DSAM’s publikationsinformation om seneste resultater inden for almenmedicinsk forskning i Danmark.

Action research led to a feasible lifestyle intervention in general practice for people with prediabetes

Maindal HT, Bonde A, Aagaard-Hansen J

Resume: Denne artikel beskriver et aktionsforskningsstudie i almen praksis. Formålet var at udvikle og pilotteste en livsstils­intervention, der kunne udføres i almen praksis, for personer med høj risiko for udvikling af diabetes. Interventionen bestod af seks konsultationer i almen praksis i løbet af det første år efter identifi­cering af risikopatienten. Den første og sidste konsultation blev typisk foretaget af lægen, mens de øvrige konsultationer blev varetaget af en praksissygeplejerske. Korttidsresultaterne viser, at interventionen kan nedbringe både patientens BMI og HbA1c. En succesful udbredelse af den nye interventionsmodel afhænger dog i høj grad af de praktiserende lægers priori­teringer, tilgængeligheden af sygeplejersker i de enkelte praksis og honorering af de deltagende læger. Studiet blev gennemført i et samarbejde mellem otte lægehuse i Vestjylland og Sydsjælland, Steno Center for Sundhedsfremme og Sektion for Sundhedsfremme og Sundhedsvæsen/sektion for almen medicin ved Institut for Folkesundhed, Aarhus Universitet.

Prim Care Diabetes. 2013 Dec 19. pii: S1751-9918(13)000155-1. doi: 10.1016/j.pcd.2013.11.007

Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial

Riis A, Jensen CE, Bro F, Maindal HT, Petersen KD, Jensen MB

Resume: Evidensbaserede kliniske retningslinjer kan forbedre kvaliteten af behandling, men implementeringen af sådanne retningslinjer er en langsommelig proces og er ofte mangelfuld. For nylig kom der nye retnings­linjer i Danmark for behandling af smerter i lænden. Formålet med de nye retningslinjer er at mindske både de personlige og samfundsmæssige udgifter, der er forbundet med denne type af smerte. Det er endnu uvist, om nye retningslinjer kan hjælpe de praktiserende læger med at ændre adfærd over for patienter med lændesmerter. I denne protokolartikel beskrives et studie, der i øjeblikket gennemføres i Nordjylland med deltagelse af 100 praksis og 2.700 patienter. Studiet skal se nærmere på, om en kompleks og multi­facetteret implementeringsstrategi for de nye kliniske retningslinjer kan reducere antallet af henvisninger til den sekundære sektor og forbedre udfaldet for patienterne. Undersøgelsen forventes at give ny viden om, hvordan kliniske retningslinjer bedst implementeres.

Implement Sci 2013 Oct 20;8(1):124

Lægekontakt – en mulig markør for symptomdebut

Ahrensberg J

Resume: Tidlig diagnose af kræft hos børn har stor betydning for barnets behandlingsmuligheder. Denne korte formidlingsartikel omtaler et videnskabeligt studie, der viser, at langt de fleste kræftramte børn har været i kontakt med almen praksis forud for diagnosetidspunktet. Tidligere studier har vist, at nogle børn oplever et langt forløb med symptomer, før den endelige diagnose stilles, men vi har endnu kun sparsom viden om, hvornår og hvordan disse sjældne sygdomme præsenterer sig. Når et barn med akut leukæmi udvikler klassiske og alvorlige symptomer på knoglemarvsdepression, bliver mistanken om livstruende sygdom for det meste hurtigt vakt. Andre kræfttyper udvikler sig langsomt og med svage symptomer, der ikke umiddelbart giver mistanke om alvorlig sygdom. Resultaterne fra dette studie viser, og at lægesøgningen tiltager fra omkring 6 måneder før diagnosen. Det er ikke så overraskende, at kontakten til almen praksis stiger umiddelbart inden diagnosetidspunktet. Tværtimod viser den stigning i lægesøgning, der ses flere måneder før, at den egentlige diagnose stilles, at der allerede her kan være tegn på sygdom, og det giver et muligt grundlag for at optimere diagnostikken af kræftsygdomme hos børn.

BestPractice Hæmatologi. 2013 (8):34-37

Reduced specialist time with direct computed tomography for suspected lung cancer in primary care

Guldbrandt LM, Fenger-Grøn M, Folkersen BH, Rasmussen TR, Vedsted P 

Lungekræft er årsag til flest kræftdødsfald i Danmark. Kræftpakker sikrer hurtig udredning, men der er kun begrænset viden om, hvordan disse forløb skal organiseres. Resultaterne af dette randomiserede studie viser, at patienterne med fordel kan henvises direkte til CT-scanning i stedet for først at blive set af en lungemediciner. Den direkte henvisning via den praktiserende læge øger ikke antallet af scanninger. Den nye fremgangsmåde giver en besparelse i lunge­medicinsk speciallægetid og samtidig stor tilfredshed hos både personale og patienter. Artiklen bygger på data fra patienter, som er blevet henvist til pakke­udredning for lungekræft fra almen praksis i Region Midtjylland i perioden 1. januar – 1. december 2012.

