An activity-based intervention for obese and physically inactive children organized in primary care: feasibility and impact on fitness and BMI: A one-year follow-up study

Objective

To investigate the feasibility and impact on BMI and physical fitness of an intervention for obese and inactive children, based on physical activity and carried out in primary health care.

Design

A prospective, longitudinal one-year follow-up study.

Setting

The community of Kristiansand, Norway (80 000 inhabitants).

Intervention

A 40-week structured intervention based on physical training with some lifestyle advice for the obese child and one parent.

Subjects

A total of 62 physically inactive children aged 6–14 years with iso-BMI ≥ 30 kg/m².

Main outcome measures

Body mass index (BMI), maximum oxygen uptake, and physical fitness in tests of running, jumping, throwing, and climbing assessed at baseline and after six and 12 months as well as number of dropouts and predicting factors.

Results

A total of 49 out of 62 children completed the first six months and 37 children completed 12 months. Dropout rate was higher when parents reported being physically inactive at baseline or avoided physical participation in the intervention. The children''s maximum oxygen uptake increased significantly after 12 months from 27.0 to 32.0 ml/kg/min (means), as did physical fitness (endurance, speed, agility, coordination, balance, strength) and BMI was significantly reduced.

Conclusion/implications

This one-year activity-based intervention for obese and inactive children performed in primary health care succeeded by increasing cardiovascular capacity and physical fitness combined with reduced BMI in those who completed. Dropout was substantial and depended on the attendance and compliance with physical activity by the parents.Key Words: BMI, childhood obesity, dropouts, family practice, fitness, parental participation, physical activity, primary careFew studies have presented intervention models for obesity among children organized by GPs. Our study focusing on physical activity showed:

• Effect on BMI and physical fitness after six months and after 12 months;
• A high dropout rate among the children, related to parents’ compliance and lifestyle;
• The child''s adherence to the training programme mainly depended on the attendance of the parents.

The prevalence of childhood obesity has increased worldwide during the most recent decades. Up to 20% of children in several Western European countries are overweight or obese, and the heaviest children seem to be becoming even more obese [1,2]. A Norwegian study among children 4–15 years old shows that 18% of boys and 20% of girls are above the 90th weight-for-height percentile and 8% of boys and 7% of girls are above the 97.5th percentile [2]. Reduced daily physical activity and sedentary leisure activities are important and modifiable causal factors for becoming overweight as a child, in addition to excessive high-caloric food intake [3]. Differences in frequency of somatic and psychological symptoms between obese, overweight and normal-weight adolescents represent medically and socially negative consequences [4].Concerns exist regarding declining levels of daily physical activity among schoolchildren [5]. International guidelines recommend children and adolescents to be physically active for at least 60 minutes a day [6]. It is well documented that regular physical activity is associated with improved health and reduced risk of mortality. Inactivity is also an important risk factor for metabolic syndrome (hypertension, glucose intolerance/insulin resistance, and abdominal adiposity) in children [7]. International studies indicate that high physical capacity in adolescence reduces the risk of cardiovascular diseases in adulthood [8]. Physical activity is shown to be effective as prevention against cancer, Type II diabetes, and cardiovascular diseases, even if patients do not reduce weight [9]. Physical activity is also important for bone density and growth in children and adolescents and has a positive influence on memory, mental capacity, and social behaviour in children, regardless of their body mass index [10]. The level of physical activity in childhood seems to continue into adulthood [11].No commonly accepted clinical guidelines on prevention or treatment of childhood obesity existed when we started our study. Only a few studies had been carried out in a primary care setting focusing on lifestyle-induced conditions in childhood [12]. Controlled obesity prevention trials had been short-term with focus on one or a few strategies and had shown little or no impact [13]. The latest agreement, however, is that prevention should include advice on increased physical activity and improved eating patterns, and be school and family based [14–16]. A meta-analysis including studies until May 2008 shows a total beneficial effect of treatment, though with differences between studies [16].The aim of our study was to implement and evaluate a primary care-based intervention over one year for obese and sedentary children aged 6–14 years. The intervention was based mainly on structured physical activity and included some lifestyle advice. Parental involvement was mandatory. We investigated the effects on physical capacity and fitness and BMI, and identified factors predicting dropout.     

A doctor close at hand: How GPs view their role in cancer care

Objective

To explore GPs’ own views on their role in cancer care.

Design

Qualitative study based on semi-structured interviews.

Setting

Norwegian primary care.

Methods

The stories of 14 GPs concerning 18 patients were analyzed for core content and abstracted into general ideas, to create a broader sense of the experienced professional role.

Results

The GPs claimed to have an important role in cancer care. In our analysis, three main aspects of GPs’ work emerged: first, as a flexible mediator, e.g. between the patient and the clinic, interpreting and translating; second, as an efficient “handyman”, solving practical problems locally; and third, as a personal companion for the patient throughout the illness.

Conclusion

The interviewed GPs see their place in cancer care as being close to their patients. In their many tasks we found three main aspects: the mediating, the practical, and the personal.Key Words: Family practice, neoplasms, primary health care, professional role, qualitative researchGPs can be seen in cancer treatment as either peripheral or having a unique role, offering continuity of care and information throughout the illness.

• GPs can accompany patients through the whole cancer journey.
• GPs talk about significant tasks in interpreting illness, mediating in the healthcare system, and handling many practical issues.
• Support of seriously ill patients and their families is seen both as very challenging and as deeply meaningful work.

A third of people in developed countries will develop cancer in their lifetime [1,2]. From small restricted lesions to infiltration of vital organs, cancer means many different diseases. Treatment can be anything from watchful waiting or one curative surgical resection, to months and years with radiation, chemo-, and hormone therapy. The biological possibility of recurrence and spread sets the stage for both treatment and follow-up of cancer, and also gives the diagnosis of cancer its existential meaning. In palliative treatment this meaning is evident.In Norway, the general practitioner (GP) is the only doctor who ideally could accompany the individual patient with cancer through the whole course of the illness. GPs could be key people for coordination and palliation, and during end-of-life care, but often they are not. Patients with cancer might disappear from the GP''s practice into hospitals [3,4] and GPs might miss the experience relevant to palliative treatment [5].Patients and their carers have been asked about the role of primary care during cancer illness. They saw GPs as having a unique role during the whole cancer course, offering continuity of care and information [6,7]. Patients appreciated GPs being accessible, having time to listen, talking about feelings, and relieving symptoms [8,9]. Some patients missed the GP''s engagement, in both diagnosis and follow-up of cancer, and felt left alone [10,11].In this situation, we found it important to ask GPs themselves, in an exploratory interview study:

• How do they perceive and describe their place in health care for people with cancer?
• What are the challenges and dilemmas that they face?

People with cancer share the experience of being thrown out of their ordinary lives into an insecure existence [12]. Other chronic conditions mainly set other terms for people''s lives. Studying GPs’ work in the heightened situation related to cancer might tell us something about the “general” in general practice [13].     

Very low calorie diet (VLCD) followed by a randomized trial of corset treatment for obesity in primary care

Objective

The primary objective was to investigate the feasibility and cost-effectiveness of weight reduction using very low calorie diet (VLCD) in groups. The secondary objective was to investigate whether subsequent corset treatment could maintain the weight reduction long term.

Design

Participants, consecutively included in groups of 8–14 subjects, underwent three months of VLCD with lifestyle advice at group meetings. Subjects attaining ≥ 8 kg reduction were randomized to corset (A) or no corset (B) treatment for nine months. Weight was registered at all meetings and after 24 months. Costs were calculated using current salaries and anti-obesity drug prices as at 2008.

Settings

Primary care in Skaraborg, Sweden.

Subjects

A total of 26 men and 65 women aged 30–60 years with BMI ≥ 30−< 45 kg/m².

Main outcome measures

Weight changes and costs of treatment.

Results

VLCD (dropout n = 14) resulted in a mean weight reduction of 20.1±6.6 kg (20 men) and 15.7±4.7 kg (57 women). These 77 subjects were randomized to treatment A (n = 39) or B (n = 38). Compliance with corset was only 20% after three months. After one year (dropout n = 17) weight loss was 11.7±8.1 kg (A) and 9.3±6.9 kg (B), p = 0.23 and after two years (dropout n = 22) 6.1±7.0 kg and 4.4±7.3 kg respectively, p = 0.94. Serum glucose and lipids were altered favourably. The cost per participant of treatments A and B was SEK 4440 and SEK 1940 respectively.

