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Woolley KE, Jones NJ, Rahim A, Withers KL, Letchford R. Application of the PAPERS Grading Criteria Within a Rapid Evidence Review to Determine the Psychometric and Pragmatic Properties of Patient Empowerment Tools. J Patient Exp 2024; 11:23743735241272191. [PMID: 39176305 PMCID: PMC11339745 DOI: 10.1177/23743735241272191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
Self-management of long-term conditions requires health professionals to understand and develop capabilities that empower the population they serve. A rapid evidence review was undertaken to assess the current evidence based on the psychometric properties of patient empowerment tools. MEDLINE was searched, and data were extracted for each publication and scored using a modified Psychometric and Pragmatic Evidence Rating Scale (PAPERS) evidence rating scale. The results were grouped into the following domains: (a) health literacy; (b) patient activation; (c) long-term conditions; (d) self-management needs and behaviors. A full-text review of 65 publications led to the inclusion of 29 primary studies. The highest scoring tools were selected with respect to performance for each domain: (a) Newest Vital Sign and the Brief Health Literacy Screen; (b) Consumer Health Activation Index and PAM-13; (c) LTCQ and LTCQ8; and (d) SEMCD and Patient Enablement Instrument. PAPERS was a useful tool in determining the generalizability, validity, and reliability of these patient empowerment tools. However, further research is required to establish whether an individual's health literacy status influences patient empowerment tool outcomes.
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Affiliation(s)
- Katherine E Woolley
- CEDAR, Centre for Healthcare Evaluation, Device Assessment and Research, Cardiff and Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - Nia J Jones
- CEDAR, Centre for Healthcare Evaluation, Device Assessment and Research, Cardiff and Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - Ayesha Rahim
- CEDAR, Centre for Healthcare Evaluation, Device Assessment and Research, Cardiff and Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - Kathleen L Withers
- CEDAR, Centre for Healthcare Evaluation, Device Assessment and Research, Cardiff and Vale University Health Board, Cardiff Medicentre, Cardiff, UK
- Welsh Value in Health Centre, DDTIV Directorate, NHS Executive, Llantrisant, UK
| | - Robert Letchford
- Physiotherapy Department, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
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Rand S, Towers AM, Allan S, Webster L, Palmer S, Carroll R, Gordon A, Akdur G, Goodman C. Exploratory factor analysis and Rasch analysis to assess the structural validity of the Adult Social Care Outcomes Toolkit Proxy version (ASCOT-Proxy) completed by care home staff. Qual Life Res 2024; 33:1555-1567. [PMID: 38507142 PMCID: PMC11116179 DOI: 10.1007/s11136-024-03631-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Rasch analysis and exploratory factor analysis (EFA) were used to evaluate the structural validity of the ASCOT-Proxy measures completed by staff on behalf of older adults resident in care homes, by comparison to the ASCOT-SCT4, the measure of social care-related quality of life (SCRQoL) from which the ASCOT-Proxy was developed. METHODS EFA was conducted on the ASCOT-SCT4 and the two ASCOT-Proxy measures (Proxy-Proxy, Proxy-Resident), to determine if they retained the single factor of the original ASCOT-SCT4 measure found in samples of older community-dwelling adults. Rasch analysis was also applied to measures with a single factor structure in the EFA. RESULTS ASCOT-Proxy-Resident had a single factor structure, as did the original ASCOT-SCT4 (also, found in this analysis when completed by care home staff). The ASCOT-Proxy-Proxy had a two factor structure. Rasch analysis of ASCOT-Proxy-Resident and ASCOT-SCT4 had an acceptable model fit, internal consistency and met the assumptions of unidimensionality and local independence. There was evidence of less than optimal distinguishability at some thresholds between responses, and low frequency of rating of the 'high level needs'. CONCLUSION The ASCOT-Proxy-Resident is a valid instrument of SCRQoL for older adults resident in care homes, completed by staff proxies. Due to the two-factor structure, which differs from the original ASCOT-SCT4, we do not recommend the use of the ASCOT-Proxy-Proxy measure, although collecting data as part of the ASCOT-Proxy questionnaire may support its feasibility and acceptability. Further qualitative study of how care home staff complete and perceive the ASCOT-Proxy is encouraged for future studies.
