Jakob Kragstrup

Does persistent involvement by the GP improve palliative care at home for end-stage cancer patients?

Objective: To analyse the effect of GP home visits on the granting of a terminal declaration (TD) and on place of death. Participants and design: A total of 2025 patients with cancer as the primary cause of death in the period 1997-1998, were investigated in a mortality follow-back design using the Danish Cancer Register and four administrative registers. The Danish TD can be issued by a physician for patients with an estimated prognosis of six months or less. The TD gives the right to economic benefits and increased care for the dying patient. Setting: The island of Funen/Denmark. Main outcome measures: Main outcome hospital death. Intermediate outcome TD. Results: A total of 38% of patients received a TD and 56% died in hospital. GP home visits in the week before TD (odds ratio (OR): 16.8; 95% CI: 8.2-34.4), as well as four weeks before TD (OR: 6.4; 95% CI: 4.5-9.2) were associated with an increased likelihood of receiving a TD. GP home visits in the group with TD (OR: 0.18; 95% CI: 0.11-0.29) and the group without TD (OR: 0.08; 95% CI: 0.05-0.13) was inversely associated with hospital death. A dose-response relationship was found in both groups. Conclusion: Persistent involvement by the GP is associated with improved end-of-life care for cancer patients. Provided that temporal relations are taken into account, the mortality follow-back design can be a suitable and ethical research method to highlight and monitor end-of-life cancer care.

Mailed prescriber feedback in addition to a clinical guideline has no impact: a randomised, controlled trial

Scand J Prim Health Sci 2002;20:000-000. ISSN 0281-3432 Objective - To evaluate the impact of feedback on the prescribing of antibiotics supplementary to clinical guidelines in the treatment of respiratory tract infections. Design - Randomised, controlled trial with GPs allocated to one of two groups. The first group received clinical guidelines on the treatment of respiratory tract infections plus postal feedback with aggregated data on their prescribing patterns for antibiotics. The second group served as controls for the first group and received the guidelines only. Setting - 299 GPs representing 181 practices with 455 843 listed patients in the County of Funen, Denmark. Main outcome measures - Effects on GP prescribing patterns were measured by means of a prescription database and followed for a period of 2 years with 2 outcome measures: 1) the antibiotic prescription rate and 2) the fraction of prescriptions for narrow-spectrum antibiotics. Results - The addition of feedback had no impact on GP prescribing patterns. Conclusion - Postal disseminated prescriber feedback in addition to a clinical guideline on the diagnosis and treatment of respiratory tract infections does not influence GP prescribing patterns. Interventions aimed at improving performance in general practice should go beyond just giving GPs information on whether they are living up to standards.

Consultation with the general practitioner triggered by advice from social network members

Objective To investigate whether advice from a persons social network triggers contact with the general practitioner (GP). Design Case-crossover design comparing the frequency of advice given to seek medical attention in the period before contact with a GP and the frequency in matching control time periods for the same individual. Setting Twenty-one Danish GPs working in single-handed practices. Subjects 322 patients, aged between 18 and 91 years, were interviewed by telephone after an unscheduled visit to their GP; 148 were interviewed again 3–6 months later. Main outcome measures The odds of individuals consulting their GP after receiving advice from network members in the period before they contacted their GP compared with the odds of those consulting their GP in the control period(s). Results Being advised by others to seek medical attention increased the likelihood of seeking primary health care approximately fivefold – single men received advice significantly less frequently (7%) than women (18%) and cohabiting men (32%). Conclusion Advice from other social network members to seek medical attention is a frequent and influential cue prompting individuals to contact their GP.

Guidelines accompanied by changes in reimbursement rules Effects on lipid-lowering drug prescribing

