The organisation of Swedish primary health care has changed following introduction of free choice of provider for the population in combination with freedom of establishment for private primary care providers. Our aim was to investigate changes in individual health care utilisation following choice and privatisation in Swedish primary care from an equity perspective, in subgroups defined by age, gender and family income.
The study is based on register data years 2007-2011 from the Skåne Regional Council (population 1.2 million) regarding individual health care utilisation in the form of visits to general practitioner (GP). Health utilisation data was matched with data about individual's age, gender and family income provided by Statistics Sweden. Multilevel, logistic regression models were constructed to analyse changes in health utilisation in different subgroups and the probability of a GP-visit before and after reform.
Health care utilisation in terms of both number of individuals that had visited a GP and number of GP-visits per capita increased in all defined subgroups, but to a varying degree. Multilevel logistic regression showed that individuals of both genders aged above 64 and belonging to a family with an income above median had more advantage of the reform, OR 1.25-1.29.
Reforms involving choice and privatisation in Swedish primary health care improved access to GP-visits generally, but more so for individuals belonging to a family with income above the median.
The majority of antibiotics consumed in developed countries are prescribed in primary care. However, little is known about resistance levels in the primary care population.
Nasopharyngeal cultures were obtained from children, 0-10 years of age, seeking care at their Primary Health Care Centre with symptoms of respiratory tract infection. Parental questionnaires were used to retrieve information about the child's previous antibiotic consumption.
Cultures from 340 children were gathered. The level of resistant Haemophilus influenzae was low and the prevalence of penicillin non-susceptible pneumococci (PNSP MIC = 0.125 mg/L) was 6% compared to 10% (p = 0.31) in corresponding cultures from children diagnosed at the local clinical microbiology laboratory. Antibiotic treatment within the previous 4 weeks predisposed for resistant bacteria in the nasopharynx, OR: 3.08, CI 95% (1.13-8.42).
Low prevalence of PNSP supports the use of phenoxymethylpenicillin as empirical treatment for childhood upper respiratory tract infections attending primary care in our setting. It is important that studies on resistance are performed in primary care populations to evaluate data from microbiological laboratories. Recent antibiotic treatment increases risk of bacterial resistance in children and continuous work to reduce unnecessary antibiotic prescribing should be prioritised.
Cites: Clin Infect Dis. 2002 May 15;34(10 ):1301-911981724
Recent reforms in Swedish primary care have involved choice of provider for the population combined with freedom of establishment and privatisation of providers. This study focus to what extent individuals feel they have exercised a choice of provider, why they exercise choice and where they search for information, based on a population survey in three Swedish counties. The design of the study enabled for studying behaviour with respect to differences in time since introduction of the reform and differences in number of alternative providers and establishments of new providers in connection with the reform. About 60% of the population in the three counties felt that they had made a choice of provider in connection with or after the introduction of a reform focusing on choice and privatisation. Establishments of new providers and having enough information increased the likelihood whereas preferences for direct access to a specialist decreased the likelihood of making a choice. The data further suggests that individuals were rather passive in their search for information and tended to choose providers that they previously had been in contact with. This is in line with results from previous studies and poses challenges for county councils governance of reforms.
Age, gender and socioeconomic status have been shown to be associated with the use of prescription drugs, even after adjustment for multimorbidity. General practitioners have a holistic and patient-centred perspective and our hypothesis is that this may reflect on the prescription of drugs. In Sweden the patient may seek secondary care without a letter of referral and the liability of the prescription of drugs accompanies the patient, which makes it suitable for this type of research. In this study we examine the odds of having prescription drug use in the population and the rates of prescription drugs among patients, issued in primary health care, according to age, gender and socioeconomic status after adjustment for multimorbidity level.
Data were collected on all individuals above 20 years of age in Östergötland county with about 400 000 inhabitants in year 2006. The John Hopkins ACG Case-mix was used as a proxy for multimorbidity level. Odds ratio (OR) of having prescription drugs issued in primary health care in the population and rates of prescription drug use among patients in primary health care, stated as incidence rate ratio (IRR), according to age, gender and socioeconomic status were calculated and adjusted for multimorbidity.
After adjustment for multimorbidity, individuals 80 years or older had higher odds ratio (OR 3.37 (CI 95% 3.22-3.52)) and incidence rate ratio (IRR 6.24 (CI 95% 5.79-6.72)) for prescription drug use. Male individuals had a lower odds ratio of having prescription drugs (OR 0.66 (CI 95% 0.64-0.69)), but among patients males had a slightly higher incidence rate of drug use (IRR 1.06 (CI 95% 1.04-1.09)). Individuals with the highest income had the lowest odds ratio of having prescription drugs and individuals with the second lowest income had the highest odds ratio of having prescription drugs (OR 1.10 (CI 95% 1.07-1.13)). Individuals with the highest education had the lowest odds ratio of having prescription drugs (OR 0.61 (CI 95% 0.54-0.67)).
Age, gender and socioeconomic status are associated with large differences in the use of prescribed drugs in primary health care, even after adjustment for multimorbidity level.
