Dorte Gannik

Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners

Abstract Objective: To explore the suitability of a screening based intervention for excessive alcohol use by describing the experiences of general practitioners who tried such an intervention in their everyday practice. Design: Qualitative interviews with general practitioners who had participated in a pragmatic study of a combined programme of screening and a brief intervention for excessive alcohol use. Doctors were interviewed either individually or in focus groups. A computer based, descriptive, phenomenological method was used to directly analyse the digitally recorded interviews. Setting and participants: 24 of 39 general practitioners in four Danish counties who volunteered to take part in the pragmatic study were interviewed. Results: The doctors were surprised at how difficult it was to establish rapport with the patients who had a positive result on the screening and to ensure compliance with the intervention. Although the doctors considered the doctor-patient relationship robust enough to sustain targeting of alcohol use, they often failed to follow up on initial interventions, and some expressed a lack of confidence in their ability to counsel patients effectively on lifestyle issues. The doctors questioned the rationale of screening in young drinkers who may grow out of excessive drinking behaviour. The programme needed considerable resources, and it interrupted the natural course of consultations and was inflexible. The doctors could not recommend the screening and brief intervention programme, although they thought it important to counsel their patients on drinking. Conclusions: Screening for excessive alcohol use created more problems than it solved for the participating doctors. The results underline the value of carrying out pragmatic studies on the suitability of seemingly efficacious healthcare programmes.

The relationship between HbA1c level, symptoms and self-rated health in type 2 diabetic patients

Abstract Objective. Improving glycaemic control is generally supposed to reduce symptoms experienced by type 2 diabetic patients, but the relationships between glycated haemoglobin (HbA1c), diabetes-related symptoms, and self-rated health (SRH) are unclarified. This study explored the relationships between these aspects of diabetes control. Design. A cross-sectional study one year after diagnosis of type 2 diabetes. Subjects. A population-based sample of 606 type 2 diabetic patients, median age 65.6 years at diagnosis, regularly reviewed in primary care. Main outcome measures. The relationships between HbA1c, diabetes-related symptoms, and SRH. Results. The patients’ median HbA1c was 7.8 (reference interval: 5.4–7.4 % at the time of the study). 270 (45.2%) reported diabetes-related symptoms within the past 14 days. SRH was associated with symptom score (γ = 0.30, p < 0.001) and HbA1c (γ = 0.17, p = 0.038) after correction for covariates. The relation between HbA1c and symptom score was explained by SRH together with other confounders, e.g. hypertension (γ = 0.02, p = 0.40). The relation between the symptom fatigue and SRH was not explained by symptom score and significantly modified the direct association between symptom score and SRH. Conclusions. Symptom relief may not occur even when HbA1c level is at its lowest average level in the natural history of diabetes, and symptoms and SRH are closely linked. Monitoring symptoms in the clinical encounter to extend information on disease severity, as measured e.g. by HbA1c, may help general practitioners and patients to understand the possible impact of treatments and of disease manifestations in order to obtain optimum disease control.

Self-referral and self-payment in Danish primary care

This study aims at characterizing the group of people who want to have the right to consult any general practitioner or practising specialist without referral on condition of part self-payment, as opposed to the group of people who choose to be registered with a general practice that offers free services but controls further access to the health care system. All adults or a 10% sample of those listed in nationwide Danish registers were examined cross-sectionally for social and demographic factors and utilization of primary and secondary health care. A minority, which totals 3% of the population, chose free choice of doctor and part self-payment. On average, this group is older and has a higher income. Its mortality and its utilization of general practice and hospital services are lower, and its use of practising specialists is higher, than the majority. Among the persons who chose free choice and self-payment, the pattern of utilization is more likely to be due to a wish for free choice and for specialized medical care than to high morbidity. Dissatisfaction caused by restrictions on self-referral to specialists can be met by offering an option of a parallel system of free choice of doctor on condition of part self-payment.