Patients with irritable bowel syndrome in primary care appear not to be heavy healthcare utilizers.

BACKGROUND: Irritable bowel syndrome is a frequently diagnosed gastrointestinal condition in general practice. Managing this chronic condition requires a co-ordinated effort between patient and doctor. AIM: To explore the patterns of treatment and healthcare utilization of irritable bowel syndrome cases in a Swedish primary care setting. METHODS: All cases with a registered diagnosis of irritable bowel syndrome were identified retrospectively for a 5-year period through computerized medical records at three primary healthcare centres in Sweden. Documentation of diagnosis, healthcare visits, treatments, investigations, medications, referrals, laboratory tests, mental and demographic data were retrieved from the records. RESULTS: Of all 723 irritable bowel syndrome patients identified, only 37% had a follow-up appointment to their General Practitioner during the study period. For 80%, the General Practitioner initiated some treatment during the initial consultation and 75% were prescribed medication. Fibre and bulking laxatives and acid-suppressive drugs were the most common medication. Almost a quarter was referred for complementary investigations at hospital, only 8.9% of the irritable bowel syndrome patients were referred to a specialist investigation. Laboratory investigations varied and were ordered more frequently (P = 0.05) for men. CONCLUSIONS: Irritable bowel syndrome patients appear not to be heavy utilizers of primary care and, of those who attend, the majority are managed by their General Practitioner.

Microbiological etiology in clinically diagnosed community-acquired pneumonia in primary care in Orebro, Sweden.

OBJECTIVE: To study the etiology of clinically diagnosed community-acquired pneumonia (CAP) in antibiotically naive patients attending a primary care center and treated at their homes. METHODS: A three-year prospective study was carried out, and 177 patients presenting with clinical signs of CAP were included. All patients had chest X-rays after inclusion, and 82 (46%) showed infiltrates. Nasopharyngeal swab culture was performed on all patients, and 51% produced a representative sputum sample. Paired sera were obtained from 176 patients. RESULTS: Among the 82 patients with radiographically proven CAP, Streptococcus pneumoniae was detected in 26 patients (32%), Haemophilus influenzae in 23 (28%), Mycoplasma pneumoniae in 15 (18%), and Chlamydia pneumoniae in four (5%). Serologic evidence of a viral infection was found in 13 patients (16%). Among the 95 patients without infiltrates, S. pneumoniae was found in 21 (22%), H. influenzae in 14 (15%), M. pneumoniae in two (2%), and C. pneumoniae in five (5%). Viral infection was detected in 19 (20%) of these 95 patients. CONCLUSION: In primary care in Sweden, the initial antibiotic treatment in any patient with pneumonia should be effective against S. pneumonia and H. influenzae. In addition, M. pneumoniae should be targeted during recurrent epidemics. C. pneumoniae, and especially Legionella, seem to be uncommon in primary care.

Asking for 'rules of thumb': a way to discover tacit knowledge in general practice.

BACKGROUND: Research in decision-making has identified heuristics (rules of thumb) as shortcuts to simplify search and choice. OBJECTIVE: To find out if GPs recognize the use of rules of thumb and if they could describe what they looked like. METHODS: An explorative and descriptive study was set up using focus group interviews. The interview guide contained the questions: Do you recognize the use of rules of thumb? Are you able to give some examples? What are the benefits and dangers in using rules of thumb? Where do they come from? The interviews were transcribed and analysed using the templates in the interview guide, and the examples of rules were classified by editing analysis. RESULTS: Four groups with 23 GPs were interviewed. GPs recognized using rules of thumb, producing examples covering different aspects of the consultation. The rules for somatic problems were formulated as axiomatic simplified medical knowledge and taken for granted, while rules for psychosocial problems were formulated as expressions of individual experience and were followed by an explanation. The rules seemed unaffected by the sparse objections given. A GP's clinical experience was judged a prerequisite for applying the rules. The origin of many rules was via word-of-mouth from a colleague. The GPs acknowledged the benefits of using the rules, thereby simplifying work. CONCLUSION: GPs recognize the use of rules of thumb as an immediate and semiconscious kind of knowledge that could be called tacit knowledge. Using rules of thumb might explain why practice remains unchanged although educational activities result in more elaborate knowledge.