Conclusions

VLCD in groups was feasible and reduced weight even after one year. The cost of treatment was lower than drug treatment. Corset treatment suffered from poor compliance and could therefore not be evaluated.Key Words: Family practice, group treatment, obesity, primary care, very low calorie dietVery low calorie diet (VLCD), mainly used as an individual treatment in specialized clinics, gives a substantial weight reduction but weight is often soon regained.

• VLCD during a three-month period in primary care was well accepted, and effective. It gave a similar weight reduction to when used in specialised clinics and reduced weight even after one year.
• Corset treatment for nine months to maintain weight reduction could not be evaluated due to poor compliance.
• The cost of VLCD treatment and group sessions with lifestyle advice was lower compared with pharmacological treatment.

Obesity, defined as body mass index (BMI) ≥30 kg/m², is a growing problem worldwide [1]. Obesity is associated with cardiovascular disease and increased cardiovascular risk [2], diabetes [3], gallstones [4], sleep apnoea [5], musculoskeletal disorders due to strain [6], reduced fertility in women [7], and psychiatric ill-health [8]. All are conditions commonly seen in primary care.Treating obesity has proved very difficult. Diet and exercise with or without additional pharmacological treatment have shown limited success [9]. Only bariatric surgery gives substantial and lasting weight reduction and decreased mortality [10]. However, it is irreversible and expensive and cannot for practical reasons be offered to all patients. Consequently, there is a need for interventions that can be used in the primary care setting.Individualized treatment with very low calorie diet (VLCD) in specialized clinics results in an average weight reduction of 13 kg for women and 20 kg for men after three months [11,12]. The use of VLCD in a structured form in primary care has only been reported in the Netherlands [13]. The weight-reducing effect of VLCD is temporary and must therefore be combined with other methods to maintain the weight loss. Garrow showed in 1981 [14] that weight reduction achieved by jaw fixation could be maintained by a nylon cord around the waist, prohibiting overeating. Anecdotally, weight reduction has been observed during treatment of scoliosis with the Boston corset, but no report has been found in the literature. Corset treatment could have similar effects to a nylon cord around the waist.Individual treatment of obesity is most common, but group treatment may be more effective with a lower dropout rate and a lower cost [15]. Social support might also be an aid in weight maintenance [16] and the adherence to group sessions rather than the type of diet seems of importance for weight loss [17]. Group therapy is suitable for primary care, which has a tradition of multiprofessional teamwork.The primary aim of this long-term follow-up study was to determine the feasibility of VLCD in groups and compare the costs with pharmacological and surgical treatment. The secondary aim was to examine whether treatment with a soft corset can maintain the weight loss achieved with VLCD.     

Good pregnancy outcome despite intrahepatic cholestasis

Objective

Pregnant women complaining of itching are screened for intrahepatic cholestasis (ICP) by laboratory tests in primary healthcare. Cases of ICP are referred to specialist care. In Finland, ICP occurs in 1% of pregnancies. The aim was to study the outcome of deliveries.

Design

Retrospective study of ICP pregnancies. Data were collected from the hospital discharge register, patient records, and the labour register.

Setting

The region of Tampere University Hospital in Finland.

Subjects

Altogether 687 ICP cases from 1969 to 1988 and two controls for each.

Main outcome measures

ICP patients were compared with controls in terms of mother''s age, pregnancy multiplicity, weeks of gestation at delivery, frequency of induction and Caesarean section, length of ward period, child''s weight, Apgar scores, and stillbirth.

Results

For ICP patients, the risk for hospital stay of 10 days or more was eightfold (OR 8.41), for gestational weeks less than 37 at delivery sevenfold (OR 7.02), for induction threefold (OR 3.26), for baby''s low weight at birth almost twofold (OR 1.86), and for Caesarean section one and a half fold (OR 1.47). The possibility of the incidence of multiple pregnancy was two and a half fold (OR 2.49, 95%). ICP was not associated with mother''s age, the baby''s risk of stillbirth, or low Apgar scores.

Conclusion

ICP mothers are found and taken care of appropriately, and thus ICP is only a minor risk for mothers and their children.Key Words: Caesarean section, intrahepatic cholestasis, length of stay, pregnancy outcome, primary healthcareIntrahepatic cholestasis of pregnancy (ICP) contains risks for the foetus. It is important that ICP cases are detected in primary healthcare.

• ICP mothers’ ages did not differ significantly from others.
• Childbirth happened at earlier weeks of gestation in ICPs, but Apgar scores were only slightly lower.
• In ICP cases labour induction and Caesarean section were more common and hospital stay was significantly longer.

In the Nordic countries maternity care is organized almost exclusively within a primary healthcare setting [1]. Deliveries are carried out mainly in hospitals [2]. In Finland midwives or nurses qualified in health nursing and midwifery are the principal staff of maternity clinics in health centres [3,4]. Midwives work with GPs, who are responsible for maternity clinics in health centres. Usually the referral system is organized with hospital maternity outpatient clinic, the same hospital where the delivery will be carried out.Intrahepatic cholestasis of pregnancy (ICP) usually manifests in the third trimester of pregnancy as skin itching and as elevation of the serum levels of bile acids and liver enzymes [5,6]. The incidence of ICP in Finland and Sweden is 0.54–1.5% [7,8,9]. ICP may recur in 40–60% of subsequent pregnancies [5,10]. In 16% of cases ICP is familial, and in those cases ICP recurs in 92% [11]. ICP is more common with mother''s age over 35 years [9] and in multiple pregnancy [12,13]. The ultimate reason for ICP is unknown. ICP is thought to be the result of insufficient liver capacity to metabolize high amounts of placental hormones during pregnancy [5,14], and symptoms fade and laboratory tests normalize quickly after the delivery. ICP increases the risk of preterm birth (12–44%) [13,15,16], fetal distress during labour (10-44%) [7,13,15,17], and intrauterine fetal death (1–3%) [7,15,17] may ensue. Bile acids have been shown to induce vasoconstriction of human placental chorionic veins, and myometrial sensitivity to oxytocin [18,19]. In clinical practice, mode and timing of labour and delivery are managed individually to reduce risks for the foetus. ICP is a minor problem for the mother during pregnancy, delivery, and postpartum. It has been stated that women with a history of ICP are more prone to several liver and biliary disorders including non-alcoholic cirrhosis, non-specific hepatitis, hepatitis C, cholelithiasis, and pancreatitis in their life, even before the first occurrence of ICP [20].According to current guidelines, the GP or midwife in the health centre maternity clinic verifies ICP with laboratory tests if a pregnant woman in her last trimester of pregnancy complains of itching, especially on her palms and soles [21]. When a woman is diagnosed with ICP, she is referred to the hospital maternity outpatient clinic. If itching is intensive and ICP is evident, the patient must be urgently referred to an obstetric clinic even without laboratory tests.The aim was to study certain characteristics of deliveries with ICP and the outcome of the pregnancies.     

Primary aldosteronism among newly diagnosed and untreated hypertensive patients in a Swedish primary care area

Objective

To evaluate the prevalence of primary aldosteronism (PA) in newly diagnosed and untreated hypertensive patients in primary care using the aldosterone/renin ratio (ARR), and to assess clinical and biochemical characteristics in patients with high and normal ARR.

Design

Patient survey study.

Setting and subjects

A total of 200 consecutive patients with newly diagnosed and untreated hypertension from six primary health care centres in Sweden were included.

Main outcome measures

ARR was calculated from serum aldosterone and plasma renin concentrations. The cut-off level for ARR was 65. Patients with an increased ARR were considered for confirmatory testing with the fludrocortisone suppression test (FST), followed by adrenal computed tomographic radiology (CT) and adrenal venous sampling (AVS).

