GP utilisation by education level among adults with COPD or asthma: A cross-sectional register-based study

Published version. Source at http://doi.org/10.1038/npjpcrm.2016.27. License CC BY 4.0.There is a marked socioeconomic gradient in the prevalence of chronic obstructive pulmonary disease (COPD) and asthma, but a large proportion of patients remain undiagnosed. It is a challenge for general practitioners (GPs) to both identify patients and contribute to equity and high quality in services delivered. The aim of this study was to identify patients with COPD and asthma diagnoses recorded by GPs and explore their utilisation of GP services by education level. This was a cross-sectional, national, register-based study from Norwegian general practice in the period 2009–2011. Based on claims from GPs, the number of patients aged ⩾40 years with a diagnosis of COPD or asthma and their GP services utilisation were estimated and linked to the national education database. Multivariate Poisson and logistic regression models were used to explore the variations in GP utilisation. In the population aged ⩾40 years, 2.8% had COPD and 3.8% had asthma according to GPs’ diagnoses. COPD was four times more prevalent in patients with basic education than higher education; this increase was ⩽80% for asthma. Consultation rates were 12% higher (P<0.001) for COPD and 25% higher (P<0.001) for asthma in patients with low versus high education in the age group of 40–59 years after adjusting for comorbidity, and patient and GP characteristics. Approximately 25% of COPD patients and 20% of asthma patients had ⩾1 spirometry test in general practice in 2011, with no significant education differences in adjusted models. The higher consultation rate in lower-education groups indicates that GPs contribute to fair distribution of healthcare

Is opportunistic disease prevention in the consultation ethically justifiable?

To access publisher version of this article. Please click on the hyperlink in Additional Links fieldTo access full text version of this article. Please click on the hyperlink "View/Open" at the bottom of this pageMedical resources are increasingly shifting from making patients better to preventing them from becoming ill. Genetic testing is likely to extend the list of conditions that can be screened for. Is it time to stop and consider whom we screen and how we approach it

Continuity of care, measurement and association with hospital admission and mortality: A registry-based longitudinal cohort study

Objective To assess whether continuity of care (COC) with a general practitioner (GP) is associated with mortality and hospital admissions for older patients We argue that the conventional continuity measure may overestimate these associations. To better reflect COC as a GP quality indicator, we present an alternative, service-based measure. Design Registry-based, population-level longitudinal cohort study. Setting Linked data from Norwegian administrative healthcare registries, including 3989 GPs. Participants 757 873 patients aged 60–90 years with ≥2 contacts with a GP during 2016 and 2017. Main outcome measure All-cause emergency hospital admissions, emergency admissions for ambulatory care sensitive conditions, and mortality, in 2018. Results We assessed COC using the conventional usual provider of care index (UPCpatient) and an alternative/supplementary index (UPCGP list) based on the COC for all other patients enlisted with the same preferred GP. For both indices, the mean index score was 0.78. Our model controls for demographic and socioeconomic characteristics, prior healthcare use and municipality-fixed effects. Overall, UPCGP list shows a much weaker association between COC and the outcomes. For both indices, there is a negative relationship between COC and hospital admissions. A 0.2-point increase in the index score would reduce admissions for ambulatory care sensitive conditions by 8.1% (CI 7.1% to 9.1%) versus merely 1.9% (0.2% to 3.5%) according to UPCpatient and UPCGP list, respectively. Using UPCGP list, we find that mortality is no longer associated with COC. There was greater evidence for an association between COC and all-cause admissions among patients with low education. Conclusions A continuity measure based on each patient’s contacts with own preferred GP may overestimate the importance of COC as a feature of the GP practice. An alternative, service-based measure of continuity could be suitable as a quality measure in primary healthcare. Facilitating continuity should be considered a health policy measure to reduce inequalities in health.publishedVersio

Statlig etterretning mot petroleumssektoren – nasjonale sikkerhetsinteresser på anbud

