Troels Kristensen

Perceived stress as a risk factor for changes in health behaviour and cardiac risk profile: a longitudinal study

Objective.u2002 The aim of this study was to evaluate the long‐term effects of stress on changes in health behaviour and cardiac risk profile in men and women.

Potential gains from hospital mergers in Denmark

The Danish hospital sector faces a major rebuilding program to centralize activity in fewer and larger hospitals. We aim to conduct an efficiency analysis of hospitals and to estimate the potential cost savings from the planned hospital mergers. We use Data Envelopment Analysis (DEA) to estimate a cost frontier. Based on this analysis, we calculate an efficiency score for each hospital and estimate the potential gains from the proposed mergers by comparing individual efficiencies with the efficiency of the combined hospitals. Furthermore, we apply a decomposition algorithm to split merger gains into technical efficiency, size (scale) and harmony (mix) gains. The motivation for this decomposition is that some of the apparent merger gains may actually be available with less than a full-scale merger, e.g., by sharing best practices and reallocating certain resources and tasks. Our results suggest that many hospitals are technically inefficient, and the expected “best practice” hospitals are quite efficient. Also, some mergers do not seem to lower costs. This finding indicates that some merged hospitals become too large and therefore experience diseconomies of scale. Other mergers lead to considerable cost reductions; we find potential gains resulting from learning better practices and the exploitation of economies of scope. To ensure robustness, we conduct a sensitivity analysis using two alternative returns-to-scale assumptions and two alternative estimation approaches. We consistently find potential gains from improving the technical efficiency and the exploitation of economies of scope from mergers.

Economies of scale and scope in the Danish hospital sector prior to radical restructuring plans

OBJECTIVEnThe Danish hospital sector faces a significant rebuilding program driven by recent regional reform and guidelines for acute admission hospitals. Within the next 5-10 years, the number of public hospitals offering acute admission will be reduced from 35 to approximately 20 larger hospitals. As the administrative data may be biased during the middle of a restructuring process our objective was to analyze whether the configuration of Danish public hospitals was subject to economies of scale and scope prior to the restructuring plans.nnnMETHODSnWe estimated a quadratic cost function using panel data on the total costs for somatic treatment, casemix adjusted DRG-production values, and other cost drivers for the three years before the 2007 reforms. A short-run cost function was used to derive estimates of a long-run cost function by applying the envelope condition. Next, we estimated economies of scale and scope.nnnRESULTSnWe identified moderate-to-significant economies of scale and scope. This indicates that the Danish hospital sector was characterized by unexploited gains from consolidation.nnnCONCLUSIONSnOur results suggest that the proposed plans have the potential to result in hospitals that are more efficient. However, post-restructuring studies elsewhere show that the strategy of horizontal integration has failed.

Cost variation in diabetes care delivered in English hospitals

Diabet. Med. 27, 949–957 (2010)

Resources allocation and health care needs in diabetes care in Danish GP clinics

BACKGROUNDnIn several countries, morbidity burdens have prompted authorities to change the system for allocating resources among patients from a demographic-based to a morbidity-based casemix system. In Danish general practice clinics, there is no morbidity-based casemix adjustment system.nnnAIMnThe aim of this paper was to assess what proportions of the variation in fee-for-service (FFS) expenditures are explained by type 2 diabetes mellitus (T2DM) patients co-morbidity burden and illness characteristics.nnnMETHODS AND DATAnWe use patient morbidity characteristics such as diagnostic markers and co-morbidity casemix adjustments based on resource utilisation bands and FFS expenditures for a sample of 6706 T2DM patients in 59 general practices for the year 2010. We applied a fixed-effect approach.nnnRESULTSnAverage annual FFS expenditures were approximately 398 euro per T2DM patient. Expenditures increased progressively with the patients degree of co-morbidity and were higher for patients who suffered from diagnostic markers. A total of 17-25% of the expenditure variation was explained by age, gender and patients morbidity patterns.nnnCONCLUSIONnT2DM patient morbidity characteristics are significant patient related FFS expenditure drivers in diabetes care. To address the specific health care needs of T2DM patients in GP clinics, our study indicates that it may be advisable to introduce a morbidity based casemix adjustment system.

Organisational determinants of production and efficiency in general practice: a population-based study

ObjectiveShortage of general practitioners (GPs) and an increased political focus on primary care have enforced the interest in efficiency analysis in the Danish primary care sector. This paper assesses the association between organisational factors of general practices and production and efficiency.MethodsWe assume that production and efficiency can be modelled using a behavioural production function. We apply the Battese and Coelli (Empir Econ 20:325–332, 1995) estimator to accomplish a decomposition of exogenous variables to determine the production frontier and variables determining the individual GPs distance to this frontier. Two different measures of practice outputs (number of office visits and total production) were applied and the results compared.ResultsThe results indicate that nurses do not substitute GPs in the production. The production function exhibited constant returns to scale. The mean level of efficiency was between 0.79 and 0.84, and list size was the most important determinant of variation in efficiency levels.ConclusionsNurses are currently undertaking other tasks than GPs, and larger practices do not lead to increased production per GP. However, a relative increase in list size increased the efficiency. This indicates that organisational changes aiming to increase capacity in general practice should be carefully designed and tested.