Results

Of 200 patients, 36 patients had an ARR > 65. Of these 36 patients, 11 patients had an incomplete aldosterone inhibition during FST. Three patients were diagnosed with an aldosterone producing adenoma (APA) and eight with bilateral adrenal hyperplasia (BHA). Except for moderately lower level of P-K in patients with an ARR > 65 and in patients with PA, there were no biochemical or clinical differences found among hypertensive patients with PA compared with patients without PA.

Conclusion

Eleven of 200 evaluated patients (5.5%) were considered to have PA. The diagnosis of PA should therefore be considered in newly diagnosed hypertensive subjects and screening for the diagnosis is warranted.Key Words: Aldosterone, aldosterone to renin ratio, family practice, hypertension, primary aldosteronism, reninPrimary aldosteronism (PA) is common in patients diagnosed with “essential hypertension” in specialized centres; however, reports on prevalence in primary care are few.

• Screening with the aldosterone to renin ratio followed by confirmatory testing showed that 5.5% of newly diagnosed and untreated hypertensive patients had PA.
• No particular clinical features could distinguish these patients from patients with essential hypertension.
• Screening for PA should always be performed in younger patients with newly diagnosed hypertension and in patients with resistant hypertension irrespective of potassium concentrations.

Hypertension affects up to 25% of the adult population in Sweden [1,2]. Primary aldosteronism (PA) is a common form of secondary hypertension, characterized by excessive aldosterone secretion and renin suppression, followed by hypertension, alkalosis and hypokalemia [3–6]. The latter is, however, not necessarily an integral element [3–6]. Resistant hypertension requiring more than three antihypertensive drugs, hypertension diagnosed at a young age, or family history of stroke at a young age are factors that suggest the possibility of PA [7]. PA arises from one or both adrenal glands. The two major subtypes are aldosterone producing adenoma (APA; 1/3 of the cases) and bilateral adrenal hyperplasia (BAH; 2/3 of the cases). APA is preferably treated by surgery while BHA is treated with aldosterone antagonists. The diagnosis thus enables tailored medical therapy or surgical intervention with possible cure [8].PA has been considered a rare cause of hypertension [9] but recent studies suggest a prevalence of 5–10% [3,4,10–17]. Frequencies vary in different study populations and are increased in severe hypertension, especially at referral centres treating resistant hypertension [12]. Despite the fact that a number of studies have been carried out, the prevalence among primary care patients still remains uncertain. In a previous study [13] we confirmed an 8.5% prevalence of PA among 200 screened hypertensive patients in primary care. However, these patients had all been treated with antihypertensive medication for several years, which might have affected the attendance for screening, since only approximately 50% of invited subjects participated. Furthermore, it is known that a number of antihypertensive drugs alter the aldosterone to renin ratio (ARR); therefore withdrawal of medication is strongly suggested before screening [18].The aim of this study was to clarify the prevalence of PA by screening newly diagnosed and medically untreated hypertensive patients in primary care. Patients with a high ARR were referred for confirmatory testing. In addition, the study compared clinical and biochemical characteristics in patients with high or normal ARR.     

Using patient-centred consultation when screening for depression in elderly patients: a comparative pilot study

Objective

Using validated screening instruments to detect depressive symptoms in the elderly has been recommended. The aim of this study was to compare a patient-centred consultation model with the PRIME-MD screening questionnaire, using the MADRS-S as reference for detecting depressive symptoms in an elderly primary care population.

Design

Comparative study.

Setting

Primary care, Sweden.

Subjects

During an 11-month period 302 consecutive patients aged 60 and over attending a primary care centre were screened with the PRIME-MD and the Montgomery-Asberg Depression Rating Scale-Self-rated version (MADRS-S) instrument. The results were unknown to the GPs who used a structured, patient-centred consultation model comprising seven open-ended “key questions”.

Main outcome measures

Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated for the PRIME-MD screening questionnaire and the patient-centred consultation model using MADRS-S as reference for possible depression at two cut-off levels with 15% prevalence.

Results

Sensitivity was lower for the consultation model than the PRIME-MD screening questionnaire: 78% and 98%, respectively. The GPs failed to identify every fifth patient using the lower cut-off (MADRS-S≥13) but the number of required diagnostic interviews decreased by almost 50%: 85 versus 162, respectively. PPV was 43% and 28%, respectively. Both instruments showed high sensitivity (93%) using the higher cut-off (MADRS-S≥20) and had high NPV: 95% and 99%, respectively.

Conclusions

The findings suggest that the consultation screening procedure might be as useful in everyday practice as the PRIME-MD screening questionnaire. Both screening procedures may also be useful for ruling out depressive symptoms.Key Words: Depressive symptoms, elderly, family practice, primary care, screening instrumentsTo enhance the detection of elderly patients with depression the use of screening instruments has been recommended. In this study a patient-centred consultation model was used as a screening procedure for detecting depressive symptoms and its performance was compared with the validated screening questionnaire of the PRIME-MD instrument.

• The patient-centred consultation has acceptable properties and is well functioning in the GP''s clinical situation in which patient-centredness plays an essential role in the diagnostics.
• The contexts of the presented symptoms need to be considered in relation to psychological, physical, and social factors before the assessment.

Detection of depressive disorders in the elderly in primary care is important since they are associated with significant burden and costs and since effective treatment is available [1]. The prevalence of depression in an elderly population is estimated at 12–15%, depending on diagnostic criteria and methodology [2].Using validated screening instruments to increase the detection of depression in primary care has been the subject of lengthy debate. Currently available findings, comprising several studies and meta-analyses, show that case-finding leads to a modest increase in recognition rates, but fails to demonstrate any consistently positive effects on either younger or older primary care patients’ outcome; screening alone is not recommended in primary care settings [3,4]. Screening of high-risk groups has been a proposed strategy but no data from randomized trials support this approach [5]. Studies have indicated that supplementing screening with feedback, diagnostic interviews, or other enhancements of care might improve outcome [6].The different screening instruments have similar operating performances and there is little evidence to support any one instrument''s superiority [6–8]. In the elderly, many instruments have good properties for screening for major depression but they lack accuracy for detection of non-major disorders, which are associated with increased morbidity and risk of developing major depression [9,10].Patient-centredness has become increasingly important in primary care. In the patient-centred consultation, it is crucial that the GP addresses the patients’ views, allowing them to express their problems, feelings, fears, conceptions, and expectations, as well as taking their values, cultures, and preferences into consideration [11–13].Older people often have multiple health problems but they participate less in their medical consultations than other patients [14]. In a study with 11 participating countries, elderly patients’ main views of their own involvement in consultations were similar [15]. The elderly are a heterogeneous group and not all patients wanted to take an active part in decision-making but they did agree on the important role of building a trusting relationship with their GPs [15]. They also wanted to be respected, receive good information on their health, and have sufficient time during the consultation [15]. A recent systematic review provided evidence that interventions enabling patients to take a more active role in deciding on and planning their medical care yield better health outcomes but it is still unclear whether these findings are applicable to the elderly [14].A few patient-centred practical models, useful in family practice, have been developed [16,17]. Asking open-ended key questions was shown to be useful when exploring female patients’ agendas [18].The aim of this study was to evaluate whether a patient-centred approach would have the capacity to explore depressive symptoms in an elderly population in a primary care setting. We wanted to study how the GPs managed the variety of conditions seen in primary care, using a well-established working tool – a patient centred-consultation model – and compare its performance in detecting depressive symptoms with the PRIME-MD screening questionnaire for depression using MADRS-S as reference, and evaluate sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) in an elderly population in a primary care setting.     

Paracetamol for feverish children: parental motives and experiences

Objective

The sale of paracetamol products for children is increasing, and more children are accidentally given overdoses, even though the use of paracetamol against fever is still under discussion. This study explores Danish parents’ use of paracetamol for feverish children and their motives for this use.

Design

A cross-sectional survey using structured interviews.

Setting

Four general practices located in city, suburb, and rural area.

Subjects

A total of 100 Danish parents with at least one child under the age of 10 years.

Main outcome measures

Number of parents administering paracetamol to feverish children, situations triggering medication of a child, parental views regarding fever and effects of paracetamol, and sources of information on fever treatment.

