Doctors are to blame for perceived medical adverse events. A cross sectional population study. The Tromsø study

Beskriver en survey hvor hensikten var å undersøke forekomst av legemiddelbivirkninger i en stor generell populasjon.Background: Most current knowledge of the incidence of medical adverse events (AEs) comes from studies carried out in hospital settings. Little is known about AEs occurring outside hospitals, in spite the fact that most of contacts between patients and health care take place in primary care. Small sample population studies report that 4-49% of the general public have experienced AEs related to their own or family members´ care. The purpose with the present study was to investigate the occurrence of experienced medical adverse events in a large general population. Methods: We invited 19763 inhabitants of a municipality in northern Norway, age 30 years and older, to fill in a questionnaire. Main outcome measures were life time prevalence of AEs experienced by respondents or their first degree relatives, perceived responsibility for and predictors of such events, as well as formal complaints as a reaction to the events. Results: The response rate was 66%. Nine and 10% of the respondents reported self-experienced adverse events, and 15 and 19% (men and women, respectively) that their relatives had experienced AEs. Logistic regression models showed that the strongest predictors of reporting self-experienced adverse events were: Having been persuaded to accept an unwanted examination or treatment, difficulties in getting a referral from primary to specialist health care, and inadequate communication with the doctor. Of the respondents who had experienced adverse events personally, 62% placed the responsibility for the event on the general practitioner, 39% on the hospital doctor, and 19% on failing routines or cooperation. Only 7% of men and 14% of women who reported self-experienced events handed in a formal complaint. Conclusions: The public predominantly place the responsibility for medical adverse events on doctors, in particular general practitioners, and to a lesser degree on the system. This should be emphasised by doctors and managers who communicate with patients who have experienced AEs, and in patient safety work. Only a small fraction of adverse events results in a formal written complaint. Therefore, such complaints are of limited value as a basis for patient safety work

The ecology of medical care in Norway: wide use of general practitioners may not necessarily keep patients out of hospitals

Background. Our aim was to investigate the pattern of self reported symptoms and utilisation of health care services in Norway. Design and methods. With data from the cross-sectional Tromsø Study (2007-8), we estimated population proportions reporting symptoms and use of seven different health services. By logistic regression we estimated differences according to age and gender. Results. 12,982 persons aged 30-87 years participated, 65.7% of those invited. More than 900/1000 reported symptoms or health problems in a year as well as in a month, and 214/1000 and 816/1000 visited a general practitioner once or more in a month and a year, respectively. The corresponding figures were 91/1000 and 421/1000 for specialist outpatient visits, and 14/1000 and 116/1000 for hospitalisations. Physiotherapists were visited by 210/1000, chiropractors by 76/1000, complementary and alternative medical providers by 127/1000, and dentists by 692/1000 in a year. Women used most health care services more than men, but genders used hospitalisations and chiropractors equally. Utilisation of all services increased with age, except chiropractors, dentists and complementary and alternative medical providers. Conclusions. Almost the entire population reported health related problems during the previous year, and most residents visited a general practitioner. Yet there were high rates of inpatient and outpatient specialist utilisation. We suggest that wide use of general practitioners may not necessarily keep patients out of specialist care and hospitals

The association between health anxiety, physical disease and cardiovascular risk factors in the general population – a cross-sectional analysis from the Tromsø study: Tromsø 7

Background: Health anxiety (HA) is defined as a worry of disease. An association between HA and mental illness has been reported, but few have looked at the association between HA and physical disease. Objective: To examine the association between HA and number of diseases, different disease categories and cardiovascular risk factors in a large sample of the general population. Methods: This study used cross-sectional data from 18,432 participants aged 40 years or older in the seventh survey of the Tromsø study. HA was measured using a revised version of the Whiteley Index-6 (WI-6-R). Participants reported previous and current status regarding a variety of different diseases. We performed exponential regression analyses looking at the independent variables 1) number of diseases, 2) disease category (cancer, cardiovascular disease, diabetes or kidney disease, respiratory disease, rheumatism, and migraine), and 3) cardiovascular risk factors (high blood pressure or use of cholesterol- or blood pressure lowering medication). Results: Compared to the healthy reference group, number of diseases, different disease categories, and cardiovascular risk factors were consistently associated with higher HA scores. Most previous diseases were also significantly associated with increased HA score. People with current cancer, cardiovascular disease, and diabetes or kidney disease had the highest HA scores, being 109, 50, and 60% higher than the reference group, respectively. Conclusion: In our general adult population, we found consistent associations between HA, as a continuous measure, and physical disease, all disease categories measured and cardiovascular risk factors

Truar skilnadene i tilvisingsratar målet om likeverdige helsetenester?

