Use of electronic patient data overview with alerts in primary care increases prescribing of lipid-lowering medications in patients with type 2 diabetes.

AIMS/HYPOTHESIS: We aimed to assess whether general practices (GPs) using an electronic disease management program (DMP) with population overviews, including alerts when patients failed to receive guideline-recommended prescription medications, increased prescriptions of lipid-lowering drugs for patients with type 2 diabetes with no history of lipid-lowering treatment. METHODS: This observational study included 165 GPs that reached a high level of use of the DMP in 2012 and a control group of 135 GPs who reached a high level of use in 2013 and, hence, who were less exposed to the DMP throughout 2012. A binary measure for having been prescribed and filled lipid-lowering drugs at any time within a 12-month exposure period was derived for all patients with type 2 diabetes who did not receive a prescription for lipid-lowering drugs in the baseline year prior to the study period (i.e. 2011). Results were derived using ORs from multivariate logistic regression analyses. Subgroup stratification based on age, sex, diabetes duration, deprivation status and Charlson Comorbidity Index (CCI) score was conducted and assessed. Placebo tests were carried out to assess bias from selection to treatment. RESULTS: Patients who did not receive a prescription of lipid-lowering drugs in the year prior to being listed with GPs that used the DMP had statistically significant greater odds of receiving a prescription of lipid-lowering medications when compared with individuals who attended control GPs (OR 1.23 [95% CI 1.09, 1.38]). When the analysis period was shifted back by 2 years, no significant differences in lipid-lowering drug prescription between the two groups were found to occur, which indicates that these results were not driven by selection bias. Subgroup analyses showed that the increase in lipid-lowering drug prescriptions was primarily driven by changes among male participants (OR 1.32 [95% CI 1.12, 1.54]), patients aged 60-70 years (OR 1.40 [95% CI 1.13, 1.74]), patients with a diabetes duration of ≤5 years (OR 1.33 [95% CI 1.13, 1.56]), non-deprived patients (OR 1.25 [95% CI 1.08, 1.45]) and patients without comorbidities (CCI score = 0; OR 1.27 [95% CI 1.11, 1.45]). CONCLUSIONS/INTERPRETATION: Access to population overviews using a DMP with alerts of clinical performance measures with regard to adhering to guideline-recommended prescription of medications can increase GP prescriptions of lipid-lowering drugs.

Involving practice nurse and other assistant clinical staff members in the management of low back pain: A qualitative interview study from Danish general practice.

OBJECTIVES: Involving practice nurse and other assistant clinical staff members in providing information and education to patients with low back pain at follow-up appointments may release more time and improve care in general practice. However, this requires a shift in the division of tasks, and general practitioners' barriers and facilitators for this are currently unknown. The objectives were to explore general practitioners' experiences and perceptions of including assistant clinical staff members in the management of low back pain. METHODS: This is a semi-structured interview study in Danish general practice. General practitioners with a variation in demographics and experience with task-delegation to clinical staff were recruited for in-depth interviews. We used a phenomenological approach to guide the data collection and the analysis in order to gain insight into the subjective experiences of the general practitioners and to understand the phenomenon of 'delegating tasks to practice staff' from the perspective of the general practitioners' lifeworld. Analysis was conducted using an inductive descriptive method. The sample size was guided by information power. RESULTS: We conducted five interviews with general practitioners. All general practitioners had experience with task delegation, but there was a variation in which tasks the general practitioners delegated and to which types of clinical staff members. The following themes were derived from the analysis: general practice organisation, delegating to clinical staff members, doctor-patient relationship, exercise instruction, clinical pathway for patients and external support. CONCLUSION: General practitioners consider patients with low back pain to be a heterogeneous group with a variety of treatment needs and a patient group without any predetermined content or frequency of consultations; this can be a barrier for delegating these patients to clinical staff members.

Why do general practitioners not refer patients to behaviour-change programmes after preventive health checks? A mixed-method study.

