High Serum Insulin-Like Growth Factor-Binding Protein 1 (IGFBP-1) is Associated with High Fracture Risk Independent of Insulin-Like Growth Factor 1 (IGF-I).

High serum levels of IGFBP-1 are related both to low body mass index (BMI) and to low insulin-like growth factor 1 (IGF-I), which both in turn are related to low bone mineral density (BMD) and to increased fracture risk. However, we have found no previous prospective studies on IGFBP-1 and fracture risk. Despite its name, IGFBP-1 is not only just a binding protein but also has its own IGF-independent effects, e.g., stimulating osteoclast differentiation. IGFBP-1 might have an IGF-related and/or an IGF-independent association to fracture risk. This is a population-based prospective cohort study with a ten-year follow-up of 351 women aged 69-79 at inclusion. Fracture and mortality data were collected from national health care registers. IGFBP-1 had a positive linear relation to the risk of both hip fractures and "major osteoporotic fractures" including fractures of the hip, spine, shoulder, and wrist. The age-adjusted hazard ratio (HR) for a hip fracture was 1.46 (95 % CI 1.08-1.99) for one SD increase in IGFBP-1. The corresponding age-adjusted HR for major osteoporotic fractures was 1.33 (95 % CI 1.05-1.69). The relation between IGFBP-1 and fracture risk was not confounded by either IGF-I or BMI. Femoral neck BMD, however, mediated 56 % of the total "effect" of IGFBP-1 on hip fracture risk. In conclusion, IGFBP-1 had a positive linear relation to fracture risk, partly mediated by BMD but not related to IGF-I or BMD. This implies that IGFBP-1 might be an important factor in bone turnover and that further studies on this would be valuable.

Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems.

BACKGROUND: Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVÅ) and SNOMED CT. METHODS: Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed. RESULTS: 417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions. CONCLUSIONS: Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT.Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.

Time trends in ischaemic heart disease incidence and mortality over three decades (1990-2019) in 20 Western European countries: systematic analysis of the Global Burden of Disease Study 2019.

AIMS: To investigate and compare changes in the rates of ischaemic heart disease (IHD) incidence and mortality between 1990 and 2019 in 20 high-income Western European countries with similar public health systems and low cardiovascular risk. METHODS AND RESULTS: The 2020 updated version of the Global Burden of Disease database was searched. Variability and differences in IHD incidence and mortality rates (per 100 000) between countries over time, were calculated. A piecewise linear (join point) regression model was used to identify the slopes of these trends and the points in time at which significant changes in the trends occur. Ischaemic heart disease incidence and mortality rates varied widely between countries but decreased for all between 1990 and 2019. The relative change was greater for mortality than for incidence. Ischaemic heart disease incidence rates declined by approximately 36% between 1990 and 2019, while mortality declined by approximately 60%. Breakpoint analysis showed that the largest decreases in incidence and mortality occurred between 1990 and 2009 (-32%, -52%, respectively), with a much slower decrease after that (-5.9%, -17.6%, respectively), and even a slight increase for some countries in recent years. The decline in both incidence and mortality was lower in the Mediterranean European countries compared to the Nordic and Central European regions. CONCLUSIONS: In the Western European countries studied, the decline in age-standardized IHD incidence over three decades was slower than the decline in age-standardized IHD mortality. Decreasing trends of both IHD incidence and mortality has substantially slowed, and for some countries flattened, in more recent years.

Health problems and disability in long-term sickness absence: ICF coding of medical certificates.

