Norwegian regular general practitioners' experiences with out-of-hours emergency situations and procedures.

OBJECTIVE: To study the participation of Norwegian regular general practitioners (RGPs) in the out-of-hours system in 2006 and what kind of emergency situations and procedures they experienced in the past 12 months. RGPs' confidence in performing certain emergency procedures was also mapped. METHODS: In May 2006 all 3804 RGPs taking part in the RGP scheme in Norway were sent a questionnaire dealing with several aspects of the emergency out-of-hours duty. The RGPs who had participated were asked about 14 pre-selected emergency situations, experiences with different pre-selected emergency procedures and their self-confidence with these in the past 12 months. RESULTS: After two reminders 2913 (78%) answered and 1832 (63%) confirmed they had taken part in emergency out-of-hours services in the past 12 months. 95% of participating RGPs answered questions about emergency situations, 74-78% about emergency procedures. The most common situations were chest pain, psychiatric problems and asthma, experienced by 94%, 92% and 88%, respectively. The number of occasions the doctors had experienced the most frequent emergency procedures (presented as median 25-75% percentiles) were: intravenous medication, three (1-10); oxygen mask, three (1-10); venous access, four (1-10). The doctors reported almost no experiences with other procedures. The doctors reported a high self-confidence in performing the emergency procedures. Male doctors working four or more shifts per month and doctors working in rural areas reported more experiences both in emergency situations and procedures. CONCLUSION: Approximately two-thirds of RGPs in Norway took part in the out-of-hours service. A wide variety of emergency cases was experienced by the RGPs. Despite this, experiences with most emergency procedures during a 12-month period are low. Regular training is therefore necessary to maintain good skill levels.

Stopping long-term drug therapy in general practice. How well do physicians and patients agree?.

BACKGROUND: GPs have a particular responsibility to limit the occurrence of polypharmacy and adverse drug reactions, and to discontinue unnecessary drug therapy. OBJECTIVE: The aim of the present study was to measure the extent to which patients and physicians agree upon information communicated in a consultation when a drug is withdrawn. METHODS: A total of 272 Norwegian GPs and 272 patients filled in questionnaires after a consultation in which a long-term drug therapy had been discontinued. Their answers were compared and the agreement measured by kappa statistics. RESULTS: There was 100% concordance between physicians and patients as to what drug had been discontinued. Most of the drugs (72%) were cardiovascular. There was fair agreement as to whether the drug was to be stopped abruptly or gradually withdrawn (kappa 0.61) and whether a follow-up appointment had been scheduled (kappa 0.41). Physicians were not able to judge patients' satisfaction accurately (kappa 0.20). Most patients (73%) were satisfied or very satisfied with the decision to withdraw the drug, and many commented that good communication and close follow-up is a prerequisite for successful withdrawal of long-term drug treatment. CONCLUSIONS: Discontinuation of drug treatment was welcomed by most patients. Physicians and patients agreed completely as to what drug was to be discontinued, and fairly well about other factual aspects, but physicians were not able to judge patients' satisfaction accurately.

A Norwegian national cohort of 3198 women treated with home-managed electrical stimulation for urinary incontinence--effectiveness and treatment results.

OBJECTIVE: The aim of this study was to analyse the effectiveness of home-managed electrical stimulation. MATERIAL AND METHODS: A prospective cohort study was conducted on all 3198 women treated with home-managed electrical stimulation in Norway during 1992-1994. Data were collected from both patients and physicians by questionnaires before and after treatment. RESULTS: 29% of the women were cured or much improved according to their own assessment; altogether 61% were improved. According to the physicians' assessment, 33% were cured or much improved; a total of 55% was improved. Thirty-seven per cent of compliers and 12% of non-compliers regarded themselves as cured or much improved. The number of incontinence episodes, amount of leakage and use of pads decreased significantly; and 44% had less severe incontinence than before treatment according to a validated severity index. CONCLUSIONS: Women treated with electrical stimulation for urinary incontinence experienced a significant reduction in incontinence problems, both subjectively and semi-objectively. The treatment results seem to be strongly dependent on good acceptance of the treatment.

[Analysis of the debate on the general practice list system on the Eyr]. / Analyse av fastlegedebatten på Eyr.

