Secular Trends in Diabetes-Related Preventable Hospitalizations in the United States, 1998�C2006

OBJECTIVE

To examine secular trends in diabetes-related preventable hospitalizations among adults with diabetes in the U.S. from 1998 to 2006.

RESEARCH DESIGN AND METHODS

We used nationally representative data from the National Inpatient Sample to identify diabetes-related preventable hospitalizations. Based on the Agency for Healthcare Research and Quality''s Prevention Quality Indicators, we considered that hospitalizations associated with the following four conditions were preventable: uncontrolled diabetes, short-term complications, long-term complications, and lower-extremity amputations. Estimates of the number of adults with diabetes were obtained from the National Health Interview Survey. Rates of hospitalizations among adults with diabetes were derived and tested for trends.

RESULTS

Age-adjusted rates for overall diabetes-related preventable hospitalizations per 100 adults with diabetes declined 27%, from 5.2 to 3.8 during 1998–2006 (P_trend < 0.01). This rate decreased significantly for all but not for short-term complication (58% for uncontrolled diabetes, 37% for lower-extremity amputations, 23% for long-term complications [all P < 0.01], and 15% for the short-term complication [P = 0.18]). Stratified by age-group and condition, the decline was significant for all age-condition groups (all P < 0.05) except short-term complications (P = 0.33) and long-term complications (P = 0.08) for the age-group 18–44 years. The decrease was significant for all sex-condition combination subgroups (all P < 0.01).

CONCLUSIONS

We found a decrease in diabetes-related preventable hospitalizations in the U.S. from 1998 to 2006. This trend could reflect improvements in quality of primary care for individuals with diabetes.Hospitalizations related to diabetes are costly and account for a major portion of the total expenditure on diabetes. In 2007, hospitalizations in the U.S. attributable to diabetes cost $58 billion or 50% of the total direct medical expenditure for diabetes (1). Nevertheless, a large portion of hospitalizations for diabetes may be preventable if primary care is effectively delivered (2–4). Timely and effective diagnosis, treatment, and education can result in better management of diabetes, prevent the development or worsening of complications, and lead to lower hospitalization rates. Thus, diabetes is often referred to as an ambulatory care–sensitive condition, and its associated hospitalizations are often referred to as preventable hospitalizations. Examining the trends of preventable hospitalization would facilitate our understanding of how access to and quality of primary care for diabetes has or has not improved. However, few analyses of trends in preventable hospitalizations for individuals with diabetes have been published.The Agency for Healthcare Research and Quality (AHRQ) developed sets of disease and procedure codes using the ICD-9-CM to identify14 sets of preventable hospitalization conditions. Of the 14 conditions, four were for diabetes: uncontrolled diabetes, diabetes short-term complications, diabetes long-term complications, and lower-extremity amputations (5). The AHRQ also reported trends in rates of diabetes-related preventable hospitalizations from 1994 to 2000 (6). However, the rates reported by AHRQ used the total population (i.e., individuals with and without diabetes) as the denominator. Rates so calculated are sensitive to changes in diabetes prevalence and thus are not ideal for examining changes in access to and quality of ambulatory care for individuals with diabetes. Here, we used only adults with diabetes as the denominator to analyze national trends in the rates of diabetes-related preventable hospitalizations.     

Adult hospital admissions associated with multiple sclerosis in Finland in 2004–2014

Introduction: Treatment of multiple sclerosis (MS) has developed significantly and several new immunotherapeutic drugs have become available in Finland since 2004. We studied whether this is associated with changes in hospital admission frequencies and healthcare costs and whether admission rates due to infection have increased.

Methods: The national Care Register for Health Care was searched for all discharges from neurological, medical, surgical, neurosurgical and intensive care units with MS as a primary diagnosis or an auxiliary diagnosis for primary infection diagnosis in 2004–2014. Only patients ≥16 years of age were included.

Results: We identified 12,276 hospital admissions for 4296 individuals. The number of admissions declined by 4.6% annually (p?=?.0024) in both genders. Proportion of admissions with an infection as the primary diagnosis increased but no change in their frequency was found. They were longer than admissions with MS as the primary diagnosis and were associated with increased in-hospital mortality. The annual aggregate cost of hospital admissions declined by 51% during the study period.

