Since 2007, the emergency healthcare system in Denmark has been reconfigured. The Danish Health Authority presented several initiatives to secure high-quality care in every part of the country at every time of day. The recommendations included fewer emergency hospitals, through the closing of small rural hospitals. Specialised treatment was centralised, including emergency care into one unit with one entrance. Also, medical specialists should be present any time of the day in the emergency departments, and in addition, mandatory referral to the EDs was implemented. A consequence of reconfiguration was increased travel time for many patients.
Mortality is generally regarded as one of the classics, crucial markers of quality of care. Evaluating the reconfiguration of emergency healthcare is complex and only a few studies have evaluated the national consequences of a reconfiguration.
The reconfiguration has had implications for the healthcare system. We hy-pothesise that reconfiguration has improved the emergency care system. Therefore, this the-sis aims to explore the change in unplanned hospital contacts and mortality before and after reconfiguration of the emergency healthcare system. First, by describing the national changes in unplanned hospital contacts during the period the reconfiguration happened. Secondly, by investigating the national change in mortality before and after reconfiguration. Thirdly, by inves-tigating the change in mortality around the time of reconfiguration at the emergency hospitals.
The three studies in this thesis are based on individual-level register-based data for all adults (age ≥ 18 years) with unplanned hospital contacts to public hospitals in Denmark from 2005 to 2017. The study cohort includes data from The Danish National Patient Registry, The Danish Civil Registration System, and registers from Statistics Denmark with information on income and education.
The first study described the annual characteristics of the study population.
The second study used an interrupted time series design to calculate changes in national in-hospital and 30-day mortality before and after the reconfiguration. We determined the adjusted odds ratios for in-hospital mortality and hazard ratios for 30-day mortality using logistic and cox regression analysis. We stratified the analyses on time of arrival and selected diagnoses.
The third study investigated the immediate changes in in-hospital and 30-day mortality rates around the time of reconfiguration at each emergency hospital.
In study 1, we included 13,524,680 unplanned hospital contacts from 2005 to 2016. The an-nual number of unplanned hospital contacts increased from 1,067,390 in 2005 to 1,221,601 in 2016 (14.4%). In addition, we found the number of unplanned hospital contacts aged ≥65 years and the number of unplanned hospital contacts with Charlson Comorbidity Index ≥3 increased over the study period.
We included 11,367,655 unplanned hospital contacts in study 2, 4,704,362 be-fore and 6,663,293 after the reorganisation of the emergency healthcare system. We found no statistically significant change in in-hospital mortality regardless of the day of week and time of day. We found an increase in 30-day mortality of 0.4% (95% CI: 0.0-0.8%) per year after the reorganisation. Unplanned hospital contacts with aortic aneurism, major trauma, myocardial infarction, and stroke had reduced mortality after the reconfiguration.
In study 3, we included 23 emergency hospitals with 11,367,655 unplanned hospital contacts. We found three hospitals had an immediate statistically significant reduction in in-hospital and 30-day mortality after the reconfiguration.
In these three studies, we found the number of unplanned hospital contacts to increase during the study period. The reconfiguration overall led to a slight increase in 30-day mortality, where-as in-hospital mortality was unaffected by the reconfiguration. Unplanned hospital contacts with aortic aneurism, major trauma, myocardial infarction, and stroke had reduced mortality after the reconfiguration. We found three hospitals to reduce in-hospital and 30-day mortality immediately after the reconfiguration.
|Translated title of the contribution||Reorganisering af det danske akut sygehus system i Danmark - fra de mange små hospitaler til de få store akut sygehuse|
- University of Southern Denmark
- Brabrand, Mikkel, Principal supervisor
- Bech, Mickael, Co-supervisor
- Bogh, Søren Bie, Co-supervisor
- Henriksen, Daniel, Co-supervisor
- Johnsen, Søren Paaske, Co-supervisor, External person
|Publication status||Published - 20. Apr 2022|
Print copy of the thesis is restricted to reference use in the Library.