Suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. A mixed method study of GPs' experiences.

OBJECTIVE: To explore Norwegian GPs' experiences with and perceived suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. DESIGN: We used a mixed methods research design. An online survey with 301 respondents was combined with qualitative interviews with ten GPs. SETTING: Norwegian general practice. RESULTS: Most GPs agreed it was difficult to assess a patient's ability to work without physical attendance for a first-time certification in remote consultations. However, extending a certification was considered less problematic. If physical examinations were required, the GPs would ask the patient to come to the office. The most suitable diagnoses for remote certification were respiratory infections and COVID-19-related diagnoses, as well as known chronic and long-term diseases. The GPs emphasized the importance of knowing both the patient and the medical problem. The GP-patient relationship could be affected by remote consultations, and there were mixed views on the impact. Many GPs found it easier to deny a request for a sickness certification in remote consultations. The GPs expressed concern about the societal costs and an increased number of certifications if remote consultations were too easily accessible. The study was conducted during the COVID-19 pandemic, and the findings should be interpreted in that context. CONCLUSIONS: Our study shows that issuing sickness certifications in remote consultations were viewed to be suitable for COVID-19 related problems, for patients the GP has met before, for the follow-up of known medical problems, and the extension of sickness certifications. Not meeting the patient face-to-face may affect the GP-patient relationship as well as make the GPs' dual role more challenging.

KEY POINTSThe GPs perceived issuing sickness certifications in remote consultations as suitable when patient and health problem are known, and when the certification is an extension.Issuing sickness certifications in remote consultations can both harm and strengthen the GP-patient relationship.The GPs were aware of their social responsibility and were concerned that issuing sickness certificates in remote consultations can change their sick-listing practice.

Promoters and inhibitors for quality improvement work in general practice: a qualitative analysis of 2715 free-text replies.

BACKGROUND: Continuous quality improvement (QI) is necessary to develop and maintain high quality general practice services. General Practitioners (GPs') motivation is an important factor in the success of QI initiatives. We aimed to identify factors that impair or promote GPs' motivation for and participation in QI projects. MATERIAL AND METHODS: We analysed 2715 free-text survey replies from 2208 GPs participating in the QI intervention 'Correct Antibiotic Use in the Municipalities'. GPs received reports detailing their individual antibiotic prescriptions for a defined period, including a comparison with a corresponding previous period. The content was discussed in peer group meetings. Each GP individually answered work-sheets on three separate time-points, including free-text questions regarding their experiences with the intervention. Data were analysed using inductive thematic analysis. RESULTS: We identified three overarching themes in the GPs' thoughts on inhibitors and promoters of QI work: (1) the desire to be a better doctor, (2) structural and organisational factors as both promoters and inhibitors and (3) properties related to different QI measures. The provision of individual prescription data was generally very well received. The participants stressed the importance of a safe peer group, like the Continuous Medical Education group, for discussions, and also underlined the motivating effect of working together with their practice as a whole. Lack of time was essential in GPs' motivation for QI work. QI tools should be easily available and directly relevant in clinical work. CONCLUSION: The desire to be good doctor is a strong motivator for improvement, but the framework for general practice must allow for QI initiatives. QI tools must be easily obtainable and relevant for practice. Better tools for obtaining clinical data for individual GPs are needed.

Improving drug prescription in general practice using a novel quality improvement model.

INTRODUCTION: Quality improvement (QI) clusters have been established in many countries to improve healthcare using the Breakthrough Series' collaboration model. We investigated the effect of a novel QI approach based on this model of performed medication reviews and drug prescription in a Norwegian municipality. METHODS: All 27 General Practitioners (GPs) in a mid-size Norwegian municipality were invited to join the intervention, consisting of three peer group meetings during a period of 7-8 months. Participants learned practical QI skills by planning and following up QI projects within drug prescription practice. Evaluation forms were used to assess participants' self-rated improvement, reported medication review reimbursement codes (MRRCs) were used as a process measure, and defined daily doses (DDDs) of potentially inappropriate drugs (PIDs) dispensed to patients aged 65 years or older were used as outcome measures. RESULTS: Of the invited GPs, 25 completed the intervention. Of these, 76% self-reported improved QI skills and 67% reported improved drug prescription practices. Statistical process control revealed a non-random increase in the number of MRRCs lasting at least 7 months after intervention end. Compared with national average data, we found a significant reduction in dispensed DDDs in the intervention municipality for benzodiazepine derivates, benzodiazepine-related drugs, drugs for urinary frequency and incontinence and non-steroid anti-inflammatory and antirheumatic medications. CONCLUSION: Intervention increased the frequency of medication reviews, resulting in fewer potentially inappropriate prescriptions. Moreover, there was self-reported improvement in QI skills in general, which may affect other practice areas as well. Intervention required relatively little absence from clinical practice compared with more traditional QI interventions and could, therefore, be easier to implement.KEY POINTThe current study investigated to what extent a novel model based on the Breakthrough Series' collaborative model affects GP improvement skills in general practice and changes their drug prescription.KEY FINDINGSMost participants reported better improvement skills and improved prescription practice.The number of dispensed potentially inappropriate drugs decreased significantly in the intervention municipality compared with the national average.The model seemed to lead to sustained changes after the end of the intervention.