Conclusions: This study shows that hospital admission rates and costs related to MS hospital admissions have markedly declined from 2004 to 2014 in Finland, which coincides with an increase in the use of disease-modifying therapies.

• Key message

• Hospital admission rates and costs related to MS hospital admissions have markedly declined from 2004 to 2014 in Finland.

• Proportion of admission related to infection has increased and they are associated with longer hospitalizations and increased in-hospital mortality pointing out the importance of infection prevention.

     

The ecology of medical care: access points to the health care system in Austria and other developed countries

Abstract

Objective: This study aimed to analyze the Austrian health care system using the ecology of care model. Our secondary aim was to compare data from Austria with those available from other countries.

Design: 3508 interviews employing a 30-item questionnaire related to the utilization of the health care system including demographic factors were conducted. Participants were chosen by a Random Digital Dialing procedure. Further, a literature review of studies of other countries use of the ecology of care model was conducted.

Main outcome measures: Austria has one of the highest utilization of health care services in any of the assessed categories. The comparison with the literature review shows that Austria has the highest utilization of specialists working in the outpatient sector as well as the highest hospitalization rates. Taiwan and Korea have comparable utilization patterns. Canada, Sweden, and Norway are countries with lower utilization patterns, and the U.S. and Japan are intermediate.

Conclusion: In Austria and similarly organized countries, high utilization of all health care services can be observed, in particular, the utilization of specialists and hospitalizations. The over-utilization of all levels of health care in Austria may be due to the lack of a clear demarcation line between the primary and secondary levels of care, and the presence of universal health coverage, which also allows for unrestricted and undirected access to all levels of care. Previous studies have shown that comparable countries lack the health benefits of a strong primary care system with its coordination function.

• Key points

• In Austria and similarly organized countries, there appears to be high utilization of health care in general, as well as with particular utilization of specialists and hospitalizations.

• The high utilization of all levels of care in Austria may be the result of competition, lack of a clear demarcation line between the primary and secondary level of care, and the presence of universal health coverage.

• Pathways between primary and secondary care should be strengthened as previous studies have shown that comparable countries lack the health benefits of strong primary care and its function for health care coordination.

     

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.

     

Quality of chronic kidney disease management in primary care: a retrospective study

Background: Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. Aim: To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Design and setting: Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). Method: CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Results: Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Conclusion: Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model.

• Key points

• Quality of care for chronic kidney disease patients in primary care can be improved.

• In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients.

• Quality of care was higher in patients with diabetes.

• Chronic kidney disease management may be improved by developing strategies similar to diabetes care.

     

Variations in older people’s use of general practitioner consultations and the relationship with mortality rate in Vantaa,Finland in 2003–2014

Abstract

Objective: It is generally expected that the growth of the older population will lead to an increase in the use of health care services. The aim was to examine the changes in the number of visits made to general practitioners (GP) by the older age groups, and whether such changes were associated with changes in mortality rates.

Design and setting: A register-based observational study in a Finnish city where a significant increase in the older population took place from 2003 to 2014. The number of GP visits made by the older population was calculated, the visits per person per year in two-year series, together with respective mortality rates.

Subjects: The study population consisted of inhabitants aged 65?years and older (65+) in Vantaa that visited a GP in primary health care.

Main outcome measures: The number of GP visits per person per year in the whole older population during the study years.

Results: In 2009–2010, there was a sudden drop in GP visits per person in the younger (65–74?years) age groups examined. In the population aged 85+, use of GP visits remained at a fairly constant level. The mortality rate decreased until the year 2008. After that, the positive trend ended and the mortality rate plateaued.

Conclusions: Simultaneously with the decline in GP visits per person in the older population, the mortality rate leveled off from its positive trend in 2009–2010. Factors identified being associated with the number of GP consultations were organizational changes in primary health care, economic recession causing retrenchment, and even vaccinations during the swine flu epidemic.

• Key points

• Along with an increasingly ageing population, concern over the supply of publicly funded health care has become more pronounced.

