Scandinavian Journal of Primary Health Care最新文献

Aims: To examine the separate associations of glycemic control and chronic kidney disease with hospitalization days over one year in patients with type 2 diabetes (T2D).

Materials and methods: A cross-sectional study using retrospective data on T2D patients in Region Halland, Sweden, during 2020. Data from the Region Halland database included hospitalizations, emergency visits, primary care encounters, glycemic control, estimated glomerular filtration rate (eGFR), comorbidities, pharmacotherapy and healthcare encounters. Negative binomial regression was used to assess associations with healthcare utilization.

Results: A total of 12,689 patients participated, with an average age of 66.0 years (67.1 years for women and 65.2 years for men, p = 0.010). Higher glycated hemoglobin (HbA1c) and elevated blood glucose levels were associated with increased hospitalization days. Relative risks (RRs) for hospitalization days were higher for HbA1c 52-70 mmol/mol (RR 1.08, 95% CI 1.01-1.15) and >70 mmol/mol (RR 1.24, 95% CI 1.12-1.37). Elevated blood glucose levels ≥7.8 mmol/L had an RR of 1.17 (95% CI 1.04-1.32), while <7.8 mmol/L had an RR of 0.85 (95% CI 0.76-0.96). Patients with an eGFR between 30 and 60 mL/min had a RR of hospitalization of 1.35 (95% CI 1.26-1.44) compared to those with an eGFR >60 mL/min. For patients with an eGFR <30 mL/min, the RR of hospitalization was 3.36 (95% CI 3.00-3.77).

Conclusions: Both poor glycemic control and decreased kidney function were associated with higher hospitalization rates in T2D patients. These findings emphasize the need for effective management of glycemic control and renal function to reduce the healthcare burden in this patient population.

Objective: To explore how trainee doctors in general practice navigate patient expectations and requests for non-indicated procedures or tests, and what factors may pressure them into practising defensively.

Design and setting: A qualitative interview study with 13 GP trainees from the Capital Region and Region Zealand in Denmark. An interview guide was developed based on existing literature and a pilot interview with an experienced GP. Data were coded in NVivo (version 15) and analysed using thematic analysis.

Results: The trainees described several challenges when facing patient requests for unnecessary procedures or tests. These challenges were linked to their own uncertainty, patient expectations and behavior, as well as external factors. The trainees described experiencing self-doubt and uncertainty, particularly when their clinical judgement was questioned by patients. Managing patient expectations, especially when patients were worried, sought tangible evidence, or had private health insurance, was described as challenging. Additionally, clinical values and a stressful environment was said to further influence decision-making processes. Together, these factors sometimes pressured the trainees into adopting a more defensive approach. With more experience, many developed greater confidence and argumentation, making it easier to refuse patient requests while maintaining a good relationship.

Conclusion: Our study indicates that uncertainty, patient expectations, and external circumstances may, in certain situations, pressure Danish GP trainees into practising defensively. Managing and navigating both their own and the patient's uncertainty emerges as a key challenge. Future research is needed to explore how trainees can be better supported and educated in managing uncertainty and patient expectations in general practice.

Objectives: Out-of-hours services (OOHS) worldwide exhibit diverse organisational models, especially within the European Union. This study aims to describe the transformation of OOHS in Region Zealand, Denmark, from a General Practitioner cooperative (GP-OOHS) to a regional organization/service, known as the 1818 Medical Helpline (1818).

Study design: Retrospective cohort study.

Methods: GP-OOHS data (January 2017-October 2023) during the transition from GP-cooperative to Regional Service (October 2022) were analysed. Coded and timestamped services retrieved from the billing system were used to identify patient pathways, defined as services within a 12-hour window. Descriptive statistics were applied.

Results: A total of 2,572,951 patient pathways were recorded, with 2,258,072 under GP-out-of-hours service and 314,879 under the 1818. Overall, patient pathway volumes declined from 412,116 in 2017 to 314,879 in 2022, and admissions fell from 64,555 to 59,967. The median patient age was 35 years. The GP-out-of-hours service had a higher average monthly volume of patient pathways (32,726 vs. 25,940), while 1818 showed a higher proportion of emergency department admissions within 24 h (19.0% vs. 17.6%), the number of admissions fell from 8.2 per 100,000 inhabitants to 7.1 per 100,000 inhabitants. Interrupted time series analysis showed that the previously increasing tendency in ED admissions flattened following the transition. Although the absolute number of children admitted decreased, the proportion of admissions increased due to overall decline in patient pathways. Face-to-face consultations (31.4% vs. 27.1%) and home visits (9.4% vs. 3.4%) were more frequent in GP-out-of-hours service, both being associated with higher admission rates.

