Marius Brostrøm Kousgaard, Volkert Siersma, Susanne Reventlow, Ruth Ertmann, Peter Felding, Frans Broch Waldorff
Implementation Science, 2013; 8:47

Abstract

BACKGROUND Computer reminders are increasingly being applied in efforts to improve quality and patient safety. However, research is still needed to establish the effectiveness of different kinds of reminders in various settings. This study aimed to evaluate the effectiveness of computer reminders for improving adherence to a quality assessment scheme for point-of-care testing in general practice.

METHOD The study was conducted as a randomized controlled crossover trial among general practices in the Capital Region of Denmark. The intervention consisted of sending computer reminders (ComRem) to practices not adhering to the guideline recommendations of split testing for hemoglobin and glucose. Practices were randomly allocated into two groups. During the first follow-up period, one of the groups received the ComRem intervention together with the general implementation activities (GIA), while the other group only received the GIA. For the second follow-up period, the intervention was switched between the two groups. Outcomes were measured as split test procedure adherence.

RESULTS A total of 142 practices were randomly allocated to the early intervention group and 144 practices to the late intervention group (the control group in the first follow-up period). In the first intervention period, the mean number of split tests performed in the group receiving ComRem group increased from 1.22 to 3.76 (out of eight possible tests) while the mean number of split tests increased from 1.11 to 2.35 in the group targeted by GIA only (p = 0.0059). After the crossover, a similar effect of reminders was observed. Furthermore, the developments in outcome measures over time showed a strong effect of computer reminders beyond the intervention periods.

CONLUSION There was a significant effect of computer reminders on adherence to the quality assessment scheme for point-of-care testing. Thus, computer reminders seem to be useful for supporting the implementation of relatively simple procedures for quality and safety. 

Laurel Austin, Susanne Reventlow , Peter Sandøe, John Brodersen
Health, Risk & Society, 2013, 15:1, 27-50

Abstract

Increasingly, medical choices involve deciding whether to look for evidence of undetected, asymptomatic conditions, or increased risk of future conditions (i.e. screening). Those who screen at sufficiently high risk face decisions about interventions to prevent or postpone the onset of possible, but not certain, future symptomatic conditions. Other preventive decisions include whether or not to accept population-based intervention, such as vaccination. Using decision trees, we model the normative structures and associated uncertainties that underlie five medical decision situations, each of which involves assessing the probabilistic hypothesis that a person has, or will in the future have, a given symptomatic condition. The probability estimate that results from assessment becomes an input into predicting treatment benefit, with the probability of benefit decreasing as that of the symptomatic condition decreases. The five situations identified in this paper involve assessing: (1) a symptomatic patient; (2) an asymptomatic individual for an undetected condition; (3) an individual for risk of a future condition; (4) an individual for multiple risks simultaneously (shotgun assessment); and (5) an individual for a population-based intervention. Analysis of these situations facilitates examination of intuitive probabilistic reasoning. Drawing on evidence in related literature, we discuss some implications of decision-makers imposing the wrong structure or probabilistic reasoning when making medical choices. In particular, we discuss (1) overestimation of expected benefit due to systematic underestimation of uncertainty in a given decision; (2) overconfidence in probabilistic test results; and (3) failure to understand the implications of cumulative probabilities when ‘shot-gun’ testing.

Susanne Reventlow, Jakob Kragstrup, Ann Dorrit Guassora, Lars Bjerrum, Niels de Fine Olivarius
Videnskabelig leder i Ugeskrift for Læger 2013;175(16):1093 

Abstract

Sundhedsvæsenet har i mange år målrettet forbedret behandlingen betydeligt af en lang række kroniske sygdomme. Der er bl.a. udarbejdet kliniske retningslinjer (KR) og forløbsprogrammer, og sygehusbehandlingen er blevet tiltagende specialiseret og effektiviseret – alt sammen byggende på et stadig større volumen af god forskning. Denne forskning retter sig imidlertid næsten altid imod enkeltsygdomme, og den tiltagende specialisering gør det ikke lettere at behandle patienter med mere end én kronisk sygdom, multimorbiditet (MM). Disse patienter har en betydelig overdødelighed, nedsat livskvalitet og hyppig kontakt med sundhedsvæsenet.

Christine Bruun, Volkert Siersma, Ann Dorrit Guassora, P Holstein, Niels de Fine Olivarius
Diabetic Medicine 2013 March 15. [Epub ahead of print] DOI 10.1111/dme.12196.

Abstract

AIMS To determine the prevalence of foot ulcers and the incidence of amputations in patients with Type 2 diabetes observed for 19 years after diagnosis. We investigated the role of gender, age and co-morbidities.