BACKGROUND: This study was embedded in the Check-In randomised controlled trial that investigated the effectiveness of general practice-based preventive health checks on adverse health behaviour and early detection of non-communicable diseases offered to individuals with low socioeconomic positions. Despite successful recruitment of patients, the intervention had no effect. One reason for the lack of effectiveness could be low rates of referral to behaviour-change programmes in the municipality, resulting in a low dose of the intervention delivered. The aim of this study is to examine the referral pattern of the general practitioners and potential barriers to referring eligible patients to these behaviour-change programmes. METHODS: A mixed-method design was used, including patients' questionnaires, recording sheet from the health checks and semi-structured qualitative interviews with general practitioners. All data used in the study were collected during the time of the intervention. Logistic regressions were used to estimate odds ratios for being eligible and for receiving referrals. The qualitative empirical material was analysed thematically. Emerging themes were grouped, discussed and the material was re-read. The themes were reviewed alongside the analysis of the quantitative material to refine and discuss the themes. RESULTS: Of the 364 patients, who attended the health check, 165 (45%) were marked as eligible for a referral to behaviour-change programme by their general practitioner and of these, 90 (55%) received referrals. Daily smoking (OR = 3.22; 95% CI:2.01-5.17), high-risk alcohol consumption (OR = 2.66; 95% CI:1.38-5.12), obesity (OR = 2.89; 95% CI:1.61-5.16) and poor lung function (OR = 2.05; 95% CI:1.14-3.70) were all significantly associated with being eligible, but not with receiving referral. Four themes emerged as the main barriers to referring patients to behaviour-change programmes: 1) general practitioners' responsibility and ownership for their patients, 2) balancing information and accepting a rejection, 3) assessment of the right time for behavioural change and 4) general practitioners' attitudes towards behaviour-change programmes in the municipality. CONCLUSION: We identified important barriers among the general practitioners which influenced whether the patients received referrals to behaviour-change programmes in the municipality and thereby influenced the dose of intervention delivered in Check-In. The findings suggest that an effort is needed to assist the collaboration between general practices and the municipalities' primary preventive services. TRIAL REGISTRATION: Clinical Trials NCT01979107 ; October 25, 2013.

A conceptual framework for increasing clinical staff member involvement in general practice: a proposed strategy to improve the management of low back pain.

BACKGROUND: Low back pain affects about 80% of all adults, many of whom consult general practice. Providing management can be challenging, in part due to the scarcity of effective treatment methods. There is broad consensus in international clinical practice guidelines to provide patients with information about the nature of their pain and recommend them to stay active despite discomfort. Delivering this information is time-demanding and challenged by the limited available resources in general practice in many countries. Furthermore, general practice settings are highly variable in size and in their composition of clinical staff members - which presents difficulties, but also opportunities for developing alternative approaches to clinical management. Expanding the patient consultation time by involving clinical staff members (aside from the general practitioner) has been found feasible for other conditions. We propose that this approach is applied for non-specific low back pain. Consequently, we suggest the involvement of clinical staff members as part of a new strategy for managing low back pain in general practice. MAIN TEXT: Multifaceted implementation strategies have the potential to effectively enable change in the clinical management of patients with low back pain in general practice if they are based on theory and are tailored to stake holders. Inspired by the Medical Research Council's guidance for complex interventions and the ChiPP (Change in professional performance) statement, we suggest applying the following two policy categories: organizational change (environmental/social planning) and service provision. This will involve attention to environmental restructuring, modelling, enabling, education, training, persuasion, and incentivising of general practices, with an over-arching strategy of involving clinical staff members in the management of low back pain. CONCLUSION: This is a pre-clinical proposal of a multifaceted strategy to support the delivery of evidence-based treatment for patients with low back pain in general practice. As an original idea, we suggest it would be feasible to involve clinical staff members in the delivery of information and advice to patients, whilst the general practitioner remains responsible for diagnostic decision-making.

Quality of life in children with otitis media--a cohort study.