Dan Med J 2013 Dec.; 60(12):A4738

Sygdom og selvopfattelse på tværs af rum

Christensen IE, Ilsvard S

Resume: Artiklen omhandler forholdet mellem fysiske rum, sygdom og selvopfattelse. Først og fremmest undersøges betydningen af fysisk-rumlige omgivelser for sygdoms- og selvopfattelsen hos mennesker med svære fysiske handicap og funktionsnedsættelser, som får vederlagsfri fysioterapi som en del af deres behandling. Det centrale omdrejningspunkt for det sociologiske studie er deltagernes subjektive oplevelser og udbytte af vederlagsfri fysioterapi. Det undersøges også, hvordan deltagerne håndterer og integrerer fysioterapiklinikkens institutionelle ramme som en fast bestanddel af hverdagslivet. Studiet konkluderer, at fysioterapiklinikken, hvori sygdom behandles og praktiseres, ikke repræsenterer et ”sygdommens rum”, men af deltagerne opleves som et tiltrængt frirum fra sygdom, hvor de føler sig som ”almindelige mennesker”. I modsætning hertil står det private hjem og det offentlige rum, som nærmere repræsenterer ”sygdommens rum”, da det er her, handicap og funktionsnedsættelser skaber barrierer for det sociale liv, og her grænserne mellem det normale og afvigende defineres. Artiklens formål er at skabe indsigt i deltagernes oplevelser og erfaringer med at opholde sig og træne i fysioterapiklinikken og undersøge rummets betydning i relation til deltagernes selvopfattelse.

Tidsskrift for forskning i sygdom og samfund, nr. 18, 87-111

The MILE study: a motivational, individual and locally anchored exercise intervention among 30-49 year-olds with low levels of cardiorespiratory fitness: a randomised controlled study in primary care

Obling KH, Overgaard K, Juul L, Maindal HT

Resume: Et lavt kondital øger risikoen for at udvikle type 2-diabetes, hjerte-kar-sygdomme sygdomme og visse typer af kræft. I Danmark er lavt kondital et stort problem for folkesundheden. Cirka 30-40 % af befolkningen i alderen 30-50 har så lavt et kondital, at de har en markant øget risiko for at udvikle sygdomme eller at dø tidligt. Fysisk aktivitet kan øge konditallet, men der mangler viden om, hvad der kan motivere, støtte og fastholde borgere med et lavt kondital i et mere fysisk aktivt liv. Formålet med studiet er at under­søge effekten af en intervention, som består af individuelt tilpasset og lokalt forankret fysisk aktivitet blandt 30-49-årige med et lavt kondital. Hvis interventionen viser sig at være en succes, kan den implemen­teres i andre danske kommuner og få stor betydning både på sundhedsområdet og for samfundet som helhed. 

BMC Public Health. 2013 Dec 23;13(1):1224

Incidence of Genital Warts in Young Danish Women

Lynge E, Kragstrup J, Bjerrum L, Rebolj M

Correspondence: The incidence of genital warts (GW) in young Danish women has recently been reported to have decreased “strongly” [1] after the implementation of the quadrivalent vaccine against human papillomavirus (HPV). Monitoring the effect of HPV vaccination is important. The vaccine was licensed based on the outcome of randomized controlled trials [2, 3]. The trial populations were, however, somewhat selected, including, for instance, only women with 4 or fewer lifetime sexual partners.
Blomberg and colleagues [1] compared GW incidence in vaccinated (at least 1 dose) and unvaccinated women. Vaccination was identified from the National Health Insurance Service Register, for women vaccinated within the free vaccination program, and from the National Prescription Register, for women who bought the vaccine themselves. The authors included 5 birth cohorts, where the proportion of vaccinated women varied from 14% in the oldest cohort (born 1989–1990) to 87% in the youngest cohort (born 1997–1999). GW incidence was measured based on treatments in outpatient and inpatient hospital wards as recorded in the National Patient Register. The hazard ratio of GW incidence in vaccinated vs unvaccinated women was 0.62 for those born in 1989–1990, decreasing to 0.12 for those born in 1995–1996. No case occurred for vaccinated women born during 1997–1999.
In the interpretation of these findings, the reader should be aware of some reservations. First, the registration of vaccinations is not comprehensive, as vaccines bought by physicians and not used within the free vaccination program are not registered. This is, however, not expected to affect the numbers substantially. Second, most GWs are treated in primary healthcare. The data on hospital-treated women will therefore be sensitive to changes over time in the referral patterns from primary to hospital care. In theory, a decline in number of hospital-treated women will be recorded if the general practitioners treat a larger fraction of patients or if more patients are referred to private gynecologists. Third, and most important, although selection was mentioned, the authors did not take into account that comparison of vaccinated and unvaccinated women entails a selection bias, which also varies over birth cohorts as the reference group of unvaccinated women constituted 86% of women born during 1989–1990, whereas only 10% of women were born in 1995–1996.
While the first 2 problems cannot be solved within the data set, the third problem can actually be accounted for by studying the time trend in GW incidence across birth cohorts with different vaccination coverage. In a previous publication [4], the same authors reported on GW incidence from 2006 to 2011, and found a decline for women aged 16–17, 18–19, 20–21, and 22–25 years, respectively. Unfortunately, the data were not reported by birth cohort, and it is therefore not possible directly to link the trend to vaccination coverage.
With the presence of population and healthcare registers, Denmark offers an optimal setting for monitoring the effect of HPV vaccination. However, proper studies still have to take the limitations in the registers and basic methodological problems into account.