PSTs åpne trusselvurdering for 2020 nevner at etterretning mot norsk petroleumsteknologi kan ha «[…] et stort og langsiktig skadepotensial for Norge, både militært, økonomisk og for nasjonal sikkerhet.». Ved problemstillingen «På hvilken måte er den økende trusselen fra utenlandsk statlig etterretning ivaretatt gjennom lovverk og reguleringsregimet for petroleumsnæringen?» har denne oppgaven sett på petroleumssektorens strukturer og lovverk, for å drøfte hvordan disse ivaretar dette trusselbildet. Samt hvilken effekt det kan ha dersom deler av petroleumssektoren blir underlagt sikkerhetsloven. Oppgaven har sett på leverandørindustrien som representant for petroleumsnæringen, og drøfter på hvilken måte det samme trusselbildet påvirker dem. Oppgaven konkluderer med at både myndigheter og næringen jobber samvittighetsfullt med å ivareta trusselbildet, men at det er noen utfordringer ved økonomisk press i leverandørindustrien som gjør at en etterretningstrussel mot nasjonen kan være vanskelig å ivareta. En tydeliggjøring i lovverket, enten i form av endringer i petroleumsloven eller i form av tilknytning til sikkerhetsloven, vil kunne sette næringen i bedre stand til å ivareta disse utfordringene. Samtidig argumenteres det for at en tilpassing av PTILs risikodefinisjon kan bidra til å bedre ivareta konsekvenser som ikke er utløst av virksomhetene selv, men likevel er knyttet til dem. På denne måten hensyntar man en trusselaktør som benytter egen virksomhet for å påvirke en tredjepart, og har større mulighet for å ivareta sikringsaspektet.PST's open threat assessment for 2020 mentions that intelligence against Norwegian petroleum technology may have "[...] a large and long-term potential for Norway, both militarily, economically and for national security." On the issue "In what way is the increasing threat from foreign state intelligence safeguarded through legislation and the regulatory regime for the petroleum industry?" this paper has looked at the petroleum sector's structures and legislation, to discuss how these can counteract the intelligence threat. And what effect it may have if parts of the petroleum sector are subject to the Norwegian security Act (sikkerhetsloven). The paper has looked at the supplier industry as a representative of the petroleum industry, and discusses how the intelligence threat affects them. The paper concludes that both the authorities and the industry work conscientiously to address the threat from foreign intelligence, but that there are some challenges with regards to financial pressures in the supplier industry, that make an intelligence threat to the nation difficult to address. Clarification in the legislation, either in the form of amendments to the Petroleum Act or in the form of amendments to the Security Act, may put the industry in a better position to address these challenges. At the same time, it is argued that adapting PTIL's risk definition can help to better address consequences that have not been triggered by the enterprises themselves, but are nevertheless linked to them. In this way, a threat actor who uses a business to influence a third party is taken into account, and has a greater opportunity to attend to the security aspect

Continuity of care for patients with chronic disease: a registry-based observational study from Norway

Background Continuity of care (CoC) is accepted as a core value of primary care and is especially appreciated by patients with chronic conditions. Nevertheless, there are few studies investigating CoC for these patients across levels of healthcare. Objective This study aims to investigate CoC for patients with somatic chronic diseases, both with regular general practitioners (RGPs) and across care levels. Methods We conducted a registry-based observational study by using nationwide consultation data from Norwegian general practices, out-of-hours services, hospital outpatient care, and private specialists with public contracts. Patients with diabetes mellitus (type I or II), asthma, chronic obstructive pulmonary disease, or heart failure in 2012, who had ≥2 consultations with these diagnoses during 2014 were included. CoC was measured during 2014 by using the usual provider of care (UPC) index and Bice–Boxerman continuity of care score (COCI). Both indices have a value between 0 and 1. Results Patients with diabetes mellitus comprised the largest study population (N = 79,165) and heart failure the smallest (N = 4,122). The highest mean UPC and COCI were measured for patients with heart failure, 0.75 and 0.77, respectively. UPC increased gradually with age for all diagnoses, while COCI showed this trend only for asthma. Both indices had higher values in urban areas. Conclusions Our findings suggest that CoC in Norwegian healthcare system is achieved for a majority of patients with chronic diseases. Patients with heart failure had the highest continuity with their RGP. Higher CoC was associated with older age and living in urban areas.publishedVersio

