Health and re-employment in a two year follow up of long term unemployed.

STUDY OBJECTIVE: The aim was to examine re-employment and changes in health during a two year follow up of a representative sample of long term unemployed. DESIGN: This was a cross sectional study and a two year follow up. Health was measured by psychometric testing, Hopkins symptom checklist, General health questionnaire, and medical examination. Health related selection to continuous unemployment and recovery by re-employment was estimated by logistic regression with covariances deduced from the labour market theories of human capital and segmented labour market. SETTING: Four municipalities in Greenland, southern Norway. SUBJECTS: Participants were a random sample of 17 to 63 year old people registered as unemployed for more than 12 weeks. MAIN RESULTS: In the cross sectional study, the prevalence of depression, anxiety, and somatic illness was from four to 10 times higher than in a control group of employed people. In the follow up study, there was considerable health related selection to re-employment. A psychiatric diagnosis was associated with a 70% reduction in chances of obtaining a job. Normal performance on psychometric testing showed a two to three times increased chance of re-employment. Recovery of health following re-employment was less than expected from previous studies. CONCLUSIONS: Health related selection to long term unemployment seems to explain a substantial part of the excess mental morbidity among unemployed people. An increased proportion of the long term unemployed will be vocationally handicapped as years pass, putting a heavy burden on social services.

Detecting hypertension: screening versus case finding in Norway.

OBJECTIVE: Evaluation of detection of hypertension in adults in the county of Nord-Trøndelag, Norway. DESIGN: Cross sectional survey with clinical follow up examinations. SETTING: Health survey by screening teams from the national health screening service, and examinations by all 106 general practitioners in the county. SUBJECTS: During 1984-6, 74,977 persons (88.1% of those aged 20 years and over) participated in the health survey. MAIN OUTCOME MEASURES: Hypertension (when assessed by standardised recording and by questionnaires on drug treatment for hypertension) according to the blood pressure thresholds used in the Norwegian treatment programme. Subjects positive on screening were grouped after clinical examination into treatment groups. RESULTS: In all, 2399 subjects were positive for hypertension. Before screening 6210 (8.3%) patients reported taking antihypertensive drugs and another 3849 (5.1%) had their blood pressure monitored regularly. All who screened positive were referred to their general practitioner and evaluated according to a standard programme. As a result, drug treatment was started in 406 (0.5%) participants screened and blood pressure monitoring in another 1007 (1.3%). Of all patients taking antihypertensive drugs after the screening, 6399 (94.0%) had been diagnosed before screening, and of those whose blood pressure was monitored after the screening, 79.3% had been diagnosed before screening. CONCLUSIONS: At the blood pressure screening thresholds used, and when hypertension is defined by an overall clinical diagnosis, the results indicate that general practitioners can find and diagnose hypertensive patients with the case finding strategy.

[Physical activity and health in the elderly--walk on!]. / Fysisk aktivitet og eldres helse--gå på!

BACKGROUND: The Norwegian population has become less physically active during the last 20-30 years, mainly because everyday life has become more sedentary. Physical activity declines with age after 60 years of age, especially in women. Thus, physical inactivity ("the disuse syndrome") is an important challenge for public health, especially among the elderly. MATERIAL AND METHODS: This article is based on reports published on exercise and health during the last five years. However, a systematic and complete search is not made, nor a formal meta-analysis. The method is a critical, but qualitative evaluation. RESULTS: Many epidemiological studies indicate that physical inactivity almost doubles the risk for total annual mortality, for coronary disease, for diabetes in the elderly, and for cancer of the colon. Furthermore, it increases the risk of physical dysfunction and dependency. Physical activity improves health and functioning and becomes more important with age. INTERPRETATION: Physical activity reduces disease and improves health and functioning. The recommendation is simple: Walk for at least 30 minutes every day. The challenge is to motivate patients and the population at large to do so. There is evidence that doctors' advice is important.

Health services research: why and how?

It is useful to divide medical research into three areas: biomedical, clinical, and health services research. The areas partly overlap, and health services research is also related to social services research. Research is carried out to solve problems and is an instrument for change. Health services research has developed over the last ten years in response to increasing problems in many health services. Superficially, these problems are caused by insufficient resources, but no service can hope to pay its way out of them. Some may be fairly accurately investigated, like need, demand, and utilization of care. Others are more complicated, e.g. evaluation of care, defining standards, and cost--benefit analyses. A few deal with fundamental values, like quality of life and responsibility of individuals and societies. So far, health services research has led to greater emphasis on primary care, but it is fair to say that it has not managed to infiltrate the service and influence people's attitudes and ambitions. In the future, one must bring health services research inside the service and involve the professionals more deeply. One must support prevention studies, attack the ethical and clinical problems related to quality of life, study the potential of non-professional support in the community, and promote rational attitudes among professions, patients, people and politicians. The task is never-ending and health services research, therefore, must be part of the programme of all medical schools.

