High Mortality Among Patients With Severe COVID-19 and Do-not-intubate Orders Despite Use of Remdesivir and Dexamethasone

Background Moderate to severe respiratory distress among patients with coronavirus disease 2019 (COVID-19) is associated with a high mortality. Dexamethasone and remdesivir were introduced in the second wave of COVID-19 in Denmark. Methods This is a retrospective study of patients with COVID-19 and a supplemental oxygen requirement of ≥15 Liters per minute (L/min). The patients were divided in two groups corresponding to the first- and second wave of COVID-19 and analysed regarding need of ventilator support and mortality dependent on orders to Do Intubate (DI) or Do Not Intubate (DNI), respectively. Results The study included 178 patients. The mortality was 24% for patients with DI orders (n=115) and 81% for patients with DNI orders (n=63) increasing to 98% (n=46) for patients with DNI orders and very high flow oxygen requirements (≥30 L/min). Use of constant continuous positive airway pressure (cCPAP) increased from 71% in the first wave to 91% in the second wave (p<0.001) whereas the use of mechanical ventilation (MV) decreased from 54% to 28% (p=0.005). Conclusion The mortality was high for patients with DNI orders and respiratory distress with very high levels in supplemental oxygen in both the first and second wave of COVID-19 despite treatment with dexamethasone and remdesivir and improved prognosis for patients with DI orders. Hence careful evaluation on transition to palliative care must be considered for these patients. Study Registration The study was retrospectively registered and approved by the Danish Patient Safety Authority (record no. 31-1521-309) and the Regional Data Protection Center (record no. WZ20017637-2020-37).

Childhood Diagnoses in Individuals Diagnosed With Autism in Adulthood

Autism is a developmental condition, where symptoms are expected to occur in childhood, but a significant number of individuals are diagnosed with autism for the first time in adulthood. Here we use the National Danish Patient Registry to investigate diagnoses given in childhood among those that are diagnosed with autism in adulthood (N = 2199). We found that most childhood diagnoses were given after the age of 12, and attention-deficit hyperactivity disorder, affective disorders, anxiety, and stress disorders were the most prevalent childhood diagnoses. However, 69% of males and 61% of females with adult autism diagnoses had not received any of the included diagnoses before the age of 18. In most cases, the late autism diagnosis is therefore unlikely to be explained by either misdiagnosis or diagnostic overshadowing. This result is at odds with the prevailing notion that autistic symptoms tend to diminish with age. Therefore, further research is warranted to examine how early signs of autism may have manifested among these individuals, and how similar they are to autistic people diagnosed earlier in their development. Milder to moderate cases of psychiatric conditions that have been solely treated by family physician or school psychologists may not be fully included in our dataset.

Healthcare inequality in compensation claims concerning acute hospital services: a Danish register-based study

Objective Although citizens’ equal right to acute healthcare of appropriate quality is an oft-cited goal for modern societies, healthcare disparities may persist. We aimed to investigate inequality in compensation claims and compensation payments regarding acute healthcare services. Design and setting We conducted a cross-sectional study of compensation claim patterns using the Danish Patient Compensation Association (DPCA) registries. Participants, interventions and main outcome measures We used register data on all cases managed by DPCA relating to acute hospital healthcare for adults (aged &gt; 18 years) from 2007 to 2017. Results In total, the DPCA had 5556 compensation claims for injuries caused by acute care services during the years 2007–2017. Age group of 50–64 years (odds ratio (OR) = 1.37 compared with those aged 18–49 years; P &lt; 0.001), marriage (OR = 1.14; P &lt; 0.001), higher income (OR = 1.55; P &lt; 0.001) and Danish origin (OR = 1.49; P &lt; 0.001) were statistically associated with higher odds for filing a compensation claim; men (OR = 0.83; P &lt; 0.001) and those with many co-morbidities were much less represented (OR = 0.24; P &lt; 0.001). Male gender (OR = 1.25; P &lt; 0.001) and higher age (OR = 2.55 (80+ years); P &lt; 0.001) were associated with higher odds for a compensation award. Failed diagnosis was also more often at stake in men (OR = 1.38; P &lt; 0.001) and in patients aged 50–64 years (OR = 1.17; P &lt; 0.001) but occurred less often in patients with multiple morbidities (OR = 0.68; P &lt; 0.001). Conclusions Findings from our Danish material suggest some inequality in compensation claims and compensation payments regarding acute healthcare services.

