The idea behind this thesis is to present how ARS and especially acute maxillary sinusitis in adults is diagnosed and treated in general practice. The study extends over many years, beginning with the first survey in 1991. Based on doctors' answers, we then investigated the diagnostic values ??of the symptoms, signs and examinations which the doctors reported using. All patients over 18 years suspected of acute maxillary sinusitis were included consecutively and only once and, after a clinical examination with the GP, they were offered the opportunity to enter into the prospective study referred to acute CT scan and by changes in the CT, immediately referred to sinus puncture. Both examinations were conducted at Aalborg Hospital. The disease was found most frequently in younger and 2/3 were women. The reason for this gender difference is unknown. We have assessed the diagnostic values of the symptoms, objective findings and investigations ??using 3 different reference standards: sinus puncture, microbiological diagnosis and CT scan described in three articles. In all examinations, it appeared that the usual signs and symptoms of acute maxillary sinusitis occur almost equally often and with a few exceptions in patients, with and without pus in the sinus cavities. Pain in the sinus cavities occurring in 95% of patients, and only elevated levels of CRP and ESR are significantly and independently associated with pus in the sinus cavities. This finding is surprising, because they are two nonspecific markers. CRP tested by near-patient testing has, within the investigations period, been introduced in general practice, and from 1999 the doctors also get reimbursed for performing the test. We have on this background originally defined a clinical criterion with pain over the sinuses accompanied by elevated values ??of CRP and/or ESR giving a sensitivity of 0.82, specificity 0.57, ppv 0.68 and npv 0.74. But looking at the ROC curve we suggest that a more clinical relevant diagnose will be based on use of CRP alone, as the test can be made easily and fast while the patient is in the clinic compared to the use of ESR. The disease is over-diagnosed in general practice. In only 53% of patients, who the GP suspected of having acute sinusitis, was there detected pus or mucopus at the sinus puncture, furthermore the patients' statements that they had had sinusitis was significantly negatively associated with current acute maxillary sinusitis. Almost all patients are prescribed topical treatment to the nose in the form of vasoconstrictor, and 50-70% also antibiotics. The most common bacteria that can be isolated are S. pneumoniae and H. influenzae. For many years the first drug of choice has been penicillin V, and treatment with penicillin V has followed Scandinavian recommendations. However, the resistance patterns in respect of H. influenzae have changed over the years and if the dominant flora is H. influenzae, then oral penicillin is not sufficient anymore, and should be replaced by amoxicillin with or without clavulanate. It is reported that the MIC of penicillin V is too high, such that oral dosage cannot provide sufficiently high concentrations. However, in daily clinical practice the doctor does not have the possibility to decide whether the infection is caused by either S. pneumoniae or H. influenzae, unless a sinus puncture is performed and it is not considered as a standard procedure. The recommended treatment is therefore starting with penicillin V, and at treatment failure switching to amoxicillin with or without clavulanate. It is well known that URTI's can exacerbate a chronic pulmonary disease - like asthma - in allergic patients, but this influence is also demonstrated as described in article 6 where ARS in adults without any sign of chronic lung disease or allergy is accompanied by a temporary reduction lung function. Future research should focus on the use of CRP in general practice, analysing cost-effectiveness of the use of CRP patient outcome in relation to antibiotic treatment, clarification of ARS as a female disease, and a detailed exploration of the relationship between URTI's and impaired lung function in lung-healthy patients.
GPs play a major role in influenza epidemics, and most patients with influenza-like-illness (ILI) are treated in general practice or by primary care doctors on duty in out-of-hours services (OOH). Little is known about the surge capacity in primary care services during an influenza pandemic, and how the relationship between them changes.
To investigate how general practice and OOH services were used by patients during the 2009 pandemic in Norway and the impact of the pandemic on primary care services in comparison to a normal influenza season.
Data from electronic remuneration claims from all OOH doctors and regular GPs for 2009.
We conducted a registry-based study of all ILI consultations in the 2009 pandemic with the 2008/09 influenza season (normal season) as baseline for comparison.