Dementia in primary care: why the low detection rate?

OBJECTIVE: The aim of the present study was to find reasons for the low detection rate of dementia in primary care. Another aim was to investigate the attitudes and knowledge on dementia among Swedish general practitioners (GPs). DESIGN: Two-hundred-and-twenty-eight postal questionnaires were distributed to GPs in the county of Ostergötland. SETTING: Primary care in Sweden. MAIN OUTCOME MEASURES: The opinions of GPs on dementia management in primary care. RESULTS: The response rate was 67%. GPs showed a good knowledge of dementia diseases but underestimated the occurrence of dementia. They presented a positive attitude towards managing patients with dementia and considered that existing drug therapy justified an active search for patients with dementia in primary care, but they believed the efficacy of the drugs to be limited. Assessing the social environment of patients and organising social support were regarded as the most difficult tasks in the management of demented patients. CONCLUSION: The study indicates that the main obstacles are a lack of resources and a sceptical attitude to the benefits of drug treatment. Co-operation between the community services, specialist clinics and the primary care team should be improved.

Is general practice effective? A systematic literature review.

OBJECTIVE: To find evidence of the effectiveness of physicians working in primary care. DESIGN: Systematic literature search in the Medline and Cochrane databases. MATERIAL: Out of 7223 titles found in the search, 45 studies, comparing, from different aspects, primary care with specialist care, were extracted. MAIN OUTCOME MEASURES: Health indicators, health care costs, quality of health care. RESULTS: Primary care contributed to improved public health, as expressed through different health parameters, and a lower utilisation of medical care leading to lower costs. Physicians working in primary care, in comparison with other specialists, took care of many diseases without loss of quality and often at lower cost. The organisation of primary care was important in respect of reimbursement by capitation, more group practices, higher personal continuity, and having generalists as primary care physicians. CONCLUSIONS: To compare the effectiveness of primary care and specialist care is a complex task and there are limitations in all studies. However, we have found evidence that increased accessibility to physicians working in primary care contributes to better health and lower total costs in the health care system. It is also clear that studies with evaluation of how to most effectively organise primary care are far too few. There is an extensive need for future research in this area, a suitable task for collaborative research between the Nordic countries.

Attitudes toward management of patients with subacromial pain in Swedish primary care.

OBJECTIVE: We aimed to describe the attitudes among GPs and physiotherapists toward the diagnostic approach and management of patients with a common shoulder disorder. METHOD: A questionnaire was sent out to 188 GPs and 71 physiotherapists. The total response rate was 71.8%. The questions were based on a written case simulation with cues about history and symptoms. RESULTS: The results showed a unanimous opinion of the diagnosis. Rotator cuff tendinitis was marked as the most probable. The two groups showed similarities in the way that they would examine the patient. The GPs referred the patients to the physiotherapists significantly more often than the other way around. The most probable choice of treatment made by the GPs was non-steroidal anti-inflammatory drugs (NSAIDs) and by the physiotherapists, movement exercises together with ergonomics. Most treatment alternatives had at least 20% of the responders marking a neutral attitude, and few treatments were disregarded. CONCLUSIONS: We conclude that in Swedish primary care GPs and physiotherapists have a uniform diagnostic approach towards patients with subacromial pain, but their choice of treatment reflects an uncertainty about the effectiveness of conservative treatments. The questioned pathogenesis of the suggested diagnosis and lack of research regarding the efficacy of conservative treatments could explain this uncertainty.

Adverse reactions to food and food allergy in young children in Iceland and Sweden.

