Socio-economic status influences blood pressure control despite equal access to care.

OBJECTIVE: Denmark has a health care system with free and equal access to care irrespective of age and socio-economic status (SES). We conducted a cross-sectional study to investigate a possible association between SES and blood pressure (BP) control of hypertensive patients treated in general practice. METHODS: We enrolled 184 general practices and 5260 hypertensive patients. The general practitioners reported information about BP and diagnosis of diabetes. Information about education, income, antihypertensive drug treatment and other co-morbidity was retrieved from relevant registers from Statistics Denmark. The outcome measure was BP control defined as BP <140/90 mmHg in general and <130/80 mmHg in diabetics. RESULTS: Patients <65 years and with an educational level of 10-12 years had increased odds ratio (OR) of BP control compared to patients with an educational level <10 years. Patients ≥65 years had increased OR of BP control if they were married/cohabiting as compared to being single, whereas education and income had no impact in this age group. Diabetics had significantly reduced odds of BP control irrespective of age, educational or income level. CONCLUSIONS: Despite equal access to care for all patients, SES had significant impact on BP control in this survey. Diabetes and cardiovascular disease also had a substantial influence irrespective of age, educational and income level.

Treatment of 5413 hypertensive patients: a cross-sectional study.

BACKGROUND: Most hypertensive patients are managed in primary care in Denmark, but previous studies have shown that only 21-43% of hypertensive patients achieve optimal blood pressure (BP) control. Antihypertensive drug treatment, risk factors and cardiovascular disease (CVD) are some of the important factors to consider when optimizing the individual treatment strategy in hypertensive patients. OBJECTIVE: To examine treatment of BP according to Danish guidelines (BP < 140/90 mmHg generally and <130/80 mmHg for diabetics) in a population from general practice in relation to risk factors, CVD and diagnosis of diabetes. METHODS: A cross-sectional study comprising 184 practices and 5413 hypertensive patients was carried out in Denmark. The general practitioners filled in information on each patient's risk factors, CVD and antihypertensive drug treatment. Patients filled in a questionnaire on risk factors. The outcome measures were optimal BP control according to Danish guidelines and antihypertensive drug treatment. RESULTS: Mean patient age was 65.9 years [95% confidence interval (CI): 65.6-66.1]. Optimal BP control was achieved in 29.1% (95% CI: 27.9-30.3) of the study population. Among 842 diabetics with or without CVD, optimal BP control was achieved in 10.9% (95% CI: 8.8-10.3), while 38.7% (35.5-41.9) of patients with CVD achieved optimal BP control. The majority of all patients were treated with 1 (32.5%, 95% CI: 32.5 (31.3-33.8)) or two antihypertensive drugs (39.0%, 95% CI: 38.2-40.8). In hypertensive diabetics, 17.7% were not treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. CONCLUSION: In general practice, the proportion of hypertensive patients achieving optimal BP control is inadequate. The majority of hypertensive patients are treated with only one or two antihypertensive drugs.

[Examination and treatment of musculoskeletal diseases in general practice investigated by medical audit]. / Undersøgelse og behandling af muskelog skeletsygdomme i almen praksis belyst ved medical audit.

The general practitioner has a central role in the investigation and treatment musculoskeletal diseases, because he often is the first to see the patient. Correct initial care can save days lost through sickness and prevent chronic courses. In May 1995, 173 general practitioners registered every patient contact with complaints from the musculoskeletal system. The registration continued for three weeks following an audit model used in Denmark among general practitioners (in total 6869 contacts). After the registration four follow-up meetings took place. The two main results were 1) frequent conventional X-rays of osteoarthritis, and 2) prescription of non-steroidal antiinflammatory drugs to every fourth contact with musculoskeletal complaints. The follow-up meetings revealed some non-professional motives for sending the patient to X-ray examination and for prescribing non-steroidal anti-inflammatory drugs. The results will form the basis for clinical guidelines for handling some of the musculoskeletal diseases.

[Medical audit in laboratory medicine. A description of the course and some results]. / Medical audit om laboratoriemedicin. En beskrivelse af forløbet og nogle resultater.

All general practitioners of the Danish counties of Funen, Vejle and North Jutland were invited to participate in a medical audit concerning laboratory medicine organised by the Audit Project Odense (APO) in co-operation with the Consultative Arrangement for General Practice, emanating from the clinical/chemical departments of Funen. During three weeks the participants registered all clinical problems which would result in one or more laboratory tests. APO performed computer registrations and analyses of the results where upon each participant received a reply letter indicating the results of his own as well as the group's registrations. At a subsequent meeting the participants discussed the conception of "good general practice" as regards the use of laboratory medicine within defined clinical problems. The course of the audit demonstrated that the APO method is suitable for identification of a number of professional problems related to general practitioners' use of laboratory medicine and to reveal the variation in general practitioners' handling of laboratory medicine. Furthermore, the project showed that continuous quality development demands profound study of and research into the professional problems which the general practitioners encounter when using laboratory medicine.

[Respiratory tract infections in general practice--the effect of a medical audit project]. / Luftvejsinfektioner i almen praksis--effekten af et auditprojekt.

A medical audit of the management of respiratory tract infections was performed among 31 general practitioners in Funen county. The first registration of prescriptions in 1992 showed that broadspectrum antibiotics were used to a higher extent than seemed necessary. An intervention with courses, visits to the department of clinical microbiology and distribution of recommendations concerning diagnosis and treatment was performed. The intention was to give the necessary and only the necessary amount of antibiotics and when an antibiotic was indicated to use penicillin as often as possible. A new registration was made one year after the first one. The proportion of antibiotic prescriptions was reduced from 0.49 to 0.38 and the proportion of prescriptions of broadspectrum antibiotics was reduced from 0.21 to 0.12. Detection of group A streptococci in tonsillitis was used more frequently in 1993 than in 1992. Medical audit performed after this model seems a good instrument for changing prescription habits. Medical audit thus seems to be a useful tool in quality improvement in general practice.