OBJECTIVE To analyse the effect of guidelines accompanied by changes in reimbursement rules for the prescription of lipid-lowering drugs (LLDs). DESIGN Observational study focusing on LLD use before (1994-98) and after an intervention (1999). SETTING Guidelines were developed by the Danish College of General Practitioners and focused on prevention of cardiovascular heart disease (CHD). Guidelines were sent out and changes in reimbursement took place in December 1998. Prescriptions for LLDs were extracted from a population-based prescription database (Odense University Pharmacoepidemiological Database, OPED) covering 10% of the Danish population (470,000 inhabitants). MAIN OUTCOME MEASURES Incidence rate and 1 year prevalence rate (annual prevalence) of LLD use. RESULTS The incidence of LLD use increased significantly in the year following the intervention. Incidence rate ratio (after/before) was 1.43 (CI 1.35-1.52). The annual prevalence of LLD use in the population increased by 0.4% after the intervention (0.2% before). The corresponding figure for patients with diabetes mellitus (treated with insulin or oral anti-diabetics) was 2.3% after the intervention (1.2% before), and for patients with CHD (treated with vasodilators) 8.1% after the intervention (5.0% before). CONCLUSION Guidelines accompanied by a change in reimbursement rules had a significant influence on the prescribing of lipid-lowering drugs.Objective - To analyse the effect of guidelines accompanied by changes in reimbursement rules for the prescription of lipid-lowering drugs (LLDs). Design - Observational study focusing on LLD use before (1994- 98) and after an intervention (1999). Setting - Guidelines were developed by the Danish College of General Practitioners and focused on prevention of cardiovascular heart disease (CHD). Guidelines were sent out and changes in reimbursement took place in December 1998. Prescriptions for LLDs were extracted from a population-based prescription database (Odense University Pharmacoepidemiological Database, OPED) covering 10% of the Danish population (470 000 inhabitants). Main outcome measures - Incidence rate and 1 year prevalence rate (annual prevalence) of LLD use. Results - The incidence of LLD use increased significantly in the year following the intervention. Incidence rate ratio (after/before) was 1.43 (CI 1.35?1.52). The annual prevalence of LLD use in the population increased by 0.4% after the intervention (0.2% before). The corresponding figure for patients with diabetes mellitus (treated with insulin or oral anti-diabetics) was 2.3% after the intervention (1.2% before), and for patients with CHD (treated with vasodilators) 8.1% after the intervention (5.0% before). Conclusion ? Guidelines accompanied by a change in reimbursement rules had a significant influence on the prescribing of lipidlowering drugs.

Placebo-Controlled Discontinuation of Long-Term Acid-Suppressant Therapy: A Randomised Trial in General Practice

Objective. To investigate whether patients on long-term antisecretory medication need to continue treatment to control symptoms. Methods. A double-blinded randomised placebo-controlled trial in general practices in Denmark. Patients aged 18–90 who were treated with antisecretory drugs on a long-term basis were randomized to esomeprazole 40 mg or identical placebo. Outcome measures were time to discontinuation with trial medication due to failed symptom control analysed as survival data. The proportion of patients stopping trial medication during the one-year follow-up was estimated. Results. A total of 171 patients were included with a median prior duration of antisecretory treatment of four years (range: 0.5 to 14.6 years). 86 patients received esomeprazole 40 mg and 85 patients received placebo. At 12 months, statistically significantly more patients in the placebo group had discontinued (73% (62/85)) compared with the esomeprazole group (21% (18/86); p < 0.001). Conclusions. Long-term users of antisecretory drugs showed a preference for the active drug compared to placebo. However, 27% of patients continued on placebo throughout the study and did not need to reinstitute usual treatment. One in five patients treated with esomeprazole discontinued trial medication due to unsatisfactory symptom control. Discontinuation of antisecretory treatment should be considered in long-term users of antisecretory drugs. This trial is registered with Trial registration ClinicalTrials.gov ID: NCT00120315.

A new method for analyzing diagnostic delay in gynecological cancer.

Objective The aim of this article is to present a new methodology to illustrate, understand, and measure delay in health care. The method is inspired by process mapping tools as analytical framework and demonstrates its usefulness for studying diagnostic delay in gynecological cancer. Materials and Methods Six women with a diagnostic delay of 6 weeks or more before treatment of gynecological cancer at a specialized regional department (the Department of Gynecology and Obstetrics, Odense University Hospital, Denmark) were included in the study. Maps of existing processes were performed for each patient reflecting the patients’ pathway through the course of the disease. We combined 2 process mapping tools, namely, value stream mapping and business process modeling notation. The first method identifies the flow in a process as timelines. The latter introduces a set of easily recognizable graphical elements. Results Detailed information concerning the cancer patients’ pathway was obtained. The method visualized the complexities within the diagnostic pathway. The role of different participants (patient, general practitioner, and local hospitals) became clear by arranging activities according to responsibilities and was shown to recurrently influence and contribute to the delay in the diagnostic process. Some important contributors to diagnostic delay in gynecological cancer, such as lack of cancer suspicion, competing diseases, negative test results, inexpedient referral patterns, and referrals without cancer suspicion, were found. Conclusions Our results point out process mapping tools as a potential analytical framework to illustrate, understand, and measure delay in health care. Furthermore, the method was able to identify important contributors to the diagnostic delay in gynecological cancer patients.

