How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes

Objective: European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates.

Design: Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates.

Setting: A total of 14 countries.

Subjects: Consensus groups of PCPs.

Main outcome measures: Probability of initial presentation to a PCP for four clinical vignettes.

Results: There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r =??0.16, 95% CI??0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r?=??0.57, 95% CI??0.83 to??0.12; ovary: r?=??0.13, 95% CI??0.57 to 0.38; breast r?=?0.14, 95% CI??0.36 to 0.58; bowel: r?=?0.20, 95% CI??0.31 to 0.62).

Conclusions: There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a “PCP-as-gatekeeper” system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival.

• KEY POINTS

• European cancer survival rates vary widely, and health system factors may account for some of these differences.

• The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP.

• The degree to which PCPs act as gatekeepers varies considerably from country to country.

• There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

     

Limited value of NT-proBNP as a prognostic marker of all-cause mortality in patients with heart failure with preserved and mid-range ejection fraction in primary care: A report from the swedish heart failure register

Abstract

Aim: The prognostic value of natriuretic peptides in the management of heart failure (HF) patients with ejection fraction (EF) <40% is well established, but is less known for those with EF ≥40% managed in primary care (PC). Therefore, the aim of this study is to describe the prognostic significance of plasma NT-proBNP in such patients managed in PC.

Subjects: We included 924 HF patients (48% women) with EF ≥40% and NT-proBNP registered in the Swedish Heart Failure Registry. Follow-up was 1100?±?687?days.

Results: One-, three- and five-year mortality rates were 8.1%, 23.9% and 44.7% in patients with EF 40–50% (HFmrEF) and 7.3%, 23.6% and 37.2% in patients with EF ≥50% (HFpEF) (p?=?0.26). Patients with the highest mean values of NT-proBNP had the highest all-cause mortality but wide standard deviations (SDs). In univariate regression analysis, there was an association only between NT-proBNP quartiles and all-cause mortality. In HFmrEF patients, hazard ratio (HR) was 1.96 (95% CI 1.60–2.39) p?<?0.0001) and in HFpEF patients, HR was 1.72 (95% CI 1.49–1.98) p?<?0.0001). In a multivariate Cox proportional hazard regression analysis, adjusted for age, NYHA class, atrial fibrillation and GFR class, this association remained regarding NT-proBNP quartiles [HR 1.83 (95% CI 1.38–2.44), p?<?0.0001] and [HR 1.48 (95% CI 1.16–1.90), p?=?0.0001], HFmrEF and HFpEF, respectively.

Conclusion: NT-proBNP has a prognostic value in patients with HF and EF ≥40% managed in PC. However, its clinical utility is limited due to high SDs and the fact that it is not independent in this population which is characterized by high age and much comorbidity.

• Key points

• It is uncertain whether NT-proBNP predicts risk in heart failure with preserved ejection fraction (EF?>?40%, HFpEF) managed in primary care.

• We show that high NT-proBNP predicts increased all-cause mortality in HFpEF-patients managed in primary care.

• The clinical use is however limited due to large standard deviations, many co-morbidities and high age.

• Many of these co-morbidities contribute to all-cause mortality and management of these patients should also focus on these co-morbidities.

     

Diabetic Retinopathy –Incidence And Risk Factors In A Community Setting- A Longitudinal Study

Aim: To evaluate the natural history of diabetic retinopathy (DR) in diabetic patients and to assess long term risk for other chronic diseases associated with DR.

Methods: Retrospective, community-based study. Diabetics who underwent their first fundoscopic examination during 2000–2002, and had at least one follow- up examination by the end of 2007 were included. The primary outcome was the development of DR (proliferative diabetic retinopathy (PDR), non PDR (NPDR) or macular edema.

Patients were followed for another 9 years for documentation of new diagnosis of related diseases.