References:
1. Blomberg M, Dehlendorff C, Munk C, Kjaer SK. Strongly decreased risk of genital warts after vaccination against human papillomavirus: nationwide follow-up of vaccinated and unvaccinated girls in Denmark. Clin Infect Dis 2013; 57:929–34.
2. Garland SM, Hernandez-Avila M, Wheeler CM, et al; Females United to Unilaterally Reduce Endo/Ectocervical Disease (FUTURE) I Investigators. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med 2007; 356:1928–43. 
3. FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent highgrade cervical lesions. N Engl J Med 2007; 356: 1915–27.
4. Baandrup L, Blomberg M, Dehlendorff C, Sand C, Andersen KK, Kjaer SK. Significant decrease in the incidence of genital warts in young Danish women after implementation of a national human papillomavirus vaccination program. Sex Transm Dis 2013; 40:130–5.
Clinical Infectious Diseases 2013. Publiceret online, doi: 10.1093/cid/cit754

A three-year follow-up on the efficacy of psychosocial interventions for patients with mild dementia and their caregivers: the multicentre, rater-blinded, randomized Danish Alzheimer Intervention Study (DAISY)

Phung KTT, Waldorff FB, Buss DV, Eckermann A, Keiding N, Rishøj S, Siersma V, Sørensen J, Søgaard R, Sørensen LV, Vogel A, Waldemar G

Objectives: To examine the long-term efficacy at the 36-month follow-up of an early psychosocial counselling and support programme lasting 8–12 months for community-dwelling patients with mild Alzheimer's disease and their caregivers.
Design: Multicentre, randomised, controlled, rater-blinded trial.
Setting: Primary care and memory clinics in five Danish districts.
Participants: 330 home-dwelling patients with mild Alzheimer's disease and their primary caregivers (dyads).
Interventions: Dyads were randomised to receive intervention during the first year after diagnosis. Both intervention and control groups had follow-up visits at 3, 6, 12 and 36 months.
Main outcome measures: Primary outcomes for the patients assessed at 36-month follow-up were changes from baseline in global cognitive function (Mini-Mental State Examination), depressive symptoms (Cornell Depression Scale) and proxy-rated EuroQoL quality of life on visual analogue scale. The primary outcomes for the caregivers were changes from baseline in depressive symptoms (Geriatric Depression Scale) and self-rated EuroQoL quality of life on a visual analogue scale. The secondary outcome measures for the patient were proxy-rated Quality of Life Scale for Alzheimer's disease (QoL-AD), Neuropsychiatric Inventory-Questionnaire, Alzheimer's disease Cooperative Study Activities of Daily Living Scale, all-cause mortality and nursing home placement.
Results: At a 36-month follow-up, 2 years after the completion of the Danish Alzheimer Intervention Study (DAISY), the unadjusted positive effects previously detected at the 12-month follow-up in one patient primary outcome (Cornell depression score) and one patient secondary outcome (proxy-rated QoL-AD) disappeared (Cornell depression score, p=0.93; proxy-rated QoL-AD, p=0.81). No long-term effect of DAISY intervention on any other primary and secondary outcomes was found at the 36-month follow-up.
Conclusions: For patients with very mild Alzheimer's disease and their caregivers, an intensive, multi-component, semitailored psychosocial intervention programme with counselling, education and support during the first year after diagnosis did not show any positive long-term effect on primary and secondary outcomes.

BMJ Open 2013;3:e003584

Cost Analysis of Early Psychosocial Intervention in Alzheimer's Disease

Søgaard R, Sørensen J, Waldorff FB, Eckermann A, Buss DV, Waldemar G

Background/Aim: To investigate the impact of early psychosocial intervention aimed at patients with Alzheimer's disease (AD) and their caregivers on resource use and costs from a societal perspective. Methods: Dyads of patients and their primary caregiver were randomised to intervention (n = 163) or control (n = 167) and followed for 3 years. Health care use was extracted from national registers, and the Resource Utilisation in Dementia questionnaire was used to measure informal care and productivity loss. Multiple imputation was used to replace missing data, and non-parametric bootstrapping was used to estimate standard errors. Results: Overall, there were no statistically significant differences because of large variation in the observations. The average additional cost of psychosocial intervention provision was estimated at EUR 3,401 per patient. This cost masked a reduced use of formal health care and an increased use of informal care. Conclusions: Early psychosocial intervention in AD could be cost-saving from a health care perspective, whereas the opposite seems to be true from a broader societal perspective.© 2013 S. Karger AG, Basel.

Dement Geriatr Cogn Disord. 2013 Oct 19;37(3-4):141-153. Epub ahead of print

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