Can drug treatment be improved by feedback on prescribing profiles combined with therapeutic recommendations? A prospective, controlled trial in general practice

We have carried out a prospective, controlled trial to ascertain whether mailed feedback on general practitioners' (GPs) own prescribing combined with relevant recommendations on drug treatment, can improve the prescribing. The GPs in the Norwegian county of Møre and Romsdal recorded all their contacts with patients and prescriptions during two periods. After the first period the GPs in Romsdal only (intervention group) received a mailed report giving their prescribing profiles as well as treatment recommendations for insomnia and acute cystitis. The total number of contacts with patients was 68,625 in which 55,747 items were prescribed. The GPs in the intervention group changed their prescribing in accordance with the intervention: they prescribed significantly less sleeping-pills for each patient, preferred short- to long-acting benzodiazepine hypnotics and tranquilizers, and they chose trimethoprim as a first line treatment for acute cystitis. We conclude that it is possible to improve the GPs' prescribing through mailed feedback.

[With Rudolf Ludwig Karl Virchow as a guide into the new community medicine]

Internationally there is an urge to vitalize the theory and practice of public health. A new public health emerges, characterized by: Knowledge base on anthropology and ecology, not on epidemiology Export of health expertise and commitment to other sectors: agriculture, urban planning, media, etc. Mobilizing and qualifying the individual as well as the local community to invest in personal and environmental health Focus on public health threats deriving from political and economic power structures. The new public health needs the old virtues of the pioneers of social medicine, in this article represented by Virchow (1821-1902): One half of the brain in biomedicine, one in social medicine Courage to confront the Establishment Respect for the people and a dedication to democratize medicine A basic instinct for social justice.

Pregnancy--a golden opportunity for promoting the cessation of smoking?

OBJECTIVE

To investigate whether daily-smoking pregnant women are more motivated to reduce their cigarette consumption than daily-smoking non-pregnant women.

DESIGN

Prospective study with self-administered questionnaires at inclusion and 18 months later.

SETTING

116 general practitioners in western Norway.

SUBJECTS

83 pregnant and 107 non-pregnant women.

MAIN OUTCOME MEASURES

Non-anonymous questionnaires focusing on smoking habits and attitudes to smoking cessation.

RESULTS

Pregnant women were more often encouraged to stop smoking by their partners than non-pregnant women (p < 0.01). More pregnant than non-pregnant women totally agreed that their GP should try to motivate their patients to stop smoking (p < 0.001). Pregnant women also predicted that they would be non-smokers in five years more often than non-pregnant women (p < 0.001). Eighteen months later no such difference was found. A reduced cigarette consumption, verified by serum thiocyanate, was found among women early in pregnancy. The reduced consumption found later in pregnancy and the first year after delivery may be explained to some extent by systematic underreporting. At the end of the study eight per cent of both pregnant and non-pregnant women had stopped smoking.

CONCLUSION

We need to develop strategies for utilizing the unique opportunity which pregnancy provides for the motivation of cessation of smoking.

The erythrocyte sedimentation rate in general practice: clinical assessment based on case histories

Thirteen case histories were mailed to 273 general practitioners to study the clinical assessment of the ESR. Participants were asked to state their reference limits for the ESR, as well as action values for the ESR in several clinical situations typical of primary care. The action value should represent the minimal ESR change from a given value necessary to initiate some kind of action towards the patient. The response rate was 76%. In most case histories, half the general practitioners reacted on an ESR change of 10 mm h-1 or less, which is usually due to analytical and biological variation, thus underlining the need for good analytical quality. In general the response was of the same magnitude irrespective of type of case history, i.e. whether the ESR was used in case finding, in diagnosis, or in follow-up. Estimation of the reference limit displayed considerable variation, and knowledge of a previous 'normal' ESR was of minor clinical importance. Furthermore, we found substantial variation regarding the change in ESR necessary to take action in different clinical situations. In principle, for many general practitioners the action value increased as the given ESR increased whereas others reacted on a constant change in ESR, or the change necessary to take action depended on the clinical situation. We conclude that both the different assessments as to the clinical significance of the ESR, and the unawareness of the significance of analytical and biological variation indicate that guidelines for rational use are needed.

