Blood pressure control in subjects with type 2 diabetes.

Blood pressure (BP) control of type 2 diabetic subjects aged under 65 years was assessed in a primary care setting. In addition, the usefulness of 24-h ambulatory BP measurement (ABPM) in the treatment of hypertension was assessed in subjects with diastolic BP (DBP) > or = 90 mm Hg. Of the total 381 diabetic subjects, 260 (68%) participated in the first phase, and 48 of the 110 subjects with DBP > or = 90 mm Hg were equipped with a Meditech ABPM-02 monitor in the second phase. The mean BP of the 260 participants was 156/91 (s.d. 22/11) mm Hg. According to the WHO criteria, 58% had hypertension, and 42% had a diagnosis of hypertension. Albuminuria > or = 20 micrograms/min was detected in 32% of the subjects. Ten percent of the subjects with diagnosed hypertension had a mean BP < 140/90 mm Hg and 50% had a mean BP > or = 160/95 mm Hg, as many as 38% of those not having a diagnosis of hypertension. Only long-term poor BP control in casual measurements was associated with albuminuria (42% vs 27%, P = 0.018). It is concluded that BP control was unsatisfactory and diagnosis of hypertension was delayed in most subjects with type 2 diabetes. Occurrence of microalbuminuria was associated with poor BP control and urinary albumin excretion rate may be useful in assessing the BP control. Further studies are needed to assess the position of 24-h ABPM in the treatment of hypertension of subjects with type 2 diabetes.

Drinking problems load health centre hospitals in Finland.

This study examined the reasons for referral of patients from general practice to health centre hospitals in central and northern Finland during one week in 1994. Participants were 806 general practitioners (GPs) from public health centres. Outcome measures were reasons for referral by ICPC codes, with respect to characteristics of patients, GPs, and practices. A total of 723 patients (1.4%) were referred from 53,633 consultations. Most referrals (532, 74%) were from out of hours consultations. The most commonly reported reasons for referral in the age group under 65 years were alcohol abuse for males and vertigo for females. For patients aged 65 or over, angina pectoris was the most common reason for referral for both male and female patients. Our results will be useful in developing primary healthcare and the training of GPs. Future research should focus on alcohol-related diseases in those patients referred to health centre hospitals.

Relative weight gain and obesity as a child predict metabolic syndrome as an adult.

OBJECTIVE: To examine whether birth weight, weight gain from birth to the age of seven or body-mass index at the age of seven have any association with metabolic syndrome as an adult. DESIGN: A population study. SUBJECTS: 210 men and 218 women out of a total 712 subjects aged 36, 41 or 46 years in Pieksämäki town, Finland. MAIN OUTCOME MEASURES: Weight at birth and weight and height at the age of seven and metabolic syndrome defined as a clustering of hypertension, dyslipidemia (hypertriglyceridaemia or low high-density-lipoprotein cholesterol), and insulin resistance (inferred by abnormal glucose tolerance or hyperinsulinaemia). RESULTS: No association was found between birth weight and the metabolic syndrome as an adult. Among obese children at the age of seven (body-mass index in the highest quartile), the odds ratio (OR) for the metabolic syndrome in adulthood was 4.4 (95% CI 2.1-9.5) as compared to the other children (the three other quartiles combined). After adjustment for age, sex and current obesity, the risk of the syndrome still was 2.4 (95% CI 2.1-9.5). CONCLUSION: We could not replicate the close association between low birth weight and the metabolic syndrome in adulthood as has been shown in some earlier studies. Obesity at the age of seven predicts the metabolic syndrome in adulthood.

They call it stormy Monday--reasons for referral from primary to secondary care according to the days of the week.

