Symptoms and signs of colorectal cancer, with differences between proximal and distal colon cancer: a prospective cohort study of diagnostic accuracy in primary care.

BACKGROUND: In an abdominal symptom study in primary care in six European countries, 511 cases of cancer were recorded prospectively among 61,802 patients 16 years and older in Norway, Denmark, Sweden, Netherlands, Belgium and Scotland. Colorectal cancer is one of the main types of cancer associated with abdominal symptoms; hence, an in-depth subgroup analysis of the 94 colorectal cancers was carried out in order to study variation in symptom presentation among cancers in different anatomical locations. METHOD: Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. Follow-up data were provided by the GP after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. Fisher's exact test was used to analyse differences between groups. RESULTS: Almost all symptoms recorded could indicate colorectal cancer. 'Rectal bleeding' had a specificity of 99.4% and a PPV of 4.0%. Faecal occult blood in stool (FOBT) or anaemia may indicate gastrointestinal bleeding: when these symptoms and signs were combined, sensitivity reached 57.5%, with 69.2% for cancer in the distal colon. For proximal colon cancers, none of 18 patients had 'Rectal bleeding' at the initial consultation, but three of the 18 did so at a later consultation. 'Abdominal pain, lower part', 'Constipation' and 'Distended abdomen, bloating' were less specific and also less sensitive than 'Rectal bleeding', and with PPV between 0.7% and 1.9%. CONCLUSIONS: Apart from rectal bleeding, single symptoms did not reach the PPV 3% NICE threshold. However, supplementary information such as a positive FOBT or persistent symptoms may revise the PPV upwards. If a colorectal cancer is suspected by the GP despite few symptoms, the total clinical picture may still reach the NICE PPV threshold of 3% and justify a specific referral.

Problems and challenges in relation to the treatment of patients with multimorbidity: General practitioners' views and attitudes.

OBJECTIVE: To explore views and attitudes among general practitioners (GPs) and researchers in the field of general practice towards problems and challenges related to treatment of patients with multimorbidity. SETTING: A workshop entitled Patients with multimorbidity in general practice held during the Nordic Congress of General Practice in Tampere, Finland, 2013. SUBJECTS: A total of 180 GPs and researchers. DESIGN: Data for this summary report originate from audio-recorded, transcribed verbatim plenary discussions as well as 76 short questionnaires answered by attendees during the workshop. The data were analysed using framework analysis. RESULTS: (i) Complex care pathways and clinical guidelines developed for single diseases were identified as very challenging when handling patients with multimorbidity; (ii) insufficient cooperation between the professionals involved in the care of multimorbid patients underlined the GPs' impression of a fragmented health care system; (iii) GPs found it challenging to establish a good dialogue and prioritize problems with patients within the timeframe of a normal consultation; (iv) the future role of the GP was discussed in relation to diminishing health inequality, and current payment systems were criticized for not matching the treatment patterns of patients with multimorbidity. CONCLUSION: The participants supported the development of a future research strategy to improve the treatment of patients with multimorbidity. Four main areas were identified, which need to be investigated further to improve care for this steadily growing patient group.

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study.

BACKGROUND: Risk factors for hip fracture are well studied because of the negative impact on patients and the community, with mortality in the first year being almost 30% in the elderly. Age, gender and fall risk-increasing drugs, identified by the National Board of Health and Welfare in Sweden, are well known risk factors for hip fracture, but how multimorbidity level affects the risk of hip fracture during use of fall risk-increasing drugs is to our knowledge not as well studied. This study explored the relationship between use of fall risk-increasing drugs in combination with multimorbidity level and risk of hip fracture in an elderly population. METHODS: Data were from Östergötland County, Sweden, and comprised the total population in the county aged 75 years and older during 2006. The odds ratio (OR) for hip fracture during use of fall risk-increasing drugs was calculated by multivariate logistic regression, adjusted for age, gender and individual multimorbidity level. Multimorbidity level was estimated with the Johns Hopkins ACG Case-Mix System and grouped into six Resource Utilization Bands (RUBs 0-5). RESULTS: 2.07% of the study population (N = 38,407) had a hip fracture during 2007. Patients using opioids (OR 1.56, 95% CI 1.34-1.82), dopaminergic agents (OR 1.78, 95% CI 1.24-2.55), anxiolytics (OR 1.31, 95% CI 1.11-1.54), antidepressants (OR 1.66, 95% CI 1.42-1.95) or hypnotics/sedatives (OR 1.31, 95% CI 1.13-1.52) had increased ORs for hip fracture after adjustment for age, gender and multimorbidity level. Vasodilators used in cardiac diseases, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers and renin-angiotensin system inhibitors were not associated with an increased OR for hip fracture after adjustment for age, gender and multimorbidity level. CONCLUSIONS: Use of fall risk-increasing drugs such as opioids, dopaminergic agents, anxiolytics, antidepressants and hypnotics/sedatives increases the risk of hip fracture after adjustment for age, gender and multimorbidity level. Fall risk-increasing drugs, high age, female gender and multimorbidity level, can be used to identify high-risk patients who could benefit from a medication review to reduce the risk of hip fracture.