BACKGROUND: The purpose of this study was to test the feasibility of International Classification of Functioning, Disability and Health (ICF) and to explore the distribution, including gender differences, of health problems and disabilities as reflected in long-term sickness absence certificates. METHODS: A total of 433 patients with long sick-listing periods, 267 women and 166 men, were included in the study. All certificates exceeding 28 days of sick-listing sent to the local office of the Swedish Social Insurance Administration of a municipality in the Stockholm area were collected during four weeks in 2004-2005. ICD-10 medical diagnosis codes in the certificates were retrieved and free text information on disabilities in body function, body structure or activity and participation were coded according to ICF short version. RESULTS: In 89.8% of the certificates there were descriptions of disabilities that readily could be classified according to ICF. In a reliability test 123/131 (94%) items of randomly chosen free text information were identically classified by two of the authors. On average 2.4 disability categories (range 0-9) were found per patient; the most frequent were 'Sensation of pain' (35.1% of the patients), 'Emotional functions' (34.1%), 'Energy and drive functions' (22.4%), and 'Sleep functions' (16.9%). The dominating ICD-10 diagnostic groups were 'Mental and behavioural disorders' (34.4%) and 'Diseases of the musculoskeletal system and connective tissue' (32.8%). 'Reaction to severe stress and adjustment disorders' (14.7%), and 'Depressive episode' (11.5%) were the most frequent diagnostic codes. Disabilities in mental functions and activity/participation were more commonly described among women, while disabilities related to the musculoskeletal system were more frequent among men. CONCLUSIONS: Both ICD-10 diagnoses and ICF categories were dominated by mental and musculoskeletal health problems, but there seems to be gender differences, and ICF classification as a complement to ICD-10 could provide a better understanding of the consequences of diseases and how individual patients can cope with their health problems. ICF is feasible for secondary classifying of free text descriptions of disabilities stated in sick-leave certificates and seems to be useful as a complement to ICD-10 for sick-listing management and research.

A randomized controlled trial of the effects of muscle stretching, manual therapy and steroid injections in addition to 'stay active' care on health-related quality of life in acute or subacute low back pain.

OBJECTIVE: To evaluate the health-related quality of life effects of muscle stretching, manual therapy and steroid injections in addition to 'stay active' care in acute or subacute low back pain patients. STUDY DESIGN: A randomized, controlled trial during 10 weeks with four treatment groups. SETTING: Nine primary health care and one outpatient orthopaedic hospital department. SUBJECTS: One hundred and sixty patients with acute or subacute low back pain. INTERVENTIONS: Ten weeks of 'stay active' care only (group 1), or 'stay active' and muscle stretching (group 2), or 'stay active', muscle stretching and manual therapy (group 3), or 'stay active', muscle stretching, manual therapy and steroid injections (group 4). MAIN MEASURES: The Gothenburg Quality of Life instrument subscales Well-being score and Complaint score. RESULTS: In a multivariate analysis adjusted for possible outcome affecting variables other than the treatment given Well-being score was 68.4 (12.5), 72.1 (12.4), 72,3 (12.4) and 72.7 (12.5) in groups 1-4, respectively (P for trend <0.05). There were significant trends for the well-being components patience (P < 0.005), energy (P < 0.05), mood (P < 0.05) and family situation (P < 0.05). The remaining two components and Complaint score showed a non-significant trend towards improvement. CONCLUSION: The effects on health-related quality of life were greater the larger the number of treatment modalities available. The 'stay active' treatment group, with the most restricted number of modalities, had the most modest health-related quality of life improvement, while group 4 with the most generous choice of treatment modalities, had the greatest improvement.

Musculoskeletal injuries in young ballet dancers.

PURPOSE: The aim of this study was to examine the incidence of musculoskeletal injuries, site and type of injury, and the most common injury diagnoses in young ballet dancers at the Royal Swedish Ballet School, a public school in Stockholm. METHODS: This retrospective study of 476 students (297 girls and 179 boys) aged 10-21 years was based on medical records for the period August 1988 to June 1995. Data on diagnosis, site of injury and type of injury were collected, and the injuries were classified as traumatic or due to overuse. RESULTS: In total, 438 injuries were recorded. The injury incidence rate was 0.8 per 1,000 dance hours in both female and male dancers and tended to increase with increasing age. Most injuries occurred as the result of overuse. Seventy-six per cent of all injuries occurred in the lower extremities. Ankle sprain was the most common traumatic diagnosis, while the most common overuse-related diagnosis was tendinosis pedis. A few gender differences were noted. CONCLUSIONS: The findings of this study suggest that there is a need to apply primary injury prevention in young ballet dancers. Future studies could aim to identify (1) injury risk factors and (2) injury prevention programmes that are effective at reducing injury rates in young dancers.

Predictors of stable return-to-work in non-acute, non-specific spinal pain: low total prior sick-listing, high self prediction and young age. A two-year prospective cohort study.