• The amount of GP visits of 65+ decreased in primary health care, especially in the youngest groups.

• However, in the oldest age groups (85+), the use of GPs remained unchanged regardless of changes in service supply.

• As the rate of GP visits among the population of 65+ declined, the positive trend in the mortality rate ceased.

     

First four years of operation of a municipal acute bed unit in rural Norway

Abstract

Objective: To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions.

Design: Observational study.

Setting: A two-bed municipal acute bed unit.

Subjects: All patients admitted to the unit between 2013 and 2016.

Main outcome measures: Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate.

Results: Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20–1.71, adjusted for age and sex).

Conclusion: Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level.

• Key Points

• Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed:

• ??Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards.

• ??Most patients were old and had complex health problems.

• ??Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level.

     

Predictors of high hospital care and medication costs and cost trajectories in community-dwellers with Alzheimer’s disease

Abstract

Objectives: We studied the determinants of high healthcare costs (highest decile of hospital care and medication costs) and cost trajectories among all community-dwellers with clinically verified Alzheimer’s disease (AD), diagnosed during 2005–2011 in Finland (N?=?70,531).

Methods: The analyses were done separately for hospital care costs, medication costs and total healthcare costs that were calculated for each 6-month period from 5 years before to 3 years after AD diagnosis.

Results: Total healthcare costs were driven mainly by hospital care costs. The definition of “high-cost person” was time-dependent as 63% belonged to the highest 10% at some timepoint during the study period and six distinct cost trajectories were identified. Strokes, cardiovascular diseases, fractures and mental and behavioural disorders were most strongly associated with high hospital care costs.

Conclusions: Although persons with AD are often collectively considered as expensive patient group, there is large temporal and inter-individual variation in belonging to the highest decile of hospitalization and/or medication costs. It would be important to assess whether hospitalization rate could be decreased by, e.g., comprehensive outpatient care with more efficient management of comorbidities. In addition, other interventions that could decrease hospitalization rate in persons with dementia should be studied further in this context.

• Key messages

• Persons with AD had large individual fluctuation in hospital care costs and medication costs over time.

• Hospital care costs were considerably larger than medication costs, with fractures, cardiovascular diseases and mental and behavioural disorders being the key predictors.

• Antidementia medication was associated with lower hospital care costs.

     

High hospital readmission rates for patients aged ≥65 years associated with low socioeconomic status in a Swedish region: a cross-sectional study in primary care

Objective: There is a presumption that hospital readmission rates amongst persons aged ≥65 years are mainly dependent on the quality of care. In this study, our primary aim was to explore the association between 30-day hospital readmission for patients aged ≥65 years and socioeconomic characteristics of the studied population. A secondary aim was to explore the association between self-reported lack of strategies for working with older patients at primary health care centres and early readmission.

Design: A cross-sectional ecological study and an online questionnaire sent to the heads of the primary health care centres. We performed correlation and regression analyses.

Setting and subjects: Register data of 283,063 patients in 29 primary health care centres in the Region Örebro County (Sweden) in 2014.

Main outcome measure: Thirty-day hospital readmission rates for patients aged ≥65 years. Covariates were socioeconomic characteristics among patients registered at the primary health care centre and eldercare workload.

Results: Early hospital readmission was found to be associated with low socioeconomic status of the studied population: proportion foreign-born (r?=?0.74; p?r?=?0.73; p?r?=?0.74; p?r?=?0.51; p?r?=??0.40; p?=?0.03). The proportion of unemployed alone could explain up to 71.4% of the variability in hospital readmission (p?Conclusion: Primary health care centres localized in neighbourhoods with low socioeconomic status had higher rates of hospital readmission for patients aged ≥65. Interventions aimed at reducing hospital readmissions for older patients should also consider socioeconomic disparities.

• Key Points

• In Sweden, hospital readmission within 30 days among patients aged ≥65 has been used as a measure of quality of primary care for the elderly.

• However, in our study, elderly 30-day readmission was associated with low neighbourhood socioeconomic status.

• A simple survey in one Swedish region showed that the primary health care centres that lacked active strategies for working with aged patients did not have higher hospital readmission rates than those that reported having strategies.