OBJECTIVE: To investigate the prevalence of adverse reactions to food and food allergy in Icelandic and Swedish 18-month-old children. DESIGN: Prospective multicentre comparative study. SETTING: Primary health care centres in Sweden and Iceland. SUBJECTS: A total of 324 children in Iceland and 328 in Sweden who attended for regular 18-month check-up. MAIN OUTCOME MEASURES: Adverse reaction to food according to questionnaire, and food allergy according to skin prick tests and double blind food challenge tests. RESULTS: Adverse reactions to food were reported in 27% of children in Iceland and 28% in Sweden. Food allergy was confirmed in 2.0% in both countries. Allergy among other family members was reported in 45% of the Icelandic children and 62% in the Swedish (p < 0.001). Indoor smoking was reported by 30% of the Icelandic families and 3% of the Swedish. Respiratory infections were reported significantly more often in Icelandic children than Swedish. CONCLUSION: Adverse reactions to food and food allergy were similar in Icelandic and Swedish children. At the age of 18 months one can expect to confirm food allergy in approximately one out of 15 children with reported adverse reactions to food.

The personal doctor reform in Sweden: perceived changes in working conditions.

BACKGROUND: In primary care in Sweden, several organizational changes have been implemented during the last decades in order to facilitate a shift from a high proportion of hospital care to a more primary-health-based care. The personal doctor reform has been one of the most important during recent years, for both personnel and patients. OBJECTIVES: We aimed to compare perceived changes in psychosocial working conditions for GP and district nurses in regions with traditional primary care and regions that have implemented a personal doctor system. METHODS: A questionnaire was mailed to 566 GPs and 554 district nurses in four selected county councils, two with traditional primary care and two with a personal doctor system. The overall response rate was 83%. A factor analysis of data concerning the experience of the organizational change revealed the following factors: fellowship at work, demands on the individual, influence and control, competence development and stimulation at work. RESULTS AND CONCLUSIONS: In the group as a whole, there was a general experience of deterioration of working conditions in all aspects except stimulation at work. This tendency was mostly marked in the regions with a personal doctor system. In these regions, GPs and district nurses reported significantly more impairments concerning demands on the individual and competence development. In addition, the district nurses also found themselves less able to exercise influence and control. These changes are neither desirable nor necessary consequences of an organizational development. It is important to follow continuously the personnel's experience in a changing primary health care system.

Differential cancer morbidity towards year 2000 in a population disease outlook across Europe. II. The male gender.

The conception of new, 'avoidable' life style diseases in affluent Western societies is largely based upon observations in groups of middle-aged urban males with mortality as the major end-point. This applies to cancer, too, and studies of morbidity, where cancer is put within the overall disease spectrum, are called for as a necessary intermediary stage for hypothesis generation and initiation of evaluative and interventive epidemiological projects in the community. Here also the conditions and circumstances that determine health and well being, that is, salutogenetic factors, come increasingly into focus. We made a comparative analysis of the total hospitalization for somatic diseases during 1986-1987 at the Linköping University Hospital in the county of Ostergötland, Sweden and the both complementary and commensurable Heraklion University Hospital on Crete. They are representative of their respective European situations, and are the only somatic hospitals in their regions. Large differences were found with lower morbidity in the more 'Arcadian', rural settings. The results provide valuable data on traits and patterns between earlier surveys such as the Seven Countries study and today. We have earlier reported on the findings from the female group of the two populations, and here wish to concentrate on the males. In particular, cancer is compared with the both prominent and 'archetypical' forms of male ill-health that are comprised by cardiovascular diseases and accidents. We discuss some of the salutogenetic as well as pathogenetic factors that call for closer study in the next stage of our project, whose emblem of Ariadne's thread we feel also has a strong bearing on the masculine gender.

Individuals living in areas with high background radon: a GIS method to identify populations at risk.

OBJECTIVE: to identify and link populations and individuals that live within high risk areas. DESIGN: census registers and disease registers which contain data on individuals can only give aggregate statistics relating to postal code districts, town, county or state boundaries. However environmental risk factors rarely, if ever, respect these man-made boundaries. What is needed is a method to rapidly identify individuals who may live within a described area or region and to further identify the disease(s) occurring among these individuals and/or in these areas. METHOD: this paper describes a method for linking the standard registers available in Sweden, notably the residence-property addresses they contain and the geographical coordinate setting of these, to map the population as a point coverage. Using standard GIS methods this coverage could be linked, merged or intersected with any other map to create new subsets of population. Representation of populations down to the individual level by automatised spatialisation of available census data is in its simplicity a new informatics method which in the designated GIS medium adds a new power of resolution. RESULTS: We demonstrate this using the radon maps provided by the local communes. The Swedish annual population registration records of 1991 for the county of Ostergötland and the property register available at the Central Statistical Bureau of Sweden formed the main data sources. By coupling the address in the population register to the property register each individual was mapped to the centroid of a property. By intersecting the population coverage with the radon maps, the population living in high, normal or low risk areas was identified and then analysed and stratified by commune, sex and age. The resulting tables can be linked to other database registers, to visualise and analyse geographical and related patterns. The methodology can be adapted for use with any other environmental map or small area. It can also be expanded to the fourth dimension by linking likewise available migration information to generate immediately coordinate-set, accumulated exposition and similar data.

