Sex differences in blood pressure in midlife: associations with risk factors and acute coronary syndromes in the Hordaland Health Studies

Bakgrunn: Blant unge voksne har friske kvinner vanligvis lavere blodtrykk (BT) enn menn. Men allerede fra 20-årene har kvinner en brattere stigning i BT enn menn på samme alder. Målet med dette arbeidet var å identifisere faktorer assosiert med BT og BT-endring i 40 årene og sammenhengen mellom BT tidlig i 40 årene og risiko for sykehusinnleggelse eller død av akutt koronarsyndrom (AKS) i løpet av 16 års oppfølging hos kvinner og menn. Materiale og metode: Arbeidet er basert på data fra den befolkningsbaserte Helseundersøkelsen i Hordaland (HUSK) og «Cardiovascular Disease in Norway Project 1994-2009» (CVDNOR). CVDNOR inneholder informasjon om alle sykehusinnleggelser og dødsfall i Norge med en hjertekar- eller diabetesdiagnose i perioden 1994-2009. Studiedeltagerne i HUSK fikk utført standardiserte BT-målinger og det ble samlet inn informasjon om kardiovaskulære risikofaktorer da de var gjennomsnittlig 41 år gamle i HUSK1 (baseline) og 6 år senere i HUSK2. Informasjon om sykehusinnleggelser eller død av AKS i løpet av 16 års oppfølgingstid ble hentet fra CVDNOR. Inflammasjonsmarkører, inkludert høysensitivt C-reaktivt protein (hs-CRP), neopterin og pyridoksal syre ratio (PAr), ble målt i HUSK2. Resultat: I studie 1 var høyere BT og kroppsmasse indeks (KMI) målt ved baseline, og stigning i KMI, kolesterol og triglyserider fra HUSK1 til HUSK 2 de viktigste faktorene assosiert med stigning i BT eller nyoppstått hypertensjon ved HUSK2 hos både kvinner og menn. I Studie 2 økte risiko for AKS med høyere BT hos begge kjønn. Kvinner som hadde et lett forhøyet BT (systolisk BT 130-139 mmHg og /eller diastolisk BT 80-89 mmHg) tidlig i 40 årene hadde doblet risiko for AKS i løpet av 16 års oppfølgingstid sammenlignet med kvinner som hadde normalt BT også etter justering for andre kardiovaskulære risikofaktorer. Tilsvarende assosiasjon fant vi ikke hos menn. Forskjellen ble dokumentert med signifikant interaksjonstest mellom BT og kjønn. I Studie 3 var hs-CRP signifikant assosiert med høyere systolisk og diastolisk BT i HUSK2, samt med nyoppstått hypertensjon de siste 6 år hos kvinner, men ikke hos menn. I tillegg var høyere serum neopterin assosiert med høyere diastolisk BT kun hos kvinner, mens høyere PAr indeks var assosiert med høyere systolisk og diastolisk BT hos menn. Disse kjønnsforskjellene ble bekreftet med signifikante interaksjonstester mellom BT og kjønn i modellen for AKS, mellom hs-CRP og kjønn i modellene for systolisk og diastolisk BT og nyoppstått hypertensjon, og mellom neopterin og kjønn i modellen for diastolisk BT. Konklusjon: Høyere baseline KMI, vektoppgang og stigning i serum lipider var de viktigste faktorene assosiert med stigning i BT og nyoppstått hypertensjon hos både kvinner og menn i 40 årene. Sammenhengen mellom inflammasjon og BT var sterkere hos kvinner enn hos menn. Å ha et lett forhøyet BT tidlig i 40 årene var en sterkere risikofaktor for AKS før fylte 60 år hos kvinner enn hos menn. Resultatene peker på et behov for kjønnsspesifikke anbefalinger for diagnostisering og forebygging av hypertensjon.Background: Among healthy young adults, women have lower blood pressure (BP) compared to their male counterparts. Then, from the third decade onwards, women have a steeper increase in BP than men. The aim of the current project was to explore factors associated with BP and BP change among women and men in their forties and to test sex-specific associations between BP in the early forties and risk of ACS over 16 years follow-up. Materials and methods: This work was performed using data from the community-based Hordaland Health Study (HUSK) and the “Cardiovascular Disease in Norway Project 1994-2009” (CVDNOR). The latter includes information about all hospital stays and deaths in Norway with a cardiovascular disease (CVD) or diabetes diagnosis in the period 1994-2009. BP was measured and information about CVD risk factors collected when participants were 41±1 years old in HUSK1 and 6 years later in HUSK2. Information about hospitalizations or death from an ACS over 16 years follow-up was obtained from the CVDNOR project. Plasma markers of inflammation, including high-sensitive C-reactive protein (hs-CRP), neopterin, and the pyridoxic acid ratio (PAr), were measured in HUSK2. Results: In study 1, initial BP, higher body mass index (BMI), weight-gain and increases in serum cholesterol and serum triglycerides were the main factors associated with increase in BP and incident hypertension from HUSK1 to HUSK2 both in women and men. In study 2, having a mildly elevated BP (systolic BP 130-139 mmHg and/or diastolic BP 80-89 mmHg) in the early forties doubled the risk of ACS over 16 years follow-up in women, compared to women with a normal BP, after adjustment for other CVD risk factors. The same association was not found in men. In study 3, after adjustment for BMI, higher levels of hs-CRP in the forties were associated with higher BP and new onset hypertension during the last 6 years in women, but not in men. Furthermore, higher levels of plasma neopterin was associated with higher diastolic BP only in women, while higher PAr was associated with higher systolic and diastolic BP in men. These sex differences were confirmed by significant interactions between BP and sex in the model on ACS, between hs-CRP and sex in the models on systolic and diastolic BP and incident hypertension, and between neopterin and sex in the model on diastolic BP. Conclusion: Among women and men in their early forties, initial BP, BMI, weight gain and increases in serum lipids were the main factors associated with increases in BP and new onset hypertension. Plasma markers of inflammation were particularly associated with higher BP level in women. Finally, having a mildly elevated BP in the early forties was a stronger risk factor for ACS before the age of 60 years in women than in men. Taken together our results suggest a need for sex-specific recommendations and actions for diagnosis and prevention of hypertension.Doktorgradsavhandlin

