Psychosocial profile in men and women with unexplained chest pain.

OBJECTIVE: The aim of this study was to compare men and women with unexplained chest pain (UCP) to a randomly selected population sample free of clinical heart disease with regard to sleep problems, mental strain at work, stress at home, negative life events and health-related quality of life (HRQOL). DESIGN AND SUBJECTS: The study was conducted at a university hospital in Sweden including 231 patients aged 25-69 without any organic cause for chest pain. As a reference group, 1069 participants, were recruited from the INTERGENE population-based study. RESULTS: Patients with UCP had more sleep problems (OR = 1.8, P < 0.0001), were almost three times more worried about stress at work (OR = 2.9, P < 0.0001), or had more stress at home (OR = 2.8, P < 0.0001), and were twice as likely to have negative life events (OR = 2.1, P < 0.0001). Women, but not men, with UCP, had a higher prevalence of cardiovascular risk factors (obesity, smoking, diabetes and hypertension) compared with references. With regard to HRQOL, UCP patients scored significantly lower than references in all dimensions of the SF-36. CONCLUSIONS: In comparison with a healthy reference group, patients with UCP reported more sleep problems, mental strain at work, stress at home and negative life events and had lower health-related quality of life. Aside from immigration the strongest independent psychosocial factors were mental strain at work and negative life events last year in men and stress at home in women.

Adverse events and patients' perceptions of antihypertensive drug effectiveness.

Adverse events that patients attribute to their drug treatment are generally considered to reduce adherence to medication. However, some patients interpret such symptoms as indicating drug effectiveness. If perceivedly effective drugs are more likely to be taken then adverse events may increase adherence. The extent to which patients interpret adverse events as indicating drug effectiveness is not well known. We investigated this in a cross-sectional questionnaire study of 1013 drug-treated hypertensive patients from 55 primary health-care centres and 11 internal medicine clinics in Sweden. We hypothesized that estimates of future risk of complications of hypertension made by hypertensive patients who had adverse events would be lower than estimates made by patients who did not have adverse events, and that these estimates would only differ when patients were estimating their risks in a setting where they continued taking antihypertensive drugs. Patients' risk estimates were measured with visual analogue scales and adverse events were detected by an open question. Contrary to our hypothesis, patients with adverse events (25.7%) gave higher estimates of future risk in the continuing medication setting. This association persisted in a multivariate analysis, where a number of factors related to adverse events and risk were controlled for (OR 1.76 (95% CI, 1.26-2.45), P=0.001 for the most highly correlated risk measure), but risk estimates did not differ between patients with and without adverse events in the setting of not continuing medication. Possible explanations for these findings are pre-existing differences in attitude towards drugs and level of fear of complications.

Taking antihypertensive medication--controlling or co-operating with patients?

Low compliance with antihypertensive drug regimens has been a well documented reason for inadequate control of hypertension. We assessed recent literature regarding compliance from different disciplines to clarify the nature of reported problems on low compliance to prescribed antihypertensive medication. Much research focuses on primary factors for compliance, methods to monitor and measure individual rates and patterns of compliance. From a behavioural oriented point of view, the focus is on understanding why patients act as they do. This review indicates that there is an almost complete lack of knowledge about how the decision making in the clinical practice is organized when prescribing antihypertensive medication and/or when following up treatment from patients already taking such drugs. Since the concrete communication and collaboration between patient and physician in the clinical setting are of prime significance for patient adherence to drug regimens, it is important to shed light on what happens in this critical situation.

Antihypertensive medication in clinical encounters.

In managing hypertension, patient participation and understanding of the nature and significance of treatment are decisive. We analysed the communication between patient and physician with respect to antihypertensive medication at a follow-up appointment, and assessed patients' knowledge of their medication. The empirical data consist of audio-recordings from 51 hypertensive patients' follow-up appointment with their physicians. Thirty-three of these patients were interviewed in depth immediately after the appointment. The study was performed in primary health care centres and at a specialist clinic for hypertension. When discussing medications, patients mainly talked about experiences of being on medication, whereas physicians generally focused on the pharmacological effect and dosage of the drug. Physicians routinely asked about compliance with drug regimen, but seldom in any depth. Little effort was invested into discussing the effect and goal of therapy. The main finding was that patients had a very fragmentary understanding of the functional nature of their antihypertensive medication. This is unsatisfactory both from the point of view of treatment efficacy and also when considering the legal requirements of involving the patient in the decision making. The follow-up appointments studied gave few possibilities for the patient to learn about their antihypertensive medication.

