Kjell Lindström

Excessive Use of Rapid Tests in Respiratory Tract Infections in Swedish Primary Health Care

A 1-y retrospective study of problem oriented electronic patient records, for encounters concerning respiratory tract infection, was performed. The aim was to analyse the management of respiratory tract infections in primary health care in terms of diagnostic coding, tests and antibiotic treatment using data from electronic patient records. 12 primary health care centres with a registered population of 102,050 residents in 3 counties in southeast Sweden participated. Data were retrieved electronically from records of patient encounters concerning respiratory tract infections. The data were: patient age and gender, date of contact, diagnostic code, CRP and GABHS tests and results, as well as antibiotic prescriptions. In a total of 19,965 encounters, the most frequent diagnoses were common cold (40%), acute tonsillitis (18%), and acute bronchitis (15%). A total of 4445 GABHS tests (in 22% of encounters) and 6141 CRP tests (31%) were performed, and both tests were done in 1910 encounters (10%). A total of 7934 antibiotic prescriptions were registered. The proportion of patients tested and prescribed an antibiotic varied greatly between centres. We found an excessive, and much varying, use of rapid tests in encounters for respiratory tract infections. Data retrieval from electronic patient record systems was a feasible method to study the use of laboratory tests in relation to pharmacological treatment.

Cardiovascular risk during early adult life. Risk markers among participants in "Live for Life" health promotion programme in Sweden.

STUDY OBJECTIVE: To study differences in cardiovascular lifestyle risk factors and biological risk markers in early adult life, with special attention to age and sex differences. Lifestyle cardiovascular risk factors included dietary habits, physical inactivity, smoking, alcohol habits, psychosocial strain, and mental stress. Biological risk markers included anthropometric variables, arterial blood pressure, and serum cholesterol concentration. DESIGN: A combined individual and community based preventive programme, including health examinations. SETTING: All communities in the County of Skaraborg in south western Sweden. PARTICIPANTS: Altogether 12,982 men and women aged 30 or 35 years who underwent health examinations over seven years. MAIN RESULTS: In both sexes, biological risk markers studied were worse in 35 year old subjects than in 30 year olds. Furthermore, a larger proportion of men aged 35 years were smokers and were physically inactive compared with 30 year old men. However, dietary habits were better in both sexes in the upper age group. At both ages there were also significant differences between men and women. Women, compared with men, had better dietary habits and lower alcohol consumption but smoked more and experienced greater mental stress and psychosocial strain. All biological risk markers were worse in men than in women at both ages studied. During the observation period, some improvement of the health profile of the participants was observed, indicating a beneficial effect of the intervention programme. CONCLUSIONS: The results indicate that the risk of cardiovascular disease, as assessed from studying lifestyle and biological risk markers, increases early in life, suggesting that preventive measures should start early.

Lifestyle changes after a health dialogue. Results from the Live for Life health promotion programme.

Objective – To evaluate the effect of a health dialogue on lifestyle habits, and to relate the lifestyle changes to changes of biological risk markers for ischaemic heart disease. Design – Cross-sectional study, intervention and follow-up. Setting – The community of Habo, population 9500, located in Skaraborg, Sweden. Patients – All 35-year-old inhabitants in Habo were invited to a health examination during a study period between 1989 and 1992. A community intervention programme was combined with a health examination consisting of a health dialogue with a specially trained nurse and use of a “health curve” as an educational tool. The effect of the health examination was examined by comparing baseline characteristics of participants in 1989–1992 with their follow-up data in 1993. Results – Participants in the health dialogue who were re-examined reported lifestyle improvements including less smoking, decreased dietary fat intake and increased physical activity. Those who reported improved dietary intake and increased physical activity improved their biological risk markers correspondingly (body mass index, waist to hip ratio, serum cholesterol concentration). Conclusions – The combination of a community and an individually based health programme can be effective with respect to lifestyle variables and, in those improving their lifestyle, in biological risk markers.

