Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review.

OBJECTIVE: The objective of this study was to determine the diagnostic accuracy in detecting valvular heart disease (VHD) by heart auscultation, performed by medical doctors. DESIGN/METHODS: A systematic literature search for diagnostic studies comparing heart auscultation to echocardiography or angiography, to evaluate VHD in adults, was performed in MEDLINE (1947-November 2021) and EMBASE (1947-November 2021). Two reviewers screened all references by title and abstract, to select studies to be included. Disagreements were resolved by consensus meetings. Reference lists of included studies were also screened. The results are presented as a narrative synthesis, and risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. MAIN OUTCOME MEASURES: Sensitivity, specificity and likelihood ratios (LRs). RESULTS: We found 23 articles meeting the inclusion criteria. Auscultation was compared with full echocardiography in 15 of the articles; pulsed Doppler was used as reference standard in 2 articles, while aortography and ventriculography was used in 5 articles. One article used point-of-care ultrasound. The articles were published from year 1967 to 2021. Sensitivity of auscultation ranged from 30% to 100%, and specificity ranged from 28% to 100%. LRs ranged from 1.35 to 26. Most of the included studies used cardiologists or internal medicine residents or specialists as auscultators, whereas two used general practitioners and two studied several different auscultators. CONCLUSION: Sensitivity, specificity and LRs of auscultation varied considerably across the different studies. There is a sparsity of data from general practice, where auscultation of the heart is usually one of the main methods for detecting VHD. Based on this review, the diagnostic utility of auscultation is unclear and medical doctors should not rely too much on auscultation alone. More research is needed on how auscultation, together with other clinical findings and history, can be used to distinguish patients with VHD. PROSPERO REGISTRATION NUMBER: CRD42018091675.

The Norwegian PraksisNett: a nationwide practice-based research network with a novel IT infrastructure.

PURPOSE: Clinical research in primary care is relatively scarce. Practice-based research networks (PBRNs) are research infrastructures to overcome hurdles associated with conducting studies in primary care. In Norway, almost all 5.4 million inhabitants have access to a general practitioner (GP) through a patient-list system. This gives opportunity for a PBRN with reliable information about the general population. The aim of the current paper is to describe the establishment, organization and function of PraksisNett (the Norwegian Primary Care Research Network). MATERIALS AND METHODS: We describe the development, funding and logistics of PraksisNett as a nationwide PBRN. RESULTS: PraksisNett received funding from the Research Council of Norway for an establishment period of five years (2018-2022). It is comprised of two parts; a human infrastructure (employees, including academic GPs) organized as four regional nodes and a coordinating node and an IT infrastructure comprised by the Snow system in conjunction with the Medrave M4 system. The core of the infrastructure is the 92 general practices that are contractually linked to PraksisNett. These include 492 GPs, serving almost 520,000 patients. Practices were recruited during 2019-2020 and comprise a representative mix of rural and urban settings spread throughout all regions of Norway. CONCLUSION: Norway has established a nationwide PBRN to reduce hurdles for conducting clinical studies in primary care. Improved infrastructure for clinical studies in primary care is expected to increase the attractiveness for studies on the management of disorders and diseases in primary care and facilitate international research collaboration. This will benefit both patients, GPs and society in terms of improved quality of care.Key pointsPractice-based research networks (PBRNs) are research infrastructures to overcome hurdles associated with conducting studies in primary careImproved infrastructure for clinical studies in primary care is expected to increase the attractiveness for studies on the management of disorders and diseases in primary care and facilitate international research collaborationWe describe PraksisNett, a Norwegian PBRN consisting of 92 general practices including 492 GPs, serving almost 520,000 patientsAn advanced and secure IT infrastructure connects the general practices to PraksisNett and makes it possible to identify and recruit patients in a novel way, as well as reuse clinical dataPraksisNett will benefit both patients, GPs and society in terms of improved quality of careThis paper may inform and inspire initiatives to establish PBRNs elsewhere.

Age, income and sleep duration were associated with outcomes in children participating in weight management.

AIM: To explore associations between baseline factors and weight-related outcomes among participants enrolled in a paediatric obesity trial. METHODS: We included children aged 6-12 years participating in a 2-year multidisciplinary family programme who attended a postintervention follow-up 36 months from baseline (n = 62). Outcome measures were change in body mass index standard deviation score (BMI SDS), reduction in BMI SDS ≥0.25 and change in waist circumference (WC). Independent variables included in linear and logistic regression models were age, sex, household income, parents' education, sleep duration, screen time and physical activity. RESULTS: Altogether, 26 children (42%) attained a reduction of BMI SDS ≥0.25. Higher family income and longer sleep duration were associated with greater change in BMI SDS (-0.05 per 100.000 NOK, p = 0.02, and -0.24 per hour, p = 0.02, respectively). Higher age was associated with greater change in WC (-2.1 cm per year, p = 0.01) but lower odds of attaining a reduction in BMI SDS ≥0.25 (OR per year 0.70, p = 0.04). There was a borderline statistically significant trend towards greater increase in WC with longer daily screen time (p = 0.05). CONCLUSION: Age, family income and sleep duration at baseline were associated with weight-related outcomes 1-year postintervention.

