Quality of life in patients with chronic type B aortic dissection.

OBJECTIVE: To study functioning and well-being among patients with conservatively treated acute type B aortic dissection. DESIGN: Cross-sectional survey. METHODS: Patients referred with acute type B dissection between January 1990 and November 2000 were prospectively followed after conservative initial management. In October 2002, we sent the SWED-QUAL questionnaire to all patients who were alive and had not undergone surgery of the dissected aorta. Fifty-three of 55 patients responded, 39 males and 14 females. Patient scores for the 12 aspects of health-related quality of life included in the SWED-QUAL were compared to a normative Swedish population, controlled for age and gender differences. RESULTS: There were only minor differences in functioning and well-being between patients and the normative population. Patients reported similar emotional well-being, cognitive functioning, quality of sleep, overall general health and quality of social relations as their normative counterparts. However, patients' perception of their current health, prior health, perceived resistance to illness and health concern was worse than in the normative population. Female patients also reported worse physical functioning and a lower satisfaction with their physical functioning than male patients or female counterparts in the normative population. We did not find any significant association between length of follow-up and quality of life scores. CONCLUSIONS: In terms of functioning and well-being, patients with uncomplicated acute type B aortic dissection, who are initially managed conservatively, differ little from a normative Swedish population. Our study supports conservative management of this group of patients.

Inflammatory mediators in autotransfusion drain blood after knee arthroplasty, with and without leucocyte reduction.

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate whether leucocyte-reducing filters influenced complement activation and the formation of pro-inflammatory cytokines in autotransfusion drain blood after knee arthroplasty. MATERIALS AND METHODS: Twenty-three patients undergoing knee arthroplasty were divided into two groups. All patients were given salvage blood postoperatively. In Group A, a leucocyte filter was connected between the wound and the drain blood container. In Group B the drain blood was not leucocyte filtered. Complement split products and cytokines were analysed in circulating blood and in drain blood, together with blood-cellular differential counts. RESULTS: Drain blood showed activation vs. venous blood, with elevated concentrations of C3a, SC5b-9, interleukin (IL)-6, IL-8, polymorphonuclear (PMN) elastase and tumour necrosis factor-alpha (TNF-alpha) (P<0.05 to P<0.001). The leucocyte filter reduced TNF-alpha (P<0.01), but triggered complement activation (P<0.05). Room-temperature incubation increased the concentration of IL-8 (P<0.01), which was seen in both venous and drain blood. The leucocyte filter prevented formation of IL-8 (P<0.01). In drain blood at 24 h the inflammatory reactions accelerated (P<0.05-0.001), although the filter reduced the leucocyte counts and TNF-alpha concentrations. CONCLUSIONS: The leucocyte filter reduced IL-8 and TNF-alpha in drain blood, but at the same time triggered complement activation. Incubation affected the inflammatory spectrum of both drain blood and control venous blood, and the filtering reduced this activation.

Quality of life of patients with chronic stable angina before and four years after coronary revascularisation compared with a normal population.

OBJECTIVE: To assess the impact of coronary revascularisation on the health related quality of life (HRQOL) of patients with chronic stable angina compared with data from "community" norms four years following revascularisation. DESIGN: Prospective survey and review of medical records. SETTING: Seven of the eight public Swedish heart centres that performed coronary artery interventions. SUBJECTS: 827 patients aged 55-79 years with chronic stable angina who underwent coronary artery revascularisation in 1994 or 1995 and completed the four year HRQOL survey. MAIN OUTCOME MEASURES: Five components of the Swedish quality of life survey. RESULTS: Compared with age and sex adjusted population norms, patients at baseline had significantly lower mean scores on all five functioning and wellbeing scales (p < 0.001). Four years after revascularisation, the mean levels of functioning and wellbeing were similar to those in the normative population (p > 0.05) except for quality of sleep (p < 0.001). The improvements were the same across age groups and for men and women. However, 36% of men and 55% of women were not completely free from angina by four years (p < 0.001). Men without angina after four years had better HRQOL than their community norms (p < 0.001) on all dimensions except quality of sleep (p > 0.05). Women without angina had less pain (p < 0.01) and better general health perception (p < 0.05) but similar physical functioning, quality of sleep, and emotional wellbeing compared with their community counterparts. Both men and women who had suffered at least one anginal attack during the preceding four weeks had significantly worse HRQOL by four years than their community norms (p < 0.01). CONCLUSIONS: By four years following revascularisation, three fifths of patients with chronic stable angina were free of angina and their HRQOL was the same as or better than that of the general Swedish population. However, fewer than half of all women and two thirds of men who underwent revascularisation were angina-free after four years. Among patients with new or persistent angina, the HRQOL was worse than that in community norms.