[General practitioners want continuing education. Audit registrations among 369 physicians in Copenhagen]. / Praktiserende laeger ønsker efteruddannelse. Auditregistrering blandt 369 laeger i København.

The purpose of the study was to evaluate general practitioners' (GPs') interest in CME. A medical audit comprising 369 GPs in three counties was conducted in 1996. During 28,550 consultations the participating GPs recorded clinical subject, handling of the consultation, problems in the consultation and perceived need for training in relation to the consultation. The interest in CME varied from GP to GP and from one clinical subject to another. Desire for CME was expressed in relation to 16% of the consultations, most frequently in relation to psychiatry, community medicine and musculoskeletal diseases. Theoretical courses were the learning style most often preferred, especially for subjects requiring biomedical knowledge. Newer educational methods were also listed. Organisers of CME for general practitioners should be aware of the wide range of needs and wishes for CME among general practitioners.

[A randomized controlled trial of the use of CRP rapid test as a guide to treatment of respiratory infections in general practice]. / Randomiseret, kontrolleret undersøgelse af anvendelsen af CRP-hurtigtest som vejledning ved behandlingen af luftvejsinfektioner i almen praksis.

INTRODUCTION: The aim was to assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a CRP rapid test to support their clinical assessment, and to examine whether the use of the test would have any effect on the course of disease. MATERIAL AND METHOD: A randomised controlled trial was carried out by 35 general practices in the County of Funen, Denmark, with 812 patients with respiratory infection. The main outcome measures were frequency of antibiotic prescriptions and morbidity one week after the consultation, as stated by the patients. RESULTS: The frequency of antibiotic prescriptions was 43% (179/414) in the CRP group and 46% (184/398) in the control group (NS, OR = 0.9). At one week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patient's general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase [mg/l], p < 0.0001). CONCLUSION: From on the present study, the use of a single CRP rapid test to support possible antibiotic treatment of respiratory infections in general practice cannot be recommended.

[Antibiotic treatment of infections in general practice. Effect of audit assessed by prescriptions data from health insurance registry and physicians' own registration]. / Antibiotikabehandling af infektioner i almen praksis. Effekten af audit bedømt ved ordinationsdata fra Sygesikringens register og laegernes selvregistrering.

The aim was to study whether an audit of treatment of infections in general practice resulted in changed prescribing habits. In 1995-1996 forty-six general practitioners (GP's) from the County of Roskilde participated in an audit regarding infectious diseases (incl. course participation and preparation of treatment guidelines). The effect evaluation was done on the basis of 1) two self-registrations of antibiotic prescriptions carried out with one year's interval, and 2) prescribing data from the National Insurance database collected over two periods, before the first and second self-registration respectively. The number of patients not receiving antibiotics increased significantly from 47.2% to 52.4% after intervention. The self-registration did not show any change in choice of antibiotics, while the registry data showed a shift from broad-spectrum to narrow-spectrum penicillin. This change was, however, also found among the GP's, who did not participate in the audit. The study demonstrated that audit can result in changes in prescribing patterns, but at the same time emphasizes the need for inclusion of external data sources and control groups in the evaluation of intervention effects.

Long-lasting improvement in general practitioners' prescribing of antibiotics by means of medical audit.

OBJECTIVE: To evaluate the usefulness of medical audit of GPs' antibiotic prescription habits. DESIGN: Medical audit according to the APO method. Registration of antibiotic prescriptions for respiratory tract infections during a 3 year period. Intervention with courses, visits to the laboratory, and distribution of recommendations concerning diagnosis and treatment of respiratory infections. SETTING: 24 Danish GPs in cooperation with Audit Project Odense (APO) and Department of Clinical Microbiology, Odense University Hospital. 207 GPs acted as controls. MAIN OUTCOME MEASURES: Changes in the number of antibiotic prescriptions and in the penicillin/broad-spectrum antibiotic ratio. RESULTS: The proportion of antibiotic prescriptions was reduced during the investigation period, but a similar reduction was found in the control groups. Only for acute sinusitis was a lasting decrease not found in the control groups recorded. The penicillin/broad-spectrum antibiotic ratio increased in the intervention group (1.33 in 1992, 1.94 in 1993 and 2.70 in 1995). This increase was significantly higher than in the control groups. The change was seen for acute sinusitis, bronchitis, and pneumonia, but not for acute otitis media or acute tonsillitis. The changes induced from 1992 to 1993 were maintained or increased from 1993 to 1995 although the educational measures had stopped. CONCLUSION: Medical audit according to the APO method is a useful tool for inducing and maintaining desirable changes in GPs' prescription habits.

Randomised controlled trial of CRP rapid test as a guide to treatment of respiratory infections in general practice.

OBJECTIVE: To assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a C-reactive protein (CRP) rapid test in support of their clinical assessment, and to study whether using the test will have any effect on the course of disease DESIGN: Randomised controlled trial. SETTING: 35 general practices, County of Funen, Denmark. PATIENTS: 812 patients with respiratory infection. MAIN OUTCOME MEASURES: Frequency of antibiotic prescriptions and morbidity 1 week after the consultation, as stated by the patients. RESULTS: In the CRP group the frequency of antibiotic prescriptions was 43% (179/414) compared with 46% (184/398) in the control group (odds ratio (OR) = 0.9, NS). After 1 week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patients' general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase (mg/l), p < 0.0001). CONCLUSION: Based on the present study, the use of the CRP rapid test in support of a possible antibiotic treatment for respiratory infections in general practice cannot be recommended.