Event-free survival was evaluated using Cox regression analysis. Compared to the 730 patients without depressive symptoms (HADS-D<8), the 167 patients with depressive symptoms (HADS-D≥8) had age- and sex-adjusted hazard ratios [HR] (95% confidence interval [CI]) of 1.53 (95% CI, 1.14–2.05) for a new cardiovascular event, 3.10 (95% CI, 2.04–4.71) for death and 1.77 (95% CI, 1.36–2.31) for a composite event. The associations were attenuated when adjusted for disease severity, comorbid conditions and physical inactivity; HR = 1.17 (95% CI, 0.85–1.61) for a new cardiovascular event, HR = 2.01 (95% CI, 1.28–3.16) for death, and HR = 1.33 (95% CI, 1.00–1.76) for a composite event. No subgroups of patients had a particularly high risk of adverse outcomes.
Depressive symptoms following first-time MI was an independent prognostic risk factor for death, but not for new cardiovascular events. We found no subgroups of patients with a particularly high relative risk of adverse outcomes.
PMCID: PMC3783427  PMID: 24086339
11.  A survey of cancer patients’ unmet information and coordination needs in handovers – a cross-sectional study 
BMC Research Notes  2013;6:378.
The care responsibilities for cancer patients are frequently handed over from one healthcare professional to another. These handovers are known to pose a threat to the safety of patients and the efficiency of the healthcare system. Little is known about specific needs of cancer patients in handovers. The objectives of this study were to examine cancer patients’ unmet needs for information and coordination in handovers and to analyse the association between patients’ demographic and clinical characteristics and unmet information and coordination needs.
Cancer patients treated in an oncology and a surgery outpatient setting completed a questionnaire developed to examine unmet information and coordination needs of cancer patients in handovers. Associations between unmet needs and comorbidity, treatment type, time since diagnosis, gender, age, and education in various handover situations were analysed.
Of 250 eligible patients 131 participated (response rate of 52%). Overall, 18% of patients had unmet coordination needs and 18% had unmet information needs.
Hospital discharge was the type of handover where patients most frequently reported unmet information needs (18%). Unmet coordination needs were most frequently reported in handovers between different hospitals (19%) and in handovers between hospital and general practice (18%). In general, age and education were statistically significantly associated with reporting unmet needs, where patients younger than 60 years and patients with a higher education were more likely to express unmet needs.
The findings indicate room for improvements regarding exchange of information and coordination between healthcare professionals, and between healthcare professionals and patients.
PMCID: PMC3850508  PMID: 24066725
Cancer; Need; Information; Coordination; Handovers
12.  General practice variation in spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease in Denmark: a population-based observational study 
BMC Family Practice  2013;14:113.
Spirometry testing is essential to confirm an obstructive lung disease, but studies have reported that a large proportion of patients diagnosed with COPD or asthma have no history of spirometry testing. Also, it has been shown that many patients are prescribed medication for obstructive lung disease without a relevant diagnosis or spirometry test registered. General practice characteristics have been reported to influence diagnosis and management of several chronic diseases. However, these findings are inconsistent, and it is uncertain whether practice characteristics influence spirometry testing among patients receiving medication for obstructive lung disease. The aim of this study was therefore to examine if practice characteristics are associated with spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease.
A national register-based cohort study was performed. All patients over 18 years receiving first-time prescriptions for medication targeting obstructive lung disease in 2008 were identified and detailed patient-specific data on sociodemographic status and spirometry tests were extracted. Information on practice characteristics like number of doctors, number of patients per doctor, training practice status, as well as age and gender of the general practitioners was linked to each medication user.
Partnership practices had a higher odds ratio (OR) of performing spirometry compared with single-handed practices (OR 1.24, CI 1.09-1.40). We found a significant association between increasing general practitioner age and decreasing spirometry testing. This tendency was most pronounced among partnership practices, where doctors over 65 years had the lowest odds of spirometry testing (OR 0.25, CI 0.10-0.61). Training practice status was significantly associated with spirometry testing among single-handed practices (OR 1.40, CI 1.10-1.79).
Some of the variation in spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease was associated with practice characteristics. This variation in performance may indicate a potential for quality improvement.
