Risk factors for recent transmission of Mycobacterium tuberculosis.

In recent decades, the decline of tuberculosis has stopped in Western Europe, mainly due to increased immigration from high-prevalence countries. The objective of the current study was to identify risk factors for developing tuberculosis following recent infection, in order to better target interventions. Strains from 861 culture-positive cases, diagnosed in Norway in 1994-1999, were analysed by use of restriction fragment length polymorphism (RFLP). A cluster was defined as two or more isolates with identical RFLP patterns. Risk factors for being part of a cluster were identified by univariate and multivariate analysis. A total of 134 patients were part of a cluster. These constituted 5% Asian-born, 18% Norwegian-born, 24% European-born and 29% African-born patients. Four independent risk factors for being part of a cluster were identified: being born in Norway, being of young age, being infected with an isoniazid-resistant strain and being infected with a multidrug-resistant strain. Transmission of tuberculosis may be further reduced by improving case management, contact tracing, preventive treatment, screening of immigrants and access to health services for the foreign-born population.

[Efficient learning with data from own practice--experiences from the SATS-project]. / Effektiv laering med data fra egen praksis--erfaringer fra SATS-prosjektet.

Between 1995 and 1998 the Norwegian Medical Association carried out a project to develop and assess a quality improvement tool for use in general practice (SATS). This method combines self-directed learning, documentation of practice and peer group support. SATS defined performance indicators for registration of practice by means of computerised patient records. Groups of four to ten general practitioners used their own consultation data as a basis for learning cycles. The practice evaluation indicates significant improvement in clinical work. Participating doctors found that having their own recorded data examined in a supportive peer environment was a major force for change. They reported satisfaction with the method, and expressed an interest in trying out new topics. However, the project demonstrated the need for simplification of terminology, further development of group process methods and computer software. There is also a need for strong local support of peer review groups.

[Waiting lists as results of statistic coincidences]. / Køer som resultat av statistiske tilfeldigheter.

Queues and waiting lists in the health services are central issues in the political debate in Norway. By means of a simulation programme (Powersim), we demonstrate some elementary properties of queuing. We show that stochastic entry to the service and stochastic need for service can produce queues. We also show that a queue-free service will need an unrealistically high and abundant capacity.

[Life expectancy in Norway. An international perspective--causes of death]. / Utviklingen av dødeligheten i Norge. Et internasjonalt perspektiv--dødsårsakene.

We have shown before that Norway is experiencing an unfavourable trend in life expectancy compared with Japan, France and several other OECD countries. In this article, we discuss the cause-specific differences in mortality that explain these contrasts. Heart infarction is the predominant cause of death in Norway, with a mortality five times higher than in Japan and three times higher than in France. Both Norway and France have three times higher mortality rates for breast cancer than found in Japan, and the mortality rate for cervical cancer is twice as high in Norway as in the two other countries. Norwegian women show a mortality rate for lung cancer that is twice as high as that of their French sisters. Suicide among young Norwegians is a rapidly growing problem, and twice as common among Norwegian men aged 20-24 than among Japanese men of the same age. We challenge the health authorities and the specialists in the relevant fields to reflect again on their preventive strategies, in light of these contrasts.

[Do people exercise less than they think?]. / Mosjonerer folk mindre enn de tror?

Physical activity is important for health. Physical inactivity is an independent risk factor for disease and speeds up aging. People say in health surveys that they exercise more than they did before. This does not conform with two important facts: Over the last 20 years people have reduced their calorie intake, but their weight is increasing. The only possible explanation is that they exercise less than before, probably because their daily life requires less and less physical activity. We believe this to be a serious health problem, and support the most recent recommendation: A daily walk for 30 minutes.

Economic consequences of sick-leave and early retirement in obese Swedish women.

OBJECTIVES: To describe the pattern of sick-leave and disability pension in an obese sample and to estimate the Incremental, indirect cost due to sick-leave and early retirement for the obese fraction of the Swedish female population. DESIGN: A retrospective study of sick-leave and disability pension in health examined obese subjects was performed. The indirect cost of obesity in Sweden was estimated from reported and recorded sick-leave and disability pension in the sample and from the estimated prevalence of obesity in the country. SUBJECTS: 1298 obese persons aged 30-59 y. The mean age was 46 years. The mean body mass Index was 39 kg/m2 (range 28-68). SETTING: The obese subjects were recruited from eight counties in Sweden. RESULTS: As compared to the general Swedish population the obese subjects had 1.5-1.9 times higher sick-leave during one year. Twelve percent of the obese women had disability pension while the corresponding figure in the general population was 5%. The incremental cost of sick-leave and disability pensions attributable to obesity was 3.6 billion SEK during one year, which is equivalent to about 300 million USD per million female adult population. The total cost for sick-leave and disability pension due to absence from work for the obese fraction of the Swedish female population was 10.5 billion SEK during one year. CONCLUSION: Obesity represents a major health problem with significant economic implications for the society. Approximately 10 percent of the total cost of loss of productivity due to sick-leave and disability pensions in women may be related to obesity and obesity-related diseases.

