Stroke follow-up in primary care: a discourse study on the discharge summary as a tool for knowledge transfer and collaboration

Background The acute treatment for stroke takes place in hospitals and in Norway follow-up of stroke survivors residing in the communities largely takes place in general practice. In order to provide continuous post stroke care, these two levels of care must collaborate, and information and knowledge must be transferred between them. The discharge summary, a written report from the hospital, is central to this communication. Norwegian national guidelines for treatment of stroke, issued in 2010, therefore give recommendations on the content of the discharge summaries. One ambition is to achieve collaboration and knowledge transfer, contributing to integration of the health care services. However, studies suggest that adherence to guidelines in general practice is weak, that collaboration within the health care services does not work the way the authorities intend, and that health care services are fragmented. This study aims to assess to what degree the discharge summaries adhere to the guideline recommendations on content and to what degree they are used as tools for knowledge transfer and collaboration between secondary and primary care. Methods The study was an analysis of 54 discharge summaries for home-dwelling stroke patients. The patients had been discharged from two Norwegian local hospitals in 2011 and 2012 and followed up in primary care. We examined whether content was according to guidelines’ recommendations and performed a descriptive and interpretative discourse analysis, using tools adapted from an established integrated approach to discourse analysis. Results We found a varying degree of adherence to the different advice for the contents of the discharge summaries. One tendency was clear: topics relevant here and now, i.e. at the hospital, were included, while topics most relevant for the later follow-up in primary care were to a larger degree omitted. In most discharge summaries, we did not find anything indicating that the doctors at the hospital made themselves available for collaboration with primary care after dischargeof the patient. Conclusions The discharge summaries did not fulfill their potential to serve as tools for collaboration, knowledge transfer, and guideline implementation. Instead, they may contribute to sustain the gap between hospital medicine and general practice.publishedVersio

Body Configuration as a Predictor of Mortality: Comparison of Five Anthropometric Measures in a 12 Year Follow-Up of the Norwegian HUNT 2 Study

Background: Distribution of body fat is more important than the amount of fat as a prognostic factor for life expectancy. Despite that, body mass index (BMI) still holds its status as the most used indicator of obesity in clinical work. Methods: We assessed the association of five different anthropometric measures with mortality in general and cardiovascular disease (CVD) mortality in particular using Cox proportional hazards models. Predictive properties were compared by computing integrated discrimination improvement and net reclassification improvement for two different prediction models. The measures studied were BMI, waist circumference, hip circumference, waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR). The study population was a prospective cohort of 62,223 Norwegians, age 20–79, followed up for mortality from 1995–1997 to the end of 2008 (mean follow-up 12.0 years) in the Nord-Trøndelag Health Study (HUNT 2). Results: After adjusting for age, smoking and physical activity WHR and WHtR were found to be the strongest predictors of death. Hazard ratios (HRs) for CVD mortality per increase in WHR of one standard deviation were 1.23 for men and 1.27 for women. For WHtR, these HRs were 1.24 for men and 1.23 for women. WHR offered the greatest integrated discrimination improvement to the prediction models studied, followed by WHtR and waist circumference. Hip circumference was in strong inverse association with mortality when adjusting for waist circumference. In all analyses, BMI had weaker association with mortality than three of the other four measures studied. Conclusions: Our study adds further knowledge to the evidence that BMI is not the most appropriate measure of obesity in everyday clinical practice. WHR can reliably be measured and is as easy to calculate as BMI and is currently better documented than WHtR. It appears reasonable to recommend WHR as the primary measure of body composition and obesity

The Intangible Legacy of the Indonesian Bajo

The Sama-Bajau, or Bajo diaspora, extends from the southern Philippines and Sabah (Malaysian Borneo) to the eastern part of Indonesia. The Indonesian Bajo, now scattered along the coasts of Sulawesi (Celebes) and East Kalimantan, the Eastern Lesser Sunda Islands and Maluku, were once mostly nomadic fishermen of the sea or ocean freight carriers. Today, the Bajo are almost all fishermen and settled. Their former and present ways of life made them favour intangible forms of culture: it is impossible to transport bulky artefacts when moving frequently by boat, or when living in stilt houses, very close to the sea or on a reef. It is therefore an intangible legacy that is the essence of the Bajo\u27s culture. Sandro healers have a vast range of expertise that allows them to protect and heal people when they suffer from natural or supernatural diseases. On the other hand, music and especially oral literature are very rich. In addition to song and the pantun poetry contests, the most prestigious genre is the iko-iko, long epic songs that the Bajo consider to be historical rather than fictional narratives. The Bajo\u27s intangible heritage is fragile, since it is based on oral transmission. In this article, I give a description of this heritage, dividing it into two areas: the knowledge that allows them to “protect and heal” on the one hand, and to “distract and relax”, on the other

Reforming disease definitions: a new primary care led, people-centred approach

Expanding disease definitions are causing more and more previously healthy people to be labelled as diseased, contributing to the problem of overdiagnosis and related overtreatment. Often the specialist guideline panels which expand definitions have close tis to industry and do not investigate the harms of defining more people as sick. Responding to growing calls to address these problems, an international group of leading researchers and clinicians is proposing a new way to set diagnostic thresholds and mark the boundaries of condition definitions, to try to tackle a key driver of overdiagnosis and overtreatment. The group proposes new evidence-informed principles, with new process and new people constituting new multi-disciplinary panels, free from financial conflicts of interest

Current European guidelines for management of arterial hypertension: Are they adequate for use in primary care? Modelling study based on the Norwegian HUNT 2 population

<p>Abstract</p> <p>Background</p> <p>Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population.</p> <p>Methods</p> <p>Implementation of the current <it>European Guidelines for the Management of Arterial Hypertension </it>was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling.</p> <p>Results</p> <p>Among individuals with blood pressure ≥120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults.</p> <p>Conclusion</p> <p>The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered.</p