Is smoking intervention in general practice more successful among pregnant than non-pregnant women?

The objective of this study was to evaluate the effect of a simple smoking intervention programme, carried out by a large number of general practitioners (GPs) among pregnant and non-pregnant women. Four groups of women were defined by the dichotomies pregnant versus non-pregnant and intervention versus control. The intervention was semistructured, using a flip-over and a booklet, and it was implemented in an ordinary sequence of consultations. The study involved 187 GPs in western Norway. The subjects were 350 daily smoking pregnant women and 274 daily smoking non-pregnant women, 18-34 years of age. The point prevalence abstinence rate at 18 months was 15 and 20% for pregnant and non-pregnant women, respectively, in the intervention groups, and 7% in the control groups (Ppregnant = 0.06, Pnon-pregnant = 0.006). Twenty-five per cent of the pregnant women and 34% of the non-pregnant women reported that they had reduced their cigarette consumption, but had not stopped smoking entirely. If we include all drop-outs as smokers, the continuous abstinence rate during 15 months was 6%/0% among pregnant women (intervention/control) and 5%/1% among non-pregnant women. Stopping smoking was associated with having a non-smoking partner (P = 0.001), and being encouraged to do so by their partner (P = 0.004). The prevalence of both pregnant and non-pregnant women who stopped smoking was higher in the intervention than in the control groups. Pregnant women stopped smoking as frequently as non-pregnant individuals.(ABSTRACT TRUNCATED AT 250 WORDS)

How to succeed in a multipractice study

BACKGROUND

In designing a multipractice study on the prescribing habits of general practitioners (GPs) in a Norwegian county, we took into account positive and negative experiences from earlier research on how to improve participation and retention of physician investigators.

METHODS

The GP recruitment took place in two phases. The first step was to establish a local network and a sense of community among GPs in the county. The second step consisted of a personal visit by the project leader to all of the practices in the county during the three months before the study started.

RESULTS

One hundred and forty-nine (96%) of a total of 156 GPs participated during the first one-month data collection period, registering 43,619 patient contacts. Only six GPs refused to participate, and one GP could not participate because of illness. During the second data collection period, four of the original nonparticipants asked to join, which gave a rate of enrollment of 98% (153 of 156). This time 46,839 contacts with patients were registered. None of the participants dropped out of the study.

CONCLUSIONS

Our design for achieving high recruitment and participation rates was successful. We found that in conducting multipractice studies it was essential to spend enough time and resources on establishing a close collaborative relationship with GPs before, during, and after the study.

Smoking habits in early pregnancy related to age of smoking debut

During 1 year, 187 general practitioners in western Norway recruited 530 daily smoking, pregnant women for a smoking cessation study. At the first medical check-up in pregnancy each woman filled in a questionnaire. Women who had started smoking within 15 years of age reported more heavy smoking the last 3 months before pregnancy (P < 0.0001) and at the first check-up in pregnancy (P < 0.01) than those who had started smoking later. They also reported less reduction in smoking habits during earlier pregnancies (P < 0.0001) and more serious tobacco addiction judged by starting smoking early in the morning (P < 0.005). However, even those who had started smoking before 15 years of age reported a reduction of 30% in cigarette consumption during the first few weeks of the present pregnancy. In addition to increasing the antismoking efforts among pregnant women, health education among girls 12-15 years of age to prevent smoking initiation should be intensified.

Withdrawing long-term diuretic treatment among elderly patients in general practice

The aim of this study was to elaborate, implement and evaluate a strategy for discontinuation of long-term diuretic treatment in elderly patients in general practice. Thirty-three patients were enrolled for a supervised step-down and withdrawal of diuretics. After withdrawal, the patients were followed up for 6 months or until diuretic treatment was re-established. Withdrawal was successful according to the protocol in 18 cases. Diuretic withdrawal failed and the treatment was re-established in 15 cases, four of which were sudden cardiovascular events. Most withdrawal failures were identified by routine examinations through the follow-up programmes, thus they had few consequences for the patients. This demonstrates that careful follow-up is essential after diuretic withdrawal. Our findings support the view that a large proportion of elderly patients on diuretics may not need such treatment.