Previous studies of specialist care have shown that the onset of acute myocardial infarction occurs most frequently on Mondays; however, the septadian pattern in the reasons for referrals from primary care to secondary care has not been examined previously. We examined daily variations in rates of referral from primary to secondary care in central and northern Finland, using International Classification of Primary Care codes, during two weeks (30 November to 6 December 1992, and 28 November to 4 December 1994) before and after the introduction of a reform in the system of financing health care. Monday peaks were observed in the occurrence of angina pectoris, fractures of the tibia/fibula, lumbar disc lesions, and infections of the eye. Tuesday peaks were found in the occurrence of headache. Two peaks (on Tuesday and Thursday) were observed for patients with suspected appendicitis. Many problems of primary health care leading to referral to secondary care are not random events but occur in a weekly pattern. Further investigation is needed within these subgroups of patients to identify the causes of this variation.

Discrepancies between the assessed urgency and the actual time taken to obtain a consultation with an internist.

OBJECTIVE: To compare postreferral waiting times to hospital in internal medicine with the urgency of the cases as assessed by a panel of doctors. DESIGN: Retrospective evaluation of referrals to three hospitals during 1 week. SETTING: Referrals to internal medicine departments of Kuopio University Hospital, Kajaani central hospital and Pieksämäki regional hospital in Finland. PARTICIPANTS: Two specialists in internal medicine working in university hospital and four specialists in general practice, two of whom were private sector general practitioners (GPs), the other two being public health centre chief physicians. OUTCOME MEASURES: Postreferral waiting times, assessment of the urgency of the referral by a panel of doctors, and the reliability of this assessment. RESULTS: Mean delay to specialist consultation was 36 days. There were no significant differences between the assessors in their opinions regarding the degree of urgency of referrals. Interobserver agreement between assessors was moderate or substantial (kappa values 0.46-0.62) and intraobserver agreement varied from moderate to almost perfect (kappa values were between 0.57 and 0.88). However, of those patients who were assessed to require examination by a consultant within 1 week only 34% actually saw the specialist within that time. Of those patients who were assessed to be require the treatments within 8-30 days, 48% were examined by a specialist within that time. CONCLUSION: It is possible to reliably assess the urgency of referrals to internal medicine departments. There is a need to improve the referral process for those patients requiring consultation with a hospital specialist within 30 days.

Hyperinsulinaemia in hypertensive subjects: validity of a test for the detection of insulin resistance in clinical practice.

OBJECTIVES: To determine the prevalence of hyperinsulinaemia in non-diabetic hypertensive subjects and to investigate the validity of a simple test for the detection of insulin resistance/hyperinsulinaemia. The test consisted of five markers: (1) obesity (body-mass index, BMI > or =30 kg/m2); (2) central adiposity (waist-to-hip ratio, WHR > or =1.00 in men and > or =0.88 in women); (3) hypertriglyceridaemia (> or =1.70 mmol/l); (4) low high-density lipoprotein (HDL) cholesterol (<1.00 mmol/l in men and <1.20 mmol/l in women); and (5) impaired glucose tolerance according to the WHO criteria. The test was defined to be positive for subjects who had simultaneously at least two of the five markers. DESIGN AND SETTING: A community-based screening programme for hypertension carried out at Pieksämäki District Health Centre, and the Community Health Centre of the City of Tampere, Finland. SUBJECTS: The 161 hypertensives who were detected by screening all subjects aged 36, 41, 46 and 51 years (n = 1148) in Pieksämäki town, and a randomly selected normotensive control group of 177 men and women aged 40 and 45 years in the City of Tampere. MAIN OUTCOME MEASURES: Hyperinsulinaemia defined by using two different cut-off points of the fasting plasma insulin (> or =13.0 mU/l and > or =18.0 mU/l). RESULTS: Hyperinsulinaemia > or =13.0 mU/l was present in 45% of hypertensive men and in 25% of hypertensive women. The sex difference was statistically significant (P < 0.01). The corresponding rates of hyperinsulinaemia > or =18.0 mU/l were 18% and 16%. The sensitivity of the test for hyperinsulinaemia > or =13.0 mU/l was 77% and specificity 73% in men, and 100% and 70% in women. The corresponding figures for hyperinsulinaemia > or =18.0 mU/l were 94% and 60% in men, and 100% and 63% in women. CONCLUSION: Our results suggest that hyperinsulinaemia/insulin resistance in hypertensives becomes identifiable by using simple measurements of BMI, WHR, serum triglycerides and HDL cholesterol as well as the oral glucose tolerance test as means.