[Good physicians--how will the students turn out?]. / Gode leger--hvordan blir studentene det?

Good medical practice requires the amalgamation of two worlds, the world of medical science and the world of sick people. Medical science has seen unbelievable progress, but criticism from patients has nevertheless increased. There is also an increasing gap between the direction of medical science and sick people's problems. The curriculum needs reforming in most medical schools. But the teachers are probably more important than the curriculum. The teachers, at least a few of them, should serve as role models and influence the students for life. I describe my three role models as an illustration. The medical schools must therefore work along two lines, they must reform the curriculum and make the teachers good role models.

What is the economic impact of secondary prevention to society?

Of the 4.1 million population of Norway about 7500 patients between 20 and 75 years of age are admitted each year to hospital for acute myocardial infarction. Of these 1100 die in hospital, and 6400 are candidates for secondary prevention. On the basis of survival curves, we present a model for calculating potential benefits of secondary prevention. We use 'years of life gained' as a measure of outcome of secondary prevention. We consider three economic elements in secondary prevention: (a) Use of health services. The drug costs are moderate. The indirect costs are unknown, but probably moderate. (b) Resumed productivity is small. (c) Pensions and other transfers will increase the public expense. The net effect is an increase in public expense. Beta blockers reduce mortality by 25% and can be given prophylactically to about one third of the patients. So far, the effect is uncertain after two years. Secondary prevention for two years will cost Norway about 3.8 million NOK (526 000 US +) per year for drugs, give 597 extra survivors and provide 0.24 additional life years per patient treated. In case of life-long treatment and effect, the result will be 1.6 years of life per patient treated. About 50% of Norwegian patients smoke. If all the men stopped, there will be no costs, about 5120 extra survivors, and 3.3 additional years of life per patient who quits smoking. The effect is not limited in time.

Physical activity, health and health economics.

Ideally this article should begin with a mathematical model--an equation. On the left we should put together contributions and expenditures in terms of hours, money and effort. On the right we should enter the profits in terms of years of life, money and quality of life. Unfortunately it is not that easy. The literature is comprehensive but also not complete. At the request of the British Department of Social Welfare, Fentem & Bassey went through the literature on exercise and health--1 334 references (4), and were unable to draw up any conclusion in the form of a mathematical equation. They could only make a declaration which they called "The case for exercise" (10). Lack of scientific proof should not stop us from drawing probable conclusions. In the article below we set out our reasons for the conclusions we have arrived at. In brief, the conclusion should be: "exercise is healthy and health is profitable".

[Longevity among Norwegian Adventists 1960-1977: a message of life style and health?]. / Høyere levealder hos norske adventister 1960-1977: et budskap om livsstil og helse?

PIP: Data on mortality of Norwegian Seventh-Day Adventists are examined for the period 1960-1977. The authors note an increase in longevity of four years for males and two years for females over the Norwegian population as a whole. The reasons for these differentials are sought in variations in health and life-style. (summary in ENG)^ieng

[The role of internal medicine in health services--time for retirement?]. / Indremedisinens rolle i helsetjenesten--moderfaget som må på gamlehjem?

Internal medicine is more than a hundred years old, even in Norway. Its intellectual fundament originates from nineteenth century medicine in Germany. Traditionally, these German physicians covered the entire field of medicine. However, due to lack of therapeutic remedies their main emphasis was on diagnosis and prognosis. During the last sixty years the tremendous increase in medical knowledge has led to a strong tendency towards organ specialization. The generalists in hospitals have met competition from general practitioners and specialists in geriatrics. At the same time their domain has steadily shrunk as the number of medical hospital beds has been reduced. Although not to the advantage of the patients, progress is wiping out the hospital generalists. Most (90%) hospital doctors are now organ specialists, although the majority of patients admitted to medical departments have diseases in more than one organ system. Therefore, generalists should be at least as equally appreciated as the organ specialists. To save the generalists the educational system must be changed. The two types of specialists should follow their own educational paths qualifying to separate and independent competence areas (general or organ-specific). Medical departments should be encouraged to maintain general sections in addition to the organ-specific sections. The generalist and the organ specialist should be professionally united in their efforts to develop internal medicine as a discipline.

