Lars Morsø

Objective: To examine socioeconomic and demographic differences in who complains about healthcare and whether these factors are associated with the outcomes of complaint cases. Design: Nationwide cross-sectional study in Denmark using linked national health, complaint and administrative registers. Setting: The Danish healthcare system provides universal coverage and has a centralised system for handling complaints with linked patient-level data to sociodemographic variables. Participants: All healthcare contacts in 2022 in general practice (GP), non-psychiatric hospitals and psychiatric hospitals were included. Primary and secondary outcome measures: We examined two outcomes: (1) submission of a complaint and (2) whether the authorities upheld the complaint. We then assessed how these outcomes varied by socioeconomic position (SEP), focusing on the contrast between patients with the lowest and highest SEP profiles. Relative risks (RRs) were estimated using modified Poisson regression with cluster-robust variance estimation at the patient level. Results: There were 31.9 million GP contacts, 4.8 million non-psychiatric hospital contacts and 345 000 psychiatric contacts, with 1381, 3545 and 439 complaints, respectively (0.43–12.7 per 10 000 contacts). Clear socioeconomic disparities emerged. Low-income patients were more likely to complain about GP and non-psychiatric hospitals, while higher education was associated with fewer complaints in these settings but more complaints about psychiatry. Patients outside the workforce were more likely to complain, whereas elderly patients were consistently underrepresented in the complaints. Low-SEP profiles had notably higher complaint probabilities than high-SEP profiles in GP (RR 2.60, 95% CI 2.22 to 3.70) and non-psychiatric hospitals (RR 1.69, 95% CI 1.40 to 1.98), but not in psychiatric hospitals (RR 0.93, 95% CI 0.47 to 1.38). Although individual SEP indicators showed no consistent differences in complaint outcomes, the combined SEP profiles revealed lower probabilities for complaints being upheld in lower SEP patients in GP (RR 0.58, 95% CI 0.22 to 0.94) and non-psychiatric hospitals (RR 0.70, 95% CI 0.43 to 0.96), while the estimate for psychiatric hospitals was inconclusive (RR 0.71, 95% CI 0.24 to 1.66). Conclusions: In this nationwide study, socioeconomic and demographic factors were linked to clear differences in both complaint submission and complaint outcomes. Except for psychiatric hospital services, patients with fewer socioeconomic resources were more likely to file a complaint yet had a lower probability of having it upheld. These findings point to disparities in who complains and in how complaints are assessed, and they underline the need to consider all complaints, regardless of outcome, when using complaint data to inform quality improvement efforts.

Background: There is increasing interest in how patient complaint material can be used to highlight areas requiring quality improvement (QI) in healthcare. However, knowledge of using complaint material to initiate or monitor QI is limited. Objectives: This review explored the use of complaint material in QI by identifying problems related to substandard care that were addressed by QI initiatives, exploring how complaint material was used before or after a QI initiative, and mapping changes in complaint material after QI initiatives. Methods: This scoping review followed the Joanna Briggs Institute methodology and adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews reporting guideline. Eligibility criteria: Studies were included if a QI initiative was initiated or monitored using complaint material. Eligible designs included observational studies, QI projects, pre-intervention and post-intervention studies and randomised controlled trials. Audio, online and symptom-based complaints were excluded. Information sources: A systematic search was conducted on 10 December 2024 in Embase, Medline, CINAHL and Web of Science, and additional sources, with no language or date limitations. Synthesis of results: Substandard problems targeted by QI initiatives were categorised using the Healthcare Complaints Analysis Tool by two independent coders. Findings were synthesised narratively and summarised using frequency analyses where applicable. Results: We identified 58 QI initiatives, most frequently targeting safety (n=39). Before QI, complaint material was usually analysed through review (n=19), counts (n=17), content categorisation (n=9) or root cause analysis (n=2). After QI, analyses included counts (n=34), rates (n=20), content categorisation (n=7) and review (n=4). Reviewing or categorisation methods were often unspecified. Among studies using complaints as an outcome, most reported complaint reductions (n=43), while a few reported increases (n=2) or mixed results (n=4). Discussion: The QI initiatives primarily targeted patient safety and applied simple quantitative analyses. Some studies relied on reviews or categorisations without reporting the validation or reliability of the used tools. Improved reporting standards are needed to strengthen learning. Furthermore, while QI initiatives appear to have the potential to change complaint patterns, this finding should be interpreted with caution, as this is based on a scoping review. Other: Preregistered protocol: https://osf.io/6g4qw .

