New institutional setting, new organizational configurations: Redesigning the Danish emergency care system via a contingency approach

As a result of major administrative reform in 2007, the Danish emergency care system is undergoing the largest reorganization in decades (MHP, 2008; Vrangbaek, 2013). The number of acute hospitals has been reduced from more than 40 to 21 and new emergency departments (EDs) have been established (MHP, 2008; Wen et al., 2013, Mattsson, Mattsson & J\uf8rsboe, 2014). The EDs are the cornerstones of the Danish National Health System (NHS), as up to 70% of all acute care patients are evaluated there; they can be treated and discharged, or admitted for further care (MHP, 2008; Wen et al., 2013). The EDs therefore play a crucial role in determining the design of the overall healthcare, being a critical pathway for acute care and addressing hospital crowding. The Danish emergency care system represents an organizational field (DiMaggio & Powell, 1983) in which highly specialized healthcare actors, such as primary care physicians (PCPs), systems of out-of-hours care clinics, ambulance systems, and hospitals, have to coordinate their actions with the ultimate objective of providing a timely and appropriate response toward the collective. On the other hand, following the general reform of 2007, the National Board of Health in Denmark (NBHD) has recommended the delivery of emergency care through fewer, larger, and more centralized EDs. This was done to concentrate specialties and provide a higher level of care with greater efficiency in a system in which the patients\u2019 overall impression of hospitalization has traditionally been positive (MHP, 2008). Moreover, the overall reform generated (external) financial crunches for healthcare providers that predictably turned into internal pressures related to efficiency (e.g., Louis et al., 1999; Lega & DePietro, 2005; Reay & Hinings, 2005, 2009). The search for efficiency through the maximization of economies of scale, by concentrating specialized knowledge and equipment, is generating some symbiotic organizational effects. These can be studied at different levels of analysis (Hackman, 2003): a) at the macro level, through a general rationalization of public expense, in two ways: a.1) regions are in charge of the planning and delivery of healthcare, and new regional mechanisms for governance and funding, resulting in the diffusion of new performance appraisal approaches; a.2) positive operational spillovers are exploited amongst agents through coordination mechanisms based on healthcare networks, with several interdependent providers covering the various phases of emergency care; b) at the meso level, via the definition of structures, roles, and procedures of emergency care. In essence, each hospital designs its own ED, with different levels of managerial autonomy, human resource specialization, technological endowment, and design of internal processes. In short, the Danish emergency care system is trying to change toward a more cost-effective but also a more patient-oriented configuration; c) at the micro level, via the design of appropriate incentives for professionals. In Fearlie and Shortell\u2019s (2001) terms, \u201cA multilevel approach to change and the associated core properties can provide a framework for assessing progress on these and related issues over the next several years\u201d (p. 307). This paper presents the preliminary results of a larger research project called DESIGN-EM, aimed at designing effective and efficient EDs. In a dynamic environment, in which each of the 21 Danish hospitals is still configuring its own ED, this research project aims to determine if differences in organization designs affect efficiency, effectiveness, the quality of patient care, and resource utilization. It reports on the part of the project attempting to investigate the meso level of analysis (hospitals/EDs), and focuses on the research gap related to the adoption of the multi-contingency approach (Burton & Obel, 1988, 2004) in the design of emergency care, with a specific focus on the EDs (Table 1). Thus, this research addresses the following research question: How can hospitals design their EDs to adapt to institutional, technological, and clinical dynamics

Prenatal antidepressant exposure and child behavioural outcomes at 7 years of age: a study within the Danish National Birth Cohort