Logics and logistics of community intervention against osteoporosis: an evidence basis.

Under designations like small areas action research and intervention, directed 'ground-up' health promotion and prevention in the population form an important part of the ongoing medical systems development. There is recent evidence of the success of community intervention against cardiovascular disease. In osteoporosis, however, there is still a lack of conclusive data on both the logics and logistics of such an approach. Since 1988, a county health policy program has been formulated and implemented in Ostergötland, Sweden, following the principles and guidelines of the WHO HFA 2000 declaration. Vadstena (n approximately 7,600) was chosen for a local and generalizable osteoporosis prevention project mediated by the primary care organization by means of health promotion and education in the community. In the present report we emphasize that community intervention is an important new advancement of the medical systems, where the basic research questions include operational and management aspects as equally vital and measurable requisites and results as other performance and outcome variables. We found that a community intervention trial against osteoporosis is both motivated and feasible and in this report wish to provide evidence on these crucial issues of logics and logistics.

Differential cancer morbidity towards year 2000 in a population disease outlook across Europe.I. The female gender.

Modern health system research emphasises the transition from mortality statistics via morbidity and risk factors observations to comparative site explorations in defined areas. The health of women from the perspective of their gender has become a priority in medical research over the last decade. Studies of morbidity have been called for as necessary intermediary stage for hypothesis generation, and the formulation and inception of epidemiological projects which are recognized as essential for attaining knowledge on the factors and circumstances that determine diseases and wellbeing in the general population. This applies especially to cancer, where the importance of seeing disease, from a ecological, cultural as well as gender context is evident. We made a comparative analysis of the hospitalization for somatic diseases during 1986-1987 at the Heraklion University Hospital on Crete, and the commensurable Linköping University Hospital in the country of Ostergötland, Sweden. They are representative of their complementary Europian situations and comprise the total hospital admissions in their regions. Large differences were found, notably regarding both cardiovascular diseases and cancer, with lower morbidity in the more 'arcadian', rural circumstances. The results provide unique data on traits and patterns intermediate to the pioneering observations of the Seven Countries survey on the rapidly changing European scene. In the field of cancer the data are effectively unmatched both as raw data and as a platform for further investigation, which we are presently pursuing under the emblem of 'Ariadne's thread'. From a salutogenetic point of view the elderly rural women on Crete, and from a pathogenetic point of view the elderly urban women in Linköping warrant particular attention.

"Phase examination" an assessment of consultation skills and integrative knowledge based in general practice.

The undergraduate medical curriculum at Linköping was changed and problem-based learning introduced in 1986. As a consequence the need for new examinations arose. To assess the students' consultation skills, ability to use theory in practice and skills in problem-based learning, a new examination called 'phase examination' was designed and introduced. The examination results of a 4-year student cohort are presented here, including descriptive statistics and correlations between phase examinations 1 and 2, as well as a semester examination consisting of modified essay questions and an objective structured clinical examination. The construct validity of the phase examination was tested by factor analysis. In general, low correlation between the three examinations were found, and interpreted as a result of inter-case and inter-rater variability. The factor analysis identified two factors in both phase examinations--one representing the solving of a learning task, the other consultation skills. The variables concerning the use of knowledge had an intermediate position, more connected to the solving factor in phase 1 and the consultation factor in phase 2. With the close connection of theory and practice in the phase examination, both by its design and the pairing of examiners (one general practitioner and one basic scientist), these examinations can be an important learning experience for both students and teachers. The deficiencies in the reliability of the phase examinations is, in our view, compensated by its directing and supporting effect on students' learning and its face and construct validity.