PMCID: PMC3750517  PMID: 23923987
Obstructive lung disease; Spirometry; Practice characteristics
13.  A randomised controlled trial to improve the role of the general practitioner in cancer rehabilitation: effect on patients’ satisfaction with their general practitioners 
BMJ Open  2013;3(7):e002726.
To test whether a complex intervention facilitating early cancer rehabilitation by involvement of the general practitioner (GP) soon after diagnosis improves patients’ satisfaction with their GPs.
A cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention or a control group before the start of the study. Patients included those with cancer who were subsequently allocated to either group based on the randomisation status of their GP.
Adult patients with cancer treated for incident cancer at the public regional hospital (Vejle Hospital, Denmark) were included between May 2008 and February 2009. A total of 955 patients registered with 323 practices were included, of which 486 patients were allocated to the intervention group and 469 to the control group.
The intervention included a patient interview assessing the need for rehabilitation, improved information from the hospital to GPs including information on the patients’ current needs along with information about needs of patients with cancer in general. Further, GPs were encouraged to proactively contact the patients and facilitate the patients’ rehabilitation course.
Outcome measures
6 months after inclusion of the patient, patient satisfaction with their GP during the last 12 months in five different dimensions of GP care was assessed using the Danish version of the EuroPEP (European Patients Evaluate General Practice Care) questionnaire (DanPEP). 14 months after inclusion, patient satisfaction with the GP regarding the cancer course and GP's satisfaction with own contribution to the patients’ rehabilitation course were assessed using ad hoc questions specifically designed for this study.
No overall effect of the intervention was observed. Subgroup analysis of the patients with breast cancer showed statistically significant improvement of satisfaction with the GP in two of the five DanPEP dimensions.
This complex intervention aiming at improving GPs’ services in cancer rehabilitation had no impact on patient satisfaction.
Trial registration, registration ID number NCT01021371
PMCID: PMC3703581  PMID: 23824312
14.  Influence of socioeconomic and demographic status on spirometry testing in patients initiating medication targeting obstructive lung disease: a population-based cohort study 
BMC Public Health  2013;13:580.
Socioeconomic status is known to influence the prevalence, severity and mortality of obstructive lung diseases, but it is uncertain whether it affects the use of diagnostic spirometry in patients initiating treatment for these conditions. The objective of this paper was to examine a possible association between education, income, labour market affiliation, cohabitation status and having spirometry performed when initiating medication targeting obstructive pulmonary disease.
We conducted a population-based cohort study. Danish national registers were linked, retrieving data on prescriptions, spirometry testing, socioeconomic and demographic variables in all first time users of medication targeting obstructive lung disease in 2008.
A total of 37,734 persons were included and approximately half of the cohort had spirometry performed. Among medication users under 65 years of age, being unemployed was significantly associated with reduced odds of having spirometry performed, the strongest association was seen in men (OR = 0.82, CI = 0.73-0.91). Medium income was associated with increased odds of having spirometry performed in men (OR = 1.18, CI = 1.06-1.30) and high educational level (>12 years) was associated with reduced odds of having spirometry performed in women (OR = 0.86, CI = 0.78-0.94). Cohabitation status was not associated with having spirometry performed. Among medication users over 65 years of age, living alone was associated with reduced odds of having spirometry performed among men (OR = 0.78, CI = 0.69-0.88).
Social inequity in spirometry testing among patients initiating medication targeting obstructive lung disease was confirmed in this study. Increased focus on spirometry testing among elderly men living alone, among the unemployed and among women with higher education is required when initiating medication.
PMCID: PMC3729528  PMID: 23768408
Socioeconomic Status; Spirometry; Obstructive Lung Disease
15.  Factors Associated with Antibiotic Prescribing in Children with Otitis Media 
ISRN Family Medicine  2013;2013:587452.