Loneliness, social isolation, and chronic disease outcomes

Background Research suggests that loneliness and social isolation are serious public health concerns. However, our knowledge of the associations of loneliness and social isolation with specific chronic diseases is limited. The present prospective cohort study investigated (a) the longitudinal associations of loneliness and social isolation with four chronic diseases (cardiovascular disease [CVD], chronic obstructive pulmonary disease [COPD], diabetes mellitus Type 2 [T2D], and cancer), (b) the synergistic association of loneliness and social isolation with chronic disease, and (c) baseline psychological and behavioral explanatory factors. Methods Self-reported data from the 2013 Danish “How are you?” survey (N = 24,607) were combined with individual-level data from the National Danish Patient Registry on diagnoses in a 5 year follow-up period (2013-2018). Results Cox proportional hazard regression analyses showed that loneliness and social isolation were independently associated with CVD (loneliness: adjusted hazard ratio (AHR) = 1.20, 95% confidence interval [CI; 1.03, 1.40]; SI: AHR = 1.23, 95% CI [1.04, 146]) and T2D (loneliness: AHR =1.90, 95% CI [1.42, 2.55]; SI: AHR = 1.59, 95% CI [1.15, 2.21]). No significant associations were found between loneliness or social isolation and COPD and cancer, respectively. Likewise, loneliness and social isolation did not demonstrate a synergistic effect on chronic disease. Multiple mediation analysis indicated that loneliness and social isolation had an indirect effect on CVD and T2D through both baseline psychological and behavioral factors. Conclusions Loneliness and social isolation were independently associated with a diagnosis of CVD and T2D within a 5 year follow-up period. The associations of loneliness and social isolation with CVD and T2D were fully explained by baseline psychological and behavioral factors. Key messages Individuals exposed to loneliness and social isolation constitute vulnerable groups in risk of chronic disease. Psychological and behavioural factors explain the associations with chronic disease.

Loneliness, Social Isolation, and Chronic Disease Outcomes

Background Research suggests that loneliness and social isolation (SI) are serious public health concerns. However, our knowledge of the associations of loneliness and SI with specific chronic diseases is limited. Purpose The present prospective cohort study investigated (a) the longitudinal associations of loneliness and SI with four chronic diseases (cardiovascular disease [CVD], chronic obstructive pulmonary disease [COPD], diabetes mellitus Type 2 [T2D], and cancer), (b) the synergistic association of loneliness and SI with chronic disease, and (c) baseline psychological and behavioral explanatory factors. Methods Self-reported data from the 2013 Danish “How are you?” survey (N = 24,687) were combined with individual-level data from the National Danish Patient Registry on diagnoses in a 5 year follow-up period (2013–2018). Results Cox proportional hazard regression analyses showed that loneliness and SI were independently associated with CVD (loneliness: adjusted hazard ratio (AHR) = 1.20, 95% confidence interval [CI; 1.03, 1.40]; SI: AHR = 1.23, 95% CI [1.04, 146]) and T2D (loneliness: AHR =1.90, 95% CI [1.42, 2.55]; SI: AHR = 1.59, 95% CI [1.15, 2.21]). No significant associations were found between loneliness or SI and COPD and cancer, respectively. Likewise, loneliness and SI did not demonstrate a synergistic effect on chronic disease. Multiple mediation analysis indicated that loneliness and SI had an indirect effect on CVD and T2D through both baseline psychological and behavioral factors. Conclusion Loneliness and SI were independently associated with a diagnosis of CVD and T2D within a 5 year follow-up period. The associations of loneliness and SI with CVD and T2D were fully explained by baseline psychological and behavioral factors.

Minding the Gap Between the Policy and Practice of Patient-Centeredness: Cocreating a Model for Tensional Dialogue in the “Active Patient Support” Program

Several studies identify obstacles to patient-centered care that can be eradicated by bridging the gap between policy goals and practice. In this article, “patient-centeredness” is theorized as an unstable entity riddled with intrinsic, ineradicable tensions. The purpose of the article is to propose a reflexive approach to the tensions as the most appropriate strategy for narrowing the gap between policy and practice. The reflexive approach is illustrated in an account of an action research project on a Danish, patient-centered initiative, “Active Patient Support.” The account focuses on the development of a dialogic communication model through collaborative, reflexive analyses of the tensions in the enactment of “patient-centeredness” in dialogue between health care practitioners and citizens—in particular, the tension between empowerment and self-discipline. Finally, the conceptual expansion of one of the dimensions of patient-centeredness, “health-practitioner-as-person,” is discussed as a platform for reflexivity, and the limitations of reflexivity are addressed.