It's all about recognition! Qualitative study of the value of interpersonal continuity in general practice

BACKGROUND

Continuity of care has traditionally been regarded as a core quality of general practice, but the long-term doctor-patient relationship has been put under pressure. In many places practices are expanding, with larger teams and more registered patients, thereby threatening the possibility of patients staying with their own general practitioner (GP). GPs often take it for granted that interpersonal continuity is valuable. However, little is known about how patient satisfaction is related to interpersonal continuity. The purpose of this study is to explore the creation of patient satisfaction or dissatisfaction in the interpersonal relation with the GP, and in a comprehensive way to investigate how this is related to continuity of care.

METHODS

Qualitative study based on 22 interviews with patients from two practices in Denmark. A total of 12 patients saw a regular doctor and 10 saw an unfamiliar doctor. The patients were selected after an observed consultation and sampled purposefully according to reason for encounter, age and sex. Interpretative phenomenological analysis (IPA) was used to study how patients perceive meeting either a regular or an unfamiliar GP. The analysis explored the patients' perception of their interpersonal relationship with their GP, and interpreted the accounts by using social psychological theories.

RESULTS

A long-term continuous relationship with the GP could be satisfactory, but it could also be the reverse. The same pattern was shown in case of an unfamiliar GP. Therefore, patient satisfaction and interpersonal continuity were not causally related. On the contrary, there was a general pattern of how the satisfactory and trustful doctor-patient relationship from the patients' point of view could be created, maintained or destroyed. A pattern where the process of recognition, by respecting and remembering, on the one hand created and maintained satisfaction while humiliation on the other hand destroyed satisfaction in the relationship.

CONCLUSION

It was not valuable to have a continuous relationship unless the GP recognized the patient. The social psychological concept of recognition had two different meanings and the GP had to do both, respect and remember the patient, in order to create and sustain the trustful relationship. The added value of interpersonal continuity had to be combined with recognition.

Impact of pharmaceutical representative visits on GPs' drug preferences

BACKGROUND

Pharmaceutical representative visits are believed to have substantial impact, but the effects on prescribing patterns have not been systematically evaluated.

OBJECTIVE

This study investigates how pharmaceutical sales representative visits influenced physicians' company-specific drug preferences and prevalence of steroid prescribing.

METHODS

Observational cohort study in Funen County, Denmark, including 165 general practices visited 832 times by pharmaceutical representatives and 54 080 patients treated with asthma drugs. Visits were conducted from 2001 to 2003. Our main outcome measures were (i) company-specific drug preferences measured as the proportion of dispensings of the promoted drug among all dispensings of fixed combinations of inhaled corticosteroid and long-acting beta2-agonists and (ii) the proportion of patients receiving repeated beta2-agonist dispensings who were treated with inhaled steroids.

RESULTS

The first visit had a statistically significant effect on the GPs' drug preference in favour of the marketed drug [odds ratio (OR), 2.39; 95% confidence interval (CI), 1.72-3.32]. The effect on drug preference increased further after the second visit (OR, 1.51; 95% CI, 1.19-1.93), while there was no significant change after the third visit (OR, 1.06; 95% CI, 0.94-1.20). Pharmaceutical sales representative visits did not influence the overall treatment pattern with inhaled steroids (OR, 1.01; 95% CI, 0.97-1.06).

CONCLUSIONS

Pharmaceutical sales representative visits markedly increased the market share of the promoted drug, but only the two first visits had significant impact. Visits had no significant impact on GPs' overall prescribing of inhaled steroids.

Can differences in medical drug compliance between European countries be explained by social factors: analyses based on data from the European Social Survey, round 2

BACKGROUND

Non-compliance with medication is a major health problem. Cultural differences may explain different compliance patterns. The size of the compliance burden and the impact of socio-demographic and socio-economic status within and across countries in Europe have, however, never been analysed in one survey. The aim of this study was to analyse 1) medical drug compliance in different European countries with respect to socio-demographic and socio-economic factors, and to examine 2) whether cross-national differences could be explained by these factors.