BACKGROUND: Non-specific spinal pain (NSP), comprising back and/or neck pain, is one of the leading disorders in long-term sick-listing. During 2000-2004, 125 Swedish primary-care patients with non-acute NSP, full-time sick-listed 6 weeks-2 years, were included in a randomized controlled trial to compare a cognitive-behavioural programme with traditional primary care. This prospective cohort study is a re-assessment of the data from the randomized trial with the 2 treatment groups considered as a single cohort. The aim was to investigate which baseline variables predict a stable return-to-work during a 2-year period after baseline: objective variables from function tests, socioeconomic, subjective and/or treatment variables. Stable return-to-work was a return-to-work lasting for at least 1 month from the start of follow-up. METHODS: Stable return-to-work was the outcome variable, the above-mentioned factors were the predictive variables in multiple-logistic regression models, one per follow-up at 6, 12, 18 and 24 months after baseline. The factors from univariate analyzes with a p-value of at most .10 were included. The non-significant variables were excluded stepwise to yield models comprising only significant factors (p < .05). As the comparatively few cases made it risky to associate certain predictors with certain time-points, we finally considered the predictors which were represented in at least 3 follow-ups. They are presented with odds ratios (OR) and 95% confidence intervals. RESULTS: Three variables qualified, all of them represented in 3 follow-ups: Low total prior sick-listing (including all diagnoses) was the strongest predictor in 2 follow-ups, 18 and 24 months, OR 4.8 [1.9-12.3] and 3.8 [1.6-8.7] respectively, High self prediction (the patients' own belief in return-to-work) was the strongest at 12 months, OR 5.2 [1.5-17.5] and Young age (max 44 years) the second strongest at 18 months, OR 3.5 [1.3-9.1]. CONCLUSIONS: In primary-care patients with non-acute NSP, the strong predictors of stable return-to-work were 2 socioeconomic variables, Low total prior sick-listing and Young age, and 1 subjective variable, High self-prediction. Objective variables from function tests and treatment variables were non-predictors. Except for Young age, the predictors have previously been insufficiently studied, and so our study should widen knowledge within clinical practice.

Knowledge of stroke risk factors among primary care patients with previous stroke or TIA: a questionnaire study.

BACKGROUND: Survivers of stroke or transient ischaemic attacks (TIA) are at risk of new vascular events. Our objective was to study primary health care patients with stroke/TIA regarding their knowledge about risk factors for having a new event of stroke/TIA, possible associations between patient characteristics and patients' knowledge about risk factors, and patients' knowledge about their preventive treatment for stroke/TIA. METHODS: A questionnaire was distributed to 240 patients with stroke/TIA diagnoses, and 182 patients (76%) responded. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/conditions ("distractors"). The patients were also asked whether they considered each disease/condition to be one of their own. Additional questions concerned the patients' social and functional status and their drug use. The t-test was used for continuous variables, chi-square test for categorical variables, and a regression model with variables influencing patient knowledge was created. RESULTS: Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%. Few patients considered the distractors as stroke/TIA risk factors (3-6%). Patients with a family history of cardiovascular disease, and patients diagnosed with carotid stenosis, atrial fibrillation or diabetes, knew these were stroke/TIA risk factors to a greater extent than patients without these conditions. Atrial fibrillation or a family history of cardiovascular disease was associated with better knowledge about risk factors, and higher age, cerebral haemorrhage and living alone with poorer knowledge. Only 56% of those taking anticoagulant drugs considered this as intended for prevention, while 48% of those taking platelet aggregation inhibitors thought this was for prevention. CONCLUSIONS: Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. However, the knowledge level was low regarding diabetes as a risk factor and regarding the use of anticoagulants and platelet aggregation inhibitors for stroke/TIA prevention. Better teaching strategies for stroke/TIA patients should be developed, with special attention focused on diabetic patients.

Assessment of nerve involvement in the lumbar spine: agreement between magnetic resonance imaging, physical examination and pain drawing findings.