Does the University of Tromsø - The Arctic University of Norway educate doctors to work in rural communities? / Utdanner Universitetet i Tromsø ­ Norges arktiske universitet leger til å arbeide i distrikter?

BACKGROUND: When Storting (the Norwegian Parliament) resolved in 1968 to build the University of Tromsø, the purpose of the study model was to promote recruitment and a stable GP density throughout North Norway. We wanted to shed light on the degree to which GPs and doctors in health trusts who were graduates of the University of Tromsø work in rural and central municipalities, and at university hospitals and other hospitals respectively. MATERIAL AND METHOD: We used de-identified data covering 406 GPs and 909 doctors in health trusts who had graduated from the University of Tromsø in the period 1979 ­ 2012. RESULTS: A larger share of GPs educated at the University of Tromsø (30 %) worked in rural municipalities compared with all GPs in Norway (19 %). GPs educated at the University of Tromsø staffed 57 % of the positions in central municipalities and 34 % of the positions in rural municipalities in North Norway. A larger share of doctors in health trusts (64 %) educated at the University of Tromsø worked at a university hospital compared with all doctors in health trusts in Norway (56 % worked at a university hospital). Over half (53 %) of the doctors at the University Hospital of North Norway were graduates of the University of Tromsø. In Nordland and Finnmark, the corresponding percentage at health trusts varied between 14 and 28 %. INTERPRETATION: Our data suggest that medical studies at the University of Tromsø make a considerable contribution to GP density in rural communities and to solid recruitment to the University Hospital of North Norway.

Associations between patients' risk attitude and their adherence to statin treatment - a population based questionnaire and register study.

BACKGROUND: Poor adherence to medical treatment may have considerable consequences for the patients' health and for healthcare costs to society. The need to understand the determinants for poor adherence has motivated several studies on socio-demographics and comorbidity. Few studies focus on the association between risk attitude and adherence. The aim of the present study was to estimate associations between patients' adherence to statin treatment and different dimensions of risk attitude, and to identify subgroups of patients with poor adherence. METHODS: Population-based questionnaire and register-based study on a sample of 6393 persons of the general. Danish population aged 20-79. Data on risk attitude were based on 4 items uncovering health-related as well as financial dimensions of risk attitude. They were collected through a web-based questionnaire and combined with register data on redeemed statin prescriptions, sociodemographics and comorbidity. Adherence was estimated by proportion of days covered using a cut-off point at 80 %. RESULTS: For the dimension of health-related risk attitude, "Preference for GP visit when having symptoms", risk-neutral and risk-seeking patients had poorer adherence than the risk-averse patients, OR 0.80 (95 %-CI 0.68-0.95) and OR 0.83 (95 %-CI 0.71-0.98), respectively. No significant association was found between adherence and financial risk attitude. Further, patients in the youngest age group and patients with no CVD were less adherent to statin treatment. CONCLUSION: We find some indication that risk attitude is associated with adherence to statin treatment, and that risk-neutral and risk-seeking patients may have poorer adherence than risk-averse patients. This is important for clinicians to consider when discussing optimal treatment decisions with their patients. The identified subgroups with the poorest adherence may deserve special attention from their GP regarding statin treatment.

GPs' Perceptions of Cardiovascular Risk and Views on Patient Compliance: A Qualitative Interview Study.

Objective. General practitioners' (GPs') perception of risk is a cornerstone of preventive care. The aims of this interview study were to explore GPs' professional and personal attitudes and experiences regarding treatment with lipid-lowering drugs and their views on patient compliance. Methods. The material was drawn from semistructured qualitative interviews. We sampled GPs purposively from ten selected practices, ensuring diversity of demographic, professional, and personal characteristics. The GPs were encouraged to describe examples from their own practices and reflect on them and were informed that the focus was their personal attitudes and experiences. Systematic text condensation was applied for analysis in order to uncover the concepts and themes. Results. The analysis revealed the following 3 main themes: (1) use of cardiovascular guidelines and risk assessment tools, (2) strategies for managing patient compliance, and (3) GPs' own risk management. There were substantial differences in the attitudes concerning all three themes. Conclusions. The substantial differences in the GPs' personal and professional risk perceptions may be a key to understanding why GPs do not always follow cardiovascular guidelines. The impact on daily clinical practice, personal consultation style, and patient behaviour with regard to prevention is worth studying further.