METHODS

A multi-country interview survey European Social Survey, Round 2 was conducted in 2004/05 comprising questions about compliance with last prescribed drug. Non-compliance was classified as primary and secondary, depending whether the drug was purchased or not. Statistical weighting allowed for adjustment for national differences in sample mechanisms. A multiple imputation strategy was used to compensate for missing values. The analytical approach included multivariate and multilevel analyses.

RESULTS

The survey comprised 45,678 participants. Response rate was 62.5% (range 43.6-79.1%). Reported compliance was generally high (82%) but the pattern of non-compliance showed large variation between countries. Some 3.2% did not purchase the most recently prescribed medicine, and 13.6% did not take the medicine as prescribed. Multiple regression analyses showed that each variable had very different and in some cases opposite impact on compliance within countries. The multilevel analysis showed that the variation between countries did not change significantly when adjusted for increasing numbers of covariates.

CONCLUSION

Reported compliance was generally high but showed wide variation between countries. Cross-national differences could, however, not be explained by the socio-demographic and socio-economic variables measured.

Antibiotic prescribing in paediatric populations: a comparison between Viareggio, Italy and Funen, Denmark

BACKGROUND

High rates of antibiotic prescribing in paediatric populations represent a major issue because of the problem of antibiotic resistance. North European countries reported an appropriate use of antibiotics in general population; few studies on this issue have been conducted until now, especially in Italy. Therefore a comparison concerning paediatric antibiotic prescribing rates between an Italian administrative area in Tuscany (Viareggio) and the county of Funen (Denmark) was conducted.

METHODS

Reimbursement data from 2003 were gathered from the Tuscany Health Authority database and from the database containing pharmacy dispensing data from the Danish Medicines Agency. All data were converted to Defined Daily Doses (DDD) per 1000 inhabitants per day (DDD/TID). Data were broken down by age, identifying four age groups: 0-4, 5-9, 10-14, 15-19 years.

RESULTS

The overall prescription of antibiotics to paediatric patients from 0 to 19 years of age was higher in Viareggio (67 DDD/TID) than in Funen (35 DDD/TID). In Viareggio amoxicillin and amoxicillin plus enzyme inhibitors ranked in the first two places as the most frequently prescribed antibiotics in the whole population. Cephalosporins were also heavily used in Viareggio with cefaclor being the third most frequently prescribed antibiotic, especially in the 0-4 and 5- to 9-year-old age groups. In Funen, phenoxymethylpenicillin was the most commonly used antibiotic in all age groups, representing almost one-third of prescriptions, followed by amoxicillin.

CONCLUSIONS

The paediatric antibiotic prescription rate is substantially higher in Viareggio compared with Funen. These data confirm possible overuse and misuse of antibiotics in the Italian paediatric population.

Exercise on prescription: a randomized study on the effect of counseling vs counseling and supervised exercise

The aim of this study was to compare short- (0-4 months) and long-term (0-10 months) effects of high-intensive Exercise on Prescription (EoP) intervention (counseling and supervised exercise) implemented in primary healthcare in a number of Danish counties with a low-intensive intervention (counseling) using maximal oxygen uptake (VO(2max)) as the primary outcome. The study was conducted as a randomized trial in 2005-2006 with a high and a low-intensive group. All the patients referred to the EoP scheme by their GP in the counties of Vejle and Ribe, Denmark, were eligible for the trial. The high-intensive EoP group received 4 months of group-based supervised training and attended five motivational counseling sessions. The low-intensive group only attended four motivational counseling sessions. Three hundred and twenty-seven patients entered the EoP scheme, and 52 (16%) volunteered for the randomized trial. No short- or long-term differences were found between the high and the low-intensive groups for VO(2max) (short-term 95% CI -1.1; 4.4 mL O(2)/(kg min), long-term 95% CI -1.6 to 2.1). The present study did not demonstrate any significant clinical outcome for the high-intensive EoP intervention as opposed to the low-intensive intervention.

Promotional methods used by representatives of drug companies: a prospective survey in general practice

OBJECTIVE

To examine the extent and composition of pharmaceutical industry representatives' marketing techniques with a particular focus on drug sampling in relation to drug age.

