Weight transitions and psychosocial factors: A longitudinal cohort study of Finnish primary school children with overweight.

For targeted prevention and treatment of childhood obesity, primary health care needs methods to identify children potentially developing obesity. The objectives of this study were to examine transitions across weight categories and their association with psychosocial family- and school-related factors, data on which were retrieved from health records. This longitudinal cohort study comprised 507 Finnish children with overweight, identified from a random sample of 2000 sixth graders in Helsinki in 2013. We applied Markov multistate models to analyze the transition rates over six primary school years between BMI SDS categories of normal weight, overweight and obesity, as assessed by Finnish BMI-for-age reference, and to examine relations between transition rates and family- and school-related factors. Among 3116 pairs of consecutive growth measurements from 225 girls and 282 boys aged 6-14, 719 transitions from weight category to another occurred. The highest 1-year probabilities were 0.76 for girls to stay in overweight and 0.80 for boys to stay in obesity. Transitions from normal weight to overweight and from obesity to overweight were more probable than vice versa. Transitions from overweight into obesity were among girls associated with older age (HR 2.63) and divorced or single parents (HR 2.29), as well as among boys with experiences of crises (HR 2.40) and being bullied (HR 1.66). Factors identifiable in school health care and associated with the probability of transition towards obesity should be considered when planning individual support and intervention programs.

Distinct age-related patterns of overweight development to guide school healthcare interventions.

AIM: We aimed to identify groups of primary school children with similar overweight development, reveal age-related patterns of overweight development in the resulting groups and analyse overweight-related school healthcare interventions. METHODS: This retrospective longitudinal register study utilised electronic health records from six primary school years. From a random sample of 2000 sixth graders, we derived a study cohort of 508 children meeting criteria for overweight at least once during primary school. We investigated how many different groups (latent classes) of children with similar weight development would emerge by applying flexible latent class mixed models on body mass index standard deviation score. We also explored the resulting groups with respect to offered overweight-related interventions. RESULTS: Per child, the data consisted in median 7 growth measurements over 5.4 years. We identified five overweight development groups for girls and four for boys. The groups converged temporarily around age 10 after which only some continued into obesity. School nurses and physicians offered overweight-related interventions to children with obesity, less to children gaining weight or with overweight. CONCLUSION: Obesity prevention might benefit from awareness of typical overweight development patterns when designing intervention studies or planning and timing multidisciplinary school health check programmes.

Usability Factors Associated With Physicians' Distress and Information System-Related Stress: Cross-Sectional Survey.

BACKGROUND: Constantly changing and difficult-to-use information systems have arisen as a significant source of stress in physicians' work. Physicians have reported several usability problems, system failures, and a lack of integration between the systems and have experienced that systems poorly support the documentation and retrieval of patient data. This stress has kept rising in the 21st century, and it seems that it may also affect physicians' well-being. OBJECTIVE: This study aimed to examine the associations of (1) usability variables (perceived benefits, technical problems, support for feedback, and user-friendliness), (2) the number of systems in daily use, (3) experience of using information systems, and (4) participation in information systems development work with physicians' distress and levels of stress related to information systems (SRIS) levels. METHODS: A cross-sectional survey was conducted among 4018 Finnish physicians (64.82%, 2572 out of 3968 women) aged between 24 and 64 years (mean 46.8 years) in 2017. The analyses of covariance were used to examine the association of independent variables with SRIS and distress (using the General Health Questionnaire) adjusted for age, gender, employment sector, specialization status, and the electronic health record system in use. RESULTS: High levels of technical problems and a high number of systems in daily use were associated with high levels of SRIS, whereas high levels of user-friendliness, perceived benefits, and support for feedback were associated with low levels of SRIS. Moreover, high levels of technical problems were associated with high levels of psychological distress, whereas high levels of user-friendliness were associated with low distress levels. Those who considered themselves experienced users of information systems had low levels of both SRIS and distress. CONCLUSIONS: It seems that by investing in user-friendly systems with better technical quality and good support for feedback that professionals perceive as being beneficial would improve the work-related well-being and overall well-being of physicians. Moreover, improving physicians' skills related to information systems by giving them training could help to lessen the stress that results from poorly functioning information systems and improve physicians' well-being.

Experienced time pressure and stress: electronic health records usability and information technology competence play a role.

