The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients

Beskriver utvikling av en klinisk relevant liste med eksplisitte kriterier for farmakologisk uhensiktsmessige medikamentforeskrivinger for eldre ≥ 70 år i allmennpraksis.Objective. To establish a clinically relevant list with explicit criteria for pharmacologically inappropriate prescriptions in general practice for elderly people ]70 years. Design. A three-round Delphi process for validating the clinical relevance of suggested criteria (n 37) for inappropriate prescriptions to elderly patients. Setting. A postal consensus process undertaken by a panel of specialists in general practice, clinical pharmacology, and geriatrics. Main outcome measures. The Norwegian General Practice (NORGEP) criteria, a relevance-validated list of drugs, drug dosages, and drug combinations to be avoided in the elderly (570 years) patients. Results. Of the 140 invited panellists, 57 accepted to participate and 47 completed all three rounds of the Delphi process. The panellists reached consensus that 36 of the 37 suggested criteria were clinically relevant for general practice. Relevance of three of the criteria was rated significantly higher in Round 3 than in Round 1. At the end of the Delphi process, a significant difference between the different specialist groups’ scores was seen for only one of the 36 criteria. Conclusion. The NORGEP criteria may serve as rules of thumb for general practitioners (GPs) related to their prescribing practice for elderly patients, and as a tool for evaluating the quality of GPs’ prescribing in settings where access to clinical information for individual patients is limited, e.g. in prescription databases and quality improvement interventions

Sleep disturbances in an arctic population: The Tromsø Study

<p>Abstract</p> <p>Background</p> <p>Prevalence estimates for insomnia range from 10 to 50% in the adult general population. Sleep disturbances cause great impairment in quality of life, which might even rival or exceed the impairment in other chronic medical disorders. The economic implications and use of health-care services related to chronic insomnia represent a clinical concern as well as a pronounced public health problem. Hypnotics are frequently prescribed for insomnia, but alcohol and over-the-counter sleep aids seem to be more widely used by insomniacs than prescription medications. Despite the complex relationship between insomnia and physical and mental health factors, the condition appears to be underrecognized and undertreated by health care providers, probably due to the generally limited knowledge of the causes and natural development of insomnia.</p> <p>Methods/Design</p> <p>The Tromsø Study is an ongoing population-based cohort study with five previous health studies undertaken between 1974 and 2001. This protocol outlines a planned study within the sixth Tromsø Study (Tromsø VI), aiming at; 1) describing sleep patterns in a community-based sample representative of the general population of northern Norway, and 2) examining outcome variables of sleep disturbances against possible explanatory and confounding variables, both within a cross-sectional approach, as well as retrospectively in a longitudinal study – exploring sleep patterns in subjects who have attended two or more of the previous Tromsø studies between 1974 and 2009. First, we plan to perform a simple screening in order to identify those participants with probable sleep disturbances, and secondly to investigate these sleep disturbances further, using an extensive sleep-questionnaire. We will also collect biological explanatory variables, i.e. blood samples, weight, height and blood pressure. We plan to merge data on an individual level from the Tromsø VI Study with data from the Norwegian Prescription Database (NorPD), which is a national registry including data for all prescription drugs issued at Norwegian pharmacies. Participants with sleep disturbances will be compared with pair-matched controls without sleep disturbances.</p> <p>Discussion</p> <p>Despite ongoing research, many challenges remain in the characterization of sleep disturbances and its correlates. Future mapping of the biological dimensions, natural history, as well as the behavioral and drug-related aspects of sleep disturbances in a representative population samples is clearly needed.</p

Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice – The Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155]

BACKGROUND: More than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved. METHODS/DESIGN: Approximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention. DISCUSSION: Improvement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides

DNA Sequence Profiles of the Colorectal Cancer Critical Gene Set KRAS-BRAF-PIK3CA-PTEN-TP53 Related to Age at Disease Onset