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.

The impact of HPV vaccination on future cervical screening: a simulation study of two birth cohorts in Denmark

Objectives To explore the interplay between primary and secondary prevention of cervical cancer by estimating future screening outcomes in women offered human papillomavirus (HPV) vaccination when they were sexually naïve. Design Estimation of outcome of liquid-based cytology screening for a post-HPV vaccination cohort using pre-vaccination screening data combined with HPV vaccination efficacy data reported in the literature. Setting Denmark. Data The number of screening diagnoses at first screen in a pre-vaccination birth cohort was multiplied by reported risk reductions expected for women who were vaccinated for HPV before sexual debut. All identified studies were reviewed by two authors, and weighted pooled estimates of vaccine efficacies were used. Main outcome measures Proportions of positive and false-positive cervical cytologies and positive predictive value (PPV) were calculated using cervical intraepithelial neoplasia (CIN) grade 2+ and 3+ as cut-off values. Results The proportion of positive screening tests was reduced from 8.7% before vaccination to 6.5% after vaccination, and the proportion of false-positive screening tests using CIN2+ as a cut-off was reduced from 5.5% pre-vaccination to 4.3% post-vaccination, and using CIN3+ as a cut-off from 6.2% to 4.7%. PPVs were reduced from 23% to 19% (cut-off CIN2+), and from 14% to 12% (cut-off CIN3+). Conclusions In our calculations, the proportion of positive screening results with liquid-based cytology will be reduced as a consequence of HPV vaccination, but the reduction is small, and the expected decline in PPV is very limited. In this situation, the information general practitioners will have to provide to their patients will be largely unchanged.

Characteristics of complaints resulting in disciplinary actions against Danish GPs

Abstract Objective. The risk of being disciplined in connection with a complaint case causes distress to most general practitioners. The present study examined the characteristics of complaint cases resulting in disciplinary action. Material and methods. The Danish Patients’ Complaints Boards decisions concerning general practice in 2007 were examined. Information on the motives for complaining, as well as patient and general practitioner characteristics, was extracted and the association with case outcome (disciplinary or no disciplinary action) was analysed. Variables included complaint motives, patient gender and age, urgency of illness, cancer diagnosis, healthcare settings (daytime or out-of-hours services), and general practitioner gender and professional seniority. Results. Cases where the complaint motives involved a wish for placement of responsibility (OR = 2.35, p = 0.01) or a wish for a review of the general practitioners competence (OR = 1.95, p = 0.02) were associated with increased odds of the general practitioner being disciplined. The odds of discipline decreased when the complaint was motivated by a feeling of being devalued (OR = 0.39, p = 0.02) or a request for an explanation (OR = 0.46, p = 0.01). With regard to patient and general practitioner characteristics, higher general practitioner professional seniority was associated with increased odds of discipline (OR = 1.97 per 20 additional years of professional seniority, p = 0.01). None of the other characteristics was statistically significantly associated with discipline in the multiple logistic regression model. Conclusion. Complaint motives and professional seniority were associated with decision outcomes. Further research is needed on the impact of professional seniority on performance.

Cancer patients’ first treatment episode with opioids: a pharmaco-epidemiological perspective

GoalThe factors underlying the choice of opioids for cancer patients in primary care are largely unknown. Our aim was to describe cancer patients’ first treatment episode with opioids in relation to disease characteristics and clinical course.Patients and methodsDuring 1997 and 1998, a population-based cohort of 4,006 incident cancer patients from a Danish county was identified. The patients were followed up from diagnosis to death or until 31 December 2003, and data on their use of opioids were obtained from a prescription database.Main resultsEventually, 54% of the cancer patients became incident users of opioids. Opioid treatment was initiated close to the diagnosis date in 20% of the patients. Most incident users (57%) were not terminal when they began using opioids, and 44% survived the first treatment episode. Of those who died, 70% received opioids in their terminal phase. The incidence rates of new opioid users were inversely related to the 5-year cancer survival period. A weak opioid was the first choice in 64% of the non-terminal users and in 43% of the terminal ones. No statistically significant differences in opioid use were found between men and women.ConclusionsOpioid use in cancer patients was not confined to the terminal course. Treatment with opioids should be viewed as a dynamic condition, with patients shifting between periods of use and non-use. The aggressiveness of the cancer and the presence of metastases were characteristics found to be strong determinants of opioid use.