Obesity type and clustering of insulin resistance-associated cardiovascular risk factors in middle-aged men and women.

OBJECTIVE: To examine different clusterings of the insulin resistance-associated cardiovascular risk factors with respect to different types of obesity. DESIGN: A screening programme for obesity (body mass index; BMI> or =30 kg/m2) and abdominal adiposity (waist-to-hip ratio; WHR > or = 1.00 in men and > or = 0.88 in women). SETTINGS: Pieksämäki District Health Centre and the Community Health Centre of the City of Tampere, Finland. SUBJECTS: All volunteers were either aged 36, 41, 46 or 51 y (n=1148) and living in the town of Pieksämäki, with a control population of 162 subjects in the City of Tampere. MAIN OUTCOME MEASURES: Different clusterings of: 1) hypertension (a systolic blood pressure > or = 160 mmHg and/or a diastolic blood pressure > or = 95 mmHg or concurrent drug treatment for hypertension); 2) hypertriglyceridaemia > or = 1.70 mmol/l; 3) a low level of high-density-lipoprotein (HDL) cholesterol; < 1.00 mmol/l in men, < 1.20 mmol/l in women; 4) abnormal glucose metabolism (impaired glucose tolerance or non-insulin-dependent diabetes) and 5) hyperinsulinaemia with a fasting plasma insulin > or = 13.0 mU/l. RESULTS: The prevalence of a cluster consisting of dyslipidaemia (hypertriglyceridaemia and/or low HDL-cholesterol) and insulin resistance (abnormal glucose metabolism and/or hyperinsulinaemia) was found to be 4% in the control subjects, 18% in the abdominal adipose subjects (WHR > or = 1.00 in men and > or = 0.88 in women with a BMI < 30 kg/m2), 28% in the 'pure' obese subjects (BMI> or = 30 kg/m2 with WHR < 1.00 in men and < 0.88 in women), and 46% in the central obese subjects (subjects showing both 'pure' obesity and abdominal adiposity). The prevalence rates of the other clusterings of abnormalities varied similarly according to the type of obesity. CONCLUSION: Clusterings of insulin resistance-associated abnormalities were related to the type of obesity in both middle-aged men and middle-aged women.

Saturday night fever? Reasons for referral from health centres to hospitals during weekends in Finland.

OBJECTIVE: We aimed to examine the reasons for referral from health centres to hospitals during the weekend in Finland. METHOD: We conducted a survey of all referrals from general practice on two weekends (30 November to 6 December 1992 and 28 November to 4 December 1994) in central and northern Finland, which covered 72% of the area of the country and one-third of the population. The participants were 178 GPs from public health centres and who made 530 referrals during these weekends. The outcome measures were reasons for referrals by ICPC codes with respect to the characteristics of patients, GPs and practices. RESULTS: During the weekends studied, 530 patients were referred from out-of-hours work. More male (53%) than female patients (47%) were referred. Out of a total of 530 patients, 213 (40%) were referred to surgery, 139 (26%) to internal medicine, 48 (9%) paediatric medicine, 32 (6%) to neurology, 28 (5%) to both ear, nose and throat (ENT) and psychiatry, 25 (5%) to gynaecology and 18 (4%) to other specialities (ophthalmology, lung disease and cancer departments). Fractures requiring surgery, angina pectoris for which patients were sent to internal medicine and stroke for which patients were sent to other specialities were the most commonly reported reasons for referral. Male patients were referred 12 times more often than females for arrhythmia (atrial fibrillation or tachyarrhythmia); males experienced dislocations eight times more often and fractures three times more often than females. CONCLUSION: Our results point out the need to train GPs about those complaints that most often require a referral to specialist care during the weekend. Future research should focus on those patients who are responsible for the huge gender gap of reasons for referral during weekends.