METHODS From the Diabetes Care in General Practice study, 1381 patients were included and examined at diabetes diagnosis, at 6 years and at 14 years after diagnosis. Register-based follow-up was for 19 years. Foot ulcers and amputations were related to gender, age and co-morbidities by odds and hazard ratios from logistic and Cox regression models, respectively.

RESULTS The incidence of any amputation and major amputation was 400 (95% CI 307–512) and 279 (95% CI 203–375) per 100 000 patient-years, respectively. At the three observation points, the foot ulcer prevalences were 2.76% (95% CI 1.89–3.63), 2.93% (95% CI 1.86–4.00) and 4.96% (95% CI 3.10–6.82). Multivariate analyses showed associations between foot ulcers and peripheral neuropathy, peripheral arterial disease, male gender, retinopathy and myocardial infarction. After multivariate adjustment, significant predictors (hazard ratio; 95% CI) of any amputation were peripheral neuropathy (hazard ratio 2.09; 95% CI 1.19–3.69), peripheral arterial disease (hazard ratio 3.43; 95% CI 1.65–7.12), microalbuminuria (hazard ratio 2.11; 95% CI 1.21–3.67), retinopathy (hazard ratio 6.42; 95% CI 2.59–15.90), impaired vision (hazard ratio 6.92; 95% CI 2.35–20.38) and male gender (hazard ratio 2.40; 95% CI 1.31–4.41). For women, the risk of amputation increased with age, but for men the risk was higher when diagnosed with diabetes at a younger age.

CONCLUSIONS Despite improved treatment regimens, the incidence of amputations is still high in this population-based patient sample. Men diagnosed with diabetes before age 65 years and patients with diabetes-related co-morbidities are at particularly high risk of foot ulcers and amputations.

Annette Sofie Davidsen
Qualitative Research in Psychology, 2013, 10, 3, 318-339 

Abstract

A whole family of qualitative methods is informed by phenomenological philosophy. When applying these methods, the material is analyzed using concepts from this philosophy to interrogate the findings and to enable greater theoretical analysis. However, the phenomenological approach represents different approaches, from pure description to those more informed by interpretation. Phenomenological philosophy developed from a discipline focusing on thorough descriptions, and only descriptions, toward a greater emphasis on interpretation being inherent in experience. An analogous development toward a broader acknowledgment of the need for interpretation, the influence of the relationship and the researcher, and the co-construction of the narrative is mirrored in qualitative analytic theory and the description of newer analytic methods as, for example, Interpretative Phenomenological Analysis and Critical Narrative Analysis, methods which are theoretically founded in phenomenology. This methodological development and the inevitable contribution of interpretation are illustrated by a case from my own research about psychological interventions and the process of understanding in general practice.

Volkert Siersma, G Waldemar , Frans Boch Waldorff
Scandinavian Journal of Primary Health Care, doi:10.3109/02813432.2012.754092 

Abstract

OBJEKTIVE To investigate the prognostic value of subjective memory complaints for all-cause mortality in order to determine whether elderly persons with subjective memory complaints may be regarded as a group of vulnerable patients who need close follow-up.

DESIGN Prospective cohort study. Setting. Primary care units in the central district of Copenhagen, Denmark.

SUBJECTS 758 community-dwellers aged 65 years and older consulting their general practitioner in October and November 2002.

MAIN OUTCOME MEASURES Information on subjective memory complaints, socio-demographics, and health-related quality of life were collected at the enrolment primary care consultation. Dates of death from all causes occurring during the four-year follow-up were retrieved from the national databases. Cox proportional hazard regression models on time to death (censored after four years) were used to examine the influence of subjective memory complaints on all-cause mortality.

RESULTS 88 patients died during the four-year follow-up. The association between subjective memory complaints and mortality had a statistically not significant hazard ratio (HR) of 0.91, adjusting for known confounders. Statistically significant predictors for mortality were Age (HR = 1.43 for 75-84 years and HR = 3.39 for 85 + years), Sex (HR = 0.51 for women), Mobility (HR = 2.39 for some problems), Self-care (HR = 2.34 for some problems) and Comorbidity (HR = 2.06, 3.19 and 5.89 for a Charlson comorbidity index of 1, 2, or ≥ 3 respectively).

CONCLUSIONS In an elderly population presenting for primary care the presence of subjective memory complaints was not significantly associated with an increase in all-cause mortality.

Harmsen CG, Støvring H, Jarbøl DE, Nexøe J, Gyrd-Hansen D, Nielsen JB, Edwards A, Kristiansen IS.
BMC Med Inform Decis Mak. 2012 Aug 9;12:89. doi: 10.1186/1472-6947-12-89.