Smoking habits in early pregnancy and attitudes towards smoking cessation among pregnant women and their partners

One-hundred and eighty-seven general practitioners in western Norway recorded smoking habits among 2379 women, consulting for their first regular medical check-up in pregnancy. Forty-six per cent had been daily smokers the last 3 months before pregnancy. Thirty-nine per cent were still smoking at the time of their first check-up. Sixteen per cent of the daily smokers stopped smoking spontaneously during the first few weeks of pregnancy. Fifty-seven per cent of women younger than 20 and 28% of women 30 years and older, did smoke at the first check-up. Single women smoked more often than women living with a partner (58% versus 38%). Smoking habits were not associated with number of previous pregnancies. At the first check-up, 530 pregnant women, still smoking daily, 18-34 years of age, living with a partner, accepted to participate in a smoking intervention study. They filled in a questionnaire about their smoking habits, the smoking habits of their partners and their attitudes towards smoking cessation. Sixty-five per cent reported a reduction in their use of cigarettes after becoming pregnant. The mean reduction in the number of cigarettes smoked daily was 4.0 (31%). Most of the respondents expressed a strong motivation to quit or reduce their smoking habits during their pregnancy. Seventy-two per cent of the partners were daily smokers. Reduction in the consumption of cigarettes, negative attitudes towards smoking and determination to stop smoking was significantly higher among women who were encouraged by their partners to stop smoking and in those who perceived that their partners were willing to reduce their consumption.

Recruitment and participation of general practitioners in a multipractice study of smoking cessation

In May 1986, all 398 general practitioners (GPs) in western Norway were invited by letter to take part in a multipractice intervention study of smoking cessation among pregnant women. The aims of the intervention study were: 1) to find out how a smoking cessation model can be implemented in ordinary consultations in general practice, and 2) to compare smoking cessation in pregnant and non-pregnant women. The intervention study lasted for three years. 187 (47%) GPs completed the study. Working in a group practice, working on regular salary, having started specialization in general practice, being less than 40 years of age, and being a non-smoker were significantly more common among the participating GPs. They also had significantly fewer consultations per week than their non-participating colleagues. A stepwise multiple logistic regression analysis revealed that smoking habits predicted participation in the study far more than any other predictor.

[Registration in practice as a tool in the compilation of a community diagnosis in Askvoll municipality]

When trying out various models for community diagnosis we registered a sample of doctor-patient contacts in Askvoll municipality over one year. One fifth of all contacts, 2,743, were registered. The contact rate per year was 3.8 per inhabitant. 79% of the contacts were consultations, 10% home visits and 11% telephone consultations. The three most commonly registered diagnostic groups were musculoskeletal diseases, cardiovascular diseases and "preventive medicine". Together with a household survey and an analysis of public statistics on mortality, morbidity and disability in our municipality, the registration of doctor-patient contacts form the basis of a community diagnosis. This community diagnosis will help to steer health planning and preventive work in our district in the right direction.

Clinical assessment of haemoglobin values by general practitioners related to analytical and biological variation

Twelve case stories were mailed to 273 general practitioners to study the clinical assessment of haemoglobin values. For each case the general practitioner was asked to fill in the haemoglobin value representing the minimal change from a given value considered necessary to take action. haemoglobin change corresponding to the median haemoglobin value stated was transformed to a so-called 'medically useful coefficient of variation' in order to relate clinical demands to analytical and biological variation. The average medically useful coefficient was calculated to 3.9% (range 2.3-7.8%). We found that general practitioners assess haemoglobin values rather uniformly, although their judgement varies substantially with the clinical situation; they are not fully aware of the consequences of analytical and biological variation, and the advantage of knowing a previous haemoglobin value is not recognized. The analytical imprecision of haemometers based on clinical demands should be 2.8%, and the analytical quality should be the same in primary and secondary care.

[Medical politics. Graffiti]

If doctors want to play a role in future health promotion, they have to leave their citadel, and come closer to life and society. Modern preventive medicine cannot be dissociated from basic political, cultural and religious values and processes. Genetic counseling and engineering, influencing lifestyle, community intervention and changing the health culture among patients and doctors all require ethical and political competence rather than traditional medical skills. The author advocates the development of a new discipline, medical politics, with two major commitments: -To define basic health rights -To study the public health consequences of political systems and decisions. In a polemic and provocative style the article enlightens the potentials and dangers associated with an expanded concept of preventive medicine.