DESIGN

A group of 47 GPs prospectively collected data on drug promotional activities during a six-month period, and a sub-sample of 10 GPs furthermore recorded the representatives' marketing techniques in detail.

SETTING

Primary healthcare.

SUBJECTS

General practitioners in the County of Funen, Denmark.

MAIN OUTCOME MEASURES

Promotional visits and corresponding marketing techniques.

RESULTS

The 47 GPs recorded 1050 visits corresponding to a median of 19 (range 3 to 63) per GP in the six months. The majority of drugs promoted (52%) were marketed more than five years ago. There was a statistically significant decline in the proportion of visits where drug samples were offered with drug age, but the decline was small OR 0.97 (95% CI 0.95;0.98) per year. Leaflets (68%), suggestions on how to improve therapy for a specific patient registered with the practice (53%), drug samples (48%), and gifts (36%) were the most frequently used marketing techniques.

CONCLUSION

Drug-industry representatives use a variety of promotional methods. The tendency to hand out drug samples was statistically significantly associated with drug age, but the decline was small.

Exercise on prescription: trial protocol and evaluation of outcomes

BACKGROUND

In many countries exercise prescriptions are used in an attempt to initiate a physically active lifestyle in sedentary populations. Previous studies have primarily evaluated low intensive exercise prescription interventions and found moderately positive effects on physical activity and aerobic fitness. In a highly intensive Danish exercise prescription scheme called 'Exercise on Prescription' (EoP) the general practitioners can prescribe EoP to sedentary patients with lifestyle diseases. The aim of this randomized trial is to assess the short- and long-term effects of the EoP scheme. Thus, the aim of this paper is to describe the randomized controlled trial designed for evaluating effectiveness of EoP, and to present results from validations of outcome measures.

METHODS/DESIGN

EoP involves a 16-week supervised training intervention and five counselling sessions (health profiles). All patients referred to EoP were eligible for the trial and were offered participation during the baseline health profile. Comparisons between the EoP group and the control group were made at baseline, and after four and ten months. Physiological measures used were maximal oxygen uptake (VO2max), glycosylated haemoglobin (HbA1c), bodyweight, and BMI. Patient-reported measures used were physical activity, health-related quality of life, amount and intensity of exercise, compliance with national guidelines for physical activity, and physical fitness. The validation of the cycle ergometer test found a strong correlation between maximal work capacity and VO2max, and acceptable test-retest reliability at group level. Calibration of the HbA1c apparatus was stable over ten weeks with minimal use, and test-retest reliability was good. High agreement percents were found for test-retest reliability for the self-administered questionnaire.

DISCUSSION

The trial is designed to provide information about the effectiveness of the EoP scheme. The trial is part of a health technology assessment of EoP, which besides the effectiveness covers the patient perspective, the organization, and the health economy. All three methods validated were found useful for the EoP trial.

Analysing duration of episodes of pharmacological care: an example of antidepressant use in Danish general practice

Analysing duration of treatment episodes has become a standard task in many pharmacoepidemiological studies. However, such analyses are often carried out in a rather simplistic manner and more subtle issues are often ignored. In this paper, methods of analysing duration treatment episodes beyond simple analyses allowing investigation of the risk for certain events over time are demonstrated. In particular, the use of cumulative incidence functions, cause-specific hazard functions, hazard rate models and expected mortality in analysing duration of episodes is presented. We used these statistical techniques in analysing the early treatment history of patients who started a regular treatment with antidepressant drugs in the primary health care sector in Denmark. We have extracted some important features: The risk of discontinuing and switching treatment was very high around 10 weeks after starting treatment. After discontinuing the first treatment period, many patients soon started a second treatment period depending on the duration of the first treatment period with highest risk around 10 weeks. The mortality rate among the patients in treatment was about three times higher than the expected mortality. The risk of dying immediately after stopping treatment was about twice the expected mortality. The analysis suggests that: (1) there is a critical period for a first discontinuing, switching and restarting treatment around 10 weeks, (2) the GPs prescribing habits have more influence on the patterns than patient or drug characteristics, (3) over time Danish GPs tend to prolong the duration of first treatment period and avoid longer treatment breaks.