Can gender difference in prescription drug use be explained by gender-related morbidity?: a study on a Swedish population during 2006.

BACKGROUND: It has been reported that there is a difference in drug prescription between males and females. Even after adjustment for multi-morbidity, females tend to use more prescription drugs compared to males. In this study, we wanted to analyse whether the gender difference in drug treatment could be explained by gender-related morbidity. METHODS: Data was collected on all individuals 20 years and older in the county of Östergötland in Sweden. The Johns Hopkins ACG Case-Mix System was used to calculate individual level of multi-morbidity. A report from the Swedish National Institute of Public Health using the WHO term DALY was the basis for gender-related morbidity. Prescription drugs used to treat diseases that mainly affect females were excluded from the analyses. RESULTS: The odds of having prescription drugs for males, compared to females, increased from 0.45 (95% confidence interval (CI) 0.44-0.46) to 0.82 (95% CI 0.81-0.83) after exclusion of prescription drugs that are used to treat diseases that mainly affect females. CONCLUSION: Gender-related morbidity and the use of anti-conception drugs may explain a large part of the difference in prescription drug use between males and females but still there remains a difference between the genders at 18%. This implicates that it is of importance to take the gender-related morbidity into consideration, and to exclude anti-conception drugs, when performing studies regarding difference in drug use between the genders.

Factors influencing the prescription of drugs of different price levels.

PURPOSE: Socioeconomic factors have been suggested to influence the prescribing of newer and more expensive drugs. In the present study, individual and health care provider factors were studied in relation to the prevalence of differently priced drugs. METHODS: Register data for dispensed drugs were retrieved for 18 486 individuals in a county council in Sweden. The prevalence of dispensed drugs was combined with data for the individual's gender, age, education, income, foreign background, and type of caregiver. For each of the diagnostic groups (chronic obstructive pulmonary disease [COPD], depression, diabetes, and osteoporosis), selected drugs were dichotomized into cost categories, lower and higher price levels. Univariate and multivariate logistic regressions were performed using cost category as the dependent variable and the individual and provider factors as independent variables. RESULTS: In all four diagnostic groups, differences were observed in the prescription of drugs of lower and higher price levels with regard to the different factors studied. Age and gender affected the prescription of drugs of lower and higher price levels more generally, except for gender in the osteoporosis group. Income, education, foreign background, and type of caregiver affected prescribing patterns but in different ways for the different diagnostic groups. CONCLUSIONS: Certain individual and provider factors appear to influence the prescribing of drugs of different price levels. Because the average price for the cheaper drugs versus more costly drugs in each diagnostic group was between 19% and 69%, there is a risk that factors other than medical needs are influencing the choice of drug.

Distance to hospital and socioeconomic status influence secondary health care use.

OBJECTIVE: The aim of this study was to investigate how distance to hospital and socioeconomic status (SES) influence the use of secondary health care (SHC) when taking comorbidity into account. DESIGN AND SETTING: A register-based study in Östergötland County. SUBJECTS: The adult population of Östergötland County. MAIN OUTCOME MEASURES: Odds of SHC use in the population and ates of SHC use by patients were studied after taking into account comorbidity level assigned using the Adjusted Clinical Groups (ACG) Case-Mix System. The baseline for analysis of SES was individuals with the lowest education level (level 1) and the lowest income (1st quartile). RESULTS: The study showed both positive and negative association between SES and use of SHC. The risk of incurring SHC costs was 12% higher for individuals with education level 1. Individuals with income in the 2nd quartile had a 4% higher risk of incurring SHC costs but a 17% lower risk of emergency department visits. Individuals with income in the 4th quartile had 9% lower risk of hospitalization. The risk of using SHC services for the population was not associated with distance to hospital. Patients living over 40 km from hospital and patients with higher SES had lower use of SHC services. CONCLUSIONS: It was found that distance to hospital and SES influence SHC use after adjusting for comorbidity level, age, and gender. These results suggest that GPs and health care managers should pay a higher degree of attention to this when planning primary care services in order to minimize the potentially redundant use of SHC.