Background. Acute otitis media (AOM) is often treated with antibiotics. However, initial observation is recommended. Denmark has a low use of antibiotics compared with other countries, but the total use of antibiotics has increased by 32% during the last decade, and it is important to know whether general practitioners (GPs) prescribe antibiotics according to guidelines. Objective. The aim of the study was to analyse associations between GPs' antibiotic prescribing for AOM and symptoms, diagnoses, and characteristics of children. Methods. A cohort study where GPs consecutively included 954 children between 0 and 7 years old with a new ear symptom was carried out. The GPs registered symptoms, results of otoscopy and tympanometry, together with diagnosis and treatment. Results. Fever with and without earache was statistically associated with prescribing antibiotics, and it applies to both children up to two years of age (OR: 5.89 (confidence interval (CI): 2.62–13.21) and OR: 8.13 (CI: 4.61–14.32)) and children older than two years of age (OR: 4.59 (CI: 2.55–8.25) and OR: 19.45 (CI: 6.38–59.24)). A red tympanic membrane was statistically associated with the prescribing antibiotics in both age groups (0–2 years: OR: 4.73 (CI: 2.52–8.86) and >2–7 years: OR: 3.76 (CI: 2.13–6.64)). A flat tympanometry curve was only statistically associated with prescribing antibiotics in the oldest children (OR: 2.42 (CI: 1.17–5.00)). Conclusion. This study indicates that GPs to a large degree prescribe antibiotics appropriately according to guidelines.
PMCID: PMC4041257  PMID: 24967325
16.  A randomised controlled trial of hospital-based case management to improve colorectal cancer patients’ health-related quality of life and evaluations of care 
BMJ Open  2012;2(6):e001481.
To analyse the effectiveness of hospital-based case management (CM) in terms of patient-reported outcomes.
Randomised controlled trial allocating participants 1 : 1 to either a CM intervention or a control group. Allocation status was evident to participants and case managers, but blinded to researchers.
Patients were recruited at a Danish surgical department where the case managers were situated.
Colorectal cancer patients who were to undergo further investigation or treatment. Exclusion criteria were participation in another study, poor Danish language skills or apparent cognitive impairment. 140 participants were randomised to each group. Recruitment period was 11 March 2009 to 29 December 2010.
Control group patients had usual care. Intervention group patients had usual care supplemented by hospital-based CM started at first visit to the out-patient clinic (before treatment start) and ended 4 weeks after completed cancer treatment. CM was conducted by nurse case managers who undertook care pathway supervision, information dissemination to health professionals and outreaching patient support.
Outcome measures
Patient-reported global quality of life measured with the EORTC QLQ-C30 and eight ad hoc, piloted patient evaluation items assessed at eight, 30 and 52 weeks after randomisation.
The two groups were comparable as to questionnaire response rates and completed scales/items. There were no statistically significant group differences on any of the health-related quality of life subscales at eight, 30 or 52 weeks. In patient evaluations, all point estimates favoured CM at week 8 and 30; at week 52, 6 of 7 estimates favoured CM.
We found no evidence that CM influenced colorectal cancer patients’ health-related quality of life. Patients allocated to CM evaluated their care more positively than patients receiving usual care.
Trial registration identifier: NCT00845247.
PMCID: PMC3532978  PMID: 23175735
17.  Evaluation of general practitioners’ assessment of overweight among children attending the five-year preventive child health examination: A cross-sectional survey 
To evaluate general practitioners’ (GPs’) assessment of potential overweight among children attending the five-year preventive child health examination (PCHE) by comparing their assessment of the children's weight-for-stature with overweight defined by body mass index (BMI) according to paediatric standard definitions.
A cross-sectional survey. Data were obtained from a questionnaire survey of children's health in general and their growth in particular.
The five-year preventive child health examination (PCHE) in general practice in the Central Denmark Region.
Children attending the five-year PCHE in general practice, regardless of their weight status.
Main outcome measures
Paediatric standard definitions for childhood overweight based on BMI were used as the gold standard for categorizing weight-for-stature. Identification of overweight was analysed with regard to sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the GPs’ assessment of weight-for-stature.
A total of 165 GPs conducted 1138 PCHEs. GPs assessed that 171 children had a weight-for-stature above normal. Use of the Danish Standards (DS), i.e. the Danish national growth charts for BMI, as the gold standard yielded a sensitivity of 70.1% (95% CI 62.0–77.3) and a specificity of 92.4% (95% CI 90.6–93.9). The sensitivity was influenced by the GPs’ use of BMI and the presence of previous notes regarding abnormal weight development.
At the five-year PCHE almost one-third of overweight children were assessed to be normal weight by GPs. Use of BMI and presence of notes on abnormal weight in medical records were positively associated with a higher identification. Hence, utilization of medical record data and BMI charts may refine GPs’ assessment of childhood overweight.