Introduction: Denmark is one of the safest places for childbirth, yet some women report dissatisfaction with their maternity care. However, some negative birth experiences may remain unreported due to thresholds for complaining. The study aimed to identify patterns of unreported negative birth experiences and to quantify the extent of these dark figures.Material and Methods: A survey was distributed to 3081 women who gave birth at a Danish hospital in 2022, resulting in 1022 responses (response rate = 33.2%). The women reported their birth experiences in categories based on the Healthcare Complaints Analysis Tool (HCAT), specifying problems, harm caused, and whether they had filed a complaint or intended to. Dark figure ratios regarding problems and harm levels were calculated by comparing unreported negative experiences to formally filed complaints based on the survey responses, covering each problem type and harm level.Results: Of the 1022 respondents, 336 (32.9%) women reported negative birth experiences, yet only 26 women had filed complaints. The remaining 310 unreported cases comprised 787 problems across HCAT categories. The most frequent problems were about communication and quality. The highest dark figure ratios were found within the management domain comprising institutional processes (13.0) and environment (9.9). The dark figure ratios showed an inverse relationship with harm severity, being highest for minimal (19.5) and minor (21.2) harm levels and decreasing for moderate (5.5), major (4.8) and catastrophic (0.3) harm levels.Conclusions: This study demonstrates a substantial underestimation of negative birth experiences when relying solely on formal complaints, with dark figure ratios ranging from 4.8 to 13, depending on the issue. The inverse relationship between harm severity and dark figure ratios suggests a threshold for filing a complaint, as the likelihood of reporting increases with greater harm. These findings provide novel insights into unreported maternity care experiences, highlighting the need to integrate patient experiences into healthcare improvements.

Objective: Conditions that could benefit from rehabilitation contribute to 310 million years of life lived with disability. Internationally rehabilitation could be part of the solution to the growing global disease burden. This register based study wanted to explore differences in patterns of rehabilitation among patients discharged from the hospital with a rehabilitation plan, explore rehabilitation initiation, and assess the activation of rehabilitation plans within legal requirements. Setting: The study was conducted at Odense University Hospital in the Region of Southern Denmark Participants: The study investigated acute contacts by utilising rehabilitation referrals, demographic and municipal data from Odense Municipality residents from 2015 to 2020. Main measures: Descriptive statistics, logistic regressions, cox regression and cumulative incidence rate were used to explore rehabilitation the activation of rehabilitation plans. Results: The cohort consisted of 225,653 hospital contacts. Overall, 10,327 (5%) received a rehabilitation plan. Contacts were more often female or had increased co-morbidity. Prescription increased with age and for ethnical Danes. Initiation of prescribed plans increased within the first weeks, levelling from 30 to 60 days. Delayed initiation of the rehabilitation plan beyond 30 days raised the likelihood of non-initiating altogether. Conclusions: Although evidence acknowledges the benefits of rehabilitation, this study showed that more than 25% of all referred municipality rehabilitation plans were never initiated. If the initiation of a rehabilitation plan was delayed beyond 30 days, it significantly reduced the likelihood of initiation. Therefore, the international community need to keep focus on early rehabilitation and increase the use of rehabilitation in the future.