[How participation in a clinical trial affects doctors' choice of treatment]

In a retrospective cohort study, the effects of participation in a company-sponsored clinical trial on asthma drug prescribing were investigated. Ten trial-conducting practices were compared with 165 control practices. Conducting the trial did not influence guideline adherence measured as the prevalence of inhaled corticosteroid use among users of inhaled beta2-agonists. However, participation in the trial led to an increased preference for sponsor's drugs.

[Skin prick tests of patients with hay fever carried out in general practices compared with those carried out in a specialist outpatient clinic]

INTRODUCTION

The aim of our study was to assess whether general practitioners and their staff (practices) who had attended a short CME course with technical instruction in the skin prick test could diagnose and treat unselected patients with allergic rhinoconjunctivitis at the same quality level as the allergy outpatient clinic.

MATERIAL AND METHODS

We performed a multicentre study with the participation of 38 general practices and the Allergy Centre at Odense University Hospital (OUH). After a two-day course for the general practitioner and his practice staff, every practice performed a skin prick test on 10 consecutive adult patients with symptoms of allergic rhinoconjunctivitis during the spring and summer. A standardised questionnaire was also filled in and sent to the Allergy Centre, where the patient subsequently had another skin prick test carried out. The results of the tests were determined in duplicate and then compared.

RESULTS

No significant differences in the quality of the skin prick test for 10 allergens or histamine control were found between the general practice and the Allergy Centre. Discordant results were found in 9%, i.e., a positive result either at the practice or the Allergy Centre, but not at both.

CONCLUSION

After a training course, general practitioners and their staff are fully able to perform and validate skin prick tests for inhalation allergens.

Economic evaluation of empirical antisecretory therapy versus Helicobacter pylori test for management of dyspepsia: a randomized trial in primary care

OBJECTIVES

An economic evaluation was performed of empirical antisecretory therapy versus test for Helicobacter pylori in the management of dyspepsia patients presenting in primary care.

METHODS

A randomized trial in 106 general practices in the County of Funen, Denmark, was designed to include prospective collection of clinical outcome measures and resource utilization data. Dyspepsia patients (n = 722) presenting in general practice with more than 2 weeks of epigastric pain or discomfort were managed according to one of three initial management strategies: (i) empirical antisecretory therapy, (ii) testing for Helicobacter pylori, or (iii) empirical antisecretory therapy, followed by Helicobacter pylori testing if symptoms improved. Cost-effectiveness and incremental cost-effectiveness ratios of the strategies were determined.

RESULTS

The mean proportion of days without dyspeptic symptoms during the 1-year follow-up was 0.59 in the group treated with empirical antisecretory therapy, 0.57 in the H. pylori test-and-eradicate group, and 0.53 in the combination group. After 1 year, 23 percent, 26 percent, and 22 percent, respectively, were symptom-free. Applying the proportion of days without dyspeptic symptoms, the cost-effectiveness for empirical treatment, H. pylori test and the combination were 12,131 Danish kroner (DKK), 9,576 DKK, and 7,301 DKK, respectively. The incremental cost-effectiveness going from the combination strategy to empirical antisecretory treatment or H. pylori test alone was 54,783 DKK and 39,700 DKK per additional proportion of days without dyspeptic symptoms.

CONCLUSIONS

Empirical antisecretory therapy confers a small insignificant benefit but costs more than strategies based on test for H. pylori and is probably not a cost-effective strategy for the management of dyspepsia in primary care.

Does persistent involvement by the GP improve palliative care at home for end-stage cancer patients?

OBJECTIVE

To analyse the effect of GP home visits on the granting of a terminal declaration (TD) and on place of death.

PARTICIPANTS AND DESIGN

A total of 2025 patients with cancer as the primary cause of death in the period 1997-1998, were investigated in a mortality follow-back design using the Danish Cancer Register and four administrative registers. The Danish TD can be issued by a physician for patients with an estimated prognosis of six months or less. The TD gives the right to economic benefits and increased care for the dying patient.