Results: 516 patients' (1,032 eyes) records were included and were followed first for an average of 4.15?±?1.27 years. During follow-up, 28 (2.7%) of the total 1,032 eyes examined were diagnosed with PDR. An additional 194 (18.8%) eyes were diagnosed with new NPDR. The cumulative incidence of NPDR was 310/1,032 (30.0%). All the patients who developed PDR had prior NDPR. By the end of the 9 years extended follow up, patients with NPDR had a greater risk for developing chronic renal failure HR?=?1.71 (1.14–2.56), ischemic heart disease HR?=?1.57 (1.17–2.09), and had an increased mortality rate HR?=?1.26 (1.02–1.57)

Conclusion: DR is associated with a higher rate of diabetes complications. Patients with DR should be followed more closely.

• Key points

• During a mean follow-up of 4.5 years, the cumulative incidence of diabetic retinopathy in a community cohort was 18.8%.

• NDPR (non-proliferative diabetic retinopathy) is a predictor of PDR (proliferative diabetic retinopathy).

• In a real life setting NPDR is a marker of a poorer prognosis.

• Patients with NDPR should be monitored more closely.

     

Reasons for attending a general emergency outpatient clinic versus a regular general practitioner – a survey among immigrant and native walk-in patients in Oslo,Norway

Objective: To explore reasons for attending a general emergency outpatient clinic versus a regular general practitioner (RGP).

Design: Cross-sectional study using a multilingual anonymous questionnaire.

Setting: Native and immigrant walk-in patients attending a general emergency outpatient clinic in Oslo (Monday–Friday, 08:00–23:00) during 2 weeks in September 2009.

Subjects: We included 1022 walk-in patients: 565 native Norwegians (55%) and 457 immigrants (45%).

Main outcome measures: Patients’ reasons for attending an emergency outpatient clinic versus their RGP.

Results: Among patients reporting an RGP affiliation, 49% tried to contact their RGP before this emergency encounter: 44% of native Norwegian and 58% of immigrant respondents. Immigrants from Africa [odds ratio (OR)?=?2.55 (95% confidence interval [CI]: 1.46–4.46)] and Asia [OR?=?2.32 (95% CI: 1.42–3.78)] were more likely to contact their RGP before attending the general emergency outpatient clinic compared with native Norwegians. The most frequent reason for attending the emergency clinic was difficulty making an immediate appointment with their RGP. A frequent reason for not contacting an RGP was lack of access: 21% of the native Norwegians versus 4% of the immigrants claimed their RGP was in another district/municipality, and 31% of the immigrants reported a lack of affiliation with the RGP scheme.

Conclusions and implications: Access to primary care provided by an RGP affects patients’ use of emergency health care services. To facilitate continuity of health care, policymakers should emphasize initiatives to improve access to primary health care services.

• KEY POINTS

• Access to immediate primary health care provided by a regular general practitioner (RGP) can reduce patients’ use of emergency health care services.

• The main reason for attending a general emergency outpatient clinic was difficulty obtaining an immediate appointment with an RGP.

• A frequent reason for native Norwegians attending a general emergency outpatient clinic during the daytime is having an RGP outside Oslo.

• Lack of affiliation with the RGP scheme is a frequent reason for attending a general emergency outpatient clinic among immigrants.

     

The need for additional care in patients with classical galactosaemia

Abstract

Purpose: Classical galactosaemia is an inborn error of galactose metabolism which may lead to impairments in body functions and accordingly, need for additional care. The primary aim of this study was to establish the type and intensity of this additional care.

Materials and methods: Patients with classical galactosaemia aged ≥2 years were evaluated with the Capacity Profile, a standardised method to classify additional care needs according to type and intensity. Based on a semi-structured interview, current impairments in five domains of body functions were determined. The intensity of additional care was assessed (from 0, usual care, to 5, total dependence).

Results: Forty-four patients with classical galactosaemia, 18 males and 26 females (median age 15 years, range 2–49 years), were included. There was a wide spectrum of impairments in mental functions. Motor function impairments were present in four patients, and mild speech impairments in eight patients. Additional care for sensory functions was uncommon. All patients needed a diet, which care is scored in the physical health domain.

Conclusions: Apart from the diet all patients need, classical galactosaemia leads to the need for additional care mainly in the domains of mental functions and speech and voice functions.

• Implications for rehabilitation

• The Capacity Profile is a useful tool to demonstrate additional care needs in classical galactosaemia.

