Segmenting Patients With Diabetes With the Navigator Service in Primary Care and a Description of the Self-Acting Patient Group: Cross-Sectional Study

BACKGROUND

The aim of patient segmentation is to recognize patients with similar health care needs. The Finnish patient segmentation service Navigator segregates patients into 4 groups, including a self-acting group, who presumably manages their everyday life and coordinates their health care. Digital services could support their self-care. Knowledge on self-acting patients' characteristics is lacking.

OBJECTIVE

The study aims are to describe how Navigator assigns patients with diabetes to the 4 groups at nurses' appointments at a health center, the self-acting patient group's characteristics compared with other patient groups, and the concordance between the nurse's evaluation of the patient's group and the actual group assigned by Navigator (criterion validity).

METHODS

Patients with diabetes ≥18 years old visiting primary care were invited to participate in this cross-sectional study. Patients with disability preventing informed consent for participation were excluded. Nurses estimated the patients' upcoming group results before the appointment. We describe the concordance (%) between the evaluation and actual groups. Nurses used Navigator patients with diabetes (n=304) at their annual follow-up visits. The self-acting patients' diabetes care values (glycated hemoglobin [HbA1c], urine albumin to creatinine ratio, low-density lipoprotein cholesterol, blood pressure, BMI), chronic conditions, medication, smoking status, self-rated health, disability (World Health Organization Disability Assessment Schedule [WHODAS] 2.0), health-related quality of life (EQ-5D-5L), and well-being (Well-being Questionnaire [WBQ-12]) and the patients' responses to Navigator's question concerning their digital skills as outcome variables were compared with those of the other patients. We used descriptive statistics for the patients' distribution into the 4 groups and demographic data. We used the Mann-Whitney U test with nonnormally distributed variables, independent samples t test with normally distributed variables, and Pearson chi-square tests with categorized variables to compare the groups.

RESULTS

Most patients (259/304, 85.2%) were in the self-acting group. Hypertension, hyperlipidemia, and joint ailments were the most prevalent comorbidities among all patients. Self-acting patients had less ischemic cardiac disease (P=.001), depression or anxiety (P=.03), asthma or chronic obstructive pulmonary disease (P<.001), long-term pain (P<.001), and related medication. Self-acting patients had better self-rated health (P<.001), functional ability (P<.001), health-related quality of life (P<.001), and general well-being (P<.001). All patients considered their skills at using electronic services to be good.

CONCLUSIONS

The patients in the self-acting group had several comorbidities. However, their functional ability was not yet diminished compared with patients in the other groups. Therefore, to prevent diabetic complications and disabilities, support for patients' self-management should be emphasized in their integrated care services. Digital services could be involved in the care of patients willing to use them. The study was performed in 1 health center, the participants were volunteers, and most patients were assigned to self-acting patient group. These facts limit the generalizability of our results.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/20570.

Experiences of patients with fibromyalgia at a Finnish Health Centre: A qualitative study

Background

Fibromyalgia is a functional syndrome. Despite recent findings, there is still considerable uncertainty about its diagnostic process.

Objectives

This study aimed to explore patients’ experiences with fibromyalgia during the diagnostic process in primary health care. Moreover, we tried to determine how diagnostic consultation could be improved.

Methods

This study is based on data from patients with fibromyalgia in a primary health care study conducted in Nokia, Finland. Patients with fibromyalgia were identified from electronic medical records. Focus-group participants with fibromyalgia diagnoses were selected using a purposive sampling method to gather a maximum variation sample. Qualitative thematic analysis was used for the coded data from four focus-group discussions in 2018. A description of the coding tree was provided and researchers organised the codes. Finally, all researchers identified themes from the data.

Results

The main unifying entities were the uncertainty and contradictions fibromyalgia patients faced on several occasions. Physicians sometimes offered other diagnoses – like depression – as an explanation for the symptoms, or used repetitive tests to eliminate other possible diagnoses. Furthermore, patients expressed their wishes for a holistic, empathetic, and up-to-date approach to their symptoms.

Conclusion

In our interviews, a good doctor-patient relationship and continuity of care were necessary, as were the physician’s attitude and knowledge of fibromyalgia. Our findings also suggest avoiding repeated or unnecessary rule-out tests and the overdiagnosis of psychiatric disorders is necessary.

Experiences of Navigator, a Finnish patient-segmentation service, in primary care: A mixed-methods study

Aging and multimorbid populations burden health services worldwide. Segmenting patients with similar health service needs into different groups and guiding care providers to tailor services to these groups could reduce this burden. Methods of patient segmentation have been based on, e.g., databases. However, the Finnish patient-segmentation innovation Navigator (Suuntima) considers patients’ perspectives on their coping in everyday life, as well as professionals’ views of the patients’ state of health. The segmentation is based on questions. The resulting care pathway related to the group helps professionals to coordinate patients’ health care and patients to utilize appropriate services. This first part of Navigator’s validation study evaluates its feasibility and content and face validity. We assess the web-service’s user experiences at nurses’ appointments with diabetic patients, time consumption, and Navigator’s question relevance, comprehensiveness, and comprehensibility. This mixed-methods study uses user experience questionnaires for both patients and professionals, and semi-structured focus-group interviews for professionals. We used descriptive statistics in the quantitative data analysis of the questionnaire study and thematic analysis to identify the codes and themes in the interview data. All 304 Navigator queries were completed at appointments. Most patients found Navigator easy to use. It helped in considering their situation better and from new perspectives. Most patients did not find it too time-consuming. Most professionals found it easy to use and suitable for appointments and patient segmentation. The questions were easy and unambiguous, and they assisted in discussing new or sensitive issues. Most queries were completed in less than 19 mins and less time was used if the patient was assigned to the nurse. Thematic analysis raised five main themes: 1) Well-functioning web-service, 2) Stimulus for conversation and action, 3) Rationale to complete Navigator with a professional, 4) Training and experience ease the use of Navigator, and 5) Navigator's room for improvement. Subthemes were identified for three main themes. We consider Navigator’s feasibility and face validity to be favorable. We suggest user instructions and the clarification of concepts to support the questions’ comprehensibility. Some patients may benefit from a nurse’s presence when responding to Navigator’s questions.

