Ingvar Krakau

Diet and exercise are equally effective in reducing risk for cardiovascular disease. Results of a randomized controlled study in men with slightly to moderately raised cardiovascular risk factors

To study the impact of diet and exercise and the combination thereof on cardiovascular risk factors, 157 healthy men aged 35-60 years (mean +/- S.D.; 46.2 +/- 5.0) with slightly to moderately raised cardiovascular risk factors, were randomized to 4 groups, diet (D, n = 40), exercise (E, n = 39), diet plus exercise (DE, n = 39), and no active intervention (controls (C, n = 39)), and investigated at baseline and after 6 months. BMI was significantly reduced in Groups E and DE (mean difference and 95% confidence intervals (CI), -0.3 (-0.5, -0.01) and -0.6 (-0.9, -0.3) kg/m2, respectively). Waist circumference was reduced in all 3 intervention groups (D, E, and DE), -1.3 (-2.5, -0.1), -2.2 (-3.2, -1.3) and -3.0 (-3.9, -2.0) cm, but not in the control group. Blood pressure (BP) was reduced in all 3 intervention groups, systolic BP 4-7 mmHg and diastolic BP 2-6 mmHg. Serum cholesterol was reduced in Group DE, -0.45 (-0.77, -0.13) mmol/l. VLDL-cholesterol was reduced in Groups E and DE, -0.14 (-0.26, -0.03) and -0.09 (-0.18, -0.01) mmol/l, whereas LDL-cholesterol was reduced in Groups D and DE -0.30 (-0.54, -0.06) and -0.35 (-0.64, -0.05) mmol/l. In contrast, neither HDL-cholesterol nor serum triglycerides were influenced by the interventions. According to the coronary risk profile derived from the Framingham study, all 3 intervention groups (D, E, and DE) significantly reduced their estimated 10-year risk (-13, -12, and -14%, respectively). We conclude that even with rather moderate changes in diet and exercise, several important cardiovascular risk factors can be affected and that diet and exercise were about equally effective in reducing cardiovascular risk.

Patient charges -- a hindrance to financially and psychosocially disadvantage groups seeking care

This study examines the extent to which people forego seeking primary health care due to the cost and to investigate the associated demographic, physical, psychological and social factors. In 1995, questionnaires were sent to a random sample of the population in two healthcare regions in the Stockholm area in Sweden covering a total of about 400,000 inhabitants. Among the sample of 8200 people over the age of 17 yr, 69% replied to the questionnaire. About 22% stated that on one or more occasions during the past year they had foregone seeking care due to the cost. About 30% stated that they had foregone or hesitated seeking medical help due to the cost during the past year. This applied to women to a greater extent than men. Not seeking medical care was strongly correlated to a self-assessment of personal finances. Among those who described their financial situation as poor, more than half stated that, on at least one occasion, they had foregone seeking medical care due to the cost. As a consequence, weaker groups in society such as the unemployed, students, foreign nationals and single mothers were overrepresented in this group. Those who had foregone care perceive their health as worse and they had a greater degree of general pains and a higher occurrence of chronic disease/disability compared to those who had not foregone care. Between 1970 and 1995, patient charges for consulting a general practitioner within Stockholm County have increased more than three times faster than the consumer price index. The results suggest that the rapidly increasing patient charges particularly affect the weaker social groups and thus pose a threat to the aim of Swedish healthcare legislation--that good care should be available to everyone on equal terms.

Birth weight and cardiovascular risk factors in a cohort followed until 80 years of age : The study of men born in 1913

Objectives.  To analyse whether there is a relation‐ship between birth weight and cardiovascular risk factors given the influence of potential modifying factors from birth time, former generations and adult life.

Cost-utility analysis of group living in dementia care.

A cost-utility analysis (CUA) was applied to group living for dementia patients. A Markov-model of an expected life-length of 8 years was used. Forty-six patients in group living were compared to 39 patients living at home by inclusion and 23 institutionalized patients. When the cost per gained quality-adjusted life-year (QALY) was calculated, the group living alternative was the most favorable for the patients, giving a cost per paired QALY of US dollars < 0. In the extensive sensitivity analysis the main result was consistent but methodological problems were indicated.

Self-rated health, symptoms of depression and general symptoms at 3 and 12 months after a first-ever stroke: a municipality-based study in Sweden

BackgroundSelf-rated health is an important indicator of quality of life as well as a good predictor of future health. The purpose of the study was to follow up the self-rated health and the prevalence of symptoms of depression and general symptoms in a population of first-ever stroke patients 3 and 12 months after stroke.MethodsAll patients surviving their first-ever stroke and residing in Nacka municipality in Stockholm County Council were included using a multiple overlapping search strategy during an 18-month period (n = 187). Our study group comprised the 145 patients who survived the first 3 months after stroke. Three and 12 months after their stroke, the patients were assessed regarding self-rated health and general symptoms using parts of the Göteborg Quality of Life Instrument (GQLI), and regarding symptoms of depression using the Montgomery Asberg Depression Scale (MADRS-S).ResultsSelf-rated health was rated as very good or rather good by 62% at 3 months after stroke and by 78% at 12 months after stroke. More than half of the patients suffered from symptoms of depression, with no significant improvement at 12 months. The most common general symptoms at 3 months after stroke were fatigue, sadness, pain in the legs, dizziness and irritability. Fatigue and sadness were still common at 12 months. Twelve months after stroke the prevalences of crying easily, irritability, impaired concentration, nausea and loss of weight were significantly lower.ConclusionThe majority of patients rated their health as rather good or very good at 3 and 12 months after stroke. However, the majority suffered from fatigue and from symptoms of depression after both 3 and 12 months. In continued care of stroke survivors, it is important to consider the fact that many patients who rate their health as good may nevertheless have symptoms of depression, and some of them may benefit from anti-depressive treatment.