The majority (82.2%) of ILI consultations during the 2009 pandemic took place in general practice. The corresponding number in the 2008/09 season was 89.3%. Compared with general practice, the adjusted odds ratio for ILI with all other diagnoses as reference in OOH services was 1.23 (95% CI, 1.18, 1.27) for the 2008/2009 season and 1.87 (95% CI, 1.84, 1.91) for the pandemic influenza season. In total there was a 3.3-fold increase in ILI consultations during the pandemic compared to the 2008/09 season. A 5.5-fold increase of ILI consultations were observed in OOH services in comparison to the 2008/09 season. Children and young adults with ILI were the most frequent users of OOH services during influenza periods.
The autumn pandemic wave resulted in a significantly increased demand on primary care services. However, GPs in primary care services in Norway showed the ability to increase capacity in a situation with increased patient demand.
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According to the World Health Organization, depression ranks as a major contributor to the global burden of disease. A large proportion of adult depressions had their first appearance in adolescence. Brief and reliable rating scales are needed for early detection.
The aim of this study is to validate the WHO-5 and the HSCL-6 for detection of depression among adolescents.
The project is a GP multicentre study conducted in Denmark and Norway. A total of 294 adolescents (14-16 years) responded by answering a paper- or web-based questionnaire and later completed a Composite International Diagnostic Interview, which was used as the gold standard. Depression was defined by ICD-10 criteria. Criterion validity was examined, the likelihood ratios measured and cut-offs for depression were calculated using the Youden index.
The prevalence of depression was 11.8% in our sample. The optimal cut-off point was 11 for the WHO-5 test and 9 for the HSCL-6 test. There were no gender differences. For the WHO-5 and the HSCL-6, respectively, the sensitivity was 0.88 [95% confidence interval (CI): 0.74-0.96] and 0.85 (95% CI: 0.70-0.94), the specificity was 0.80 (95% CI: 0.75-0.85) and 0.79 (95% CI: 0.74-0.84) and the likelihood ratio was 4.5 and 3.8 (P = 0.39). We observed no statistically significant diagnostic differences with respect to nationality or administration procedure.
The WHO-5 and the HSCL-6 may both serve as valid case finding instruments for depression in young people in primary care.
There is a large variation in referral rates to secondary care among GPs, which is partly unexplained.
To explore associations between reasons for referral to secondary care and patient, GP, and healthcare characteristics.
A cross-sectional study in Northern Norway.
Data were derived from 44 (42%) of 104 randomly selected GPs between 2008 and 2010. GPs scored the relevance of nine predefined reasons for 595 referrals from 4350 consecutive consultations on a four-level categorical scale. Associations were examined by multivariable ordered and multivariable multilevel logistic regression analyses.
Medical necessity was assessed as a relevant reason in 93% of the referrals, 43.7% by patient preference, 27.5% to avoid overlooking anything, and 14.6% to reassure the patient. The higher the referral rates, the more frequently the GPs referred to avoid overlooking anything. Female GPs referred to reassure the patient and due to perceived deficient medical knowledge significantly more often than male GPs. However, perceived easy accessibility of specialists was significantly less frequently given as a reason for referral by female GPs compared with male GPs. When the GPs scored the referrals to be of lesser medical necessity, male GPs referred significantly more frequently than female GPs to reassure the patient due to patient preference and perceived deficient medical knowledge.
There are striking differences in reasons for referral between Norwegian male and female GPs and between GPs with high and low referral rates, which reflects difficulties in handling professional uncertainty. Referring to reassure the patients, especially when referrals are less medically necessary, may reflect consideration and acquiescence towards the patients.
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In Denmark, patients referred from the general practitioner (GP) to the emergency department (ED) can be referred with either specific symptoms or with a presumptive diagnosis. The aim of the present study was to evaluate the diagnostic accuracy for various presumptive diagnoses made by the GP in a population acutely referred to an ED.
This was a retrospective cohort study of all registered acute referrals for admission to Kolding ED in 2010. Eight presumptive diagnoses were selected for further studies: meningitis, acute coronary syndrome (ACS), pulmonary embolism, pneumonia, pancreatitis, deep venous thrombosis (DVT), pyelonephritis and intestinal obstruction. The presumptive diagnoses were compared with the final diagnosis on discharge. Sensitivity, specificity, predictive values and likelihood ratios were calculated.
