Frequent use of primary health care service in Greenland: an opportunity for undiagnosed disease case-finding

High quality of diabetes care in Greenland since the launch of Steno Diabetes Center Greenland 2020 - geographical disparities need attention

The aim of this study was to estimate the prevalence of diagnosed diabetes in Greenland and evaluate quality of care according to sex, region and healthcare unit within regions. Data on all inhabitants registered with diabetes were extracted from the electronic medical record. We found a crude prevalence of diagnosed diabetes in the population aged ≥ 20 years to be 4.7%, and the prevalence of diabetes standardised to the WHO world population was 4.0%. Compared to males, a significantly higher proportion of females had mean glycated haemoglobin (HbA1c) level below 7% (68.9% vs. 57.5%) and blood pressure below 140/90 mmHg (83.4% vs. 73.5%). Regarding healthcare unit within regions, quality of care was higher in regional cities compared to smaller cities, concerning proportion of persons having blood pressure measured regularly (86.0% vs. 71.7%), urine tested for albuminuria (70.6% vs. 51.2%), receiving eye examination (86.9% vs. 79.5%) and foot examination (87.9% vs. 79.4%). In conclusion, the prevalence of diagnosed diabetes in Greenland is the highest reported yet. The overall quality of diabetes care was high and significantly improved compared to 2018. We observed geographical inequality in diabetes care and improvements in the quality of care in specific remote locations are necessary to minimise health care disparities.

Patterns in contacts with primary health care centres in Greenland

The aim of this study was to evaluate the activity within the primary health care (PHC) in Greenland by identifying the patterns of all registered contacts made by patients in 2021, and to compare the most frequently used types of contacts and diagnostic codes in Nuuk to the rest of Greenland. The study was designed as a cross-sectional register study using data from the national electronic medical records (EMR) and diagnostic codes from the ICPC-2-system. In 2021, 83.7% (46,522) of the Greenlandic population were in contact with the PHC, resulting in 335,494 registered contacts. The majority of the contacts with PHC was made by females (61.3%). On average, females were in contact with PHC 8.4 times per patient per year, while males were in contact with PHC 5.9 times per patient per year. The most frequently used diagnostic group was "General and unspecified", followed by "Musculoskeletal" and "Skin". The results are in line with studies from other northern countries and indicate an easily accessible PHC system, with a predominance of female contacts.

Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients

This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi² or Fisher's exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi², p = 0.010), olanzapine (Fisher's test, p = 0.003), and aripiprazole (Fisher's test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi², p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.

Low Prevalence of Chronic Obstructive Pulmonary Disease in Greenland-A Call for Increased Focus on the Importance of Diagnosis Coding

The aim of this study was to estimate the prevalence of patients diagnosed with chronic obstructive pulmonary disease (COPD) according to age, gender, and residence in Greenland and to investigate the associated quality of care. The study was performed as an observational cross-sectional study using data on patients diagnosed with COPD, extracted from the electronical medical record (EMR) in Greenland. The total prevalence of patients aged 20-79 years diagnosed with COPD in Greenland in 2022 was 2.2%. The prevalence was significantly higher in the capital Nuuk compared to the remaining parts of Greenland (2.4% vs. 2.0%, respectively). Significantly more women than men were diagnosed with COPD, but the lung function of men was found to be significantly reduced/impaired compared to women. The prevalence of patients aged 40 years or above was 3.8%. The quality of care was significantly higher among patients living in Nuuk compared to the remaining parts of Greenland for eight out of ten quality indicators. The prevalence of COPD in Greenland is lower than in other comparable populations and might be underestimated. Continued focus on early detection of new cases and initiatives to improve and expand monitoring of quality-of-care measurements, including both additional clinical and patient reported outcomes, are recommended.

Prevalence of users of medication targeting obstructive lung disease, the reasons for prescriptions and the use of spirometry in Upernavik Health Center in the period from 2011-2016, a retrospective observational study as basis for future quality development

Chronic obstructive pulmonary disease (COPD) is a health problem globally. Smoking is a risk factor. In Greenland over 50% are smokers. Upernavik Healthcare Center serves the town of Upernavik and its 9 remote settlements. Many patients were treated with medications targeting obstructive pulmonary disease (ATC code R03). This retrospective observational study estimated the prevalence of users of R03 medication aged 50 years or above, investigated if spirometry was performed, the reason for prescription and smoking status. The study is based on review of data from the electronic medical journal. Permanent residents with prescriptions of R03 medication within a period of 5 years were included. Reasons for prescription and smoking status was registrated. The prevalence of users of R03 medications was 7,6%. 37,8% had a spirometry performed. The reason for prescribing varied from no reason to COPD-like. R03 medications were prescribed years before spirometry. 37,8% of the patients were smokers. Prevalence of users was comparable to other studies in Greenland. There was lack of spirometry and a discrepancy to guidelines. Patients had prescriptions of R03 medication years without a specific diagnosis. This warrant a new strategy for identification, increase of spirometry and treatment of patients with COPD to be developed.