Hearing impairment among adults--extent of the problem and scientific evidence on the outcome of hearing aid rehabilitation.

Scientific surveys on current and estimated prevalence of hearing impairment (HI) in adult populations (> or = 18 years of age) in Denmark, Finland, Norway, Sweden and the United Kingdom, and scientific reports on the outcome of hearing aid (HA) rehabilitation worldwide were reviewed. Only a few of the studies meet strict scientific criteria, and many locally clinically relevant studies cannot be generalized to larger populations. Population-based studies indicate an increase in prevalence of HI with age, but because of differences in study populations and available national population statistics, the studies do not allow reliable comparisons between countries or estimation of future prevalence of HI. Studies on HA prescription or outcomes do not provide uniform data in favour of non-linear amplification, but they do show some subject preference for the newer technology. No conclusions can be drawn regarding the degree of HI and the effects of amplification. The literature review alone gives only limited information regarding the extent of the problem of HI in adult populations in the target countries. Similarly, only a few studies on HA outcome meet strict scientific criteria and even fewer studies correlate rehabilitation outcome with the degree of HI, disability or handicap.

The Swedish Council on Technology Assessment in Health Care (SBU) systematic overview of chemotherapy effects in some major tumour types--summary and conclusions.

This report by The Swedish Council on Technology Assessment in Health Care (SBU) reviews, classifies, and grades the scientific literature on cancer chemotherapy in some major tumour types, describes the practice of chemotherapy in Sweden, compares practice with scientific knowledge, and analyses the costs and cost-effectiveness of chemotherapy. The report is intended primarily for decision-makers at various levels, both practitioners and administrators. It is also of interest for the medical profession. The extensive body of scientific literature was reviewed according to strict criteria that reflected the scientific weight of the literature. Sixteen experts representing different disciplines (oncology, surgery, internal medicine, health economy and quality of life research) participated in the literature review. Each section was discussed within the project group and was reviewed by at least one, but usually two international researchers. Additional input was provided by national experts representing different scientific disciplines. For the final evaluation to be as close to the objective truth as possible, a concerted effort was made to guarantee objectivity and thorough assessment of current knowledge about the effects of chemotherapy on the selected cancers. The tumour types selected for this assessment include firstly those types where three investigations had shown an increased use of chemotherapy in Sweden during the latest decade. These were non-small cell lung cancer (NSCLC), gastric cancer, pancreatic cancer, colorectal cancer and urinary bladder cancer. Secondly, the two tumour types comprising the greatest number of patients treated with chemotherapy in Sweden, breast cancer and haematological malignancies, were included. Among the haematological malignancies, the most prevalent ones, acute myeloid leukaemia (AML), chronic lymphocytic leukaemia (CLL), Hodgkin's disease (HD), aggressive non-Hodgkin's lymphoma (NHL) of the large B-cell type and indolent NHL of follicular type were evaluated. These constitute about 75%, of all haematological malignancies. Thirdly, ovarian cancer was included since chemotherapy has been extensively used and since, at the time of the planning of this overview, a group of very expensive drugs, the taxanes, had preliminarily shown promising results. A wealth of scientific literature has been published on cancer therapy. The review presented in this report is limited to scientific studies judged to be important for evaluating chemotherapy efficacy. Assessments of the content and quality of these studies, and a critical summary of the results in all stages of the selected tumours, have never before been attempted in this way. However, similar comprehensive overviews of certain stages of the tumours have previously been made. These overviews were also critically evaluated. Totally 1,496 studies involving 558,743 patients were reviewed. The survey of practice of chemotherapy use involved all departments of surgery, urology, gynaecology, internal medicine including haematologic units, pulmonary medicine and general and gynaecologic oncology at 16 hospitals in two health care regions in Sweden, covering 39% of the Swedish population. During the 4 weeks of the survey, all patients with the diagnoses concerned who received chemotherapy were registered. The study included 1,590 patients. The working group's general conclusions are summarised in the following points: The literature on the effects of chemotherapy is extensive. Chemotherapy has a well-documented role in the curative and palliative treatment of patients with several types of cancer. The use of chemotherapy is of utmost importance for the possibility of cure in certain tumour types. In other tumours, chemotherapy increases the possibility of cure when added to local and regional treatments, particularly surgery. In the instances of no possibility of cure, chemotherapy may to a variable extent improve both patient survival and well-being. In Sweden chemotherapy is largely used in accordance with that documented in the scientific literature. The extent of both over- and under-treatment seems to be limited but cannot be excluded at the individual patient level. The literature-based knowledge is scientifically of lower quality in the most chemotherapy sensitive tumours than in tumours showing more limited sensitivity. In the more sensitive tumours, positive effects on a symptomatic stage and survival were seen several decades ago. In those days, clinical treatment studies did not fulfil the current high quality requirements. Small life-prolonging effects of chemotherapy are sometimes very well documented in large, high quality scientific studies. Some of these s