Web-Based Patient Segmentation in Finnish Primary Care: Protocol for Clinical Validation of the Navigator Service in Patients With Diabetes

BACKGROUND

An aging population and increasing multimorbidity challenge health care systems worldwide. Patient segmentation aims to recognize groups of patients with similar needs, offer targeted services to these groups, and reduce the burden of health care. In this study, the unique Finnish innovation Navigator, a web-based service for patient segmentation, is presented. Both patients and health care professionals complete the electronic questionnaire concerning patients' coping in everyday life and health state. Thus, it considers the patient perspective on self-care. One of four customership-strategy (CS) groups (self-acting, community, cooperating, and network) is then proposed in response to the answers given. This resulting strategy helps both professionals to coordinate patient health care and patients to utilize appropriate health services.

OBJECTIVE

This study aims to determine the feasibility, validity, and reliability of the Navigator service in the segmentation of patients with diabetes into four CS groups in a primary care setting. Patient characteristics concerning demographic status, chronic conditions, disabilities, health-related quality of life, and well-being in different CS groups will be described. We hypothesize that patients in the network group will be older, have more illnesses, chronic conditions or disabilities, and require more health care services than patients in the self-acting group.

METHODS

In this mixed methods study, data collection was based on questionnaires (user experience of Navigator, demographic and health status, World Health Organization Disability Assessment Schedule 2.0, EuroQol 5D, Wellbeing Questionnaire 12, and the Diabetes Treatment Satisfaction Questionnaire) issued to 300 patients with diabetes and on user-experience questionnaires for and semistructured focus-group interviews with 12 nurses. Navigator-database reports and diabetes-care values (blood pressure, BMI, HbA1c, low-density lipoprotein, albumin-creatinine, smoking status) were collected. Qualitative and descriptive analyses were used to study the feasibility, content, concurrent, and face validity of Navigator. While criterion and concurrent validity were examined with correlations, reliability was examined by calculating Cohen kappa and Cronbach alpha. Construct validity is studied by performing exploratory-factor analysis on Navigator data reports and by hypothesis testing. The values, demographics, and health status of patients in different groups were described, and differences between groups were studied by comparing means. Linear regression analysis was performed to assess which variables affect CS group variation.

RESULTS

Data collection was completed in September 2019, and the first feasibility results are expected by the end of 2020. Further results and publications are expected in 2021 and 2022.

CONCLUSIONS

This is the first scientific study concerning Navigator's psychometric properties. The study will examine the segregation of patients with diabetes into four CS groups in a primary care setting and the differences between patients in groups. This study will assist in Navigator's further development as a patient segmentation method considering patients' perspectives on self-care. This study will not prove the effectiveness or efficacy of Navigator; therefore, it is essential to study these outcomes of separate care pathways.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20570.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres

BACKGROUND

The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility.

RESULTS

The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period.

CONCLUSIONS

The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Patient enablement after a consultation with a general practitioner-Explaining variation between countries, practices and patients

BACKGROUND

Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking.

OBJECTIVE

To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement.

DESIGN

We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated.

SETTING AND PARTICIPANTS

A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data.

RESULTS

In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported.

DISCUSSION AND CONCLUSIONS

There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.

Long-term survival after intrahepatic cholestasis of pregnancy: A follow-up of 571 mothers

OBJECTIVE

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder during pregnancy. ICP has been associated with morbidity but little is known about women's long-term survival. Our aim was to determine whether ICP is associated with mothers' long-term survival.

STUDY DESIGN

The study population comprised 571 women with ICP in at least one pregnancy seen at Tampere University Hospital in Finland between 1969‒1988. The reference group comprised 1333 women: the previous and the following participant in the maternity ward diary. The data were obtained from Statistics Finland in March 2017 containing deaths among the study participants between 1971‒2015. The follow-up time of the cohort was 27-46 years. The Kaplan-Meier method was used.

RESULTS

Totally, 39 of the mothers with ICP (6.8%) and 111 of the reference group (8.3%) had died by the end of 2015 (p = 0.267). The mean survival time of ICP women was 77.4 years and of the reference group 79.2 years (p = 0.288). The mean survival time from labour in the ICP group was 45.0 years and in the reference group 44.8 years (p = 0.259).

CONCLUSIONS

Based on this study ICP does not seem to be associated with women's survival. There is no need to follow-up ICP mothers' health because of the nonexistent risk of premature death.

Comparison of the Patient Enablement Instrument (PEI) with two single-item measures among Finnish Health care centre patients

Background

The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients.

Methods

Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points.

Results

Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low.

Conclusions

Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

The association between bullying victimization in childhood and fibromyalgia. Data from the nationwide Finnish health and social support (HeSSup) study based on a sample of 64,797 individuals

BACKGROUND

Fibromyalgia is a functional pain syndrome presenting with various psychological symptoms. Several studies have shown that adverse life events are associated with fibromyalgia. The aim of the current study is to explore the association between self-reported bullying victimization in childhood and self-reported fibromyalgia in adulthood.