Results

Three in four parents use paracetamol for feverish children, mainly to reduce temperature, to decrease pain, and to help the child fall asleep. Highly educated parents medicate more often than less educated. Parents often fear fever but this does not clearly affect their use of paracetamol. Many parents believe in perceived beneficial effects of paracetamol, such as increased appetite and well-being, better sleep, and prevention of fever seizures. These expectations of paracetamol influence parental use of the drug. Parents’ main source of information on fever and paracetamol is their general practitioner (GP).

Conclusions

Danish parents regularly treat feverish children with paracetamol. Although parents contact their GP for advice on fever treatment, paracetamol is sometimes given to children on vague indications. Clearer information for parents on when to give paracetamol as fever treatment may help regulate its use.Key Words: Antipyretic, children, family practice, fever, gender, paracetamol, parents, primary healthcareThe sale of child-friendly paracetamol products is increasing in Denmark, even though use of paracetamol as treatment of fever is still being debated.

• Parents give paracetamol to improve well-being, appetite, and sleep of feverish children – research only vaguely supports this use.
• Highly educated parents medicate more often than less educated.
• Danish parents’ main source of information concerning fever and its treatment is their general practitioner.

Fever is a common symptom in childhood and a frequent reason for parents to contact their general practitioner (GP) [1]. Antipyretics are widely used for treating feverish children [2–5]. In Denmark, the most common antipyretic substance for children is paracetamol. The sale of child-friendly paracetamol products, i.e. suppositories and mixtures, has increased 23% in the last five years (55.9–68.4 defined daily doses (DDD)/1,000 inhabitants/year) [5,6].Paracetamol is considered a safe drug when taken in prescribed doses; however, overdosing may cause liver failure and death. Recent studies also show that intoxication in children happens after repeated doses only slightly above recommendations [7]. The number of Danish children (aged 0–11 years) hospitalized with paracetamol or acetylsalicylic acid (ASA) poisoning has increased from 23 in 1997 to 81 in 2006 [8].The use of paracetamol against fever is still under discussion [9,10]. Fever involves discomfort; however, the rise in body temperature is believed to assist the immune response against infection [11,12]. A minority of children experience fever seizures; these are often frightening to parents, but today if short-lasting they are considered benign [13]. Paracetamol has shown to be an effective analgesic and antipyretic; however, it is still unclear if the drug increases the well-being, the sleep, or the appetite of a feverish child [14–16]. Paracetamol has not yet proved effective in preventing fever seizures [13,17,18]. Conversely, no studies have documented a positive effect of not giving paracetamol to feverish children. NICE guidelines recommend use of paracetamol mainly in cases of fever and discomfort or pain [19].Internationally, numerous parents regularly give paracetamol against fever [2,3,20]. The most frequent reason for giving the drug to a feverish child is simply to lower the temperature. Some parents believe that paracetamol relieves their children of discomfort, and gives them more appetite and energy. [3,20,21]. Additionally, paracetamol may be a way of coping with a sick child in a busy daily life [20].Some parents fear that fever might harm their child by causing seizures, brain damage, and even death, if the temperature is high or rapidly rising. This unrealistic fear, termed fever phobia, may be linked to the wide use of antipyretics among parents [22–24]. For some parents fever is considered the disease in itself, and paracetamol is believed to cure the child [20].This study aimed at exploring:

1. to what extent and in which situations parents give their children antipyretics;
2. if parental views of the effects of paracetamol are consistent with existing evidence, and if their views influence the use of the drug;
3. if fever phobia is present among parents and if it motivates them to give paracetamol;
4. where parents seek information on handling a feverish child.

     

The Patient Experiences Questionnaire for Out-of-Hours Care (PEQ-OHC): data quality,reliability, and validity

Objective

To develop and evaluate the Patient Experiences Questionnaire for Out-of-Hours Care (PEQ-OHC) in Norway.

Design

Questionnaire development was based on a systematic literature review of existing questionnaires, interviews with users, and expert group consultation. Questionnaire testing followed a postal survey of users who had attended out-of-hours centres in the North, West, and South of Norway.

Setting

Primary care out-of-hours services.

Subjects

The questionnaire was pre-tested with 13 users and was then mailed to 542 users who had had telephone contact and/or had a consultation with one of three out-of-hours centres.

Main outcome measures

Data quality, internal consistency, reliability, and construct validity.

Results

The questionnaire was considered to have good content validity by the expert group. There were 225 (41.51%) respondents to the postal questionnaire. Levels of missing data at the item and scale level were acceptable. Principal component analysis supported the four scales of user experiences relating to telephone contact, doctor services, nursing services, and organization. Item-total correlations were all above 0.5 and Cronbach''s alpha was above 0.80 for all scales. Statistically significant associations based on explicit hypotheses were evidence for the construct validity of the PEQ-OHC.

Conclusion

The development of the PEQ-OHC followed a rigorous process based on a systematic review, interviews with users, and an expert group which lend the questionnaire content validity. The PEQ-OHC has evidence for data quality, internal consistency, reliability, and construct validity.Key Words: Family practice, out-of-hours, patient satisfaction, questionnaire, reliability, survey, validityQuestionnaires are increasingly used for assessing patient experiences of out-of-hours care.

• Existing questionnaires have limitations relating to data quality, reliability, and validity.
• The PEQ-OHC has undergone a rigorous process of development following a systematic review and interviews with patients.
• The PEQ-OHC has good evidence for data quality, reliability, and validity.

There have been considerable changes in the organization of out-of-hours primary care in Europe [1–3]. The care setting has moved away from the home to the primary care centre and telephone consultations, which has followed the growth of GP cooperatives and deputizing services [4]. However, the evaluation of developments within out-of-hours care has been limited in scope focusing on the process of care [5], which may stem from the lack of availability of questionnaires that are based on the views of users concerning their experiences or satisfaction with services [4,6,7]. There are several questionnaires that assess user experiences and satisfaction with primary healthcare more generally [8–10] but there is a lack of questionnaires specific to out-of-hours care that have sufficient evidence for data quality, reliability, and validity [7].According to a systematic review there was just one questionnaire relating to user satisfaction with out-of-hours care that was published before 2005 [7]. The review identified four questionnaires, two from the Netherlands and two from the UK, concluding that all four had limitations in terms of their development and evaluation. The development of the questions within two questionnaires did not include users, which has implications for content validity [8]. Two questionnaires had poor reliability estimates and there was evidence for item redundancy within a third. Evidence for the validity of all four questionnaires was considered to be limited [7].It is important that these shortcomings are addressed through further development and evaluative work to ensure that such questionnaires meet the necessary criteria for use within evaluative studies and for quality improvement initiatives [11]. Questionnaires that are valid and reliable and based on the views of users [8] are also required for national surveys of user views of out-of-hours care such as that undertaken within the Netherlands [4] and for providers wishing to monitor user experiences and satisfaction as has been recommended in the UK [12].Norway has a programme of national surveys that measure user experiences of care [13–16]. The survey results are designed to inform patient choice and healthcare quality improvement. The survey questionnaires are based on the views of users and experts and have good evidence for data quality, reliability, and validity [13–16]. A systematic review was undertaken that was designed to inform a survey of users of out-of-hours care in Norway [7]. The work that follows describes the development of the Patient Experiences Questionnaire for Out of Hours Care (PEQ-OHC) and testing for data quality, internal consistency, reliability, and validity. This Norwegian questionnaire is available for forward–backwards translation for countries with a similar provision of out-of-hours care but the relevance of the content of the PEQ-OHC must first be considered.     

Ecology of medical care in a publicly funded health care system: a registry study in Sweden

Objective

To explore the influence of sociodemographic factors on access to appointments with physicians in primary, secondary, and tertiary health care in a publicly funded health care system.

Design

A population-based registry study.

Setting

Different health care settings in Västernorrland county, Sweden.

Subjects

All residents in the county at the end of 2006.

Main outcome measures

The number of people per 1000 residents who had at least one appointment with a physician in an average month in different health care settings.

Results

A total of 87 people had appointments with a physician in primary health care, 44 in outpatient clinics at a regional hospital, 20 in an emergency department, 14 in home care, and two in a university hospital outpatient clinic. Twelve were hospitalized at a regional hospital and <1 at the university hospital. Being young or elderly, female, divorced, widowed, and having a contractor as usual source of care were all independently associated with higher odds of receiving primary care.