The incidence of colorectal cancer (CRC) increases with age and early onset indicates an increased likelihood for genetic predisposition for this disease. The somatic genetics of tumor development in relation to patient age remains mostly unknown. We have examined the mutation status of five known cancer critical genes in relation to age at diagnosis, and compared the genomic complexity of tumors from young patients without known CRC syndromes with those from elderly patients. Among 181 CRC patients, stratified by microsatellite instability status, DNA sequence changes were identified in KRAS (32%), BRAF (16%), PIK3CA (4%), PTEN (14%) and TP53 (51%). In patients younger than 50 years (n = 45), PIK3CA mutations were not observed and TP53 mutations were more frequent than in the older age groups. The total gene mutation index was lowest in tumors from the youngest patients. In contrast, the genome complexity, assessed as copy number aberrations, was highest in tumors from the youngest patients. A comparable number of tumors from young (<50 years) and old patients (>70 years) was quadruple negative for the four predictive gene markers (KRAS-BRAF-PIK3CA-PTEN); however, 16% of young versus only 1% of the old patients had tumor mutations in PTEN/PIK3CA exclusively. This implies that mutation testing for prediction of EGFR treatment response may be restricted to KRAS and BRAF in elderly (>70 years) patients. Distinct genetic differences found in tumors from young and elderly patients, whom are comparable for known clinical and pathological variables, indicate that young patients have a different genetic risk profile for CRC development than older patients

Assessment of febrile seizures in children

Abstract Febrile seizures are the most common form of childhood seizures, affecting 2-5% of all children and usually appearing between 3 months and 5 years of age. Despite its predominantly benign nature, a febrile seizure (FS) is a terrifying experience for most parents. The condition is perhaps one of the most prevalent causes of admittance to pediatric emergency wards worldwide. FS, defined as either simple or complex, may be provoked by any febrile bacterial or (more usually) viral illness. No specific level of fever is required to diagnose FS. It is essential to exclude underlying meningitis in all children with FS, either clinically or, if any doubt remains, by lumbar puncture. There is no evidence, however, to support routine lumbar puncture in all children admitted with simple FS, especially when typical clinical signs of meningitis are lacking. The risk of epilepsy following FS is 1-6%. The association, however small, between FS and epilepsy may demonstrate a genetic link between FS and epilepsy rather than a cause and effect relationship. The effectiveness of prophylactic treatment with medication remains controversial. There is no evidence of the effectiveness of antipyretics in preventing future FS. Prophylactic use of paracetamol, ibuprofen or a combination of both in FS, is thus a questionable practice. There is reason to believe that children who have experienced a simple FS are overinvestigated and over-treated. This review aims to provide physicians with adequate knowledge to make rational assessments of children with febrile seizures

A cluster-randomized educational intervention to reduce inappropriate prescription patterns for elderly patients in general practice - The Prescription Peer Academic Detailing (Rx-PAD) study [NCT00281450]

Background Age-related alterations in metabolism and excretion of medications increase the risk of adverse drug events in the elderly. Inappropriate polypharmacy and prescription practice entails increased burdens of impaired quality of life and drug related morbidity and mortality. The main objective of this trial is to evaluate effects of a tailored educational intervention towards general practitioners (GPs) aimed at supporting the implementation of a safer drug prescribing practice for elderly patients ≥ 70 years. Methods/design Approximately 80 peer continuing medical education (CME) groups (about 600 GPs) in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. The control group will not receive any intervention towards prescription patterns in elderly, but will be the target of an educational intervention for prescription of antibiotics for respiratory tract infections. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, a set of quality indicators (QIs), i.e. explicit recommendations for safer prescribing for elderly patients, will be presented and discussed. Software will be handed out for installation in participants' practice computers to enable extraction of pre-defined prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Feedback reports will include QI-scores on individual- and group levels, before and after the intervention. The main outcome of this trial is the change in proportions of inappropriate prescriptions (QIs) for elderly patients ≥ 70 years following intervention, compared to baseline levels. Discussion Improvement of prescription patterns in medical practice is a challenging task. Evidence suggests that a thorough evaluation of diagnostic indications for drug treatment in the elderly and/or a reduction of potentially inappropriate drugs may impose significant clinical benefits. Our hypothesis is that an educational intervention program will be effective in improving prescribing patterns for elderly patients in GP settings

Self-reported sleeplessness in 12,655 persons living in the north of Norway: The Tromsø Study.