• Interventions aimed at reducing elderly hospital readmissions should therefore also consider the socioeconomic disparities in the elderly.

     

Meeting the mental health needs of people with multiple sclerosis: a qualitative study of patients and professionals

Purpose: To explore perspectives and experiences of people with multiple sclerosis (MS) and health care professionals of mental health support for MS in the UK.

Method: 24 people with MS, 13 practice nurses, 12 general practitioners (GPs) and 9?MS specialist nurses were recruited through community groups and primary care practices across North West England. Semi-structured interviews were conducted, and data analyzed thematically using constant comparative analysis within and across the data sets. The theoretical framework of candidacy was used to interrogate data.

Results: Four themes were identified: candidates for care, management choices, defining roles, and permeability and responsiveness.

Discussion: Candidacy for care, and symptom management, depended on the framing of symptoms through a social or medical model of depression. Normalizing symptoms could prevent help-seeking by patients. Reported referral behavior varied by professional group, based on perceived remit, competency and training needs. GPs were perceived by patients and other professionals as central for management of mental health needs in MS, but may not perceive this role themselves, suggesting a need for increased knowledge, training, and improved access to specialist care.

• Implications for Rehabilitation

• Anxiety and depression are common in people with MS.

• Management of mental health needs in people with MS relies on complex decisions made by both people with MS and health care professionals.

• General practitioners may play a key role in the ongoing management of mental health needs of people with MS.

     

The relationship between health related quality of life and sensory deficits among patients with diabetes mellitus

Abstract

Purpose: (1) To profile sensory deficits examined in the ability to process sensory information from daily environment and discriminate between tactile stimuli among patients with controlled and un-controlled diabetes mellitus. (2) Examine the relationship between the sensory deficits and patients’ health-related quality of life.

Methods: This study included 115 participants aged 33–55 with uncontrolled (n?=?22) or controlled (n?=?24) glycemic levels together with healthy subjects (n?=?69). All participants completed the brief World Health Organization Quality of Life Questionnaire, the Adolescent/Adult Sensory Profile and performed the tactile discrimination test.

Results: Sensory deficits were more emphasized among patients with uncontrolled glycemic levels as expressed in difficulties to register sensory input, lower sensation seeking in daily environments and difficulties to discriminate between tactile stimuli. They also reported the lowest physical and social quality of life as compared to the other two groups. Better sensory seeking and registration predicted better quality of life. Disease control and duration contributed to these predictions.

Conclusions: Difficulties in processing sensory information from their daily environments are particularly prevalent among patients with uncontrolled glycemic levels, and significantly impacted their quality of life. Clinicians should screen for sensory processing difficulties among patients with diabetes mellitus and understand their impacts on patients’ quality of life.

• Implications for Rehabilitation

• Patients with diabetes mellitus, and particularly those with uncontrolled glycemic levels, may have difficulties in processing sensory information from daily environment.

• A multidisciplinary intervention approach is recommended: clinicians should screen for sensory processing deficits among patients with diabetes mellitus and understand their impacts on patients’ daily life.

• By providing the patients with environmental adaptations and coping strategies, clinicians may assist in optimizing sensory experiences in real life context and elevate patients’ quality of life.

• Relating to quality of life and emphasizing a multidisciplinary approach is of major importance in broadening our understanding of health conditions and providing holistic treatment for patients.

     

Seasonality of stroke in Finland

Introduction: The burden of stroke is increasing globally. Reports on seasonal variations in stroke occurrence are conflicting and long-term data are absent.

Methods: A retrospective cohort study using discharge registry data of all acute stroke admissions in Finland during 2004–2014 for patients?≥18 years age. A total of 97,018 admissions for ischemic stroke (IS) were included, 18,252 admissions for intracerebral hemorrhage (ICH) and 11,271 admissions for subarachnoid hemorrhage (SAH).

Results: The rate of IS admissions increased (p?=?0.025) while SAH admission rate decreased (p?Conclusions: All major stroke subtypes occurred most commonly in autumn and most infrequently in summer. Seasonality of in-hospital mortality and length of hospital stay appears to vary by stroke subtype. The seasonal pattern of ischemic stroke occurrence appears to have changed during the past decades.