Conclusions

The physician''s office in primary care is the setting that has the potential to affect the largest number of people. The extent of the use of health care was independently influenced by all sociodemographic characteristics studied, which highlights the importance of individual factors in future resource allocation. Regarding availability the ecology model provides superior information as compared with the absolute number of physicians'' appointments. The prerequisites in Sweden of high-quality registries and unique personal identification numbers encourage future research on the ecology model to optimize accessibility of health care.Key Words: Delivery of health care, health services research, medical ecology, resource allocationThe medical ecology model has been used to assess health care use in private and mixed-finance systems but not in publicly funded systems. In the present study of a publicly funded health care system highly reliable population-based registers on an individual level were used.

• The physician''s office in primary care is the setting that has the potential to affect the largest number of people.
• Sociodemographic characteristics influenced the proportion of physician appointments, which highlights the importance of individual factors in future resource allocation.

An ecological model of health care organization was shown to demonstrate a valid perspective of medical care use in the 1960s [1] in a model extended from general practice [2]. The model organizes complex relationships known to affect health care and the health of populations [3], with implications for the organization of health care, medical training, and research [4–6]. The model has also stated geo-demographic and socioeconomic status as factors influencing health care use [5,7]. Despite substantial changes in medicinal care, including improved techniques for data collection, a reassessment of health care use by the ecology model showed similar structures to those in the 1960s [7,8].For several decades welfare policies in Sweden have provided a high level of social security protection to all residents, resulting in less income inequality and lower poverty rates, as compared with other European countries [9]. This includes health and medical care services that are financed primarily by taxation and to some extent by fees and government subsidies. At national level the county councils are responsible for management, including record keeping. This offers excellent opportunities to study health care use in the total population.Previous studies in privately or mixed-finance systems using the ecology model have demonstrated two critical elements required for a balanced health care system: having health insurance and having a usual source of care [10]. No previous study has investigated health care use with the ecology model in a publicly funded system in a total population study.The present study focuses on the influence of sociodemographic factors on access to appointments with physicians in primary, secondary, and tertiary health care in one publicly funded Swedish county.     

Use of proton-pump inhibitors and their associated risks among frail elderly nursing home residents

Objective

The aim of this study is to investigate the use of proton-pump inhibitors (PPI) and their associated risks among frail elderly nursing home residents.

Design

A cross-sectional study.

Setting

General practice.

Subjects

An assessment of residents (n = 1987, mean age 83.7 years) in all nursing homes in Helsinki was carried out in February 2003. Data included demographic characteristics, symptoms such as diarrhea, vomiting and constipation, use of various drugs, and medical diagnoses.

Outcome

Coded data analysis with NCSS statistical program. Multivariate logistic regression analysis served to determine which variables were independently associated with diarrhea; variables which were statistically significant or near p < 0.05 in univariate analyses were included.

Results

Altogether 433 residents were on PPIs. The factors associated with regular PPI use in univariate analyses included poor functional status, higher number of comorbidities, higher number of medications and lactose intolerance. The users had suffered from a prior ventricular or duodenal ulcer, cancer and coronary heart disease more often than the non-users. In accordance with our hypothesis, the users of PPIs more often had diarrhea (19.7%) than the non-users (12.9%) (p < 0.001), and they had a prior hip fracture (28.5%) more often than the non-users (19.4%) (p < 0.001). In logistic regression analysis the use of PPIs had an independent association with diarrhea (OR 1.60 (95% CI 1.20 to 2.15).

Conclusion

Physicians should avoid unnecessary long-term use of PPIs, particularly among frail elderly long-term care patients.Key Words: Aged, diarrhea, family practice, hip fracture, proton pump inhibitors, risksThe well-known benefits of proton-pump inhibitors (PPIs) have led to their increased and long-term use as “all purpose” protectors of the GI tract among older patients.

• Among nursing home residents 22% were administered PPIs regularly.
• Regular PPI use was associated with diarrhea, prior hip fracture, coronary heart disease, and lactose intolerance indicating possible adverse events or their use for inappropriate therapeutic intent.
• Unnecessary long-term use of PPIs should be avoided among frail, older patients.

Proton-pump inhibitors (PPIs) are the most effective drugs available to reduce gastric acid secretion [1]. They are widely used by primary care physicians in the effective management of many acid peptic disorders [2–4]. In addition, they are also used to reduce the risk of gastrointestinal (GI) bleeding related to the use of non-steroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin [5].PPI use has increased dramatically over the past years [6]. Once started, these drugs are often used for longer time periods among elderly people who are vulnerable to GI bleeding and even without clear therapeutic intent [7].In general, these drugs have been considered to be safe [8]. However, PPIs have been suggested to predispose to gastrointestinal infections [9] and even to pneumonia [10]. There are several reports showing the associations of PPIs with bacterial overgrowth as well as with Cl. difficile infections [9,11].The PPI therapy may also be associated with a significantly increased risk of hip fractures [12]. It has been suggested that PPIs may interfere with calcium absorption through induction of hypochlorhydria, and may reduce bone resorption through inhibition of osteoclastic vacuolar proton pumps [13].Nursing home patients represent the frailest sector of the elderly population, often taken care of by primary care physicians. They have multiple comorbidities and are often administered a high number of concomitant drugs [14,15]. Thus, they are prone to drug–drug interactions and various adverse events. In addition, few patients in nursing homes have the opportunity for a thorough reassessment of their medication after admission to a nursing home [14]. Thus, their use of those drugs intended to be used for a limited time is often extended for long durations [16].This study aims to test the associated risks of the use of PPIs in a large sample of frail elderly people in all nursing homes in Helsinki, Finland. To our knowledge, no such extensive epidemiological study of the PPI use in the frail elderly population has yet been undertaken.     

Comprehensive discharge follow-up in patients’ homes by GPs and district nurses of elderly patients: A randomized controlled trial

Objectives

Many hospital admissions are due to inappropriate medical treatment, and discharge of fragile elderly patients involves a high risk of readmission. The present study aimed to assess whether a follow-up programme undertaken by GPs and district nurses could improve the quality of the medical treatment and reduce the risk of readmission of elderly newly discharged patients.

Design and setting

The patients were randomized to either an intervention group receiving a structured home visit by the GP and the district nurse one week after discharge followed by two contacts after three and eight weeks, or to a control group receiving the usual care.

Patients

A total of 331 patients aged 78+ years discharged from Glostrup Hospital, Denmark, were included.

Main outcome measures

Readmission rate within 26 weeks after discharge among all randomized patients. Control of medication, evaluated 12 weeks after discharge on 293 (89%) of the patients by an interview at home and by a questionnaire to the GP.

Results

Control-group patients were more likely to be readmitted than intervention-group patients (52% v 40%; p = 0.03). In the intervention group, the proportions of patients who used prescribed medication of which the GP was unaware (48% vs. 34%; p = 0.02) and who did not take the medication prescribed by the GP (39% vs. 28%; p = 0.05) were smaller than in the control group.

Conclusion

The intervention shows a possible framework securing the follow-up on elderly patients after discharge by reducing the readmission risk and improving medication control.Key Words: Discharge, elderly, family practice, home visit, medication, primary care, readmissionFewer readmissions and better control of medication is generally strived for. A follow-up programme by the GPs and district nurses after discharge found:

• A 23% relative readmission risk reduction within six months after discharge.
• Better follow-up including better control of medication after discharge.
• A cost-neutral intervention featuring a tendency towards reduced costs.

Because of their often frail condition, discharged, impaired elderly patients face a high risk of readmission [1–5] and they risk being “left in limbo” if a healthcare professional is not assigned explicit responsibility for their bio-psychosocial situation upon their discharge [6]. Readmission can be diminished according to studies of home follow-up on elderly patients involving advanced practice nurses and geriatric teams drawn from hospital staff and other kinds of intervention with improved discharge support for elderly patients with specific diseases [1–3,5,7,8]. Two reviews found that the documented impact of discharge planning without follow-up care was uncertain [4,5]. They concluded that more research and health economic analysis were needed, exploring intervention across the hospital–community interface.In Denmark (5.5 million inhabitants), the healthcare system is tax-financed with no payment at the point of care. GPs are independent contractors to public health insurance. They act as gatekeepers for 98% of the population. Municipalities run a district nurse system that mainly focuses on care for the frail elderly [9].Inappropriate medical treatment often has inadvertent effects, and a considerable number of admissions are attributable to inappropriate medical treatment that could be avoided [10,11].Only a few trials have focused on the effect of improved effort by the existing staff in the primary sector [12]. The aim of this study was to evaluate a simple intervention aimed at improving the interdisciplinary care given by GPs and district nurses.     