BAKGRUNN - Sogn og Fjordane fylke har i landsmålestokk, og serleg i høve til dei andre fylka i Helse Vest, hatt eit høgt forbruk av spesialisthelsetenester. Utover det at fylket har to små lokalsjukehus, har lite vore kjent som kunne forklare det høge forbruket, og serskilt ikkje om det eksisterer kontrastar i forbruk mellom kommunane i fylket. MATERIALE OG METODE - Med utgangspunkt i data frå Norsk pasientregister og journalsystemet DIPS for 2009 har vi samanlikna alders- og kjønnsjusterte forbruksratar på kommunenivå, saman med ujusterte tilvisingsratar til spesialisthelsetenesta på kommune- og enkeltlegenivå. RESULTAT - Det var store skilnader i forbruk mellom kommunane både i kontaktratar og DRG-poeng. Skilnaden mellom kommunen med høgaste og lågaste forbruk var om lag 90 DRG-poeng per 1 000 innbyggjarar. Kommunen med det høgaste forbruket brukar 36 DRG-poeng per 1 000 innbyggjarar i året meir enn gjennomsnittet for Sogn og Fjordane. Ei nøyare samanlikning av tre kommunar med ulikt forbruk viser store og samanfallande skilnader i tilvisingsratar mellom kommunane og mellom enkeltlegar. TOLKING - Det høge og sprikande kommunale forbruket av spesialisthelsetenester i Sogn og Fjordane ser ut til å ha samanheng med tilsvarande høge og enno meir sprikande tilvisingsratar frå primærlegar i dei same kommunane

High referral rates to secondary care by general practitioners in Norway are associated with GPs' gender and specialist qualifications in family medicine, a study of 4350 consultations

This article is part of Unni Ringberg's doctoral thesis which is available in Munin at http://hdl.handle.net/10037/7607Referral rates of general practitioners (GPs) are an important determinant of secondary care utilization. The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The main objective of this study was to assess the GPs’ referral rate to secondary care in Norway, any associations between the referral decision and patient, GP, health care characteristics and who initiated the referring issue in the consultation. The probabilities of referral to secondary care and/or radiological examination were examined in 100 consecutive consultations of 44 randomly chosen Norwegian GPs. The GPs recorded whether the issue of referral was introduced, who introduced it and if the patient was referred. Multilevel and naive multivariable logistic regression analyses were performed to explore associations between the probability of referral and patient, GP and health care characteristics. Of the 4350 consultations included, 13.7% (GP range 4.0%-28.0%) of patients were referred to secondary somatic and psychiatric care. Female GPs referred significantly more frequently than male GPs (16.0% versus 12.6%, adjusted odds ratio, AOR, 1.25), specialists in family medicine less frequently than their counterparts (12.5% versus 14.9%, AOR 0.76) and salaried GPs more frequently than private practitioners (16.2% versus 12.1%, AOR 1.36). In 4.2% (GP range 0%-12.9%) of the consultations, patients were referred to radiological examination. Specialists in family medicine, salaried GPs and GPs with a Norwegian medical degree referred significantly more frequently to radiological examination than their counterparts (AOR 1.93, 2.00 and 1.73, respectively). The issue of referral was introduced in 23% of the consultations, and in 70.6% of these cases by the GP. The high referrers introduced the referral issue significantly more frequently and also referred a significantly larger proportion when the issue was introduced. The main finding of the present study was a high overall referral rate, and a striking range among the GPs. Male GPs and specialists in family medicine referred significantly less frequently to secondary care, but the latter referred more frequently to radiological examination. Our findings indicate that intervention on high referrers is a potential area for quality improvement, and there is a need to explore the referral decision process itself

PSA-måling og prostatakreft – overdiagnostisering og overbehandling?

BAKGRUNN - PSA-testing og risiko for overdiagnostisering av prostatakreft har fått økende oppmerksomhet. Vi undersøker her hvordan antallet PSA-prøver har utviklet seg over tid i norske fylker og relaterer denne utviklingen til den fylkesvise kreftinsidensen samt ratene for prostatacancerkirurgi. MATERIALE OG METODE - Data for insidens, overlevelse og dødelighet ble innhentet fra offentlige registre. Antallet utførte PSA-tester ble samlet inn fra norske laboratorier. Fylkesvise rater av PSA-prøver og korrelasjon med insidensrater for prostatakreft og kirurgirater ble undersøkt. Utviklingen for Sogn og Fjordane, som har landets høyeste forekomst av prostatakreft, ble kartlagt særskilt. Det ble gjennomført en nettbasert utspørring om fastlegenes holdninger og praksis. RESULTATER - Antallet PSA-tester økte betydelig i perioden 1999 – 2011 og tilsvarte testing av 45 % av den samlede mannlige befolkningen over 40 år i Norge i 2011. Antallet PSA-tester i 2011 korrelerte med fylkesvis forekomst av prostatakreft i tidsperioden forut (Pearsons r = 0,41). Korrelasjonen mellom kreftforekomst og kirurgiske inngrep var 0,66. I Sogn og Fjordane er forekomst og overlevelse av prostatakreft sterkt økende, mens dødeligheten er på nivå med dødeligheten i landet for øvrig. Fastlegene etterkommer ofte pasientenes ønske om PSA-testing og finner det vanskelig ikke å henvise videre der det er forhøyede verdier. FORTOLKNING - Den økte forekomsten av prostatakreft har trolig sammenheng med omfanget av PSA-testingen. Etterlevelse av retningslinjene for testing bør bli bedre, og klinikere kan praktisere en mer avventende holdning til videre behandling ved forhøyet PSA-verdi