General practitioners' altered preferences for private practice vs. salaried positions: a consequence of proposed policy regulations?

BACKGROUND: General practitioners (GPs) in most high-income countries have a history of being independent private providers with much autonomy. While GPs remain private providers, their autonomous position appears to be challenged by increased policy regulations. This paper examines the extent to which GPs' preferences for private practice vs. salaried contracts changed in a period where a new health care reform, involving proposed increased regulations of the GPs, was introduced. METHODS: We use data collected from Norwegian GPs through structured online questionnaires in December 2009 and May 2012. RESULTS: We find that the proportion of GPs who prefer private practice (i.e. the default contract for GPs in Norway) decreases from 52% to 36% in the period from 2009 to 2012. While 67% of the GPs who worked in private practice preferred this type of contract in 2009, the proportion had dropped by 20 percentage points in 2012. Salaried contracts are preferred by GPs who are young, work in a small municipality, have more patients listed than they prefer, work more hours per week than they prefer, have relatively low income or few patients listed. CONCLUSION: We find that GPs' preferences for private practice vs. salaried positions have changed substantially in the last few years, with a significant shift towards salaried contracts. With the proportions of GPs remaining fairly similar across private practice and salaried positions, there is an increasing discrepancy between GPs' current contract and their preferred one.

Would GPs advise patients with respiratory tract infections to refrain from exercise, stay indoors or stay in bed? Survey of GPs in Poland and Norway.

BACKGROUND: For patients with respiratory tract infections evidence regarding bed rest, staying indoors and refraining from exercise is sparse. OBJECTIVES: To explore how general practitioners (GPs) in Poland and Norway would advise such patients. METHODS: Convenience samples of GPs in Poland (n = 216) and Norway (n = 171) read four vignettes in which patients presented symptoms consistent with pneumonia, sinusitis, common cold and exacerbation of chronic obstructive pulmonary disease (COPD), respectively. For each vignette, GPs were asked whether they would recommend staying indoors, staying in bed and refraining from exercise, and if so, for how many days. RESULTS: For each vignette, the proportions of GPs recommending the patient to stay indoors in Poland versus Norway were 98% versus 72% (pneumonia), 92% versus 26% (sinusitis), 87% versus 9% (common cold) and 92% versus 39% (exacerbation of COPD). In regression analysis adjusted relative risks (95% CI) for recommending the patient to stay indoors in Poland versus Norway was 1.4 (1.2-1.5), 3.7 (2.8-4.8), 10.6 (6.3-17.7) and 2.5 (2.0-3.1), respectively. Among those who would recommend the patient to stay indoors, mean durations were 8.1, 6.6, 5.1 and 6.7 days in Poland versus 3.2, 2.8, 2.6 and 4.1 days in Norway, respectively. Polish GPs were also more likely to recommend staying in bed and refraining from exercise, and for a longer time, than their Norwegian colleagues. CONCLUSION: GPs in Poland were more likely to recommend bed rest, staying indoors and refraining from exercise. This suggests that they perceived the cases as more serious than their Norwegian colleagues.

What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners.

BACKGROUND: Health reforms in many countries affect the scope and nature of primary care. General Practitioners (GPs) are expected to spend more time developing public health, preventive health care, coordination of care and teamwork. We aimed to explore which professional activities GPs consider to be meaningful and how they would like to prioritise tasks. METHODS: In a cross sectional online survey 3,270 GPs were invited to consider twenty different activities in general practice. They were asked to rate each of them on a Likert scale anchored from 1 (not meaningful) to 5 (very meaningful). They then selected three activities from the item list on which they would like to spend more time and three activities on which they would like to spend less time. We used multinomial logistic regression to explore associations between the GPs' preferences for time spent on preventive health care activities and age, gender and practice characteristics. RESULTS: Approximately 40% (n=1,308) responded. The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%). In terms of priority the same items prevailed except that GPs would like to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services. In multivariate regression models physician and practice characteristics explained no more than 10% of the variability in the GPs' preferences for time spent on preventive health care services. CONCLUSIONS: The GPs found diagnosis and treatment of diseases most meaningful. Their priorities were partly at odds with those of the health authorities and policy makers.

Willingness-to-pay for a statistical life in the times of a pandemic.

