Flemming Bro

Patient delay in cancer studies: a discussion of methods and measures

BackgroundThere is no validated way of measuring the prevalence and duration of patient delay, and we do not know how people perceive and define the time intervals they are asked to report in patient delay studies. This lack of a validated measure hampers research in patient delay and is counterproductive to efforts directed at securing early diagnosis of cancer.DiscussionThe main argument of the present paper is that current studies on patient delay do not sufficiently consider existing theories on symptom interpretation. It is illustrated that the interpretation of bodily sensations as symptoms related to a specific cancer diagnosis is embedded within a social and cultural context. We therefore cannot assume that respondents define delay periods in identical ways.SummaryIn order to improve the validity of patient delay studies, it is suggested that research be strengthened on three counts: More research should be devoted to symptom interpretation processes, more research should seek to operationalise patient delay, and, importantly, more research is needed to develop valid instruments for measuring patient delay.

'Containment' as an analytical framework for understanding patient delay: A qualitative study of cancer patients' symptom interpretation processes

Recent decades have seen much variation in survival and mortality among European cancer patients, with rather small increases in survival, especially among patients in UK and Denmark. This poor outcome has been ascribed tentatively to patient delay since an estimated 20-25% of all cancer patients report having experienced cancer-related symptoms for more than three months before seeking care. In this article we analyse semi-structured interviews with 30 adult Danish cancer patients and their families. Special focus is given to symptom interpretation processes, and how these processes potentially delay care-seeking decisions. The paper adopts a contextual approach inspired mainly by the sociologist Alonzos (1979, 1984) concept of containment. Alonzos theory is supplemented with recent anthropological and sociological literature on how people establish the relation between bodily sensations and symptoms and decide how to respond adequately to these. We present an analysis illustrating that bodily sensations and symptoms are potentially contained in a dynamic interplay of factors related to specific social situations, life biographies and life expectations and their accordance with culturally acceptable values and explanations. Finally, we discuss the implications of the analysis for future studies on patient delay.

Does the organizational structure of health care systems influence care-seeking decisions? A qualitative analysis of Danish cancer patients' reflections on care-seeking

Abstract Objective. The absence of a more significant improvement in cancer survival in countries such as the UK and Denmark may be partly rooted in delayed care-seeking among cancer patients. Past research on patient delay has mainly focused on patient characteristics (e.g. sociodemographic and psychological factors and symptom recognition) as causes of delayed care-seeking, while few studies have examined how the organizational structure of health care systems may influence patients’ reflections on seeking care. The aim of this study was to explore this relationship. Design. The analysis presented is based on semi-structured interviews with 30 cancer patients and their families. Results. The article raises two hypotheses on the relationship between structural elements of a health care system and peoples reflections on seeking health care: (1) Gatekeeping introduces an asymmetrical relationship between the patient and the GP which potentially results in self-restricting care-seeking, (2) Continuity in the doctor–patient relationship may negatively influence patient reflections on access to health care, as the focus shifts from the medical issues of the consultation to reflections on how to properly interact with the GP and the system in which she/he is situated. Conclusion. It is concluded that these hypotheses form a sound basis for further primary care research on how the organizational structure of health care systems influences patient reflections on access to medical care.

Use of antibiotics in general practice in Denmark in 1987

The worldwide usage of antibiotics is increasing making detailed information on prescribing patterns and intervention methods necessary. This investigation focused on the general practitioners (GPs) usage of antibiotics in Denmark. Information on 7,607 patients treated by 602 GPs during 1 week in March 1987 were collected. The most commonly treated infectious diseases were upper respiratory tract infections (40%) and lower respiratory tract infections (17%). Penicillin was by far the most frequently prescribed antibiotic (44%), followed by antibiotics used locally (17%) and ampicillins (14%). Compared with previous investigations, this result indicated a relative increase in prescription of penicillin during recent years. The mean number of daily dosages was 2-3 and the duration of treatment 6-7 days, with ampicillin generally given 1 day longer than penicillin. The differences between prescribed daily dosages (PDD) found and defined daily dosages (DDD) ranged from + 40% to - 50%, making estimations of numbers of treated patients from total usage of antibiotics in DDD/1,000 inhabitants/day impossible.

Sick leave and work disability in primary care patients with recent-onset multiple medically unexplained symptoms and persistent somatoform disorders: a 10-year follow-up of the FIP study.

OBJECTIVE The objective was to explore patient characteristics and 10-year outcome of sick leave and work disability for patients with recent-onset multiple medically unexplained symptoms (MUS) and persistent somatoform disorders (SD). METHOD Consecutive patients consulting their family physician (FP) completed a preconsultation questionnaire on symptoms and mental illness (n=1785). The main problem was categorized by the FP after the consultation, and a stratified subsample was examined using a standardized diagnostic interview (n=701). Patients were grouped into three cohorts: recent onset of multiple MUS (n=84); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, persistent SD (n=183); and reference group with well-defined physical disease according to FP (n=833). Register data on sick leave and disability pension were obtained. RESULTS At index consultation, disability pension was received by 8.3% (n=7) in the recent-onset multiple MUS group, 19.1% (n=35) in the SD group and 3.5% (n=29) in the reference group. Both the recent-onset multiple MUS group [hazard ratio (HR)=2.28, 95% confidence interval (CI): 1.14-4.55] and the SD group (HR=3.26, 95% CI:1.93-5.51) had increased risk of new disability pension awards. Furthermore, the SD group had increased risk of sick leave. CONCLUSIONS Both recent-onset and persistent MUS have significant long-term impact on patient functioning in regard to working life; this calls for early recognition and adequate management of MUS in primary care.