Would you be interested in participating in a study about hospital readmissions…? Experiences with methodological strategies and techniques for recruiting GPs to participate in qualitative research

General Practitioners (GPs) are an asset in healthcare research, considering the amount of knowledge they hold about the primary healthcare service. However, GPs have proven difficult to recruit as participants in both quantitative and qualitative research (Asch, Connor, Hamilton, & Fox, 2000; Hummers-Pradier et al., 2008; Parkinson et al., 2015). The difficulties in recruiting GPs have been attributed to their great workload and their perception of a gap between the theory-laden research and their own practical work (Rosemann & Szecsenyi, 2004; Leysen et al., 2019). However, own experiences of recruiting GPs to participate in a qualitative study disclosed that the picture might be more nuanced than described in previous reports. The objective of this paper is to describe the methodological strategies and techniques for the recruitment process, and discuss the difficulties in recruiting GPs to participate in research and possible reasons for such difficulties. It was based on experiences from a recently conducted study on GPs, which aimed to increase knowledge about the GPs’ role in hospital readmissions from the primary healthcare service (Glette, Kringeland, Røise, & Wiig, 2018).publishedVersio

Digital transformasjon i revisjonsbransjen

Mye av litteraturen rundt digitalisering og revisjon omhandler hvilke fordeler og muligheter dette gir. Målet med denne masteroppgaven er imidlertid å få bedre innsikt i hvor den digitale transformasjonen i revisjonsbransjen står i dag, og hvilke faktorer som påvirker fokuset på digitalisering hos landets største revisjonsselskaper. Dette har ledet til følgende problemstillingen for oppgaven: Hvordan blir de fem store revisjonsselskapene i Norge påvirket av den digitale transformasjonen? For å besvare problemstillingen har vi foretatt en innholdsanalyse av selskapenes lovpålagte åpenhetsrapporter i perioden 2016 til 2020, og støttet dette opp med dybdeintervju av informanter fra KPMG, Deloitte, PWC, EY og BDO. Vi har tatt utgangspunkt i de tre komponentene i TOE-modellen; Technology, Organization, Environment (Teknologi, Organisasjon og Omgivelser), og drøftet sentrale drivere for digital transformasjon i revisjonsbransjen for hver komponent. Hovedfunnene i studien viser en endring i selskapenes digitaliseringsfokus de siste årene. I 2016 ble digitalisering omtalt som et satsingsområde, mens selskapene i dag omtaler digitalisering som en implementert del av selskapenes revisjonsmetodikk. Informantenes definisjon av digitalisering tyder på at dette er komplekst og at det kan være vanskelig å ta inn over seg at digitalisering krever endring av både forretningspraksis, forretningsmodell og verdisystemer. Våre funn viser at IT-infrastruktur er av mindre betydning for den faktiske digitaliseringen i selskapet, men at dersom denne er på plass, vil organisasjonen lettere ta i bruk digitale løsninger ved ytre press. Ledelsens rolle i digitaliseringen, samt dens evne til å bygge en kultur med rom for prøving og feiling er den mest avgjørende organisatoriske faktoren. Studien indikerer også at de viktigste omgivelsesbaserte faktorene, er forventninger fra markedet, samt presset om å være lønnsomme. De sterke regulatoriske kravene bransjen er underlagt, utpekes derimot som den største barrieren for digital transformasjon Oppsummert er de omgivelsesbaserte faktorene driverne for digitalisering, mens suksessfaktorene for adopsjon av digitale løsninger knyttes til de organisatoriske faktorene