PMCID: PMC3443942  PMID: 22934817
Assessment; children; Denmark; general practice; overweight; preventive child health examination
18.  Associations between reporting of cancer alarm symptoms and socioeconomic and demographic determinants: a population-based, cross-sectional study 
BMC Public Health  2012;12:686.
Reporting of symptoms which may signal cancer is the first step in the diagnostic pathway of cancer diseases. Cancer alarm symptoms are common in the general population. Public awareness and knowledge of cancer symptoms are sparse, however, and many people do not seek medical help when having possible cancer symptoms. As social inequality is associated with cancer knowledge, cancer awareness, and information-seeking, our hypothesis is that social inequality may also exist in the general population with respect to reporting of cancer alarm symptoms. The aim of this study was to investigate possible associations between socioeconomic and demographic determinants and reporting of common cancer alarm symptoms.
A cross-sectional questionnaire survey was performed based on a stratified sample of the Danish general population. A total of 13 777 randomly selected persons aged 20 years and older participated. Our main outcome measures were weighted prevalence estimates of self-reporting one of the following cancer alarm symptoms during the preceding 12 months: a lump in the breast, coughing for more than 6 weeks, seen blood in urine, or seen blood in stool. Logistic regression models were used to calculate unadjusted and adjusted odds ratios with 95% confidence intervals for the associations between each covariate and reporting of cancer alarm symptoms.
A total of 2 098 (15.7%) of the participants reported one or more cancer alarm symptoms within the preceding 12 months.
Women, subjects out of the workforce, and subjects with a cancer diagnosis had statistically significantly higher odds of reporting one or more cancer alarm symptoms. Subjects with older age and subjects living with a partner had lower odds of reporting one or more cancer alarm symptoms. When analysing the four alarm symptoms of cancer separately most tendencies persisted.
Socioeconomic and demographic determinants are associated with self-reporting of common cancer alarm symptoms.
PMCID: PMC3560107  PMID: 22914003
Breast cancer; Colorectal cancer; Cross-sectional survey; Lung cancer; Socioeconomic factors; Signs and symptoms; Urinary tract cancer
19.  The Danish Model for Improvement of Diabetes Care in General Practice: Impact of Automated Collection and Feedback of Patient Data 
Background. Sentinel Data Capture is an IT program designed to collect data automatically from GPs' electronic health record system. Data include ICPC diagnoses, National Health Service disbursement codes, laboratory analysis, and prescribed drugs. Quality feedback reports are generated individually for each practice on the basis of the accumulated data and are available online only for the specific practice. Objective. To describe the development of the quality of care concerning drug prescriptions for diabetes patients listed with GPs using the Data Capture module. Methods. In a cohort study, among 8320 registered patients with diabetes, we analyzed the change in the proportion of medication for uncontrolled cases of diabetes. Results. From 2009 to 2010, there was an absolute risk reduction of 1.35% (0.89–1.81: P < 0.001) in proportion of persons not in antidiabetic medication despite an HbA1c above 7.0. Similarly, there was a 4.51% (3.42–5.61: P < 0.001) absolute risk reduction in patients not in antihypertensive treatment despite systolic blood pressure above 130 mm Hg and 4.73% (3.56–5.90: P < 0.001) absolute risk reduction in patients with total cholesterol level above 4.5 mmol/L and not receiving lipid-lowering treatment. Conclusions. Structured collection of electronic data from general practice and feedback with reports on quality of care for diabetes patient seems to give a significant reduction in proportion of patients with no medical treatment over one year for participating GPs. Due to lack of a control group, we are, however, not able to say if the drop in the proportion of uncontrolled cases is a result of participation in collection of electronic data and feedback alone.
PMCID: PMC3409523  PMID: 22888424
20.  Enhanced involvement of general practitioners in cancer rehabilitation: a randomised controlled trial 
BMJ Open  2012;2(2):e000764.
To test the hypothesis that a multimodal intervention giving the general practitioner (GP) an enhanced role in cancer rehabilitation improves patients' health-related quality of life and psychological distress.
Cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention group or to a control group. Patients were subsequently allocated to intervention or control (usual procedures) based on the randomisation status of their GP.
All clinical departments at a public regional hospital treating cancer patients and all general practices in Denmark.
Adult patients treated for incident cancer at Vejle Hospital, Denmark, between 12 May 2008 and 28 February 2009. A total of 955 patients (486 to the intervention group and 469 to the control group) registered with 323 general practices were included.
