Risk factor analysis for a rapid progression of chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is a growing global health concern. Identifying individuals in routine clinical care with new onset CKD at high risk of rapid progression of the disease is imperative to guide allocation of prophylactic interventions, but community-based data are limited. We aimed to examine the risk of rapid progression, kidney failure, hospitalisation and death among adults with incident CKD stage G3 and to clarify the association between predefined risk markers and rapid CKD progression. METHODS: Using plasma creatinine measurements for the entire Danish population from both hospitals and primary care, we conducted a nationwide, population-based cohort study, including adults in Denmark with incident CKD stage G3 in 2017-2020. We estimated 3-year risks of rapid progression (defined by a confirmed decline in estimated glomerular filtration rate of ≥5 ml/min/1.73 m2/year), kidney failure, all-cause hospitalisation and death. To examine risk markers, we constructed a heat map showing the risk of rapid progression based on predefined markers: albuminuria, sex, diabetes and hypertension/cardiovascular disease. RESULTS: Among 133 443 individuals with incident CKD stage G3, the 3-year risk of rapid progression was 14.6% (95% confidence interval (CI): 14.4-14.8). The 3-year risks of kidney failure, hospitalisation and death were 0.3% (95% CI: 0.3-0.4), 53.3% (95% CI: 53.0-53.6) and 18.1% (95% CI: 17.9-18.4), respectively. In the heat map, the 3-year risk of rapid progression ranged from 7% in females without albuminuria, hypertension/cardiovascular disease or diabetes, to 46-47% in males and females with severe albuminuria, hypertension/cardiovascular disease and diabetes. CONCLUSION: This population-based study shows that CKD stage G3 is associated with considerable morbidity in a community-based setting and underscores the need for optimised prophylactic interventions among such patients. Moreover, our data highlight the potential of using easily accessible markers in routine clinical care to identify individuals who are at high risk of rapid progression.

Exploring diagnostic events and first referrals in cancer patient pathways in primary care. A questionnaire survey.

BACKGROUND: Cancer diagnostic pathways in general practice are often nonlinear, and several events can delay timely diagnosis. OBJECTIVES: To explore cancer diagnostic processes in general practice, examining how patients' symptom presentations, sex, and age are associated with the occurrence of predefined potentially delaying events and the first referrals. METHOD: General practices in 3 Danish Regions were invited to participate in a questionnaire survey, addressing patient's symptom presentation, diagnostic process events, and first referral. The general practitioners (GPs) received a list of their incident cancer patients from the preceding 2 years. RESULTS: In total 187 general practices participated, including 5,908 patients with the cancer diagnostic pathways initiated in general practice. Presenting with nonspecific symptoms was associated with potentially delaying events, even when the patient also had specific symptoms. Almost half of the patients were referred to a cancer patient pathway (CPP) first, men more often than women, and 10% were referred for acute hospitalization. In 23% of the diagnostic processes, GPs initially treated or referred patients on suspicion of another disease rather than cancer and waited due to normal examinations in 1 out of 20 patients. Excluding sex-specific cancers, these 2 events were more prevalent in women. Men less often complied to the follow-up agreement. Younger patients were less often first referred to a CPP and together with older patients more often first acutely hospitalized. CONCLUSION: In cancer diagnostic processes in general practice, first referrals and the occurrence of potentially delaying events are associated with the patient's age, sex, and specificity of symptoms.

Coping in the Danish general population: psychometric properties of the Danish version of the Brief Approach/Avoidance Coping Questionnaire.

OBJECTIVE: To enable measurement of coping in the general Danish population the aims of this study are to 1) describe the translation and cultural adaption of the Danish Brief Approach/Avoidance Coping Questionnaire (BACQ) and 2) investigate the psychometric properties of the Danish BACQ. DESIGN: The BACQ was translated and adapted into Danish, and the psychometric properties tested in two samples of adult Danish citizens: Sample A = 167, used for exploratory factor analysis (EFA), and Sample B = 330 persons, used for confirmatory factor analysis (CFA). Internal consistency was evaluated by Cronbach's Alpha, item-to-rest correlation, and scale-to-scale Pearson correlation. RESULTS: The EFA suggested reasonable fits for both a three-factor and four-factor model, confirmed by the CFA with acceptable goodness-of-fit indices for both models. Using the four-factor-model would require a re-evaluation of the scale. The three-factor model had admissible internal consistency with an overall Cronbach's alpha of 0.66. Individuals with low self-rated health, extreme concern about current health and poor physical fitness, respectively, had lower Approach and higher Diversion and Resignation scores. CONCLUSION: The psychometric properties showed that the Danish BACQ could be used as a three-factor model. With some limitations, the Danish version had acceptable construct validity, internal consistency, and content validity.