Conclusions: OOHS patient pathways declined over the study period and continued to decline following the organizational change. The absolute number of emergency department admissions also decreased, while the relative proportion of admissions increased. These findings indicate a continued decline in OOHS activity and a slight shift toward more acute cases after the reorganisation.

Purpose: To shed a nuanced light on the experiences of taking part in a rehabilitation programme using acceptance and commitment therapy (ACT) for people living with persistent pain and fatigue.

Materials and methods: The ACT intervention, designed by the Pain Clinic of a University Hospital, consisted of six four-hour sessions, each for four groups of 6-8 participants, given over the course of four months. An interdisciplinary research team thematically analysed 13 post-programme individual interviews with people aged 21 to 54 with different symptoms and diagnoses using systematic text condensation.

Results: Participants reported that while illness had led to feelings of loneliness, loss and failure, participating in a safe and supportive group setting led to a nurturing sense of shared community, understanding and learning. Increased self-awareness, self-acceptance and self-compassion were valued outcomes of the programme. Most felt that they had acquired new tools, such as exercises, practices and altered ways of thinking. A few participants were uncomfortable with the sharing practices and felt that the programme brought few benefits for them.

Conclusions: The study indicates the value of a sense of community and experiencing illness as a shared human condition. Learning to see oneself as worthy of self-compassion, suggested in the literature as key to pain rehabilitation, was connected to group validation and ACT-specific sessions. Information, exercises and sharing practices could have been even better targeted and tailored to individual participants.

Background and aim: Patients with COPD and concurrent depression and/or anxiety are known to have an increased risk of exacerbations, morbidity, mortality, and deteriorated quality of life. Early detection of depression/anxiety may enable early interventions. The aims of this study were to describe the occurrence of depression and anxiety in primary care patients with COPD in Sweden, and to investigate age and gender differences together with other clinical factors associated with this comorbidity.

Methods: A cross-sectional study was performed on a cohort of patients with doctor's diagnoses of COPD. Patients were randomly selected based on the patients' contact with 98 primary healthcare centers and 13 hospitals in Sweden in 2014. Information about self-reported depression/anxiety, patient characteristics, symptoms, and comorbidity, were collected using patient self-completion questionnaires. Lung function data were extracted from medical records.

Results: Of the 2245 patients recruited, 23% (n = 524) reported depression/anxiety, 29% in women and 16% in men (p <0.001). Factors associated with depression/anxiety were being a woman (OR = 2.06 [95% CI 1.56-2.72]), current smoking (1.83 [1.37-2.43]), comorbid asthma (1.77 [1.32-2.37]), dyspnea (the modified Medical Research Council dyspnea scale ≥2 points) (1.58 [1.17-2.13]) and age <65 years (1.57 [1.17-2.10]). The youngest age groups had the highest proportions of patients with depression/anxiety.

Conclusions: Healthcare professionals need to be particularly aware of depression/anxiety in patients with COPD who are younger, women, current smokers, have comorbid asthma, or dyspnea.

Background: Online symptom checkers are increasingly used for diagnostic support and triage. However, evidence on their performance and evaluations with real-world data remains limited.

Objective: The aim of this study was to evaluate the performance of a digital symptom checker using clinical vignettes derived from real-world cases that had previously been incorrectly triaged.

Methods: A patient-facing, rule-based digital symptom checker used in Swedish primary care was assessed in this study. Vignettes were constructed from cases reported to the Swedish Health and Social Care Inspectorate due to erroneous telephone triage. We hypothesized that the digital symptom checker could provide appropriate triage for these cases. Seven physicians independently simulated patients by entering symptoms in the symptom checker based on each vignette. Triage outcomes were assessed against the Swedish National Triage Guidelines (RGS), evaluating the accuracy and the safety of the triage recommendation.

Results: A total of 69 unique vignettes yielded 483 individual trials. After excluding 93 trials due to significant deviations from the original vignette description (adding or omitting symptoms), 390 trials were included in the primary analysis. The symptom checker achieved 91% accuracy (95% CI 88-94%) and 94% safety (95% CI 91-96%).

Conclusions: The symptom checker demonstrated high accuracy and safety when triaging a subset of vignettes based on real-world cases that had been previously erroneously triaged. This study also highlights the difficulties of using vignettes when evaluating symptom checkers. To our knowledge, this is the first study to evaluate such systems using vignettes based on actual patient cases with known triage errors.

