Håkon Sandholdt

Social disparities in diabetes care: a general population study in Denmark

Abstract Objective: We investigated the association between socioeconomic factors and the attainment of treatment goals and pharmacotherapy in patients with type 2 diabetes in Denmark. Design: A cross-sectional population study. Setting: The municipality of Naestved, Denmark. Subjects: We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens. Main outcome measures: The proportion of patients who were not achieving goals for diabetes care based on their HbA1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication. Methods: We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease. Results: Middle age (40–65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES. Conclusions: In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care. KEY POINTS Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Association of socioeconomic factors with pharmacotherapy was inconsistent.

Prevalence and clinical significance of neutropenia discovered in routine complete blood cell counts: a longitudinal study

Neutropenia, defined as an absolute blood neutrophil count (ANC) <1.5 G L−1, may accompany a variety of diseases. However, the clinical significance of neutropenia detected in a routine complete blood cell count is poorly understood.

Antibiotic prescriptions for suspected respiratory tract infection in primary care in South America

Objectives To describe and compare antibiotic prescribing patterns for primary care patients with respiratory tract infections (RTIs) in four South American countries. Methods This was a prospective observational study. General practitioners (GPs) from Argentina, Bolivia, Paraguay and Uruguay registered data about all consultations of patients with suspected RTIs in the winter of 2014 (June–August). Variation in antibiotic prescriptions was assessed using a two-level hierarchical logistic model. Results Participating GPs (n = 171) registered 11 446 patients with suspected RTI; 3701 (33%) of these received an antibiotic prescription. There was a wide variation across countries in the use and selection of antibiotics. For example, 94% of patients with acute bronchitis were prescribed antibiotics in Bolivia, while in Uruguay only 21% received antibiotics. Amoxicillin was the most commonly prescribed antibiotic across countries, but prescription rates varied between 45% in Bolivia and 69% in Uruguay. Compared with the overall mean prescribing rate, and after adjusting for clinical presentation and demographics, prescribing of antibiotics varied by a factor of 6, the OR ranging from 0.37 (95% CI = 0.21–0.65) in Uruguay to 2.58 (95% CI = 1.66–4) in Bolivia. Conclusions The large variation in use and selection of antibiotics across countries is not explained by different patient populations. It could be explained by diagnostic uncertainty and contextual characteristics beyond clinical practice. Reducing uncertainty and country variation requires greater support from the healthcare systems by providing GPs with evidence-based guidelines and tools to apply them.

Predictors of undiagnosed prevalent type 2 diabetes - The Danish General Suburban Population Study.

AIMS To investigate how self-reported risk factors (including socioeconomic status) predict undiagnosed, prevalent type 2 diabetes mellitus (T2DM). To externally validate Leicester Risk Assessment Score (LRAS), Finnish Diabetes Risk Score (FINDRISC) and Danish Diabetes Risk Score (DDRS), and to investigate how these predict a European Heart SCORE≥5% in a Danish population study. METHODS We included 21,205 adults from the Danish General Suburban Population Study. We used relative importance calculations of self-reported variables in prediction of undiagnosed T2DM. We externally validated established prediction models reporting ROC-curves for undiagnosed T2DM, pre-diabetes and SCORE. RESULTS More than 20% of people with T2DM were undiagnosed. The 7 most important self-rated predictors in sequential order were high BMI, antihypertensive-therapy, age, cardiovascular disease, waist-circumference, fitness compared to peers and family disposition for T2DM. The Area Under the Curve for prediction of undiagnosed T2DM was 77.1 for LRAS; 75.4 for DDRS and 67.9 for FINDRISC. AUCs for SCORE was 75.1 for LRAS; 62.3 for DDRS and 54.3 for FINDRISC. CONCLUSIONS BMI and self-reported cardiovascular disease are important risk factors for undiagnosed T2DM. LRAS performed better than DDRS and FINDRISC in prediction of undiagnosed T2DM and SCORE≥5%. SCORE performed best in predicting pre-diabetes.

Full journal publication of abstracts presented at the Nordic Congress of General Practice in 2009 and 2011

Abstract Objective: To determine the overall publication rates for abstracts presented at two consecutive Nordic Congresses of General Practice and to evaluate determinants for these publication rates. Design: Prospective study. Setting: MEDLINE (PubMed) and Google Scholar were searched for relevant publications from 1 January 2009 up until 31 August 2014. Methods: Abstracts accepted for oral or poster presentation were identified from the original congress booklets from the Nordic Congresses of General Practice in 2009 and 2011. Based on PubMed and Google Scholar searches, we subsequently identified full journal publications within a 36-month follow-up from both congresses. In cases of doubt, the first author was contacted directly. Main outcome measures: Full journal publication within 36 months after the congress. Results: A total of 200 abstracts were analyzed. Of these, 85 (42.5%) were identified with a full publication within 36 months after the congress. More abstracts from the 2011 congress were published compared to the 2009 congress odds ratio (OR) 1.97, 95% confidence interval (CI) (1.10; 3.50). Abstracts accepted for oral presentation were more often published OR 1.94, 95% CI (1.08; 3.50) than accepted poster abstracts. In the multivariate analysis, a university affiliation for both first and last author increased the probability for publication OR 4.23, 95% CI (1.71; 10.42), as well as more than two authors. An optimal number, based on the highest OR, seems to be 3–4 authors with OR 2.43, 95% CI (1.07; 5.54). Qualitative studies were published at the same frequency as quantitative studies OR 1.36, 95% CI (0.57; 3.24). Conclusion: Less than half of the abstracts accepted for oral or poster presentation at two consecutive Nordic Congresses of General Practice were published as full text articles within 36 months. Key points Congress abstracts accepted for Nordic Congress of General Practice are not indexed in international search databases. Less than half of the abstracts accepted for oral or poster presentation at two consecutive Nordic Congresses of General Practice were published as full text articles within 36 months. Future congress committees could address this aspect in order to increase the visibility of and accessibility to research within the field of general practice.

Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice

Objectives In Denmark, general practice is responsible for 75% of antibiotic prescribing in the primary care sector. We aimed to identify practice-related factors associated with high prescribers, including prescribers of critically important antibiotics as defined by WHO, after accounting for case mix by practice. Methods We performed a nationwide register-based survey of antibiotic prescribing in Danish general practice from 2012 to 2013. The unit of analysis was the individual practice. We used multivariable regression analyses and an assessment of relative importance to identify practice-related factors driving high antibiotic prescribing rates. Results We included 98% of general practices in Denmark ( n  =   1962) and identified a 10% group of high prescribers who accounted for 15% of total antibiotic prescriptions and 18% of critically important antibiotic prescriptions. Once case mix had been accounted for, the following practice-related factors were associated with being a high prescriber: lack of access to diagnostic tests in practice (C-reactive protein and urine culture); high use of diagnostic tests (urine culture and strep A throat test); a low percentage of antibiotic prescriptions issued over the phone compared with all antibiotic prescriptions; and a high number of consultations per 1000 patients. We also found that a low number of consultations per 1000 patients was associated with a reduced likelihood of being a high prescriber of antibiotics. Conclusions An apparent underuse or overuse of diagnostic tests in general practice as well as organizational factors were associated with high-prescribing practices. Furthermore, the choice of antibiotic type seemed less rational among high prescribers.

How well do general practitioners know their elderly patients' social relations and feelings of loneliness?

BackgroundSocial relationships are important to people and affect their quality of life, morbidity and mortality. The aim of this study was to examine the correlation between elderly patients’ descriptions of their social relations and feelings of loneliness, and their general practitioners’ assessments of these.MethodsCross-sectional study in 12 general practices in the Capital Region of Denmark. During a three-week period each practice asked their patients aged 65 and older to fill out a questionnaire regarding health, social relations and loneliness; the general practitioner (GP) filled out a matching questionnaire regarding their perception of the patient’s social relations and loneliness. Data were collected from February to September 2014.ResultsOf the 767 eligible patients 476 were included in the study. For 447 patients both GP and patient had answered at least one question on loneliness or social participation. The correlations between patients’ and GPs’ answers regarding social participation and loneliness were low (0.04–0.26). While GPs were less able to identify lonely patients and patients with low social participation, they were better at identifying not-lonely patients or those with high social participation. It was especially difficult for GPs to identify lonely patients when they were not living alone or if the GP believed the patient had high social participation.ConclusionGPs have difficulty identifying patients who are lonely or have low social participation and this ability is further diminished when the patients do not live alone or if the GP believes them to have high social participation. Given the consequences of loneliness and limited social participation on patients’ health and well-being, and GPs’ limited ability to identify these patients, GPs’ obligations and resources in this area need to be clarified.

Anemia is present years before myelodysplastic syndrome diagnosis – results from the pre-diagnostic period

expected to improve. The reason for lower Hb levels in mPV has not been elucidated, although one postulated theory is iron deficiency. However, there were no differences in ferritin levels between PV-N and PV-08 patients in our study. The CYTO-PV randomized trial reported that Hct levels below 45% was the optimal threshold to reduce cardiovascular complications in PV patients. Therefore, under-diagnosed PV patients with Hct over 45% could potentially be at risk for cardiovascular complications, and we searched our cohort for such a population. Importantly, even after application of the 2016 WHO criteria for PV, we still found 17 JAK2V617F-positive MPN patients showing relatively high Hct levels (45-49% in males and 45-48% in females) (high hematocrit MPN: HH-MPN) who could not be diagnosed as any of the defined PV criteria (PV-08, PV-16, or mPV). Of these 17 patients, median Plt counts and JAK2V617F allele burdens were 748 3 10/L and 35.2%, respectively. We previously reported that median Plt counts and JAK2V617F allele burdens in JAK2V617Fpositive PV and JAK2V617F-positive ET were 504.6 3 10/L and 889.7 3 10/L, 71.7% and 35.5%, respectively. Thus, Plt counts and JAK2V617F allele burdens in HH-MPN patients resembled that of ET and not PV. Moreover, when the British Committee of Standards in Haematology (BCSH) criteria was applied to these 17 HHMPN patients, 13 patients were diagnosed with ET and four patients did not meet the criteria for any of the MPNs. On top of this, only two of the HH-MPN patients showed BM pathology in line with PV. Therefore, it can be concluded that as a whole, HH-MPN represented ET patients, and the 2016 WHO criteria correctly excluded these patients from a diagnosis of PV. Distinguishing PV from ET is important because life expectancy is lower in PV, thrombotic events and transformation to myelofibrosis are more frequent in PV, and most of all, management recommendations differ between PV and ET. In conclusion, the 2016 WHO criteria rendered a diagnosis of PV to a wider range of patients including all masked PV patients while maintaining diagnostic accuracy. As a result, the 2016 WHO criteria can be expected to raise treatment rates and bring about better outcomes in PV patients.