Set i lyset af, at forholdsvis mange patienter fravælger eller ophører medicinsk behandling, særligt inden for forebyggelse af hjertekarsygdomme, ønskede vi at opnå en bedre forståelse for patienters valg ved at belyse, hvorfor patienter vælger eller fravælger medicinsk behandling. Et udsnit af den danske befolkning blev præsenteret for et hypotetisk scenarie, hvor de skulle forestille sig at være i øget risiko for at få en hjertekarsygdom, tage stilling til et tilbud om medicinsk forebyggende behandling, og begrunde deres valg. Vi fandt, at flertallet af de adspurgte ønskede at påbegynde medicinsk behandling, og at afgørende for dette valg ikke primært kunne tilskrives information om den medicinske effekt men i høj grad også tidligere personlig erfaring med hjertekarsygdom. Det er vigtigt for behandlere ikke kun at fokusere på den medicinske effekt, men også at kunne identificere de årsager, som i øvrigt begrunder deres patienters valg vedrørende medicinsk behandling.

Abstract

Background. Shared decision-making and patients' choice of interventions are areas of increasing importance, not least seen in the light of the fact that chronic conditions are increasing, interventions considered important for public health, and still non-acceptance of especially risk-reducing treatments of cardiovascular diseases (CVD) is prevalent. A better understanding of patients' medication-taking behavior is needed and may be reached by studying the reasons why people accept or decline medication recommendations. The aim of this paper was to identify factors that may influence people's decisions and reasoning for accepting or declining a cardiovascular preventive medication offer.

Methods. From a random sample of 4,000 people aged 40-59 years in a Danish population, 1,169 participants were asked to imagine being at increased risk of cardiovascular disease and being offered a preventive medication. After receiving 'complete' information about effectiveness of the medication they were asked whether they would accept medication. Finally, they were asked about reasons for the decision.

Results. A total of 725 (67%) of 1,082 participants accepted the medication offer. Even quite large effects of medication (up to 8 percentage points absolute risk reduction) had a smaller impact on acceptance to medication than personal experience with cardiovascular disease. Furthermore, increasing age of the participant and living with a partner were significantly associated with acceptance. Some 45% of the respondents accepting justified their choice as being for health reasons, and they were more likely to be women, live alone, have higher income and higher education levels. Among those who did not accept the medication offer, 56% indicated that they would rather prefer to change lifestyle.

Conclusions. Medication effectiveness seems to have a moderate influence on people's decisions to accept preventive medication, while factors such as personal experience with cardiovascular disease may have an equally strong or stronger influence, indicating that practitioners could do well to carefully identify the reasons for their patients' treatment decisions.

Harmsen CG, Jarbøl DE, Nexøe J, Støvring H, Gyrd-Hansen D, Nielsen JB, Edwards A, Kristiansen IS.
BMC Health Serv Res. 2013 Feb 25;13:76. doi: 10.1186/1472-6963-13-76.

I et klinisk cluster-randomiseret design ønskede vi at undersøge brugen af to numeriske effektformater, absolut risikoreduktion hhv. levetidsforlængelse, i risikokommunikationen mellem praktiserende læge og patient i den ”virkelige” konsultation, hvor patienten, konfronteret med egen risiko for at dø af en hjertekarsygdom, på baggrund af numerisk information om den forventede effekt af forebyggende kolesterolsænkende medicinsk behandling, skal træffe et valg vedrørende opstart af behandling. Vi ønskede at belyse en eventuel forskel mellem de to effektformater på patienters beslutning vedrørende forebyggende kolesterolsænkende medicinsk behandling, og på patienternes tillid til den beslutning de har truffet og tilfredshed med samtalen med deres læge. Artiklen præsenterer protokollen over studiet.

Abstract

Background. Risk communication is an integral part of shared decision-making in health care. In the context of interventions for chronic diseases it represents a particular challenge for all health practitioners. By using two different quantitative formats to communicate risk level and effectiveness of a cholesterol-lowering drug, we posed the research question: how does the format of risk information influence patients' decisions concerning therapy, patients' satisfaction with the communication as well as confidence in the decision. We hypothesise that patients are less prone to accept therapy when the benefits of long-term intervention are presented in terms of prolongation of life (POL) in months compared to the absolute risk reduction (ARR). We hypothesise that patients presented with POL will be more satisfied with the communication and confident in their decision, suggesting understanding of the time-related term.