Developing and Validating a Lung Cancer Risk Prediction Model: A Nationwide Population-Based Study.

Lung cancer can be challenging to diagnose in the early stages, where treatment options are optimal. We aimed to develop 1-year prediction models for the individual risk of incident lung cancer for all individuals aged 40 or above living in Denmark on 1 January 2017. The study was conducted using population-based registers on health and sociodemographics from 2007-2016. We applied backward selection on all variables by logistic regression to develop a risk model for lung cancer and applied the models to the validation cohort, calculated receiver-operating characteristic curves, and estimated the corresponding areas under the curve (AUC). In the populations without and with previously confirmed cancer, 4274/2,826,249 (0.15%) and 482/172,513 (0.3%) individuals received a lung cancer diagnosis in 2017, respectively. For both populations, older age was a relevant predictor, and the most complex models, containing variables related to diagnoses, medication, general practitioner, and specialist contacts, as well as baseline sociodemographic characteristics, had the highest AUC. These models achieved a positive predictive value (PPV) of 0.0127 (0.006) and a negative predictive value (NPV) of 0.989 (0.997) with a 1% cut-off in the population without (with) previous cancer. This corresponds to 1.2% of the screened population experiencing a positive prediction, of which 1.3% would be incident with lung cancer. We have developed and tested a prediction model with a reasonable potential to support clinicians and healthcare planners in identifying patients at risk of lung cancer.

Can National Registries Contribute to Predict the Risk of Cancer? The Cancer Risk Assessment Model (CRAM).

PURPOSE: To develop a predictive model based on Danish administrative registers to facilitate automated identification of individuals at risk of any type of cancer. METHODS: A nationwide register-based cohort study covering all individuals in Denmark aged +20 years. The outcome was all-type cancer during 2017 excluding nonmelanoma skin cancer. Diagnoses, medication, and contact with general practitioners in the exposure period (2007-2016) were considered for the predictive model. We applied backward selection to all variables by logistic regression to develop a risk model for cancer. We applied the models to the validation cohort, calculated the receiver operating characteristic curves, and estimated the corresponding areas under the curve (AUC). RESULTS: The study population consisted of 4.2 million persons; 32,447 (0.76%) were diagnosed with cancer in 2017. We identified 39 predictive risk factors in women and 42 in men, with age above 30 as the strongest predictor for cancer. Testing the model for cancer risk showed modest accuracy, with an AUC of 0.82 (95% CI 0.81-0.82) for men and 0.75 (95% CI 0.74-0.75) for women. CONCLUSION: We have developed and tested a model for identifying the individual risk of cancer through the use of administrative data. The models need to be further investigated before being applied to clinical practice.

Risk of serious infections in arthritis patients treated with biological drugs: a matched cohort study and development of prediction model.

OBJECTIVES: Serious infection is a concern for patients with inflammatory joint diseases treated with biological drugs (bDMARDs). The objectives were to compare risk of serious infection, defined as infection leading to hospitalization, in patients initiating bDMARD treatment with that in the general population and, second, to develop a simple clinical prediction model and to obtain risk estimates for individual patients. METHODS: This was a matched-cohort study based on nationwide registries in Denmark. Patients with RA, axial SpA and PsA initiating first bDMARD monitored in the DANBIO registry were matched 1:10 by age, gender and postal code with controls from the general population. The risk of serious infection during 12 months' follow-up was assessed with Cox regression. Prediction models were developed using logistic regression and compared using area under the receiver operating characteristic curve (AUC). RESULTS: We included 11 372 patients and 113 715 controls. During follow-up, 522 patients (4.6%) and 1434 controls (1.3%) developed a serious infection (hazard ratio 3.7, 95% CI 3.4, 4.1). Age-stratified risk was largely similar across diagnoses. A simple prediction model, the 'DANBIO infection risk score', based on age and a count of six clinical risk factors had moderate discriminative power (internal validation: AUC 0.69) that was comparable to that of the existing RABBIT (Rheumatoide Arthritis Beobachtung der BIologika-Therapie) Risk Score (external validation: AUC 0.68). CONCLUSION: Patients with inflammatory joint diseases initiating bDMARD treatment had a four times increased risk of serious infection compared with the general population. A simple prediction model, feasible for shared decision-making, was developed to obtain risk estimates for individual patients.

