Exercise on prescription: a randomized study on the effect of counseling vs counseling and supervised exercise.

The aim of this study was to compare short- (0-4 months) and long-term (0-10 months) effects of high-intensive Exercise on Prescription (EoP) intervention (counseling and supervised exercise) implemented in primary healthcare in a number of Danish counties with a low-intensive intervention (counseling) using maximal oxygen uptake (VO(2max)) as the primary outcome. The study was conducted as a randomized trial in 2005-2006 with a high and a low-intensive group. All the patients referred to the EoP scheme by their GP in the counties of Vejle and Ribe, Denmark, were eligible for the trial. The high-intensive EoP group received 4 months of group-based supervised training and attended five motivational counseling sessions. The low-intensive group only attended four motivational counseling sessions. Three hundred and twenty-seven patients entered the EoP scheme, and 52 (16%) volunteered for the randomized trial. No short- or long-term differences were found between the high and the low-intensive groups for VO(2max) (short-term 95% CI -1.1; 4.4 mL O(2)/(kg min), long-term 95% CI -1.6 to 2.1). The present study did not demonstrate any significant clinical outcome for the high-intensive EoP intervention as opposed to the low-intensive intervention.

Defining cancer patients as being in the terminal phase: who receives a formal diagnosis, and what are the effects?

PURPOSE: Physicians either do not define cancer patients as being terminal, or their prognostic estimates tend to be optimistic. This might affect patients' appropriate and timely referral to specialist palliative care services or can lead to unintended acute hospitalization. PATIENTS AND METHODS: We used the Danish Cancer Register and four administrative registers to perform a retrospective cohort study in 3,445 patients who died as a result of cancer. We used the Danish "terminal declaration" issued by a physician as a proxy for a formal terminal diagnosis (prognosis of death within 6 months). The terminal declaration gives right to economic benefits and increased care for the dying. We investigated patient-related factors of receiving an explicit terminal diagnosis by logistic regression and then analyzed the effects of such a diagnosis on admission rate per week and place of death. RESULTS: Thirty-four percent of patients received a formal terminal diagnosis. Age of > or = 70 years (odds ratio [OR], 0.44; 95% CI, 0.34 to 0.56; P < .001), women (OR, 0.81; 95% CI, 0.69 to 0.96; P = .02), hematologic cancer (OR, 0.20; 95% CI, 0.09 to 0.41; P < .001), and a less than 1-month survival time (OR, 0.10; 95% CI, 0.07 to 0.15; P < .001) were associated with a lesser likelihood of receiving a formal terminal diagnosis. Explicit terminal diagnosis was associated with lower admission rate and an adjusted OR of hospital death of 0.25 (95% CI, 0.21 to 0.29). CONCLUSION: Women and the elderly were less likely to receive a formal terminal diagnosis. The formal terminal diagnosis reduced hospital admissions and increased the possibilities of dying at home.

Socio-economic inequalities in first-time use of antidepressants: a population-based study.

OBJECTIVE: To analyse whether first-time use of antidepressants (incidence) and selection of TCAs (tricyclic antidepressants) versus new-generation drugs are associated with socio-economic status and psychiatric history. METHOD: We conducted a population-based cohort study using registry data covering Funen County, Denmark. A total of 305,953 adult residents without antidepressant prescriptions 5 years prior to the study period (1998) were included. RESULTS: The 1-year incidence rate of antidepressant prescription (1.7%) increased with age. It was higher in people who were female, less educated, unemployed, those receiving old-age or disability pension, low-income groups, and singles. The proportion prescribed new-generation antidepressants (82%) showed no difference according to socio-economic variables (education, annual income and socio-economic group), but was higher among the young and single. Admission to psychiatric hospital within 4 years prior to the study period was associated with high-incidence rate of antidepressant prescription and overall a preference for the new-generation antidepressants. CONCLUSION: Socio-economic status did not seem to influence the selection of TCAs versus new-generation antidepressants. Compatible with the general epidemiology of depression, low socio-economic status was associated with a high number of first-time users of antidepressants in the population, and the incidence rate increased with age.

Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission.