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Affiliation(s)
- Stacey Rand
- Personal Social Services Research Unit (PSSRU), University of Kent, Canterbury, UK.
| | - Ann-Marie Towers
- Centre for Health Services Studies (CHSS), University of Kent, Canterbury, UK
| | - Stephen Allan
- Personal Social Services Research Unit (PSSRU), University of Kent, Canterbury, UK
| | - Lucy Webster
- Centre for Health Services Studies (CHSS), University of Kent, Canterbury, UK
| | - Sinead Palmer
- Personal Social Services Research Unit (PSSRU), University of Kent, Canterbury, UK
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Morrissey E, Murphy A, Murphy P, O'Grady L, Byrne M, Casey M, Dolan E, Duane S, Durand H, Gillespie P, Hayes P, Hobbins A, Hynes L, McEvoy JW, Newell J, Molloy G. Supporting GPs and people with hypertension to maximise medication use to control blood pressure: Protocol for a pilot cluster RCT of the MIAMI intervention. HRB Open Res 2023; 6:6. [PMID: 38779427 PMCID: PMC11109531 DOI: 10.12688/hrbopenres.13661.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 05/25/2024] Open
Abstract
Background: Hypertension is one of the most important risk factors for stroke and heart disease. Recent international guidelines have stated that 'poor adherence to treatment - in addition to physician inertia - is the most important cause of poor blood pressure control'. The MaxImising Adherence, Minimising Inertia (MIAMI) intervention, which has been developed using a systematic, theoretical, user-centred approach, aims to support general practitioners (GPs) and people with hypertension to maximise medication use, through the facilitation of adequate information exchange within consultations about long-term antihypertensive medication use and adherence skill development. The aim of the MIAMI pilot cluster randomised controlled trial (RCT) is to gather and analyse feasibility data to allow us to (1) refine the intervention, and (2) determine the feasibility of a definitive RCT. Methods: GP practices (n = 6) will be recruited and randomised to the intervention arm (n = 3) or usual care control arm (n = 3). Each practice will recruit 10 patient participants. For a patient to be eligible they must have a diagnosis of hypertension, be on two or more anti-hypertensive medications, must not be achieving recommended blood pressure levels, and be over the age of 65 years. Participants in the intervention arm will meet their GP and receive the MIAMI intervention twice over three months. Quantitative data collection will take place at baseline and three month follow up. A pilot health economic analysis and a qualitative sub-study will also be incorporated into the study. Discussion: This pilot cluster RCT of the MIAMI intervention will allow us to gather valuable acceptability and feasibility data to further refine the intervention so it optimally designed for both GP and patient use. In particular, the qualitative component will provide an insight into GP and patient experiences of using the intervention.
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Affiliation(s)
| | - Andrew Murphy
- HRB Primary Care Clinical Trials Network, University of Galway, Galway, Ireland
| | - Patrick Murphy
- HRB Primary Care Clinical Trials Network, University of Galway, Galway, Ireland
| | - Louise O'Grady
- School of Psychology, University of Galway, Galway, Ireland
| | - Molly Byrne
- School of Psychology, University of Galway, Galway, Ireland
| | - Monica Casey
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Eamon Dolan
- Connolly Hospital, Blanchardstown, Dublin, Ireland
| | - Sinead Duane
- J.E. Cairnes School of Business and Economics, University of Galway, Galway, Ireland
- HRB Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - Hannah Durand
- Division of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, UK
| | - Paddy Gillespie
- Health Economics and Policy Analysis Centre, Institute for Lifecourse and Society, University of Galway, Galway, Ireland
- CURAM, SFI Research Centre for Medical Devices (13/RC/2073_P2), University of Galway, Galway, Ireland
| | - Peter Hayes
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Anna Hobbins
- Health Economics and Policy Analysis Centre, Institute for Lifecourse and Society, University of Galway, Galway, Ireland
- CURAM, SFI Research Centre for Medical Devices (13/RC/2073_P2), University of Galway, Galway, Ireland
| | - Lisa Hynes
- Croí, The West of Ireland Cardiac and Stroke Foundation, Galway, Ireland
| | - John William McEvoy
- National Institute for Prevention and Cardiovascular Health, University of Galway, Galway, Ireland
| | - John Newell
- School of Mathematical and Statistical Sciences, University of Galway, Galway, Ireland
| | - MIAMI PPI group
- School of Psychology, University of Galway, Galway, Ireland
- HRB Primary Care Clinical Trials Network, University of Galway, Galway, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
- Connolly Hospital, Blanchardstown, Dublin, Ireland
- J.E. Cairnes School of Business and Economics, University of Galway, Galway, Ireland
- HRB Trials Methodology Research Network, University of Galway, Galway, Ireland
- Division of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, UK