BACKGROUND: Electronic health records (EHRs) are an elementary part of the work of registered nurses (RNs) in healthcare. RNs are the largest group of healthcare workers, and their experiences with EHRs and their informatics competence play a crucial role in a fluent workflow. The present study examined EHR usability factors and nurses' informatics competence factors related to self-reported time pressure and psychological distress. METHODS: A nationwide survey was conducted for working-age registered nurses in 2017. The study sample included 3607 nurses (5% men) in Finland. The association of age, sex, employment sector, EHR usability factors, and nurses' informatics competence factors with time pressure and psychological distress were examined with analyses of covariance. RESULTS: The EHR usability factors that were associated with high time pressure were low EHR reliability and poor user-friendliness. Regarding the nurses' informatics competence factors, only low e-Care competence was associated with time pressure. Of the EHR usability factors, low EHR reliability and low support for cooperation were associated with high psychological distress. Of the nurses' informatics competence factors, low e-Care competence was associated with high psychological distress. CONCLUSIONS: Unreliability and poor user-friendliness of EHRs seem to be prominent sources of time pressure and psychological distress among registered nurses. User-friendly EHR systems and digital tools in healthcare are needed. Nurses' competence to use eHealth tools to tailor patient care should be strengthened through organizational and regional actions. For example, house rules about how to use eHealth tools and instructions on common practices in cooperation with other organizations could be useful.

Screening and treatment of obesity in school health care - the gap between clinical guidelines and reality.

AIMS: School health care offers a natural setting for childhood obesity interventions. Earlier studies reveal inadequate screening and treatment in primary care. However, longitudinal studies in unselected populations are lacking. We aimed to examine how school nurses and physicians identified obesity, diagnosed it and offered interventions over primary school. We compared the results with Finnish recommendations. METHODS: From our cohort of 2000 primary school sixth graders (aged 12-14), 172 were obese at least once during primary school. We manually collected retrospective electronic health record (EHR) data of these 'ever-obese' children. RESULTS: Of the ever-obese children, 96% attended annual nurse assessments more than twice. School physicians met 53% of the ever-obese children at health checks at first grade and 93% at fifth grade. Of overweight-related extra visits to school nurses, 94% took place without parents. Parents were present in 48% of extra school physician visits. Only 29% of the 157 who became obese during the first five school grades received an obesity diagnosis. However, school physicians mentioned weight problems in EHR for 90% of the children and, similarly, school nurses for 99%. The majority received a treatment plan at least once. For 78%, at least one plan was made with the parents. Still, 28% missed nutrition plans, 31% exercise plans and 90% lacked recorded weight development targets. CONCLUSIONS: The gap between clinical guidelines and reality in school health care could be narrowed by improving diagnosing and parent collaboration. Obstacles in parent involvement and work methods in school health care need further study.

Case-mix tool, costs and effectiveness in improving primary care mental health and substance abuse services.

BACKGROUND: Despite its importance in improving care and developing services, high-quality data evaluating cost-effectiveness and services in different case-mix populations is scarce in primary care. AIMS: The objective was to investigate the service use of those mental health and substance abuse patients, who use lots of services. METHODS: Primary health care diagnosis-related groups (pDRG) is a tool to evaluate service provider system and improve efficiency, productivity and quality. We viewed all pDRG results available from the year 2015 concerning municipal mental health and substance abuse services. RESULTS: In primary care mental health and substance abuse services, the most common ICD-10-codes were depression and substance abuse. One-fifth of patients produced 57% of costs. Their medium of appointments was 16 per year versus 6 per year of all patients. Only 54% of their diagnoses were recorded in the electronic health records versus 75% of all patients. They made 5.7 different pDRG episodes, including 1.8 episodes of depression, per patient. The average episode cost for this patient group was 301€. CONCLUSIONS: pDRG makes health care production transparent also in mental health and substance abuse services. It is easy to identify patients, who use a lot of services and thus induce the majority of costs, and focus on their needs in managing and developing services.

Development of overweight and obesity among primary school children-a longitudinal cohort study.

BACKGROUND: School health care is crucial for obesity prevention. Data on constancy of childhood obesity are still scarce, but highly necessary for risk evaluation. OBJECTIVES: We examined from electronic health records (EHRs) the continuity of obesity during primary school and searched for social and behavioural characteristics associated with childhood obesity. METHODS: From randomly selected 2000 Finnish sixth graders (aged 12-14), we identified 402 'ever overweight' and 172 'ever obese' children who were overweight or obese at least once since their first grade. These cohort data of growth measurements and the content of all pre-seventh grade health checks were retrospectively analysed from EHRs. RESULTS: Of the ever obese and ever overweight children, 69.3% (95% CI: 65.2-73.4%) continued to be overweight or obese in sixth grade. Of the ever obese children, nearly 40% were obese in first grade and 56% were obese or overweight in all six grades. Furthermore, 80% were obese or overweight already before school age. Obese children had experienced more bullying than overweight children (43.6% versus 30.8%, P = 0.003), had more frequently special needs for studying (25.6% versus 14.7%, P = 0.002) or had undergone a serious family crisis (20.3% versus 11.4%, P = 0.005). CONCLUSIONS: Electronic data on children's growth and psychosocial characteristics are potentially useful when aiming for early action to counter obesity. Such routinely collected data appear to be underutilized and should be further exploited both in individual and population level to develop screening and treatment processes.