BACKGROUND: Studies about health-related quality of life (HRQOL) in children with otitis media have primarily focused on short-term effects of the disease, and how treatment with insertion of ventilation tubes (VTs) affects the HRQOL. More knowledge is needed about how long-term HRQOL is associated with different factors like insertion of VT and use of antibiotics. OBJECTIVE: We aimed to analyse HRQOL in children with otitis media 1 year after inclusion and to what extent insertion of VT, use of antibiotics, diagnoses, symptoms in the children, day-care attention, parental absence from work and parental smoking were associated with the long-term HRQOL in children with otitis media. METHODS: A cohort study including 397 children was carried out. The children were followed for 13 months, and symptoms, HRQOL and so on were identified by means of questionnaires. RESULTS: HRQOL in children with otitis media was significantly improved after 13 months. The improvement of HRQOL was significantly lower for children with sleep problems compared with children without sleep problems. The improvement in HRQOL was significantly lower in children whose parents had been absent from work during the preceding 3 months due to the child' s otitis media compared with children with parents not being absent from their work. There were no statistically significant differences in the improvement of HRQOL in children who had received a VT during the follow-up period compared with children without a VT. CONCLUSION: HRQOL in children with otitis media was significantly improved after 13 months. The improvement in HRQOL was significantly lower for children with sleep problems. The improvement in HRQOL was significantly lower in children whose parents had been absent from work due to the child's otitis media. There were no statistically significant differences in the improvement of HRQOL in children who had received a VT during the follow-up period.

Multimorbidity and blood pressure control in 37 651 hypertensive patients from Danish general practice.

BACKGROUND: Patients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices. METHODS AND RESULTS: Using the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men. CONCLUSION: In Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.

A systematic review of the effect of tympanostomy tubes in children with recurrent acute otitis media.

OBJECTIVE: Documentation of the effect of tympanostomy tubes in children with recurrent acute otitis media (RAOM) is limited. A recently published Cochrane review on the effect of tympanostomy tubes in children with RAOM was based on only two studies. Could the documentation be increased by including other randomized studies? METHODS: A MEDLINE and EMBASE search for randomized controlled trials was performed and 143 eligible papers were found. Only five studies could be included. All five were randomized studies with a total of 519 children, four randomized by children and one by ears. All five studies had different designs and control groups, making a proper meta-analysis impossible. Three studies had an antibiotic treated group, two studies a placebo group, and two studies a no treatment group as comparison group. Outcome measures were rates of AOM or fraction free of AOM in six or 12 months. RESULTS: Between two and five children have to be treated with tympanostomy tubes to prevent one child from attacks of acute otitis media (AOM) in six months. Tube treatment could reduce AOM with about one attack in six months after operation. Six months treatment with antibiotics was not different from treatment with tubes. No study reported quality of life for child and family or parental absence from day care or work. CONCLUSION: Insertion of tympanostomy tubes or long-term treatment with antibiotics seems to prevent one attack of AOM or keep one child out of three free from AOM in six months.

The RISAP-study: a complex intervention in risk communication and shared decision-making in general practice.

BACKGROUND: General practitioners (GPs) and patients find it difficult to talk about risk of future disease, especially when patients have asymptomatic conditions, and treatment options are unlikely to cause immediate perceptible improvements in well-being. Further studies in risk communication training are needed. AIM: 1) to systematically develop, describe and evaluate a complex intervention comprising a training programme for GPs in risk communication and shared decision-making, 2) to evaluate the effect of the training programme on real-life consultations between GPs and patients with high cholesterol levels, and 3) to evaluate patients' reactions during and after the consultations. METHODS/DESIGN: The effect of the complex intervention, based around a training programme, will be evaluated in a cluster-randomised controlled trial with an intervention group and an active control group with 40 GPs and 280 patients in each group.The GPs will receive a questionnaire at baseline and after 6 months about attitudes towards risk communication and cholesterol-reducing medication. After each consultation with a participating high cholesterol-patient, the GPs will complete a questionnaire about decision satisfaction (Provider Decision Process Assessment Instrument). The patients will receive a questionnaire at baseline and after 3 and 6 months. It includes questions about adherence to chosen treatment (Morisky Compliance Scale), self-rated health (SF-12), enablement (Patient Enablement Instrument), and risk communication and decision-making effectiveness (COMRADE Scale). Prescriptions, contacts to the health services, and cholesterol level will be drawn from the registers.In each group, 12 consultations will be observed and tape-recorded. The patients from these 24 consultations will be interviewed immediately after the consultation and re-interviewed after 6 months.Eight purposefully selected GPs from the intervention group will be interviewed in a focus group 6 months after participation in the training programme.The process and context of the RISAP-study will be investigated in detail using an action research approach, in order to analyse adaptation of the intervention model to the specific context. DISCUSSION: This study aims at providing GPs and patients with a firm basis for active deliberation about preventive treatment options, with a view to optimising adherence to chosen treatment. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration System NCT01187056.