Prevalence of patients using antihypertensive medication in Greenland, and an assessment of the importance of diagnosis for the associated quality of care - a cross-sectional study

This study aimed to estimate the age- and sex specific prevalence of patients using antihypertensive medication in Greenland, and compared the quality of care between patients with and without a diagnosis for hypertension. The study was a cross-sectional study comparing patients using antihypertensive medication in 2020 (6,629 patients) and 2021 (7,008 patients), respectively. For data from 2021, patients with a medical diagnosis code were identified. Data was obtained from the Greenlandic electronic medical record. The population of Greenland was used as background population. Quality of care was evaluated based on suggested indicators by international guidelines and goals from Steno Diabetes Centre Greenland. The prevalence of patients aged ≥20 years using antihypertensive medication had increased from 16.7% in 2020 to 17.5% in 2021. The prevalence increased by age and was higher among women compared to men. In 2021, the prevalence of patients aged ≥20 years with a medical diagnosis code for hypertension was 7.9%. The use of antihypertensive medication in Greenland is common. The associated quality of care was low. However, process indicators were significantly improved when patients had a medical diagnosis code. Future focus must be on initiating initiatives ensuring that more patients are registered with a medical diagnosis code.

Polypharmacy and potential drug–drug interactions among Greenland’s care home residents

Background:

As lifetime expectancy in Greenland is steadily increasing, so is the proportion of elderly Greenlanders. Old age is associated with polypharmacy, and in this study, we aim to describe the prevalence and characteristics of polypharmacy among the care home residents in Greenland.

Methods:

Eight care homes in Greenland were visited between 2010 and 2016. Questionnaires including information on prescribed medication and comorbidities were collected and analyzed. Drugs were categorized according to Anatomical Therapeutic Chemical (ATC) category, and potential drug–drug interactions (pDDIs) were assessed using the Danish Interaction Database. Polypharmacy was defined as five or more prescribed drugs.

Results:

All 244 eligible residents were included in the study. The median number of prescribed drugs per resident was six, and women were prescribed more drugs than men (median six versus five). More than 60% of all residents fulfilled the criteria for polypharmacy. The residents in the polypharmacy group had a higher body mass index (26.9 versus 24.3) and more chronic diseases (median two versus one), and more often pulmonary (14% versus 1%) or endocrine disease (22% versus 2%) than in the non-polypharmacy group. The most prescribed drugs belonged to ATC category N (nervous system, 78% of the residents). Finally, pDDIs were found among 61% of the residents and were more common in the capital (77%), which also had the highest proportion of residents with polypharmacy (77%).

Conclusion:

This is the first study to describe the patterns of polypharmacy and pDDIs among the elderly in care homes in Greenland. Our findings indicate that polypharmacy is as common in Greenland as elsewhere in the Western world, but there are local differences in the prevalence.

Plain Language Summary

Polypharmacy among the elderly in care homes in Greenland

The lifetime expectancy of the Greenlandic population is increasing, and so is the number of elderly Greenlanders. Previous studies have shown that the elderly have a higher risk of being treated with five drugs or more which is called polypharmacy. Polypharmacy can cause unwanted interactions and side effects. In this study, we examine the characteristics of the residents in Greenlandic care homes belonging to this group.

Using questionnaires, we gathered information from 244 residents from care homes in eight different towns and settlements in Greenland. Data included types of medication prescribed to the resident, age, gender, cause of stay, and medical history, which allowed us to compare the results between genders and towns.

We found that among 244 residents, more than half of all residents were prescribed five or more different drugs, and women were generally prescribed more drugs than men. Those prescribed five or more drugs had a higher body mass index and more diseases than those prescribed fewer drugs. We also found that certain types of medication, mainly painkillers, were the most prescribed. Finally, residents in the care home in Greenland’s capital Nuuk were more often prescribed five or more drugs than elsewhere in Greenland, indicating local differences in Greenland.

Our results give an essential insight into the health and medication of the most fragile elderly in Greenland. Polypharmacy seems to be as common here as elsewhere in the Western world and is a point of focus.