Predictive values of lung cancer alarm symptoms in the general population: a nationwide cohort study.

We aimed to firstly determine the 1-year predictive values of lung cancer alarm symptoms in the general population and to analyse the proportion of alarm symptoms reported prior to diagnosis, and secondly analyse how smoking status and reported contact with general practitioners (GPs) regarding lung cancer alarm symptoms influence the predictive values. The study was a nationwide prospective cohort study of 69,060 individuals aged ≥40 years, randomly selected from the Danish population. Using information gathered in a survey regarding symptoms, lifestyle and healthcare-seeking together with registry information on lung cancer diagnoses in the subsequent year, we calculated the predictive values and likelihood ratios of symptoms that might be indicative of lung cancer. Furthermore, we analysed how smoking status and reported contact with GPs regarding the alarm symptoms affected the predictive values. We found that less than half of the patients had reported an alarm symptom six months prior to lung cancer diagnosis. The positive predictive values of the symptoms were generally very low, even for patients reporting GP contact regarding an alarm symptom. The highest predictive values were found for dyspnoea, hoarseness, loss of appetite and for current heavy smokers. The negative predictive values were high, all close to 100%. Given the low positive predictive values, our findings emphasise that diagnostic strategies should not focus on single, specific alarm symptoms, but should perhaps focus on different clusters of symptoms. For patients not experiencing alarm symptoms, the risk of overlooking lung cancer is very low.

Prescribing of proton-pump inhibitors: auditing the management and reasons for prescribing in Danish general practice.

BACKGROUND: Prescribing of proton-pump inhibitors has substantially increased. Information from clinical settings is warranted to gain insight into reasons for prescribing. AIM: To investigate Danish General Practitioners' management and reasons for prescribing of proton-pump inhibitors and to identify areas for quality improvement. METHODS: All general practitioners in the Region of Southern Denmark and their staff were invited to participate in a 4-week audit on all contacts with patients prescribed proton-pump inhibitors. For each contact, patient characteristics, treatment duration, dose and causes of treatment, previous gastroscopy, Helicobacter pylori test, and decision about future treatment were recorded. RESULTS: A total of 51 general practitioners and 47 staff members sampled information about 1101 and 741 patients, respectively. Proton-pump inhibitors had been taken for more than 2 years in 58% of the cases, and 64% of the patients used it daily. Treatment was based on an appropriate reason in three of the four patients, most often due to acid-related symptoms. No gastroscopy had been performed in 46% of the patients, and one of four had had a consultation with the general practitioner regarding proton-pump inhibitor within the last year. CONCLUSION: Most patients treated with proton-pump inhibitors are treated daily, on a long-term basis, and due to symptoms. Few consultations led to alterations in treatment, and only 25% of patients had a consultation regarding proton-pump inhibitor treatment with their general practitioner within the last year. Substantial variability between general practitioners with regard to management was detected.

Barriers to health care seeking with bothersome lower urinary tract symptoms among men-a nationwide study.

BACKGROUND: The majority of men who report urological symptoms of extreme concern or influence on daily activities do not contact their general practitioner (GP). No previous study on barriers to health care seeking with lower urinary tract symptoms in men has been carried out in a population-based setting. OBJECTIVES: (i) To examine associations between different types of lower urinary tract symptoms and barriers to contact a GP in men with urological symptoms reported to be of concern or influencing daily activity (termed 'bothersome'); (ii) to examine associations between age and barriers to health care seeking in men with bothersome lower urinary tract symptoms. STUDY DESIGN: A population-based cross-sectional study design. METHODS: A total of 48 910 men aged 20 or older were randomly selected from the general Danish population. Data was collected in 2012. Logistic regression was used to calculate odds ratios for reporting different barriers to health care seeking with bothersome lower urinary tract symptoms according to age and urological symptom. RESULTS: A total of 23 240 men participated. Among men aged 20-39 years who reported bothersome lower urinary tract symptoms, the proportion who did not contact their GP ranged from 73.4% (incontinence) to 84.5% (nocturia). Men younger than 60 years of age had significantly higher odds for reporting any barriers to health care seeking compared to older men. The odds for reporting each of the barriers differed significantly according to the different urological symptoms. CONCLUSION: Younger men more often report barriers to health care seeking, but the barriers differ between the different urological symptoms.