SETTING

The island of Funen/Denmark.

MAIN OUTCOME MEASURES

Main outcome--hospital death. Intermediate outcome--TD.

RESULTS

A total of 38% of patients received a TD and 56% died in hospital. GP home visits in the week before TD (odds ratio (OR): 16.8; 95% CI: 8.2-34.4), as well as four weeks before TD (OR: 6.4; 95% CI: 4.5-9.2) were associated with an increased likelihood of receiving a TD. GP home visits in the group with TD (OR: 0.18; 95% CI: 0.11-0.29) and the group without TD (OR: 0.08; 95% CI: 0.05-0.13) was inversely associated with hospital death. A dose-response relationship was found in both groups.

CONCLUSION

Persistent involvement by the GP is associated with improved end-of-life care for cancer patients. Provided that temporal relations are taken into account, the mortality follow-back design can be a suitable and ethical research method to highlight and monitor end-of-life cancer care.

How conducting a clinical trial affects physicians' guideline adherence and drug preferences

CONTEXT

General practitioners are frequently involved in clinical trials sponsored by pharmaceutical companies but the effects of participation on their prescribing patterns have not been evaluated.

OBJECTIVE

To determine how conducting a company-sponsored clinical trial influenced physicians' adherence to international treatment recommendations and their prescribing of the pharmaceutical company's drugs.

DESIGN, SETTING, AND PATIENTS

Observational cohort study in Funen County, Denmark, comparing 10 practices that were conducting a trial on asthma medicine with 165 control (non-trial-conducting) practices. The study population included 5439 patients treated with asthma drugs from the trial-conducting practices and 59,574 patients from the control practices. Practices conducted the trial between April 26, 2001, and October 7, 2002.

MAIN OUTCOME MEASURES

Adherence to guidelines measured as use of inhaled corticosteroids among asthma patients. Prevalence of use of the company's drugs and the trial sponsor's share of the total volume of asthma drugs prescribed.

RESULTS

The baseline proportion of asthma patients using inhaled corticosteroids was 68.5% in trial-conducting and 69.1% in control practices. Conducting the trial did not influence guideline adherence (odds ratio [OR] after 2 years, 1.00; 95% confidence interval [CI], 0.84-1.19). In trial-conducting practices, the sponsoring company's share of the total prescribed volume of asthma drugs increased compared with control practices (6.7%; 95% CI, 3.0%-11.7%). This could be attributed to a significantly higher preference for the company's inhaled corticosteroids (OR, 1.26; 95% CI, 1.04-1.54) and trends toward increased prescribing of the company's other asthma drugs.

CONCLUSION

Conducting a trial sponsored by a pharmaceutical company had no significant impact on physicians' adherence to international treatment recommendations but increased their use of the trial sponsor's drugs.

Narrow and wide prescribers among general practitioners: a cohort study of drug formularies used for new treatments

OBJECTIVE

The aims of this study were to analyse (1) if it is possible to classify general practitioners (GPs) or groups of practitioners (practice units) as overall narrow or wide prescribers and (2) to what extent the size of practice drug formularies is associated with general prescribing behaviour, practice activity and demography.

METHODS

Data were retrieved from the Odense University Pharmacoepidemiologic Database (OPED) and the prescribing patterns of 177 practice units were analysed in a 4-year period including 2000 and 2003. We characterised the drug repertoire for new treatments using a Formulary Diversity Scale based on two formulary measures, the DU 90% and the Formulary Selectivity Index. Multiple regressions were used to analyse the association between formulary size and practice characteristics.

RESULTS

The final Formulary Diversity Scale comprised 15 therapeutic drug groups and 151 different analogues. The average score based on the DU 90% segment was 46 drugs (range: 28-65) corresponding to 30% of drugs available. Using the Formulary Selectivity Index the average diversity score was 0.70. Practices with a high number of patients and a high percentage of elderly patients were more likely to use a wide range of drugs.