BACKGROUND: Detection of nerve involvement originating in the spine is a primary concern in the assessment of spine symptoms. Magnetic resonance imaging (MRI) has become the diagnostic method of choice for this detection. However, the agreement between MRI and other diagnostic methods for detecting nerve involvement has not been fully evaluated. The aim of this diagnostic study was to evaluate the agreement between nerve involvement visible in MRI and findings of nerve involvement detected in a structured physical examination and a simplified pain drawing. METHODS: Sixty-one consecutive patients referred for MRI of the lumbar spine were - without knowledge of MRI findings - assessed for nerve involvement with a simplified pain drawing and a structured physical examination. Agreement between findings was calculated as overall agreement, the p value for McNemar's exact test, specificity, sensitivity, and positive and negative predictive values. RESULTS: MRI-visible nerve involvement was significantly less common than, and showed weak agreement with, physical examination and pain drawing findings of nerve involvement in corresponding body segments. In spine segment L4-5, where most findings of nerve involvement were detected, the mean sensitivity of MRI-visible nerve involvement to a positive neurological test in the physical examination ranged from 16-37%. The mean specificity of MRI-visible nerve involvement in the same segment ranged from 61-77%. Positive and negative predictive values of MRI-visible nerve involvement in segment L4-5 ranged from 22-78% and 28-56% respectively. CONCLUSION: In patients with long-standing nerve root symptoms referred for lumbar MRI, MRI-visible nerve involvement significantly underestimates the presence of nerve involvement detected by a physical examination and a pain drawing. A structured physical examination and a simplified pain drawing may reveal that many patients with "MRI-invisible" lumbar symptoms need treatment aimed at nerve involvement. Factors other than present MRI-visible nerve involvement may be responsible for findings of nerve involvement in the physical examination and the pain drawing.

Views of diagnosis distribution in primary care in 2.5 million encounters in Stockholm: a comparison between ICD-10 and SNOMED CT.

BACKGROUND: Primary care (PC) in Sweden provides ambulatory and home health care outside hospitals. Within the County Council of Stockholm, coding of diagnoses in PC is mandatory and is done by general practitioners (GPs) using a Swedish primary care version of the International Statistical Classification of Diseases, version 10 (ICD-10). ICD-10 has a mono-hierarchical structure. SNOMED CT is poly-hierarchical and belongs to a new generation of terminology systems with attributes (characteristics) that connect concepts in SNOMED CT and build relationships. Mapping terminologies and classifications has been pointed out as a way to attain additional advantages in describing and documenting healthcare data. A poly-hierarchical system supports the representation and aggregation of healthcare data on the basis of specific medical aspects and various levels of clinical detail. OBJECTIVE: To describe and compare diagnoses and health problems in KSH97-P/ICD-10 and SNOMED CT using primary care diagnostic data, and to explore and exemplify complementary aggregations of diagnoses and health problems generated from a mapping to SNOMED CT. METHODS: We used diagnostic data collected throughout 2006 and coded in electronic patient records (EPRs), and a mapping from KSH97-P/ICD-10 to SNOMED CT, to aggregate the diagnostic data with SNOMED CT defining hierarchical relationship Is a and selected attribute relationships. RESULTS: The chapter level comparison between ICD-10 and SNOMED CT showed minor differences except for infectious and digestive system disorders. The relationships chosen aggregated the diagnostic data to 2861 concepts, showing a multidimensional view on different medical and specific levels and also including clinically relevant characteristics through attribute relationships. CONCLUSIONS: SNOMED CT provides a different view of diagnoses and health problems on a chapter level, and adds significant new views of the clinical data with aggregations generated from SNOMED CT Is a and attribute relationships. A broader use of SNOMED CT is therefore of importance when describing and developing primary care.

Improving fast and frugal modeling in relation to regression analysis: test of 3 models for medical decision making.

BACKGROUND: Data from 2 previous studies were reanalyzed, one on judgments regarding drug treatment of hyperlipidemia and the other on diagnosing heart failure. The original MH model and the extended MH model were compared with logistic regression (LR) in terms of fit to actual judgments, number of cues, and the extent to which the cues were consistent with clinical guidelines. RESULTS: There was a slightly better fit with LR compared with MH. The extended MH model gave a significantly better fit than the original MH model in the drug treatment task. In the diagnostic task, the number of cues was significantly lower in the MH models compared to LR, whereas in the therapeutic task, LR could be less or more frugal than the matching heuristic models depending on the significance level chosen for inclusion of cues. For the original MH model, but not for the extended MH model or LR, the most important cues in the drug treatment task were often used in a direction contrary to treatment guidelines. CONCLUSIONS: The extended MH model represents an improvement in that prevalence of cue values is adequately taken into account, which in turn may result in better fit and in better agreement with medical guidelines in the evaluation of cues.

Subacute and chronic, non-specific back and neck pain: cognitive-behavioural rehabilitation versus primary care. A randomized controlled trial.