Preventive health screenings and health consultations in primary care increase life expectancy without increasing costs.

AIMS: The intention was to investigate whether preventive health checks and health discussions are cost effective. METHODS: In a randomized trial the authors compared two intervention groups (A and B) and one control group. In 1991 2,000 30- to 49-year-old persons were invited and those who accepted were randomized. Both intervention groups were offered a broad (multiphasic) screening including cardiovascular risk and a personal letter including screening results and advice on healthy living. Individuals in group A could contact their family physician for a normal consultation whereas group B were given fixed appointments for health consultations. The follow-up period was six years. Analysis was carried out on the "intention to treat" principle. Outcome parameters were life years gained, and direct and total health costs (including productivity costs), discounted by 3% annually. Costs were based on register data. Univariate sensitivity analysis was carried out. RESULTS: Both intervention groups have significantly better life expectancy than the control group (no intervention). Group B and (A) significantly gain 0.14 (0.08) life years more than the control group. There were no differences in average direct (3,255 euro (3,703 euro) versus 4,186 euro) and total costs (10,409 euro (9,399 euro) versus 10,667 euro). The effect in group B is, however, better than in group A with no significant differences in costs. The results are insensitive to a range of assumptions regarding costs, effects, and discount rates. CONCLUSIONS: Preventive health screening and consultation in primary care in 30- to 49-year-olds produce significantly better life expectancy without extra direct and total costs over a six-year follow-up period.

Hearing loss diagnosis followed by meningitis in Danish children, 1995-2004.

OBJECTIVE: A higher risk of meningitis associated with cochlear implants may be explained in part by a generally higher risk of meningitis in children with severe to profound hearing loss. We investigated whether children with hearing loss have an increased risk of meningitis. STUDY DESIGN AND SETTING: A historical cohort study of all children born in Denmark between January 1, 1995, and December 31, 2004, was conducted. The cohort was selected through the Danish Medical Birth Registry, and information on hearing loss and meningitis was obtained from the National Hospital Registry. RESULTS: We identified 39 children with both hearing loss and meningitis. Of these children, five were diagnosed first with hearing loss and later with meningitis. The relative risk of meningitis in the group of children with a hearing loss diagnosis, as compared with the non-hearing loss group, was 5.0 (95% CI, 2.0 to 12.0). CONCLUSIONS: The study provides evidence for an association between hearing loss and the development of meningitis. Parents and health care providers of children with hearing loss should be more alert for possible signs and symptoms of meningitis, and vaccination should be considered.

Secondary healthcare contacts after multiphasic preventive health screening: a randomized trial.

AIM: To analyze the consequence of preventive health screenings and discussions on the utilization of secondary healthcare. METHODS: All 30- to 49-year-old residents registered with a general practitioner in the district of Ebeltoft, Denmark, were included (n = 3,464) in a randomized controlled trial with eight years' follow-up. A random sample of 2,030 subjects was selected for invitation (Invited). The remaining 1,434 persons were never contacted and served as external control group (Non-Invited). Persons accepting participation were randomly divided into one internal control group (Questionnaire) and two intervention groups. One intervention group was offered three health screenings (Health Screening) during the five years. The other intervention group were in addition offered a yearly health discussion with their general practitioner (Health Screening and Discussion). RESULTS: The rate ratio for hospital admissions was 0.97 (95% confidence interval 0.80 to 1.18) in the Invited group compared with the Non-Invited. The annual admission rates showed a significant trend (p = 0.0003) with a decrease four and five years after intervention launch for the Invited group compared with the Non-Invited. A similar trend was found when comparing the internal control group with intervention groups (p = 0.0016). CONCLUSIONS: A 30- to 49-year-old general population's utilization of secondary healthcare did not increase in response to a general health promotion offer. During the observation period a significant decline in annual hospital admission rates was seen.

