Jorma Takala

Pain as a reason to visit the doctor: a study in Finnish primary health care

&NA; This study aims to demonstrate the prevalence of pain as a reason for seeing a physician in primary care. We also performed an analysis of the localization, duration and frequency of pains, as well as the diagnoses of patients having pain. A total of 28 physicians at 25 health centers in Finland collected the data, comprising 5646 patient visits. Pain was identified as the reason for 2237 (40%) of the visits. The most common localizations were in the lower back, abdomen and head. One‐fifth of the pain patients had experienced pain for over six months. Analysis of the diagnoses revealed half of the pains to be musculoskeletal. Patients experienced considerable limitations in various activities of life due to pain. A quarter of the pain patients of active working age received sick leave. Our results confirm that pain is a major primary health care problem, which has an enormous impact on public health.

Good continuity of care may improve quality of life in Type 2 diabetes

Some features of diabetes care and diabetes treatment regimen which may have an impact on health-related quality of life (HRQOL) in people with diabetes were studied cross-sectionally using the SF-20 questionnaire. Of the 381 subjects with Type 2 diabetes aged under 65 years, 260 (68%) participated in the study. On univariate analysis, HRQOL was associated with regular clinical review (check-up at least twice a year) and continuity of care (the same GP for at least 2 years), education by a diabetes nurse, and satisfaction with diabetes education. No associations were found between the HRQOL dimensions and home glucose monitoring, participation in educational courses, or satisfaction with care. On logistic regression analysis only good continuity of care was significantly associated with the better well-being dimensions of the SF 20 (ORs 2.5-6.0). However, good continuity of care was also associated with less satisfactory glucose control (HbA(1c) 8.9 +/- 2.0 (+/- SD) vs 8.3 +/- 2.0%, P=0.04). It is concluded that a permanent physician-patient relationship may improve HRQOL in subjects with Type 2 diabetes, but further prospective studies are needed to confirm this finding.

Direct and indirect costs of managing patients with musculoskeletal pain—challenge for health care

Musculoskeletal pain is an outstanding symptom among the patients of primary health care. However, there are few studies of management and costs of musculoskeletal pain at primary health care level. The aim of this study was to describe the diagnostic investigations, management, referral rate and sick leaves related to visits prompted by musculoskeletal pain as well as to assess their costs. A total of 28 general practitioners (GPs) at 25 randomly selected health centres throughout Finland collected the data for this 4 week study, which covered 1 week from each of the four seasons. All visits, except those occurring after hours, were recorded. Altogether 1123 patients visited GPs because of musculoskeletal pain. Laboratory tests were ordered for 12% and imaging investigations for 24%. A total of 16% of the patients suffering from musculoskeletal pain received a prescription for physiotherapy, and analgesics were prescribed to 61% of them. Physicians referred 7% of the pain patients to specialist care. One out of every four patients was prescribed sick leave. The mean cost of the investigations, therapy, referrals, and sick leaves was as high as 530 EUR per visit, with absenteeism from work constituting two‐fifths of the total costs. Musculoskeletal pain is not just a frequent complaint but also has extensive economic consequences for society. Investigations and therapy at the primary health care level play a minor role in the costs as compared with specialist care and sick leaves.

‘Metabolic Syndrome’ in a Middle-Aged Finnish Population

Objective To investigate methods for the detection of different clusterings of the insulin-resistant abnormalities consistent with the concept of the ‘metabolic syndrome’ in clinical practice, and to research the occurrence of these clusters in a middle-aged Finnish population. Methods We studied a random sample of 207 middle-aged subjects in the city of Tampere, and all 1148 subjects of four middle-aged age groups in Pieksämäki town, in central Finland. Clusterings of the following eight markers of insulin resistance were recorded as the main outcome measures: 1) at least one first-degree relative with non-insulin-dependent diabetes (NIDDM); 2) obesity: Body mass index (BMI) ≥30 kg/m2; 3) central adiposity: Waist-to-hip ratio (WHR) ≥ 1.00 in men and ≥ 0.88 in women; 4) hypertension: Systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 95 mmHg, or receiving drug treatment for hypertension; 5) hypertrigly-ceridaemia ≥ 1.70mmol/l; 6) low high-density lipoprotein (HDL) cholesterol: < 1.0 mmol/l in men and < 1.20mmol/l in women; 7) abnormal glucose metabolism according to WHO criteria and 8) hyperinsulinaemia: Fasting plasma insulin ≥ 13.0 mU/l. Results The metabolic syndrome, defined as a clustering of dyslipidaemia (hypertriglyceridaemia, low HDL cholesterol, or both) and insulin resistance (abnormal glucose tolerance, hyperinsulinaemia, or both) was present in 17% of men and in 8% of women; this sex difference was statistically significant (P< .001). The syndrome was detectable with a sensitivity of 96% and a specificity of 55% by the combined four markers of insulin resistance (NIDDM in a close relative, obesity, central adiposity and hypertension). Conclusion In clinical practice, the metabolic syndrome can be detected during normal clinical examination. The occurrence of the syndrome is already high by middle age.