OBJECTIVE: The aim of the study was to examine patient delay (time from onset of chest pain to patient seeking medical care) among patients who were admitted to hospital with suspected acute coronary syndrome (ACS). DESIGN AND RESULTS: For 337 patients acutely admitted to the Cardiology Department, Odense University Hospital, during a 3-month period in 1998 with suspected ACS, patient delay and the total pre-hospital delay were registered. In addition, information on patient characteristics, patient behaviour and symptom perception was obtained. The median patient delay was 2.85 h (range 0.2-91 h), of this the "silent" patient delay represented 1 h (range 1 min-11.3 h). The total pre-hospital delay was median 3.88 h. Thirty-one per cent of the patients had confirmed acute myocardial infarction (AMI), and this patient group had a significantly shorter patient delay compared with the group without AMI, 2.05 h vs 3.12 h, p = 0.01. Patient delay of more than 2 h was associated with the factors "self-medication" and "wanted to wait and see if the symptoms went away". A smaller than average risk of patient delay was found in the case of "suspicion of heart attack" and "suspicion of a serious condition". CONCLUSION: Patient delay is considered to be a serious impediment to markedly improving the prognosis in the case of ACS.

Guidelines accompanied by changes in reimbursement rules. Effects on lipid-lowering drug prescribing.

OBJECTIVE: To analyse the effect of guidelines accompanied by changes in reimbursement rules for the prescription of lipid-lowering drugs (LLDs). DESIGN: Observational study focusing on LLD use before (1994-98) and after an intervention (1999). SETTING: Guidelines were developed by the Danish College of General Practitioners and focused on prevention of cardiovascular heart disease (CHD). Guidelines were sent out and changes in reimbursement took place in December 1998. Prescriptions for LLDs were extracted from a population-based prescription database (Odense University Pharmacoepidemiological Database, OPED) covering 10% of the Danish population (470,000 inhabitants). MAIN OUTCOME MEASURES: Incidence rate and 1 year prevalence rate (annual prevalence) of LLD use. RESULTS: The incidence of LLD use increased significantly in the year following the intervention. Incidence rate ratio (after/before) was 1.43 (CI 1.35-1.52). The annual prevalence of LLD use in the population increased by 0.4% after the intervention (0.2% before). The corresponding figure for patients with diabetes mellitus (treated with insulin or oral anti-diabetics) was 2.3% after the intervention (1.2% before), and for patients with CHD (treated with vasodilators) 8.1% after the intervention (5.0% before). CONCLUSION: Guidelines accompanied by a change in reimbursement rules had a significant influence on the prescribing of lipid-lowering drugs.

[Influenza vaccinations in Denmark during the season 1999-2000]. / Influenzavaccinationer i Danmark i saesonen 1999-2000.

INTRODUCTION: During the influenza season of 1999-2000, private vaccination clinics in Denmark increasingly offered influenza vaccination in competition with general practitioners (GPs). The clinics arranged group vaccinations in the local community or at workplaces at prices below the standard price. The aim of this study was to assess the actual proportion of people vaccinated, both in the elderly and in the younger population, and to elucidate the effect of marketing by the private vaccination clinics. MATERIAL AND METHOD: In February 2000, a questionnaire about influenza vaccination and general health was posted to 2,144 persons aged 65 or older and 1,717 aged 18-64 years randomly drawn from the Home Office Central Person Register. The questionnaire was completed by 70% in the older group and 66% in the younger group. RESULTS: In Denmark, 47% of the older group and 8% of the younger group were vaccinated against influenza. In the municipality of Copenhagen the acceptance rate was 66% in the older group, compared to 46% in the rest of the country. General practitioners vaccinated 69% of the older group and 66% of the younger group, 24% were vaccinated at a vaccination clinic, and 7% were vaccinated elsewhere. Half the 18-64 year-olds were vaccinated by their own GP, 33% at their workplace, 11% at a vaccination clinic, and 6% elsewhere. DISCUSSION: Based on this study, it is recommended that more effort is made to vaccinate young people in treatment for a chronic illness and the elderly against influenza. Influenza vaccination campaigns aimed at defined target groups could easily be done by general practitioners without establishing a new ad hoc organisation.

Changes in the utilisation of lipid-lowering drugs over a 6-year period (1993-1998) in a Danish population.