A prospective study of the use of chemotherapy in Sweden and assessment of the use in relation to scientific evidence.

A prospective study on total utilisation of cytotoxic drugs for selected cancers was carried out in two Swedish health service regions, during four weeks in the autumn of 1997. The study included 1,590 patients; 1,169 with solid tumours and 421 with haematological malignancies. The majority of patients (75% to 80%) were treated at university/regional hospitals, often at oncology or haematology departments, and most received treatment as outpatients. Furthermore, most were treated according to recommendations in regional or national clinical guidelines, so-called care programmes, although the percentage varied by diagnosis. Only 10% were participants in a clinical trial. In approximately 40% of the patients, treatment was aimed at cure. However, this percentage varied between 0% and 94% depending on tumour type. At the population level, a comparison of the scientific evidence according to a literature review (Acta Oncol, this issue) with the survey showed that treatment with cytotoxic drugs in Sweden was largely evidence-based. A high percentage of patients received cytotoxic drugs for diseases where recommendations to treat were strong, i.e. outcomes were well-documented in the literature. A low percentage of patients received chemotherapy in disease settings with little or no scientific documentation. The percentage of patients treated was also limited in cases where the effects of chemotherapy are relatively small, although scientifically well-documented. For methodological reasons, one cannot exclude the possibility that cytotoxic drugs may be overutilised at the individual level for palliative purposes, e.g. by not discontinuing treatment despite the absence of clinical benefits. Likewise, one cannot exclude the possibility of underutilisation, e.g. by patients declining treatment because they were not informed about the potential benefits.

Quality of life of chronic stable angina patients 4 years after coronary angioplasty or coronary artery bypass surgery.