The intervention included an interview about rehabilitation needs with a rehabilitation coordinator at the regional hospital, information from the hospital to the GP about individual needs for rehabilitation and an encouragement of the GP to contact the patient to offer his support with rehabilitation.
Main outcome measures
The primary outcome was health-related quality of life measured 6 months after inclusion using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Secondary outcomes included quality of life at 14 months and additional subscales of the EORTC QLQ-C30 at 6 and 14 months and psychological distress at 14 months using the Profile of Mood States Scale.
No effect of the intervention was observed on primary and/or secondary outcomes after 6 and 14 months.
A multimodal intervention aiming to give the GP an enhanced role in cancer patients' rehabilitation did not improve quality of life or psychological distress.
Trial registration, registration ID number NCT01021371.
Article summary
Article focus
Cancer patients experience a wide range of problems during and after treatment. Unmet rehabilitation needs are frequent.
GPs are expected to play a central role in cancer rehabilitation.
We tested the impact of a multimodal intervention aiming at enhancing GP involvement in cancer rehabilitation on quality of life and psychological distress of the patients.
Key messages
A multimodal intervention comprising a patient interview about unmet needs and an encouragement to the GP to initiate the rehabilitation process did not improve quality of life or psychological distress of cancer patients.
Interventions aiming to give the GP an enhanced role in cancer rehabilitation seem to have difficulties improving quality of life.
Future studies should evaluate the importance of GP involvement in and the organisation of cancer treatment and rehabilitation.
Strengths and limitations of this study
The study is the largest of its kind evaluating effect of GP involvement in cancer rehabilitation targeting a broad group of patients.
Albeit relevant and well-validated outcome measures were used, some sorts of effects of the intervention may not have been detected.
PMCID: PMC3332246  PMID: 22508956
21.  Participation in cancer rehabilitation and unmet needs: a population-based cohort study 
Supportive Care in Cancer  2012;20(11):2913-2924.
To investigate associations between cancer survivors’ sex, age, and diagnosis in relation to their (1) need for rehabilitation, (2) participation in rehabilitation activities, and (3) unmet needs for rehabilitation in a 14-month period following date of diagnosis.
A population-based cohort study was performed on incident cancer patients diagnosed from 1 October 2007 to 30 September 2008. Fourteen months after diagnosis, participants completed a questionnaire developed to measure the aspects of rehabilitation. Logistic regression analyses were used to explore the association between sex, age, and diagnosis, and the outcome variables for rehabilitation.
A total of 3,439 patients participated, yielding an overall response rate of 70%. One third of the cancer patients reported a need for physical rehabilitation and one third for psychological rehabilitation. Half of the patients participated in at least one activity. Unmet needs were most often reported in psychological, sexual, and financial areas. Women expressed more needs, participated more often in rehabilitation activities, and had, to a higher extent, their emotional needs fulfilled. Breast cancer patients participated more often in physical rehabilitation. Elderly who expressed rehabilitation needs more often had them unresolved.
A substantial variation in rehabilitation needs, participation in activities, and unmet needs in relation to sex, age, and cancer type was observed. Cancer care ought to systematically address the wide range of needs in all groups through integration of systematic needs assessment and targeted supply of offers.
PMCID: PMC3461205  PMID: 22415608
Cancer; Patient; Rehabilitation; Unmet needs; Participation
22.  Rehabilitation status three months after first-time myocardial infarction 
To describe the rehabilitation status three months after first-time myocardial infarction (MI) to identify focus areas for long-term cardiac rehabilitation (CR) in general practice.
Population-based cross-sectional study.
Setting and subjects
Patients with first-time MI in 2009 from the Central Denmark Region. Data were obtained from patient questionnaires and from registers.
Of the 1288 eligible patients, 908 (70.5%) responded. The mean (SD) age was 67.1 (11.7) years and 626 (68.9%) were men. Overall, 287 (31.6%) of the patients lived alone and 398 (45.4%) had less than 10 years of education. Upwards of half (58.5%) of the patients stated that they had participated in hospital-based rehabilitation shortly after admission. A total of 262 (29.2%) were identified with anxiety or depressive disorder or both, according to the Hospital Anxiety and Depression Scale. Of these, 78 (29.8%) reported that they had participated in psychosocial support, and 55 (21.0%) used antidepressants. One in five patients smoked three months after MI although nearly half of the smokers had stopped after the MI. Regarding cardioprotective drugs, 714 (78.6%) used aspirin, 694 (76.4%) clopidogrel, 756 (83.3%) statins, and 735 (81.0%) beta-blockers.