OBJECTIVE: The effect of lipid-lowering drugs (LLDs) on coronary heart disease is well established. However, their utilisation is often suspected to be too low. The aim of this study was to describe the epidemiology of LLD use with special emphasis on the development of utilisation over a 6-year period in a Danish population. METHODS: For all people who purchased LLDs from 1993 to 1998 in Funen County, all prescriptions for LLDs and co-medication with cardiovascular and antidiabetic drugs were retrieved from Odense University Pharmacoepidemiologic Database (OPED). RESULTS: During the study period, LLD use increased nearly exponentially. In 1998, statins accounted for 95% of the total LLD consumption. The incidence increased markedly around the time of the publication of the Scandinavian Simvastatin Survival Study (4S). Only 3% of the statins were purchased without reimbursement. The female/male ratio was 0.69 and the median age was 60 years. General practitioners issued 73% of the total number of LLD prescriptions, and 55% of the treatments were initiated in general practice. A larger fraction of females and elderly started treatment in general practice. About 40% of the treatments were hospital initiated, and about one-third were followed up in general practice within the first year. CONCLUSIONS: Over the 6 years studied, utilisation of LLDs approached a level that may correspond to the current guideline recommendations. Compliance with guidelines should, however, be studied by following people with coronary heart disease.

[A randomized controlled trial of the use of CRP rapid test as a guide to treatment of respiratory infections in general practice]. / Randomiseret, kontrolleret undersøgelse af anvendelsen af CRP-hurtigtest som vejledning ved behandlingen af luftvejsinfektioner i almen praksis.

INTRODUCTION: The aim was to assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a CRP rapid test to support their clinical assessment, and to examine whether the use of the test would have any effect on the course of disease. MATERIAL AND METHOD: A randomised controlled trial was carried out by 35 general practices in the County of Funen, Denmark, with 812 patients with respiratory infection. The main outcome measures were frequency of antibiotic prescriptions and morbidity one week after the consultation, as stated by the patients. RESULTS: The frequency of antibiotic prescriptions was 43% (179/414) in the CRP group and 46% (184/398) in the control group (NS, OR = 0.9). At one week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patient's general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase [mg/l], p < 0.0001). CONCLUSION: From on the present study, the use of a single CRP rapid test to support possible antibiotic treatment of respiratory infections in general practice cannot be recommended.

[Antibiotic treatment of infections in general practice. Effect of audit assessed by prescriptions data from health insurance registry and physicians' own registration]. / Antibiotikabehandling af infektioner i almen praksis. Effekten af audit bedømt ved ordinationsdata fra Sygesikringens register og laegernes selvregistrering.

The aim was to study whether an audit of treatment of infections in general practice resulted in changed prescribing habits. In 1995-1996 forty-six general practitioners (GP's) from the County of Roskilde participated in an audit regarding infectious diseases (incl. course participation and preparation of treatment guidelines). The effect evaluation was done on the basis of 1) two self-registrations of antibiotic prescriptions carried out with one year's interval, and 2) prescribing data from the National Insurance database collected over two periods, before the first and second self-registration respectively. The number of patients not receiving antibiotics increased significantly from 47.2% to 52.4% after intervention. The self-registration did not show any change in choice of antibiotics, while the registry data showed a shift from broad-spectrum to narrow-spectrum penicillin. This change was, however, also found among the GP's, who did not participate in the audit. The study demonstrated that audit can result in changes in prescribing patterns, but at the same time emphasizes the need for inclusion of external data sources and control groups in the evaluation of intervention effects.

[Unplanned emergency admission of dying patients. Causes elucidated by focus group interviews with general practitioners]. / Utilsigtet akut indlaeggelse af døende. Arsager belyst ved fokusgruppeinterview med praktiserende laeger.

Research indicates that the major part of terminally ill and dying patients wish to die at home, but in 1993 actually only 24% of Danish cancer patients died at home. The aim of this study was to analyse some barriers the general practitioners meet in the care for dying patients. The focus was unplanned hospitalisation in the final days of the patient's life contrary to home death as planned. The informal carer's lack of resources and insufficient control of symptoms were found to be the immediate reasons for acute hospitalisation. In addition, if the general practitioner did not have a central position in home care, we found a greater risk of unplanned hospitalisation. The conditions for improving home care for the dying are better support for the informal carer, ongoing access to experts in palliation and improved communication overall in the health service.

[Big differences in the frequency of polypharmacy between physicians]. / Store forskelle i forekomsten af polyfarmaci mellem praktiserende laeger.