• In classical galactosaemia additional care is mostly indicated by mental impairments and speech and voice functions.

• One-fifth of patients have impairment of speech and voice functions at time of the study, and half of all patients had received speech therapy in childhood.

• Over 70% of patients need additional care/help due to impairment of mental functions, ranging from coaching due to social vulnerability to full day care.

     

Patient experience after lower extremity amputation for sarcoma in England: a national survey

Purpose: After amputation, rehabilitation and limb fitting services are critically important to optimise outcomes. We investigated the reported patient experience and variation in limb fitting services after amputation for musculoskeletal tumours in England.

Methods: A postal survey instrument was developed following literature review, patient and clinician consultation and piloting. The survey was sent from each of the five bone tumour surgical centres in England.

Results: One hundred and five responses were received from 250 patients (42%). The number of limb fitting centres accessed by each surgical centre varied from 2 to 28. Many patients reported care falling short of national standards in areas including pre-amputation counselling, information provision, meeting someone with a similar amputation before surgery, psychological support and falls management. Patients were seen sooner where limb fitting services were on site. Many patients rely on being driven, ambulance and public transport to access services.

Conclusion: This study demonstrates variation in the reported experience of limb fitting services by sarcoma patients. Areas for improvement include information provision, pre-amputation counselling, psychological support and falls management. Clinicians should be aware services are highly variable, and this may impact on outcomes. Patients treated in sarcoma centres with limb fitting services on site may experience better care.

• Implications for Rehabilitation

• Rehabilitation services should strive to meet agreed national standards consistently.

• Where preamputation counselling involving meeting someone with a similar amputation is not possible, good information including video could be helpful.

• Services should support rehabilitation in the form of early walking aids and efficient prosthetic repair and maintenance.

• Psychological support, occupational therapy and physiotherapy support must be provided in the acute and chronic phases, including access to long-term rehabilitation care.

• Rehabilitation programmes must include training to patients and families on reporting, prevention and management of falls.

• On site services may support better care.

• Mechanisms for delivering expert specialist care close to home are needed.

     

Fractures diagnosed in primary care – a five-year retrospective observational study from a Norwegian rural municipality with a ski resort

Abstract

Objective: The aim of this study was to characterize fractures recorded at a Norwegian primary care centre near a ski resort.

Design: A retrospective five-year observational study in the period 2010–2014.

Setting: A primary care centre equipped with an x-ray machine and located near a ski resort in a small rural municipality of 931 inhabitants in Norway. The X-ray images are digitalized and instantly transferred for assessment of a radiologist and/or an orthopedic surgeon both before and after treatment.

Subjects: All patients with radiologically confirmed fractures.

Results: A total of 1154 X-ray examinations were done, out of which 480 (41.6%) were fractures verified by a radiologist. The most frequent fractures were in the wrist (30%), collarbone (15%), shin (11%), humerus (9%) and ankle (8%). 316 (66%) of the fractures were in males and of these 225 were in age group 10–19?years. Males dominated among fractures in collarbone (92% males), finger (80% males), and foot (85% males). Women with fractures of the wrist, ankle, humerus and metacarpal bones, had a higher median age than men with similar fractures. Nonsurgical treatment with cast or braces was initially offered in 371 (77%) of the fracture-cases at the primary care level.

Conclusion: Young men acquired most of the fractures, predominantly in the wrist, and mostly during the winter sport season. Nearly eight of ten fractures were treated locally in primary care centre.

• Key points

• A large seasonal variation was found in number of patients with fractures.

• More than 60% had fractures in the wrist, collarbone, shin or ankle.

• More than half of the patients with a fracture were males and below 20 years old.

• Most fractures were ski-related.

     

Client and family engagement in rehabilitation research: a framework for health care organizations

Purpose: To describe the development and implementation of an organizational framework for client and family-centered research.

Method: Case report.

Results: While patient-centered care is now well established, patient-centered research remains underdeveloped. This is particularly true at the organizational level (e.g., hospital based research institutes). In this paper we describe the development of an organizational framework for client and family centered research at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Canada.

Conclusion: It is our hope that, by sharing our framework other research institutions can learn from our experience and develop their own research patient/client/family engagement programs.