[Perestroika--in medicine too]

The article criticizes the one-dimensionality of natural science and the one-way concept of causality in medicine. The crisis in medical practice and health economy is considered in the light of an outdated and rigid health ideology with parallels in the "scientific" dogmas that have now been discarded in Eastern Europe. In this article we try to point a way out of this unfortunate situation: how would a change of paradigm affect clinical practice, health ideology and our concept of social policy?

[Written information from hospital to primary physician about discharged patients]

Discharge communications from hospitals to general practitioners in respect of 203 patients have been analyzed in two municipalities in Western Norway. The average interval between discharge from hospital and the first visit to the GP was 25 days (1-198 days). The mean period before arrival of the final report was 28 days (0-175 days). In 38% of the cases the GPs had received no written communication from the hospital upon first contact after discharge. 42% of the preliminary reports and 18% of the final reports were judged to be inadequate. At the first attendance, the GPs were uncertain about the drug regimen in 25% of the cases and about other forms of treatment in 32%. They felt uncertainty about follow-up procedures in the case of 44%. As evaluated by the GPs, in 22% of the cases the absence or inadequacy of the discharge letters might have had a negative influence on the patient's health. A survey of the literature provides a basis for the following recommendations: On leaving the hospital the patient should be given an interim discharge summary containing any information essential for immediate follow-up, to be delivered to the general practitioner by hand. The final discharge letter should focus upon topics of particular interest for the general practitioner: results from clinical examinations and laboratory investigations should be restricted to data necessary for making clinical decisions; treatment given in hospital, including adverse reactions, and drug regimen at discharge; any information on the nature and prognosis of the disease given to the patient and/or relatives during the stay in hospital; evaluation of prognosis and advice on sociomedical rehabilitation in everyday life and at work; a plan for future management of the patient with emphasis on well-defined sharing of tasks and responsibilities between the hospital, the outpatient department and the GP.

[Use of public health statistics in the development of community diagnosis]

A community diagnosis which describes the health of the local population may be an important instrument in promoting health and preventing disease. Most general practitioners do not have time to carry out individual surveys in the local community. Therefore it seems relevant to look into the possibility of utilizing official health statistics as a basis for community diagnosis. We obtained and analysed demographic data, mortality data, statistics on cancer, data on causes of invalidity and risk factors for cardiovascular diseases for Askvoll municipality. This article demonstrates possibilities, obstacles and constraints in the use of such statistics. Suppliers of register data should make routine health statistics more available for use in the district health services. In this connection we recommend the development of a central health data information system.

The duration of acute respiratory tract infections in children

In a rural district in Western Norway with 400 children under 16 years, we recorded all children with acute respiratory infections who attended their general practitioner during a period of four months. 90 cases were recorded, giving an incidence of 5.6% per month. Half of the patients contacted the doctor within four days from the initial symptom, every sixth waited more than two weeks. Their symptoms were monitored by the parents. Low fever, nasal discharge and cough were the most long-standing symptoms. After three weeks less than 50% of the patients were completely recovered. The children under one year of age recovered more quickly than the rest. No serious complications or sequelae were recorded.

Effect of fish oil on blood pressure and blood lipids in men with mild to moderate hypertension

Forty men with mild to moderate hypertension were given one of two dietary supplements for 6 weeks: 20 capsules of fish oil (MaxEPA) or placebo (olive and corn oil). The MaxEPA supplement provided about 7 g omega-3-fatty acids pr day, whereas the placebo contained about 7 g omega-6-fatty acids and only 0.2 g omega-3-fatty acids. A clinical insignificant reduction in blood pressure was noted in both groups. In the fish oil group, the serum triglyceride levels fell by 30%. A decrease in the ratio total cholesterol/high density lipoprotein (HDL-) cholesterol was noted in both groups, most pronounced in the placebo group. No significant effect on total serum cholesterol level was observed during this study.