Symptoms and signs of urogenital cancer in primary care.

BACKGROUND: Urogenital cancers are common, accounting for approximately 20% of cancer incidence globally. Cancers belonging to the same organ system often present with similar symptoms, making initial management challenging. In this study, 511 cases of cancer were recorded after the date of consultation among 61,802 randomly selected patients presenting in primary care in six European countries: a subgroup analysis of urogenital cancers was carried out in order to study variation in symptom presentation. METHODS: Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. The general practitioner (GP) provided follow-up data after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. RESULTS: The most common symptoms were mainly associated with one or two specific types of cancer: 'Macroscopic haematuria' with bladder or renal cancer (combined sensitivity 28.3%), 'Increased urinary frequency' with bladder (sensitivity 13.3%) or prostatic (sensitivity 32.1%) cancer, or to uterine body (sensitivity 14.3%) cancer, 'Unexpected genital bleeding' with uterine cancer (cervix, sensitivity 20.0%, uterine body, sensitivity 71.4%). 'Distended abdomen, bloating' had sensitivity 62.5% (based on eight cases of ovarian cancer). In ovarian cancer, increased abdominal circumference and a palpable tumour also were important diagnostic elements. Specificity for 'Macroscopic haematuria' was 99.8% (99.7-99.8). PPV > 3% was noted for 'Macroscopic haematuria' and bladder or renal cancer combined, for bladder cancer in male patients. In males aged 55-74, PPV = 7.1% for 'Macroscopic haematuria' and bladder cancer. Abdominal pain was an infrequent symptom in urogenital cancers. CONCLUSIONS: Most types of urogenital cancer present with rather specific symptoms. If the GP considers ovarian cancer, increased abdominal circumference should be actively determined. Several cases were clarified through the GP's clinical examination, or laboratory investigations.

Licit prescription drug use in a Swedish population according to age, gender and socioeconomic status after adjusting for level of multi-morbidity.

BACKGROUND: There is a great variability in licit prescription drug use in the population and among patients. Factors other than purely medical ones have proven to be of importance for the prescribing of licit drugs. For example, individuals with a high age, female gender and low socioeconomic status are more likely to use licit prescription drugs. However, these results have not been adjusted for multi-morbidity level. In this study we investigate the odds of using licit prescription drugs among individuals in the population and the rate of licit prescription drug use among patients depending on gender, age and socioeconomic status after adjustment for multi-morbidity level. METHODS: The study was carried out on the total population aged 20 years or older in Östergötland county with about 400 000 inhabitants in year 2006. The Johns Hopkins ACG Case-mix was used as a proxy for the individual level of multi-morbidity in the population to which we have related the odds ratio for individuals and incidence rate ratio (IRR) for patients of using licit prescription drugs, defined daily doses (DDDs) and total costs of licit prescription drugs after adjusting for age, gender and socioeconomic factors (educational and income level). RESULTS: After adjustment for multi-morbidity level male individuals had less than half the odds of using licit prescription drugs (OR 0.41 (95% CI 0.40-0.42)) compared to female individuals. Among the patients, males had higher total costs (IRR 1.14 (95% CI 1.13-1.15)). Individuals above 80 years had nine times the odds of using licit prescription drugs (OR 9.09 (95% CI 8.33-10.00)) despite adjustment for multi-morbidity. Patients in the highest education and income level had the lowest DDDs (IRR 0.78 (95% CI 0.76-0.80), IRR 0.73 (95% CI 0.71-0.74)) after adjustment for multi-morbidity level. CONCLUSIONS: This paper shows that there is a great variability in licit prescription drug use associated with gender, age and socioeconomic status, which is not dependent on level of multi-morbidity.

GPs' decision-making--perceiving the patient as a person or a disease.

BACKGROUND: The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work. METHODS: A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients. RESULTS: 68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person. CONCLUSIONS: The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.