• Implications for rehabilitation

• Family engagement in rehabilitation research

• ?Rehabilitation research is crucial to the development and improvement of rehabilitative care.

• ?The relevance, appropriateness, and accountability of research to patients, clients and families could be improved.

• ?Engaging clients and families as partners in all aspects of the research process is one way to address this problem.

• ?In this paper, we describe a framework for engaging clients and families in research at the organizational level.

     

Upper extremity movement reliability and validity of the Kinect version 2

Purpose: Studies have shown that marker-less motion detection systems, such as the first generation Kinect (Kinect 1), have good reliability and potential for clinical application. Studies of the second generation Kinect (Kinect 2) have shown a large range of accuracy relative to balance and joint localization; however, few studies have investigated the validity and reliability of the Kinect 2 for upper extremity motion. This investigation compared reliability and validity among the Kinect 1, Kinect 2 and a video motion capture (VMC) system for upper extremity movements.

Design: One healthy, adult male performed six upper extremity movements during two separate sessions. All movements were recorded on the Kinect 1, Kinect 2 and VMC simultaneously. Data were analyzed using MATLAB (Natick, MA), Microsoft Excel (Redmond, WA), and SPSS (Armonk, NY).

Results: Results indicated good reliability for both Kinects within a day; results between days were inconclusive for both devices due to the inability to exactly repeat the desired movements. Range of motion (ROM) magnitudes for both Kinects were different from the VMC, yet patterns of motion were very highly correlated for both devices.

Conclusion: Simple transformations of Kinect data could bring magnitudes in line with those of the VMC, allowing the Kinects to be used in a clinical setting.

• Implications for Rehabilitation

• The clinical implications of the investigation support the notion that the Kinects could be used in the clinical setting if an understanding of their limitations exists.

• Using the Kinects to make assessments with a given data collection session is acceptable. Using the Kinects to make comparisons across different days such as before or after an intervention should be approached with caution.

• The Kinect 2 provides a more cost effective option compared to the VMC. Additionally, the Kinect is more portable, requires less time to set-up, and takes up less space, thus increasing its overall usability compared to the VMC.

     

Cancer patients’ use of primary care out-of-hours services: a cross-sectional study in Norway

Objective: To investigate how cancer patients in Norway use primary care out-of-hours (OOH) services and describe different contact types and procedures.

Design: A retrospective cross-sectional registry study using a billing registry data source.

Setting: Norwegian primary care OOH services in 2014.

Subjects: All patients’ contacts in OOH services in 2014. Cancer patients were identified by ICPC-2 diagnosis.

Main outcome measures: Frequency of cancer patients’ contacts with OOH services, contact types, diagnoses, procedures, and socio-demographic characteristics.

Results: In total, 5752 cancer patients had 20,220 contacts (1% of all) in OOH services. Half of the contacts were cancer related. Cancer in the digestive (22.9%) and respiratory (18.0%) systems were most frequent; and infection/fever (21.8%) and pain (13.6%) most frequent additional diagnoses. A total of 4170 patients had at least one cancer-related direct contact; of these, 64.5% had only one contact during the year. Cancer patients had more home visits and more physicians’ contact with municipal nursing services than other patients, but fewer consultations (p?p?Conclusion: There was no indication of overuse of OOH services by cancer patients in Norway, which could indicate good quality of cancer care in general.

• KEY POINTS

• Many are concerned about unnecessary use of emergency medical services for non-urgent conditions.

• ??There was no indication of overuse of out-of-hours services by cancer patients in Norway.

• ??Cancer patients had relatively more home visits, physician’s contact with the municipal nursing service, and weekend contacts than other patients.

• ??Cancer patients in the least central municipalities had relatively more contacts with out-of-hours services than those in more central municipalities.

     

Insulins NPH,glargine, and detemir,and risk of severe hypoglycemia among working-age adults*

Introduction: The longer acting basal insulin analogs glargine and detemir have shown a lower incidence of hypoglycemia compared to insulin NPH in clinical studies. We evaluated the real-life risk of severe hypoglycemia among new users of insulins in the working-age population in Finland.