Metabolic syndrome' in a middle-aged Finnish population.

OBJECTIVE: To investigate methods for the detection of different clusterings of the insulin-resistant abnormalities consistent with the concept of the 'metabolic syndrome' in clinical practice, and to research the occurrence of these clusters in a middle-aged Finnish population. METHODS: We studied a random sample of 207 middle-aged subjects in the city of Tampere, and all 1148 subjects of four middle-aged age groups in Pieksamaki town, in central Finland. Clusterings of the following eight markers of insulin resistance were recorded as the main outcome measures: 1) at least one first-degree relative with non-insulin-dependent diabetes (NIDDM); 2) obesity: body mass index (BMI) > or = 30 kg/m2; 3) central adiposity: waist-to-hip ratio (WHR) > or = 1.00 in men and > or = 0.88 in women; 4) hypertension: systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg, or receiving drug treatment for hypertension; 5) hypertriglyceridaemia > or = 1.70 mmol/l; 6) low high-density lipoprotein (HDL) cholesterol: < 1.0 mmol/l in men and < 1.20 mmol/l in women; 7) abnormal glucose metabolism according to WHO criteria and 8) hyperinsulinaemia: fasting plasma insulin > or = 13.0 mU/l. RESULTS: The metabolic syndrome, defined as a clustering of dyslipidaemia (hypertriglyceridaemia, low HDL cholesterol, or both) and insulin resistance (abnormal glucose tolerance, hyperinsulinaemia, or both) was present in 17% of men and in 8% of women; this sex difference was statistically significant (P< .001). The syndrome was detectable with a sensitivity of 96% and a specificity of 55% by the combined four markers of insulin resistance (NIDDM in a close relative, obesity, central adiposity and hypertension). CONCLUSION: In clinical practice, the metabolic syndrome can be detected during normal clinical examination. The occurrence of the syndrome is already high by middle age.

Diagnostic methods in dyspepsia: the usefulness of upper abdominal ultrasound and gastroscopy.

OBJECTIVES: To examine the diagnostic value of gastroscopy and upper abdominal ultrasound, which are frequently used as primary tests in dyspeptic patients in general practice. To test the influence of age for accuracy of both diagnostic methods. DESIGN: Clinical study. SETTING: Four health centres in Kuopio Province, Finland. SUBJECTS: Four hundred unselected consecutive dyspeptic patients (91 less than 45 years of age) who consulted their general practitioners. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values (PV), efficiency and usefulness index (UI) were calculated for upper abdominal ultrasound and for gastroscopy in detecting the causes of dyspepsia in primary care. Final diagnosis was determined after one year follow-up. RESULTS: The sensitivity of upper abdominal ultrasound in detecting the cause of dyspepsia was 0.07, the specificity 0.91, PV+ 0.36, PV- 0.56, and UI -0.001. Ultrasound was not more efficient in older patients. Gastroscopy was the most efficient method with a sensitivity of 0.75, specificity 1.00, PV+ 0.99, PV- 0.83 and UI 0.56. The usefulness of gastroscopy was even better among patients over 45 years of age. CONCLUSIONS: The usefulness of upper abdominal ultrasound is low regardless of patient's age. Gastroscopy is superior to upper abdominal ultrasound as a first line diagnostic method in diagnosing dyspepsia, especially among patients over 45 years of age.

Hyperinsulinemia and clustering of cardiovascular risk factors in middle-aged hypertensive Finnish men and women.

