A comparative study of prescribing of hormone replacement therapy in USA and Europe.

OBJECTIVES: The use of hormone replacement therapy (HRT) has been shown to vary from one country to another through international studies of sample populations and by comparison of data obtained from comparable national studies. Drawing international prescribing comparisons is very difficult as data sources are few, incomplete and of uncertain accuracy and comparability. As an alternative to direct prescribing information, pharmaceutical sales information indicates medication used. This paper sought to demonstrate international differences in the use of HRT using an economic analysis methodology based on national pharmaceutical sales statistics. METHODS: A recognised economic analysis methodology was used to translate 1991/1992 pharmaceutical sales data into women treatment years of HRT used in each country. From this was calculated the percentage of the female population in each country, eligible for HRT, who would have been taking HRT. RESULTS: The results show a wide variance in the percentage of the eligible female population in each country calculated to have been taking HRT, from <1%-20%. The results indicated that HRT usage fell into three groupings: USA being the greatest user with UK and Scandinavian countries in the middle group and continental Europe having the lowest usage. CONCLUSIONS: National patterns of HRT usage, as calculated by this study, correlate well with those of other studies. Since similar morbidity could be expected as menopause is a naturally occurring event, not a disease, possible reasons for the variance in national prescribing patterns are discussed. The study indicates the need for further research on health beliefs and physicians' and women's attitudes to HRT in different countries to explain the variance in HRT usage, also considering access to healthcare, in particular women's health services. It confirms the validity of using economic analysis of pharmaceutical sales data as a proxy for prescribing data in the arena of prescribing research.

Out of hours service: the Danish solution examined.

In Denmark the provision of out of hours care by general practitioners came under increasing pressure in the 1980s because of growing demand for services by the public and increasing complaints from rural doctors about their heavy workload and disproportionately low remuneration in comparison with urban doctors. As a result, the out of hours service was reformed at the start of 1992: locally negotiated rota systems were replaced with county based services. Each county now has a coordination centre, where all patients' calls are received by a team of doctors. The doctors may give a telephone consultation, advise the patient to attend one of the emergency clinics strategically placed about the county, or arrange for a home visit. Doctors on home visiting duty are located at bases throughout the county and keep in touch with the coordination centre with mobile telephones. Graded fees mean that doctors are encouraged to give telephone consultations rather than arrange for clinic consultations or home visits. The reforms have reduced doctors' out of hours workload and the number of home visits made and have proved acceptable to patients, doctors, and administrators.

Urinary symptoms in the community: how bothersome are they?

OBJECTIVES: To measure the level of reported urinary symptoms presumed to be associated with benign prostatic hyperplasia (BPH) among men aged 40 years and over in the community, and to assess how bothersome these symptoms are perceived to be. SUBJECTS AND METHODS: All ambulant men aged 40 years and over who were registered in a general practice (703) were invited to attend the health centre to complete a questionnaire containing the Maine prostatectomy scale and the International Continence Society-BPH questionnaire, and to undergo uroflowmetry. RESULTS: The prevalence of symptomatic BPH (as defined by a numerical score > or = 11 on the Maine score, a urinary peak flow of < 15 ml/s, and failure to void > or = 150 ml on three separate occasions) was 284/1000 for men aged 40 years and over. This prevalence increased from 179/1000 in men aged 40-49 to 500/1000 in men aged 70 years and over. The most commonly reported symptoms were those typically associated with BPH (terminal dribble, hesitancy, intermittency, urgency). The symptoms that caused men the greatest degree of bother were frequency, nocturia and those causing incontinence or social embarrassment. CONCLUSION: The high prevalence of urinary symptoms assumed to be related to BPH in men in the community does not necessarily suggest that these men will require treatment. Common symptoms, typically associated with BPH, were tolerated. Further research is required to investigate the natural history of urinary symptoms, the relationships between symptoms and bladder outflow obstruction secondary to BPH, and to determine the most appropriate management for men in the community, ranging from 'watchful waiting' (monitoring without treatment) to medical or surgical treatment.

Factors associated with regular episodes of dysuria among women in one rural general practice.