Hyperinsulinemia and clustering of cardiovascular risk factors in middle-aged hypertensive Finnish men and women

Objective To examine the relationship between hyperinsulinemia and clusters of cardiovascular risk factors in middle-aged hypertensive patients. Design A population-based study. Setting Pieksämäki District Health Center, and the Community Health Center of the city of Tampere, in central Finland. Subjects Hypertensive men and women aged 36, 41, 46, and 51 years (n = 161) in the town of Pieksämäki, and a normotensive control population of 177 subjects aged 40 and 45 years in the city of Tampere. Main outcome measures Clusters of obesity (body mass index > 30.0 kg/m2), abdominal adiposity (waist: hip ratio > 1.00 for men and > 0.88 for women), hypertriglyceridemia (> 1.70 mmol/l), a low level of high-density lipoprotein cholesterol (< 1.0 mmol/l in men and < 1.20 mmol/l in women) and abnormal glucose metabolism (impaired glucose tolerance or noninsulin-dependent diabetes as defined by World Health Organization criteria) according to statistical quartiles of the fasting plasma insulin concentration. Results Among the hypertensives, there was a 2.0- to 3.6-fold higher risk of having a clustering of the insulin-resistance associated cardiovascular risk factors compared with that of the normotensives. Among the hypertensive subjects in the highest quartile of fasting plasma insulin there was a six- to 12-fold increase in risk associated with having two or more insulin resistance associated cardiovascular risk factors compared with the subjects in the lowest quartile. There was a positive correlation between a high number of ascertained risk factors and high levels of fasting plasma insulin. Conclusion In clinical practice, knowledge of the close relationship between risk-factor cluster status and fasting plasma insulin levels offers a tool to evaluate the occurrence of hyperinsulinemia in middle-aged hypertensive men and women.

Overweight, underweight and mortality among the aged

OBJECTIVE To clarify the influence of overweight and underweight on the total mortality as well as on different causes of death in an unselected population of old people. DESIGN The cohort of the aged population was examined in 1971. The survival time of the cohort was followed for ten years. SETTINGS Rural commune of Hankasalmi in Central Finland. PARTICIPANTS 721 (80% of total aged population) subjects aged 65 years or over (310 men and 411 women). OUTCOME MEASURES 10 years survival rate and causes of death by body mass index quartiles and sex. RESULTS The women in the lowest BMI quartile had the highest mortality in ten-year follow-up (a 26% decrease in survival time). The differences between the total mortality of the other quartiles were small. In the lowest BMI quartile there was overmortality from respiratory diseases and tumours, and undermortality from cardiovascular diseases. In the highest BMI quartile the main groups of causes of death did not differ essentially from those in the whole cohort. CONCLUSION Underweight was as strong a predictor of mortality, and even stronger, than overweight.

Access to and continuity of primary medical care of different providers as perceived by the Finnish population.

Objective. To study peoples views on the accessibility and continuity of primary medical care provided by different providers: a public primary healthcare centre (PPHC), occupational healthcare (OHC), and a private practice (PP). Design. A nationwide population-based questionnaire study. Setting. Finland. Subjects. A total of 6437 (from a sample of 10 000) Finns aged 15–74 years. Main outcome measures. Period of time (in days) to get an appointment with any physician was assessed via a single structured question. Accessibility and continuity were evaluated with a five-category Likert scale. Values 4–5 were regarded as good. Results. Altogether 72% had found that they could obtain an appointment with a physician within three days, while 6% had to wait more than two weeks. Older subjects and subjects with chronic diseases perceived waiting times as longer more often than younger subjects and those without chronic diseases. The proportion of subjects who perceived access to care to be good was 35% in a PPHC, 68% in OHC, and 78% in a PP. The proportion of subjects who were able to get successive appointments with the same doctor was 45% in a PPHC, 68% in OHC, and 81% in a PP. A personal doctor system was related to good continuity and access in a PPHC. Conclusions. Access to and continuity of care in Finland are suboptimal for people suffering from chronic diseases. The core features of good primary healthcare are still not available within the medical care provided by public health centres.

