Variation in plasma calcium analysis in primary care in Sweden - a multilevel analysis

<p>Abstract</p> <p>Background</p> <p>Primary hyperparathyroidism (pHPT) is a common disease that often remains undetected and causes severe disturbance especially in postmenopausal women. Therefore, national recommendations promoting early pHPT detection by plasma calcium (P-Ca) have been issued in Sweden. In this study we aimed to investigate variation of P-Ca analysis between physicians and health care centres (HCCs) in primary care in county of Skaraborg, Sweden.</p> <p>Methods</p> <p>In this cross sectional study of patients' records during 2005 we analysed records from 154 629 patients attending 457 physicians at 24 HCCs. We used multilevel logistic regression analysis (MLRA) and adjusted for patient, physician and HCC characteristics. Differences were expressed as median odds ratio (MOR).</p> <p>Results</p> <p>There was a substantial variation in number of P-Ca analyses between both HCCs (MOR_HCC1.65 [1.44-2.07]) and physicians (MOR_physician1.95 [1.85-2.08]). The odds for a P-Ca analysis were lower for male patients (OR 0.80 [0.77-0.83]) and increased with the number of diagnoses (OR 25.8 [23.5-28.5]). Sex of the physician had no influence on P-Ca test ordering (OR 0.93 [0.78-1.09]). Physicians under education ordered most P-Ca analyses (OR 1.69 [1.35-2.24]) and locum least (OR 0.73 [0.57-0.94]). More of the variance was attributed to the physician level than the HCC level. Different mix of patients did not explain this variance between physicians. Theoretically, if a patient were able to change both GP and HCC, the odds of a P-Ca analysis would in median increase by 2.45. Including characteristics of the patients, physicians and HCCs in the MLRA model did not explain the variance.</p> <p>Conclusions</p> <p>The physician level was more important than the HCC level for the variation in P-Ca analysis, but further exploration of unidentified contextual factors is crucial for future monitoring of practice variation.</p

Elevated calcium concentration, is it dangerous? Long-term follow-up in primary care

Background and aims: Patients with hypercalcaemia are relatively common in primary care; the most frequent causes are primary hyperparathyroidism (pHPT) and cancer. Many patients with pHPT have such discrete symptoms that they are difficult to detect without a calcium analysis. To increase the detection of pHPT, more calcium analyses are recommended by Swedish authorities. The aim of this thesis was to study the care of patients with elevated calcium concentrations and to investigate factors contributing to the variation in calcium analyses between physicians and health care centres (HCC) in primary care. Material and Methods: First, we investigated all patients with elevated calcium concentrations (n=142) at Tibro HCC between the years 1995−2000. In the following studies, HCC patients with normal calcium concentrations were used as controls. Both groups were offered an examination after 10 years with new blood analyses and questions concerning diseases, medication and quality of life. In the last study, the variation in the ordering of calcium analyses between 457 physicians and 24 HCCs was investigated through a multilevel analysis. Results: In the first study we tried to survey the underlying causes in patients with elevated calcium concentrations; however, no cause was found in 70 % of the patients. pHPT and cancer were among the most common diagnoses. At follow-up, 88 % of the patients with elevated calcium concentrations turned out to have an underlying disease. Many women had pHPT, while men showed an increased mortality from cancer. Patients with elevated calcium concentrations had poorer quality of life and increased health care utilisation than patients with normal calcium concentrations. There were large differences in the number of calcium analyses ordered, both between physicians and HCCs. A patient’s likelihood of an analysis could increase 2.5 times if both the physician and the HCC were changed. Physicians in education ordered more and locums fewer calcium analyses than the average general practitioner

Diagnoses have the greatest impact on variation in sick-leave certification rate among primary-care patients in Sweden: A multilevel analysis including patient, physician and primary health-care centre levels.