CONCLUSION

The Formulary Diversity Scale revealed wide variation between practice units, indicating the existence of both overall narrow and wide prescribers among GPs. The number of patients attending the practice and the percentage of elderly patients were directly associated with the use of more analogues.

Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspepsia? A cluster-randomized trial

OBJECTIVES

The optimal approach for management of patients with dyspepsia has not been determined. The aim of this study was to compare the efficacy of three strategies for management of dyspepsia: empirical antisecretory therapy, testing for Helicobacter pylori (H. pylori), or a combination of the two.

METHODS

Cluster-randomized trial in general practices. Initial treatment with proton pump inhibitor (PPI) was performed in 222 patients, H. pylori test-and-eradicate in 250 patients, and PPI followed by H. pylori-testing if symptoms improved in 250 patients. Symptoms, quality of life, patient satisfaction, and use of resources were recorded during a 1-yr follow-up.

RESULTS

The prevalence of H. pylori infection was 24%. We found no difference among the three strategies (p=0.16) in terms of the proportion of days without dyspeptic symptoms. After 1 yr gastrointestinal symptom scores and quality-of-life scores had improved significantly and equally in the three groups (p<0.001), but no statistically significant differences were found among the groups. The mean use of endoscopies per patient after 1 yr was higher in the PPI group (0.36 [95% CI 0.30-0.43]) than in the test-and-eradicate group (0.28 [95% CI 0.23-0.34]) and the combination group (0.22 [95% CI 0.17-0.27]), p=0.02. H. pylori-positive patients given eradication therapy had more days without dyspeptic symptoms (p<0.001), used less antisecretory therapy (p<0.01), and were more satisfied (p<0.001) than H. pylori-negative patients.

CONCLUSION

The strategies based on H. pylori test enjoyed similar symptom resolution, but reduced endoscopic workload and lower 1-yr total costs compared with empirical antisecretory therapy.

General practitioners' adoption of new drugs and previous prescribing of drugs belonging to the same therapeutic class: a pharmacoepidemiological study

AIM

To test the hypothesis that general practitioners (GPs) with high prescribing levels of certain drugs will adopt new drugs belonging to the same therapeutic group faster than those with low prescribing levels.

METHODS

The adoption of four new drugs: esomeprazol, selective cyclo-oxygenase-2 inhibitors, new triptans, and angiotensin-II receptor blockers were analysed using population-based prescription data. We used the preference proportion (prescriptions for new rather than older alternatives for the same indication) to measure GPs' adoption rate. Annual prescribing volume and prevalence were used to measure previous prescribing of older drug alternatives. We modelled the preference proportion using multiple linear regression analysis and the prescribing of older drugs as independent variables. We controlled for the GPs' general prescribing level and weighted for practice size. In the first three analyses, we dichotomized data using the median, lower and upper quartile as cut-off point. Next, we grouped data into quartiles and finally, we used continuous data.

RESULTS

For esomeprazol and new triptans there was a higher preference for new drugs among "high prescribers", but only when this term was defined as the upper quarter and the upper half of previous prescribing levels, respectively (mean difference in preference proportion: 10.2% (99% confidence interval = 1.3%, 19.1%) and 8.2% (0.2%, 16.2%)). For the remaining two drug classes the associations were weak and almost all statistically nonsignificant.

CONCLUSION

There is no consistent association between GPs' level of drug prescribing and their adoption of new drugs of the same therapeutic group.

Intensive community pharmacy intervention had little impact on triptan consumption: a randomized controlled trial

OBJECTIVE

To evaluate the impact of an intensive pharmaceutical care campaign targeting inappropriate use of triptans.

DESIGN

Randomized controlled trial.

SETTING

22 community pharmacies in the County of Funen, Denmark.

SUBJECTS

A total of 1123 triptan users at intervention pharmacies and 1340 at control pharmacies.

INTERVENTION

Intervention pharmacy staff received information on migraine and other types of headache, detection of inappropriate triptan use and other drug-related problems, and techniques for establishing a dialogue with patients. Intervention consisted of a folder and a structured dialogue with the pharmacy staff. The folder included questions aimed at detecting overuse and inappropriate triptan use.