METHODS

The basic study setting is cross-sectional - with focused use of retrospective data - derived from a large on-going postal follow up survey (sample N = 64,797) initiated in Finland in 1998. Only respondents having answered the questions on fibromyalgia in both follow ups in 2003 and 2012 were included (N = 11,924). Severity of bullying was divided into three groups starting from no bullying followed by minor and severe bullying. Covariates having shown statistically significant associations with fibromyalgia in cross tabulation using Pearson's chi-squared test were included in the final multiple logistic regression analyses.

RESULTS

In our study, 50.6% of the respondents reported victimization of minor and 19.6% of severe bullying in childhood. Participants reporting fibromyalgia in adulthood reported more bullying, and in females alone this association was statistically significant (p = .027). In multiple logistic regression analysis statistically significant associations between bullying victimization in childhood (reference: no bullying) and fibromyalgia were found: adjusted odds ratio (OR) for minor bullying was 1.35 (95% CI 1.09-1.67) and for severe bullying 1.58 (95% CI 1.21-2.06). However, in log-linear and logistic regression interaction models the association between bullying and fibromyalgia was not statistically significant when depression was included in the models.

CONCLUSIONS

Our results suggest that peer bullying victimization might be associated with fibromyalgia. However, in logistic log linear and logistic interaction models there was no statistically significant association when depression was included. As a result, there is need for further, preferably prospective cohort studies. The findings also emphasize the importance of actions to prevent childhood bullying.

Primary health care in transition: Variations in service profiles of general practitioners in Estonia and in Finland between 1993 and 2012

INTRODUCTION

Since the early 1990s, the Estonian and Finnish health systems have undergone various changes which are expected to have impacted the type and range of services provided by general practitioners (GPs).

OBJECTIVE

To compare GP services between Estonia and Finland in 1993 and 2012 and draw a parallel with transformations occurred in the health systems of both countries during these two decades.

METHODS

Data were collected through surveys among 129 and 288 GPs from Estonia and Finland in 2012 and 139 Estonian and 239 Finnish GPs in 1993. Descriptive statistics were used to compare between countries and years.

RESULTS

Between 1993 and 2012, the number of working hours per week and consultations per day increased in Estonia and decreased in Finland. In 2012, GPs in were more often the first contact for psychosocial and women´s and children´s in Estonia, whereas this decreased in Finland. The frequency of treating acute patients mostly decreased in both countries. We observed a decrease in medical procedures in Finland and an increase in Estonia. Finnish GPs still conducted more procedures in 2012.

CONCLUSION

Due to partly opposite changes, the services provided by Finnish and Estonian GPs became more similar. Still, there are large differences in services provided, possibly arising from differences in the organisation of health services, the training of doctors and patients' preferences.

Successful Curriculum Change in Health Management and Leadership Studies for the Specialist Training Programs in Medicine in Finland

In Finland, the specialization programs in Medicine and Dentistry can be undertaken at all five university medical faculties in 50 specialization programs and in five programs for Dentistry. The specialist training requires 5 or 6 years (300–360 ECTS credits) of medical practice including 9 months of service in primary health care centers, theoretical substance specific education, management studies, and passing a national written exam. The renovation of the national curriculum for the specialization programs was implemented, first in 2008 and officially in August 2009, when theoretical multi-professional social, health management and leadership studies (10–30 ECTS credits) were added to the curriculum. According to European Credit Transfer and Accumulation System (ECTS), 1 ECTS credit (henceforth, simply “ECTS”) means 27–30 h of academic work¹ National guidelines for the multi-professional leadership training include the basics of organizational management and leadership, the social and healthcare system, human resources (HR) management, leadership interaction and organizational communication, healthcare economy, legislation (HR) and data management. Each medical faculty has implemented management studies autonomously but according to national guidelines. This paper will describe how the compulsory management studies (10 ECTS) have been executed at the Universities of Tampere and Turku. In Tampere, the 10 ECTS management studies follow a flexible design of six academic modules. Versatile modern teaching methods such as technology-assisted and student orientated learning are used. Advanced supplementary management studies (20 ECTS) are also available. In Turku, the 10 ECTS studies consist of academic lectures, portfolio and project work. Attendees select contact studies (4–6 ECTS) from yearly available 20 ECTS and proceed at their own pace. Portfolio and project comprise 2–5 ECTS each. The renovation of medical specializing physicians' management and leadership education has been a successful reform. It has been observed that positive attitudes and interest toward management overall are increasing among younger doctors. In addition, management and leadership education will presumably facilitate medical doctors' work as managers also. Continuous development of medical doctors' management and leadership education for physicians and dentists is needed while the changing and complex healthcare environment requires both professional and leadership expertise.

Analysis of factors associated with waiting times for GP appointments in Finnish health centres: a QUALICOPC study

Objective

Access to care is a multidimensional concept, considered as a structural aspect of health care quality; it reflects the functioning of a health care organization. The aim of this study was to investigate patients’ experiences of access to care and to analyse factors associated with waiting times to GP appointments at Finnish health centres. A questionnaire survey was addressed to Finnish GPs within the Quality and Costs of Primary Care in Europe study framework. Two to nine patients per GP completed the questionnaire, altogether 1196. Main outcome measures were waiting times for appointments with GPs and factors associated with waiting times. In addition, patients’ opinions of access to appointments were analysed.

Results

Of the 988 patients who had made their appointment in advance, 84.9% considered it easy to secure an appointment, with 51.9% obtaining an appointment within 1 week. Age and reason for contact were the most significant factors affecting the waiting time. Elderly patients tended to have longer waiting times than younger ones, even when reporting illness as their reason for contact. Thus, waiting times for appointments tend to be prolonged in particular for the elderly and there is room for improvement in the future.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3316-7) contains supplementary material, which is available to authorized users.