The relationship between HbA1c level, symptoms and self-rated health in type 2 diabetic patients

Objective

Improving glycaemic control is generally supposed to reduce symptoms experienced by type 2 diabetic patients, but the relationships between glycated haemoglobin (HbA_1c), diabetes-related symptoms, and self-rated health (SRH) are unclarified. This study explored the relationships between these aspects of diabetes control.

Design

A cross-sectional study one year after diagnosis of type 2 diabetes.

Subjects

A population-based sample of 606 type 2 diabetic patients, median age 65.6 years at diagnosis, regularly reviewed in primary care.

Main outcome measures

The relationships between HbA_1c, diabetes-related symptoms, and SRH.

Results

The patients’ median HbA_1c was 7.8 (reference interval: 5.4–7.4 % at the time of the study). 270 (45.2%) reported diabetes-related symptoms within the past 14 days. SRH was associated with symptom score (γ = 0.30, p < 0.001) and HbA_1c (γ = 0.17, p = 0.038) after correction for covariates. The relation between HbA_1c and symptom score was explained by SRH together with other confounders, e.g. hypertension (γ = 0.02, p = 0.40). The relation between the symptom fatigue and SRH was not explained by symptom score and significantly modified the direct association between symptom score and SRH.

Conclusions

Symptom relief may not occur even when HbA_1c level is at its lowest average level in the natural history of diabetes, and symptoms and SRH are closely linked. Monitoring symptoms in the clinical encounter to extend information on disease severity, as measured e.g. by HbA_1c, may help general practitioners and patients to understand the possible impact of treatments and of disease manifestations in order to obtain optimum disease control.Key Words: Family practice, glycosylated haemoglobin A, health status, signs and symptoms, type 2 diabetes mellitusTo reduce complications, lowering of HbA1c is a primary objective in diabetes care.

• Many patients experience diabetes-related symptoms in spite of acceptable glycaemic control.
• These symptoms are closely related to poor SRH while the association with HbA_1c is weak.

Patients with type 2 diabetes mellitus (T2DM) are commonly treated in general practice where treatment typically aims to improve glycaemic control in order to prevent complications [1], reduce symptom burden, and improve perceived health [2]. Moreover, the experience of obtaining these goals may improve patients’ motivation for treatment adherence, e.g. lifestyle changes and medication [3,4].Poor glycaemic control is related to symptoms such as frequent urination, genital itching, and unintended weight loss [5,6]. The association between glycated haemoglobin (HbA_1c) levels and specific symptoms is not necessarily close [7,8] except among dysregulated patients, e.g. at the time of diagnosis [5] or in patients with longstanding diabetes [2,6]. Despite the central role of symptom amelioration in treatment, few studies have looked into the relation between HbA_1c level and symptoms when HbA_1c is supposed to be at its lowest average level in the natural history of diabetes [7,9].General practitioners (GPs) and patients may evaluate the patient''s health differently [10]. The association between the patient''s HbA_1c level and perceived health is weak [2], or non-existent [1,11]. The patients’ perceived health gauged by a single question, known as perceived health, self-assessed health, or self-rated health (SRH), has been shown to vary with other factors than HbA_1c such as symptoms [12,13], sociodemographic factors [14], comorbidities [14–16], and functional ability [12,14]. Recent research has shown that SRH predicts which patients have a higher risk of diabetic complications even after accounting for established risk factors such as HbA_1c, but this predictive value may be mediated by presence of symptoms which were not accounted for [16]. Yet the relationships between HbA_1c and symptoms, both of which are important treatment targets, and SRH, which is a motivational factor for treatment adherence [2,3], are unclarified. A better insight into these relationships may help GPs to tailor treatments such as to maintain or improve patients’ health, which may include motivating the patient for treatment adherence.In a population-based sample of patients with T2DM seen in general practice one year after diabetes diagnosis we examined the relationships between HbA_1c, symptoms, and SRH primarily to see whether high HbA_1c levels are associated with many symptoms and low SRH ratings, and whether many symptoms are associated with low SRH ratings.     

Severe hypoglycaemia in drug-treated diabetic patients needs attention: a population-based study

Objective

To study one-year incidence and risk factors of severe hypoglycaemias (SH) in adult drug-treated diabetic patients living in two Finnish communities.

Design

The episodes of SH and their risk factors were identified from local ambulance registers, from the databases of local health care units, and from patient questionnaires.

Setting

The target population consisted of all drug-treated diabetic patients from the two middle-sized communities in southern Finland, altogether 1776 patients. The study was retrospective.

Subjects

A total of 1469 patients (82.7% of the target population) gave informed consent for the use of their medical records and 1325 patients (74.6% of the target population) returned the detailed 36-item questionnaire.

Results

Of type 1 and type 2 insulin-treated diabetic patients, 14.6% and 1.0%, respectively, needed ambulance or emergency room care (incidence of 30.5 and 3.0 per 100 patient years). However, 31.0% of type 1 and 12.3% of type 2 diabetic patients reported at least one episode of SH (incidence of 72.0 and 27.0 per 100 patient years). Of all insulin-treated patients, 53 (7.8%) reported three or more episodes of SH. Significant independent risk factors for SH were depression, daily exercise, and nephropathy but not glycaemic control.

Conclusion

The incidence of SH was high in both types of insulin-treated diabetic patients. However, the recurrent episodes of SH were clustered in a small minority of insulin-treated patients with diabetes. The risk of SH should be considered when assessing the treatment target for an individual diabetic patient.Key Words: Insulin-treated diabetes, oral antidiabetic therapy, severe hypoglycaemia, type 1 diabetes, type 2 diabetesThe risk of severe hypoglycaemia (SH) has not been thought to be a problem in the treatment of type 2 diabetes.

• In this population-based study cohort severe hypoglycaemias in both type 1 and type 2 insulin-treated diabetic patients seemed to be more common than previously thought.
• Severe hypoglycaemias seem, however, to be clustered in a small minority of insulin-treated diabetic patients.
• The risk of severe hypoglycaemia should be considered when assessing the treatment target for an individual diabetic patient.

The risk of severe hypoglycaemias (SH) or the fear of them poses the greatest obstacle to achieving good glucose control in insulin-treated diabetic patients [1,2]. The population-based studies of the epidemiology of SH in patients with both type 1 and type 2 diabetes are quite limited and somewhat controversial [3–7]. Intensive antihyperglycaemic therapy and unawareness of hypoglycaemic symptoms increase the risk of SH in patients with type 1 diabetes [8–11], although this has not been the case in all studies [12,13].Recent prospective clinical trials with very intensive glucose lowering have also shown an increased risk of SH in patients with type 2 diabetes [14,15], although some clinical trials have suggested that the risk of SH is not a problem in insulin-treated patients with type 2 diabetes [16–19] and may be related to the insulin regimen used [7]. Use of sulphonylureas may increase the risk of SH, especially in old patients [7].In our retrospective population-based study we analysed the rate and risk factors of SH episodes, which were either self-reported or resulted in ambulance or emergency room care among diabetic residents of two Finnish communities during a one-year period.     

Reasons for ordering laboratory tests and relationship with frequency of abnormal results

Objective

Laboratory tests are ordered on a daily basis, even though disease probability is often very low. Abnormal results, especially mildly abnormal results, can be difficult to interpret in these circumstances. Further insights into the occurrence of abnormalities can help improve rational test ordering and test interpretation. The objective was therefore to examine the frequency of mildly and markedly abnormal results and their relationship with physicians'' reasons for ordering tests.

Design

Prospective study.

Participants

A total of 87 primary care physicians in the Netherlands collected data on 1775 patients.