How well did Norwegian general practice prepare to address the COVID-19 pandemic?

OBJECTIVES: We aimed to describe the quality improvement measures made by Norwegian general practice (GP) during the COVID-19 pandemic, evaluate the differences in quality improvements based on region and assess the combinations of actions taken. DESIGN: Descriptive study. SETTING: Participants were included after taking part in an online quality improvement COVID-19 course for Norwegian GPs in April 2020. The participants reported whether internal and external measures were in place: COVID-19 sign on entrance, updated home page, access to video consultations and/or electronic written consultations, home office solutions, separate working teams, preparedness for home visits, isolation rooms, knowledge on decontamination, access to sufficient supplies of personal protective equipment (PPE) and COVID-19 clinics. PARTICIPANTS: One hundred GP offices were included. The mean number of general practitioners per office was 5.63. RESULTS: More than 80% of practices had the following preparedness measures: COVID-19 sign on entrance, updated home page, COVID-19 clinic in the municipality, video and written electronic consultations, knowledge on how to use PPE, and home office solutions for general practitioners. Less than 50% had both PPE and knowledge of decontamination. Lack of PPE was reported by 37%, and 34% reported neither sufficient PPE nor a dedicated COVID-19 clinic. 15% reported that they had an isolation room, but not enough PPE. There were no geographical differences. CONCLUSIONS: Norwegian GPs in this study implemented many quality improvements to adapt to the COVID-19 pandemic. Overall, the largest potentials for improvement seem to be securing sufficient supply of PPE and establishing an isolation room at their practices.

Associations between night work and BMI, alcohol, smoking, caffeine and exercise--a cross-sectional study.

BACKGROUND: Shift work is associated with negative health effects. Increased prevalence of several cardiovascular risk factors among shift workers/night workers compared with day workers have been shown resulting in increased risk of cardiovascular events among shift workers and night workers. Previous studies have taken a dichotomous approach to the comparison between day and night workers. The present study uses a continuous approach and provides such a new perspective to the negative effects of night work load as a possible risk factor for undesirable health effects. METHODS: This cross sectional study (The SUrvey of Shift work, Sleep and Health (SUSSH)) uses data collected from December 2008 to March 2009. The study population consists of Norwegian nurses. The study collected information about demographic and lifestyle factors: Body Mass Index (BMI), smoking habits, alcohol consumption, caffeine consumption and exercise habits. The lifestyle parameters were evaluated using multiple hierarchical regression and binary logistic regression. Number of night shifts worked last year (NNL) was used as operationalization of night work load. Adjustment for possible confounders were made. Obesity was defined as BMI > 30. Alcohol Consumption was evaluated using the short form of the Alcohol Use Disorders Identification Test Consumption (AUDIT-C). Data were analyzed using SPSS version 22. RESULTS: We had data from 2059 nurses. NNL was significantly and positively associated with BMI, both when evaluated against BMI as a continuous parameter (Beta = .055, p < .05), and against obesity (OR = 1.01, 95 % CI = 1.00-1.01). The AUDIT-C score was significantly and positively associated with hours worked per week (OR = 1.03, 95 % CI = 1.01-1.05). CONCLUSIONS: We found a positive significant association between night work load and BMI. This suggests that workers with a heavy night work load might need special attention and frequent health checks due to higher risk of undesirable health effects.

Associations between night work and anxiety, depression, insomnia, sleepiness and fatigue in a sample of Norwegian nurses.