The aims of this study were to determine and evaluate simultaneously the importance of factors known to influence sick-leave certification such as the sick leave-related diagnoses, the patients' socio-economic status, and characteristics of the physicians

Bone mineral density in primary care patients related to serum calcium concentrations: a longitudinal cohort study from Sweden

Objective: Elevated calcium concentration is a commonly used measure in screening analyses for primary hyperparathyroidism (pHPT) and cancer. Low bone mineral density (BMD) and osteoporosis are common features of pHPT and strengthen the indication for parathyroidectomy. It is not known whether an elevated calcium concentration could be a marker of low BMD in suspected pHPT patients with a normal parathyroid hormone concentration. Purpose: To study if low BMD and osteoporosis are more common after ten years in patients with elevated compared with normal calcium concentrations at baseline. Design: Prospective case control study. Setting: Primary care, southern Sweden. Subjects: One hundred twenty-seven patients (28 men) with baseline elevated, and 254 patients (56 men) with baseline normal calcium concentrations, mean age 61 years, were recruited. After ten years, 77% of those still alive (74 with elevated and 154 with normal calcium concentrations at baseline) participated in a dual energy x-ray absorptiometry measurement for BMD assessment and analysis of calcium and parathyroid hormone concentrations. Main outcome measures: Association between elevated and normal calcium concentration at base-line and BMD at follow-up. Correlation between calcium and parathyroid hormone concentrations and BMD at follow-up. Results: A larger proportion of the patients with elevated baseline calcium concentrations who participated in the follow-up had osteoporosis (p value = 0.036), compared with the patients with normal concentrations. In contrast, no correlation was found between calcium or parathyroid hormone concentrations and BMD at follow-up. Conclusions: In this study, patients with elevated calcium concentrations at baseline had osteoporosis ten years later more often than controls (45% vs. 29%), which highlights the importance of examining these patients further using absorptiometry, even when their parathyroid hormone level is normal.Key Points Osteoporosis is common, difficult to detect and usually untreated. It is not known whether elevated calcium concentrations, irrespective of the PTH level, could be a marker of low bone mineral density. No correlation was found between calcium or parathyroid hormone concentrations and bone mineral density at follow-up. In this study, patients with elevated calcium concentrations at baseline had osteoporosis ten years later more often than controls (45% vs. 29%)

No physician gender difference in prescription of sick-leave certification: A retrospective study of the Skaraborg Primary Care Database

Background and aims: Sickness insurance is a hallmark of most welfare states. The rising costsof sickness insurance in Sweden have been attributed to varying sickness certification practices among physicians. Other factors, such as the gender and socioeconomic status of the patient, or the experience of the physician, may affect the rate of sickness certification. The importance of these factors alone and in relation to each other has been the focus of the two first studies in this thesis. The government introduced new reforms, the so-called “sick leave billion”, in 2006 to improve the quality of the sick leave process and reduce the costs of sickness insurance. It is of interest to investigate how these reforms have affected the quality of the sick leave process and the physicians’ views of their working conditions. Symptom diagnoses (R diagnoses) in sickness certificates are easy to capture in national registries and have been shown to predict poor certificate quality. The potential usefulness of this marker was investigated in the third study. Primary health care physicians consider sickness certification problematic. The aim of the fourth study was to investigate whether the views of physicians changed after the introduction of the reforms. Methods: Study I and II: Retrospective study of computerised medical records from 24 Primary Health Care Centres (PHCCs), 589 physicians and 88,780 patients in 2005. Study I: Comparison of sickness certification rates and duration between physicians of different gender and experience. Study II: Multilevel logistic regression analysis of variations in sickness certification at three levels: patients (n = 64,354: gender, age, socio-economic status, workplace factors and diagnoses); physicians (n = 574: gender and experience), and PHCCs (n = 24). Study III: Retrospective study of computerised medical records and texts from sickness certificates from PHCCs, 2013-2014. Patients with a symptom diagnosis (SD) in the certificate, n = 222, and controls with disease-specific diagnoses, n=222, matched for sex and age, were compared concerning health care consumption, quality of the text in the certificates, duration of sick leave and time to contact for rehabilitation. Study IV: Qualitative design, six focus group interviews were performed in PHCCs in Västra Götaland in 2015, including GPs, interns, GP trainees and locums (n = 28). Qualitative content analysis was used to explore the views of physicians on the sickness certification process after introduction of the reforms. Conclusions: Physicians of different gender handle sickness certification in a similar way. GPs issued certificates of longer duration. In the multilevel model, the most important factors for variation in sickness certification were patient-related (diagnosis and socioeconomic status) and the physician’s contribution was small. Symptom diagnoses in the certificate were associated with higher health care consumption and poorer quality of the sick leave process. The focus group interviews showed that the physicians perceived the sickness certification process as emotive and a challenge to master, with different demands and expectations from the management and the patients