Main outcome measures

The physicians recorded the reason for ordering the tests, the most probable diagnosis and the pretest probability. The laboratories'' reference values and specified “action limits” were used to assess the number of abnormal results and markedly abnormal results, respectively.

Results

Laboratory results were received for 1621 patients and 15,603 tests were reported (mean 9.6). The proportion of abnormal test results increased with increasing pretest probability (from 13.9% to 34.7%) and was 13.4% for tests ordered to reassure the patient and 13.3% for psychosocial diagnoses. The proportion of patients with at least one abnormal test result was high: 53.1% for tests ordered to reassure and 57.7% in patients with low pretest probability. Corresponding values for a marked abnormality were 11.1% and 12.4%, respectively.

Conclusion

Abnormal laboratory test results were frequent, even when pretest probability was low. Physicians should therefore carefully consider when tests are necessary. Future research could explore physicians'' interpretation of test results and its impact on diagnosis and management.Key Words: Clinical chemistry tests, diagnostic tests, family practice, interpretation of laboratory tests, laboratory utilization, primary healthcareTests are often ordered even though disease probability is low. The frequency of abnormal results in these situations was unknown.

• Even when tested for reasons such as “patient reassurance”, many patients have abnormal results.
• Most abnormalities are only slightly abnormal.
• Physicians should carefully consider when tests are necessary. Future research could explore the interpretation of results and the impact on diagnosis and management.

In primary care, correct interpretation of abnormal test results may be difficult. For instance, abnormal results can sometimes lead to an unjustified cascade of further investigations [1,2], while on the other hand they may erroneously fail to be further investigated [3].These difficulties with the interpretation of abnormal results may have several causes. For example, the pretest probability of disease is usually low in primary care. Also, physicians may suspect that complaints and symptoms are related to psychosocial problems [4,5]. Many tests are indeed ordered for reasons such as excluding pathology or reassuring the patient [6–8]. Furthermore, many abnormal lab results represent only minor deviations, and physicians may doubt their clinical relevance [9]. It is in particular the combination of minor abnormalities and a low pretest probability which may be difficult to interpret, as it is often easier to decide on the basis of more markedly abnormal results.While several authors reported high percentages of abnormal laboratory results [10,11], the relationship with the physicians’ reasons for ordering tests and the frequency of mildly or markedly abnormal results are unknown. More information on this relationship could be important for education as well as to improve rational test ordering. It may also help in exploring areas of potential difficulty in the interpretation of results.The aim of this study was therefore to examine the frequency of mildly and markedly abnormal results in routine practice, and to investigate how they relate to the reasons for ordering laboratory tests.     

Contacts related to mental illness and substance abuse in primary health care: A cross-sectional study comparing patients' use of daytime versus out-of-hours primary care in Norway

Objective

To investigate prevalence, diagnostic patterns, and parallel use of daytime versus out-of-hours primary health care in a defined population (n = 23,607) in relation to mental illness including substance misuse.

Design

Cross-sectional observational study.

Setting

A Norwegian rural general practice cooperative providing out-of-hours care (i.e. casualty clinic) and regular general practitioners’ daytime practices (i.e. rGP surgeries) in the same catchment area.

Subjects

Patients seeking medical care during daytime and out-of-hours in 2006.

Main outcome measures

Patients’ diagnoses, age, gender, time of contact, and parallel use of the two services.

Results

Diagnoses related to mental illness were given in 2.2% (n = 265) of encounters at the casualty clinic and in 8.9% (n = 5799) of encounters at rGP surgeries. Proportions of diagnoses related to suicidal behaviour, substance misuse, or psychosis were twice as large at the casualty clinic than at rGP surgeries. More visits to the casualty clinic occurred in months with fewer visits to rGP surgeries. Most patients with a diagnosis related to mental illness at the casualty clinic had been in contact with their rGP during the study period.

Conclusion

Psychiatric illness and substance misuse have lower presentation rates at casualty clinics than at rGP surgeries. The distribution of psychiatric diagnoses differs between the services, and more serious mental illness is presented out-of-hours. The casualty clinic seems to be an important complement to other medical services for some patients with recognized mental problems.Key Words: After-hours care, emergency medical services, family practice, physician''s practice patterns, primary health care, psychiatryMost mentally ill patients in Norway are dealt with by the primary health care system, and out-of-hours GP services are the main source of acute referrals to psychiatric wards. Differences between daytime and out-of-hours services regarding relative prevalence, diagnostic challenges, and parallel use have previously been unknown.

• Prevalence of diagnoses related to mental illness is lower at out-of-hours services compared with daytime services. However, suicidal behaviour, substance misuse, and psychosis are more prevalent out-of-hours than during the daytime.
• Use of out-of-hours services increases in periods with low use of daytime services.
• Most patients with diagnoses related to mental illness out-of-hours had also seen their regular general practitioner during the study period.

Norway has a two-tier public health care system where regular general practitioners (rGPs) serve as gatekeepers for all specialized health services including psychiatric health care [1,2]. Most patients with mental illness are therefore dealt with by the primary health care system, with relatively few patients referred to psychiatrists [3,4].Local municipalities (Norwegian kommuner) are responsible for providing all primary health care, including access to an rGP and 24-hour access to emergency health care [5,6]. Although optional, almost all Norwegians are listed with an rGP in their residing municipality. The rGPs provide emergency care to their listed patients during office hours. Out-of-hours, most municipalities organize the emergency care with one or more GPs on call, usually based in a casualty clinic. Depending on the size of the municipality and the population served, the casualty clinic might be cooperatively shared between several municipalities [1]. Henceforth casualty clinic is used as a general term for out-of-hours services, and rGP surgeries refer to rGPs’ work during normal office hours. At a national level, approximately 66% of inhabitants annually have at least one appointment with their rGP and 16% contact the casualty clinics [7].International studies indicate that psychiatric patients are frequent users of emergency medical health services [12–14]. In Norway, however, diagnoses related to mental illness are given in only 2–5% of patient contacts with casualty clinics [7,9,10,15], while mental illness accounts for 5–12% of consultations at rGP surgeries [7–11]. Nevertheless, casualty clinics are the major source of acute referrals to psychiatric wards [16]. This raises the possibility that patients’ use of the two primary health care services may differ, and that casualty clinics mainly deal with more severe mental illness.In this study we compared a defined population''s use of daytime rGP appointments versus their use of the out-of-hours casualty clinic in relation to mental illness. Main measures were relative prevalence and diagnostic differences. We also studied patients’ parallel use of these two services.     

Usefulness of natriuretic peptides in primary health care: An exploratory study in elderly patients

Objective

To explore the negative predictive value (NPV), positive predictive value (PPV), sensitivity, and specificity of natriuretic peptides, cut-off levels, and the impact of gender and age in elderly patients with systolic heart failure (HF).

Design

Cross-sectional exploratory study.

Setting

One primary healthcare centre.

Patients

A total of 109 patients with symptoms of HF were referred for echocardiographic examination with a cardiovascular consultation. Systolic HF was diagnosed (ESC guidelines) in 48 patients (46% men, 54% women, mean age 79 years) while 61 patients (21% men, 79% women, mean age 76 years) had no HF.

Main outcome measures

NPV, PPV, sensitivity, specificity, and cut-off levels.

Results

Including all 109 patients, NPV was 88% for NT-proBNP (200 ng/L) and 87% for BNP (20 pg/ml). PPV was 81% for NT-proBNP (500 ng/L) and 68% for BNP (50 pg/ml). Sensitivity was 96% for NT-proBNP (100 ng/L) and 96% for BNP (10-20 pg/ml). Specificity was 87% for NT-proBNP (500 ng/L) and 71% for BNP (50 pg/ml). Nt-proBNP (β = 0.035; p < 0.001) and BNP (β = 0.030; p < 0.001) were associated with age, but not with gender. In a multivariate analysis age (β = 0.036; p < 0.001) and male gender (β = 0.270; p = 0.014) were associated with NT-proBNP, but only age for BNP (β = 0.030; p < 0.001).