Self-monitoring of blood glucose and glycaemic control in type 2 diabetes

Objective. Previous studies have shown inconsistent results with regard to whether or not self-monitoring of blood glucose (SMBG) is related to better glycaemic control in type 2 diabetes. The aim of this study was to explore the use of SMBG and its association with glycaemic control in patients with type 2 diabetes in primary care. Design. A cross-sectional observational study was conducted in 2003 at 18 primary health care centres in Sweden, in which all known patients with diabetes were surveyed. The study included 6495 patients with type 2 diabetes. A sample of 896 patients was selected for further exploration of data from medical records. A telephone interview was performed with all patients in this group using SMBG (533 patients). Results. There were no differences in HbA1c levels between users (6.9%) and non-users (6.8%) of SMBG in patients treated with insulin or in patients treated with oral agents (6.3% in both groups). In patients treated with diet only, users of SMBG had higher levels of HbA1c compared with non-users (5.5% vs. 5.4%, p =0.002). Comparing medical records between users and non-users of SMBG showed no differences in diabetes-related complications in any treatment category group. Conclusion. The use of SMBG was not associated with improved glycaemic control in any therapy category of patients with type 2 diabetes in primary care. The absence of difference in glycaemic control between users and non-users of SMBG could not be explained by differences in comorbidity between users and non-users of SMBG.

A study of men aged 33–42 in Habo, Sweden with special reference to cardiovascular risk factors Design, health profile and characteristics of participants and non-participants

An intervention study of men living in the Community of Habo in southwestern Sweden has been carried out. All men aged 33–42 and living in the community were invited. Altogether 652 men participated. The study included a questionnaire, an interview made by a nurse, anthropometric measurements, blood pressure measurements, measurements of respiratory function and work performance capacity, and blood sampling for chemical analyses. The participation rate was high, 86.1%, after one mail invitation even considering the fact that two reminders were sent. Most of the non-participants had recently been in contact with the health care organisation, either because they were high-consumers of health care, or because they had attended a health examination at work. A health profile was worked out comprising 11 different potential risk factors for coronary heart disease. This health profile turned out to be a useful educational tool when discussing the results of the examination with the participants. Risk points were given according to certain predetermined criteria. The distribution of risk factors was similar in the different ages studied. Most of the participants had at least one risk factor as defined, but many of them had two or more risk factors.

Evaluation of “Live for Life”, a health promotion programme in the County of Skaraborg, Sweden

STUDY OBJECTIVE To evaluate a health promotion programme, combining a population and individual based strategy, in the County of Skaraborg, Sweden, with special attention to outcome. DESIGN The evaluation was subdivided into structure, process and outcome. The evaluation procedure as a total is described here, but the results presented refer only to outcome. In order to study the potential effect of the individually based health examination, 35 year old subjects who had participated five years previously were in 1994–1996 compared with 35 year old subjects who had not participated before, and compared with their own values five years earlier. The results during 1995–1996 were compared with those of 1989–1990 for corresponding ages in order to study the effect of, particularly, the population based strategy. SETTING The County of Skaraborg in the south western part of Sweden with about 270 000 inhabitants. In addition to population strategy, involving the total county, men and women aged 30 and 35 years were invited to an individually based examination. MAIN RESULTS Factors related to body weight increased during the study period, while other factors mostly changed in the direction wanted. As a whole the changes were rather modest. There were favourable changes in lifestyle variables, for example, concerning smoking and dietary habits. CONCLUSIONS There were beneficial effects from the health promotion programme, but there is a need for continuous improvement of methods of intervention referred to lifestyle.

Time for a "vision zero" concerning premature death from ischaemic heart disease?