The cost of monitoring warfarin in patients with chronic atrial fibrillation in primary care in Sweden

BackgroundWarfarin is used for the prevention of stroke in chronic atrial fibrillation. The product has a narrow therapeutic index and to obtain treatment success, patients must be maintained within a given therapeutic range (International Normalised Ratio;INR). To ensure a wise allocation of health care resources, scrutiny of costs associated with various treatments is justified. The objective of this study was to estimate the health care cost of INR controls in patients on warfarin treatment with chronic atrial fibrillation in primary care in Sweden.MethodsData from various sources were applied in the analysis. Resource consumption was derived from two observational studies based on electronic patient records and two Delphi-panel studies performed in two and three rounds, respectively. Unit costs were taken from official databases and primary health care centres.ResultsThe mean cost of one INR control was SEK 550. The mean costs of INR controls during the first three months, the first year and during the second year of treatment were SEK 6,811, SEK 16,244 and SEK 8,904 respectively.ConclusionINR controls of patients on warfarin treatment in primary care in Sweden represent a substantial cost to the health care provider and they are particularly costly when undertaken in home care. The cost may however be off-set by the reduced incidence of stroke.

Provision for clinic patients in the ED produces more nonemergency visits

This study sought to evaluate how the addition of a general practitioner (GP) surgery influences the utilization of an emergency department (ED). An intervention trial with historical control was conducted in a Swedish university hospital ED. A GP surgery was established in the ED by the addition of GP physicians without the addition of other personnel (nurses, secretaries, aids). The number of persons evaluated and managed by the GP physicians and ED physicians were quantified preintervention (April 1992 to October 1993) and postintervention (April 1994 to October 1995). Further information was obtained by questionnaires distributed to all physicians and patients during three sample study weeks: 1 week before intervention and 6 and 18 months after the intervention. Patient volume, percentages of inappropriate visits, and types of services were recorded. The addition of GP physicians increased the number of visits to the ED by 27% (4,694 per month to 5,952 per month). The percentage of patients managed in the ED who had nonurgent complaints (primary health care needs) increased with the intervention from 22% (95% confidence interval [CI] 19%, 25%) to 33% (95% CI 30%, 37%). The increased demand on the ED of patients with nonurgent complaints increased the average waiting time for patients with urgent or emergent complaints from 35 minutes to 40 minutes (14%). The introduction of GPs to an ED increased the number and proportion of patients presenting to the ED with nonurgent complaints.

Prevention of cardiovascular disease within the primary health care system: Feasibility of a prevention programme within the Sollentuna primary health care catchment area

OBJECTIVE To integrate prevention of cardiovascular disease within the primary health care. DESIGN A prevention programme which combines population and individual high-risk strategy. SETTING The Primary Health Care in Sollentuna, Stockholm, Sweden. MAIN OUTCOME MEASURE Characteristics of, and risk factor prevalence among, persons registered in the prevention programme. RESULTS During the first year more than 2000 persons, representing every tenth visitor and 6% of the population aged 15-60 years, were registered in the prevention programme. 90% were < or = 60 years and 62% were women. A large proportion (70%) had risk factors that required advice, treatment, and follow up. 24% of the men and 27% of the women were smokers, 68% and 62% respectively, had serum cholesterol > or = 5.2 mmol/l, and 33% and 22% had a diastolic blood pressure > or = 90 mmHg. CONCLUSION The present study implies that it is possible to integrate a large scale prevention programme in the existing primary health care organization. The prevalence of risk factors in those who enter the prevention programme is high, which places great demands for treatment and follow up.

Perception of Health and Use of Health Care Services in a Swedish Primary Care District. A ten Year's Perspective

In a study that covered ten years a questionnaire about perceived health and use of health care services was mailed each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district. The majority of respondents thought that their health was good, and only a small minority reported themselves as quite, or very sick. Those assessments were stable during the ten year period. The tendency to visit the health services increased with the degree of severity of the illness. This increase was most marked in the case of visits to emergency departments and visits by appointment at hospitals, and least in the case of visits to private doctors and company/school physicians, while visits to doctors at health centres and to district nurses occupied an intermediate position. Thus, by including a simple question about perceived health in a questionnaire designed to measure use of health care services, important information about the relations between use of health services and health conditions could be obtained.

Quality of life is not negatively affected by diet and exercise intervention in healthy men with cardiovascular risk factors.

Health-related quality of life was assessed in a diet and exercise intervention study among 157 healthy men aged 35–60 years (mean ± s.d.; 46.2 ± 5.0) with moderately raised cardiovascular risk factors. The men were randomized to four groups, diet (D, n=40), exercise (E, n=39), diet plus exercise (DE, n=39), and no active intervention (controls (C) n=39). Quality of life was measured with two self-administered questionnaires; Subjective Symptoms Assessment Profile and Minor Symptom Evaluation Profile, at baseline and after 1.5, 3 and 6 months. Cardiovascular risk factors were investigated at baseline and after 6 months. As a result of changes in dietary habits and physical exercise in the three intervention groups, several important cardiovascular risk factors were significantly reduced. The quality of life/well-being did not differ between the four groups and did not change significantly in any of the groups during the study. There was, however, a tendency towards fewer gastrointestinal symptoms in group D and fewer cardiac symptoms in group DE. We conclude that advice on lifestyle changes in the form of diet and exercise reduce risk factors in middle-aged men without negative effects on their quality of life.