Patient Enablement After a Single Appointment With a GP: Analysis of Finnish QUALICOPC Data

Background: Patient enablement is described as patient’s ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. Methods: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. Results: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant (P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. Conclusions: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.

Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study

OBJECTIVE

We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries.

DESIGN AND SETTING

We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe.

SUBJECTS

875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices.

MAIN OUTCOME MEASURES

The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses.

RESULTS

The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted intrauterine devices significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries.

CONCLUSION

GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered.

Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study

OBJECTIVE

We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries.

DESIGN AND SETTING

We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe (QUALICOPC).

SUBJECTS

A total of 875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices.

MAIN OUTCOME MEASURES

The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses.

RESULTS

The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted IUDs significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries.

CONCLUSIONS

GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered.

Enrolment of 22,000 adolescent women to cancer registry follow-up for long-term human papillomavirus vaccine efficacy: guarding against guessing

Human papillomaviruses (HPVs, most notably types 16 and 18) cause cervical carcinoma, the second most common cancer among women. Vaccination of adolescents against HPV16/18 might prevent large proportion of cervical and other anogenital cancers. However, because of ethical reasons this cannot be proven by clinical studies. To determine the long-term vaccine efficacy (VE) of HPV16/18 virus-like-particle (VLP) vaccine against cervical carcinoma in situ (CIS+) and invasive cervical carcinoma, the following three population-based cohorts of adolescent women have been enrolled: (1) women vaccinated with the HPV vaccine; (2) women vaccinated with hepatitis A control vaccine; and (3) unvaccinated control women. These cohorts will be passively followed for cumulative incidence of CIS+ endpoints by population-based cancer registry. Overall 24,046 16- to 17-year-old adolescent women from 18 cities in Finland were invited between May 2004 and June 2005 to participate in a phase III trial with bivalent HPV16/18 VLP vaccine. A total of 58,996 18- to 19-year-old women were invited in May 2005 to participate as unvaccinated controls. Women who reported their willingness to participate in an HPV vaccination trial had they been 1–2 years younger were eligible. Cumulative incidence (CI) of CIS+ in our cohorts over 15 years is approximately 0.45%. VE of 70% against CIS+ with 80% power requires 3357–3189 HPV16/18 vaccine recipients, 3357–3189 other vaccine recipients, and 6714–9567 unvaccinated controls. We have now enrolled 2404 HPV16/18 vaccine recipients, 2404 hepatitis A-vaccine recipients, and 5130 unvaccinated controls. This enrolment in addition to our earlier enrolment in another phase III trial guarantees enough power so that by 2020 we can ultimately provide data on the efficacy of HPV16/18 vaccination against CIS+.

Men’s Health Is Not Affected by Their Mothers’ Intrahepatic Cholestasis of Pregnancy

Little is known about the effects of mother’s intrahepatic cholestasis of pregnancy (ICP) on the health of sons born to these mothers. The purpose of the present study was to explore the health of sons born to mothers with ICP. The study design was a retrospective study of ICP mothers’ sons. In the region of Tampere University Hospital in Finland, 365 sons of mothers with ICP during 1969 to 1988 and 617 sons of mothers without ICP were sent a questionnaire in 2010. The response rates were 37.8% ( n = 138) and 36.6% ( n = 226), respectively. Only minor differences were reported between the two groups. Self-evaluated health was similar. There were no significant differences between the groups regarding symptoms and complaints, diagnosed diseases, mental health, and use of medicines. Cough was 10.8 percentage points less common among ICP mothers’ sons than among controls ( p = .034). Urticaria was more common among ICP mothers’ sons, the difference in percentage points being 2.2 ( p = .026). In general, a mother’s ICP does not affect her son’s health.

What predicts doctors' satisfaction with their chosen medical specialty? A Finnish national study

BACKGROUND

In Finland the number of medical specialists varies between specialties and regions. More regulation of the post-graduate medical training is planned. Therefore, it is important to clarify what predicts doctors' satisfaction with their chosen specialty.

METHODS

A random sample contained 50% of all Finnish doctors under 70 years of age. The respose rate was 50.5%. Working-age specialists were asked to value their motives when choosing a specialty. They were also asked if they would choose the same specialty again. The odds ratios for not choosing the same specialty again were tested.

RESULTS

Diversity of work was the most important motive (74% of respondents). Seventeen percent of GPs would not choose the same specialty again, compared to 2% of ophthalmologists and 4% of pediatricians. A major role of Diversity of work and Prestigious field correlated with satisfaction whereas Chance with dissatisfaction with the specialty.

DISCUSSION

Motives and issues related to the work and training best correlate with satisfaction with the specialty.

CONCLUSIONS

When the numbers of Finnish postgraduate medical training posts become regulated, a renewed focus should be given to finding the most suitable speciality for each doctor. Information about employment and career advice should play an important role in this.

[Pregnancy contraception (Current Care Guideline)]

There are no age limits for the start or use of contraception. Prior gynecological examination or cervical smear is not needed. Condom is the only method that protects from sexually transmitted diseases. An increase in the risk of venous thromboembolism (VTE) is associated only with combined contraceptives. However, the risk is remarkably higher with pregnancy, puerperium or with smoking. The most effective reversible methods are intrauterine devices (IUD) and implants, as these do not depend on daily memory. Natural family planning methods are not reliable, and effective contraception should be easily available for all at all times.

Do clinicians understand the size of treatment effects? A randomized survey across 8 countries

BACKGROUND

Meta-analyses of continuous outcomes typically provide enough information for decision-makers to evaluate the extent to which chance can explain apparent differences between interventions. The interpretation of the magnitude of these differences - from trivial to large - can, however, be challenging. We investigated clinicians' understanding and perceptions of usefulness of 6 statistical formats for presenting continuous outcomes from meta-analyses (standardized mean difference, minimal important difference units, mean difference in natural units, ratio of means, relative risk and risk difference).