The validity and relevance ofinternational cardiovasculardisease prevention guidelinesfor general practice

Background Cardiovascular diseases (CVD) are currently the leading cause of death worldwide, and a major cause of disability. CVD, including supervision of risk factors with respect to prevention, have in recent decades become an increasingly important topic for general practice. These issues have also become prominent in public debate and health care policy. Specific strategies of individual prevention are to a large extent, at least in the Western world, in the hands of the general practitioners (GPs). In recent years, there has been much emphasis on clinical practice guidelines to aid GPs in their preventive work and guide them to the most cost-effective management. This refers both to recommendations on therapeutic options as well as methods to identify those who would benefit the most from preventive treatment. These guidelines can provide important and updated information for clinicians and function as an instrument for quality improvement and potentially also performance assessment in clinical practice. However, various studies have shown that GPs only follow the guidelines to a certain extent, and that recommended treatment goals are often not reached. Some authors have explained this in terms of physicians' inadequacy, whilst others have pointed out that at least part of the explanation is likely to lie in the nature of the guidelines as such. The quality and usefulness of clinical guidelines for prevention of CVD are of great importance to many, both on the level of individual health care and from the perspective of resource allocation. Aims The objective of this project was to study and discuss the validity and relevance of international CVD prevention guidelines for general practice. More specifically: - To document the CVD risk profile of a general population as defined by selected, authoritative preventive clinical guidelines, by means of modelling studies. - To estimate the workload associated with following the recommendations of the selected guidelines for a well-defined general population in whole. - To identify potential causes of guidelines' overestimation of risk, focusing on individual risk factors. Material and methods This dissertation is based on analyses of data from the Norwegian HUNT 2 population survey, including roughly 65 000 participants. Two studies were conducted to document the CVD risk profile of this general population and to model the implications of implementing current clinical guidelines, regarding the proportion of the population identified at “increased risk”, and the clinical workload associated with following the guideline recommendations. Subsequently, two studies were conducted to analyse whether potential causes of guidelines' overestimation of CVD risk might stem from the way two individual risk factors, cholesterol and obesity, are handled in the guidelines. The dissertation further includes analysis and identification of additional factors potentially limiting the validity and relevance of preventive CVD guidelines. Results If authoritative guideline recommendations for CVD prevention are literally applied, a vast majority of adults in Norway would exhibit “unfavourable” CVD risk profiles and thus be considered in need of individual, clinical attention and follow-up. The potential workload associated with implementing current European clinical guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthyliving nations, by international comparison. Total cholesterol was not found to be as predictive of mortality as generally assumed. Thus, possible errors regarding the role of total cholesterol in the CVD risk algorithms of many clinical guidelines were identified. If our findings are generalisable, clinical and public health recommendations regarding the “dangers” of cholesterol should be revised. Body mass index, the most widely recommended measure of obesity in preventive CVD guidelines, was found to be inferior to waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and waist circumference in relation to predicting mortality. WHR and WHtR exhibited the best predictive properties. It appears reasonable to recommend WHR as the primary clinical measure of body composition and obesity for preventive purposes. Conclusion There currently appears to be a range of factors limiting the validity and relevance of clinical practice guidelines on prevention of CVD, at least in Norway. Such limitations may have important effects on clinical practice and resource allocation, as well as population health. The guidelines appear to overestimate CVD risk and fail to correctly identify a manageable proportion of the population as “high-risk individuals”, for whom individual preventive strategies would be effective and beneficial. The strategy of targeting individuals at risk ends up being recommended at the level of mass strategy, which can hardly be regarded as sustainable or responsible. A number of factors potentially limiting the validity and relevance of current guidelines were identified. The dissertation includes a proposal of ways to improve the guidelines

Stroke follow-up in primary care: a Norwegian modeling study on the implications of multi morbidity for guideline adherence

Background Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients’ multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice. Methods The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases. Result All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10–11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity. Conclusions Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable

Stroke follow-up in primary care: a prospective cohort study on guideline adherence

Background After a stroke, a person has an increased risk of recurrent strokes. Effective secondary prevention can provide significant gains in the form of reduced disability and mortality. While considerable efforts have been made to provide high quality acute treatment of stroke, there has been less focus on the follow-up in general practice after the stroke. One strategy for the implementation of high quality, evidence-based treatment is the development and distribution of clinical guidelines. However, from similar fields of practice, we know that guidelines are often not adhered to. The purpose of this study was to investigate to what degree patients who have suffered a stroke are followed up in general practice, if recommendations in the national guidelines are followed, and if patients achieve the treatment goals recommended in the guidelines. Methods The study included patients with cerebral infarction identified by the ICD-10 discharge diagnoses I63.0 trough I63.9 in two Norwegian local hospitals. In total 51 patients participated. They were listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ (GPs’) medical records for these patients in the first year of follow-up; in total 381 consultations. Results Of the 381 consultations during the first year of follow-up, 71 (19%) had stroke as the main topic. The blood pressure (BP) target value < 140/90 mmHg was reached by 24 patients (47%). The low density lipoprotein (LDL) cholesterol target value < 2.0 mmol/L was reached by 14 (27%) of the 51 patients. In total six patients (12%) got advice on physical activity and three (6%) received dietary advice. No advice about alcohol consumption was recorded. Conclusions The findings support earlier claims that the development and distribution of guidelines alone is not enough to implement a certain practice. Despite being a serious condition, stroke gets limited attention in the first year of follow-up in general practice. This can be explained by the complexity of general practice, where even a serious condition loses the competition for attention to other apparently equally important issues