Polypharmacy, the simultaneous use of multiple drugs, is associated with adverse drug reactions, medication errors, and increased risk of hospitalisation. When the number of drugs is five or more (major polypharmacy), a significant risk may be present. We analysed the prevalence of major polypharmacy among listed patients, and identified possible predictors of major polypharmacy related to the practice. Prescription data were retrieved from the Odense Pharmaco-epidemiological Database and the age and sex standardised prevalence rate of major polypharmacy was calculated for each practice (n = 173). Possible predictors of major polypharmacy related to the GPs were analysed by backward stepwise linear multiple regression. A six-fold variation between practices in the prevalence of major polypharmacy was found, i.e. from 16 to 96 per 1000 listed patients (median: 42). Predictors related to the practice structure, workload, clinical work profile, and prescribing profile could explain 56% of the variation.

Randomised controlled trial of CRP rapid test as a guide to treatment of respiratory infections in general practice.

OBJECTIVE: To assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a C-reactive protein (CRP) rapid test in support of their clinical assessment, and to study whether using the test will have any effect on the course of disease DESIGN: Randomised controlled trial. SETTING: 35 general practices, County of Funen, Denmark. PATIENTS: 812 patients with respiratory infection. MAIN OUTCOME MEASURES: Frequency of antibiotic prescriptions and morbidity 1 week after the consultation, as stated by the patients. RESULTS: In the CRP group the frequency of antibiotic prescriptions was 43% (179/414) compared with 46% (184/398) in the control group (odds ratio (OR) = 0.9, NS). After 1 week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patients' general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase (mg/l), p < 0.0001). CONCLUSION: Based on the present study, the use of the CRP rapid test in support of a possible antibiotic treatment for respiratory infections in general practice cannot be recommended.

[Polypharmacy estimated by means of a population-based prescription database]. / Polyfarmaci belyst ved hjaelp af en populationsbaseret receptdatabase.

The aim was to investigate estimators of polypharmacy (PP) from a population based prescription database. Data were retrieved from Odense Pharmacoepidemiological Database and contained a 10% random sample (n = 26,977) of drug users in 1994. PP was defined as simultaneous treatment with different drugs, and the duration of treatment was calculated from the date of purchase and the number of defined daily doses prescribed. This estimator was compared with an estimator based on the number of drugs purchased during a three month period. On an average day 8.7% were exposed to minor PP (two to four drugs) and 1.2% to major PP (five or more drugs). Purchase of five or more drugs during a three month period predicted episodes of major PP with a positive predictive value of 80%. Epidemiological measures of multiple drug use can be estimated from a prescription database. Conceptually, an estimator based on the number of simultaneously used drugs is preferable, but the number of drugs purchased during a three month period may be a useful alternative estimator.

How well do patient and general practitioner agree about the content of consultations?

OBJECTIVE: To analyse agreement between patients' and general practitioners' perception of content of consultations. DESIGN: Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs). SETTING: General practices in the County of Funen, Denmark. SUBJECTS: All 291 GPs in the County were invited to join the investigation, and 137 accepted. All patients who consulted the participating GPs in a 3 day period were included in the investigation. The GPs registered 6021 patients, of whom 3578 (59%) returned the completed questionnaire. MAIN OUTCOME MEASURES: GPs and patients were asked about the urgency of the consultation, number of problems presented, duration of consultation, and quality of communication. The GPs' and patients' answers were matched, and variables of agreement were made. Patients were furthermore asked about their satisfaction with the consultation. RESULTS AND CONCLUSION: Agreement for the four matched answers varied from 69% to 83%. Disagreement was observed more often in consultations where the patient's self-evaluated health was poor, the patient was female, had a chronic disease, expected a prescription or felt that the GP had little knowledge of his/her life circumstances. Agreement concerning urgency, number of problems and quality of communication was associated with a higher degree of patient satisfaction.

Randomized controlled trial of the effect of medical audit on AIDS prevention in general practice.