METHODS

We invited 610 staff and trainees in internal medicine and family medicine programs in 8 countries to participate. Paper-based, self-administered questionnaires presented summary estimates of hypothetical interventions versus placebo for chronic pain. The estimates showed either a small or a large effect for each of the 6 statistical formats for presenting continuous outcomes. Questions addressed participants' understanding of the magnitude of treatment effects and their perception of the usefulness of the presentation format. We randomly assigned participants 1 of 4 versions of the questionnaire, each with a different effect size (large or small) and presentation order for the 6 formats (1 to 6, or 6 to 1).

RESULTS

Overall, 531 (87.0%) of the clinicians responded. Respondents best understood risk difference, followed by relative risk and ratio of means. Similarly, they perceived the dichotomous presentation of continuous outcomes (relative risk and risk difference) to be most useful. Presenting results as a standardized mean difference, the longest standing and most widely used approach, was poorly understood and perceived as least useful.

INTERPRETATION

None of the presentation formats were well understood or perceived as extremely useful. Clinicians best understood the dichotomous presentations of continuous outcomes and perceived them to be the most useful. Further initiatives to help clinicians better grasp the magnitude of the treatment effect are needed.

[Acute head injuries in primary health care--internet survey conducted with general practitioners]

Patients with head injury constitute a large population treated in primary health care. It is essential to recognize patients with traumatic brain injury among this notable population to determine the need for more specific evaluation. General practitioners (n=331) in Pirkanmaa hospital district in Finland received an email link to answer the survey. The response rate was 54.1% (n=179). Mean survey score was 20.5 points (max. 25). Only acquaintance with the national traumatic brain injury practice guidelines was associated with greater survey scores. The general practitioners' level of knowledge in managing head injuries was good. Deficiencies were found in the questions dealt with post-traumatic amnesia and the definition of traumatic brain injury.

Quality of the contraceptive service structure: a pilot study in Finnish health centre organisations

OBJECTIVES

To evaluate the quality of the contraceptive service structure in health centre organisations (HCOs) in western Finland and to establish whether the characteristics of the HCOs are associated with the quality measured.

METHODS

Survey data were collected from all HCOs in a university hospital area in western Finland (N = 63). Quality was evaluated using a score of ten indicators. Associations between the score and the characteristics of the HCOs were studied using rank correlation analysis and a multivariate ordered logit model.

RESULTS

Among 51 HCOs yielding complete data for the evaluation, the quality score ranged from 3 to 10, the mean being 5.8. From 25 variables studied, 'a chief nursing officer or leading nurse engaged in the HCO' (p = 0.001) and 'an appointed person responsible for management of health promotion' (p = 0.006) were found to be associated with a good score in the rank correlation analysis, and they also remained significant in multivariate analysis (Odds Ratio [OR] = 11.5, 95% confidence interval [CI] 2.3-56.5 and OR = 5.9, 95% CI 1.6-21.5, respectively).

CONCLUSIONS

In the majority of the HCOs involved, the quality of service structure was rated average, but there was much variation between the HCOs. The results of the multivariate analysis emphasise the importance of good management of services.

Initiation of postpartum contraception: a survey among health centre physicians and nurses in Finland

OBJECTIVE

To examine self-reported professional practices of postpartum contraceptive counselling at Finnish community health centres.

DESIGN

A survey study with self-administered online questionnaires.

SETTING

All local municipalities (n = 107) in the Expert Responsibility Area of Tampere University Hospital in Western Finland in 2005.

SUBJECTS

A total of 69 (64% of 107) health centre physicians and 80 (75%) nurses performing postpartum check-ups.

MAIN OUTCOME MEASURES

Contraceptive method most often initiated or recommended to breastfeeding women at postpartum visit; timing of postpartum initiation of hormonal and intrauterine contraceptive methods in relation to breastfeeding and resumption of menses.

RESULTS

The most common contraceptive method initiated or recommended to breastfeeding women by both physicians (41%) and nurses (45%) was the condom, followed by progestin-only pills and intrauterine contraception. Few professionals recommended breastfeeding (lactational amenorrhea) as the only contraceptive method. Only eight (12%) physicians inserted a copper-releasing intrauterine device and five (7%) a levonorgestrel-releasing intrauterine system typically at the postpartum visit; the majority delayed the insertions until the resumption of menses. Fifty-three (77%) physicians initiated combined oral contraceptives mostly when breastfeeding was terminated and menses had returned. Over half of the municipalities involved in the study did not provide any medical contraceptives free of charge postpartum.

CONCLUSION

Professionals' reports indicate that initiation of effective contraceptive methods is delayed after childbirth. In order to promote better postpartum contraception practices, updated evidence-based guidelines are needed.

Risk-taking behaviour is more frequent in teenage girls with multiple sexual partners

OBJECTIVE

To investigate associations between sexual behaviour and risk-taking health behaviour among adolescent females in our changing sexual culture.

DESIGN

A questionnaire study. Girls who had had multiple sexual partners (at least five in their lifetime or four during the last six months) were compared with those with fewer partners. Logistic regression was applied.

SETTING

The Adolescent Clinic, a primary healthcare unit in the city of Tampere, Finland.

SUBJECTS

A sample of 247 female clients aged 15-18 years who had experienced sexual intercourse.

MAIN OUTCOME MEASURES

Contraceptive practices, substance use, and sexual attitudes.