Methods: All persons aged 18–65 years with diabetes mellitus who were newly prescribed with insulins NPH, glargine, or detemir during 2006–2009, were identified from national registers. Risk of severe hypoglycemia requiring hospital care was compared between insulin types.

Results: A total of 16,985 persons initiated basal insulin treatment (5586, 7499, and 3900 patients started NPH, glargine, and detemir, respectively) during follow-up. Five hundred and thirty-six persons were hospitalized because of severe hypoglycemia. Absolute rate (per 1000 patient-years) was 20.6 (95% CI 17.9, 23.8), 17.8 (15.6, 20.3), and 12.4 (9.9, 15.5) for NPH, glargine, and detemir initiators, respectively. With NPH as reference, the adjusted hazard ratio (HR) was 0.92 (95% CI 0.74, 1.15, p?=?0.47) for glargine, and 0.70 (0.51, 0.94, p=?0.018) for detemir. The HR for detemir compared to glargine was 0.76 (0.58, 0.99, p?=?0.040).

Conclusions: Initiating insulin treatment with detemir, but not with glargine, was associated with a significantly lower risk of severe hypoglycemia compared to NPH, among working-age adults.

• KEY MESSAGES

• The comparative safety of modern basal insulins regarding hypoglycemia among the working-age population is unclear.

• Large reductions in the incidence of severe hypoglycemia were seen among real-life patients who started insulin detemir, as compared to patients who initiated glargine or especially NPH insulin.

• Given the large amount of patients using insulin, these findings may have considerable clinical consequences at the population level.

     

Clinical relevance of the modified physical performance test versus the short physical performance battery for detecting mobility impairments in older men with peripheral arterial disease

Abstract

Purpose: The study is to compare the Modified Physical Performance Test (MPPT) and Short Physical Performance Battery (SPPB) as metrics of mobility and function in older men with peripheral arterial disease (PAD).

Materials and methods: A total of 51 men (55–87?years) with PAD underwent functional testing including the SPPB, MPPT, Walking Impairment Questionnaire (WIQ), stair ascent, and 6-min walk distance. Individuals were grouped according to SPPB and MPPT scores as not limited on either, limited only on the MPPT, or limited on both.

Results: The MPPT identified a higher proportion of patients as being functionally limited than the SPPB (p?<?0.001). Men identified as limited only by the MPPT, and not the SPPB, were subsequently confirmed to have lower function on all measures compared to those not identified as limited by either the SPPB or the MPPT (p?<?0.02).

Conclusions: These findings suggest the MPPT is an appropriate measure to identify early declines in men with PAD and may identify global disability better than SPPB.

• Implications for rehabilitation

• Individuals with peripheral arterial disease have low activity levels and are at risk for a loss of independence and global disability.

• Early detection of decline in mobility and global function would allow for interventions before large changes in ambulatory ability or a loss of functional independence occur.

• This study shows the Modified Physical Performance Test may be an appropriate test to identify early decline in function in men with peripheral arterial disease.

     

Time pressured deprioritization of COPD in primary care: a qualitative study

Objective: To identify factors that hinder discussions regarding chronic obstructive pulmonary disease (COPD) between primary care physicians (PCPs) and their patients in Sweden. Setting: Primary health care centres (PHCCs) in Stockholm, Sweden. Subjects: A total of 59 PCPs. Design: Semi-structured individual and focus-group interviews between 2012 and 2014. Data were analysed inspired by grounded theory methods (GTM). Results: Time-pressured patient–doctor consultations lead to deprioritization of COPD. During unscheduled visits, deprioritization resulted from focusing only on acute health concerns, while during routine care visits, COPD was deprioritized in multi-morbid patients. The reasons PCPs gave for deprioritizing COPD are: “Not becoming aware of COPD”, “Not becoming concerned due to clinical features”, “Insufficient local routines for COPD care”, “Negative personal attitudes and views about COPD”, “Managing diagnoses one at a time”, and “Perceiving a patient’s motivation as low’’. Conclusions: De-prioritization of COPD was discovered during PCP consultations and several factors were identified associated with time constraints and multi-morbidity. A holistic consultation approach is suggested, plus extended consultation time for multi-morbid patients, and better documentation and local routines.