[Update on Current Care Guideline: Physical activity and exercise training for adults in sickness and in health]. / KÄYPÄ HOITO -SUOSITUS (Päivitystiivistelmä). Liikunta.

The purpose of the guideline is to promote physical activity in the prevention, treatment and rehabilitation of diseases. Physical activity plays a key role in the management of several chronic noncommunicable diseases. In this guideline, the following diseases are discussed: endocrinological, cardiovascular, musculoskeletal and respiratory diseases, as well as depression and cancer. In addition, physical activity during pregnancy and in senior citizens is reviewed. Exercise counseling should be included as part of disease management and lifestyle guidance.

[Update on Current Care guidelines: obesity (children)]. / Käypä hoito -suosituksen päivitystiivistelmä: Lihavuus (lapset).

Childhood obesity is an increasing health problem. There may be possibilities to prevent obesity in childhood, and efficient interventions to treat obese children have been published. Local and regional strategies to prevent and to treat childhood obesity are needed.

Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study.

BACKGROUND: Antihypertensive drug choices and treatment levels are not in accordance with the existing guidelines. We aimed to assess the impact of a guideline implementation intervention on antihypertensive drug prescribing. METHODS: In this controlled before and after study, the effects of a multifaceted (education, audit and feedback, local care pathway) quality programme was evaluated. The intervention was carried out in a health centre between 2002 and 2003. From each health care unit (n = 31), a doctor-nurse pair was trained to act as peer facilitators in the intervention.All antihypertensive drugs prescribed by 25 facilitator general practitioners (intervention GPs) and 53 control GPs were retrieved from the nationwide Prescription Register for three-month periods in 2001 and 2003. The proportions of patients receiving specific antihypertensive drugs and multiple antihypertensive drugs were measured before and after the intervention for three subgroups of hypertension patients: hypertension only, with coronary heart disease, and with diabetes. RESULTS: In all subgroups, the use of multiple concurrent medications increased. For intervention patients with hypertension only, the odds ratio (OR) was 1.12 (95% CI 0.99, 1.25; p = 0.06) and for controls 1.13 (1.05, 1.21; p = 0.002). We observed no statistically significant differences in the change in the prescribing of specific antihypertensive agents between the intervention and control groups. The use of agents acting on the renin-angiotensin-aldosterone system increased in all subgroups (hypertension only intervention patients OR 1.19 (1.06, 1.34; p = 0.004) and controls OR 1.24 (1.15, 1.34; p < 0.0001). CONCLUSIONS: A multifaceted guideline implementation intervention does not necessarily lead to significant changes in prescribing performance. Rigorous planning of the interventions and quality projects and their evaluation are essential.

Evaluating risk for cardiovascular diseases--vain or value? How do different cardiovascular risk scores act in real life.

BACKGROUND: Screening tools to identify persons with high cardiovascular risk exist, but less is known about their validity in different population groups. The aim of this article is to compare the sensitivity and specificity of three different cardiovascular disease risk scores and their ability to detect high-risk individuals in daily practice. METHODS: The sensitivity and specificity of risk charts based on Framingham Risk Function, SCORE and cardiovascular disease (CVD) Risk Score were analysed using a large population risk factor survey database in Finland. For different cardiovascular disease end-points in 10-year follow-up true positive, false positive, true negative and false negative cases were identified using different risk charts. Subjects over 40 years (n = 25 059) of the FINRISK Study were used in analyses. RESULTS: Risk scores differed depending on gender, age and cardiovascular outcome. Among men the sensitivity of CVD Risk Score and Framingham Risk Function at risk of >or=10% for each end point was higher than of SCORE or Framingham Risk Function at risk of 20%. The specificity of Framingham Risk Function at risk of 20% was higher than the specificity of other risk charts. Among women in all endpoints the sensitivity was highest in CVD Risk Score and lowest in Framingham Risk Function at risk of >or=20%. Specificity for all different endpoints was highest in SCORE and Framingham Risk Function at risk of 20%. CONCLUSIONS: Sensitivity and specificity varied markedly in between three cardiovascular risk evaluation tools. Practitioners should be aware of their limitations especially when estimating risk among women and younger patients.

Primary care guidelines: Senior executives' views on changing health centre practices in hypertension treatment.