Setting priorities in primary health care--on whose conditions? A questionnaire study.

BACKGROUND: In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. METHODS: Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. RESULTS: Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. CONCLUSIONS: The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.

Co-morbidity and health care utilisation five years prior to diagnosis for depression. A register-based study in a Swedish population.

BACKGROUND: Depressive disorders have been associated with a number of co-morbidities, and we hypothesized that patients with a depression diagnosis would be heavy users of health care services, not only when first evaluated for depression, but also for preceding years. The aim of this study was to investigate whether increased health care utilisation and co-morbidity could be seen during five years prior to an initial diagnosis of depression. METHODS: We used a longitudinal register-based study design. The setting comprised the general population in the county of Östergötland, south-east Sweden. All 2470 patients who were 20 years or older in 2006 and who received a new diagnosis of depression (F32 according to ICD-10) in 2006, were selected and followed back to the year 2001, five years before their depression diagnosis. A control group was randomly selected among those who were aged 20 years or over in 2006 and who had received no depression diagnosis during the period 2001-2006. RESULTS: Predictors of a depression diagnosis were a high number of physician visits, female gender, age below 60, age above 80 and a low socioeconomic status.Patients who received a diagnosis of depression used twice the amount of health care (e.g. physician visits and hospital days) during the five year period prior to diagnosis compared to the control group. A particularly strong increase in health care utilisation was seen the last year before diagnosis. These findings were supported with a high level of co-morbidity as for example musculoskeletal disorders during the whole five-year period for patients with a depression diagnosis. CONCLUSIONS: Predictors of a depression diagnosis were a high number of physician visits, female gender, age below 60, age above 80 and a low socioeconomic status. To find early signs of depression in the clinical setting and to use a preventive strategy to handle these patients is important.

[How do we want to organize health centres? 838 Swedish general practitioners' attitudes to a personal patient list]. / Så vill vi organisera vårdcentraler.

In Swedish primary care patients are registered at health centres where different professions, such as general practitioners (GPs), nurses, assistant nurses, counsellors, physiotherapists, psychologists and biomedical analysts, work. In an international comparison personal physician continuity is low in Sweden. Several governmental inquiries propose that patients register with one GP or a care team. Do Swedish GPs want a personal patient list and how should this best be realised? A web survey was distributed to the members of the Swedish Union of General Practitioners and was answered by 838 GPs. 91% wanted a personal patient list if reasonably sized, the option to limit their list, and shared responsibility for the list with colleagues or a team. To be able to plan the working day themselves and designated time for collegial dialogue was considered essential for increased efficiency, well-being and reduced risk of patients harm due to their doctor's knowledge gaps.

[Significant over- and misuse of PPIs]. / Stor överförskrivning och ökat bruk av protonpumpshämmare.

PPIs (Proton-pump inhibitors) offers the best treatment for acid related diseases. The predominant indications for PPI prescription are: GERD eradication of H. pylori-infection in combination with antibiotics H. pylori-negative peptic ulcer  healing of and prophylaxis against NSAID/COXIB--induced gastroduodenal lesions  acid hypersecretory states such as Zollinger-Ellisons syndrome. The market for PPIs continues to expand in most countries. A significant over- and misuse of PPIs prevails in hospital care as well as in general practice. The predominant reasons for and mechanisms behind the over- and misuse of PPIs are well recognised. The most important consequences of this overprescription of PPIs are increasing medical costs and risk for long-term adverse side effects. Continued education and dedicated information are key factors to guide physicians, medical personnel and patients to adopt to generally accepted principles for and balanced use of PPIs.

Priority setting in primary health care - dilemmas and opportunities: a focus group study.

BACKGROUND: Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria. METHODS: Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work. RESULTS: The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patient's), 2) timeframe (now or later), and 3) evidence level (group or individual). CONCLUSIONS: The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.

Survival, hazard function for a new event, and healthcare utilization among stroke patients over 65 years old.