OBJECTIVE: To examine the relationship between hyperinsulinemia and clusters of cardiovascular risk factors in middle-aged hypertensive patients. DESIGN: A population-based study. SETTING: Pieksämäki District Health Center, and the Community health Center of the city of Tampere, in central Finland. SUBJECTS: Hypertensive men and women aged 36, 41, 46, and 51 years (n = 18) in the town of Pieksämäki, and a normotensive control population of 177 subjects aged 40 and 45 years in the city of Tampere. MAIN OUTCOME MEASURES: Clusters of obesity (body mass index > 30.0 kg/m2), abdominal adiposity (waist:hip ratio > 1.00 for men and > 0.88 for women), hypertriglyceridemia (> 1.70 mmol/l), a low level of high-density lipoprotein cholesterol (< 1.0 mmol/l in men and < 1.20 mmol/l in women) and abnormal glucose metabolism (impaired glucose tolerance or noninsulin-dependent diabetes as defined by World Health Organization criteria) according to statistical quartiles of the fasting plasma insulin concentration. RESULTS: Among the hypertensives, there was a 2.0- to 3.6-fold higher risk of having a clustering of the insulin-resistance associated cardiovascular risk factors compared with that of the normotensives. Among the hypertensive subjects in the highest quartile of fasting plasma insulin there was a six- to 12-fold increase in risk associated with having two or more insulin resistance-associated cardiovascular risk factors compared with the subjects in the lowest quartile. There was a positive correlation between a high number of ascertained risk factors and high levels of fasting plasma insulin. CONCLUSION: In clinical practice, knowledge of the close relationship between risk-factor cluster status and fasting plasma insulin levels offers a tool to evaluate the occurrence of hyperinsulinemia in middle-aged hypertensive men and women.

Reasons for referral from general practice in Finland.

OBJECTIVE: To examine the reasons for referral from general practice in Finland. DESIGN: Survey over one week of all referrals from general practice. SETTING: Central and northern Finland, comprising 72% of the area of the country and one-third of the population. PARTICIPANTS: 851 general practitioners (GPs) from public health centres. OUTCOME MEASURES: Referrals by speciality and reasons for referrals by ICD-9 and ICPC codes in terms of characteristics of patients, GPs, and practices. RESULTS: A higher proportion of male (39%) than female (33%) patients were referred to surgical speciality (p < 0.001). Ten per cent of the patients referred by female GPs were referred to gynaecology departments, compared with 5% of those referred by male GPs (p < 0.001). Otitis media in children and abdominal pain in adults were the commonest reasons for referral of both male and female patients. CONCLUSION: Our results will be useful in developing the training of GPs with respect to those health problems that most commonly lead to a referral to hospital.

A list system can help to reduce the proportion of out of hours referrals for male patients.

OBJECTIVE: To examine differences in referral patterns by general practitioners (GPs) with and GPs without a list of patients. DESIGN: Survey of all referrals from primary to secondary care during one week. SETTING: Central and northern Finland, in a region comprising 72% of the area of the country and one-third of the population. PARTICIPANTS: 851 GPs, of whom 199 (23%) had a list system. OUTCOME MEASURES: Referrals in terms of practice characteristics. RESULTS: There were 58760 consultations during the study period, and 2921 patients were referred to secondary care. GPs with a list referred 64% of all referred male patients and 63% of all referred female patients during normal working hours. The corresponding referral figures for GPs without a list were 43% and 58%. CONCLUSION: GPs with a list of patients had a more appropriate distribution of referrals between normal and out of hours work than GPs without a list. Our results may help in developing solutions to problems of providing good primary health care.

Where have all the back pains gone? Changes in the reasons for requiring out-of-hours medical care from a centralized primary care centre after changing to a list system.