• Key points

• Under-diagnosis and insufficient management of chronic obstructive pulmonary disease (COPD) are common in primary health care. A patient–doctor consultation offers a key opportunity to identify and provide COPD care.

  • Time pressure, due to either high number of patients or multi-morbidity, leads to omission or deprioritization of COPD during consultation.

  • Deprioritization occurs due to lack of awareness, concern, and local routines, negative personal views, non-holistic consultation approach, and low patient motivation.

  • Better local routines, extended consultation time, and a holistic approach are needed when managing multi-morbid patients with COPD.

     

Sex-based influence on clinical outcomes after drug-eluting stent implantation in real-world patients: insight from the FOCUS registry

Objectives: To investigate the impact of sex on clinical outcomes after drug-eluting stent (DES) implantation in real-world patients.

Methods and results: A total number of 4720 patients (3365 males and 1355 females) undergoing the second-generation cobalt-chromium sirolimus-eluting stent (CoCr-SES) implantation from the FOCUS registry were included in this analysis. The cumulative incidences of major adverse cardiovascular event (MACE) (1.5% vs. 2.4%; p?=?.03), cardiovascular death (0.5% vs. 1.0%; p?=?.02) and target vessel revascularization (TVR) (0.3% vs. 0.8%; p?=?.01) within six months were significantly higher in females and the risks of MACE (adjusted hazard ratio [HR] 0.5 (0.3–0.9); p?=?.01) and TVR (adjusted HR 0.1(0.0–0.5); p?=?.001) remained significant in multivariate analysis. Reversely, the cumulative incidences of MACE (5.4% vs. 4.8%; p?=?.04) and any revascularization (5.1% vs. 3.3%; p?=?.01) were significantly higher in males beyond six months and the risks of all-cause death (adjusted HR 1.6 (1.1–2.5); p?=?.03) and cardiovascular death (adjusted HR 1.9 (1.1–3.6); p?=?.03) turned out to be significant in multivariate analysis. Notes: All cumulative incidences were presented as male vs. female; all HRs were calculated as male relative to female.

Conclusions: Females were associated with higher risk of early adverse events, while, males were associated with higher risk of late adverse events.

• Key messages

• Females undergoing PCI are typically older, have more cardiovascular risk factors, while, males in need of PCI are more frequently associated with complex lesions.

• The overall three-year cumulative incidences of adverse events are not significantly different between males and females but numerically higher in males.

• Females are associated with significantly higher risks of MACE and TVR within six months, while, males are associated with significantly higher risk of all-cause mortality and cardiac mortality beyond 6 months.

     

Increased serum C-reactive protein levels are associated with shorter survival and development of second cancers in chronic lymphocytic leukemia

Background: Chronic lymphocytic leukemia (CLL) is characterized by a heterogeneous clinical course, ranging from stable to more aggressive disease. Herein, we determined the prognostic significance of serum C-reactive protein (CRP) levels in patients with CLL

Methods: A retrospective cohort study reviewing the records of 107 consecutive treatment naïve patients with CLL and a control group comprised of apparently healthy individuals attending for periodic health examinations.

Results: The median CRP level of patients with CLL was 0.19?mg/dL (0–2.9). In univariate analysis, high-CRP levels (≥0.4 mg/dL) were significantly associated with an increased risk of mortality (HR?=?3.97, 95%CI 1.64–9.62, p?=?.002) and development of second solid cancers (HR?=?4.54, 95%CI 1.57–13.11, p?=?.005), compared to low-CRP values (<0.4 mg/dL). In multivariate analysis, high-CRP retained statistical significance for all-cause mortality (HR?=?2.81, 95%CI 1.04–7.57, p?=?.04) and the development of second solid malignancies (HR?=?4.54, 95%CI 1.57–13.11, p?=?.005). Moreover, when compared to an apparently healthy population, CLL patients with high CRP levels had more than an eightfold risk of cancer.

Conclusions: Elevated baseline CRP levels are associated with shorter survival and development of second cancers in patients with CLL. We suggest that increased CRP in patients with CLL may justify a more rigorous search for second cancers.