Methods for analysing recurrent events in health care data. Examples from admissions in Ebeltoft Health Promotion Project.

BACKGROUND: Evaluation of health care contacts from first events alone often misses large amounts of potentially important data and may produce different results than evaluation of all data including recurrent events. OBJECTIVE: We aim to bring the different methodological approaches for analysing longitudinal health care data to the attention of researchers in primary care. METHODS: We used hospital admission data from the Ebeltoft Health Promotion Project, a randomized trial in primary care examining the effect of preventive health checks. Comparisons included three randomized groups: an intervention group receiving health checks, a group where intervention consisted of a health check followed by a health discussion with the GP and one control group. RESULTS: Both intervention groups had approximately 20% fewer hospital admissions than the control group over a 6 year period. If dependence among recurrent events is excluded, such a reduction amounts to a highly significant effect. Use of the standard Poisson distribution for analysing recurrent events and exclusion of their dependent structure causes data interpretation to be incorrect, because the model does not account for the extra variability between persons; the resulting 95% CIs would therefore be too small. CONCLUSION: Analysis of health care contacts should embrace both first and recurrent events and it should use a model appropriate to these data. An individual rate model that includes a parameter of an unspecified individual event distribution frailty may be a natural choice when analysing longitudinal data of contacts to the health care system in broad terms.

Impact of dietary FA and energy restriction on plasma leptin and ob gene expression in mice.

The aim of the present study was to elucidate whether the qualitative composition of dietary fat influences plasma leptin and adipose tissue ob gene expression differentially. Two high-fat diets and a diet rich in carbohydrate were each administered both ad libitum and with a 25% energy restriction. The high-fat diets contained 58 energy percent as either monounsaturated FA (MUFA) or saturated FA (SAFA), whereas the carbohydrate-rich diet (CH) contained 7 energy percent as fat. We aimed at obtaining the same final weight for the animals in the ad libitum group as in the energy-restricted groups. This goal was reached at the same time (days 22-24) for all groups except for the ad libitum animals fed on saturated fat (day 36). The plasma leptin concentrations on ad libitum CH and MUFA diets did not differ significantly (24.3 +/- 2.1 and 34.7 +/- 6.7 ng/mL, respectively) whereas the saturated fat diet caused a lower concentration (13.9 +/- 1.9 ng/mL; P < 0.05). Interestingly, no differences in plasma leptin levels between groups were seen in the energy-restricted groups (mean 8.0 +/- 1.0 ng/mL). The type of diet did not alter the ob gene expression in intraabdominal white adipose tissue; however, a lower expression level was found in the energy-restricted groups. The percentage of body fat in the three ad libitum fed groups did not differ (23 +/- 1%). Thus, short-term administration of a diet rich in SAFA suppresses circulating leptin levels without altering the adipose tissue ob gene expression. This indicates that saturated fat may alter protein handling by adipose tissue or the whole body clearance of leptin.

Low prevalence of ischemic electrocardiographic findings in a Danish population.

OBJECTIVE: Mortality and incidence of cardiovascular disease have declined during the past 35-40 years. The dual aim of this study is to investigate whether the prevalence of electrocardiographic findings is low compared with older studies and to describe the prevalence of electrocardiographic findings in the Danish population, which has not been reported since 1981. DESIGN: Cross-sectional study based on electrocardiograms obtained from a random sample of the population in the district of Ebeltoft, Denmark, December 1991-June 1992. RESULTS: The age and sex stratified prevalence of abnormal electrocardiograms ranged from 6.8% (95% CI: 4.01-10.7%) in women to 15.0% (95% CI: 10.6-20.4%) in men aged 41-51 years. Men had significantly more electrocardiographic changes than women (p = 0.004). Frequent findings were signs of earlier myocardial infarction (3.1%; 95% CI: 2.1-4.5%), axis deviation (3.1%; 95% CI: 2.1-4.5%) and incomplete right bundle branch block (1.2%; 95% CI: 0.6-2.2%). CONCLUSION: Prevalence of ischemic electrocardiographic findings is low when compared with studies from the past 50 years.