Objective: To investigate the impact of prenatal antidepressant exposure on behavioural problems in children at 7 years of age. Design: Nationwide population-based study. Setting: Danish National Birth Cohort. Population: A cohort of 49 178 pregnant women recruited between 1996 and 2002. Methods: Data obtained from computer-assisted telephone interviews twice during pregnancy were used to identify children born to: (i) depressed women who took antidepressants during pregnancy (n = 210); (ii) depressed women who did not take any antidepressants during pregnancy (n = 231); and (iii) healthy women who were not depressed (n = 48 737). Childhood behavioural problems at 7 years of age were examined using the validated Danish parent-report version of the Strengths and Difficulties Questionnaire (SDQ). Main outcome measures: SDQ scores. Results: No associations were observed between prenatal antidepressant exposure and abnormal SDQ scores for overall problem behaviour (adjusted relative risk, aRR 1.00; 95% confidence interval, 95% CI 0.49–2.05), hyperactivity/inattention (aRR 0.99; 95% CI 0.56–1.75), or peer problems (aRR 1.04; 95% CI 0.57–1.91). Although prenatal antidepressant exposure appeared to be associated with abnormal SDQ scores on the subscales of emotional symptoms (aRR 1.68; 95% CI 1.18–2.38) and conduct problems (aRR 1.58; 95% CI 1.03–2.42), these associations were significantly attenuated following adjustment for antenatal mood status (aRR 1.20; 95% CI 0.85–1.70 and aRR 1.19; 95% CI 0.77 1.83, respectively). Untreated prenatal depression was associated with an increased risk of all behavioural outcomes evaluated, compared with unexposed children, with significant attenuation following adjustment for antenatal mood status. Conclusions: The results of this study suggest that independent of maternal illness, prenatal antidepressant exposure is not associated with an increased risk of behavioural problems in children at 7 years of age.LE Grzeskowiak, JL Morrison, TB Henrikse, BH Bech, C Obel, J Olsen, LH Pederse

CD4 cell count and the risk of AIDS or death in HIV-Infected adults on combination antiretroviral therapy with a suppressed viral load: a longitudinal cohort study from COHERE.

BACKGROUND: Most adults infected with HIV achieve viral suppression within a year of starting combination antiretroviral therapy (cART). It is important to understand the risk of AIDS events or death for patients with a suppressed viral load. METHODS AND FINDINGS: Using data from the Collaboration of Observational HIV Epidemiological Research Europe (2010 merger), we assessed the risk of a new AIDS-defining event or death in successfully treated patients. We accumulated episodes of viral suppression for each patient while on cART, each episode beginning with the second of two consecutive plasma viral load measurements 500 copies/µl, the first of two consecutive measurements between 50-500 copies/µl, cART interruption or administrative censoring. We used stratified multivariate Cox models to estimate the association between time updated CD4 cell count and a new AIDS event or death or death alone. 75,336 patients contributed 104,265 suppression episodes and were suppressed while on cART for a median 2.7 years. The mortality rate was 4.8 per 1,000 years of viral suppression. A higher CD4 cell count was always associated with a reduced risk of a new AIDS event or death; with a hazard ratio per 100 cells/µl (95% CI) of: 0.35 (0.30-0.40) for counts <200 cells/µl, 0.81 (0.71-0.92) for counts 200 to <350 cells/µl, 0.74 (0.66-0.83) for counts 350 to <500 cells/µl, and 0.96 (0.92-0.99) for counts ≥500 cells/µl. A higher CD4 cell count became even more beneficial over time for patients with CD4 cell counts <200 cells/µl. CONCLUSIONS: Despite the low mortality rate, the risk of a new AIDS event or death follows a CD4 cell count gradient in patients with viral suppression. A higher CD4 cell count was associated with the greatest benefit for patients with a CD4 cell count <200 cells/µl but still some slight benefit for those with a CD4 cell count ≥500 cells/µl

The HIV continuum of care in European Union countries in 2013: data and challenges