BACKGROUND: In the industrial world, non-specific back and neck pain (BNP) is the largest diagnostic group underlying sick-listing. For patients with subacute and chronic (= full-time sick-listed for 43 - 84 and 85 - 730 days, respectively) BNP, cognitive-behavioural rehabilitation was compared with primary care. The specific aim was to answer the question: within an 18-month follow-up, will the outcomes differ in respect of sick-listing and number of health-care visits? METHODS: After stratification by age (< or = 44/> or = 45 years) and subacute/chronic BNP, 125 Swedish primary-care patients were randomly allocated to cognitive-behavioural rehabilitation (rehabilitation group) or continued primary care (primary-care group). Outcome measures were Return-to-work share (percentage) and Return-to-work chance (hazard ratios) over 18 months, Net days (crude sick-listing days x degree), and the number of Visits (to physicians, physiotherapists etc.) over 18 months and the three component six-month periods. Descriptive statistics, Cox regression and mixed-linear models were used. RESULTS: All patients: Return-to-work share and Return-to-work chance were equivalent between the groups. Net days and Visits were equivalent over 18 months but decreased significantly more rapidly for the rehabilitation group over the six-month periods (p < .05). Subacute patients: Return-to-work share was equivalent. Return-to-work chance was significantly greater for the rehabilitation group (hazard ratio 3.5 [95%CI1.001 - 12.2]). Net days were equivalent over 18 months but decreased significantly more rapidly for the rehabilitation group over the six-month periods and there were 31 days fewer in the third period. Visits showed similar though non-significant differences and there were half as many in the third period. Chronic patients: Return-to-work share, Return-to-work chance and Net days were equivalent. Visits were equivalent over 18 months but tended to decrease more rapidly for the rehabilitation group and there were half as many in the third period (non-significant). CONCLUSION: The results were equivalent over 18 months. However, there were indications that cognitive-behavioural rehabilitation in the longer run might be superior to primary care. For subacute BNP, it might be superior in terms of sick-listing and health-care visits; for chronic BNP, in terms of health-care visits only. More conclusive results concerning this possible long-term effect might require a longer follow-up.

A guideline-based computerised decision support system (CDSS) to influence general practitioners management of chronic heart failure.

OBJECTIVES: To explore the influence of a guideline-based computerised decision support system (CDSS) on general practitioners' (GPs') management of patient cases of chronic heart failure in a pragmatic clinical situation. We assessed changes in the GPs' confidence in the diagnosis, their considerations about investigations and medications and the support they perceived from using the CDSS. STUDY DESIGN: Five GPs assessed the medical records of 48 of their own authentic patient cases using a guideline-based CDSS accessible on the internet for the diagnosis and treatment of chronic heart failure, and completed a questionnaire for each case. OUTCOME MEASURES: Number of cases where the GP reported a change in confidence in the diagnosis, where the GP considered further investigations or changes in medication and the perceived support marked on a visual analogue scale. RESULTS: The GPs' confidence in the diagnosis changed in 25% of the cases, with equal numbers of increases and decreases in confidence. The GPs considered further investigations in 31% of the cases and medication changes in 19%. Fourteen of the 31 considered investigations and four of the ten considered changes in medications which were in agreement with the CDSS's suggestions. The GPs tended to consider further investigations more often in cases when the CDSS found the diagnosis uncertain. There was a wide range in the values for perceived support, but it could be described as substantial in 35% of the cases. CONCLUSION: Using a guideline-based CDSS for the GPs' own patient cases had an impact on the GPs' confidence in the diagnosis of chronic heart failure and their considerations about investigations and medications: they also perceived substantial support in every third case. Applying a CDSS developed using evidence-based guidelines for chronic heart failure in primary care could have a significant influence on GPs' disease management.

The effect of transvaginal estradiol on bone in aged women: a randomised controlled trial.

OBJECTIVES: To investigate the effect of transvaginal estradiol on bone mineral density and bone metabolism. METHODS: One hundred and fifteen women (mean age 73.8+/-3.2 years) were randomly assigned to a 2-year open-label parallel group clinical trial and were treated with either transvaginal estradiol (7.5 microg/24h), or no estradiol. Both groups received 400 IU vitamin D and 500 mg calcium/day. The bone mineral density (BMD) was assessed in the hip and spine using DXA technique and in the heel using DXL technique. RESULTS: The intention to treat analysis showed that the increase in BMD in the estradiol group was significant at total hip by 0.6% (P=0.04) while the control group decreased in their BMD by 0.7%. At lumbar spine the estradiol group increased in BMD by 2.6% (P=0.011) while the control group increased by 2.2%. Bone turnover markers and PTH-levels decreased while 25-OH vitamin D levels increased in both groups, a probable effect of the calcium and vitamin D supplementation. The bone resorption marker CTx decreased more significantly in the treatment group (P=0.016). CONCLUSIONS: The transvaginal estradiol treatment of 7.5 microg/24h had a small but significant effect on the BMD of total hip and lumbar spine after a follow-up of 2 years.