RESULTS

Girls with multiple sexual partners (n = 69) and the reference group (n = 178) did not differ from each other significantly by age, age at menarche, or educational status. In univariate analysis, age at sexual debut, contraceptive practices, and various substance uses were strongly associated with having multiple sexual partners. Ever-use of emergency contraception was marginally associated, while ever-use of conventional hormonal contraception or condoms was not. In multivariate analysis, low age at sexual debut (OR 8.75 for age 11-13), omitting contraception at the most recent intercourse (OR 3.48), ever-use of withdrawal as a contraceptive method (OR 2.34), and repeated use of drugs (OR 4.10) were associated with having multiple sexual partners.

CONCLUSION

Different types of risk-taking behaviour are still interlinked. In discussions with adolescents showing one type of risk behaviour health service providers should make an effort to identify other modes of risk-taking.

Emergency contraception among Finnish adolescents: awareness, use and the effect of non-prescription status

BACKGROUND

Adolescents need to be aware that there is a method of preventing pregnancy even after an unprotected intercourse. Limited information is available on the awareness of young adolescents and the effects of selling emergency contraception (EC) over-the-counter, and the findings are controversial. The aims of this study were to investigate awareness and use of EC among Finnish girls aged 12-18 years in 1999-2003, and to assess the effect of the 2002 non-prescription status on the use.

METHODS

A self-administered questionnaire was sent to a population-based sample of 12-18-year-olds girls in 1999, 2001, and 2003. Response rate was 83% in 1999 (N = 4,369), 79% in 2001 (N = 4,024) and 77% in 2003 (N = 3,728), altogether N = 12,121. Logistic regression model was used to examine the association of unawareness and use of EC with socio-economic background and health behaviour.

RESULTS

In 2001, nearly all 14-18-year-olds and a majority of 12-year-olds were aware of EC. Among 12-14-year-olds, a slight increase in awareness between 1999 and 2003 was observed but this was not related to non-prescription status. Health-compromising behavior (alcohol use, smoking), dating and having good school achievement were related to higher awareness of EC.Nine percent of 14-18-year-olds had used EC once and 1% three times or more. No statistically significant change in EC use was found after non-prescription status. EC use increased with increasing alcohol consumption, particularly at age 14. Smoking, dating, and poor school achievement were related to increased use as well as not living in nuclear family. A lower use was observed if living in rural area or father's education was high. Mother's education was not related to use.

CONCLUSION

Adolescent girls were well aware of the existence of emergency contraception even before the non-prescription status. Over-the-counter selling did not increase the use.

Anticipated acceptance of HPV vaccination at the baseline of implementation: a survey of parental and adolescent knowledge and attitudes in Finland

We evaluated acceptance of human papillomavirus (HPV) vaccination by adolescents and their parents, 83% and 86% of whom accepted vaccination. Improving knowledge and awareness of HPV, and addressing parental concerns about vaccinating adolescents, most notably on vaccinating against a sexually transmitted disease, should help tackle factors associated with being resistant to accepting HPV vaccination.

The use of oral contraceptives among Finnish teenagers from 1981 to 2003

PURPOSE

The teenage abortion rate has increased in Finland since 1995, after a long-term decrease. We studied changes in the use of oral contraceptives (OC) among 14-18-year-old Finnish girls from 1981 to 2003.

METHODS

A self-administered questionnaire (the Adolescent Health and Lifestyle Survey) was sent biennially to a representative sample of 14-18-year-olds from 1981-2003. Numbers of respondents varied between 1200 and 4100 and response rates between 77% and 90%. Altogether, 35,939 girls participated. OC use, and individual, family, and place of residence factors were examined. Logistic regression models were run separately for 1981-1991 and 1993-2003.

RESULTS

The proportion of OC users doubled from 1981 to 1991, from 9.5% to 19.3%. The rising trend leveled off after 1991 and settled down at around 19% to 20%. During both periods, OC use was higher among girls with early age at menarche, still in school at age 16-18 years, poor school achievement, living in one-parent families or with a stepparent, and girls whose parents had a low level of education. OC use decreased in the capital area in the early 1990s, unlike in other areas.

CONCLUSIONS

Adolescent OC use increased in the 1980s. A decade later, despite known increase in sexual activity, OC use remained unchanged. This was probably a result of deteriorated access to contraceptive counseling after changes in health service, and may have contributed to the increased abortion rate. Except for a decrease in OC use in the capital area, the association of individual, family, and regional factors with OC use remained mostly stable during 1981-2003.

Population-based enrolment of adolescents in a long-term follow-up trial of human papillomavirus vaccine efficacy

We evaluated a study setting for assessment of the long-term vaccine efficacy (VE) of human papillomavirus (HPV) virus-like-particle (VLP) vaccine against cervical carcinoma. A total of 22,412 16- to 17-year old adolescent women from seven cities in Finland were invited by letter to participate in a phase III study of a quadrivalent HPV (types 6, 11, 16, 18) VLP vaccine, between September 2002 and March 2003. A total of 30,947 18-year old women were invited to participate as unvaccinated controls. These women were asked about their willingness to participate in an HPV vaccination trial and to fill a health questionnaire. These three population-based cohorts of adolescent women, including women vaccinated with HPV vaccine or placebo vaccine and unvaccinated control women, are systematically followed over time. The study cohort database will be linked with the Finnish Cancer Registry using cervical carcinoma in situ (CIS) and invasive cervical carcinoma (ICC) as endpoints. Assuming that the cumulative incidence of CIS and ICC over 15 years is 0.45%, and that there is no loss to follow-up, and power of 80%, the determination of 70% total VE will require 3357 HPV vaccine recipients, 3357 placebo vaccine recipients, and 6714 unvaccinated controls. At the baseline, 2632 (12%) of the invited adolescents volunteered to the phase III vaccination trial, and 6790 (22%) responded to the questionnaire study. During a recruitment period of 10 months, 874 HPV vaccine recipients, 875 placebo recipients and 1919 unvaccinated controls were enrolled. Population-based enrollment of large cohorts of vaccinated and unvaccinated adolescents for passive registry-based follow-up with cervical carcinoma as the end-point is feasible and currently going on in Finland.