OBJECTIVE: We aimed to study changes in reasons for seeking assistance during out-of-hours work in a single health centre before and after introduction of the list system. METHOD: A questionnaire concerning all out-of-hours general practice consultations for 1 week each month in two separate years (in 1990 and 1993) was completed in one health centre in central Finland (Palokka health centre) in a region with 39,465 inhabitants (37,960 inhabitants in 1990). All patients contacting the health centre to request medical help during out-of-hours work were asked to complete the questionnaire. Outcome measures were consultation rates by ICPC main codes. RESULTS: The annual out-of-hours consulting rate per 1000 inhabitants decreased from 823 to 533 (35%) (P < 0.001). The clearest decrease (57%) from 172 to 74 consultations per 1000 inhabitants occurred in patients with musculoskeletal problems. A marked reduction (75%; from 52 to 13 consultations per 1000 inhabitants) was found in male patients with back symptoms. For female patients with neck problems the reduction of out-of-hours consultations was also marked (67% reduction; from 12 to 4 consultations per 1000 inhabitants). CONCLUSION: Improvement of continuity of care for patients having musculoskeletal problems is partly a question of organization, and it is also economically justifiable.

Does the doctors' professional experience reduce referral rates? Evidence from the Finnish referral study.

OBJECTIVE: To examine hospital referral rates in Finnish health centres according to doctors' and health centres characteristics. DESIGN: Survey of all general practice hospital referrals over one week. SETTING: Central and northern part of Finland, in a region comprising 72% of the area of the country and one-third of the population. PARTICIPANTS: 851 health centre doctors. OUTCOME MEASURES: Referral rates in terms of characteristics of doctors and health centres. RESULTS: During the study period, the 851 health centre doctors had 58 760 consultations (mean 69 patients/week), and 2 921 (5%) patients were referred to secondary care. The variation between the highest and lowest referral quintile of the doctors was almost 17-fold, and of the health centres 2.4-fold. Relatively more referrals were made by locums, young, not yet graduated and female doctors than by specialized, more experienced and male doctors. CONCLUSION: A low referral rate is closely connetected with the extent of the general practitioners' professional experience and specialist training. Investing in specialist training and continuing medical education seems to be the best way to reduce high referral rates.

General practice consultations in central and northern Finland.

OBJECTIVE: To examine general practice consultations in health centres in central and northern parts of Finland. DESIGN: A questionnaire concerning all general practice consultations during one week. SETTING: Central and northern parts of Finland in a region comprising 72% of the area of the country and one-third of its population. PARTICIPANTS: 851 health centre doctors. OUTCOME MEASURES: Consultation rates by age and sex of the patients and by characteristics of doctors and their practices. RESULTS: The average consultation rate per 1,000 female inhabitants was 43 and per 1,000 male inhabitants 34 per week. For total contacts, a J-shaped association with increasing age was demonstrated for both sexes. The average number of consultations per doctor in a week was 72. Consultation rates were lowest among physicians over 45 years of age. A low consultation rate was also found among general practitioners not participating in the personal doctor programme and among those who worked in municipalities with over 30,000 inhabitants. CONCLUSION: In Finland, consultation rates per 1,000 inhabitants, as well as per general practitioner, are remarkably lower than in most European countries. The personal doctor programme with defined lists of patients seems to be associated with high consultation rates.

Overweight, underweight and mortality among the aged.

OBJECTIVE: To clarify the influence of overweight and underweight on the total mortality as well as on different causes of death in an unselected population of old people. DESIGN: The cohort of the aged population was examined in 1971. The survival time of the cohort was followed for ten years. SETTINGS: Rural commune of Hankasalmi in Central Finland. PARTICIPANTS: 721 (80% of total aged population) subjects aged 65 years or over (310 men and 411 women). OUTCOME MEASURES: 10 years survival rate and causes of death by body mass index quartiles and sex. RESULTS: The women in the lowest BMI quartile had the highest mortality in ten-year follow-up (a 26% decrease in survival time). The differences between the total mortality of the other quartiles were small. In the lowest BMI quartile there was overmortality from respiratory diseases and tumours, and undermortality from cardiovascular diseases. In the highest BMI quartile the main groups of causes of death did not differ essentially from those in the whole cohort. CONCLUSION: Underweight was as strong a predictor of mortality, and even stronger, than overweight.