BACKGROUND AND PURPOSE: The natural history of stroke is still incompletely understood. The aim of this study was to present detailed data on survival, recurrence, and all types of healthcare utilization before and after a stroke event in patients with stroke. METHODS: Three hundred ninety stroke survivors constituted the study population. Information on survival data during 5 years of follow-up, all hospital admissions since 1971, all outpatient and primary care consultations, and all municipal social service support during the year before and after the index stroke admission and patient interviews 1 week after discharge were obtained. RESULTS: The risk of death or a new stroke was high in the early phase after admission but then decreased rapidly during the next few months. Mortality during the first 5 years was influenced by age and functional ability, whereas the risk of stroke recurrence was influenced by number of previous strokes, hypertension diagnosis, and sex. On a day-by-day basis, 35% were dependent on municipal support before and 65% after the stroke. The corresponding proportions in outpatient care were 6% and 10%, and for hospital inpatient care 1% to 2% and 2% to 3%. Of the health care provided, nursing care dominated. CONCLUSIONS: The risk of dying or having a new stroke event decreased sharply during the early postmorbid phase. Healthcare utilization increased after discharge but was still moderate on a day-by-day basis, except for municipal social service support, which was substantial.

Primary care patients' attitudes to priority setting in Sweden.

OBJECTIVE: To analyse attitudes to priority setting among patients in Swedish primary healthcare. DESIGN: A questionnaire was given to patients comprising statements on attitudes towards prioritizing, on the role of politicians and healthcare staff in prioritizing, and on patient satisfaction with the outcome of their contact with primary healthcare (PHC). SETTINGS: Four healthcare centres in Sweden, chosen through purposive sampling. PARTICIPANTS: All the patients in contact with the health centres during a two-week period in 2004 (2517 questionnaires, 72% returned). MAIN OUTCOMES: Patient attitudes to priority setting and satisfaction with the outcome of their contact. RESULTS: More than 75% of the patients agreed with statements like "Public health services should always provide the best possible care, irrespective of cost". Almost three-quarters of the patients wanted healthcare staff rather than politicians to make decisions on priority setting. Younger patients and males were more positive towards priority setting and they also had a more positive view of the role of politicians. Less than 10% of the patients experienced some kind of economic rationing but the majority of these patients were satisfied with their contact with primary care. CONCLUSIONS: Primary care patient opinions concerning priority setting are a challenge for both politicians and GPs. The fact that males and younger patients are less negative to prioritizing may pave the way for a future dialogue between politicians and the general public.

[The doctor's personal knowledge of patients saved resources and reduced mortality in an American study. How should a care system in Sweden be designed to get similar effects?] / Läkares personkännedom sparade liv och resurser - Personlig kontinuitet viktig i ett nytt svenskt vårdsystem.

In a recent study of more than 500 000 hospitalisations, doctors with personal knowledge of their patients used less resources, more often discharged them to their own home and their patients had lower mortality. Furthermore, other studies have shown that personal continuity increases patient satisfaction as well as compliance and reduces costs for medical services and visits to emergency services. In a Swedish context we discuss how a combination of organizational factors and personal listing on physicians and continuity of care favour personal knowledge between physician and patient and contribute to a primary care that works well for both the frail elderly and the healthy young.

[Personal physician continuity in primary care associated with fewer emergency room visits]. / Hög personlig läkar­kontinuitet i primärvård förenad med färre besök på akutmottagning - En populationsbaserad studie i Jönköpings sjukvårdsregion.

Overloading of the emergency departments in hospitals is, in Sweden, a common problem that is often blamed on lack of access to primary care.  We have conducted a cross-sectional study comprising more than 40% of the 347 837  inhabitants of Region Jönköping with access to complete individual data on healthcare consumption, personal doctor continuity, socio-economics, and accessibility data for all of the region's health centres. Individuals with high personal continuity at their own health centre had significantly fewer emergency room visits compared to those with the lowest continuity: for younger adults 55% and for elderly 34% fewer emergency room visits. Access to doctor consultations or to counselling nurses in primary care was not associated with a lower number of emergency room visits. Our results show the importance of personal doctor continuity also for the group of younger adults.

[The paradigm shift for peptic ulcer disease]. / Magsårssjukdomens paradigmskiften ­ från högspecialiserad vårdorganisation till egenvård.

Knowledge development and paradigm shift for peptic ulcer disease is described over a fifty-year period using four levels of knowledge that place demands on the healthcare organization. When medical knowledge reached a healing level, continuity became subordinate. However, accessibility to treatment became more important. An important task for future healthcare will be to define and create broader knowledge structures. Efficiency losses can occur when control instruments apply to medical problems at low levels of knowledge which are not mature for this.