Reasons for adherence with antihypertensive medication.

BACKGROUND: Hypertension is often insufficiently controlled in clinical practice, a prominent reason for this being poor patient adherence with therapy. Little is known about the underlying reasons for poor adherence. We set out to investigate hypertensive patients' self-reported reasons for adhering to or ignoring medical advice regarding antihypertensive medication. METHODS: Qualitative analysis of semi-structured interviews with 33 hypertensive patients in a general-practice centre and a specialist hypertension unit in Southern Sweden. Blood-pressure measurements and laboratory measurements of antihypertensive medication were performed. RESULTS: Nineteen out of 33 patients were classified as adherent. Adherence was a function of faith in the physician, fear of complications of hypertension, and a desire to control blood pressure. Non-adherence was an active decision, partly based on misunderstandings of the condition and general disapproval of medication, but mostly taken in order to facilitate daily life or minimize adverse effects. Adherent patients gave less evidence of involvement in care than non-adherent patients. There was no obvious relation between reported adherence, laboratory markers of adherence and blood-pressure levels. CONCLUSIONS: The interview is a powerful tool for ascertaining patients' concepts and behaviour. To optimize treatment of hypertension, it is important to form a therapeutic alliance in which patients' doubts and difficulties with therapy can be detected and addressed. For this, effective patient-physician communication is of vital importance.

Antihypertensive treatment and patient autonomy--the follow-up appointment as a resource for care.

Since hypertension is a chronic condition which generally requires long-term commitment to pharmacological therapy as well as alterations of patient lifestyle, the patient-physician communication in the clinical setting is an important determinant of the quality of care and health outcome. The aim of the present study was to explore the structure and content of the communication between the patient and the physician, and the process of decision-making at a routine follow-up appointment for hypertension. The study was based on 51 audio-recordings of authentic consultations. Most patients had a passive role in the consultations, and initiated few topics of conversation. The few topics that the patients initiated were usually not about hypertension. Patients' questions about medication mainly referred to unwanted effects of the drugs. Little time was invested in discussing risks related to hypertension. A collaborative shared decision-making was seldom observed in the consultations.

Twenty-year trends in incidence and 1-year mortality in Swedish patients hospitalised with non-AMI chest pain. Data from 1987-2006 from the Swedish hospital and death registries.

OBJECTIVE: To study trends for 20 years in incidence and 1-year mortality in hospitalised patients who received a diagnosis of either angina or unexplained chest pain (UCP) in Sweden. DESIGN AND SETTING: Register study of all patients aged 25-84 years identified from the Swedish National Hospital Discharge Register who were hospitalised with a first-time diagnosis of UCP or angina pectoris during 1987 to 2006. PARTICIPANTS: A total of 378 454 patients, 235 855 with UCP and 142 599 with angina. MAIN OUTCOME MEASURES: 1-Year mortality and standardised mortality ratios (SMRs). RESULTS: From the period 1987-1991 to 2002-2006, the observed 1-year mortality rate in men and women with UCP aged 25-74 years decreased from 2.19% to 1.45% and from 1.85% to 0.91%, respectively. SMRs decreased from 1.67 (95% CI 1.39 to 1.95) and 1.63 (1.27 to 2.00) to 1.09 (0.96 to 1.23) and 0.88 (0.75 to 1.00). Corresponding decreases in 1-year mortality for a discharge diagnosis of angina were from 6.50% to 2.49% in men and from 4.80% to 1.68% in women, with SMRs decreasing from 2.69 (2.33-3.05) and 2.59 (2.06-3.12) to 1.09 (0.93-1.25) and 1.05 (0.81-1.29), respectively. Similar changes occurred in patients aged 75-84 years. Only men with UCP aged 75-84 years still retained a slightly increased mortality (SMR 1.14 (1.01-1.28)). CONCLUSIONS: The prognosis of patients admitted with chest pain in which acute myocardial infarction has been ruled out has improved for the past 20 years, such that the 1-year mortality of these patients is now similar to that in the general population.

Single application of a fluorescent test cream by healthy volunteers: assessment of treated and neglected body sites.