OBJECTIVE: To evaluate the quality of life experienced by chronic stable angina patients with one- or two-vessel coronary artery disease treated with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 601 Swedish chronic stable angina patients with one- or two-vessel disease who underwent CABG (n = 252) or PTCA (n = 349) between May 1994 and January 1995. MAIN OUTCOME MEASURES: We assessed five components of the Swedish Quality of Life Survey, anginal frequency, sublingual nitroglycerin use, and survival at 6, 21 and 48 months following coronary revascularization. RESULTS: Anginal frequency and sublingual nitroglycerin use decreased for all patients by 6 months, but more amongst surgery patients than amongst angioplasty patients (P < 0.05). At 48 months, more bypass patients reported that they had not used sublingual nitroglycerin during the preceding 4 weeks (73.1 vs. 63.4%, P < 0.05). At 6 months, bypass patients had greater levels of improvement in physical functioning (15.3 vs. 10.5, P < 0.05) and general health perception (16.5 vs. 10.2, P < 0.05) than angioplasty patients. Bypass patients also had better relief from pain (19.4 vs. 14.6, P < 0.05), quality of sleep (17.6 vs. 4.6, P < 0.05) and general health perception (17.3 vs. 12.1, P < 0.05) at 21 months. By 48 months follow-up, there was no longer any difference in these measures between groups. CONCLUSIONS: Both bypass surgery and angioplasty lead to improved quality of life for patients with chronic stable angina and one- or two-vessel coronary artery disease. Bypass surgery is associated with better quality of life at 6 months, but by 48 months quality of life is similar for patients initially treated by either procedure.

Functioning and well-being of patients with type 2 diabetes or angina pectoris, compared with the general population.

This study compares the health-related quality of life (HRQOL) of patients with type 2 diabetes mellitus or angina pectoris with that of a standard population sample (SPS). The HRQOL was assessed by the Swedish Health-Related Quality of Life Survey (SWED-QUAL), a generic HRQOL questionnaire adapted from the Medical Outcomes Study (MOS), with twelve scales tapping aspects of physical, mental, social and general health. Subjects between 45 and 84 years of age who answered the questionnaire were included, i.e. 266 patients with type 2 diabetes, 758 patients with mild angina pectoris (Canadian Classes I and II) and 908 with severe angina (Canadian Classes III and IV). As controls, we used 1126 subjects from the SPS. Patients with type 2 diabetes, mild angina and severe angina showed an increasing degree of health disturbance, compared with the SPS. Diabetic patients with no heart disease showed only a minor impact on the HRQOL, while the presence of a heart disease showed a considerable impact. In angina patients, the presence of diabetes also to some extent added to the decrease in HRQOL. On comparing the impact of the heart disease and diabetes on the HRQOL, the heart disease showed a stronger effect on most aspects of the HRQOL than diabetes. It is concluded that coronary heart disease is an important predictor of the impact on the HRQOL of type 2 diabetes patients.

Assessing sexual functioning in patients with chronic disorders by using a generic health-related quality of life questionnaire.

This study was an assessment of sexual functioning by making cross-sectional surveys of patients aged 45 84 years with chronic disorders; 397 had diabetes, 248 had glaucoma and 1914 had chronic, stable, angina pectoris; 1669 came from a standard population sample (SPS). Sexual functioning was assessed on one scale from the Swedish health-related quality of life survey (SWED-QUAL), adapted from the medical outcomes study (MOS). Both sexual functioning in general and specific sexual items were studied. Values were adjusted for non-respondents and standardised to the Swedish population. Response rates in the samples were 54-64% among men and 22-41% among women, decreasing with age for women. General sexual functioning decreased with age and was most apparent in patients with diabetes and angina pectoris, while glaucoma patients reported better results than the SPS. Loss of male erectile function was as common in diabetes (30%) as in angina pectoris (29%) and significantly higher than in the SPS (20%) (p < 0.001). Besides age, significant factors for erectile dysfunction were, in diabetes, the presence of microvascular complications, treatment with long-acting nitroglycerine and psychiatric disease, and in angina, the presence of diabetes and peripheral artery disease.

Quality of life in relation to comorbidity among diabetic patients followed for three years in Swedish primary health care.