[Ambulance helicopters in the mountains. An evaluation of the 1-year activity at the Dombås base]. / Legehelikopter i fjellbygder. Evaluering av ett års drift av Dombåsbasen.

On 1 January 1988 the Norwegian Air Ambulance Plan was put into effect. The operational base for the regional counties Oppland, parts of South Trøndelag, Møre and Romsdal and Hedmark was established in the township of Dombås. The base had a helicopter staffed with a specialist in emergency medicine. The operation of this base was evaluated for the period 1 February 1988 to 1 February 1989. 242 missions were undertaken. In 27 of 184 primary missions (15%) and in 11 of 32 secondary missions (33%) the service was judged to have given health benefit. It may have prevented the death of 13 patients. The service costs during the year were approximately NOK 10 million. The cost-benefit ratio is judged to be too high. In inland-Norway, with a widely scattered population, it is probably better to improve the quality of the emergency services offered by general practitioners and ordinary road ambulances than to use a helicopter staffed with a specialist in emergency medicine.

Relation between drug utilization and morbidity pattern: antihypertensive drugs.

Drug utilization studies are a valuable tool in health services research aiming to improve quality of health care and use of resources. We first present a simple model for drug utilization studies and then give practical examples from our studies in Norway, mainly dealing with the treatment of hypertension. There are marked differences in drug utilization between hospitals, counties, and the five Nordic countries. The medical consequences of these differences are probably small, but they have important economic implications. The marked regional differences in drug utilization argue for better organization of health care, for standardized treatment programs, and for continuing education of doctors.

[Treatment of myocardial infarction--current status at Norwegian hospitals]. / Infarktbehandling--status ved norske sykehus.

Present routines for examination, treatment and follow-up of myocardial infarction were registered at all hospitals in Norway. Heparin and salicylic acid are given as standard treatment. Streptokinase is given regularly to patients with a short case-history, while beta-blockers are used mostly in secondary prevention. Patients with unstable angina pectoris are offered acute coronary by-pass operation in 90% of the hospitals. The hospitalization period is short, varying from approximately ten days for patients with large myocardial infarctions, to seven days for patients with small infarctions. Most hospitals have a progressive rehabilitation program which stimulates early discharge of the patients. In general, Norwegian hospitals follow "modern" principles in the treatment of myocardial infarction. The routines are fairly similar in small and large hospitals, and in various parts of the country.

Expenditures on health care in the last year of life.

18-26% of public expenditure on health care is devoted to care of patients in their last year of life. 60% of this expenditure is on patients in somatic nursing homes. The figures do not tell directly whether too much or too little money in Norwegian health care is spent on people in the end stage of life. In order to answer this question, one must look at the quality of terminal care and assess the share of patients having a reasonable benefit of the care they receive.

[Cooperation between regional and central hospitals--how to achieve the best results?]. / Samarbeidet mellom region-og sentralsykehus--hvordan kan det bli best mulig?

The authors reviews a recent governmental analysis of cooperation between third-line university clinics and local and central hospitals. The hospitals are owned by the government (mainly by the counties), and the various Acts and regulation permit the central authorities to make decisions on all aspects of highly specialized medicine. The analysis concludes that a limited number of problems should be solved by decision of the central government, but only those where national concerns are involved. The counties within a health region should cooperate within a Regional Health Policy Board, to create plans for flow of patients through the health care system, specified for each field of medicine. When such plans have been approved by the Regional Health Policy Board, each county should be willing to accept them. In the event of local disagreement, the central government should decide.

[The child with bronchial obstruction in general practice. Need for better follow-up]. / Barn med bronkial obstruksjon i allmennpraksis. Behov for bedre oppfølging.

Early diagnosis and adequate follow-up routines are important in giving children with bronchial asthma good care and treatment. The aim of this study was to evaluate how children with bronchial obstruction and possible asthma were detected and treated in general practice. Children with bronchial obstruction (78) were registered in two municipalities in Nord-Trøndelag county, Norway. The data were supplemented by data from children with asthma (392) describing the situation before they received the diagnosis. In regard to frequency of symptoms and symptoms without infection, too few reported having bronchial asthma. Most children with repeated contacts because of bronchial obstruction had been examined by different doctors, and only seldom was a follow-up appointment made. Not all children with bronchial asthma had been referred to a paediatrician. The study shows that follow-up routines for children with bronchial obstruction are inadequate.