BACKGROUND: Management of dermatological self-treatment is demanding. Imperfect application of creams and ointments and poor adherence to topical treatment are common, resulting in unsatisfactory treatment outcome. OBJECTIVES: To assess the technique and precision of test subjects' self-application of a test cream. Treated and neglected skin sites were measured after intended widespread single application of a fluorescent test cream. METHODS: Twenty healthy volunteers (10 women, 10 men) were included. They were asked to treat their whole skin surface with the fluorescent test cream, except the head and neck and skin covered by underwear. Treated and untreated sites were subsequently measured under Wood's ultraviolet radiation. RESULTS: Thirty-one per cent of the skin surface that was a target for application did not show any fluorescence and thus was assumed to have been untreated. Typical neglected sites included the central back, the upper breast, the axilla with surrounding skin, the legs and the feet, particularly the sole. The posterior aspect of both trunk and extremities, not easily inspected, was more often neglected. In the treated sites the fluorescence was typically uneven. CONCLUSIONS: Qualified and motivated persons with no obvious physical limitations practised imperfect self-application of a test cream mimicking a therapeutic cream product. As much as 31% of the skin surface was neglected. Sites especially prone to nonapplication were identified. This might imply that dermatological patients on long-term self-treatment may practise local application very poorly, a problem of major therapeutic and economic importance. A fluorescent test cream can be used for research, and as an educational tool in the training of dermatological patients on how to apply local treatment.

Risk communication in consultations about hormone therapy in the menopause: concordance in risk assessment and framing due to the context.

BACKGROUND: It is important for the physician and the patient to have a mutual understanding of the possible consequences of different treatment alternatives in order to achieve a partnership in decision-making. OBJECTIVE: The aim of this study was to explore to which degree first-time consultations for discussion of climacteric discomfort achieved shared understanding of the risks and benefits associated with hormone therapy in the menopausal transition. METHODS: Analysis of structure and content of transcribed consultations (n = 20), and follow-up interviews of the women (n = 19 pairs of consultations and interviews), from first-time visits for discussion of climacteric discomfort and/or HT with five physicians at three different outpatient clinics of gynecology in Sweden. RESULTS: Four distinctively different interpretations of risk, depending on whether or not benefits were discussed in the same context, emerged from the analysis. On average, five advantages (range 0-11) and two (0-3) disadvantages were mentioned during the consultations. In the interviews, the women expressed on average four advantages (0-7) and one disadvantage (0-3). There were major variations between advantages and disadvantages expressed in the consultation and the following interview. CONCLUSION: Even though the consultations scored high in patient involvement, the information in most consultations was not structured in a way that made it possible to achieve a shared or an informed decision-taking.

Obesity, dietary pattern and physical activity among children in a suburb with a high proportion of immigrants.

BACKGROUND: Obesity among children is a growing problem. Interventions should be planned to meet needs in different cultural settings. The objective of this study was to explore dietary patterns, physical activity and perceptions of relationships between life-style and health among children in a suburb with low socio-economic status and a high proportion of immigrants and refugees. METHODS: All children (n = 114) in Grades 5 and 6, aged 11 to 12 years, at a local Swedish school were invited, 112 participated. Food and exercise habits and perceptions on health and body image were assessed by a validated questionnaire and an interview. Height and weight were measured and risk for passing BMI 25 and 30 kg/m(2), respectively at the age of 18 was calculated. RESULTS: Thirty-one percent of the children were obese or overweight. Thirty-four percent spent more than 3 h daily watching TV or using computer, a behaviour, which clustered with excess intake of sweet drinks and habitually skipping breakfast. Only about half of the children believed that their life-style could affect their health. The results show that low socio-economic status and migration are proxies for overweight and obesity. CONCLUSIONS: Obesity, unhealthy living and a low awareness of relations between life-style and health call for action, for culturally sensitive prevention and treatment approaches.

The nurse--a resource in hypertension care.

AIM OF THE STUDY: To explore the content and structure of communication between patient and nurse at follow-up appointments concerning hypertension. BACKGROUND: Hypertension is a chronic condition and calls for co-operation between health care providers and patients over a long period of time. One important purpose of the follow-up consultations is to transfer knowledge between patients and health care providers in order to empower patients. This is an important determinant of the quality of care. DESIGN/METHODS: The study was based on 20 audio-recordings of actual follow-up appointments and was approved by ethics committees. The consultations took place at four different health care units for hypertensive patients. FINDINGS: The average length of consultations was 18 minutes. In the consultations, patients initiated an average of eight new topics and nurses an average of 20. All nurses talked with patients about life style. Compared with previous studies of follow-ups with physicians, consultations with nurses addressed lifestyle factors and adherence to treatment to a higher degree. It was also observed that patients were more actively involved in interaction with nurses compared with the follow-ups with physicians. CONCLUSIONS: Active patient participation in care is a critical factor in improving adherence to treatment. It would be of value to develop and assess a more patient-centred organization of hypertension care and thereby more individualized hypertension treatment. Nurses may have a pivot role in such care.