Problem-based medical education in general practice and health care quality assurance.

States that health systems globally are in transition, for which also a correspondingly reformed education is required, involving new--and renewed--basic sciences, principles, skills and methods. To that end, demonstrates how problem-based learning in general practice is almost ideal, although still sparsely implemented, and has much in common with health care quality assurance. Contends that primary care in many ways comprises the most important platform and vehicle of modern health services and their interaction with the population. Uses the example of the Faculty of Health Sciences in Linköping, where all curricula are integrated, community-oriented, problem-based and have a focus on primary care and general practice. Represents a useful and hitherto insufficiently recognized widening of the overall field of health care quality assurance, and summarizes some of the experiences therein. Also provides a brief overview of the literature.

Essential data set for computer management of distributed primary care services.

Reported here is a personal computer-based registration program of medical consultations in general practice that has been implemented in six communities ('primary health care districts'; total population 112623) in the county of Jönköping, southern Sweden. The program enabled decentralized monitoring and management of the primary health care organization in the communities. The objective of the present paper is to give, from one year's experience of about 137000 recorded visits, a broad overview of the program structure, briefly considering the questions associated with routine registration of medical consultations, to discuss how the system is used for decision and steering support as well as to summarize its overall performance, results and costs in relation to the general utility of accurate information on health service delivery and consumption in the population.

Undergraduate medical students' rating of clerkship in general practice.

In recent years there has been an increasing demand for more involvement of general practice in undergraduate medical education. General practice and primary care can contribute with a relevant clinical content but also be a major resource in facilitating of professional development of the medical student. In the reformed undergraduate medical education of the Faculty of Health Sciences, University of Linköping, Sweden, general practice has been given an important and extensive role. To evaluate the students' opinion on the recurrent clerkships in general practice a written questionnaire was given to all students after each clerkship. In the autumn of 1992, 74% of the 115 students answered this questionnaire. The questionnaire was focused on qualities regarded as important for creating the best educational milieu for the professional development of the student. Factor analysis of the different questionnaire headings showed a good construct validity. The distinct constituent elements were those of the clerkship structure, the amount of tutoring, and the student-tutor relationship. The students' overall satisfaction was high. It was not gender-related, nor did it fall with increasing semester stage. It was mainly determined by the qualitative clerkship and provider factors. The strongest of these was the 'quality of tutoring' whereas the 'quantity of tutoring' was weakest. Considering that the general practitioners were relatively inexperienced as educators, these results were both gratifying and promising, although they indicate a need for further improvement of the competence of the tutoring general practitioners.

Problem-based medical education in general practice: experience from Linköping, Sweden.

Medical services which are better suited to the needs of the community are increasingly demanded, for example by national governments, and depend to a great extent on education of the new generations of doctors. Problem-based learning in general practice at the community level represents a method of providing appropriate education. This paper describes some of the experiences of undergraduate and continuing medical education at the Faculty of Health Sciences, Linköping University, Sweden, which since 1986 have been entirely problem-based. General practice forms the backbone of the curriculum and is its largest subject. Problem-based learning in general practice and quality assurance have much in common. This applies over the spectrum of lifelong education, from the undergraduate curriculum through vocational training to later stages of continuing medical education. Involvement and understanding, a feeling of purpose, sharing and cooperation and a wish for self-improvement are all stimulated by the problem-based method. This approach has helped in the creation of a curriculum with general practice as the largest contributor, with early contact with patients in the community, and with ordinary general practitioners as teachers, tutors and examiners in spite of a relatively poorly developed primary care organization.

Integrated education of health care professionals applied to social medicine in primary health care.

A Regional Health University is planned at the University of Linköping, Sweden. To evaluate new educational principles, a trial project was carried out in which medical and nursing students trained together in a two-week full-time course aimed at patient-oriented clinical social medicine and epidemiological field work in primary health care and involving a high degree of group activity and responsibility. The students' expectations concerning improvement in theoretical and applied knowledge and motivation for co-operation in future work situations were fulfilled. The students also enjoyed the way of working. The programme requires more time in planning and supervision than a traditional one.