BACKGROUND: UNAIDS has set a 90-90-90 target to curb the HIV epidemic by 2020, but methods used to assess whether countries have reached this target are not standardised, hindering comparisons. METHODS: Through a collaboration formed by the European Centre for Disease Prevention and Control (ECDC) with European HIV cohorts and surveillance agencies, we constructed a standardised, four-stage continuum of HIV care for 11 European Union (EU) countries for 2013. Stages were defined as: 1) number of people living with HIV (PLHIV) in the country by end of 2013; 2) proportion of stage 1 ever diagnosed; 3) proportion of stage 2 ever initiated ART; and 4) proportion of stage 3 who became virally-suppressed (≤200 copies/mL). Case surveillance data were used primarily to derive stages 1 (using back-calculation models) and 2, and cohort data for stages 3 and 4. RESULTS: In 2013, 674,500 people in the 11 countries were estimated to be living with HIV, ranging from 5,500 to 153,400 in each country. Overall HIV prevalence was 0.22% (range 0.09%-0.36%). Overall proportions, of each previous stage, were 84% diagnosed, 84% on ART, and 85% virally-suppressed (60% of PLHIV). Two countries achieved ≥90% for all stages, and over half had reached ≥90% for at least one stage. CONCLUSIONS: EU countries are nearing the 90-90-90 target. Reducing the proportion undiagnosed remains the greatest barrier to achieving this target, suggesting further efforts are needed to improve HIV testing rates. Standardising methods to derive comparable continuums of care remains a challenge

Surfactant protein-D is an independent predictor of all-cause mortality in men with peripheral artery disease diagnosed by population-based screening

Introduction: Peripheral artery disease (PAD) is a common condition caused by atherosclerosis, which leads to reduced blood flow to the limbs. PAD is associated with major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Surfactant protein-D (SP-D) is a defense lectin expressed in the lungs and vasculature and has been previously associated with PAD. Methods: We aimed to examine the prognostic value of plasma SP-D in relation to MACE, MALE, and all-cause mortality in 913 men with PAD diagnosed through population-based screening. The cohort was divided into low plasma SP-D (&lt;420.4 ng/ml) and high SP-D (≥420.4 ng/ml) based on the 95th percentile of baseline measurements. The data were analyzed using univariate and multivariate Cox regression analyses. Results: SP-D was not associated with MACE or MALE. All-cause mortality was significantly increased in the high SP-D group compared with the low SP-D group (31.1% vs. 14.9%, p = 0.003), with an adjusted hazard ratio of 2.40 (1.36–4.24), p = 0.003, over a mean follow-up period of 5.2 ± 1 years. Discussion: SP-D is not associated with MALE and MACE but is an independent predictor of all-cause mortality in men with PAD diagnosed through population-based screening.</p

The strengths and difficulties questionnaire as a predictor of parent-reported diagnosis of autism spectrum disorder and attention deficit hyperactivity disorder

notes: PMCID: PMC3848967This is a freely-available open access publication. Please cite the published version which is available via the DOI link in this record.The Strengths and Difficulties Questionnaire (SDQ) is widely used as an international standardised instrument measuring child behaviour. The primary aim of our study was to examine whether behavioral symptoms measured by SDQ were elevated among children with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) relative to the rest of the population, and to examine the predictive value of the SDQ for outcome of parent-reported clinical diagnosis of ASD/ADHD. A secondary aim was to examine the extent of overlap in symptoms between children diagnosed with these two disorders, as measured by the SDQ subscales. A cross-sectional secondary analysis of data from the Millennium Birth Cohort (n = 19,519), was conducted. Data were weighted to be representative of the UK population as a whole. ADHD or ASD identified by a medical doctor or health professional were reported by parents in 2008 and this was the case definition of diagnosis; (ADHD n = 173, ASD n = 209, excluding twins and triplets). Study children's ages ranged from 6.3-8.2 years; (mean 7.2 years). Logistic regression was used to examine the association between the parent-reported clinical diagnosis of ASD/ADHD and teacher and parent-reported SDQ subscales. All SDQ subscales were strongly associated with both ASD and ADHD. There was substantial co-occurrence of behavioral difficulties between children diagnosed with ASD and those diagnosed with ADHD. After adjustment for other subscales, the final model for ADHD, contained hyperactivity/inattention and impact symptoms only and had a sensitivity of 91% and specificity of 90%; (AUC) = 0.94 (95% CI, 0.90-0.97). The final model for ASD was composed of all subscales except the 'peer problems' scales, indicating of the complexity of behavioural difficulties that may accompany ASD. A threshold of 0.03 produced model sensitivity and specificity of 79% and 93% respectively; AUC = 0.90 (95% CI, 0.86-0.95). The results support changes to DSM-5 removing exclusivity clauses.ESRCNational Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsul

Nutritive value of unconventional fibrous ingredients fed to Guinea pigs in the Democratic Republic of Congo

peer reviewedThe energy and protein value for Guinea pigs (GP) of 9 forages (7 dicots and 2 grasses) and 5 hay-based diets was determined. The apparent faecal digestibility of dry matter, organic matter, crude protein and energy was measured on GP housed in metabolic cages. The forages and the diets were digested in vitro using pepsin and pancreatin hydrolysis and gas fermentation test to simulate stomach, small intestine and large intestine, respectively. Most of the dicots had high digestible crude protein content (152–201 g/kg DM) and the 2 grasses showed lower values (80–85 g/kg DM). Digestible energy content of the forages ranged between 5.79 to 13.08 MJ/kg DM. None of the forage species or hay-based diets provided sufficient energy to supply the 11.7 MJ/kg metabolic energy requirements. The influence of intestinal fermentation on energy and protein values was highlighted by correlations (P<0.05) between in vivo and in vitro data, including gas fermentation. It is the first time that such relationships are reported in single-stomach animals

The association between preschool behavioural problems and internalizing difficulties at age 10-12 years

The aim was to study the association between preschool behavioural problems and emotional symptoms in 10- to 12-year-old children. The study was based on the Aarhus Birth cohort, Denmark, and included 1,336 children. Based on the parent-administered preschool behaviour questionnaire (PBQ), we identified three not mutually exclusive preschool behavioural categories: anxious–fearful (n = 146), hyperactive–distractible (n = 98), and hostile–aggressive (n = 170). Children without any known symptoms were considered well adjusted (n = 1,000). Borderline emotional (n = 105) and emotional difficulties (n = 136) were measured at age 10–12 years with the parent-administered strength and difficulties questionnaire (SDQ). Multinomial logistic regression analyses were used to adjust for potential confounding factors. We found that anxious–fearful behaviour and hostile–aggressive preschool behaviour were associated with twice the risk of school-age emotional difficulties. Comorbidity or confounding failed to explain these results. Hyperactive–distractible preschool behaviour was not associated with school-age emotional difficulties. Preschool anxious–fearful behaviour was associated with school-age emotional difficulties, suggesting internalizing symptom stability in some children from early childhood. Preschool hostile–aggressive behaviour was also associated with school-age emotional difficulties, which suggests transformation of one behavioural dimension into another through childhood, and the need to focus on both early internalizing difficulties and hostile–aggressive behaviour as risk factors for later internalizing difficulties

Association Study of Common Genetic Variants and HIV- 1 Acquisition in 6,300 Infected Cases and 7,200 Controls

Multiple genome-wide association studies (GWAS) have been performed in HIV-1 infected individuals, identifying common genetic influences on viral control and disease course. Similarly, common genetic correlates of acquisition of HIV-1 after exposure have been interrogated using GWAS, although in generally small samples. Under the auspices of the International Collaboration for the Genomics of HIV, we have combined the genome-wide single nucleotide polymorphism (SNP) data collected by 25 cohorts, studies, or institutions on HIV-1 infected individuals and compared them to carefully matched population-level data sets (a list of all collaborators appears in Note S1 in Text S1). After imputation using the 1,000 Genomes Project reference panel, we tested approximately 8 million common DNA variants (SNPs and indels) for association with HIV-1 acquisition in 6,334 infected patients and 7,247 population samples of European ancestry. Initial association testing identified the SNP rs4418214, the C allele of which is known to tag the HLA-B*57:01 and B*27:05 alleles, as genome-wide significant (p = 3.6×10−11). However, restricting analysis to individuals with a known date of seroconversion suggested that this association was due to the frailty bias in studies of lethal diseases. Further analyses including testing recessive genetic models, testing for bulk effects of non-genome-wide significant variants, stratifying by sexual or parenteral transmission risk and testing previously reported associations showed no evidence for genetic influence on HIV-1 acquisition (with the exception ofCCR5Δ32 homozygosity). Thus, these data suggest that genetic influences on HIV acquisition are either rare or have smaller effects than can be detected by this sample size