OBJECTIVE: To describe the adoption of the national Hypertension Guideline in primary care and to evaluate the consistency of the views of the health centre senior executives on the guideline's impact on clinical practices in the treatment of hypertension in their health centres. DESIGN: A cross-sectional telephone survey. SETTING: All municipal health centres in Finland. SUBJECTS: Health centres where both the head physician and the senior nursing officer responded. MAIN OUTCOME MEASURES: Agreement in views of the senior executives on the adoption of clinical practices as recommended in the Hypertension Guideline. RESULTS: Data were available from 143 health centres in Finland (49%). The views of head physicians and senior nursing officers on the adoption of the Hypertension Guideline were not consistent. Head physicians more often than senior nursing officers (44% vs. 29%, p < 0.001) reported that no agreements on recording target blood pressure in patient records existed. A similar discrepancy was seen in recording cardiovascular risk (64% vs. 44%, p < 0.001). Senior executives agreed best on the calibration of sphygmomanometers and the provision of weight-control group counselling. CONCLUSIONS: Hypertension Guideline recommendations that require joint agreements between professionals are less often adopted than simple, precise recommendations. More emphasis on effective multidisciplinary collaboration is needed.

Facilitating as a guidelines implementation tool to target resources for high risk patients - the Helsinki Prevention Programme (HPP).

Interprofessional care may provide some answers to the challenge of scarce healthcare resources, through the utilization of the expertise of various professionals to improve evidence-based care. This was a two-year programme in primary care, where doctor and nurse pairs acted as intrinsic facilitators creating and implementing local guidelines and encouraging multiprofessional teamwork. The effect of implementation was studied by auditing professional opinion change, blood pressure, serum lipid and HbA1C levels. After one year, 20 health stations reported improvement in treatment practices of hypertension and the division of tasks across team members, and seven and eight health stations reported improvement in treatment of diabetes and dyslipidemia. After two years, the corresponding figures were 29, 25 and 22, respectively. Active guidance to home measurements increased from 90% to 100% and every health station identified a dedicated area for patient self-measurement. At baseline, in poor control were 17% of blood pressure measurements, and 31% of diabetic and 71% of dyslipidemic patients. At follow-up, the corresponding figures were 22%, 34% and 64%, respectively. Multiprofessional facilitation and learning proved to be effective in implementing guidelines, improving multiprofessional collaboration and sharing duties and responsibilities, as well as targeting preventative activities and resources adequately.

Prioritizing guideline topics: development and evaluation of a practical tool.

RATIONALE, AIMS AND OBJECTIVES: A clear process for selecting and adopting clinical practice guidelines in the new topic areas is needed. The aim of this study is to design and develop a practical tool to assess guideline topics that have been suggested to the organization responsible for producing guidelines. METHODS: We carried out an iterative development, feasibility and validation study of a guideline topic prioritization tool. The setting included the guideline producer organization and the tax-funded health care system. In the first stage of the tool development, participants were researchers, members of the Current Care Board and experts from health care organizations. In the second stage, the evaluation was done internally within the project by three independent reviewers. The main outcome measures were responses to an evaluation questionnaire, qualitative process feedback and analysis of the performance of the instrument on a random set of guidelines. RESULTS: Evaluations by three independent reviewers revealed good agreement and face validity with respect to its feasibility as a planning tool at the guideline board level. Feedback from board members suggested that the instrument is useful in prioritizing guideline topics. CONCLUSION: This instrument was accepted for use by the Board. Further developments are needed to ensure feedback and acceptability of the instrument by those proposing topics.

Guidelines in context of evidence.

OBJECTIVE: In clinical practice guidelines, the quality of the available evidence is graded according to its reliability and quality. This study aimed to evaluate the quality of the available research evidence, using the levels of evidence, in the evidence summaries of 64 Finnish national evidence-based Current Care guidelines. DESIGN: Descriptive assessment. SETTING: Electronic web-based guidelines in Finland. MAIN OUTCOME MEASURES: The proportions of evidence summaries with different levels of evidence (A-D). RESULTS: The 64 guidelines had a total of 2419 evidence summaries. Of these, 532 (22.0%) were evidence level A, 891 (36.8%) were evidence level B, 808 (33.4%) were evidence level C, and 188 (7.8%) were evidence level D. Most--that is, 81% of the level C and D evidence summaries dealt with diagnosis and treatment. Most of the evidence summaries pertained to treatment (58.2%) and diagnosis (22.4%). The sections on diagnosis and treatment represented 80% of all the level A and level B evidence, and 81% of all the level C and level D evidence. CONCLUSIONS: There is adequate high-quality evidence (level A) to support only a fifth of the main statements of the 64 guidelines. This is most likely an optimistic estimate, since level D evidence often does not have an evidence summary. The guideline development groups find it easier to agree on recommendations based on level A and level B evidence.