Continuity in general practice as a predictor of mortality, acute hospitalization, and use of out-of-hours care: registry-based observational study in Norway

Background Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere. Aim To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality. Design and setting Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs. Method Duration of RGP–patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP–patient relationship was categorised as 1, 2–3, 4–5, 6–10, 11–15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses. Results Compared with a 1-year RGP–patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2–3 years’ duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2–3 years’ duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2–3 years’ duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP–patient relationship of >15 years. Conclusion Length of RGP–patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose–response relationship between continuity and these outcomes indicates that the associations are causal.publishedVersio

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

Continuity of care and mortality for patients with chronic disease: an observational study using Norwegian registry data

Background Research on continuity of care (CoC) is mainly conducted in primary care and has received little acknowledgment in other levels of care. This study sought to investigate CoC across care levels for patients with selected chronic diseases, along with its association with mortality. Methods In a registry-based cohort study, patients with ≥1 consultation in primary or specialist healthcare or hospital admission with asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, or heart failure in 2012 were linked to disease-related consultation data in 2013–2016. CoC was measured by Usual Provider of Care index (UPC) and Bice–Boxermann continuity of care score (COCI). Values equal to one were categorized into one group and the rest into three equal groups (tertiles). The association with mortality was determined by Cox regression models. Results The highest mean UPCtotal was measured for patients with diabetes mellitus (0.58) and the lowest for those with asthma (0.46). The population with heart failure had the highest death rate (26.5). In adjusted Cox regression analyses for COPD, mortality was 2.6 times higher (95% CI 2.25–3.04) for patients in the lowest tertile of continuity compared to those with UPCtotal = 1. Patients with diabetes mellitus and heart failure showed similar results. Conclusion CoC was moderate to high for disease-related contacts across care levels. A higher mortality associated with lower CoC was observed for patients with COPD, diabetes mellitus, and heart failure. A similar, but not statistically significant trend was found for patients with asthma. This study suggests that higher CoC across levels of care can decrease mortality.publishedVersio

Young adults with depression: A registry-based longitudinal study of work-life marginalisation. The Norwegian GP-DEP study

Aims: To explore the association between a depression diagnosis in young adulthood and risk of marginalisation at age 29 years, among those who had completed upper secondary school and those who had not completed at age 21. Methods: In a longitudinal cohort study based on nationwide registers we followed 111,558 people from age 22–29 years. Outcomes were risk of marginalisation and educational achievement at age 29. Exposure was a diagnosed depression at ages 22–26 years. Comorbid mental and somatic health conditions, gender and country of origin were covariates. Relative risks were estimated with Poisson regression models, stratified by educational level at age 21. Results: For people who had not completed upper secondary school at age 21 years, a depression diagnosis at age 22–26 increased the risk of low income (relative risk = 1.33; 95% confidence interval = 1.25–1.40), prolonged unemployment benefit (1.46; 1.38–1.55) and social security benefit (1.56; 1.41–1.74) at age 29 compared with those with no depression. Among those who had completed upper secondary school at age 21 years, depression increased the risk of low income (1.71; 1.60–1.83), prolonged unemployment benefit (2.17; 2.03–2.31), social security benefit (3.62; 2.91–4.51) and disability pension (4.43; 3.26–6.01) compared with those with no depression. Mental comorbidity had a significant impact on risk of marginalisation in both groups. Conclusions: Depression in one’s mid-20s significantly increases the risk of marginalisation at age 29 years, and comorbid mental health conditions reinforce this association. Functional ability should be given priority in depression care in early adulthood to counteract marginalisation.publishedVersio