Methods/Design. In 2009 a sample of 328 general practitioners (GPs) in the Region of Southern Denmark was invited to participate in a primary care-based clinical trial among patients making real-life clinical decisions together with their GP. Interested GPs were cluster-randomised to inform patients about cardiovascular disease (CVD) risk and the effectiveness of statin therapy using either POL or ARR. The GPs attended a training session before informing their patients. Before training and after the trial period they received a questionnaire about their attitudes to risk communication and the use of numerical information. Patients' redemptions of statin prescriptions will be registered in a regional prescription database to evaluate a possible association between redemption rates and effectiveness format. The Combined Outcome Measure for Risk Communication And Treatment Decision Making Effectiveness (COMRADE) questionnaire will be used to measure patients' confidence and satisfaction with the risk communication immediately after the conversation with their GPs.

Discussion. This randomised clinical trial compares the impact of two effectiveness formats on real-life risk communication between patients and GPs, including affective patient outcomes and actual choices about acceptance of therapy. Though we found difficulties in recruiting GPs, according to the study protocol we have succeeded in engaging sufficient GPs for the trial, enabling us to perform the planned analyses.

(dansk titel: Psykologiske og sociale problemer hos patienter i almen praksis: praktiserende lægers vurdering og klassifikation)
Marianne Rosendal, Peter Vedsted, Kaj Sparle Christensen og Grete Moth
Scandinavian Journal of Primary Health Care 2013. 31(1): 43-49. ISSN: 0281-3432

I almen praksis får 11 % af patienterne en diagnose, der vedrører psykisk sygdom. Heraf har halvdelen en depression eller en belastningstilstand. Kun 18 af de 43 tilgængelige diagnoser i ICPC anvendes regelmæssigt. Sociale problemer angives sjældent som primær problemstilling (0,5 %).
Uafhængigt af diagnoser vægter praktiserende læger generelt det biomedicinske aspekt i en konsultation meget højt (78 % i gennemsnit), mens det sociale aspekt vægtes meget lavt (5 %). Det psykologiske aspekt ser ud til at få større vægt i opfølgende konsultationer i forhold til første henvendelse .
Resultaterne stammer fra en tværsnitsundersøgelse af Kontakt og Sygdomsmønsteret i almen praksis i Region Midtjylland foretaget i 2008-2009 (KoS2008) og baseret på spørgeskemaer. Fra praksis deltog 387 læger, som beskrev 5543 patienter i forbindelse med konsultation i praksis eller ved sygebesøg.
Vi har begrænset viden om, hvor meget psykisk sygdom og sociale problemstillinger fylder i konsultationerne i almen praksis, og om hvordan vores diagnoseklassifikation tilgodeser disse lidelser. Der foregå i øjeblikket en revision af internationale klassifikationssystemer, og denne undersøgelse bidrager til dette arbejde med viden om relevante diagnosekoder. Derudover viser undersøgelsen, at den bio-psyko-sociale model helt generelt appliceres yderst skævt i almen praksis, og der kan være behov for fremadrettet at drøfte implikationerne heraf.

Linda Huibers, Frede Olesen og Grethe Moth
Tidsskrift for Dansk Sundhedsvæsen (TFDS 3-2013). ISSN: 0909-6388

Artiklen beskriver det danske og hollandske sundhedsvæsen kort og fokuserer på lægevagten. Begge landene har lægevagter, men der er interessante forskelle i organisering. Største forskel er i telefon visitation, med sygeplejersker i Holland og læger i Danmark. I artiklen drøfter vi om hvad det betyder hvis danske lægevagter skifter fra læger til sygeplejersker. Vi synes at artiklen er relevant, særlig nu med debat og ændringer i Region Hovedstad.

Jacob Reinholdt Jensen, Christina Trankjær Ryborg, Margrethe Smidth, Peter Haastrup og Rasmus Køster-Rasmussen
Practicus 2013 215: 7. ISSN 0109-2235.

Ideen om DAF udsprang på en indisk restaurant for to år siden, da repræsentanter fra det daværende Forskningsudvalg var til Society for Academic Primary Care (SAPC) i Bristol. En konference, hvor den nyeste forskning og de hotteste forskere inden for almen medicin i Storbritannien var repræsenteret. Tanken var oplagt: Hvorfor har vi ikke en lignende dag i Danmark? En dag, hvor alle forskere inden for almen medicin samles til gensidig inspiration og erfaringsudveksling. Ideen kogte nogle år i Forskningsudvalget for endelig at blive effektueret med et brag en kold januardag i 2013. 

Forsvaret finder sted fredag den 17. maj 2013 kl. 14-16 i Samfundsmedicinsk Auditorium (lokale 101), bygning 1262, Bartholins Allé 4, 8000 Aarhus C.