Explaining risk reductions in medical practice : prevention or postponement?

Diagnosis, treatment and follow up of risk conditions such as hypercholesterolemia and osteoporosis are prominent tasks of contemporary medical practice. The aim is to prevent, or at least postpone the onset of adverse health outcomes such as angina pectoris, heart attacks, strokes and fractures. Dealing with risks involves decision making under uncertainty. For patients to be able to engage meaningfully in shared decision making, benefits of risk reducing interventions must be communicated in easily comprehensible ways. From randomised controlled trials effectiveness of such interventions may be estimated and conveyed in traditional formats such as relative risk reduction, absolute risk reduction or number needed to treat (NNT), Alternatively, to account for the time dimension, prolongation of (disease free) life or, equivalently, postponement of adverse events may be used. There is ample evidence that the different formats for risk reductions yield different decisions, i.e. framing effects. The most consistent finding is that decision makers are more inclined to accept interventions when risk reductions are explained in relative rather than absolute terms. To some extent decisions on hypothetical drug therapies by NNT and postponement of adverse outcomes have been studied empirically. It appears that lay people are insensitive to effect size in terms of NNT but sensitive to the length of postponement. The aim of this Ph. D. study was to explore how physicians and lay people understand and respond to the concepts of NNT and postponement when making decisions about risk reducing interventions against cardiovascular diseases and osteoporosis

Age, income and sleep duration were associated with outcomes in children participating in weight management

Aim To explore associations between baseline factors and weight-related outcomes among participants enrolled in a paediatric obesity trial. Methods We included children aged 6–12 years participating in a 2-year multidisciplinary family programme who attended a postintervention follow-up 36 months from baseline (n = 62). Outcome measures were change in body mass index standard deviation score (BMI SDS), reduction in BMI SDS ≥0.25 and change in waist circumference (WC). Independent variables included in linear and logistic regression models were age, sex, household income, parents' education, sleep duration, screen time and physical activity. Results Altogether, 26 children (42%) attained a reduction of BMI SDS ≥0.25. Higher family income and longer sleep duration were associated with greater change in BMI SDS (−0.05 per 100.000 NOK, p = 0.02, and −0.24 per hour, p = 0.02, respectively). Higher age was associated with greater change in WC (−2.1 cm per year, p = 0.01) but lower odds of attaining a reduction in BMI SDS ≥0.25 (OR per year 0.70, p = 0.04). There was a borderline statistically significant trend towards greater increase in WC with longer daily screen time (p = 0.05). Conclusion Age, family income and sleep duration at baseline were associated with weight-related outcomes 1-year postintervention

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

Background - How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. Method - The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. Results - Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. Conclusion - Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing

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

Symptoms of respiratory tract infection and associated care-seeking in subjects with and without obstructive lung disease; The Tromso Study: Tromso 6.

Respiratory tract infections (RTIs) may be more severe in those with asthma or COPD and these patients are more frequently in need of health care. The aim of the study was to describe the frequency of RTI symptoms in a general adult population and how care-seeking is associated with the presence of obstructive lung disease. Cross-sectional data including spirometry and self-reported chronic diseases were collected among middle-aged and elderly subjects in the Tromso population survey (Tromso 6). Self- reported RTI symptoms, consultations and antibiotic use were the main outcome variables. Possible predictors of RTI symptoms were evaluated by multivariable logistic regression. Of the 6414 subjects included, 798 (12.4 %) reported RTI symptoms in the previous week. RTI symptoms were reported less frequently by subjects aged 75 years or above, than by those younger than 55 years (OR 0.5). Winter season (OR 1.28), current smoking (OR 1.60), low self-rated health (OR 1.26) and moderate to severe bronchial obstruction (OR 1.51), were also statistically significant independent predictors of RTI symptoms, but these variables did not predict RTI symptoms that had started within the previous seven days. Among subjects with RTI symptoms, 5.1 % also reported a consultation with a doctor. In those with bronchial obstruction by spirometry, who did not report asthma or COPD, this frequency was 2.4 %. Antibiotic treatment was reported by 7.4 % of the participants, among whom one third had consulted a doctor. Antibiotics were taken more frequently when asthma or COPD was reported (13.7 %), but not in subjects with bronchial obstruction who did not report these diseases (7.2 %). RTI symptoms seldom led to consultation with a doctor and not even in subjects with obstructive lung disease. This was in particular the case in subject who did not know about their obstructive lung disease. Strategies for early diagnosis of COPD and providing health care to subjects with such disease cannot rely on their doctor visits due to respiratory symptoms

Continuity of GP care is associated with lower use of complementary and alternative medical providers: a population-based cross-sectional survey

BACKGROUND: Continuity of general practitioner (GP) care is associated with reduced use of emergency departments, hospitalisation, and outpatient specialist services. Evidence about the relationship between continuity and use of complementary and alternative medical (CAM) providers has so far been lacking. The aim of this study was to test the association between continuity of GP care and the use of CAM providers. METHODS: We used questionnaire data from the sixth Tromsø Study, conducted in 2007–8. Using descriptive statistical methods, we estimated the proportion using a CAM provider among adults (30–87 years) who had visited a GP during the last 12 months. By means of logistic regressions, we studied the association between the duration of the GP-patient relationship and the use of CAM providers. Analyses were adjusted for the frequency of GP visits, gender, age, marital status, income, education, and self-rated health and other proxies for health care needs. RESULTS: Of 9,743 eligible GP users, 85.1% had seen the same GP for more than two years, 83.7% among women and 86.9% among men. The probability of visiting a CAM provider was lower among those with a GP relationship of more than 2 years compared to those with a shorter GP relationship (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.68-0.96). Other factors associated with CAM use were female gender, poor health, low age and high income. There was no association with education. CONCLUSIONS: Continuity of GP care as measured by the duration of the GP-patient relationship was associated with lower use of CAM providers. Together with previous studies this suggests that continuity of GP care may contribute to health care delivery from fewer providers