Objective - To study the trend in premature mortality (before 75 years of age) from ischaemic heart disease (IHD) in a Swedish primary health care district compared to communities of similar demographic situation and all Sweden. Design - Mortality from IHD in men and women was compared between the community of Habo and other Swedish communities of similar size and all Sweden for the period 1984-96. Setting - The community of Habo in Sweden with about 9600 inhabitants. Intervention - Intensified efforts by the local primary health care organisation, in co-operation with the community, in respect of primary and secondary cardiovascular prevention since the beginning of the 1980s. Results - Mortality from IHD has decreased significantly both in Habo and in Sweden during these years. The decrease has been more prominent in Habo than in Sweden as a whole and other Swedish communities of similar demographic situation. Conclusion - With increased and purposeful efforts in primary and secondary prevention, in co-operation between the community and primary health care, it is possible to substantially decrease mortality from IHD in the community.

Data from electronic patient records are suitable for surveillance of antibiotic prescriptions for respiratory tract infections in primary health care.

Diagnoses and antibiotic treatments were analysed in relation to respiratory tract infections (RTI). A 1-y retrospective study was made of electronic patient records (EPR) for encounters concerning RTIs in primary health care in Sweden. The study covered a registered population of 102,050 individuals at 12 primary health care centres in 3 counties. Data were recorded on number of episodes, encounters, diagnostic codes and antibiotic prescriptions. The yearly number of episodes of RTIs was 16,964 or 166 per 1000 inhabitants per y. The total number of encounters was 19,965. The most frequent diagnoses were common cold (40%), acute tonsillitis (18%), and acute bronchitis (15%). The yearly number of antibiotic prescriptions was 7961, accounting for 47% of the episodes or 78 per 1000 inhabitants per y. The most frequently prescribed antibiotics were phenoxymethylpenicillin (61%), tetracyclines (18%) and macrolides 8%). Standard EPRs provide a feasible source of clinical information which, taking limitations into consideration, could be used for the follow-up of trends in antibiotic prescribing and of adherence to guidelines with regard to RTIs.

Determinants of hospitalisation rates: does primary health care play a role?

Scand J Prim Health Care 2003;21:15-20. ISSN 0218-3432 Objective - To analyse the influence of rates of general practitioner visits on rates of hospitalisations. Design - Ecological cross-sectional study of factors influencing hospitalisation rates. Aggregated data on primary care centre area level. Setting - The county of ÖstergÖtland, Sweden, with 3 hospital districts and 41 primary health care centres, and the hospital district of JÖnkÖping in the county of JÖnkÖping, Sweden, with 11 primary health care centres. Outcome measure - Hospitalisation rates. Results - Age and rates of outpatient hospital visits were the most important factors explaining the variation in rates of hospitalisations between the primary health care centre areas. Hospital districts, socioeconomic factors and rates of GP visits also influenced the rates of hospitalisations. Conclusion - When evaluating the influence of primary health care on the rates of hospitalisations, both socioeconomic factors and health care structure must be taken into consideration. Doing this, the rates of GP visits correlated negatively with the rates of hospitalisations.

Can selective serotonin inhibitor drugs in elderly patients in nursing homes be reduced

Objective. To investigate whether treatment with selective serotonin reuptake inhibitors (SSRIs) could be withdrawn for elderly residents who had been on treatment for at least one year and to evaluate a method for systematic drug review. Design. Open, prospective, interventional study. Setting. Four counties in Sweden. Subjects. Elderly residents at 19 nursing homes, with ongoing treatment with SSRIs for more than one year. Main outcome measures. Clinical evaluation, registration of drugs used and rating with Montgomery–Åsberg Depression Rating Scale (MADRS). A semi-structured telephone interview with 15 participating physicians and 19 nurses. Results. About one-third of all 822 residents in the nursing homes had ongoing antidepressant treatment, predominantly with SSRIs; 75% of them had been treated with SSRIs for at least one year and 119 (60%) of these were considered eligible for the study. The intervention was judged successful in 52% of these residents of whom 88% had a MADRS rating of less than 20 points. The GPs and the nurses experienced the method as practicable. Conclusions. Withdrawal of SSRI treatment was successful in the majority of cases. The MADRS may be a valuable addition to clinical evaluation when deciding whether to end or continue SSRI treatment.