The effect of reimbursement on the use of antibiotics.

OBJECTIVE To examine the effect of a reduction on the reimbursement of drugs on the use of antibiotics by general practitioners in Denmark. DESIGN A prospective study using a questionnaire comparing the results with a similar study 3 years before, a period with normal reimbursement. PARTICIPANTS 553 general practitioners prescribed antibiotics for 5765 patients. MAIN OUTCOME MEASURE Number of treated patients and choice of antibiotics. RESULTS 7607 patients were treated in 1987 compared with 5765 in 1990, the relative number of patients treated for sinusitis, other upper respiratory tract infections, acute bronchitis, pneumonia and upper gynaecological infections was significantly less in 1990 than in 1987. Other infections, particularly those that are often diagnosed by culture or microscopy by the general practitioners themselves, increased significantly. They included tonsillitis and urinary tract infections. CONCLUSION Reimbursement can be a very powerful tool controlling the use of antibiotics by general practitioners.

HbA1c in an unselected population of 4438 people with Type 2 diabetes in a Danish county

OBJECTIVE To describe the use and level of HbA1c in a large unselected Type 2 diabetic population in Denmark. In addition, to describe the characteristics of the patients and the general practitioners in relation to the monitoring of HbA1c. DESIGN Data were collected from public data files for the period January 1993 to December 1997. SETTING The County of Vejle with a background population of 342,597 citizens, 303,250 of whom were listed with participating general practitioners. PATIENTS The Type 2 diabetic population alive and resident in the county on 1 January 1997. RESULTS In a population of 4438 Type 2 diabetics, 73% had a minimum of one annual HbA1c measurement in 1997. No HbA1c measurement was associated with a long history of diabetes, diet treatment or old age. Poor glycaemic regulation was found in 65% of the Type 2 diabetics in 1997. Poor glycaemic regulation was associated with tablet or insulin treatment, age under 70 years and long history of diabetes. The interpractice variation was huge. CONCLUSION The quality of HbA1c monitoring of Type 2 diabetics needs to be improved. Possibilities for improvement seem to be present.

Diffusion of an e-learning programme among Danish General Practitioners: A nation-wide prospective survey

BackgroundWe were unable to identify studies that have considered the diffusion of an e-learning programme among a large population of general practitioners. The aim of this study was to investigate the uptake of an e-learning programme introduced to General Practitioners as part of a nation-wide disseminated dementia guideline.MethodsA prospective study among all 3632 Danish GPs. The GPs were followed from the launching of the e-learning programme in November 2006 and 6 months forward. Main outcome measures: Use of the e-learning programme. A logistic regression model (GEE) was used to identify predictors for use of the e-learning programme.ResultsIn the study period, a total of 192 different GPs (5.3%) were identified as users, and 17% (32) had at least one re-logon. Among responders at first login most have learnt about the e-learning programme from written material (41%) or from the internet (44%). A total of 94% of the users described their ability of conducting a diagnostic evaluation as good or excellent. Most of the respondents used the e-learning programme due to general interest (90%). Predictors for using the e-learning programme were Males (OR = 1.4, 95% CI 1.1; 2.0) and members of Danish College of General Practice (OR = 2.2, 95% CI 1.5; 3.1), whereas age, experience and working place did not seem to be influential.ConclusionOnly few Danish GPs used the e-learning programme in the first 6 months after the launching. Those using it were more often males and members of Danish College of General Practice. Based on this study we conclude, that an active implementation is needed, also when considering electronic formats of CME like e-learning.Trial RegistrationClinicalTrials.gov Identifier: NCT00392483.

Metronidazole Pessaries Compared with Placebo in the Treatment of Bacterial Vaginosis

In a randomized, double-blind clinical trial from general practice, 500 mg metronidazole pessaries applied once daily for seven days were compared with placebo in the treatment of bacterial vaginosis. Seventy-five women completed the study. At the follow-up visit immediately after completion of treatment, none of the patients on metronidazole fulfilled the criteria for bacterial vaginosis, compared with 12 (35%) in the placebo group (p less than 0.001). Nine (22%) of the patients treated with metronidazole harboured Gardnerella vaginalis after treatments, compared with 31 (91%) in the placebo group (p less than 0.001). Symptoms had improved or disappeared in 33 (80%) on metronidazole, and in 18 (53%) on placebo therapy (p less than 0.05). Four weeks after the follow-up visit, symptoms were reported by 28% in the metronidazole group and by 44% in the placebo group (p greater than 0.05). Metronidazole pessaries are effective in the treatment of bacterial vaginosis.

The Diagnosis of Candida Vaginitis in General Practice

In a multi-practice study, 29 general practitioners registered 361 women with increased vaginal discharge, malodour, or pruritus, and 229 women without vaginal complants. A wet-smear was examined for Candida by the general practitioner. Culture for Candida was performed in the general practitioners laboratory, and at a microbiological laboratory. Candida was found by microscopy or culture in 140 (39%) women with vaginal symptoms, compared with 51 (22%) without vaginal complaints (p less than 0.001). In 34 women with symptoms (24%) Candida was found by wet-smear microscopy, in 98 (76%) by microscopy or culture in the general practitioners laboratory, and in 126 (90%) by microscopy or culture at the microbiological laboratory. No relation was found between the number of Candida isolated and the presence of vaginal symptoms (p greater than 0.05). The sensitivity of microscopy was low compared with previous studies and underlines the need for multi-practice studies in the evaluation of diagnostic procedures. Vagicult is recommended for general practice, but problems exist in the interpretation of a positive culture result.