- Health Economics and Policy Analysis Centre, Institute for Lifecourse and Society, University of Galway, Galway, Ireland
- CURAM, SFI Research Centre for Medical Devices (13/RC/2073_P2), University of Galway, Galway, Ireland
- Croí, The West of Ireland Cardiac and Stroke Foundation, Galway, Ireland
- National Institute for Prevention and Cardiovascular Health, University of Galway, Galway, Ireland
- School of Mathematical and Statistical Sciences, University of Galway, Galway, Ireland
| | - Gerard Molloy
- School of Psychology, University of Galway, Galway, Ireland
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Morrissey E, Murphy A, Murphy P, O'Grady L, Byrne M, Casey M, Dolan E, Duane S, Durand H, Gillespie P, Hayes P, Hobbins A, Hynes L, McEvoy JW, Newell J, Molloy G. Supporting GPs and people with hypertension to maximise medication use to control blood pressure: Protocol for a pilot cluster RCT of the MIAMI intervention. HRB Open Res 2023. [DOI: 10.12688/hrbopenres.13661.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Hypertension is one of the most important risk factors for stroke and heart disease. Recent international guidelines have stated that 'poor adherence to treatment – in addition to physician inertia - is the most important cause of poor blood pressure control'. The MaxImising Adherence, Minimising Inertia (MIAMI) intervention, which has been developed using a systematic, theoretical, user-centred approach, aims to support general practitioners (GPs) and people with hypertension to maximise medication use, through the facilitation of adequate information exchange within consultations about long-term antihypertensive medication use and adherence skill development. The aim of the MIAMI pilot cluster randomised controlled trial (RCT) is to gather and analyse feasibility data to allow us to (1) refine the intervention, and (2) determine the feasibility of a definitive RCT. Methods: GP practices (n = 6) will be recruited and randomised to the intervention arm (n = 3) or usual care control arm (n = 3). Each practice will recruit 10 patient participants. For a patient to be eligible they must have a diagnosis of hypertension, be on two or more anti-hypertensive medications, must not be achieving recommended blood pressure levels, and be over the age of 65 years. Participants in the intervention arm will meet their GP and receive the MIAMI intervention twice over three months. Quantitative data collection will take place at baseline and three month follow up. A pilot health economic analysis and a qualitative sub-study will also be incorporated into the study. Discussion: This pilot cluster RCT of the MIAMI intervention will allow us to gather valuable acceptability and feasibility data to further refine the intervention so it optimally designed for both GP and patient use. In particular, the qualitative component will provide an insight into GP and patient experiences of using the intervention.
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Lambert SD, Bartlett SJ, McCusker J, Yaffe M, Ciampi A, Belzile E, de Raad M. Development and psychometric evaluation of the CanSmart questionnaire to measure chronic disease self-management tasks. BMC Psychol 2022; 10:293. [PMID: 36476620 PMCID: PMC9730574 DOI: 10.1186/s40359-022-00995-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Psychometrically sound measures of chronic disease self-management tasks are needed to improve identification of patient needs and to tailor self-management programs. This study aimed to develop and conduct a preliminary psychometric analysis of the CanSMART questionnaire among a diverse, multimorbid Canadian population. METHODS The data were drawn from a cross-sectional online survey to examine self-management needs and support preferences. Participants were 306 Canadian adults with one or more physical and/or emotional chronic conditions. The questionnaire on frequency of self-management tasks was developed with substantial patient partner input. We conducted Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) of the 11 self-management tasks comprising the scale in two randomly selected subsamples, followed by Rasch analysis. Associations between patient characteristics and the self-management task subscales and individual items were explored. RESULTS The factor analyses identified two self-management task subscales that were labelled Coping tasks (6 items) and Physical tasks (3 items), with Cronbach's alpha of 0.70 and 0.67, respectively. Rasch analysis suggested that participants had difficulty discriminating between response options "mostly" and "always". In analyses of independent associations with patient characteristics, both Coping and Physical tasks were associated with reporting more than one chronic disease and employment disability. The Coping tasks subscale was associated with female sex. Two items, on medication use and monitoring biological parameters, did not load on either scale. Both were associated with specific diagnoses. CONCLUSIONS In this preliminary analysis, two self-management tasks subscales exhibit good psychometric properties. Two items that did not load on either scale may represent additional dimensions of self-management. This work provides the basis for further scale development and use in research and clinical practice.