Barriers to contacting general practice with alarm symptoms of colorectal cancer: a population-based study.

Background: A prerequisite for general practitioners (GPs) being able to refer patients with cancer alarm symptoms for further investigations is that individuals present to the GP. Knowledge of barriers to help-seeking is, however, sparse. Objectives. The aim of this study was to analyse associations between the experience of recent-onset alarm symptom of colorectal cancer and four different barriers towards GP contact. Methods: A nationwide web-based cohort survey was conducted in 100000 individuals aged 20 years or above, randomly selected from the Danish Civil Registration System. Items regarding experience of four predefined alarm symptoms of colorectal cancer (rectal bleeding, abdominal pain, change in stool texture and change in stool frequency), decisions about contact to GPs and barriers towards GP contact were included. Results: A total of 37455 respondents over 40 years (51.8%) completed the questionnaire. The proportion of individuals with no contact to the GP varied between 69.8% and 79.8% for rectal bleeding and change in stool frequency, respectively. The most widely reported barriers were being worried about wasting the doctor's time and being too busy to make time to visit the doctor. Men with rectal bleeding significantly more often reported being worried about what the doctor might find. The proportion of individuals who reported barriers was, in general, higher among the youngest age group. Conclusion: Barriers to contacting the GP were frequent when experiencing alarm symptoms of colorectal cancer. Reporting the different barriers was significantly associated with gender and age.

Gynecological cancer alarm symptoms: is contact with specialist care associated with lifestyle and socioeconomic status? A population-based study.

INTRODUCTION: The aim of this study was to determine the proportion of patients who were referred to specialist care after reporting gynecological cancer alarm symptoms to their general practitioner. We sought to investigate whether contact with specialist care was associated with lifestyle factors or socioeconomic status. MATERIAL AND METHODS: Nationwide population-based prospective cohort study in Denmark, based on a random sample of 51 090 women aged 20 years or older from the general population. A web-based questionnaire regarding gynecological alarm symptoms and lifestyle was distributed to the invited individuals. Data about contact with specialist care were obtained from the National Patient Register and the National Health Insurance Service Registry, whereas information about socioeconomic status was collected from Statistics Denmark. Main outcome measures were percentages of patients having contact with specialist care and odds ratios (ORs) for associations between specialist care contact, lifestyle factors and socioeconomic status. RESULTS: The study included 25 866 nonpregnant women; 2957 reported the onset of at least one gynecological cancer alarm symptom, and 683 of these (23.1%) reported symptoms to their general practitioner. The proportion of individuals having contact with specialist care ranged from 39.3% (pain during intercourse) to 47.8% (bleeding during intercourse). Individuals with higher educational level had significantly higher odds of contact with a specialist (OR 1.86, 95% CI 1.17-2.95). CONCLUSIONS: Educational level influences contact with specialist care among patients with gynecological cancer alarm symptoms. Future studies should investigate inequalities in access to the secondary healthcare system.

Associations between patients' adherence and GPs' attitudes towards risk, statin therapy and management of non-adherence--a survey and register-based study.

BACKGROUND: Previous studies suggest that doctors' personal lifestyle, risk taking personality and beliefs about risk reducing therapies may affect their clinical decision-making. Whether such factors are further associated with patients' adherence with medication is largely unknown. OBJECTIVE: To estimate associations between GPs' attitudes towards risk, statin therapy and management of non-adherence and their patients' adherence, and to identify subgroups of GPs with poor patient adherence. METHODS: All Danish GPs were invited to participate in an online survey. We asked whether they regarded statin treatment as important, how they managed non-adherence and whether non-adherence annoyed them. The Jackson Personality Inventory-revised was used to measure risk attitude. The GPs' responses were linked to register data on their patients' redeemed statin prescriptions. Mixed effect logistic regression was used to estimate associations between patient adherence and GPs' attitudes. Adherence was estimated by the proportion of days covered in a 1-year period using an 80% cut-off. RESULTS: We received responses from 1398 GPs (42.2%) who initiated statin therapy in 12 192 patients during the study period. In total 6590 (54.1%) of these patients were adherent. Patients who had GPs rarely assessing their treatment adherence were less likely to be adherent than those who had GPs assessing their patients' treatment adherence now and then, odds ratio (OR) 0.86 [confidence interval (CI) 0.77-0.96]. No other associations were found between patients' adherence and GPs' attitudes. CONCLUSIONS: Our findings suggest that GPs' attitudes to risk, statin therapy or management of non-adherence are not significantly associated with their patients' adherence.