The aim of this study was to follow health-related quality of life (HRQOL) in diabetic subjects over a three-year period in relation to their medical situation. Forty-eight subjects 42-81 years of age in 1992 were identified as those responding to the HRQOL questionnaire on both occasions from a larger study of 341 diabetic patients in 1992 and 413 in 1995 in Stockholm County. Age- and sex-matched controls were taken from randomly collected samples of the general Swedish population. HRQOL was assessed by the SWED-QUAL (the Swedish Health-Related Quality of Life Survey). Medical data were extracted from medical records at community health centres. Pearson's correlation coefficient for SWED-QUAL results over time exceeded 0.60 for seven of the ten scales (p < 0.001). A significant difference between 1992 and 1995 was found only for "Physical functioning" (p < 0.01). The general deterioration in health seen in medical records was accompanied by a decrease in the "Sleep problems" scale. In conclusion, worse outcome was noted only for "Physical functioning", while deterioration in health according to medical records was related to a worse outcome with respect to "Sleep problems". However, as the sample was small and not randomly selected, the results should be interpreted with caution and need confirmation in further studies.

Comparison of diabetic and non-diabetic patients referred for coronary angiography.

AIM: To evaluate whether diabetic patients differ from non-diabetic patients when referred for coronary angiography regarding previous history, indication for and findings at coronary angiography, use of medication, exercise test results and mortality. METHODS: Data were prospectively collected on patients referred for consideration of coronary revascularization to seven of the eight public Swedish heart centers that performed approximately 92% of all bypass operations in Sweden in 1994. RESULTS: 2762 patients were included of whom 406 (15%) had a history of diabetes mellitus. There was no difference in age or sex in the two groups. Chronic stable angina was the most common indication (73% in both groups) and only 3% were admitted due to silent ischemia. Diabetic patients had more severe symptoms (Canadian Cardiovascular Society III-IV) than non-diabetic patients (66% vs. 58%, p<0.01). They more frequently used ACE-inhibitors (33% vs. 19%, p<0.0001) and calcium channel blockers (47% vs. 40%, p<0.01) and more often had a diagnosis of arterial hypertension than non-diabetic patients (50% vs. 33%, p<0.0001). Diabetic patients more often had depressed myocardial function (EF<35%); 12% and 8%, respectively (p<0.01), and more extensive coronary artery disease (left main/3-VD; 48% vs. 37%, p<0.001). The mortality during the subsequent 21 months was 7.9% among diabetic patients and 3.6% among non-diabetic patients (p<0.001). CONCLUSION: Among patients being referred for coronary angiography in Sweden, 15% were patients with a history of diabetes. They differed from patients without such a history by more often having severe symptoms and a higher prevalence of left main/triple vessel disease. Coronary angiography may thus be underused in diabetic patients with chest pain.

Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group.

OBJECTIVE: To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES: Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS: Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS: Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated.

Factors associated with the use of various medications amongst patients with severe coronary artery disease. SECOR/SBU Project Group.

AIM: To describe variations by age, sex, symptom severity and hospital region in the use of various medications amongst patients with stable angina pectoris who are candidates for coronary revascularization. PATIENTS: Patients (n = 2030) with chronic stable angina pectoris participating in a national survey evaluating the appropriateness of the use of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). METHODS: As part of a national study of the appropriateness of coronary revascularization, data were prospectively collected on patients referred for consideration of coronary revascularization to seven of the eight public Swedish heart centres that performed approximately 92% of all bypass operations in Sweden in 1994. RESULTS: Amongst all patients 76% were treated with beta blockers, 41% with calcium antagonists and 71% with long-acting nitrates and 70% were treated with at least two of these three drugs. Eighty-two per cent of the patients used aspirin and 14% lipid-lowering drugs. According to logistic regression analysis, with medication as the dependent variable and independent variables of age, sex, angina functional class, findings at exercise test, history of various diseases and region in Sweden where the investigation took place, the most consistent factor explaining the use of various medications was found to be geographical region. A previous history of acute myocardial infarction (AMI) was also associated with the use of all drugs and age was associated with all with the exception of beta blockers. Sex was not an independent factor explaining the use of any of the drugs. CONCLUSION: In a national survey including patients with stable angina pectoris who are potential candidates for coronary revascularization, the most important predictor for the use of various medications was the geographical region in which the investigation took place.