[Quality development in family practice--development and use of health indicators]. / Kvalitetsutvikling i allmennpraksis--utvikling og bruk av indikatorsett.

In 1995 the Norwegian general practitioners' associations embarked upon a three-year project to assess a new model for improving the quality of primary health care. Indicators are proposed for assessing quality and setting standards in local practice. Software has been developed to simplify collection of data and production of reports from computerized medical records. Peer groups of 5-10 practitioners discuss results, agree on local standards and plan improvements. General practitioners who participate in a cycle of quality improvement will be awarded credits for recertification as specialists in general practice. The initial topics are: care of diabetics, use of laboratory tests, management of sore throat, and management of migraine. This national project will be evaluated both in terms of improvement in the quality of care, and of the views of the participating practitioners.

[Life expectancy in Norway--an international perspective]. / Utviklingen av dødeligheten i Norge--et internasjonalt perspektiv.

Contrasts in life expectancy among countries are an important input for defining targets for the health service and for setting priorities for disease prevention and health promotion. In this article, the trend in life expectancy in Norway is compared with the trend in a selection of other OECD countries. Standardised measures of life expectancy were collected from WHO and OECD statistics. In 1960 Norwegians ranged among the top three countries as regards life expectancy for both women and men. In 1990 Norwegians ranged tenth for women and ninth for men. Life expectancy was two years shorter for Norwegian than for Japanese women in 1990, corresponding to a 20% surplus mortality throughout life. Similar differences were found for men. If Japanese age specific death rates are applied to the Norwegian population, this corresponds to a reduction of 9,600 deaths this year. The relatively unfavourable trend in life expectancy in Norway relative to other OECD countries raises concern, and should be considered when designing the future health policy.

Cost effectiveness of cholesterol-lowering drugs: a review of the evidence.

Four studies of the cost per life year saved through lipid lowering with lovastatin or simvastatin showed considerable variation in the results. For example, the cost per life year saved on administration of simvastatin 20 mg/day for primary prevention in men 42 years old at the start of therapy and with an initial cholesterol level of 8 mmol/L, was 19,000 1994-US dollars according to one study, and 55,000 according to another. Both when the differences were due to different cost estimates and when they were due to different estimates of the number of life years saved, plausible explanations for the discrepancies between the cost-effectiveness ratios were generally found. The cost per life year saved through primary prevention was about three times greater among women than men at age 40, twice greater at age 60, an 1.3 times greater at age 70. The accordance between the studies was not good regarding how cost per life year saved varies with age at the start of drug therapy. According to one study, the cost per life year saved for secondary prevention is generally low. We also compared the estimates for statins with estimates for several other life-extending health interventions. Given current guidelines for the prescription of cholesterol-lowering drugs, primary prevention with statins seems generally to be one of the less cost-effective life extending health interventions, especially for women. The cost effectiveness of statins is likely to become more favorable, though, when the patients on these drugs expire.

[Month of birth and prevalence of fibromyalgia]. / Fødselsmåned og prevalens av fibromyalgi.

We have studied the possible influence of season of birth on prevalence of fibromyalgia. Data from the Norwegian Fibromyalgia Association, where diagnosis is compulsory, were compared with mean figures for 1936-65 from the National Register of Births. Figures for 8,125 patients were correlated with figures for two million persons from the register. Unlike other musculoskeletal diseases, which are more prevalent in summerborn persons, and certain mental diseases, which are more prevalent in winterborn persons, no such association was found for fibromyalgia.

Detecting hypertension: screening versus case finding in Norway.

OBJECTIVE: Evaluation of detection of hypertension in adults in the county of Nord-Trøndelag, Norway. DESIGN: Cross sectional survey with clinical follow up examinations. SETTING: Health survey by screening teams from the national health screening service, and examinations by all 106 general practitioners in the county. SUBJECTS: During 1984-6, 74,977 persons (88.1% of those aged 20 years and over) participated in the health survey. MAIN OUTCOME MEASURES: Hypertension (when assessed by standardised recording and by questionnaires on drug treatment for hypertension) according to the blood pressure thresholds used in the Norwegian treatment programme. Subjects positive on screening were grouped after clinical examination into treatment groups. RESULTS: In all, 2399 subjects were positive for hypertension. Before screening 6210 (8.3%) patients reported taking antihypertensive drugs and another 3849 (5.1%) had their blood pressure monitored regularly. All who screened positive were referred to their general practitioner and evaluated according to a standard programme. As a result, drug treatment was started in 406 (0.5%) participants screened and blood pressure monitoring in another 1007 (1.3%). Of all patients taking antihypertensive drugs after the screening, 6399 (94.0%) had been diagnosed before screening, and of those whose blood pressure was monitored after the screening, 79.3% had been diagnosed before screening. CONCLUSIONS: At the blood pressure screening thresholds used, and when hypertension is defined by an overall clinical diagnosis, the results indicate that general practitioners can find and diagnose hypertensive patients with the case finding strategy.