BACKGROUND: The most heavily discussed subject on Eyr, the Norwegian mailing list for general practitioners, has been the introduction of a general practice list system (GPLS). MATERIAL AND METHODS: All messages in the GPLS debate were recorded from its start in August 1996 up until the GPLS was introduced nationwide in June 2001. RESULTS: During this period, 243 different persons posted 2,153 messages about the GPLS, 232 of the participants were physicians, 203 of them GPs. Mean age was 46 years; males were strongly overrepresented (87%). 80% of the participants posted ten or fewer messages, 10% posted 11-20 messages, and 10% posted more than 20 messages. GPs sent most of their messages in the evenings, academics and public health officers sent most of their messages during work hours. Mean length of the messages was 179 words, 72% were responses to earlier messages. Most of the messages were neutral regarding the GPLS, 207 (9.6%) were negative, and 181 (8.4%) positive. Academics, public health officers, and participants in a GPLS trial were heavily overrepresented with positive messages. INTERPRETATION: It is concluded that this debate has been fairly balanced. Participation greatly exceeded what would have been possible in traditional media.

A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trøndelag.

OBJECTIVES: The aim was to assess the prevalence of any urinary leakage in an unselected female population in Norway, and to estimate the prevalence of significant incontinence. METHODS: The EPINCONT Study is part of a large survey (HUNT 2) performed in a county in Norway during 1995-97. Everyone aged 20 years or more was invited. 27,936 (80%) of 34,755 community-dwelling women answered a questionnaire. A validated severity index was used to assess severity. RESULTS: Twenty-five percent of the participating women had urinary leakage. Nearly 7% had significant incontinence, defined as moderate or severe incontinence that was experienced as bothersome. The prevalence of incontinence increased with increasing age. Half of the incontinence was of stress type, 11% had urge and 36% mixed incontinence. CONCLUSIONS: Urinary leakage is highly prevalent. Seven percent have significant incontinence and should be regarded as potential patients.

[The district practitioner (1836-1984)]. / Distriktslegen (1836-1984).

In 1836, a system of district physicians was established in Norway. In addition to providing individual medical services, the district physicians supervised other health care providers and looked after vulnerable groups of patients. They were also chairmen of the local boards of health, and were supposed to engage in anything that might improve local health conditions. The first district physicians were given responsibility for enormous areas, and would rarely get in close contact with the people in their districts. When the districts were divided into smaller units, they came closer to the local people, but they had to struggle hard for recognition. Over the years, however, they succeeded by means of health information and increasingly effective medical remedies. In the late 1950s, local health services were in a deep crisis, but towards the end of the 1960s new and radical political trends initiated a revitalisation. Primary health care became increasingly popular among young doctors, and a large number of new positions were established. However, in 1984, at the height of this boom, the government chose to close down the district physician service.

A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests.

In epidemiological surveys of female urinary incontinence, it is not feasible to demonstrate urine loss objectively. The aim of this study was to develop a valid epidemiological instrument (a severity index) for assessing the severity of incontinence. The severity index is based on information about frequency (four levels) and amount of leakage (two or three levels). By multiplication, an index value (1-8 or 1-12) is reached. This index value is further categorized into a severity index of three or four levels. The index was compared with the results of 315 pad-weighing tests performed by 265 women in hospital and general practice. Data from an epidemiological survey were also re-analyzed by applying the four-level severity index. Mean pad-weighing results (grams per 24 hours, 95% confidence interval) for the three-level severity index was slight (6; 2-9), moderate (17; 13-22), and severe (56; 44-67). For the four-level severity index, the results were slight (6; 2-9), moderate (23; 15-30), severe (52; 38-65), and very severe (122; 84-159). Spearman's correlation coefficient for pad-weighing results and the three-level severity index was 0.47 (P < 0.01) and for the four-level severity index 0.54 (P< 0.01). The four-level severity index gave a more balanced distribution among the women in the clinical materials, and data from the epidemiological survey showed that the four-level severity index identifies a sub-group of older women with very severe incontinence. The four-level severity index seems to be a valid representation of incontinence severity as measured by pad-weighing tests in women presenting for clinical care. It should be considered a potentially valid measure of incontinence severity in epidemiological studies. Neurourol. Urodynam. 19:137-145, 2000.