Teenage Contraceptive Use in Iceland: A Gender Perspective

Different gender beliefs toward contraception may affect contraceptive use among teenagers and need to be explored for the development of sexuality education and services aimed at this age group. A cross-sectional national survey was conducted. A random sample of 1,405 sexually active teenagers, 1,181 girls, and 224 boys was studied. One quarter of the girls and one fifth of the boys had often/always used unsafe methods (withdrawal and natural methods), and about one third of the teenagers used contraceptive methods sporadically or not at all. Generally, teenage girls had more positive beliefs toward use of contraceptives, more positive friends, and more supportive parents regarding contraception than boys. Both genders were more likely to use contraceptives if they recognized the seriousness of pregnancy and easiness of making contraceptive plans. Additionally, teenage girls were more likely to use contraceptives if they were older at the time of sexual debut, were in a steady sexual relationship, considered contraceptive services good, believed in not taking chances, and their parents knew about their contraceptive use. Preventive strategies must primarily target those teenagers who start sexual debut early, are not in a steady relationship, and are not receiving parental support.

Attitudes to terminal patients? unorthodox therapy: Finnish doctors? responses to a case scenario

We carried out a postal survey of a sample of Finnish doctors ( n=1182) concerning their attitudes and ethical decisions in end-of-life care. A scenario was presented in which a patient with terminal cancer wished to obtain unorthodox treatment. Factors possibly influencing decision making such as general attitudes, life values and demographics were investigated. The response rate was 62%. The patient's plan to use unorthodox treatment was accepted by 54% of doctors. Gender or speciality did not influence the decision, but doctor's age was a significant factor ( P=0.0005). Doctors aged 35-49 years were more accepting; younger and older ones less accepting. Doctors who had clinical experience in terminal care were more compliant to the patient's plan ( P=0.034). A stepwise logistic regression analysis was used to create a model for explaining not accepting versus accepting the treatment with the background variables. Altogether eight independent significant variables were included in the final model of explaining a doctor's choice in the presented scenario. According to the model the patient's wish was more frequently accepted if the doctor was middle-aged, had clinical experience in terminal care, valued a high standard of living, considered terminal care satisfying, was less critical of health economics, considered advance directives helpful, had a high fear-of-death index score, and valued professional status less.

Pubertal timing, sexual behaviour and self-reported depression in middle adolescence

The associations between pubertal timing, sexual activity and self-reported depression were analysed in a population sample of 17,082 girls and 15,922 boys aged 14-16 as a par of a classroom survey. Pubertal timing was assessed by age at onset of menstruation (menarche) or ejaculations (oigarche). Sexual experiences elicited included kissing, light petting, heavy petting and intercourse. Self-reported depression was measured by the 13-item Beck Depression Inventory. Among girls, self-reported depression was associated with early puberty and intimate sexual relationship. Among boys depression was associated with very early and late puberty and experience of intercourse. Early puberty is a risk factor for self-reported depression. Intimate sexual relationships in middle adolescent are likely to indicate problems in adolescent development rather than successful adolescent passage.

Risk-taking sexual behaviour and self-reported depression in middle adolescence--a school-based survey

BACKGROUND

Early sexual activity has been widely studied in the context of pregnancies, substance use and antisocial behaviour, but the aspects of psychosexual health have received less attention.

AIM

To study the associations of early sexual activity and self-reported depression.

SETTING

A school survey in Finland in 1999 and 2000 in the eighth and ninth grades.

METHODS

Adolescents with experience of sexual intercourse were studied (11,793 girls and 10,443 boys, mean age 15.5 years). Scores of 8 or more in the Beck Depression Inventory were regarded as indicative of self-reported depression. Associations with sexual behaviour variables were analysed using logistic regression models.

RESULTS

In both genders, self-reported depression increased in proportion to the number of sexual partners and with the non-use of contraception. A higher number of coital experiences correlated with depression only among boys. Adjusting for age and age at menarche/oigarche did not affect the associations detected. In stepwise logistic regression, an increasing number of partners increased the risk for self-reported depression [for boys with at least five partners odds ratio (OR) 2.5, 95% confidence intervals (CI) 2.2-3.0, and for girls OR 2.7, 95% CI 2.3-3.2]. Boys and girls who did not use contraception showed roughly twice as high a risk as contraceptive users. However, girls with five or more coital experiences had a significantly lower risk for depression compared to girls with only one sexual intercourse.

CONCLUSIONS

Multiple sexual partners and non-use of contraception may reflect a depressive disorder in both genders. While adolescent health service providers should be aware of the risk for depression among sexually active adolescents, the sexual health of depressed adolescents also warrants special attention.

Trends in teenage fertility, abortion, and pregnancy rates in Iceland compared with other Nordic countries, 1976-99

BACKGROUND

Iceland is often considered very similar to the other Nordic countries. The purpose of this study was to explore trends in teenage fertility, abortion, and pregnancy rates in Iceland, compare these trends with corresponding rates in Denmark, Finland, Norway, and Sweden during the period 1976-99, and to evaluate similarities and dissimilarities.

METHODS

The study is based on data about fertility, abortion, and pregnancy rates obtained from the Icelandic and Nordic national population and abortion registers for the age group 15-19 years years.

