Ramune Jacobsen

Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches

BackgroundSelf-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.MethodsWe conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice.ResultsSelf-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture.ConclusionsAlthough collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.

Reported barriers to evaluation in chronic care: Experiences in six European countries.

INTRODUCTION The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries. METHODS We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation. RESULTS We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors. CONCLUSIONS This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies.

Procedural pain of an ultrasound-guided brachial plexus block: a comparison of axillary and infraclavicular approaches

Background: Ultrasound (US)‐guided infraclavicular (IC) and axillary (AX) blocks have similar effectiveness. Therefore, limiting procedural pain may help to choose a standard approach. The primary aims of this randomized study were to assess patients pain during the block and to recognize its cause.

The Danish version of the Medication Adherence Report Scale: Preliminary Validation in Cancer Pain Patients

Objective:  To examine the psychometric properties of the Danish version of the Medication Adherence Report Scale (DMARS‐4) adapted to measure adherence to analgesic regimen among cancer patients.

The influence of early exposure to vitamin D for development of diseases later in life

BackgroundVitamin D deficiency is common among otherwise healthy pregnant women and may have consequences for them as well as the early development and long-term health of their children. However, the importance of maternal vitamin D status on offspring health later in life has not been widely studied. The present study includes an in-depth examination of the influence of exposure to vitamin D early in life for development of fractures of the wrist, arm and clavicle; obesity, and type 1 diabetes (T1D) during child- and adulthood.Methods/designThe study is based on the fact that in 1961 fortifying margarine with vitamin D became mandatory in Denmark and in 1972 low fat milk fortification was allowed. Apart from determining the influences of exposure prior to conception and during prenatal life, we will examine the importance of vitamin D exposure during specific seasons and trimesters, by comparing disease incidence among individuals born before and after fortification. The Danish National databases assure that there are a sufficient number of individuals to verify any vitamin D effects during different gestation phases. Additionally, a validated method will be used to determine neonatal vitamin D status using stored dried blood spots (DBS) from individuals who developed the aforementioned disease entities as adults and their time and gender-matched controls.DiscussionThe results of the study will contribute to our current understanding of the significance of supplementation with vitamin D. More specifically, they will enable new research in related fields, including interventional research designed to assess supplementation needs for different subgroups of pregnant women. Also, other health outcomes can subsequently be studied to generate multiple health research opportunities involving vitamin D. Finally, the results of the study will justify the debate of Danish health authorities whether to resume vitamin D supplementation policies.

Gestational and Early Infancy Exposure to Margarine Fortified with Vitamin D through a National Danish Programme and the Risk of Type 1 Diabetes: The D-Tect Study

The objective of the study was to assess whether gestational and early infancy exposure to low dose vitamin D from a mandatory margarine fortification programme in Denmark influenced the risk of developing type 1 diabetes (T1D) before age of 15 years. The study population included all individuals born in Denmark from 1983 to 1988 and consisted of 331,623 individuals. The 1st of June 1985, which was the date of issue of the new ministerial order cancelling mandatory fortification of margarine with vitamin D in Denmark, served as a reference point separating the studied population into various exposure groups. We further modelled birth cohort effects in children developing T1D as a linear spline, and compared the slopes between the birth cohorts with various prenatal and infancy exposures to vitamin D fortification. In total, 886 (0.26%) individuals developed T1D before the age of 15 years. The beta coefficients (95% CI), or slopes, for linear birth cohort effect in log Hazard Ratio (HR) per one month of birth in individuals born during the periods of gestational exposure, wash-out, and non-exposure were: 0.010 (-0.002/0.021), -0.010 (-0.035/0.018), and 0.008 (- 0.017/0.032), respectively. The beta coefficients (95% CI) for individuals born during the periods of first postnatal year exposure, wash-out, and non-exposure were: 0.007 (-0.016/0.030), 0.006 (-0.004/0.016), and 0.007 (-0.002/0.016), respectively. In conclusion, we found no evidence to support that exposure to low dose vitamin D from the Danish mandatory margarine fortification regimen during gestational and first postnatal year of life changed the risk of developing T1D before the age of 15 years.

Exposure to sunshine early in life prevented development of type 1 diabetes in Danish boys.

Abstract Background: We aimed to assess the association between exposure to sunshine during gestation and the risk of type 1 diabetes (T1D) in Danish children. Methods: The study population included 331,623 individuals born in Denmark from 1983 to 1988; 886 (0.26%) developed T1D by the age of 15 years. The values of sunshine hours were obtained from the Danish Meteorological Institute. Gestational exposure to sunshine was calculated by summing recorded monthly sunshine hours during the full 9 months prior to the month of birth. The linear variable then was split into two categories separated by the median value. Results and Conclusions: Cox regression models showed that more sunshine during the third gestational trimester was associated with lower hazards (HR) of T1D at age 5–9 years in males: HR (95% CI): 0.60 (0.43–0.84), p=0.003. Our results should be considered in the context of evidence-based recommendations to the public about skin protection from the sun.

Barriers to cancer pain management in Danish and Lithuanian patients treated in pain and palliative care units.

The prevalence of cancer-related pain is high despite available guidelines for the effective assessment and management of that pain. Barriers to the use of opioid analgesics partially cause undertreatment of cancer pain. The aim of this study was to compare pain management outcomes and patient-related barriers to cancer pain management in patient samples from Denmark and Lithuania. Thirty-three Danish and 30 Lithuanian patients responded to, respectively, Danish and Lithuanian versions of the Brief Pain Inventory pain scale, the Barriers Questionnaire II, the Hospital Anxiety and Depression Scale, the Specific Questionnaire On Pain Communication, and the Medication Adherence Report Scale. Emotional distress and patient attitudes toward opioid analgesics in cancer patient samples from both countries explained pain management outcomes in the multivariate regression models. Pain relief and pain medication adherence were better in Denmark, and the country of origin significantly explained the difference in the regression models for these outcomes. In conclusion, interventions in emotional distress and patient attitudes toward opioid analgesics may result in better pain management outcomes generally, whereas poor adherence to pain medication and poor pain relief appear to be more country-specific problems.

Impact of Exercise Capacity on Dyspnea and Health-Related Quality of Life in Patients With Chronic Obstructive Pulmonary Disease.

PURPOSE: To assess the impact of the amount of exercise training during pulmonary rehabilitation (PR) program for improvements in dyspnea and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD). METHODS: Data on COPD patient health, exercise capacity, dyspnea, and HRQOL were collected at the start and at the end of PR, which was provided in the ambulatory section of the hospital and lasted for 7 weeks. Pulmonary rehabilitation program included exercise training, education, smoking cessation, and diet consultation sessions. Data were analyzed using multivariable linear regression. RESULTS: Baseline data were obtained from a total of 143 patients with followup data in 108 patients available at the end of PR. The majority of the patient population had severe disease progression of COPD as exhibited by spirometry test results. Results of multivariable analyses showed that after adjustment for sociodemographic characteristics and baseline patient characteristics, changes in dyspnea and exercise capacity were directly and linearly predicted by the number of exercise training sessions attended. Changes in disease-specific and general HRQOL outcomes were not predicted by the amount of exercise training received during PR. CONCLUSIONS: Quality of life in patients with COPD is predicted by dyspnea. Thus, to further investigate the influence of exercise training on quality of life in patients with CODP, simultaneous assessment of dyspnea should be considered.

The Danish Barriers Questionnaire-II: preliminary validation in cancer pain patients.

Objective:  The objective of this study was to examine the psychometric properties of the Danish version of the Barriers Questionnaire‐II (DBQ‐II).