Polypharmacy is known to increase the risk for drug-related problems, and some drugs, potentially inappropriate medications (PIMs), are especially troublesome.
To analyse the effects on prescription of PIMs of the SÄKLÄK project, an intervention model created to improve medication safety for elderly patients in primary care.
The SÄKLÄK project was a multiprofessional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. Five Swedish primary care centres participated in the intervention and five served as comparison group. Data were collected from the Swedish Prescribed Drug Register on PIMs (long-acting benzodiazepines, anticholinergics, tramadol, propiomazine, antipsychotics and non-steroidal anti-inflammatory drugs) prescribed to patients aged 65 years and older. Total number of patients and change in patients using PIMs before and after intervention with-in groups was analysed as well as differences between intervention and comparison group.
A total of 32566 prescriptions of PIMs were dispensed before the intervention, 19796 in the intervention group and 12770 in the comparison group. After intervention a decrease was seen in both groups, intervention-22.2% and comparison-8.8%. All groups of PIMs decreased, except for antipsychotics in the comparison group. For the intervention group, a significant decrease in mean dose/patient was seen after the intervention but not in the comparison group.
Our study shows this method has some effects on prescription of PIMs. The evaluation indicates this is a feasible method for improvement of medication use in primary care and the method should be tested on a larger scale.
Drug use among the elderly population is generally extensive and the use of potentially inappropriate medications (PIMs) is common, which increases the risk for drug-related problems (DRP). Medication reviews are one method to improve drug therapy by identifying, preventing and solving DRPs. The aim of this study was to evaluate the effect of medication reviews on total drug use and potentially inappropriate drug use in elderly patients, as well as describe the occurrence and types of drug-related problems.
This was a cross-sectional analysis to study medication reviews conducted by trained clinical pharmacists followed by team-based discussions with general practitioners (GPs) and nurses, for elderly primary care patients in Skåne, Sweden. Included in the analysis were patients =75 years living in nursing homes or in their own homes with home care, who received a medication review during 2011-2012. Documented DRPs were described as both the type of DRPs and as pharmacists' recommendations to the GP. The usage of =3 psychotropics and PIMs (antipsychotics, anticholinergics, long-acting benzodiazepines, tramadol and propiomazine) at baseline and after medication review were also studied.
The analysis included a total of 1720 patients. They were on average aged 87.5 years, used typically 11.3 drugs (range 1-35) and 61% of them used 10 drugs or more. Of the patients, 84% had at least one DRP with a mean of 2.2 DRPs/patient. Of the DRPs, 12% were attributable to PIMs. The proportion of patients with = one PIM was reduced significantly (p?
It is a known fact that the 1990s brought a decrease in mortality after myocardial infarction in Sweden but that differences in mortality rates following myocardial infarction still remain between the Swedish counties. Unresolved, however, are questions as to what these inter-county differences mean for the individual patient and what role hospital care plays in this context. We analysed all patients aged 64-85 years who were hospitalised following diagnosis of myocardial infarction in Sweden during the period 1993-1996. To gain an understanding of the relevance of geographical differences in mortality after myocardial infarction for the individual patient we applied multi-level regression analysis and calculated county and hospital median odds ratios (MORs) in relation to 28-day mortality. For hospitalised patients with myocardial infarction, being cared for in another hospital with higher mortality would increase the risk of dying by 9% (MOR = l.09) in men and 12% in women. If these patients moved to another county with higher mortality the risk would increase by 7% and 3%, respectively. The small geographical differences in 28-day mortality after myocardial infarction found in Sweden suggest a high degree of equality across the country; however, further improvement could be achieved in hospital care, especially for women--an issue that deserves further analysis.
Comment In: Lakartidningen. 2005 Jan 3-16;102(1-2):9-1015707101
The Basic Surgical Skills course uses an assessment score interval of 0-3. An extended score interval, 1-6, was proposed by the Swedish steering committee of the course. The aim of this study was to analyze the trainee scores in the current 0-3 scored version compared to a proposed 1-6 scored version.
Sixteen participants, seven females and nine males, were evaluated in the current and proposed assessment forms by instructors, observers, and learners themselves during the first and second day. In each assessment form, 17 tasks were assessed. The inter-rater reliability between the current and the proposed score sheets were evaluated with intraclass correlation (ICC) with 95% confidence intervals (CI).
The distribution of scores for 'knot tying' at the last time point and 'bowel anastomosis side to side' given by the instructors in the current assessment form showed that the highest score was given in 31 and 62%, respectively. No ceiling effects were found in the proposed assessment form. The overall ICC between the current and proposed score sheets after assessment by the instructors increased from 0.38 (95% CI 0.77-0.78) on Day 1 to 0.83 (95% CI 0.51-0.94) on Day 2.
A clear ceiling effect of scores was demonstrated in the current assessment form, questioning its validity. The proposed score sheet provides more accurate scores and seems to be a better feedback instrument for learning technical surgical skills in the Basic Surgical Skills course.
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