Background: Transitions in healthcare settings can be a challenge for patients and they express a need for guidance and support to cope with these transitions. The aim of this scoping review was to investigate if interventions can improve patients’ experiences when transitioning between healthcare settings. Methods: This review was conducted following the Johanna Briggs Institute’s methods and reported according to the PRISMA-ScR Checklist. Included articles were published and peer-reviewed, and reported qualitative and quantitative findings on patient experiences with interventions when transitioning between healthcare settings. The search was conducted in May 2024 in Medline Ovid, Embase Ovid, and Cinahl. Results: Twenty-three studies were included. Factors extracted from the studies were: author(s), year of publication, country of origin, study design, theoretical methods, population description, intervention, phenomena of interest(s), and key findings. There has been an increase in published studies on the subject in the last few years, and most of the included studies originated from Western countries. Most studies were quantitative, primarily RCTs, and the theoretical methods were thus mainly statistical analysis. The study populations were found to be heterogeneous. The interventions were categorized: care coordinator, program, integrated care, online communication platform, coaching, discharge care plan, and miscellaneous interventions. Conclusions: Overall, interventions were found to improve the patient experience. Centralization of healthcare has increased the number of transitions, and patients express that the coordination of healthcare transitions can be improved. This review’s findings should be used alongside other research on interventions’ effect on factors like hospital readmissions and mortality to determine the optimal intervention to implement.

No reviews so far have been conducted to define the constructs of patient-experienced quality in healthcare transitions or to identify existing generic measures of patients’ experience of the quality within healthcare transitions. Our aim was to identify domains relevant for people experiencing healthcare transitions when evaluating the quality of care they have received, map the comprehensiveness of existing patient-reported experience measures (PREM), and evaluate the PREMs’ content validity. The method was guided by the Joanna Briggs Institutes’ guidance for scoping reviews. The search was performed on 07 December 2021 and updated 27 May 2024, in the electronic databases Medline (Ovid), Embase (Ovid), and Cinahl (EBSCO). The search identified 20,422 publications, and 190 studies were included for review. We identified 30 PREMs assessing at least one aspect of adults’ experience of transitions in healthcare. Summarising the content, we consider a model with two domains, organisational and human-relational, likely to be adequate. However, a more comprehensive analysis and adequate definition of the construct is needed. None of the PREMs were considered content valid.

Introduction Patient safety is a high priority in the Danish health care system, including that hospital patients get the proper nutrition during their stay. A Nutrition Committee at Odense University Hospital is responsible for policy regarding nourishment at the hospital. If patients experience suboptimal treatment, i.e. improper nourishment, in the Danish health care system, they have the right to file a complaint. These complaints enable the improvement potentials based on the patients’ first hand experiences. Therefore, our aim was to examine the nutrition complaint pattern and to get a deeper understanding of the context surrounding nutrition problems, allowing the extraction of learning potentials. Methods We analysed complaints submitted to Odense University Hospital between 2018 and 2022 using the Healthcare Complaint Analysis Tool. The complaints were categorised into categories, levels of severity and overall patient harm. The complaints containing a high-severity nutrition problem were read through and thematised into aspects not defined in the Healthcare Complaint Analysis Tool. Results Between 2018 and 2022, 60 complaint cases containing 89 nutrition problems were filed to Odense University Hospital. Most (58.3%) of these were filed by the patients’ relatives. The nutrition problems were mostly of low severity (56.2%), while 23.6% were severe, and 20.2% were very severe. The reading of 18 very severe nutrition complaints revealed a cascade of problems triggered by the nutrition problem in six cases. Moreover, we saw that two high-severity nutrition problems led to catastrophic harm. Discussion A low proportion of nutrition problems may express an underestimation regarding nourishment at the hospital. A patient’s threshold may not be exceeded by suboptimal nutrition and therefore does not file a complaint. However, complaints contain important insights contributing to wider learning, given that improvements at the hospital so far are based on clinicians’ reporting, overlooking the patient perspective.