• Key messages

• All major stroke subtypes (ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage) occurred most frequently in autumn and least frequently in summer.

• Seasonal patterns of in-hospital mortality and length of stay differed markedly by stroke subtype.

• The seasonal pattern of ischemic stroke occurrence in Finland seems to have changed compared to 1982–1992.

     

Effects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study

Objective: To determine the effect of a large-scale program to strengthen general practice on hospitalisation rates.

Methods: This observational study compared enrolled patients in the program and a sample of non-participating patients from non-participating GPs in the same geographic area in Germany. Key components of the program are: prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices. The outcomes in this study were hospitalisation, rehospitalisation, and avoidable hospital admission up to four years after patient inclusion. Poisson regression models and generalized estimating equations were used to estimate intervention effects.

Results: In the baseline year, 19.1% were hospitalised and 13.6% had a potentially avoidable hospitalisation, 14.5% were rehospitalised within 4 weeks. Across the four observed years, yearly hospitalisations were 9.8 to 14.9% lower in enrolled patients, yearly re-hospitalisations were 5.3 to 11.5% lower, and yearly avoidable hospitalisations were 6.8 to 8.6% lower compared to the control cohort (all differences were statistically significant). The trend in the between-group difference for hospitalisations and re-hospitalisations increased, while it remained stable for avoidable hospitalisations.

Conclusion: This study provides strong indications for the positive impact of strong general practice care on population outcomes.

• Key points

• A program to strengthen general practice in Germany comprised of prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices.

• Patients who remained in the program during 4 years had increasingly lowered rates of hospitalisation and rehospitalisation compared to a control group of patients.

• Avoidable hospitalisations were also lower, but no trend of further lowering was found. This might suggest a ceiling effect to impact of strong general practice on hospitalisations.

     

Legitimacy of work tasks,psychosocial work environment,and time utilization among primary care staff in Sweden

Abstract

Objective: Primary care staff faces a complex work environment including a heavy administrative work load and perceive some work tasks as illegitimate. This study aimed to elucidate associations between the perceived legitimacy of work tasks, the psychosocial work environment, and the utilization of work time among Swedish primary care staff.

Design and setting: The study was designed as a multicenter study involving all staff categories, i.e. registered nurses, primary care physicians, care administrators, nurse assistants and allied professionals, at eleven primary care centers in Sweden.

Subjects: Participants completed the Bern Illegitimate Tasks Scale and the Copenhagen Psychosocial Questionnaire. They also recorded time spent on all work tasks, day by day during two separate weeks.

Main outcome measures and results: More than a quarter (27%) of primary care physicians perceived a high proportion of unnecessary work tasks. After adjusting for profession, age and gender, the perception of having to perform unreasonable work tasks was positively associated with experiencing role conflicts and with the proportion of organization-related administration and service work tasks.

Conclusion: Across all staff groups, the perception of unreasonable work tasks was more pronounced among staff with a high proportion of non-patient related administration. Also, the perception of having to perform a large amount of illegitimate work tasks affected the psychosocial work environment negatively, which might influence staffs perception of their professional roles. These results illuminate the importance of decision makers to thoroughly consider the distribution and allocation of non-patient related work tasks among staff in primary care.

• Key points

• We observed an interaction between perception of having a large proportion of illegitimate work tasks and impaired psychosocial work environment.

• ??More than a quarter of the primary care physicians perceived a high proportion of unnecessary work tasks.

• ??Across all staff groups, performing unreasonable work tasks was associated with an experience of having role conflicts.

• ??Across all staff groups, a perception of performing unreasonable work tasks was associated with the proportion of non-patient related administrative work tasks.