Specific and non-specific symptoms of colorectal cancer and contact to general practice.

BACKGROUND: To improve survival rates for colorectal cancer, referral guidelines have been implemented. First step in the diagnostic process is for the individual to recognize the symptoms and contact his/her general practitioner (GP) for evaluation. OBJECTIVES: To determine (i) the prevalence of specific and non-specific symptom experiences indicative of colorectal cancer, (ii) the proportion of subsequent contacts to GPs, (iii) to explore the possible differences in symptom experience and contact to GPs between age and sex. METHODS: A nationwide study of 100000 adults, aged 20 years and older, were randomly selected in the general population and invited to participate in an internet-based survey. Items regarding experience of specific and non-specific alarm symptoms of colorectal cancer within the preceding 4 weeks and contact to GP were included. RESULTS: A total of 49706 subjects completed the questionnaire. Abdominal pain was the most common specific alarm symptom (19.7%) and tiredness was the most common non-specific symptom (49.8%). The experiences of symptoms were more common among women and more common in the youngest age groups for both sexes. The symptom leading to the highest proportion of GP contacts was rectal bleeding (33.8%). When experiencing any combination of two specific alarm symptoms, the proportion who contacted a GP was less than 50%. The combination of a non-specific and a specific alarm symptom gave rise to the highest proportion of GP contacts. CONCLUSION: Although specific and non-specific alarm symptoms of colorectal cancer are common in the general population, the proportion of GP contacts is low.

Specific and unspecific gynecological alarm symptoms--prevalence estimates in different age groups: a population-based study.

OBJECTIVE: To determine prevalence estimates of gynecological alarm symptoms in different age groups and to describe common patterns of gynecological symptoms. DESIGN: Web-based cross-sectional survey study. SETTING: Nationwide in Denmark. POPULATION: A random sample of 51,090 women aged 20 years or above from the general population. METHODS: An internet-based questionnaire study regarding the prevalence estimates of symptom experiences. A total of 18 symptoms of cervical, endometrial and ovarian cancer were selected through an extensive literature search, which included national and international guidelines. MAIN OUTCOME MEASURES: Prevalence estimates of self-reported experience of gynecological alarm symptoms within the preceding 4 weeks. RESULTS: A total of 26,466 women (54.5%) participated in the study. Some 80.3% had experienced at least one of the alarm symptoms within the preceding 4 weeks, and the median number of experienced symptoms was 2 (interquartile range 1-4). The most common symptoms were tiredness (53.0%) and abdominal bloating (36.7%); postmenopausal bleeding (2.3%) and involuntary weight loss (2.8%) were least frequent. Most of the symptoms were more prevalent among younger women, whereas only dyspnea and increased urgency of urination were more frequent among older women. Among younger women, multiple abdominal symptoms often occurred simultaneously and frequently in combination with pelvic pain, whereas older women were more likely to report single symptoms. CONCLUSIONS: Gynecological alarm symptoms are frequent in the general population, mostly among younger women. Older women reported fewer symptoms, and these often appeared as single symptoms.

Strategies for discontinuation of proton pump inhibitors: a systematic review.