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Affiliation(s)
- Sylvie D. Lambert
- grid.14709.3b0000 0004 1936 8649Ingram School of Nursing, McGill University, 680 Sherbrooke Ouest, #1800, Montreal, QC H3A 2M7 Canada ,St. Mary’s Research Centre, Hayes Pavilion, Suite 3734, 3830 Avenue Lacombe, Montreal, QC H3T 1M5 Canada
| | - Susan J. Bartlett
- grid.14709.3b0000 0004 1936 8649Divisions of Clinical Epidemiology, Rheumatology and Respiratory Epidemiology and Clinical Trials Unit, Department of Medicine, McGill University, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada ,grid.63984.300000 0000 9064 4811McGill University Health Center Research Institute, 5252 Boul. de Maisonneuve Ouest, Montreal, QC H4A 3S5 Canada
| | - Jane McCusker
- St. Mary’s Research Centre, Hayes Pavilion, Suite 3734, 3830 Avenue Lacombe, Montreal, QC H3T 1M5 Canada ,grid.14709.3b0000 0004 1936 8649Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 942 Avenue des Pins Ouest, Montreal, H3A 1A2 Canada
| | - Mark Yaffe
- grid.14709.3b0000 0004 1936 8649Department of Family Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Montreal, H3S 1Z1 Canada ,grid.416526.2Family Medicine Centre, St. Mary’s Hospital Center, 3830 Avenue Lacombe, Montreal, H3T 1M5 Canada
| | - Antonio Ciampi
- St. Mary’s Research Centre, Hayes Pavilion, Suite 3734, 3830 Avenue Lacombe, Montreal, QC H3T 1M5 Canada ,grid.14709.3b0000 0004 1936 8649Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 942 Avenue des Pins Ouest, Montreal, H3A 1A2 Canada
| | - Eric Belzile
- St. Mary’s Research Centre, Hayes Pavilion, Suite 3734, 3830 Avenue Lacombe, Montreal, QC H3T 1M5 Canada
| | - Manon de Raad
- St. Mary’s Research Centre, Hayes Pavilion, Suite 3734, 3830 Avenue Lacombe, Montreal, QC H3T 1M5 Canada
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Reform of the Health Insurance Funding Model to Improve the Care of Noncommunicable Diseases Patients in Saudi Arabia. Healthcare (Basel) 2022; 10:healthcare10112294. [PMID: 36421618 PMCID: PMC9690478 DOI: 10.3390/healthcare10112294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
Abstract
Health insurance models are being considered as part of health system reforms in Saudi Arabia. This paper assesses the attributes of health funding models that support better control of non-communicable diseases (NCDs) and perspectives on health insurance as a model from the perspective of patients, clinicians, and managers. The study employed a mixed-methods research design that included quantitative and qualitative data gathering and analysis. Study findings indicated concerns that the current health funding mechanism is financially unsustainable and, as a result, there will be a greater reliance on personal health insurance to support government spending on healthcare. Essential elements of any health insurance model to support effective NCD management identified from a review of the literature and interviews include the following: ensuring continuity of care and equity; funding chronic disease prevention interventions; prioritising primary healthcare; and maintaining the principle of community rating to prevent insurers from discriminating against members. Other desirable attributes for the funding model includes collaboration across primary, secondary, and tertiary care. Healthcare finance reform aimed at adopting and increasing personal health insurance coverage may play a critical role in extending access to healthcare, eliminating health inequities, enhancing population health, and reducing government spending on healthcare if appropriately considered.
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Hazazi A, Wilson A. Improving Management of Non-communicable Chronic Diseases in Primary Healthcare Centres in The Saudi Health Care System. Health Serv Insights 2022; 15:11786329221088694. [PMID: 35342294 PMCID: PMC8949774 DOI: 10.1177/11786329221088694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/24/2022] [Indexed: 12/24/2022] Open
Abstract
Evaluation of patient perceptions of quality and adequacy of care is a critical component of continuous improvement in chronic disease care. The purpose of this study was to ascertain how patients with non-communicable diseases (NCDs) assess their routine care in primary care centres in Saudi Arabia and to identify areas for improvement. This cross-sectional study used the PACIC questionnaire to assess the quality of care received by these patients in primary care centres in Saudi Arabia. Data collection took place between May 2019 and July 2019. The questionnaire was self-completed anonymously by 315 patients with NCD attending primary health care centres in Riyadh, Saudi Arabia. The results showed that the average overall PACIC score was 2.97 (SD = 0.65), the mean scores for the subscales ranged from 2.76 (SD = 0.78) for the subscale of goal settings/tailoring to 3.17 (SD = 0.78) for delivery system design/decision support. PACIC scores varied significantly with age, occupation, monthly income, type and duration of chronic illness and educational attainment. In conclusion, patients with NCDs prioritised improvements in organised care that; is comprehensive, focussed on their needs, helps them identify clear goals for their treatments and become more involved in their condition(s) management.