The prevalence of atrial fibrillation in Greenland: a register-based cross-sectional study based on disease classifications and prescriptions of oral anticoagulants

   Previous studies of the prevalence of atrial fibrillation (AF) in Greenland are based on either single-point electrocardiograms (ECGs) or patients admitted with stroke. This study estimates the prevalence of AF based on disease classifications in the electronic medical record system (EMR) and prescriptions of oral anticoagulants (OACs). Patients given a diagnose classification code for AF or atrial flutter or prescribed the vitamin K antagonist Warfarin or the direct-acting oral anticoagulant Rivaroxaban were identified in the EMR. Descriptive data and selected laboratory values were extracted, and a minimum CHA₂DS₂-VASc score was calculated for the 790 patients identified in the EMR (66% men). A total prevalence of AF of 1.4% was found in the general population (1.8% among men and 1.0% among women), with a significantly lower prevalence among women younger than 70 years. There was a significant increase in AF-prevalence with advancing age (p<0.001) for both men and women. A minimum CHA₂DS₂-VASc was estimated and app. 10% of the patients may be undertreated with OACs. The prevalence of AF found in this study is higher than that found in previous studies in Greenland and comparable to the prevalence found in other Western countries, indicating that AF is common in Greenland.

Prevalence and quality of care among patients using medication targeting obstructive lung disease: a cross-sectional study in the five regions of Greenland

The aim of this study was to estimate the age- and gender-specific prevalence and quality of care among patients using medication targeting obstructive lung disease in the five regions of Greenland. The study was designed as a cross-sectional study. Data on patients using medication targeting obstructive lung disease was obtained from the electronically medical record used in Greenland. The prevalence was calculated using the population of Greenland as background population. The quality of care was determined using indicators proposed by international literature and the Steno Diabetes Center Greenland guidelines. The total prevalence of patients using medication targeting obstructive lung disease was 7.5%. The prevalence was significantly higher among women compared to men and differed significantly between the five regions. Smoking status, blood pressure and spirometry were registered within one/two years for 29.8%/43.2%, 29.2%/41.1% and 15.9%/26.0% of the patients, respectively. Regional differences were observed for all indicators.

The use of medication targeting obstructive lung disease is common in Greenland. Yet, the quality of care was low and interventions improving the quality of care is recommended.

Prevalence, incidence, mortality, and quality of care of diagnosed diabetes in Greenland

AIMS

To estimate prevalence, incidence, and mortality of diagnosed diabetes in Greenland, and to evaluate quality of diabetes care among men and women, and patients living in towns and settlements.

METHODS

This study was designed as an observational cross-sectional study based on review of data obtained from the electronic medical record (EMR) in Greenland. All permanent residents of Greenland registered with a diabetes diagnosis in the EMR (N = 1498) were included.

RESULTS

The age-standardized prevalence of diabetes was 2.19% as of Nov 30, 2018. The age-standardized incidence was 147 per 100,000 per year and the age-standardized mortality was 62 per 10,000 person-year among people aged ≥0 years old (Dec 1, 2017 to Nov 30, 2018). Quality of diabetes care was slightly higher among women compared to men concerning proportion with annual measurement of glycated haemoglobin (HbA_1c) (89.9% vs. 85.8%; p < 0.015), blood pressure (83.7% vs. 76.7%; p < 0.001).The only difference observed in quality of care among settlements and towns was lower proportion tested for microalbuminuria within one year in settlements (50.3% vs. 40.1%; p < 0.001).

CONCLUSIONS

The age-standardized prevalence of diagnosed diabetes in Greenland was 2.19% and the prevalence of diagnosed diabetes among adults aged ≥20 years was 3.7%. Only minor differences in quality of care related to gender and place of residence were observed. Further improvements in quality of care are warranted.

Diabetes care in the dispersed population of Greenland. A new model based on continued monitoring, analysis and adjustment of initiatives taken