BACKGROUND: Night work has been reported to be associated with various mental disorders and complaints. We investigated relationships between night work and anxiety, depression, insomnia, sleepiness and fatigue among Norwegian nurses. METHODS: The study design was cross-sectional, based on validated self-assessment questionnaires. A total of 5400 nurses were invited to participate in a health survey through the Norwegian Nurses' Organization, whereof 2059 agreed to participate (response rate 38.1%). Nurses completed a questionnaire containing items on demographic variables (gender, age, years of experience as a nurse, marital status and children living at home), work schedule, anxiety/depression (Hospital Anxiety and Depression Scale), insomnia (Bergen Insomnia Scale), sleepiness (Epworth Sleepiness Scale) and fatigue (Fatigue Questionnaire). They were also asked to report number of night shifts in the last 12 months (NNL). First, the parameters were compared between nurses i) never working nights, ii) currently working nights, and iii) previously working nights, using binary logistic regression analyses. Subsequently, a cumulative approach was used investigating associations between NNL with the continuous scores on the same dependent variables in hierarchical multiple regression analyses. RESULTS: Nurses with current night work were more often categorized with insomnia (OR = 1.48, 95% CI = 1.10-1.99) and chronic fatigue (OR = 1.78, 95% CI = 1.02-3.11) than nurses with no night work experience. Previous night work experience was also associated with insomnia (OR = 1.45, 95% CI = 1.04-2.02). NNL was not associated with any parameters in the regression analyses. CONCLUSION: Nurses with current or previous night work reported more insomnia than nurses without any night work experience, and current night work was also associated with chronic fatigue. Anxiety, depression and sleepiness were not associated with night work, and no cumulative effect of night shifts during the last 12 months was found on any parameters.

Increased health risk in subjects with high self-reported seasonality.

BACKGROUND: Seasonal variations in mood and behaviour, termed seasonality, are commonly reported in the general population. As a part of a large cross-sectional health survey in Hordaland, Norway, we investigated the relationship between seasonality, objective health measurements and health behaviours. METHODOLOGY/PRINCIPAL FINDINGS: A total of 11,545 subjects between 40-44 years old participated, completing the Global Seasonality Score, measuring seasonality. Waist/hip circumference, BMI and blood pressure were measured, and blood samples were analyzed for total cholesterol, HDL cholesterol, triglycerides and glucose. Subjects also completed a questionnaire on miscellaneous health behaviours (exercise, smoking, alcohol consumption). Hierarchical linear regression analyses were used to investigate associations between seasonality and objective health measurements, while binary logistic regression was used for analysing associations between seasonality and health behaviours. Analyses were adjusted for sociodemographic factors, month of questionnaire completion and sleep duration. Seasonality was positively associated with high waist-hip-ratio, BMI, triglyceride levels, and in men high total cholesterol. Seasonality was negatively associated with HDL cholesterol. In women seasonality was negatively associated with prevalence of exercise and positively associated with daily cigarette smoking. CONCLUSIONS/SIGNIFICANCE: High seasonality was associated with objective health risk factors and in women also with health behaviours associated with an increased risk for cardiovascular disease.

[Symptom patterns in chronic sleep disorders]. / Symptommønstre ved kroniske søvnsykdommer.

BACKGROUND: Sleep disorders are classified into six main categories: insomnias, circadian rhythm disorders, sleep-related movement disorders, sleep-related breathing disorders, hypersomnias and parasomnias. The aim of this article is to shed light on differences between these categories with respect to symptom patterns. MATERIAL AND METHODS: The main sources of information are the diagnosis manual published by the American Academy of Sleep Medicine in 2005 and papers identified through non-systematic searches in Pubmed. RESULTS: Long sleep onset latency is most common in patients with insomnia, delayed sleep phase syndrome and restless legs while nightly awakenings are most common in patients with insomnia, restless legs and the sleep apnoea syndrome. Excessive daytime sleepiness is most pronounced in patients with hypersomnia, sleep apnoea syndrome and delayed sleep phase syndrome, whereas patients with insomnia rarely have this problem. Fatigue is a common feature of all sleep disorders, especially insomnia. The diagnosis of insomnia, circadian rhythm disturbances, restless legs and most parasomnias is mainly based on anamnestic data. Objective sleep recordings are necessary to diagnose sleep apnoea syndrome, hypersomnia and periodic leg movement during sleep. INTERPRETATION: The six sleep disorder categories differ substantially with respect to symptom patterns. Sleep disorders can often be distinguished from each other by use of anamnestic data without resorting to further assessment, but objective sleep recordings are needed for accurate diagnosis of some patients.

[Insomnia]. / Insomni.