PURPOSE: Proton pump inhibitors (PPIs) are considered to be overprescribed. Consensus on how to attempt discontinuation is, however, lacking. We therefore conducted a systematic review of clinical studies on discontinuation of PPIs. METHODS: Systematic review based on clinical studies investigating discontinuation strategies and discontinuation rates for users of antisecretory medication judged eligible for withdrawal. The databases Medline, Embase and Cochrane Library were searched to December 2013 using the terms antisecretory, anti-ulcer, PPI, acid suppressant, discontinuation, step-down, step down, cessation, tapering, withdrawal and withhold. Search terms were used either singularly or in combination. Papers written in English or Scandinavian were included. Concurrent hand searching was undertaken to pursue references of references. The website ClinicalTrials.gov was searched for unpublished results and ongoing studies. A total of 371 abstracts were scrutinized to determine relevancy. RESULTS: The thorough search resulted in six clinical studies on strategies for discontinuation of PPIs. All discontinuation regimens used in the studies differed, and several interventions have been tested in order to decrease use of PPIs. Discontinuations were reported across all studies ranging from 14% to 64% without deteriorating symptom control. Tapering seems to be a more effective discontinuation strategy than abrupt discontinuation. CONCLUSION: Discontinuation of PPIs is feasible in a clinical setting, and a substantial number of the patients treated without a clear indication can safely reduce or discontinue treatment. Tapering seems to be the most effective way of doing this.

Patients' concern about their medicine after a generic switch: a combined cross-sectional questionnaire and register study.

PURPOSE: This study aims to investigate the possible association between patients' concerns about their medicine and generic switch. METHODS: Cross-sectional survey was carried out comprising responses from 2217 randomly selected persons aged 20 years or older and living in the Region of Southern Denmark, who had redeemed generically substitutable drugs in September 2008. For each patient, we focused on the purchase of one generically substitutable drug (index drug). We applied the specific concerns subscale from the Beliefs about Medicine Questionnaire (BMQ) to analyse lack of confidence in treatment. We also included general beliefs about medicine (BMQ), views on generic medicine and confidence in the health-care system. The information about the patients' generic switch was obtained from a prescription database and not provided by the patients. Data were analysed using linear regression. RESULTS: No statistically significant associations were found between concerns about the index medicine and the generic switch (-0.02 95% CI: -0.10; 0.05). Viewing medicines as harmful in general was associated with increased concerns (BMQ general harm: 0.39 95% CI: 0.30; 0.47 and BMQ general overuse: 0.28 95% CI: 0.20; 0.35). Patients having high confidence in the health-care system showed less concern (-0.16 95% CI: -0.27; -0.06). CONCLUSION: This study showed that for all three drug categories investigated, the patients who experienced a generic switch did not have more concerns about their index medicine than patients who did not switch.

General practice variation in spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease in Denmark: a population-based observational study.

BACKGROUND: Spirometry testing is essential to confirm an obstructive lung disease, but studies have reported that a large proportion of patients diagnosed with COPD or asthma have no history of spirometry testing. Also, it has been shown that many patients are prescribed medication for obstructive lung disease without a relevant diagnosis or spirometry test registered. General practice characteristics have been reported to influence diagnosis and management of several chronic diseases. However, these findings are inconsistent, and it is uncertain whether practice characteristics influence spirometry testing among patients receiving medication for obstructive lung disease. The aim of this study was therefore to examine if practice characteristics are associated with spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease. METHODS: A national register-based cohort study was performed. All patients over 18 years receiving first-time prescriptions for medication targeting obstructive lung disease in 2008 were identified and detailed patient-specific data on sociodemographic status and spirometry tests were extracted. Information on practice characteristics like number of doctors, number of patients per doctor, training practice status, as well as age and gender of the general practitioners was linked to each medication user. RESULTS: Partnership practices had a higher odds ratio (OR) of performing spirometry compared with single-handed practices (OR 1.24, CI 1.09-1.40). We found a significant association between increasing general practitioner age and decreasing spirometry testing. This tendency was most pronounced among partnership practices, where doctors over 65 years had the lowest odds of spirometry testing (OR 0.25, CI 0.10-0.61). Training practice status was significantly associated with spirometry testing among single-handed practices (OR 1.40, CI 1.10-1.79). CONCLUSION: Some of the variation in spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease was associated with practice characteristics. This variation in performance may indicate a potential for quality improvement.

Associations between health care seeking and socioeconomic and demographic determinants among people reporting alarm symptoms of cancer: a population-based cross-sectional study.