Exploring physicians' decision-making in hospital readmission processes - a comparative case study

© The Author(s) 2018Background Hospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs’ gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs’ and nursing home physicians’ decision making. Method The study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality. Results Seven themes describing how different factors influence physicians’ decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians’ decision-making. Conclusion Communication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs’ and nursing home physicians’ decision-making, nursing home nurses and home care nurses’ experience of hospital readmissions and discharges is needed.publishedVersio

High-normal blood pressure in midlife is a stronger risk factor for incident hypertension 26 years later in women than men: the Hordaland Health Study

Purpose To identify modifiable risk factors in early midlife associated with incident hypertension 26 years later in women and men. Materials and methods We used data from 1025 women and 703 men in the community-based Hordaland Health Study examined at the mean age of 42 years (baseline) and after a 26-year follow-up. Patients with hypertension at baseline were excluded. Blood pressure (BP) was classified according to European guidelines. Factors associated with incident hypertension were identified in logistic regression analyses. Results At baseline, women had a lower average BP and a lower prevalence of high-normal BP (19% vs 37%, p < .05). Overall, 39% of women and 45% of men developed hypertension during follow-up (p < .05). Among those with high-normal BP at baseline, 72% of women and 58% of men developed hypertension (p < .01). In multivariable logistic regression analyses, high-normal BP at baseline was a stronger predictor of incident hypertension in women (odds ratio, OR 4.8, [95% confidence interval, CI 3.4–6.9]) than in men (OR 2.1, [95% CI 1.5–2.8]), p < .01 for sex interaction. A higher baseline body mass index (BMI) was associated with incident hypertension in both sexes. Conclusions High-normal BP in midlife is a stronger risk factor for developing hypertension 26 years later in women than in men, independent of BMI.publishedVersio

Subclinical cardiac organ damage in patients with moderate to severe psoriasis

We explored the association between subclinical cardiac organ damage (OD) with comorbidities and psoriasis severity in 53 psoriasis patients on infliximab treatment (age 47 ± 15 years, 30% women) and 99 controls without psoriasis (age 47 ± 11 years, 28% women). Cardiac OD was assessed by echocardiography as the presence of increased left ventricular (LV) relative wall thickness (RWT), LV hypertrophy or dilated left atrium. Psoriasis severity was graded using the psoriasis area and severity index (PASI). The prevalence of hypertension was 66% in psoriasis vs. 61% in controls (p = 0.54) and cardiac OD seen in 51 and 73%, respectively (p = 0.007). Psoriasis was associated with a lower prevalence of cardiac OD (odds ratio (OR) 0.32, 95% confidence interval (CI) 0.13–0.77, p = 0.01) independent of age, sex, smoking, body mass index, and hypertension. Among psoriasis patients, hypertension was associated with increased risk of subclinical cardiac OD (OR 6.88, 95% CI 1.32–35.98, p = 0.02) independent of age, sex, and body mass index. PASI at treatment initiation was associated with a higher RWT at follow-up, independent of sex, age, and hypertension (β 0.36, p = 0.006) while no association with current PASI was found. In conclusion, cardiac OD was less prevalent in psoriasis patients on infliximab treatment than controls. Hypertension was the major covariable for subclinical cardiac OD in psoriasis.publishedVersio

Stage 1 hypertension, sex, and acute coronary syndromes during midlife: the Hordaland Health Study