MAIN OUTCOME MEASURES

Change in average triptan consumption in doses per month measured by means of a prescription database with information on all purchases of reimbursed drugs at the level of the individual patient.

RESULTS

Overall, intervention had no statistically significant short-term impact on patients' consumption of triptans either among incident users (intervention/control ratio 1.02; 95% confidence interval 0.95 to 1.12), or among prevalent users (1.02; 0.97 to 1.08). No effects were observed after 6 and 9 months, apart from a possible borderline effect after 9 months among prevalent users with intermediate triptan consumption (0.93; 0.87 to 1.00).

CONCLUSION

The pharmaceutical care campaign did not reduce the use of triptans.

Characteristics of middle-aged and elderly women with urinary incontinence

OBJECTIVE

To describe the prevalence of urinary incontinence and to find characteristics useful in general practice for identifying middle-aged and elderly women with the problem.

DESIGN

Cross-sectional interview study.

SETTING

Population-based samples of Danes.

SUBJECTS

A total of 5795 women older than 45 years (46+ years).

MAIN OUTCOME MEASURES

Prevalence of incontinence and clinical characteristics assessed by standardized interview questions.

RESULTS

The overall prevalence of urinary incontinence was 20% among women less than 60 years of age and 44% among those older than 80 years. Increasing age was highly associated with both forms of incontinence (stress and urge). High body mass index (BMI), chronic lung disease, and stroke were also associated with both forms, while number of children was associated with stress incontinence only. Predictive models show that 56% of women characterized by high age (older than 80 years) and overweight (BMI higher than 30) will suffer from urinary incontinence. The low-risk group defined by these two parameters (aged 46-60 years and not overweight) still had a 19% prevalence in the last month.

CONCLUSION

The prevalence of urinary incontinence increased with age. Even in the low-risk groups the problem was very common in old age. Questions about incontinence should, therefore, be asked in relevant consultations with all elderly female patients.

Defining Cancer Patients As Being in the Terminal Phase: Who Receives a Formal Diagnosis, and What Are the Effects?

Purpose

Physicians either do not define cancer patients as being terminal, or their prognostic estimates tend to be optimistic. This might affect patients' appropriate and timely referral to specialist palliative care services or can lead to unintended acute hospitalization.

Patients and Methods

We used the Danish Cancer Register and four administrative registers to perform a retrospective cohort study in 3,445 patients who died as a result of cancer. We used the Danish “terminal declaration” issued by a physician as a proxy for a formal terminal diagnosis (prognosis of death within 6 months). The terminal declaration gives right to economic benefits and increased care for the dying. We investigated patient-related factors of receiving an explicit terminal diagnosis by logistic regression and then analyzed the effects of such a diagnosis on admission rate per week and place of death.

Results

Thirty-four percent of patients received a formal terminal diagnosis. Age of ≥ 70 years (odds ratio [OR], 0.44; 95% CI, 0.34 to 0.56; P < .001), women (OR, 0.81; 95% CI, 0.69 to 0.96; P = .02), hematologic cancer (OR, 0.20; 95% CI, 0.09 to 0.41; P < .001), and a less than 1-month survival time (OR, 0.10; 95% CI, 0.07 to 0.15; P < .001) were associated with a lesser likelihood of receiving a formal terminal diagnosis. Explicit terminal diagnosis was associated with lower admission rate and an adjusted OR of hospital death of 0.25 (95% CI, 0.21 to 0.29).

Conclusion

Women and the elderly were less likely to receive a formal terminal diagnosis. The formal terminal diagnosis reduced hospital admissions and increased the possibilities of dying at home.

General practitioners choose within a narrow range of drugs when initiating new treatments: a cohort study of cardiovascular drug formularies

OBJECTIVE

The aims of this study were (1) to develop and evaluate a new method for investigating personal drug formularies in general practice and (2) to test the hypothesis that there is a difference between personal drug formularies for incident and ongoing drug use.