Diabetic patients in primary health care--quality of care three years apart.

OBJECTIVE: To compare registering of diabetic complications and metabolic control in diabetic subjects in primary health care in 1992 and 1995. DESIGN: Cross-sectional surveys of medical records. SETTING: Three community health centres in Stockholm County. SUBJECTS: Diabetic patients aged 18-84 years in 1992 (n = 177) and in 1995 (n = 413). MAIN OUTCOME MEASURES: Rate of noted diabetic complications and metabolic values. RESULTS: Retinopathy examination was noted in 64% in 1992 versus 65% in 1995, neuropathy examination in 44 versus 49%, and urine examination in 88% versus 73% (p < 0.001). HbA1c was examined in 52% in 1992 versus 68% (p < 0.001) in 1995, fasting blood glucose in 89 versus 90%, and cholesterol in 34 versus 42%. Acceptable HbA1c values were noted in 51% in 1992 versus 46% in 1995. Smoking habits were available in 26% in 1992 versus 53% in 1995 (p < 0.001) and BMI in 5 versus 39% (p < 0.001). Diabetic blindness was present in 2.2% in 1995, uraemia in 0.3%, and amputation due to gangrene in 1.2%. CONCLUSION: Documented examination rates of diabetic patients are unacceptably low, and the metabolic level unsatisfactory in most cases. Severe complications are, however, rare.

Quality of life among diabetic patients in Swedish primary health care and in the general population: comparison between 1992 and 1995.

To assess change over time in health-related quality of life (HRQoL) in diabetic patients in primary health care and differences to general Swedish population samples, 341 diabetic subjects in 1992 and 413 in 1995, aged 20-84 years, were chosen from three community health centres (CHCs) in the Metropolitan Stockholm area and compared to controls matched by age and sex in randomly selected samples of 2,366 subjects in 1991 and 2,500 in 1995 from the general population. HRQoL was assessed by the Swedish Health-Related Quality of Life Survey (SWED-QUAL), adapted from the Medical Outcomes Study, which measures aspects of physical, mental, social and general health in 13 scales. Information on diabetic and general medical data were extracted from the medical records at the CHCs. HRQoL was lower in diabetic subjects compared with the general population in both 1992 and 1995 in all scales except family functioning and marital functioning. The level of HRQoL did not change significantly between the diabetic samples, but decreased in the population samples, making the difference compared to diabetic patients smaller in five of the scales. The most significant predicting factors for the SWED-QUAL results in diabetic patients in 1995 were the vascular and non-vascular co-morbidity.

Waiting for coronary revascularization: a comparison between New York State, The Netherlands and Sweden.

OBJECTIVE: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. METHODS: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n = 1486). We measured the median waiting time between coronary angiography and PTCA or CABG. RESULTS: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P < 0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (P < 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. CONCLUSIONS: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved.

Quality of life in diabetic patients registered with primary health care services in Sweden.

OBJECTIVE: To evaluate the health-related quality of life in diabetic subjects in primary health care. DESIGN: A cross-sectional, questionnaire survey of diabetic patients registered with primary health services, compared with a standard population sample. SETTING: Three community health centres in the Metropolitan Stockholm area. SUBJECTS: 341 diabetic individuals aged 21-84 years, with 229 respondents, i.e. 67%. Matched controls of the same age and sex from a standard population sample of 2366 individuals. MAIN OUTCOME MEASURES: Quality of life was assessed by the Swedish Health-Related Quality of Life Survey (SWEDQUAL), adopted from the Medical Outcomes Study and consisting of 61 items covering aspects of physical, mental, social, and general health. Medical data were extracted from the medical records. RESULTS: Diabetic patients had significantly lower scores on all scales (p < 0.001 for ten, and p < 0.01 for one), except for social health, when compared with the standard population sample. Outcomes were correlated with vascular and non-vascular comorbidity, age, and income, but not with level of metabolic control. CONCLUSIONS: Diabetic patients in primary health care have a markedly lower health-related quality of life, compared with a standard population.