BACKGROUND: Insomnia is the most prevalent sleep disorder. Chronic insomnia affects about 10% of the adult population. MATERIAL AND METHOD: This review is based on the authors' experience, as well as articles identified through non-systematic searches in Pubmed. RESULTS: Insomnia is characterized by problems with falling asleep, difficulty maintaining sleep, waking up to early and/or poor sleep quality. The diagnosis implies that the problem causes some type of daytime impairment. Insomnia is divided into several different subtypes. Recent studies indicate that insomnia is an independent risk factor for sick leave and disability pension. Non-pharmacological treatment, i.e. stimulus control and sleep restriction yields better outcome than hypnotics, particularly on a long-term basis. INTERPRETATION: Insomnia is highly prevalent, and non-pharmacological therapy is the best documented treatment.

Self-reported seasonality is associated with complaints of sleep problems and deficient sleep duration: the Hordaland Health Study.

Change in sleep duration dependent on time of year is a central characteristic of seasonal affective disorder (SAD). In a community health survey, we analysed associations between seasonality, subjective sleep problems and sleep duration. Totally, 8860 subjects (3531 men and 5329 women) aged between 40 and 44 years were included in the study. Seasonal changes in mood and behaviour were measured by the Global Seasonality Score (GSS) questionnaire, and subjects were grouped in high (GSS > or = 11), moderate (GSS 8-10) or low (GSS < 8) seasonality groups. Sleep symptomatology was assessed using a modified version of the Karolinska Sleep Questionnaire. Significant sleep duration deficiency was defined as the difference between subjective sleep need and sleep duration of at least 1 h. Sleep problems suggesting insomnia as well as increased daytime sleepiness were more prevalent in the high/moderate seasonality groups compared with the low seasonality group. Seasonality was furthermore associated with shorter sleep duration and increased subjective sleep need. Significant sleep duration deficiency was more prevalent in subjects reporting high (men 20% and women 21%) and moderate (men 13% and women 19%) seasonality than subjects reporting low (men 10% and women 14%) seasonality. In conclusion, we found seasonal changes in mood and behaviour to be associated with several sleep-related complaints. Sleep duration deficiency increased with increasing seasonality, mainly due to increasing subjective sleep need.

Seasonality is associated with anxiety and depression: the Hordaland health study.

BACKGROUND: The purpose of this study was to assess how seasonal changes in mood and behaviour were associated with depression and anxiety symptoms in a sample from a general population, and to investigate how prevalence figures were affected by month of questionnaire completion. METHODS: The target population included all individuals in the Hordaland county (Norway) born 1953-57 (N=29,400). In total, 8598 men (57% response rate) and 9983 women (70% response rate) attended the screening station. Half of the men (randomly chosen) and all of the women were offered a questionnaire to fill in with items on seasonality. This was measured using the Global Seasonality Score (GSS), a central component of the Seasonal Pattern Assessment Questionnaire (SPAQ). The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression. Both questionnaires were completed by 2980 men (68.9%) and 8074 women (80.9%). RESULTS: Seasonality was positively associated with levels of both anxiety and depression regardless of the season the interview took place. In subjects with a low/moderate degree of seasonality there were modestly higher levels of depressive symptoms during November through March than the other months. LIMITATIONS: We had a substantial number of non-responders. CONCLUSIONS: Our results raise the possibility of seasonality being a separate dimensional trait associated with both anxiety and depression.

Randomized placebo-controlled field study of the effects of bright light and melatonin in adaptation to night work.

OBJECTIVES: This study evaluated the effects of bright light and melatonin on adaptation to night work on an oil rig in the North Sea. METHODS: Seventeen persons working a schedule of 2 weeks on a 12-hour shift, with the first week on night shift and the second week on day shift (ie, the swing shift schedule) participated. In a randomized controlled crossover design, the shift workers received a placebo, melatonin (3 mg, 1 hour before bedtime), or bright light (30-minute exposure, individually scheduled) during the first 4 days on the night shift and during the first 4 days on the day shift. Subjective and objective measures of sleepiness (Karolinska Sleepiness Scale and a simple serial reaction-time test) and sleep (diary and actigraphy) were recorded. RESULTS: Subjective measures indicated that melatonin modestly reduced sleepiness at work during the day shift and increased sleep by 15-20 minutes per day. Bright light gave values in between those of melatonin and the placebo, but with few significant results. According to the objective measures, bright light improved sleep to a minor degree during the night shift. Hardly any side-effects were reported. CONCLUSIONS: Melatonin and bright light modestly improved sleep and sleepiness in this field study. In well-controlled simulated nightwork studies, both melatonin and bright light are more effective in alleviating sleepiness and sleep problems. The less effect in this field study may be due to competing or conflicting factors present in real life or to an inoptimal timing and duration of the treatments.

The association between sleep duration, body mass index and metabolic measures in the Hordaland Health Study.