Sleep disturbances cause great impairment in quality of life. In this cross-sectional study, we analysed questionnaire-collected data from 12,655 persons (30-87 years) who participated in the sixth survey of the Tromsø Study carried out in 2007-2008. First, using this community-based sample representative of the general population of northern Norway, we performed a simple screening to identify individuals with self-reported sleeplessness among those survey participants who provided information about their sleep patterns. Self-reported sleeplessness was defined as responding “More than once a week” to the research question “How often have you suffered from sleeplessness during the last 12 months?” Second, we analysed the associations between selfreported sleeplessness and the following variables: age, gender, living with a spouse or not, level of education, employment status, income, smoking, alcohol consumption, body mass index, level of self-reported health, and psychological distress. Self-reported sleeplessness had a prevalence of 12.6% in this study population. For both men and women, the variables having the strongest association with sleeplessness were low levels of self-reported health (men, OR=8.70; women, OR=5.73) and the presence of psychological distress (men, OR=4.15; women, OR=2.76). In men, high levels of household income and education were both inversely related to the frequency of self-reported sleeplessness, while being unemployed was much more strongly associated with sleeplessness than being employed. We conclude that sleeplessness was frequent in this large population sample, affecting up to one in eight individuals. Subjects with self-reported sleeplessness had a distinctly different socio-economic profile and self-perceived health than those without complaints of sleeplessness

Prescription peer academic detailing to reduce inappropriate prescribing for older patients: a cluster randomised controlled trial

Artikkelen beskriver funn fra en studie som har undersøkt om en sammensatt pedagogisk intervensjon har effekt på allmennlegenes potensielt uhensiktsmessige legemiddelforskrivning for eldre pasienter.BACKGROUND: Older patients are at particular risk for adverse drug reactions. In older people, interventions targeting potentially inappropriate prescriptions (PIPs) are considered important measures to minimise drug-related harm, especially in the general practice setting where most prescriptions for older patients are issued. AIM: To study the effects of a multifaceted educational intervention on GPs' PIPs for older patients. DESIGN AND SETTING: This was a cluster randomised, educational intervention study in Norwegian general practice. Pre-study data were captured from January 2005 to December 2005 and post-study data from June 2006 to June 2007. The educational intervention was carried out from January 2006 to June 2006. METHOD: Eighty continuing medical education (CME) groups (465 GPs) were randomised to receive the educational intervention on GPs' PIPs for older patients (41 CME groups; 256 GPs) or another educational intervention (39 CME groups; 209 GPs); these two groups acted as controls for each other. GPs' prescription data from before and after the intervention were assessed against a list of 13 explicit PIP criteria for patients aged ≥70 years. In the CME groups, trained GPs carried out an educational programme, including an audit, focusing on the 13 criteria and their rationale. RESULTS: A total of 449 GPs (96.6%) completed the study; 250 in the intervention group and 199 in the control group. After adjusting for baseline differences and clustering effects, a reduction relative to baseline of 10.3% (95% confidence interval = 5.9 to 15.0) PIPs per 100 patients aged ≥70 years was obtained. CONCLUSION: Educational outreach visits with feedback and audit, using GPs as academic detailers in GPs' CME groups, reduced PIPs for older patients aged ≥70 years in general practice

Self-reported sleeplessness in 12,655 persons living in the north of Norway: The Tromsø Study.

Sleep disturbances cause great impairment in quality of life. In this cross-sectional study, we analysed questionnaire-collected data from 12,655 persons (30-87 years) who participated in the sixth survey of the Tromsø Study carried out in 2007-2008. First, using this community-based sample representative of the general population of northern Norway, we performed a simple screening to identify individuals with self-reported sleeplessness among those survey participants who provided information about their sleep patterns. Self-reported sleeplessness was defined as responding “More than once a week” to the research question “How often have you suffered from sleeplessness during the last 12 months?” Second, we analysed the associations between selfreported sleeplessness and the following variables: age, gender, living with a spouse or not, level of education, employment status, income, smoking, alcohol consumption, body mass index, level of self-reported health, and psychological distress. Self-reported sleeplessness had a prevalence of 12.6% in this study population. For both men and women, the variables having the strongest association with sleeplessness were low levels of self-reported health (men, OR=8.70; women, OR=5.73) and the presence of psychological distress (men, OR=4.15; women, OR=2.76). In men, high levels of household income and education were both inversely related to the frequency of self-reported sleeplessness, while being unemployed was much more strongly associated with sleeplessness than being employed. We conclude that sleeplessness was frequent in this large population sample, affecting up to one in eight individuals. Subjects with self-reported sleeplessness had a distinctly different socio-economic profile and self-perceived health than those without complaints of sleeplessness