Length of sick leave – Why not ask the sick-listed? Sick-listed individuals predict their length of sick leave more accurately than professionals

BACKGROUND: The knowledge of factors accurately predicting the long lasting sick leaves is sparse, but information on medical condition is believed to be necessary to identify persons at risk. Based on the current practice, with identifying sick-listed individuals at risk of long-lasting sick leaves, the objectives of this study were to inquire the diagnostic accuracy of length of sick leaves predicted in the Norwegian National Insurance Offices, and to compare their predictions with the self-predictions of the sick-listed. METHODS: Based on medical certificates, two National Insurance medical consultants and two National Insurance officers predicted, at day 14, the length of sick leave in 993 consecutive cases of sick leave, resulting from musculoskeletal or mental disorders, in this 1-year follow-up study. Two months later they reassessed 322 cases based on extended medical certificates. Self-predictions were obtained in 152 sick-listed subjects when their sick leave passed 14 days. Diagnostic accuracy of the predictions was analysed by ROC area, sensitivity, specificity, likelihood ratio, and positive predictive value was included in the analyses of predictive validity. RESULTS: The sick-listed identified sick leave lasting 12 weeks or longer with an ROC area of 80.9% (95% CI 73.7–86.8), while the corresponding estimates for medical consultants and officers had ROC areas of 55.6% (95% CI 45.6–65.6%) and 56.0% (95% CI 46.6–65.4%), respectively. The predictions of sick-listed males were significantly better than those of female subjects, and older subjects predicted somewhat better than younger subjects. Neither formal medical competence, nor additional medical information, noticeably improved the diagnostic accuracy based on medical certificates. CONCLUSION: This study demonstrates that the accuracy of a prognosis based on medical documentation in sickness absence forms, is lower than that of one based on direct communication with the sick-listed themselves

Is imposing risk awareness cultural imperialism?

Epidemiology is the main supplier of "bases of action" for preventive medicine and health promotion. Epidemiology and epidemiologists therefore have a responsibility not only for the quality and soundness of the risk estimates they deliver and for the way they are interpreted and used, but also for their consequences. In the industrialised world, the value of, and fascination with health is greater than ever, and the revelation from epidemiological research of new hazards and risks, conveyed to the public by the media, has become almost an every-day phenomenon. This "risk epidemic" in the modern media is paralleled in professional medical journals. It is in general endorsed by health promoters as a necessary foundation for increased health awareness and a desirable impetus for people to take responsibility for their own health through behavioural changes. Epidemiologists and health promoters, however, have in general not taken the possible side effects of increased risk awareness seriously enough. By increasing anxiety regarding disease, accidents and other adverse events, the risk epidemic enhances both health care dependence and health care consumption. More profoundly, and perhaps even more seriously, it changes the way people think about health, disease and death -- and ultimately and at least potentially, their perspective on life more generally. The message from the odds ratios from epidemiological research advocates a rationalistic, individualistic, prospective life perspective where maximising control and minimising uncertainty is seen as a superior goal. The inconsistency between applying an expanded health concept, comprising elements of coping, self-realisation and psycho-physical functioning, and imposing intolerance to risk and uncertainty, is regularly overlooked. Acceptance and tolerance of risk and uncertainty, which are inherent elements of human life, is a prerequisite for coping and self-realisation. A further shift away from traditional working-class values like sociability, sharing, conviviality and tolerance can not be imposed without unwanted side effects on culture and human interaction. The moral and coercive crusade for increased risk awareness and purity in life style can too readily take on the form of cultural imperialism towards conformity. Epidemiologists and the health care movement in general have a mandate to fight disease and premature death; they have no explicit mandate to change culture.epidemiology risk health social class culture

Determinants and dimensions involved in self-evaluation of health

This study explores mechanisms involved in self-evaluation of health by making specifications of linkages among various dimensions of health status, physiological measures, social and behavioral factors or characteristics. The proposed structural equation model is tested by using data from a comprehensive health survey of the population of Finmark county, Norway (1987-1988), including 4549 men and 4360 women aged 30-62. The findings suggest the burden of physical distress and reliance on permanent disablement benefit to play the key role in reducing self-evaluated health. The seemingly strong labelling impact of permanent work disability, contrasted to modest effect of diagnoses of chronic disease. Moreover, the impact of both these key factors and other important determinants is strongly socially patterned. Positive health related life-style appeared to have a positive impact on self-rated health, while preoccupation with health had a negative impact. This finding adds some credibility to the suggestion that the growing occupation and fascination with health have some negative health outcomes.self-rated health health status structural equation model