A contingent valuation was performed based on cross-sectional web-based interviews of individuals aged 16-82 years of age presenting a scenario of influenza pandemic. The mean WTP for a course of Tamiflu was NOK 1034 (median NOK 250). Anxious individuals perceived the pandemic mortality risk to be higher than others, but also perceived the benefit of Tamiflu as greater. They also expressed a higher WTP for Tamiflu, but the implied VOSL was less than for other respondents. The results suggest that fear and anxiety distort decision making under uncertainty and decrease focus on the perceived risk reduction.

Critiques of the risk concept--valid or not?

The increasing use of the risk concept in healthcare has caused concern among medical doctors, especially general practitioners (GPs). Critics have claimed that risk identification and intervention create unfounded anxiety, that the concept of risk is not useful at the individual patient level, that patients' risk concept is different from an epidemiological one, that resources are better spent elsewhere, or that commercial interests take advantage of risk information to promote sales. In this paper the authors discuss the concept of risk and address the critique. There is evidence that commercial interests promote risk interventions, that patients may misunderstand risk information, and that risk information can cause unnecessary anxiety. The authors have found no empirical data on the amount of time primary healthcare providers spend on risk interventions, and have not identified any valid arguments that risk information is not useful for the individual patient. Decision-making under uncertainty is a core element of medical practice, and GPs need to be suitably trained to inform patients such that they make good decisions when they are faced with uncertainty. The concept of risk is therefore useful for GPs, and in fact a key issue. It is concluded that risk critique should be based on sound theory and empirical data. Critics may do well in making clear distinctions between facts and value judgements.

Decisions on drug therapies by numbers needed to treat: a randomized trial.

BACKGROUND: The number needed to treat (NNT) has been promoted as the preferred effect measure when patients and physicians share decision making. Our aim was to explore the impact of the NNT on laypeople's decisions about preventive drug therapies. METHODS: Two thousand subjects were selected for the survey; 1201 (60%) responded for a representative sample of the Norwegian population. Respondents were allocated to scenarios with random combinations of a disease to be prevented, drug treatment costs, and effect size in terms of NNT. They were interviewed about their hypothetical consent to the therapy, then randomized to different interpretations of NNT and asked to reconsider their initial responses. RESULTS: The proportions consenting varied from 76% when the NNT was 50 to 67% when the NNT was 1600 (P for trend = .06). When faced with the prospect of avoiding lethal disease, stroke, myocardial infarction, or hip fracture, the proportions consenting were 84%, 76%, 68%, and 53%, respectively (P<.01). Across different treatment costs ($37, $68, $162, and $589) the proportions consenting varied from 78% to 61% (P for trend <.01). Twenty-four percent of the respondents changed their decision when informed about how to interpret the NNT, and 93% of those switched from positive to negative decisions, regardless of the magnitude of NNT. CONCLUSIONS: Respondents' decisions were influenced by the type of disease to be prevented and the cost of the intervention, but not by the effect size in terms of NNT. This suggests that NNT is difficult to understand and that other effect formats should be considered for shared decision making.

Medical doctors' perception of the "number needed to treat" (NNT). A survey of doctors' recommendations for two therapies with different NNT.

OBJECTIVE: While the number needed to treat (NNT) is in widespread use, empirical evidence that doctors or patients interpret the NNT adequately is sparse. The aim of our study was to explore the influence of the NNT on medical doctors' recommendation for or against a life-long preventive drug therapy. DESIGN: Cross-sectional study with randomisation to different scenarios. SETTING: Postal questionnaire presenting a clinical scenario about a hypothetical drug as a strategy towards preventing premature death among healthy people with a known risk factor. Benefit after 5 years of treatment was presented in terms of NNT, which was set at 50 for half of the respondents and 200 for the other half. SUBJECTS: Representative sample (n = 1616) of Norwegian medical doctors. MAIN OUTCOME MEASURES: Proportion of doctors that would prescribe the drug. Reasons for recommending against the therapy. RESULTS: With NNT set at 50, 71.6% (99% CI 66.8-76.4) of the doctors would prescribe the drug, while the proportion was 52.3% (99% CI 47.5-57.1) with an NNT of 200 (chi = 50.7, p < 0.001). Multivariate logistic regression analysis indicated that the effect of NNT on the likelihood for recommending the therapy was age-dependent; young doctors ( < 36 of age) were more sensitive to the difference in NNTs than older doctors. Thirty-six percent (n = 464) of the doctors would not prescribe the drug, and 77.4% (99% CI 68.5-86.2) of those agreed with an argument stating that only one out of NNT patients would benefit from the treatment. CONCLUSION: Medical doctors appear to be sensitive to the magnitude of the NNT in their clinical recommendations. However, many doctors believe that only one out of NNT patients benefits from therapy. Clinical recommendations based on this assumption may be misleading.