After three months, there is a considerable potential for further rehabilitation of MI patients. In particular, the long-term CR should focus on mental health, smoking cessation, and cardioprotective drugs.
PMCID: PMC3308468  PMID: 22126219
Depression; drug therapy; family practice; myocardial infarction; rehabilitation; smoking
23.  Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients 
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.
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.
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)).
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 4th 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.
PMCID: PMC3217887  PMID: 22027084
24.  General practitioner characteristics and delay in cancer diagnosis. a population-based cohort study 
BMC Family Practice  2011;12:100.
Delay in cancer diagnosis may have serious prognostic consequences, and some patients experience delays lasting several months. However, we have no knowledge whether such delays are associated with general practitioner (GP) characteristics. The aim of the present study was to analyse whether GP and practice characteristics are associated with the length of delay in cancer diagnosis.
The study was designed as a population-based cohort study. The setting was the County of Aarhus, Denmark (640,000 inhabitants). Participants include 334 GPs and their 1,525 consecutive, newly diagnosed cancer patients. During one year (September 2004 to August 2005), patients with incident cancer were enrolled from administrative registries. GPs completed questionnaires on the patients' diagnostic pathways and on GP and practice characteristics. Delay was categorised as patient-related (more than 60 days), doctor-related (more than 30 days) and system-related (more than 90 days). The associations between delay and characteristics were assessed in a logistic regression model using odds ratios (ORs).
No GP characteristics (seniority, practice organization, list size, participation in continuing medical education, job satisfaction and level of burnout) were associated with doctor delay. Patients of female GPs more often had a short patient delay than patients of male GPs (OR 0.44, 95% confidence interval (95%CI) 0.28 to 0.71). Patients whose GPs provided many services (OR 0.66, 95%CI 0.44 to 0.95) and patients attending GPs with little former knowledge of their patients (OR 0.68, 95%CI 0.47 to 0.99) more often experienced a short system delay than patients attending GPs with less activity and more knowledge of their patients. Patients listed with a female GP more often experienced a long system delay than patients of male GPs (OR 1.50, 95%CI 1.02 to 2.21). Finally, patients with low GP-reported compliance more often experienced a long system delay (OR 1.73, 95%CI 1.07 to 2.80) than patients with higher compliance.
GP characteristics were not statistically significantly associated with doctor delay. However, some GP characteristics were associated with patient and system delay, which indicates that these factors may be important for understanding patient delay (e.g. perceived GP accessibility and the GP-patient relationship) and system delay (e.g. the GP's experience and opportunities for referring and coordinating diagnostic work-up).
PMCID: PMC3191468  PMID: 21943310
Cancer diagnosis; delay; GP characteristics; Denmark; family practice
25.  Does the organizational structure of health care systems influence care-seeking decisions? A qualitative analysis of Danish cancer patients' reflections on care-seeking 
The absence of a more significant improvement in cancer survival in countries such as the UK and Denmark may be partly rooted in delayed care-seeking among cancer patients. Past research on patient delay has mainly focused on patient characteristics (e.g. sociodemographic and psychological factors and symptom recognition) as causes of delayed care-seeking, while few studies have examined how the organizational structure of health care systems may influence patients’ reflections on seeking care. The aim of this study was to explore this relationship.
The analysis presented is based on semi-structured interviews with 30 cancer patients and their families.
The article raises two hypotheses on the relationship between structural elements of a health care system and people's reflections on seeking health care: (1) Gatekeeping introduces an asymmetrical relationship between the patient and the GP which potentially results in self-restricting care-seeking, (2) Continuity in the doctor–patient relationship may negatively influence patient reflections on access to health care, as the focus shifts from the medical issues of the consultation to reflections on how to properly interact with the GP and the system in which she/he is situated.
It is concluded that these hypotheses form a sound basis for further primary care research on how the organizational structure of health care systems influences patient reflections on access to medical care.
PMCID: PMC3347951  PMID: 21861597
Cancer; care-seeking; health care systems; patient delay

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