Practice variation in surgical procedures and IUD-insertions among general practitioners in Norway – a longitudinal study

Published version. Source at http://doi.org/10.1186/s12875-017-0581-9. License CC BY-NC-SA 4.0.Background: Studies of Primary Health Care (PHC) reveal considerable practice variations in terms of the range of services provided. In Norway, general practitioners (GPs) are traditionally expected to perform IUD-insertions and several surgical procedures as a part of comprehensive PHC. We aimed to investigate variation in the provision of surgical procedures and IUD-insertions across GPs and over time and explore determinants of such variation. Methods: Retrospective registry study of Norwegian GPs. From a comprehensive database of GPs’ reimbursement claims, we obtained procedure codes and GP characteristics such as age, gender, list size and municipality characteristics from 2006 through 2013. Multivariable logistic regression models were fitted to explore determinants of practice variation. Results: We extracted data from 4,828 GPs. In 2013, 91.0, 76.1 and 74.8% were reimbursed at least once for minor and major surgical procedures and IUD-insertion, respectively. Female GPs had lower odds for performing major surgical procedures (OR 0.38, 95% CI 0.32–0.45) and higher odds for performing IUD-insertions (OR 6.28, 95% CI 4. 47–8.82) than male GPs. Older GPs and GPs with shorter patient lists were less likely to perform surgical procedures. GPs with longer patient lists had higher odds for performing IUD-insertions. The proportion of GPs performing surgical procedures increased over time, while the proportion decreased for IUD-insertions. The number of IUD-insertions in specialist care increased from 12,575 in 2011 to 15 216 (+21.0%) in 2014. Conclusion: We observed a large variation in the provision of surgical procedures and IUD-insertions amongst GPs in Norway. The GPs’ age, gender, list size and size of municipality were associated with performing the procedures. Our findings suggest a shift of IUD-insertions from primary to specialist care

Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review

Objective The objective of this study was to determine the diagnostic accuracy in detecting valvular heart disease (VHD) by heart auscultation, performed by medical doctors. Design/methods A systematic literature search for diagnostic studies comparing heart auscultation to echocardiography or angiography, to evaluate VHD in adults, was performed in MEDLINE (1947–November 2021) and EMBASE (1947–November 2021). Two reviewers screened all references by title and abstract, to select studies to be included. Disagreements were resolved by consensus meetings. Reference lists of included studies were also screened. The results are presented as a narrative synthesis, and risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. Main outcome measures Sensitivity, specificity and likelihood ratios (LRs). Results We found 23 articles meeting the inclusion criteria. Auscultation was compared with full echocardiography in 15 of the articles; pulsed Doppler was used as reference standard in 2 articles, while aortography and ventriculography was used in 5 articles. One article used point-of-care ultrasound. The articles were published from year 1967 to 2021. Sensitivity of auscultation ranged from 30% to 100%, and specificity ranged from 28% to 100%. LRs ranged from 1.35 to 26. Most of the included studies used cardiologists or internal medicine residents or specialists as auscultators, whereas two used general practitioners and two studied several different auscultators. Conclusion Sensitivity, specificity and LRs of auscultation varied considerably across the different studies. There is a sparsity of data from general practice, where auscultation of the heart is usually one of the main methods for detecting VHD. Based on this review, the diagnostic utility of auscultation is unclear and medical doctors should not rely too much on auscultation alone. More research is needed on how auscultation, together with other clinical findings and history, can be used to distinguish patients with VHD

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Purpose: To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations. Methods: Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong. Results: Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities. Conclusion: Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations

Reliability of maximum oxygen uptake in cardiopulmonary exercise testing with continuous laryngoscopy

Aims: A cardiopulmonary exercise test (CPET) is the gold standard to evaluate symptom-limiting exercise intolerance, while continuous laryngoscopy performed during exercise (CLE) is required to diagnose exercise-induced laryngeal obstruction. Combining CPET with CLE would save time and resources; however, the CPET data may be distorted by the extra equipment. We therefore aimed to study whether CPET with CLE influences peak oxygen uptake (V′O2peak) and other gas exchange parameters when compared to a regular CPET. Methods: Forty healthy athletes without exercise-related breathing problems, 15–35 years of age, performed CPET to peak exercise with and without an added CLE set-up, in randomised order 2–4 days apart, applying an identical computerised treadmill protocol. Results: At peak exercise, the mean difference (95% confidence interval) between CPET with and without extra CLE set-up for V′O2peak, respiratory exchange ratio (RER), minute ventilation (V′E) and heart rate (HR) was 0.2 (−0.4 to 0.8) mL·kg−1·min−1, 0.01(−0.007 to 0.027) units, 2.6 (−1.3 to 6.5) L·min−1 and 1.4 (−0.8 to 3.5) beats·min−1, respectively. Agreement (95% limits of agreement) for V′O2peak, RER and V′E was 0.2 (±3.7) mL·kg−1·min−1, 0.01 (±0.10) units and 2.6 (±24.0) L·min−1, respectively. No systematic or proportional bias was found except for the completed distance, which was 49 m (95% CI 16 to 82 m) longer during CPET. Conclusion: Parameters of gas exchange, including V′O2peak and RER, obtained from a maximal CPET performed with the extra CLE set-up can be used interchangeably with data obtained from standard CPET, thus preventing unnecessary additional testing.publishedVersio