Several studies show that short self-reported sleep duration is associated with elevated body mass index (BMI). Short sleep duration may change appetite hormones, but whether this also influences metabolic measures like cholesterol and triglycerides is less clear. Furthermore, obesity is linked to increases in blood pressure, and recently, short sleep duration has been shown to be an independent risk factor for hypertension. This is a population-based cross-sectional study (The Hordaland Health Study). A subgroup of 8860 subjects, aged 40-45 years, answered a sleep questionnaire. Body weight, height and blood pressure were measured, and non-fasting blood samples were collected and analyzed for total cholesterol, HDL-cholesterol and triglycerides. Sleep duration was divided into the following subgroups: < 5, 5-5.99, 6-6.99, 7-7.99, 8-8.99 and > or = 9 h. The results show that short sleep duration was associated with elevated BMI and increased prevalence of obesity. Similar to BMI, levels of cholesterol, triglycerides, systolic and diastolic blood pressure were higher in subjects with short sleep duration. This co-variation seemed to be attributed to variables like gender, smoking and BMI. In conclusion, our study confirms a clear association between short sleep duration and elevated BMI and obesity. Furthermore, levels of total cholesterol, HDL-cholesterol, triglycerides and blood pressure were associated with sleep duration.

Subjective and objective measures of adaptation and readaptation to night work on an oil rig in the North Sea.

STUDY OBJECTIVES: To study the adaptation and readaptation processes to 1 week of night work (6:30 PM to 6:30 AM) followed by 1 week of day work (6:30 AM to 6:30 PM). DESIGN: Part of a randomized, placebo-controlled, crossover field study. Here, data from the placebo arm are presented. SETTING: Oil rig in the North Sea. Work schedule: 2 weeks on a 12-hour shift, with the first week on the night shift and the second week on the day shift. PARTICIPANTS: Subjects complaining about problems with adjusting to shift work. Seventeen workers completed the study. INTERVENTIONS: N/A. MEASUREMENTS: Subjective and objective measures of sleepiness (Karolinska Sleepiness Scale and simple serial reaction time test) and sleep (diary and actigraphy). RESULTS: Both subjective and objective measures improved gradually during night work. The return to day work after 1 week on the night shift led to a clear increase in subjective sleepiness and worsening of sleep parameters. During the week on the day shift, sleepiness and sleep gradually improved, similar to the improvement seen during night work. The workers indicated that the day shift was worse than the night shift on some of the measures, e.g., sleep length was significantly longer during the night-shift period. CONCLUSIONS: This is one of few studies showing how shift workers in a real-life setting adjust to night work. Both subjective and objective sleepiness and subjective sleep improved across days. The effects were especially pronounced for the subjective data.

Seasonal variations in mood and behaviour associated with gender, annual income and education: the Hordaland Health Study.

OBJECTIVE: To explore the relationship between demographic factors and seasonal changes in mood and behaviour. METHOD: A health survey was conducted among 40-45 year old inhabitants in Hordaland County, Norway. The Global Seasonality Score, investigating seasonal symptoms, was given to 4299 men and 9983 women. Response rates among those receiving the questionnaire were 79.8% for men (n = 3432) and 81.2% for women (n = 8223). RESULTS: High seasonality was reported by 18.4% of men and 22.2% of women. Female gender, low educational level, high level of affective symptomatology and low household income correlated with high seasonality. Among men, being single was also a determinant factor for high seasonality. Reported seasonality also depended on which month the questionnaire was filled in. CONCLUSIONS: In this study, high seasonality was most prevalent among females, being single, having a low annual income and a low education level. The latter two findings are different from expectations which could be drawn from previous studies suggesting an opposite association.

Sleep disturbances in adolescents and young adults with autism and Asperger syndrome.

Sleep problems are commonly reported in children with autistic disorders. Most studies are based on sleep questionnaires and sleep diaries, but polysomnographic and actigraphic data have also been used. In this study we investigated sleep in older individuals (aged 15-25 years) with autism and Asperger syndrome, using sleep questionnaires, sleep diaries and actigraphy. Although the sleep questionnaires completed by parents and caretakers revealed only a moderate degree of sleep problems, greater sleep disturbance was recorded with actigraphy. Using the latter method, low sleep efficiency (below 85 percent) or long sleep latency (more than 30 minutes) were found in 80 percent of the individuals. There was no early morning awakening, contrary to some earlier reports. This study suggests that even though subjective complaints of sleep disturbances are less common in adolescents and young adults with autism, this may be due to an adaptation process rather than an actual reduction in sleep disturbances.