Aims Hypertension has been suggested as a stronger risk factor for acute coronary syndromes (ACS) in women than men. Whether this also applies to stage 1 hypertension [blood pressure (BP) 130–139/80–89 mmHg] is not known. Methods and results We tested associations of stage 1 hypertension with ACS in 12 329 participants in the Hordaland Health Study (mean baseline age 41 years, 52% women). Participants were grouped by baseline BP category: Normotension (BP < 130/80 mmHg), stage 1 and stage 2 hypertension (BP ≥140/90 mmHg). ACS was defined as hospitalization or death due to myocardial infarction or unstable angina pectoris during 16 years of follow-up. At baseline, a lower proportion of women than men had stage 1 and 2 hypertension, respectively (25 vs. 35% and 14 vs. 31%, P < 0.001). During follow-up, 1.4% of women and 5.7% of men experienced incident ACS (P < 0.001). Adjusted for diabetes, smoking, body mass index, cholesterol, and physical activity, stage 1 hypertension was associated with higher risk of ACS in women [hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.32–3.60], while the association was non-significant in men (HR 1.30, 95% CI 0.98–1.71). After additional adjustment for systolic and diastolic BP, respectively, stage 1 diastolic hypertension was associated with ACS in women (HR 2.79 [95% CI 1.62-4.82]), but not in men (HR 1.24 [95% CI 0.95-1.62]), while stage 1 systolic hypertension was not associated with ACS in either sex. Conclusion Among subjects in their early 40s, stage 1 hypertension was a stronger risk factor for ACS during midlife in women than in men.publishedVersio

Arterial Stiffness in Overweight and Obesity: Association with Sex, Age, and Blood Pressure

Introduction: Obesity has been associated with increased arterial stiffness. Sex-differences in arterial stiffness in obesity have been less explored. Aim: To explore sex-differences in arterial stiffness by applanation tonometry in 323 women and 225 with overweight and obesity, free of cardiovascular disease. Methods: Covariables of arterial stiffness were identified in multivariable linear regression analyses in the total cohort and separately in women and men. Results: In the total study cohort, women had higher augmentation pressure (AP) and augmentation index (AIx), and lower carotid-femoral pulse wave velocity (cf-PWV) than men, independent of confounders (all p < 0.001). In sex-specific analyses, higher AP was associated with higher age and 24-hours systolic blood pressure (BP), and with lower heart rate in women (all p < 0.001), and with higher age and BP in men (all p < 0.001). Similarly, higher AIx was associated with higher age and BP, and lower body mass index (BMI) and heart rate in women (all p < 0.05), and with higher age in men (all p < 0.001). Higher cf-PWV correlated with higher age and BP in women (all p < 0.005), and additionally with higher heart rate and non-smoking in men (all p < 0.05). When replacing BMI with waist-hip ratio, higher waist-hip ratio was associated with higher cf-PWV in men only (p < 0.05). Conclusions: Among subjects with overweight and obesity, AP and AIx were higher in women, and cf-PWV was higher in men. Age and 24-hours systolic BP were the main factors associated with arterial stiffness in both sexes, while measures of adiposity had little impact on arterial stiffness.publishedVersio

Inflammation, sex, blood pressure changes and hypertension in midlife: the Hordaland Health Study

Our aim was to test sex-specific associations of circulating markers of inflammation with blood pressure (BP) and incident hypertension in midlife. Participants in the Hordaland Health study (n = 3280, 56% women, mean age 48 years) were examined at baseline and followed for 6 years. Circulating levels of inflammatory markers including high-sensitive C-reactive protein (hs-CRP), neopterin, and pyridoxic acid ratio (PAr) index were measured at follow-up. The associations with systolic/diastolic BP and incident hypertension were tested in sex-specific linear- or logistic-regression analyses adjusted for body mass index, serum triglycerides, creatinine, physical activity, smoking and diabetes. At follow-up, women had lower mean BP than men (124/72 vs. 130/78 mmHg, p < 0.001). Higher hs-CRP was significantly associated with greater systolic and diastolic BP (standardized β = 0.07 and β = 0.09, both p < 0.01) in women, but not in men. Higher neopterin was associated with higher diastolic BP in women and higher PAr index was associated with higher diastolic BP in women and higher systolic and diastolic BP in men (all p < 0.01). Compared to hs-CRP < 1 mg/l, higher levels of hs-CRP 1–<3 mg/l and hs-CRP ≥ 3 mg/l were associated with new-onset hypertension only in women (odds ratio (OR) 1.74, 95% CI 1.20–2.53 and OR 1.87, 95% CI 1.20–2.90). Sex-interactions were found for hs-CRP and neopterin in models on incident hypertension and diastolic BP, respectively (both p < 0.05). Higher levels of circulating markers of inflammation were associated with higher BP and incident hypertension in a sex-specific manner. Our results suggest a sex-specific interaction between cardiovascular inflammation and BP in midlife.publishedVersio