BACKGROUND: Late diagnosis of cancer may partly be explained by the fact that some patients do not seek health care promptly when experiencing an alarm symptom. Socioeconomic and demographic differences exist concerning knowledge and awareness of cancer alarm symptoms in the general population and socioeconomic differences are found in cancer incidence and survival. We therefore hypothesise that socioeconomic and demographic differences in health care-seeking behaviour are present among people with alarm symptoms. OBJECTIVES: To analyse associations between health care seeking and socioeconomic and demographic factors among people reporting cancer alarm symptoms. METHODS: A questionnaire survey comprising 20000 people aged >20 from the Danish population. The questionnaire concerned alarm symptoms of common cancers and subsequent health care seeking. Data on socioeconomic factors were obtained from Statistics Denmark. MAIN OUTCOMES: health care seeking and patient interval. RESULTS: A total of 26.1% of all subjects reported that they did not seek health care when having experienced an alarm symptom. Women-subjects aged >40, subjects living with a partner and subjects having a cancer diagnosis-were more likely to seek health care, whereas medium educational level was negatively associated with health care seeking. Further, women were more likely to seek health care within 1 month, whereas subjects out of the workforce were less likely to do so. CONCLUSIONS: Approximately three out of four subjects sought health care when having experienced an alarm symptom but 50% waited for at least 1 month. Some demographic factors were found to be associated with health care-seeking behaviour and the patient interval, whereas no consistent associations were found with regard to socioeconomics.

Influence of socioeconomic and demographic status on spirometry testing in patients initiating medication targeting obstructive lung disease: a population-based cohort study.

BACKGROUND: Socioeconomic status is known to influence the prevalence, severity and mortality of obstructive lung diseases, but it is uncertain whether it affects the use of diagnostic spirometry in patients initiating treatment for these conditions. The objective of this paper was to examine a possible association between education, income, labour market affiliation, cohabitation status and having spirometry performed when initiating medication targeting obstructive pulmonary disease. METHODS: We conducted a population-based cohort study. Danish national registers were linked, retrieving data on prescriptions, spirometry testing, socioeconomic and demographic variables in all first time users of medication targeting obstructive lung disease in 2008. RESULTS: A total of 37,734 persons were included and approximately half of the cohort had spirometry performed. Among medication users under 65 years of age, being unemployed was significantly associated with reduced odds of having spirometry performed, the strongest association was seen in men (OR = 0.82, CI = 0.73-0.91). Medium income was associated with increased odds of having spirometry performed in men (OR =1.18, CI = 1.06-1.30) and high educational level (>12 years) was associated with reduced odds of having spirometry performed in women (OR = 0.86, CI = 0.78-0.94). Cohabitation status was not associated with having spirometry performed. Among medication users over 65 years of age, living alone was associated with reduced odds of having spirometry performed among men (OR = 0.78, CI = 0.69-0.88). CONCLUSION: Social inequity in spirometry testing among patients initiating medication targeting obstructive lung disease was confirmed in this study. Increased focus on spirometry testing among elderly men living alone, among the unemployed and among women with higher education is required when initiating medication.

A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome.

BACKGROUND & AIMS: Guidelines recommend a positive strategy based on symptom criteria to diagnose patients with irritable bowel syndrome (IBS). We conducted a randomized noninferiority trial to determine whether a positive diagnostic strategy is noninferior to a strategy of exclusion, with regard to patients' health-related quality of life (HRQOL). METHODS: We studied 302 patients (18-50 years old) from primary care who were suspected of having IBS and referred by general practitioners. Patients who fulfilled the Rome III criteria for IBS with no alarm signals were randomly assigned to groups assessed by a strategy of exclusion (analyses of blood, stool samples for intestinal parasites, and sigmoidoscopies with biopsies) or a positive strategy (analyses of blood cell count and C-reactive protein). Patients were followed for 1 year. The primary end point was difference in change of HRQOL from baseline to 1 year between groups (on the basis of the Short Form 36 health survey, physical component summary, and noninferiority margin of 3 points). Secondary outcomes were change in gastrointestinal symptoms, satisfaction with management, and use of resources. Findings of diagnostic misclassification were registered. RESULTS: A positive strategy was noninferior to a strategy of exclusion (difference, 0.64; 95% confidence interval, -2.74 to 1.45). The positive diagnostic strategy had lower direct costs. Each approach had similar effects on symptoms, satisfaction, and subsequent use of health resources. No cases of inflammatory bowel disease, colorectal cancer, or celiac disease were found. CONCLUSIONS: In diagnosing IBS in primary care, use of a positive diagnostic strategy is noninferior to using a strategy of exclusion with regard to the patients' HRQOL. Our findings support the current guideline recommendations.