Conclusion

Natriuretic peptides in an elderly population showed high NPVs, but not as high as in younger patients with HF in other studies. Age and male gender were associated with higher levels of NT-proBNP while only age was related to elevated BNP levels.Key Words: Echocardiography, elderly, family practice, gender, natriuretic peptides, primary health care, systolic heart failureKnowledge of the utility of natriuretic peptides in elderly patients with suspected heart failure in primary healthcare is still limited.

• Natriuretic peptides showed high negative predictive values, but not as high as in younger patients with heart failure in other studies.
• Natriuretic peptides are useful as diagnostics tools even in elderly patients but the most precise cut-off levels still have to be determined.
• Age and male gender were associated with higher levels of NT-proBNP, while only age was related to elevated BNP levels.

Natriuretic peptides (NT-proBNP and BNP) have emerged as valuable tools in excluding HF [1,2], mostly in patients with new onset and untreated heart failure (HF). Accordingly, the European Society of Cardiology (ESC) has recommended the use of natriuretic peptides in a diagnostic algorithm in their 2005 guidelines, mainly to rule out HF [3]. These recommendations are based on studies with patients 70 years of age and younger [1,4]. They underline the importance of recognizing female gender and increasing age when setting cut-off points [5]. Elderly, and especially elderly female patients with HF, are more often treated by general practitioners than by cardiologists [6,7]. In primary healthcare there is a strong need for easily accessible and accurate diagnostic methods, as availability of echocardiography may be limited.The present study was performed because there are still unresolved questions regarding the diagnostic accuracy and cut-off values of natriuretic peptides in elderly patients in primary healthcare (PHC) with suspected HF [8].The aim of this study was, primarily, to explore the sensitivity, specificity, negative and positive predictive values (NPV, PPV) of NT-proBNP and BNP in a cross-sectional study of primary health care patients with systolic HF and, secondarily, to evaluate the impact of age and gender on natriuretic peptides levels.     

Poor self-rated health in adult patients with type 2 diabetes in the town of S?dert?lje: A cross-sectional study

Objective

Several studies indicate that ethnicity may be a strong predictor of poor self-rated health (SRH). The aims of the present study were to investigate whether there was an association between ethnicity and poor SRH in subjects with type 2 diabetes and to determine if the association remained after adjusting for possible confounders such as age, gender employment, marital status, and education.

Design

A cross-sectional study based on a patient population in the town of Södertälje. An unconditional logistic regression was performed to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs).

Setting

Four primary health care centers.

Subjects

A total of 354 individuals were included: Assyrian/Syrian-born (n = 173) and Swedish-born (n = 181).

Results

The odds ratio for rating poor SRH for Assyrian/Syrian subjects with type 2 diabetes was 4.5 times higher (95% CI = 2.7–7.5) than for Swedish patients in a crude model. After adjusting for possible confounders, unemployed/retired people had 5.4 times higher odds for reporting poor SRH than employees (OR = 5.4; 95% CI = 2.3–12.5). Women had 1.8 times higher odds (95% CI = 1.0–3.0) for reporting poor SRH than men. In the final model poor SRH among Assyrians/Syrians decreased but still remained significant (OR=3.7; 95% CI = 2.5–6.6).

Conclusions

The findings in this study are important for planning primary health care services. They highlight the crucial importance of being aware of the subjective health status of immigrants fleeing from war in the Middle East and resettling in Sweden.Key Words: Assyrians/Syrians, ethnicity, self-rated health, type 2 diabetesThis study highlights the relationship between self-rated health and ethnicity in subjects with type 2 diabetes.

• Socioeconomic factors did not explain the ethnic differences in rating poor general health.
• Unemployed/retired patients with type 2 diabetes, regardless of ethnicity, had the highest odds ratio for reporting poor general health.

Self-rated health (SRH) is a powerful and independent predictor of long-standing chronic diseases; although its biological basis is unknown some studies have shown an association with circulating cytokines in women [1]. It has been documented that SRH is a major predictor of morbidity, mortality, and health services utilization [2]. Furthermore, SRH is an important indicator of the quality of life as well as a good predictor of future health [6] and mortality in persons with diabetes [7]. In addition, age and gender [8], life satisfaction [9], and heritability [10] are factors related to SRH.Several studies indicate that SRH is poorer among immigrants than in native populations in Western countries, and belonging to a particular ethnic group has been shown to be a strong predictor of poor mental health and poor subjective health [11–13]. However, there are some studies showing that immigrants in general have a higher prevalence of poor SRH [14,15] and that Swedes report the highest prevalence of good health compared to ten European countries [16].The novelty of this primary health care study is the analysis of SRH in a group of foreign-born patients, i.e. Assyrians/Syrians with type 2 diabetes, and their controls in Södertälje, south of Stockholm.The aims of the study were to investigate whether there was an association between ethnicity and poor self-rated health in subjects with type 2 diabetes and to analyze whether the association remained after adjusting for possible confounders such as gender, age, employment, marital status, and educational level.     

Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints

Objectives

To explore GPs’ considerations in decision-making regarding sick-listing of patients suffering from SHC.

Design

Qualitative analysis of data from nine focus-group interviews.

Setting

Three cities in different regions of Norway.

Participants

A total of 48 GPs (31 men, 17 women; aged 32–65) participated. The GPs were recruited when invited to a course dealing with diagnostic practice and assessment of sickness certificates related to patients with composite SHCs.

Results

Decisions on sick-listing patients with SHCs were regarded as a very challenging task. Trust in the patient''s own story and self-judgement was deemed crucial, but many GPs missed hard evidence of illness and loss of function. Several factors that might influence decision-making were identified: the patients’ ability to present their story to evoke sympathy, the GP''s prior knowledge of the patient, and the GPs’ own experience as a patient and their tendency to avoid conflicts. The approach to the task of sick-listing differed from patient-led cooperation to resistant confrontation.

Conclusion and implications

Issuing sickness certification in patients with composite health complaints is considered challenging and burdensome. It is seen as mainly patient-driven, and the decisions vary according to GPs’ attitudes, beliefs, and personalities. Guiding the GPs to a more focused awareness of the decision process should be considered.Key Words: Education, family practice, primary health care, sickness certification, sick-listing, subjective health complaints, work incapacityAlthough we have some knowledge concerning GPs’ practices on sick-listing in general, less is known about how GPs make their assessments regarding sick-listing in the more complex cases of patients with subjective health complaints (SHCs).

• Decisions on sick-listing patients with SHCs are considered by GPs as a demanding and challenging task and are seen as mainly patient-driven.
• Handling of the sick leave decisions varies greatly, according to GPs’ attitudes, beliefs, and personalities.
• Focused awareness of the decision process through more specific education and training among students and GPs should be considered.

Subjective health complaints (SHCs) account for a great proportion of the encounters in general practice [1,2], and include conditions like musculoskeletal pain, tiredness, fibromyalgia, gastrointestinal complaints, depression, and anxiety [3–9]. SHCs are characterized by a plurality of symptoms and often a lack of objective findings or specific pathology to fully explain the complaints [7,10–12]. Lack of objective findings makes assessment difficult and leaves room for great variation in assessment of these patients, including the decision on whether to grant sick leave.A sickness certificate may be granted in Norway if a reduction in work capacity is due to disease or injury [13,14]. Some 79% of the total number of sickness certificates are issued by general practitioners (GPs) [13]. This assessment is often difficult and complex, and many physicians are uncomfortable carrying out these duties [15], being caught in the crossfire between the patients’ demands for sick-listing and society''s pressure to act more restrictively [15,16]. Knorring and her collaborators [17] report that many GPs expressed fatigue, despair, and lack of pride in their work concerning sick-listing. GPs find it particularly challenging to deal with issues of sick-listing when the decision is solely based on the patient''s own report of complaints [17,18].The GP''s age, sex, and whether the GP is a specialist or not, and also how the patients present their problem are factors found to influence decisions regarding sick-listing [19,20,22]. Norrmen et al. [21] found that the strongest predictors for granting sickness certification were agreement between patients’ and GPs’ assessment of reduced work capacity. When the patient''s complaints were judged to be non-somatic, the risk of being sick-listed also increased. However, there is scarce knowledge concerning how physicians actually make their assessment, especially in the more complex cases. The aim of this study was to explore what considerations are made by GPs when they decide whether patients with SHCs are eligible for sick-listing.