METHODS

In 2002, we studied prescribing patterns of beta-blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin-II antagonists and statins in the County of Funen, Denmark (180 general practices, 472,000 inhabitants). For each practice, we distinguished between an incident drug formulary consisting of prescriptions for new users and an ongoing drug formulary including prescriptions for patients already in treatment. Prescription data were retrieved from the Odense University Pharmacoepidemiologic Database (OPED). Four different formulary measures were evaluated and used for comparing incident and ongoing drug use.

RESULTS

General practitioners' (GPs') incident drug formularies comprised significantly fewer drugs than their ongoing drug formularies for all drug groups except angiotensin-II antagonists. The difference in the total number of drugs used was between 1.8 and 3.3. We found differences between 0.5 and 1.6 analogues in the DU 90% (number of analogues accounting for 90% of the prescribed volume measured in defined daily doses) segment and the formulary selectivity index between 0.05 and 0.12. The preference for the most prescribed analogue was 9-18% higher among incident patients. The formulary selectivity index was highly correlated with the other formulary measures and quantified both range and skewed distribution of drug choice.

CONCLUSION

Analysing GPs' prescriptions to incident patients is a simple and inexpensive method for studying their own current personal drug formularies. GPs choose within a narrow range of analogues for incident patients.

Cancer patients’ first treatment episode with opioids: a pharmaco-epidemiological perspective

GOAL

The factors underlying the choice of opioids for cancer patients in primary care are largely unknown. Our aim was to describe cancer patients' first treatment episode with opioids in relation to disease characteristics and clinical course.

PATIENTS AND METHODS

During 1997 and 1998, a population-based cohort of 4,006 incident cancer patients from a Danish county was identified. The patients were followed up from diagnosis to death or until 31 December 2003, and data on their use of opioids were obtained from a prescription database.

MAIN RESULTS

Eventually, 54% of the cancer patients became incident users of opioids. Opioid treatment was initiated close to the diagnosis date in 20% of the patients. Most incident users (57%) were not terminal when they began using opioids, and 44% survived the first treatment episode. Of those who died, 70% received opioids in their terminal phase. The incidence rates of new opioid users were inversely related to the 5-year cancer survival period. A weak opioid was the first choice in 64% of the non-terminal users and in 43% of the terminal ones. No statistically significant differences in opioid use were found between men and women.

CONCLUSIONS

Opioid use in cancer patients was not confined to the terminal course. Treatment with opioids should be viewed as a dynamic condition, with patients shifting between periods of use and non-use. The aggressiveness of the cancer and the presence of metastases were characteristics found to be strong determinants of opioid use.

Population-based study of place of death of patients with cancer: implications for GPs

BACKGROUND

A majority of patients with cancer who are seriously ill have a preference of dying at home. However, only a minority of patients actually die at home in most Western countries.

AIM

To explore factors associated with place of death in an unselected population of patients with cancer.

DESIGN OF STUDY

Case-control study.

SETTING

County of Funen, Denmark.

METHOD

Register linkage from six Danish healthcare registers.

RESULTS

The GP's home visit during the last 3 months before death was inversely associated with dying in hospital (adjusted odds ratio [OR] = 0.08, 95% confidence interval [CI] = 0.06 to 0.12) and so were community nurses visiting the home (OR = 0.36, 95% CI = 0.26 to 0.48). Furthermore, being married (OR = 0.68, 95% CI = 0.56 to 0.85), and age at death of 40-65 years (OR = 0.70, 95% CI = 0.56 to 0.90) seemed to have an effect. Hospital death was associated with survival time of less than 1 month (OR = 2.27, 95% CI = 1.69 to 3.13). Type of cancer, sex, or residence (urban versus rural) were not associated with a hospital death in this multivariate analysis.

CONCLUSIONS

Dying at home was, to a higher extent, associated with GP visit and, to a lesser extent, community nurse visit than with clinical and sociodemographic characteristics of patients with cancer. In our view, these findings indicate the importance of the GP in particular. To increase the opportunity to die at home, more research is needed on the role of the GP and the interface between GPs and other providers of health care at home for patients who are terminally ill with cancer.