A total of 8,841 patients were enrolled. The highest and lowest sensitivities were seen for DVT (90%) and meningitis (36%), respectively; and the highest and lowest values for specificity were observed for meningitis (99%) and ACS (30%), respectively. The positive predictive value had a wide range with the lowest value for ACS (9%) and the highest for pneumonia (59%). For pyelonephritis, meningitis and pancreatitis, the likelihood ratio of a positive test was above 10. The likelihood ratio of a negative test was above 0.1 for all diagnoses.
Patients referred with the presumptive diagnoses pyelonephritis, meningitis and pancreatitis had a high likelihood of having the disease in question. It is important not to discard any of the included presumptive diagnoses even if the GPs fail to suggest them on admission.
Knowledge is sparse on the prevalence of suspicion of cancer and other serious diseases in general practice. Likewise, little is known about the possible implications of this suspicion on future healthcare use and diagnoses.
To study the prevalence of GPs' suspicions of cancer or other serious diseases and analyse how this suspicion predicted the patients' healthcare use and diagnoses of serious disease.
Prospective population-based cohort study of 4518 patients consulting 404 GPs in a mix of urban, semi-urban and rural practices in Central Denmark Region during 2008-2009.
The GPs registered consultations in 1 work day, including information on their suspicion of the presence of cancer or another serious disease. The patients were followed up for use of healthcare services and new diagnoses through the use of national registers.
Prevalence of suspicion was 5.7%. Suspicion was associated with an increase in referrals (prevalence ratio [PR] = 2.56, 95% confidence interval [CI] = 2.22 to 2.96), especially for diagnostic imaging (PR = 3.95, 95% CI = 2.80 to 5.57), increased risk of a new diagnosis of cancer or another serious disease within 2 months (hazard ratio [HR] = 2.98, 95% CI = 1.93 to 4.62)--especially for cancer (HR = 7.55, 95% CI = 2.66 to 21.39)--and increased use of general practice (relative risk [RR] = 1.14, 95% CI = 1.06 to 1.24) and hospital visits (RR = 1.90, 95% CI = 1.62 to 2.23). The positive predictive value of a GP suspicion was 9.8% (95% CI = 6.4 to 14.1) for cancer or another serious disease within 2 months.
A GP suspicion of serious disease warrants further investigation, and the organisation of the healthcare system should ensure direct access from the primary sector to specialised tests.
Chlamydia trachomatis is suspected of causing female infertility. It is the most widespread sexually transmitted infection with an estimated general prevalence of ~5-10% with a peak in younger individuals. C. trachomatis infection is more prevalent among lower social classes.
In this study, the association between age, gender, social status and testing and positive rates is investigated in the age group 15-24 years.
Case-control study linked to data from Statistics Denmark.
Data from the Department of Microbiology, Hvidovre University Hospital, Copenhagen were used and included 21887 people tested by general practitioners (GPs) and 3177 people tested at a venereological clinic. The age range was 15-24 years in 2011. These data were linked with the parental educational status delivered by Statistics Denmark, which also delivered a matched control group. The data were analysed using a case-control design.
Testing was more frequent in the following groups: age range 20-24 years, females and patients with higher parental educational status. About 87.3% of patient had been tested by GPs. Positive rates were highest among males at the general practice constituting 17.1% versus females 10.6%, younger individuals and patients with lower parental educational status.
The C. trachomatis testing pattern and positive rates highlight a need for a greater focus on males, younger patients and individuals with a lower social status.
This PhD thesis was written during my employment at the Research Unit of General Practice in Odense, University of Southern Denmark. It comprises an overview and three papers, all published or submitted for publication in international peer-reviewed scientific journals.