OBJECTIVE: We aimed to evaluate the effect of a medical audit on AIDS prevention in general practice. METHODS: We conducted a prospective randomized controlled study performed as 'lagged intervention'. At the time of comparison, the intervention group had completed 6 months of audit including a primary activity registration, feedback of own data and a meeting with colleagues and experts, and had received brief summaries of the meetings and reminders about the project (a full 'audit circle'). The participants were from general practices in Copenhagen and the Counties of Funen and Vejle, Denmark. One hundred and thirty-three GPs completed the project. The main outcome measures were the number of consultations involving AIDS prevention and the number of talks about AIDS initiated by the GP, and some elements of the content were registered on a chart. RESULTS: No statistically significant difference was observed in the frequency of consultations involving AIDS prevention between the intervention group (1.2% of consultations) and the control group (1.4%). Furthermore, no significant differences were observed regarding the content of these consultations or regarding the fraction of such consultations initiated by the GPs. CONCLUSIONS: Medical audit had no observed effect on AIDS prevention in general practice.

Decision on influenza vaccination among the elderly. A questionnaire study based on the Health Belief Model and the Multidimensional Locus of Control Theory.

OBJECTIVE: To create an empirical model, describing factors of importance to the elderly in accepting influenza vaccinations. DESIGN: Epidemiologic study with two coupled questionnaires. In September 1996 a 46-item questionnaire was sent to 2147 elderly people (> or = 65 years). The questionnaire comprised questions about general health, and questions based on the Health Belief Model and the Multidimensional Locus of Control Theory. In February 1997 a postcard questionnaire was sent to the same elderly people asking whether they had been vaccinated against influenza in the past season. SETTING: All Danish counties. SUBJECTS: 2147 persons randomly sampled from the The Civil Registration System. MAIN OUTCOME MEASURE: Factors influencing the rate of influenza vaccine uptake in the elderly. Influenza vaccination rates. RESULTS: In the high-risk group 51% (95% confidence interval: 46-55%) were vaccinated compared to 29% (26-32%) in the low-risk group as regards influenza. By logistic regression the Health Belief Model dimensions "perceived barriers", "perceived benefits" and "perceived severity" were found to be significant predictors of acceptance of influenza vaccinations. CONCLUSIONS: An empirical model based on the Health Belief Model predicting acceptance of influenza vaccinations with a positive predictive value of 91% (87-94%) and a negative predictive value of 86% (83-88%) was obtained.

Polypharmacy in general practice: differences between practitioners.

BACKGROUND: Polypharmacy, the simultaneous use of multiple drugs, is associated with adverse drug reactions, medication errors, and increased risk of hospitalization. When the number of concurrently used drugs totals five or more (major polypharmacy), a significant risk may be present. AIM: To analyse the interpractice variation in the prevalence of major polypharmacy among listed patients, and to identify possible predictors of major polypharmacy related to the practice. METHOD: Prescription data were retrieved from the Odense Pharmacoepidemiological Database, and individuals subject to major polypharmacy were identified. The age- and sex-standardized prevalence rate of major polypharmacy was calculated for each practice in the County of Funen in Denmark (n = 173), using the distribution of age and sex of the background population as a reference. The practice characteristics were retrieved from the Regional Health Insurance System. Possible predictors of major polypharmacy related to the general practitioners (GPs) were analysed using backward stepwise linear multiple regression. RESULTS: A six-fold variation between the practices in the prevalence of major polypharmacy was found (16 to 96 per 1000 listed patients; median = 42). Predictors related to the practice structure, workload, clinical work profile, and prescribing profile could explain 56% of the variation. CONCLUSION: A substantial part of the variation in major polypharmacy between practices can be explained by predictors related to practice.

[A screening test for depression in general practice. The COOP/WONCA chart]. / Screeningstest for depression i almen praksis. COOP/WONCA-kort.

Depressed patients in general practice may be difficult to identify. Questionnaires may be used for screening but some of the existing instruments are difficult to use and have only to a limited degree been introduced in general practice. In this study 798 patients' answers to the COOP/WONCA chart "Feelings" were compared to GPs' diagnosis according to ICD-10 criteria for depressive single episode (F32). At cut-off2/3 (slight/moderate problems) the chart had a sensitivity of 89% (76-100%) and specificity of 75% (72-78%). The predictive value of a positive test was not higher than 33% for any cut-off point and the predictive value of a negative test never less than 98%. A two-phased diagnostic strategy with the COOP/WONCA chart as step one is suggested as a possible and relatively simple way to optimize recognition of depressive patients in general practice.