Diabetes used to be a rare condition among Inuit in Greenland. However, research in recent decades has shown a high prevalence of undiagnosed diabetes. Addressing diabetes in the geographically dispersed population of Greenland presents a challenge to the health care system. In 2008, a new model of diabetes care was introduced in Greenland that included continual monitoring, analysis, and adjustment of initiatives taken. The overall aim of this review was to review the feasibility of the monitoring of an ongoing national diabetes care programme. After ten years of observation it was clear that monitoring of such a programme based on information in electronic medical records in Greenland was feasible. It was found that the majority of the population in Greenland was in contact with the health care system. Increased diagnostic activity resulted in an increased prevalence of diagnosed diabetes. The quality of diabetes care in Greenland and the testing effectiveness of gestational diabetes were improved. Microvascular complications were frequently observed among Greenlandic diabetic patients, except for retinopathy that was as an exception. In summary, this model may improve diabetes care and potentially care for other chronic conditions in Greenland, and may also be helpful in other remote settings where chronic disease care is difficult.Abbreviations: AD: Anno Domini; ADA: American Diabetes Association; BC: Before Christ; BMI: Body Mass Index; BP: Blood Pressure; CWB: Capillary Whole Blood; EMR: Electronic Medical Record; EASD: European Association for Study of Diabetes; GA: Gestational Age; GDM: Gestational Diabetes Mellitus; FIGO: The International Federation of Gynaecology and Obstetrics; HbA1c: Glycosylated haemoglobin; IDF: International Diabetes Federation; LDL: Low density lipoprotein; NDQIA: National Diabetes Quality Improvement Alliancel; NICE: National Institute for Health and Care Excellence; OECD: Organisation for Economic Co-operation and Development; OGTT: Oral Glucose Tolerance Test; QIH: Queen Ingrid Hospital; RCT: Randomised Controlled Tria;l T1D: Type 1 Diabetes; T2D: Type 2 Diabetes; UACR: Urine Albumin Creatinine Ratio; WHO: World Health Organisation.

High awareness of diabetes in the health care system in Greenland measured as a proportion of population tested with glycated haemoglobin within 2 years

BACKGROUND

Sixty years ago diabetes was almost non-existent in Greenland and until the beginning of this century awareness of diabetes was quite minimal. A high prevalence of undiagnosed diabetes has been reported in repeated population surveys. Increased focus on diabetes has been made a priority within the health care system since 2008, and in 2010 glycated haemoglobin was introduced as a diagnostic tool to further facilitate the diagnosis of diabetes.

OBJECTIVE

The aim of this study was to estimate the age and gender specific use of glycated haemoglobin in 2014 and 2015, as an indicator of diagnostic activity and awareness of diabetes, and to estimate the prevalence of diagnosed pre-diabetes and diabetes among adults in Greenland aged 20-79 years of age.

METHODS

The study was performed as an observational, cross sectional register study based on information gleaned from the electronically laboratory system used in Greenland including all patients tested with glycated haemoglobin at least once in 2014 or 2015.

RESULTS

A total of 10,127 patients were tested with glycated haemoglobin in 2014 or 2015 corresponding to 18.1% of the whole population. Among adults aged 20-79 years 9506 patients were tested corresponding to 24.0% of the total adult population. More females (32.5%) than males (16.5%) aged 20-79 years old were tested (p < 0.001). The prevalence of diagnosed diabetes and high risk pre-diabetes among adults aged 20-79 years was 4.3 and 6.8% respectively.

CONCLUSION

In conclusion use of glycated haemoglobin is widely used in the health care system in Greenland indicating a high awareness of diabetes in the population and by the health care system. Still, awareness of undiagnosed diabetes remains an important issue and additional strategies targeting males under 70 years old must be considered.

Children in Greenland: disease patterns and contacts to the health care system

Background

Previous studies of Greenlandic children’s disease pattern and contacts to the health care system are sparse and have focused on the primary health care sector.

Objective

We aimed to identify the disease pattern and use of health care facilities of children aged 0–10 in two Greenlandic cohorts.

Methods and design

In a retrospective, descriptive follow-up of the Ivaaq (The Greenland Child Cohort) and the CLEAR (climate changes, environmental contaminants and reproductive health) birth cohorts (total n=1,000), we reviewed medical records of children aged 6–10 in 2012 with residence in Nuuk or Ilulissat (n=332). Data on diseases and health care system contacts were extracted. Diagnoses were validated retrospectively. Primary health care contacts were reviewed for a random sample of 1:6.

Results

In 311 children with valid social security number, the total number of health care system contacts was 12,471 equalling 4.6 contacts per child per year. The annual incidence rate of hospital admissions was 1:10 children (total n=266, 1,220 days, 4.6 days/admission), outpatient contacts 2:10 children and primary care 3.6 per child. Contacts were overall more frequent in boys compared with girls, 39.5 versus 34.6 during the study period, p=0.02. The highest annual contact rates for diseases were: hospitalisations/acute respiratory diseases 13.9:1,000; outpatient contacts/otitis media 5.1:1,000; primary care/conjunctivitis or nasopharyngitis 410:1,000 children. Outpatient screening for respiratory tuberculosis accounted 6.2:1,000, primary care non-disease (Z-diagnosis) 2,081:1,000 annually. Complete adherence to the child vaccination programme was seen in 40%, while 5% did not receive any vaccinations.