The aim of this study was to ascertain the factors associated with frequency-dysuria (urethral) syndrome in a population of women. The study included all women aged 25 years and over on 1 May 1987 who had been registered with one rural, dispensing practice over the study period, 1 May 1985 to 1 May 1989. A self-administered questionnaire was sent to the women on 1 May 1987 and a second, similar, questionnaire was sent two years later. A total of 721 women responded to the two questionnaires (response rate 97%). Regular symptoms of frequency and dysuria were reported by 8% of women in 1987 and 14% in 1989. Four percent of women reported symptoms throughout the four year study period. Symptoms were found to be least common in the 55-74 years age group. Although none of the women who were sexually inactive reported regular symptoms no association was reported between recent sexual intercourse and symptoms. Neither was an association demonstrated between type of contraception used and symptoms. However, it was found that premenopausal women reported significantly more symptoms than postmenopausal women. The number of women involved in this study was too small to allow the importance of change of sexual partner to be determined. Significantly more of the women who reported regular symptoms had been treated for urinary tract infection than of those who did not report regular symptoms. Although a history of regular frequency and dysuria points to a diagnosis of urethral syndrome, general practitioners must assess each case in order to exclude urinary tract infection.

The reported prevalence of urinary symptoms in women in one rural general practice.

In May 1989 a questionnaire to determine the prevalence of urinary symptoms and vaginal discharge in the community was sent to all women patients born before May 1962 who had been registered with one rural practice for the previous two years. The response rate was 97%. The patients' clinical records were used to validate the replies of those who claimed to have consulted the doctor with these symptoms together with a sample of those who claimed not to have consulted. The reported prevalence of dysuria among the women over the previous two years was 27% and the prevalence of frequency was 34%. However, only 8% of women had received treatment for vaginal infections and 15% treatment for urinary symptoms (10% had confirmed bacteruria). Thirty four per cent of women said they would treat themselves prior to consulting a doctor and 17% would buy proprietary medicines. When asked how long they would wait between the onset of symptoms and seeking medical advice the responses ranged from one to 20 days, with 36% of women reporting that they would wait five days or longer before consulting. Fifty eight per cent of the women patients did not believe that urinary tract infections could have serious consequences and this figure increased to 76% among women who had consulted previously for a urinary tract infection. Patients with recurrent urinary symptoms did not consult any earlier than other women or treat themselves any less often. It can be concluded that there is a need for increased patient education in this area.

Diagnosis and management of female urinary incontinence in general practice.

In response to an invitation sent to women who had complained previously of regular incontinence, 65 women with regular incontinence were seen by their general practitioner. A diagnosis was made using a personally administered questionnaire and appropriate examination. Patients were placed in one of three diagnostic/management categories--stress, urge or stress/urge incontinence--and were given an appropriate treatment programme. Fifty six women were recruited as matched controls from non-responders while attending the surgery for other reasons. They underwent identical entry procedures but were not offered a treatment programme. All the patients were reassessed after 12 weeks at which time significant improvement in incontinence was reported by the treated women in the stress and urge categories compared with the controls. There was no significant difference in reported efficacy of treatment between age groups and treatment was shown to be effective irrespective of the duration of incontinence. This study shows that for the majority of women reporting incontinence the condition can be diagnosed by a general practitioner and significantly improved by appropriate intervention.

Reported prevalence of urinary incontinence in women in a general practice.

To determine the prevalence of urinary incontinence and other urinary symptoms a questionnaire was sent to all women aged 25 and over and to women under 21 taking oral contraceptives registered with a rural practice (n = 937); the questionnaire was completed by 833 women (89%). The overall prevalence of urinary incontinence was 41% (343/833); rates were lower in nulliparous and postmenopausal women (30/181 (17%) and 120/344 (35%) respectively) than parous and premenopausal women (313/652 (48%) and 225/479 (47%) respectively). Incontinence was significantly associated with perineal suturing after childbirth, being present in 201 of 376 (53%) women with sutures compared with 113 of 270 (42%) without. Of the 166 women with a history of minor gynaecological surgery, 100 had symptoms of incontinence, compared with 263 of the 657 (37%) without such a history. Incontinence was not related to type of delivery, and postnatal exercises for the pelvic floor were not beneficial. Inappropriate leakage of urine is perceived by many women as common and therefore not serious; thus it is often not reported to the doctor. Nevertheless, the 6% of women who always require protection against leakage could be helped by treatment.