Non-infectious dyspnoea, chronic cough and wheezing are common symptoms in the population. Patients often present with these symptoms in general practice and have a high probability of having obstructive lung diseases. However, there is an indication that the majority of these patients are treated empirically with pharmacotherapy targeting obstructive lung disease and only few have additional tests conducted, although the predictive value of respiratory symptoms for diagnosing obstructive lung disease has proven to be low. Spirometry is recommended as the gold standard for confirming obstructive lung disease, and testing can also rule out airway obstruction in patients with respiratory symptoms caused by other illnesses, such as heart failure or lung cancer. Initiating medication for obstructive lung disease without spirometry entails the risk of these patients experiencing unnecessary delay in the diagnostic process and being exposed to unnecessary economic costs and medication risks. The literature has indicated that many users of medication targeting obstructive lung medication have not had spirometry performed and do not actually have obstructive lung disease. This potential quality gap needs to be assessed. Also, in order to target interventions enhancing earlier spirometry utilisation among patients initiating medication targeting obstructive lung disease, improved knowledge on patient and practice factors associated with spirometry testing is needed.
Among first time users of obstructive lung medication we aimed: - To assess to what extent spirometry was performed within the first year of medication use (Study I) - To assess if patient characteristics like socioeconomic and demographic status were associated with spirometry testing (Studies I &II) - To assess if general practice characteristics were associated with spirometry testing (Study III)
Register-based observational studies on first time users of medication targeting obstructive lung disease among adults over 18 years of age in 2008. The patient cohort was identified in the Danish National Prescription Register where all redeemed prescriptions for medication targeting obstructive lung disease are registered. All spirometry tests provided to the patient cohort in the time period 2007-2010 were extracted from the Danish National Health Service Register and the Danish National Patient Register and we assessed if patients had a spirometry registered in an 18- month time period counting from 6 months before to 12 months after their first redemption of medication. We linked socioeconomic and demographic patient variables and variables on practice characteristics from National registers to assess their association with patients having spirometry performed.
A total of 40,969 adults initiated medication targeting obstructive lung medication in 2008 in Denmark. The mean age of the cohort was 55.6 years (SD18.7) and approximately half of the mediations users had spirometry test performed. Initiating several types of medication targeting obstructive lung disease within the first year and redeeming medication repeatedly increased the odds of having spirometry performed. Women and patients in the oldest age categories had reduced odds of having spirometry performed. Being unemployed reduced the odds for spirometry testing among adults less than 65 years of age. Also, among the elderly (>65 years) living alone reduced the odds for spirometry testing; however this was only statistically significant among men. Some practice characteristics also influenced the odds for spirometry testing. Patients in partnership practices had higher odds for spirometry testing. Among singlehanded practices higher odds for spirometry testing was seen if practice had training practice status. We saw decreasing odds for spirometry testing with increasing age among doctors.
This study has shown a lack of spirometry testing among patients initiating medication targeting obstructive lung disease. This underuse of spirometry testing indicates a quality gap and increased focus of spirometry utilization is needed when patients initiate medication targeting obstructive lung disease. The variation reported in spirometry testing across patient and practice characteristics was most predominant with regard to increasing age among patients and doctors, the remaining variables only account for small variations. However identification of these variations can help guide general practitioners to identify patients at increased risk of not having spirometry performed and help target future interventions for primary care.
We examined trends in prescription recommendations for treatment of bipolar disorder (BD) in Canada during 2002-2010.
Data collected by IMS Brogan in a database known as the Canadian Disease and Therapeutic Index were used for this analysis. These data are collected from a representative physician panel who record each drug recommendation and reason for recommendation in their practices for 2 consecutive days each calendar quarter of the year. Prescription patterns of medications for BD, including lithium, anticonvulsants, antipsychotic agents, anxiolytics, and antidepressants, were evaluated both for general practitioners and for specialists.
The number of prescription recommendations for BD increased by 72.1% from 2002 to 2009, and then dropped by 24.8% from 2009 to 2010. This increase from 2002 to 2009, and subsequent decrease from 2009 to 2010, was observed for all classes of medications. The overall increase from 2002 to 2010 was statistically significant for the atypical antipsychotics (P = 0.04). The largest change for an individual drug during this period was a 438% increase in recommendations for quetiapine (P = 0.01).
The number of prescription recommendations for BD increased substantially from 2002 to 2009 and sharply dropped in the following year. These results suggest that the influence of the concept of the bipolar spectrum and its promotion may have resulted in a substantial increase in treatment that has recently begun to wane.