The reliability of a 10-test package for patients with prolonged back and neck pain: could an examiner without formal medical education be used without loss of quality? A methodological study.

BACKGROUND: In the rehabilitation of patients with prolonged back and neck pain, the physical impairment should be assessed. Previous research has exclusively engaged medically educated examiners, mostly physiotherapists. However, less biased evaluations of efforts at rehabilitation might be achieved by personnel standing outside the treatment work itself. Therefore, if medically untrained examiners could be used without cost to the quality, this might produce a better evaluation at defensible cost and could also be useful in a research context. The aim of this study was to answer the question: given a 10-test package for patients with prolonged back and neck pain, could an examiner without formal medical education be used without loss of quality? Five of the ten tests required the examiner to keep a firm hold against the foundation of those parts of the participant's body that were not supposed to move during the test. METHODS: Examination by an experienced physiotherapist (A) in performing the package was compared with that by a research assistant (B) without formal medical education. The reliability, including inter- and intra-rater reliability, was assessed. In the inter-rater reliability study, 50 participants (30 patients + 20 healthy subjects) were tested once each by A and B. In the intra-rater reliability study, the 20 healthy subjects were tested twice by A or B. One-way ANOVA intra-class-correlation coefficient (ICC) was calculated and its possible systematic error was determined using a t-test. RESULTS: All five tests that required no manual fixation had acceptable reliability (ICC > .60 and no indication of systematic error). Only one of the five tests that required fixation had acceptable reliability. The difference (five vs. one) was significant (p = .01). CONCLUSION: In a 10-test package for patients with prolonged back and neck pain, an examiner without formal medical education could be used without loss of quality, at least for the five tests requiring no manual fixation. To make our results more generalizable and their implications more searching, a similar study should be conducted with two or more examiners with and without formal medical education, and the intra-rater reliability study should also include patients and involve more participants.

Mapping the categories of the Swedish primary health care version of ICD-10 to SNOMED CT concepts: rule development and intercoder reliability in a mapping trial.

BACKGROUND: Terminologies and classifications are used for different purposes and have different structures and content. Linking or mapping terminologies and classifications has been pointed out as a possible way to achieve various aims as well as to attain additional advantages in describing and documenting health care data. The objectives of this study were: to explore and develop rules to be used in a mapping process, to evaluate intercoder reliability and the assessed degree of concordance when the 'Swedish primary health care version of the International Classification of Diseases version 10' (ICD-10) is matched to the Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT), to describe characteristics in the coding systems that are related to obstacles to high quality mapping. METHODS: Mapping (interpretation, matching, assessment and rule development) was done by two coders. The Swedish primary health care version of ICD-10 with 972 codes was randomly divided into an allotment of three sets of categories, used in three mapping sequences, A, B and C. Mapping was done independently by the coders and new rules were developed between the sequences. Intercoder reliability was measured by comparing the results after each set. The extent of matching was assessed as either 'partly' or 'completely concordant' RESULTS: General principles for mapping were outlined before the first sequence, A. New mapping rules had significant impact on the results between sequences A-B (p < 0.01) and A-C (p < 0.001). The intercoder reliability in our study reached 83%. Obstacles to high quality mapping were mainly a lack of agreement by the coders due to structural and content factors in SNOMED CT and in the current ICD-10 version. The predominant reasons for this were difficulties in interpreting the meaning of the categories in the current ICD-10 version, and the presence of many related concepts in SNOMED CT. CONCLUSION: Mapping from ICD-10-categories to SNOMED CT needs clear and extensive rules. It is possible to reach high intercoder reliability in mapping from ICD-10-categories to SNOMED CT. However, several obstacles to high quality mapping remain due to structure and content characteristics in both coding systems.

Using medical knowledge sources on handheld computers--a qualitative study among junior doctors.