Background: Around 95% of all websites selling medicines globally are illegal and contribute to the spread of substandard and falsified medicines. Hence, it is important to identify legal pharmacies when accessing medicines online. During 2022-2024, 250 million prescriptions were legally dispensed in Sweden, and 69% were prescribed in primary care. Pharmacists and general practitioners are key healthcare professionals who can guide people to safe online purchases. The overall aim was to describe Swedes' online purchasing habits for medicines.

Methods: We used a cross-sectional design and collected information from the general population through an annual digital questionnaire for three years in a row, 2022-2024. In total, 6006 respondents, 18-79 years old, were included.

Results: Fifty-two percent had bought medicines online in the last year. Most respondents, 91%, did not recognise the common EU logo mandatory for authorised online pharmacies. People buying over-the-counter medicines online were significantly younger than those buying prescription-only medicines online. Female gender and higher level of education were associated with more online purchases of medicines. Most respondents' purchasing habits were not influenced by external factors. Reasons for increased online purchases were, for example, that it helps planning regarding access to treatment.

Conclusions: Half of the study participants have used online pharmacies, but fewer than 10% know how to identify a safe online pharmacy, i.e. many are at risk for fraud. Increasing this knowledge by informing those who prefer online purchases has the possibility to use the advantages and avoid the risks associated with online purchases of medicines.

Purpose: To examine the association between uncomplicated urinary tract infections and subsequent type 2 diabetes (T2D) diagnosis in women. Materials and methods: We included 1,840,044 women without previously diagnosed type 2 diabetes (T2D) or redeemed antidiabetic drugs. Results and conclusions: During the 12-year study period, women with uncomplicated urinary tract infections (cystitis and pyelonephritis), diagnosed within two years before T2D, did not have higher subsequent risks of T2D compared to those without urinary tract infections.

Introduction: Understaffing and dependence on temporary physicians known as locums are common in primary healthcare in Sweden. In this study, we investigate the impact of locum staffing on the quality of antibiotic prescribing for respiratory tract infections. We used two neighbouring cities in northern Sweden with large differences in staffing conditions: Skellefteå, with a 10-fold higher reliance on locum physicians compared to Umeå, which has low locum staffing.

Methods: We used data extracted from patient records for all visits, from the four largest healthcare centres in each of the cities Umeå and Skellefteå, for respiratory tract infections, including the ICD-10 diagnosis code and whether antibiotic treatment was prescribed or not. Data on the contracted hours of locum staff for each healthcare centre were also obtained. Statistical analyses were performed with Spearman correlation, Chi-square and Poisson tests. Logistic regression was used to investigate whether prescribing patterns were affected by the level of relay physicians.

Results: We analysed antibiotic prescriptions for respiratory tract infections based on data from 11,228 patient visits. Regardless of the statistical method used, we found a statistically significant difference, with higher rates of antibiotic prescribing for diagnoses where antibiotics generally are not recommended or where they should be prescribed restrictively. For pneumonia, where antibiotics should normally be prescribed, no difference was seen. The odds of antibiotic prescription for acute upper respiratory tract infection in Skellefteå were 2.5 times higher than in Umeå, with a positive correlation between locum staffing and antibiotic prescriptions for diagnoses where antibiotics should be used restrictively.

Conclusions: Our findings show that a high level of locum staffing and thus insufficient staffing with permanent General practitioners leads to higher rates of inappropriate antibiotic prescribing. This is shown both at the level of individual primary care healthcare centres and at the community level.

Introduction: Assessing work capacity and determining appropriate sick leave is a complex process. Despite the importance of fair and consistent assessments, evidence suggests that evaluations may vary. However, previous studies have been inconclusive and have mainly focused on whether sick leave should be recommended or not. The present study examined the medical reliability and consistency of physicians' assessments of work capacity, as indicated by the reported percentage of reduced work capacity and the recommended length of sick leave.

Methods: A cross-sectional survey was conducted with 142 primary care physicians from four Swedish counties. Participants assessed six anonymised, authentic medical certificates related to mental health and pain-related conditions. For each case, they estimated the degree of reduced work capacity and the recommended sick leave duration, which were combined into a sick leave score. Physician characteristics (e.g. gender, professional status) and perceived managerial support were also measured.

Results: There was considerable variation in sick leave scores, both across physicians and between certificates. Male physicians and those with more years of experience recommended longer sick leave for pain-related cases, while specialists showed less variation in their assessments. Perceived support from frontline managers was associated with lower scores. No significant associations were found for patient involvement.

Conclusions: The findings suggest that sick leave assessments may lack consistency and be influenced by physician-related factors, particularly for pain-related conditions. Stronger support structures, opportunities for knowledge exchange, and clearer guidelines may help reduce unwarranted variation and promote more reliable assessments.