Diagnostic methods in dyspepsia: the usefulness of upper abdominal ultrasound and gastroscopy

OBJECTIVES To examine the diagnostic value of gastroscopy and upper abdominal ultrasound, which are frequently used as primary tests in dyspeptic patients in general practice. To test the influence of age for accuracy of both diagnostic methods. DESIGN Clinical study. SETTING Four health centres in Kuopio Province, Finland. SUBJECTS Four hundred unselected consecutive dyspeptic patients (91 less than 45 years of age) who consulted their general practitioners. MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive values (PV), efficiency and usefulness index (UI) were calculated for upper abdominal ultrasound and for gastroscopy in detecting the causes of dyspepsia in primary care. Final diagnosis was determined after one year follow-up. RESULTS The sensitivity of upper abdominal ultrasound in detecting the cause of dyspepsia was 0.07, the specificity 0.91, PV+ 0.36, PV- 0.56, and UI -0.001. Ultrasound was not more efficient in older patients. Gastroscopy was the most efficient method with a sensitivity of 0.75, specificity 1.00, PV+ 0.99, PV- 0.83 and UI 0.56. The usefulness of gastroscopy was even better among patients over 45 years of age. CONCLUSIONS The usefulness of upper abdominal ultrasound is low regardless of patients age. Gastroscopy is superior to upper abdominal ultrasound as a first line diagnostic method in diagnosing dyspepsia, especially among patients over 45 years of age.

Reasons for referral from general practice in Finland

OBJECTIVE To examine the reasons for referral from general practice in Finland. DESIGN Survey over one week of all referrals from general practice. SETTING Central and northern Finland, comprising 72% of the area of the country and one-third of the population. PARTICIPANTS 851 general practitioners (GPs) from public health centres. OUTCOME MEASURES Referrals by speciality and reasons for referrals by ICD-9 and ICPC codes in terms of characteristics of patients, GPs, and practices. RESULTS A higher proportion of male (39%) than female (33%) patients were referred to surgical speciality (p < 0.001). Ten per cent of the patients referred by female GPs were referred to gynaecology departments, compared with 5% of those referred by male GPs (p < 0.001). Otitis media in children and abdominal pain in adults were the commonest reasons for referral of both male and female patients. CONCLUSION Our results will be useful in developing the training of GPs with respect to those health problems that most commonly lead to a referral to hospital.

Population-based audit of non-insulin-dependent diabetic patients aged under 65 years in primary health care

OBJECTIVE To audit treatment of non-insulin-dependent diabetes mellitus (NIDDM). DESIGN Cross-sectional, descriptive, population-based study. SETTING Primary health care. SUBJECTS NIDDM patients aged under 65 years in Mikkeli District, in eastern Finland. RESULTS Of 381 (220 men) eligible NIDDM patients, 260 (141 men) participated (68%). Of subjects with at least two fasting blood glucose values > or = 6.7 mmol/l, diabetes diagnosis had been set to 63%. Eighty seven per cent had been annually checked up, and 36% had a satisfactory (< 7.5%) glycosylated haemoglobin A1c. Retinopathy, neuropathy and occasional microalbuminuria were detected in 13, 59 and 32% of patients, respectively. Patient education had been given to 85% of patients by the diabetes nurse. Of the patients, 79% were satisfied with the quality of diabetes education and care. MAIN OUTCOME MEASURES Diagnostics of hyperglycaemia, regularity and continuity of care, metabolic control, complications, patient education and satisfaction. CONCLUSIONS The metabolic control was poor among NIDDM patients in the study area. The diagnostics, regularity of care and the treatment of hyperglycaemia should be improved. Nevertheless, most patients were satisfied with both diabetes care and patient education.