Health information and interaction on the internet: a survey of female urinary incontinence.

OBJECTIVE: To evaluate the internet as a source of information about urinary incontinence and to explore interactive facilities. DESIGNLimited survey of internet resources. SUBJECTS: 75 websites providing information about incontinence and an opportunity for interactivity, 25 web doctors, and two news groups. MAIN OUTCOME MEASURES: Quality scores according to predefined general and specific criteria. Internet popularity indexes according to number of links to websites. Correlation between quality scores and popularity indexes. RESULTS: Few sites provided comprehensive information, but the information actually provided was mostly correct. Internet popularity indexes did not correlate with quality scores. The most informative site was easily found with general internet search engines but was not found in any of the medical index sites investigated. Sixty six per cent of sites responded to an email request for advice from a fictitious incontinent woman, half of them within 24 hours. Twelve responders provided vital information that the woman might suffer from drug induced incontinence. CONCLUSIONS: Excellent information about urinary incontinence was found on the internet, but the number of links to a site did not reflect quality of content. Patients may get valuable advice and comfort from using interactive services.

Prescribing systemic antibiotics in general practice. A report from the Møre & Romsdal Prescription Study.

OBJECTIVE: To describe general practitioners' (GPs) prescribing patterns for antibiotics and to compare them with therapeutic guidelines. DESIGN: Cross-sectional, observational study. SETTING: In the Norwegian county Møre & Romsdal the GPs recorded all contacts with patients and prescriptions during two months. SUBJECTS: 69,843 contacts with 56,758 prescriptions, of which 7905 were for systemic antibiotics. MAIN OUTCOME MEASURES: Prescriptions in relation to diagnosis, kind of consultation, and patients' age and sex. RESULTS: 61% of all antibiotic prescriptions were for females, 26% were issued during indirect contacts, and 14% were repeat prescriptions. Phenoxymethylpenicillin was prescribed most frequently (32%), followed by co-trimoxazole (19%), tetracyclines (18%), erythromycin (16%), and penicillins with extended spectrum (6%). Urinary tract infection was the most frequent diagnosis for antibiotic prescribing (24%), followed by acute bronchitis (13%), ear infections (9%), upper respiratory tract infections (8%), and acute tonsillitis (8.2%). A regression analysis showed that first-time consultations for tonsillitis and otitis, but not for acute bronchitis and pneumonia, patient age 13-64 years, female physician, urban practice location, and a fixed. GP salary were associated with the prescribing of phenoxymethylpenicillin in contrast to other antibiotics. CONCLUSION: Antibiotics are often prescribed for viral infections (e.g., acute bronchitis). Broad spectrum antibiotics are often prescribed for diagnoses where penicillin is recommended as first choice. The issue of antibiotic misuse should be addressed more explicitly in general practice.

[Feet--a diagnostic tool?]. / Føttene--et diagnostisk hjelpemiddel?

We wanted to test the specific theory behind foot reflexology. Three reflexotherapists examined 76 patients of whom they had no previous knowledge. They were to localize the patients' problems and complaints by examination of the foot soles only; they had no other information about the patients. Each patient and the therapist graded problems related to 13 different parts of the body. Interrater agreement, measured by weighted Kappa, ranged from 0.04 to 0.22, and was significantly better than chance (p < 0.05) for six parts of the body. The overall Kappa was 0.11 (95% CI: 0.08-0.14). A score based on a detailed examination of the "colon zone" showed no significant difference between patients with many or few distal intestinal complaints. Generally, the therapists tended to score higher than the patients, thus overdiagnosing problems. The statistical agreement may be better than pure chance, but is too low to be of any clinical significance.

["Earth rays"--an underground phenomenon?]. / "Jordstråler"--et underjordisk fenomen?

According to reports in the Norwegian lay press, a lot of illness can be ascribed to "earth rays". Earth rays are presumed to form a square pattern, but can only be demonstrated by dowsing. No documentation has been reported which supports their existence. However, many patients have experienced considerable relief after a protecting copper net has been placed under their beds. Four dowsers participated in an experiment where, independently of each other, they were to demonstrate the pattern of earth rays in a gymnasium. Four supervisors ensured that the dowsers could not communicate with each other during the experiment. As it turned out, they came up with four totally different patterns. Thus, any protective treatment prescribed by the dowsers seems to be based on pure chance.