• KEY MESSAGES

• Elevated CRP levels are associated with a shorter overall survival in CLL.

• Elevated CRP levels are associated with an increased risk of second cancers in CLL.

• Increased CRP in patients with CLL may justify a more rigorous search for second cancers.

     

Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Association of thiazolidinedione with a lower risk of Parkinson’s disease in a population with newly-diagnosed diabetes mellitus

Objectives: We investigated the association of thiazolidinedione and its dose effect with the risk of Parkinson’s disease (PD) in patients with diabetes mellitus (DM).

Methods: This study enrolled 38,521 patients with newly-diagnosed DM, between 2001 and 2013, and compared them to the matched subjects without DM. The hazard ratios (HRs) for PD were compared between the thiazolidinedione-treated and non-thiazolidinedione-treated groups of the study cohort, and between subgroups who received different cumulative dosages of thiazolidinedione.

Results: We observed that 544 (1.4%) patients developed PD during the follow-up median duration of 6.2 years in patients with newly-diagnosed DM or had a higher risk for PD than patients without DM (HR?=?1.150). In the study cohort, the risk of PD was significantly lower in the thiazolidinedione-treated group (HR?=?0.399) compared to the non-thiazolidinedione-treated group. Thiazolidinedione reduced the risk of PD in a dose-dependent manner, with HRs ranging from 0.613 to 0.081 with defined daily doses of 0–90 to >720, respectively.

Conclusions: Thiazolidinedione use was associated with a significantly reduced risk of PD in patients with newly-diagnosed DM. Further studies to elucidate the common mechanism of PD and DM may provide novel therapies for these two diseases.

• Key messages

• Newly-diagnosed diabetes mellitus slightly increases the risk for Parkinson’s disease.

• Thiazolidinedione is associated with a lower risk of Parkinson's disease in a dose-dependent manner in patients with newly-diagnosed diabetes mellitus.

     

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs’ experiences

Abstract

Objective: Explore general practitioners’ (GPs’) views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases.

Design: Qualitative content analysis of five focus-group discussions.

Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden.

Subjects: 29 GPs.

Main outcome measures: GPs’ views and experiences of care managers for patients with depression.

Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases.

Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members’ roles must be clear.

• KEY POINTS

• A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs’ experiences of this kind of collaborative care is limited.

• GPs find that care managers provide support for patients and security and relief for GPs.

• GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager.

• GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

     

Prevalence,impact and treatment of spasticity in nursing home patients with central nervous system disorders: a cross-sectional study

Purpose To assess prevalence, impact and treatment of spasticity in nursing home patients with central nervous system (CNS) disorders. Methods The Modified Ashworth Scale was used as the main indicator of spasticity to assess muscle tone of the extremities. Further information was obtained on burden of care, level of independence, sleeping pattern, complaints, restrictions in functions/activities/participation and indication for treatment. Clinical assessments included coordination/sensibility parameters and various tests to assess motor performance. Results Fifty-six out of 77 participants (73%) with CNS disorders had spasticity, of whom 38 subjects also showed pathologically enhanced reflexes and 45 subjects had contractures in various joints. A high burden of care was observed in 71% and cramps/pain, cosmetic problems or other complaints due to spasticity were seen in 46, 20 and 26%, respectively. The vast majority of subjects were dependent for daily living activities and ambulation. Extra treatment of spasticity was indicated for 36% of the patients. Conclusion A high prevalence of spasticity was observed in nursing home residents with CNS disorders associated with substantial impact in terms of caregiving, complaints and compromised clinical outcome measures. To further optimize the treatment of spasticity in this vulnerable population, regional treatment plans should be developed.

• Implications for Rehabilitation

• The prevalence of spasticity in nursing home residents with central nervous system disorders is high (73%).

• The impact of spasticity is substantial in terms of increased dependency in activities of daily living, increased burden of care, sleeping problems and many complaints.

• Thirty-six percent of patients could be helped by extra specialized treatment, so the challenge for the multidisciplinary rehabilitation team is huge.

• Regional treatment plans should be developed to further optimize the treatment of spasticity in the vulnerable ageing population of nursing home residents.