Resource allocation and the burden of co-morbidities among patients diagnosed with chronic obstructive pulmonary disease: An observational cohort study from Danish general practice

BackgroundChronic obstructive pulmonary disease is a leading cause of mortality, and associated with increased healthcare utilization and healthcare expenditure. In several countries, morbidity-based systems have changed the way resources are allocated in general practice. In primary care, fee-for-services tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated expenditures for patients with chronic obstructive pulmonary disease has not previously been examined. The aim of this study is to analyze fee-for-service expenditure of patients diagnosed with chronic obstructive pulmonary disease visiting Danish general practice clinics and further to assess what proportion of fee-for-service expenditure variation was explained by patient morbidity and general practice clinic characteristics, respectively.MethodsWe used patient morbidity characteristics such as diagnostic markers and multi-morbidity adjustment based on adjusted clinical groups (ACGs) and fee-for-service expenditure for a sample of primary care patients for the year 2010. Our sample included 3,973 patients in 59 general practices. We used a multi-level approach.ResultsThe average annual fee-for-service expenditure of caring for patients diagnosed with chronic obstructive pulmonary disease in general practice was about EUR 400 per patient. Variation in the expenditures was driven by multimorbidity characteristics up to 28xa0% where as characteristics such as age and gender only explained 5xa0%. Expenditures increased progressively with the degree of multimorbidity. In addition, expenditures were higher for patients who had diagnostic markers based on ICPC-2 (body systems and/or components such as infections and symptoms). Nevertheless, 9.8–15.4xa0% of the variation in expenditure was related to the clinic in which the patient was cared for.ConclusionPatient morbidity and general practice clinic characteristics are significant patient-related fee-for-service expenditure drivers in chronic obstructive pulmonary disease care.

Association between fee-for-service expenditures and morbidity burden in primary care

BackgroundIn primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined.ObjectivesTo examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures.MethodsWe applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics.ResultsOut of the individual expenditures, 31.6xa0% were explained by age, gender and RUB, and around 18xa0% were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0–RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44xa0%; 3.8–9.4xa0% of the variation in expenditures was related to the GP clinic in which the patient was treated.ConclusionsMorbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.

Empathy Variation in General Practice: A Survey among General Practitioners in Denmark

Background: Previous studies have demonstrated that high levels of physician empathy may be correlated with improved patient health outcomes and high physician job satisfaction. Knowledge about variation in empathy and related general practitioner (GP) characteristics may allow for a more informed approach to improve empathy among GPs. Objective: Our objective is to measure and analyze variation in physician empathy and its association with GP demographic, professional, and job satisfaction characteristics. Methods: 464 Danish GPs responded to a survey containing the Danish version of the Jefferson Scale of Empathy for Health Professionals (JSE-HP) and questions related to their demographic, professional and job satisfaction characteristics. Descriptive statistics and a quantile plot of the ordered empathy scores were used to describe empathy variation. In addition, random-effect logistic regression analysis was performed to explore the association between empathy levels and the included GP characteristics. Results: Empathy scores were negatively skewed with a mean score of 117.9 and a standard deviation of 10.1 within a range from 99 (p5) to 135 (p95). GPs aged 45–54 years and GPs who are not employed outside of their practice were less likely to have high empathy scores (≥120). Neither gender, nor length of time since specialization, length of time in current practice, practice type, practice location, or job satisfaction was associated with odds of having high physician empathy. However, odds of having a high empathy score were higher for GPs who stated that the physician-patient relationship and interaction with colleagues has a high contribution to job satisfaction compared to the reference groups (low and medium contribution of these factors). This was also the trend for GPs who stated a high contribution to job satisfaction from intellectual stimulation. In contrast, high contribution of economic profit and prestige did not contribute to increased odds of having a high empathy score. Conclusions: Albeit generally high, we observed substantial variation in physician empathy levels among this population of Danish GPs. This variation is positively associated with values of interpersonal relationships and interaction with colleagues, and negatively associated with middle age (45–54 years) and lack of outside employment. There is room to increase GP physician empathy via educational and organizational interventions, and consequently, to improve healthcare quality and outcomes.

Variation in Point-of-Care Testing of HbA1c in Diabetes Care in General Practice

Background: Point-of-care testing (POCT) of HbA1c may result in improved diabetic control, better patient outcomes, and enhanced clinical efficiency with fewer patient visits and subsequent reductions in costs. In 2008, the Danish regulators created a framework agreement regarding a new fee-for-service fee for the remuneration of POCT of HbA1c in general practice. According to secondary research, only the Capital Region of Denmark has allowed GPs to use this new incentive for POCT. The aim of this study is to use patient data to characterize patients with diabetes who have received POCT of HbA1c and analyze the variation in the use of POCT of HbA1c among patients with diabetes in Danish general practice. Methods: We use register data from the Danish Drug Register, the Danish Health Service Register and the National Patient Register from the year 2011 to define a population of 44,981 patients with diabetes (type 1 and type 2 but not patients with gestational diabetes) from the Capital Region. The POCT fee is used to measure the amount of POCT of HbA1c among patients with diabetes. Next, we apply descriptive statistics and multilevel logistic regression to analyze variation in the prevalence of POCT at the patient and clinic level. We include patient characteristics such as gender, age, socioeconomic markers, health care utilization, case mix markers, and municipality classifications. Results: The proportion of patients who received POCT was 14.1% and the proportion of clinics which were “POCT clinics” was 26.9%. There were variations in the use of POCT across clinics and patients. A part of the described variation can be explained by patient characteristics. Male gender, age differences (older age), short education, and other ethnicity imply significantly higher odds for POCT. High patient costs in general practice and other parts of primary care also imply higher odds for POCT. In contrast, high patient costs for drugs and/or morbidity in terms of the Charlson Comorbidity index mean lower odds for POCT. The frequency of patients with diabetes per 1000 patients was larger in POCT clinics than Non-POCT clinics. A total of 22.5% of the unexplained variability was related to GP clinics. Conclusions: This study demonstrates variation in the use of POCT which can be explained by patient characteristics such as demographic, socioeconomic, and case mix markers. However, it appears relevant to reassess the system for POCT. Further studies are warranted in order to assess the impacts of POCT of HbA1c on health care outcomes.