Hypertensive patients' knowledge of high blood pressure.

OBJECTIVE: To investigate hypertensive patients' understanding of the circulatory system, in particular high blood pressure. DESIGN: Semi-structured audio-taped interviews of patients immediately after a regular follow-up appointment with their physician. SETTING: A primary health care centre and a specialist clinic (hypertension unit) in southern Sweden. PATIENTS: 33 hypertensive patients, consecutively selected. MAIN OUTCOME MEASURE: Focus was set on the exploration of patients' understanding/knowledge. RESULTS: In spite of a long history of hypertensive care, on average ten years, patients had a less than satisfactory understanding of their condition. Most patients knew their blood pressure values, but very few were able to give an account of what high blood pressure implies in functional terms. Knowledge of high blood pressure seems mainly to be derived from sources other than the health care system, in particular from the mass media. Knowledge of the risks associated with hypertension was quite good, as was the insight into how these risks could be managed. CONCLUSION: An assessment of patient knowledge of high blood pressure ought to be a starting point for educational strategies that aim to deepen patients' understanding of their state of health.

Perceived symptoms amongst hypertensive patients in routine clinical practice- a population-based study.

OBJECTIVES: To compare perceived symptoms between patients undergoing antihypertensive therapy and hypertensive patients without drug treatment, and to assess reasons for change of antihypertensive medication in routine clinical practice. DESIGN: Population-based multicentre study. Consecutive patients from a randomized sample of centres were given a standardized questionnaire to assess symptoms as well as opinions about their antihypertensive drugs. SETTING: Fifty-five Swedish primary health care centres and 11 clinics of internal medicine. PATIENTS: One thousand and thirteen hypertensive patients on their individually prescribed antihypertensive medication and 13 5 without antihypertensive therapy. MAIN OUTCOME MEASURES: Prevalence and perception of symptoms with and without antihypertensive drug therapy, changes of medication and reasons for this. RESULTS: Amongst the group of patients on antihypertensive medication, 57% spontaneously reported having had symptoms of high blood pressure before they started their drug therapy. Amongst the patients without antihypertensive drugs, 52% reported having such symptoms. When answering direct questions about different symptoms related to current drug treatment or increased blood pressure, patients with and without medication reported symptoms to a similar extent: 80 and 85%, respectively. A majority of patients (64%) had changed their medication during the course of treatment (range 0-61 years). The mean number of changes was 2.4 times over 12 years. The most common reported cause for changing drug treatment was side-effects (42%). CONCLUSIONS: The study shows that patients in general perceive symptoms from hypertension. Antihypertensive medication decreases the frequency and intensity of symptoms that might be related to high blood pressure but adds other symptoms linked to the medication. Changes in medication were mostly related to side-effects. The follow-up should pay attention to patients' experience of treatment. A sign of a well-managed hypertension population would be a decrease of symptoms over time.

Patients' and physicians' assessment of risks associated with hypertension and benefits from treatment.

BACKGROUND: Perceptions of effects of a medical regimen may affect patients' adherence to therapy. OBJECTIVE: To assess concordance between patients' and physicians' estimations of the risks of hypertension and benefits of treatment during a regular follow-up appointment. DESIGN: A population-based Swedish multicentre study. Patients were included consecutively from a randomized selection of centres (55 primary health care centres and 11 clinics of internal medicine). METHODS: A questionnaire was given to 1013 patients undergoing their individually prescribed antihypertensive therapy and 212 physicians who were caring for these patients. RESULTS: Without therapy, patients perceived the risks of cardiovascular complications to be higher than did their physicians. Patients were not aware that an increasing number of risk factors has an impact on the risk of complications. Patients furthermore rated the benefits of treatment higher than did their physicians (P<0.001). Of the patients, 14% had blood pressures < or = 140/90 mmHg. Most of the patients (61%) were not aware of their target blood pressure. However, when the target pressure was communicated to patients by the physician, patients remembered it accurately. The patients were generally not willing to trade even minor side effects from antihypertensive therapy for benefits of treatment. CONCLUSIONS: There was a high degree of inconsistency between patients' and physicians' estimations of risks of hypertension. Patients estimated the effects of treatment to be more beneficial than did their physicians.