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Affiliation(s)
- Ahmed Hazazi
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Public Health, Faculty of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia
- Ahmed Hazazi, Menzies Centre for Health Policy and Economics, Sydney School of Public Health, University of Sydney, No. 2W21/Level 2, Charles Perkins Centre D17, Sydney, NSW 2006, Australia.
| | - Andrew Wilson
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
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Frølich A, Nielsen A, Glümer C, Eriksen CU, Maindal HT, Kleist BH, Birke H, Stockmarr A. Patients' assessment of care for type 2 diabetes: Results of the Patient Assessment of Chronic Illness Care scale in a Danish population. BMC Health Serv Res 2021; 21:1069. [PMID: 34627257 PMCID: PMC8501600 DOI: 10.1186/s12913-021-07051-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/17/2021] [Indexed: 12/02/2022] Open
Abstract
Background The Patient Assessment of Chronic Illness Care (PACIC) scale is the most appropriate for assessing self-reported experience in chronic care. We aimed to validate the PACIC questionnaire by (1) assess patients’ perception of the quality of care for Danish patients with type 2 diabetes, (2) identify which factors are most important to the quality of care designated by the five subscales in PACIC, and (3) the validity of the questionnaire. Methods A survey of 7,745 individuals randomly selected from the National Diabetes Registry. Descriptive statistics inter-item and item-rest correlations and factor analysis assessed the PACIC properties. Quality of care was analysed with descriptive statistics; linear and multiple regression assessed the effect of forty-nine covariates on total and subscale scores. Results In total, 2,696 individuals with type 2 diabetes completed ≥ 50 % of items. The floor effect for individual items was 8.5–74.5 %; the ceiling effect was 4.1–47.8 %. Cronbach’s alpha was 0.73–0.86 for the five subscales. The comparative fit index (CFI) and the Tucker–Lewis index (TLI) were 0,87, and 0,84, respectively. Mean PACIC score was 2.44 (± 0.04). Respondents, who receive diabetes care primarily at general practice and outpatient clinics had higher scores compared to those receiving care at a private specialist. Receiving rehabilitation was followed by higher scores in all subscales. Those 70 years or older had lower mean total and subscale scores compared to younger patient groups. A higher number of diabetes visits were associated with higher total scores; a higher number of emergency department visits were associated with lower total scores. The effects of healthcare utilisation on subscale scores varied. Conclusions These results provide insight into variations in the quality of provided care and can be used for targeting initiatives towards improving diabetes care. Factors important to the quality of perceived care are having a GP or hospital outpatient clinic as the primary organization. Also having a higher number of visits to the two organizations are perceived as higher quality of care as well as participating in a rehabilitation program. Floor and ceiling effects were comparable to an evaluation of the PACIC questionnaire in a Danish population. Yet, floor effects suggest a need for further evaluation and possible improvement of the PACIC questionnaire in a Danish setting. Total PACIC scores were lower than in other healthcare systems, possible being a result of different contexts and cultures, and of a need for improving diabetes care in Denmark. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07051-6.
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Affiliation(s)
- Anne Frølich
- Section of General Practice, Department of Public Health, University of Copenhagen, 1356 K, Copenhagen, Denmark. .,Innovation and Research Centre for Multimorbidity, Slagelse Hospital, 4200, Slagelse, Denmark.
| | - Ann Nielsen
- Danish Dementia Research Centre, Rigshospitalet, University of Copenhagen, 2100, Copenhagen, Denmark
| | | | | | | | | | - Hanne Birke
- Center for clinical Research and Prevention, Frederiksberg Hospital, Frederiksberg, Denmark
| | - Anders Stockmarr
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, 2800, Kgs. Lyngby, Denmark
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