     

Prevalence of comorbidity in primary care patients with type 2 diabetes and its association with elevated HbA1c: A cross-sectional study in Croatia

Objective To the authors’ knowledge, there are few valid data that describe the prevalence of comorbidity in type 2 diabetes mellitus (T2DM) patients seen in family practice. This study aimed to investigate the prevalence of comorbidities and their association with elevated (≥?7.0%) haemoglobin A1c (HbA1c) using a large sample of T2DM patients from primary care practices. Design A cross-sectional study in which multivariate logistic regression was applied to explore the association of comorbidities with elevated HbA1c. Setting Primary care practices in Croatia. Subjects Altogether, 10 264 patients with diabetes in 449 practices. Main outcome measures Comorbidities and elevated HbA1c. Results In total 7979 (77.7%) participants had comorbidity. The mean number of comorbidities was 1.6 (SD 1.28). Diseases of the circulatory system were the most common (7157, 69.7%), followed by endocrine and metabolic diseases (3093, 30.1%), and diseases of the musculoskeletal system and connective tissue (1437, 14.0%). After adjustment for age and sex, the number of comorbidities was significantly associated with HbA1c. The higher the number of comorbidities, the lower the HbA1c. The prevalence of physicians’ inertia was statistically significantly and negatively associated with the number of comorbidities (Mann–Whitney U test, Z?=?–12.34; p?Conclusion There is a high prevalence of comorbidity among T2DM patients in primary care. A negative association of number of comorbidities and HbA1c is probably moderated by physicians’ inertia in treatment of T2DM strictly according to guidelines.

• Key points

• There is a high prevalence of comorbidity among T2DM patients in primary care.

• Patients with breast cancer, obese patients, and those with dyslipidaemia and ischaemic heart disease were more likely to have increased HbA1c.

• The higher the number of comorbidities, the lower the HbA1c.

     

Psychoeducation against depression,anxiety, alexithymia and fibromyalgia: a pilot study in primary care for patients on sick leave

Objectives: Feasibility testing of a psychoeducational method -The Affect School and Script Analyses (ASSA) – in a Swedish primary care setting. Exploring associations between psychological, and medically unexplained physical symptoms (MUPS).

Design: Pilot study.

Setting: Three Swedish primary care centers serving 20,000 people.

Intervention: 8 weekly 2-hour sessions with a 5–7 participant group led by two instructors - followed by 10 individual hour-long sessions.

Subjects: Thirty-six patients, 29 women (81%), on sick-leave due to depression, anxiety, or fibromyalgia.

Outcome measures: Feasibility in terms of participation rates and expected improvements of psychological symptoms and MUPS, assessed by self-report instruments pre-, one-week post-, and 18 months post-intervention. Regression coefficients between psychological symptoms and MUPS.

Results: The entire 26-hour psychoeducational intervention was completed by 30 patients (83%), and 33 patients (92%) completed the 16-hour Affect School. One-week post-intervention median test score changes were significantly favorable for 27 respondents, with p?Conclusions: A psychoeducational method previously untested in primary care for mostly women patients on sick-leave due to depression, anxiety, or fibromyalgia had?>80% participation rates, and clear improvements of self-assessed psychological symptoms and MUPS. The ASSA intervention thus showed adequate feasibility in a Swedish primary care setting.

• Key Points

• ?A pilot study of a psychoeducational intervention – The Affect School and Script Analyses (ASSA) – was performed in primary care

• ??The intervention showed feasibility for patients on sick-leave due to depression, anxiety, or fibromyalgia

• ??92% completed the 8 weeks/16?hours Affect School and 83% completed the entire 26-hour ASSA intervention

• ??9 of 11 self-reported measures improved significantly one-week post intervention

• ??7 of 11 self-reported measures improved significantly 18 months post-intervention

     

Creating a safety net for patients with depression in primary care; a qualitative study of care managers’ experiences

Abstract

Objective: The aim of this study was to explore nurses’ experiences and perceptions of working as care managers at primary care centers.

Design: Qualitative, focus group study. Systematic text condensation was used to analyze the data.

Setting: Primary health care in the region of Västra Götaland and region of Dalarna in Sweden.

Subjects: Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support.

Main outcome measures: The nurses’ experiences and perceptions of working as care managers at primary care centers.

Results: The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression.

Conclusion: The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care.

• Key Points

• The care managers described their role as an additional support to the already existing care at the primary care center.

• ?? They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression.

• ?? Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful.

• ?? Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.