BACKGROUND: The emergence of mobile computing could have an impact on how junior doctors learn. To exploit this opportunity it is essential to understand their information seeking process. AIM: To explore junior doctors' experiences of using medical knowledge sources on handheld computers. METHOD: Interviews with five Swedish junior doctors. A qualitative manifest content analysis of a focus group interview followed by a qualitative latent content analysis of two individual interviews. RESULTS: A focus group interview showed that users were satisfied with access to handheld medical knowledge sources, but there was concern about contents, reliability and device dependency. Four categories emerged from individual interviews: (1) A feeling of uncertainty about using handheld technology in medical care; (2) A sense of security that handhelds can provide; (3) A need for contents to be personalized; (4) A degree of adaptability to make the handheld a versatile information tool. A theme was established to link the four categories together, as expressed in the Conclusion section. CONCLUSION: Junior doctors' experiences of using medical knowledge sources on handheld computers shed light on the need to decrease uncertainty about clinical decisions during medical internship, and to find ways to influence the level of self-confidence in the junior doctor's process of decision-making.

Clinical categories of patients and encounter rates in primary health care - a three-year study in defined populations.

BACKGROUND: The objective was to estimate the proportion of inhabitants with a diagnosis-registered encounter with a general practitioner, and to elucidate annual variations of clinical categories of patients in terms of their individual comorbidity. METHODS: A three-year retrospective study of encounter data from electronic patient records, with an annual-based application of the Johns Hopkins Adjusted Clinical Groups (ACG) system. Data were retrieved from every patient with a diagnosis-registered encounter with a GP during the period 2001-2003 at 13 publicly managed primary health care centres in Blekinge county, southeastern Sweden, with about 150000 inhabitants. MAIN OUTCOME MEASURES: Proportions of inhabitants with a diagnosis-registered encounter, and ranges of the annual proportions of categories of patients according to ACGs. RESULTS: The proportion of inhabitants with a diagnosis-registered encounter ranged from about 64.0% to 90.6% for the primary health care centres, and averaged about 76.5% for all inhabitants. In a three-year perspective the average range of categories of patients was about 0.4% on the county level, and about 0.9% on the primary health care centre level. About one third of the patients each year had a constellation of two or more types of morbidity. CONCLUSION: About three fourths of all inhabitants had one or more diagnosis-registered encounters with a general practitioner during the three-year period. The annual variation of categories of patients according to ACGs was small on both the county and the primary health care centre level. The ACG system seems useful for demonstrating and predicting various aspects of clinical categories of patients in Swedish primary health care.

Time trends in statin utilisation and coronary mortality in Western European countries.

OBJECTIVES: To determine whether there is a relation between statin utilisation and coronary heart disease (CHD) mortality in populations with different levels of coronary risk, and whether the relation changes over time. DESIGN: Ecological study using national databases of dispensed medicines and mortality rates. SETTING: Western European countries with similar public health systems. MAIN OUTCOME MEASURES: Population CHD mortality rates (rate/100,000) as a proxy for population coronary risk level, and statin utilisation expressed as Defined Daily Dose per one Thousand Inhabitants per Day (DDD/TID), in each country, for each year between 2000 and 2012. Spearman's correlation coefficients between CHD mortality and statin utilisation were calculated. Linear regression analysis was used to assess the relation between changes in CHD mortality and statin utilisation over the years. RESULTS: 12 countries were included in the study. There was a wide range of CHD mortality reduction between the years 2000 and 2012 (from 25.9% in Italy to 57.9% in Denmark) and statin utilisation increase (from 121% in Belgium to 1263% in Denmark). No statistically significant relations were found between CHD mortality rates and statin utilisation, nor between changes in CHD and changes in statin utilisation in the countries over the years 2000 and 2012. CONCLUSIONS: Among the Western European countries studied, the large increase in statin utilisation between 2000 and 2012 was not associated with CHD mortality, nor with its rate of change over the years. Factors different from the individual coronary risk, such as population ageing, health authority programmes, guidelines, media attention and pharmaceutical industry marketing, may have influenced the large increase in statin utilisation. These need to be re-examined with a greater emphasis on prevention strategies.

General practitioners' reasoning when considering the diagnosis heart failure: a think-aloud study.

BACKGROUND: Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines. METHODS: Think-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines. RESULTS: Information about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument. CONCLUSIONS: The clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way.