[Patient encounters in general practice. An epidemiological survey in Møre and Romsdal]. / Pasientkontakter i allmennpraksis. En epidemiologisk undersøkelse i Møre og Romsdal.

In 1988 and 1989 all general practitioners (GPs) in Møre & Romsdal recorded all encounters with patients over a period of two months. The participation rate was close to 100% and a total of 90,458 encounters were recorded. Of all encounters 61% involved female patients. Female GPs had more female patients than their male colleagues (71% versus 59%). The discrepancy was most pronounced for sex-specific diagnoses. Home visits accounted for 9% of all direct encounters, an increase from the 5-6% reported in the 1970s. 37% of all contacts occurred by phone or messenger. The diagnostic distribution compares well with Olav Rutle's findings in 1978. Cardiovascular diseases, however, seem to have become less prominent since that time. The most frequent ICPC diagnoses were musculoskeletal (17%), respiratory (14%), cardiovascular (12%), and psychiatric (12%). Respiratory diseases dominated among children, musculoskeletal diseases among adults, and cardiovascular diseases among the elderly.

[Group sequential experiments. Short introduction and review]. / Gruppesekvensielle forsøksplanar. Kort innføring og oversikt.

Group sequential experiments are terminated when an interim statistical test turns out to be "significant", or when maximum study size is attained. To ensure a stipulated total level of significance the interim tests have to be performed at a stricter level of significance determined by the maximum number of interim tests. As for fixed size studies, it is possible to determine a study size leading to a stipulated power. This study size depends on expected effect of intervention, number of interim tests and level of significance. Tables and computer simulation programs have been developed to facilitate the design of such plans. If the intervention turns out to be about as effective as expected, a saving in study size of about 30% can be expected in the long run, relative to studies of fixed size. If the intervention is much more effective than expected, larger savings can be achieved.

[10,850 general practice consultations with elderly patients. From diagnosis-prescription-examination in Møre and Romsdal]. / 10,850 kontorkonsultasjoner med eldre pasienter i allmennpraksis. Fra diagnose-resept-undersøkelsen i Møre og Romsdal.

Over a period of two months in 1988 and 1989 general practitioners in the Norwegian county of Møre and Romsdal recorded all contacts with their patients. Participation was close to 100%. We report data from 10,850 surgery consultations with elderly patients (65 years and older). 60% of the consultations involved female patients, and 58% of the patients were 65-74 years old. New diagnoses were made in one-third of the cases; two-thirds were follow-ups. The most common groups of diagnoses were cardiovascular (28%), musculoskeletal (13%), psychiatric (8%) and respiratory diseases (8%). Almost 10% of all consultations were for hypertension. Drugs were prescribed in 45% of all cases. 27% of all prescriptions were for cardiovascular drugs, and 25% were for drugs for the nervous system. The 20 most common diagnoses made up more than half of the total number of diagnoses. Almost 70% of all prescriptions were for the ten most common therapeutic groups.

[1384 house calls to elderly patients in family practice. From diagnosis-prescriptions-examination in Møre and Romsdal]. / 1384 hjemmebesøk til eldre pasienter i allmennpraksis. Fra diagnose-resept-undersøkelsen i Møre og Romsdal.

Over a period of two months in 1988 and 1989 all general practitioners in the Norwegian county of Møre and Romsdal recorded all contacts with their patients. We report data from 1,384 house calls to elderly patients (65 years and older). House calls made up 11.3% of all face-to-face contacts between general practitioners and elderly patients. 59% of the visits were to female patients, and 60% were to patients 75 years and older. 23% of the house calls took place during weekends, and new diagnoses were made in 58% of the cases. The most common groups of diagnoses were cardiovascular (21%), respiratory (16%), and musculoskeletal diseases (13%). Drugs were prescribed for 42% of the house calls. 28% of all drugs prescribed were for the nervous system, while 26% were antibiotics for systemic use. Most house calls were made because of acute illnesses. Our results suggest that preventive home visits to the elderly are rarely, if ever, performed in general practice.