Conclusions

In this first study of its kind, the health care contact pattern in Greenlandic children showed a relatively high hospitalisation rate and duration per admission, and a low primary health care contact rate. The overall contact rate and disease pattern resembled those in Denmark, except for tuberculosis screening. Adherence to the vaccination programme was low. These findings may be helpful for the organisation and dimensioning of the Greenlandic health care system for children.

Spirometry in Greenland: a cross-sectional study on patients treated with medication targeting obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is globally increasing in frequency and is expected to be the third largest cause of death by 2020. Smoking is the main risk factor of developing COPD. In Greenland, more than half of the adult population are daily smokers, and COPD may be common. International guidelines recommend the usage of spirometry as a golden standard for diagnosing COPD. The current number of spirometries performed among patients treated with medication targeting obstructive pulmonary disease in Greenland remains unexplored.

OBJECTIVE

To estimate the prevalence of patients aged 50 years or above treated with medication targeting obstructive pulmonary disease and the extent to which spirometry was performed among them within 2 years.

DESIGN

An observational, cross-sectional study based on the review of data obtained from electronic medical records in Greenland was performed. The inclusion criterion was that patients must have been permanent residents aged 50 years or above who had medication targeting obstructive pulmonary disease prescribed within a period of 15 months prior to data extraction. A full review of electronic patient records was done on each of the identified users of medication targeting obstructive pulmonary disease. Information on age, gender, town and spirometry was registered for each patient within the period from October 2013 to October 2015.

RESULTS

The prevalence of patients treated with medication targeting obstructive pulmonary disease aged 50 years or above was 7.9%. Of those, 34.8% had spirometry performed within 2 years and 50% had a forced expiratory volume (1 sec)/ forced vital capacity (FEV1/FVC) under 70% indicating obstructive pulmonary disease.

CONCLUSION

The use of medication targeting obstructive pulmonary disease among patients over 50 years old is common in Greenland. About one third of the patients had a spirometry performed within 2 years. To further increase spirometry performance, it is recommended to explore possible barriers in health care professionals' usage of spirometry in different health care settings in Greenland.

Prevalence and management of patients using medication targeting obstructive lung disease: a cross-sectional study in primary healthcare in Greenland

Objective

The aim of this study was to estimate the prevalent use of drugs targeting obstructive lung diseases among adults aged 50 or above in Greenland and to assess the use of spirometry testing among these medication users.

Study design

Observational cross-sectional study based on reviews of electronic medical records.

Methods

The study was performed in the 6 largest primary healthcare clinics in Greenland, representing approximately 67.0% of the population in Greenland. Adults aged 50 years or above, who had at least one electronically prescribed drug targeting obstructive lung diseases within a 15-month time interval, were identified. We assessed whether a spirometry test was registered in their medical records within previous 2- and 4-year periods.

Results

A total of 565 persons were identified. This corresponds to a prevalent medication use of 6.1% (565/9,023) among adults aged 50 years or above. Among these medication users, 14.1% (80/565) had a spirometry test performed within 2 years. Within the 4-year period this increased to 17.9% (101/565).

Conclusion

The use of medication targeting obstructive lung diseases in Greenland among adults aged 50 years or above is common. However, spirometry testing among medication users is low and interventions aiming to increase focus on spirometry testing should be integrated in the primary healthcare system.

Frequent use of primary health care service in Greenland: an opportunity for undiagnosed disease case-finding

OBJECTIVES

To estimate the age- and gender-specific consultation rates of patients who availed primary health care service in Greenland and to analyse contact patterns among patients in Nuuk.

DESIGN

Observational and cross-sectional register study using data captured from the medical records.

MATERIALS AND METHODS

The number of patients specified by age and gender who had contacted the primary health care centres within the last year was identified using a statistic module applied to the electronic medical records system. The population as it was on the 1st of January 2011 was used as the background population. The age- and gender-specific consultation rates were calculated. Review of most recent contact was performed in a subsample of patients from Nuuk, and information of the type of contact and diagnoses was obtained.

RESULTS

Eighty-three percent of the population in Greenland had been in contact with the primary health care centre within the last year. Females were more frequent users than males. A subsample of 400 patients in Nuuk was identified. Personal contact was the most frequent type of consultation (75.8%), followed by telephone (14.8%) and e-mail (9.8%) consultations. Musculoskeletal symptoms accounted for the most frequent bases for diagnoses.

CONCLUSION

More than 80% of the whole population has been in contact with the primary health care system within the last year. This indicates that opportunistic case-finding of chronic diseases such as diabetes, hypertension, etc. providing a possible strategy for decreasing the number of undiagnosed cases.