RESULTS

Teenage fertility and pregnancy rates in the five Nordic countries declined over the study period by 57-67% and 31-50%, respectively, and in Iceland they remained significantly higher than in the Nordic countries. In 1999 almost every other teenage pregnancy in Iceland (45.9/1000) resulted in a childbirth (24.4/1000). Regional fertility rates were highest in the countryside. While the abortion rate has been declining in the four Nordic countries by 20-41%, they have concurrently been rising in Iceland by 133% (9.4/1000 in 1976-80, 21.9/1000 in 1996-99) and are presently higher than in the other Nordic countries. Regionally, abortion rates in Iceland were highest in the Capital area.

CONCLUSIONS

The teenage pregnancy rate is higher in Iceland than in the other Nordic countries. This may be explained by cultural norms in Iceland's society regarding childbearing, early initiation of sexual intercourse, more limited sex education, and less effective delivery and use of contraceptive methods. There is a need to promote sexual and reproductive health to young people in Iceland by combining diverse preventive approaches.

Sociodemographic differences in the occurrence of teenage pregnancies in Finland in 1987-1998: a follow up study

STUDY OBJECTIVE

To analyse sociodemographic differences in the occurrence of pregnancies to 14 to 19 year olds and changes in these differences from 1987 to 1998.

DESIGN

Follow up of adolescent survey respondents using registers.

SETTING AND SUBJECTS

The dataset includes information on all registered pregnancies (abortions, births, and miscarriages, n=2743) of the female respondents (n=28 914) to the Adolescent Health and Lifestyle Survey (AHLS) from 1987 to 1998. In the AHLS, self administered questionnaires were mailed every second year to independent samples of 12, 14, 16, and 18 year olds representative for Finland.

MAIN OUTCOME MEASURE

Relative risk (hazard) of becoming pregnant at teenage.

MAIN RESULTS

Girls from lower socioeconomic background had a higher pregnancy risk. Girls who did not live with both parents at the baseline survey had higher pregnancy risk than those who did, and girls who lived in a stepfamily had a higher risk than those who lived in a one parent family. Swedish speaking girls had a lower pregnancy risk than the Finnish speaking girls. There was no systematic change from 1987 to 1998 in most sociodemographic differentials in the teenage pregnancy risk, however, there was some increase in the differences by family structure. Changes in the sociodemographic structure did not explain the levelling off of the downward trend in teenage pregnancy risk, nor did the regional socioeconomic differences explain regional differentials in teenage pregnancy risk.

CONCLUSION

Although the reduction of socioeconomic and regional differences has been a general objective in Finnish social and health policies, the relative differences in teenage pregnancies have not decreased.

Decision making in terminal care: a survey of finnish doctors' treatment decisions in end-of-life scenarios involving a terminal cancer and a terminal dementia patient

GOALS

The physicians' decision-making process in terminal care is complex: medical, ethical, legal and psychological aspects are all involved, particularly in critical situations. Here, a study was made of the association of personal background factors with end-of-life decisions.

METHODS

A questionnaire was sent to 300 surgeons, 300 internists, 500 health centre practitioners (GPs) and all 82 Finnish oncologists. The response rate was 62%. Two scenarios were presented: one involving a terminal cancer patient, the other a dementia patient. Sociodemographic factors, general life values and attitudes related to end-of-life care were asked.

MAIN RESULTS

In the cancer case (Scenario 1) 17%, and in the dementia case (Scenario 2) 43% of all the respondents chose active treatment. In a logistic regression analysis of treatment decisions in Scenario 1, physician's age, specialty, marital status and attitudes to assisted suicide and withdrawal of life-sustaining treatment (LST) entered the model. In Scenario 2, the variables were physician's age, physician's own experience of severe disease in the family, attitude to withdrawal of LST and opinion of advanced directives.

CONCLUSIONS

Doctors' end-of-life decisions vary widely according to personal background factors. The findings underline the importance of advance communication, making these decisions in accordance with the patient's wishes.

Factors affecting physicians' decisions to forgo life-sustaining treatments in terminal care

OBJECTIVES

Treatment decisions in ethically complex situations are known to depend on a physician's personal characteristics and medical experience. We sought to study variability in decisions to withdraw or withhold specific life-supporting treatments in terminal care and to evaluate the association between decisions and such background factors.

DESIGN

Readiness to withdraw or withhold treatment options was studied using a terminal cancer patient scenario with alternatives. Physicians were asked about their attitudes, life values, experience, and training; sociodemographic data were also collected.

SETTING

Finnish physicians, postal survey.

SURVEY SAMPLE

Five hundred general practitioners, 300 surgeons, 300 internists, and 82 oncologists.

RESULTS

Treatments most often forgone were blood transfusion (82%) and thrombosis prophylaxis (81%). Least willingly abandoned were intravenous (i.v.) hydration (29%) and supplementary oxygen (13%). Female doctors were less likely to discontinue thrombosis prophylaxis (p=0.022) and supplementary oxygen (p<0.001), but more readily x ray (p=0.039) and laboratory (p=0.057) examinations. Young doctors were more likely to continue antibiotics (p=0.025), thrombosis prophylaxis (p=0.006), supplementary oxygen (p=0.004) and laboratory tests (p=0.041). Oncologists comprised the specialty most ready to forgo all studied treatments except antibiotics and blood transfusion. The family's wishes (alternative 1) significantly increased treatment activity. Young and female practitioners and oncologists were most influenced by family appeal. Advance directives (alternative 2) made decisions significantly more reserved and uniform. Different factors in the physician's background were found to predict decisions to withdraw antibiotics or i.v. hydration.

CONCLUSION

The considerable variation observed in doctors' decisions to forgo specific life-sustaining treatments (LST) was seen to depend on their personal background factors. Experience, supervision, and postgraduate education seemed to be associated with more reserved treatment decisions. To increase the objectivity of end of life decisions, training, and research are of prime significance in this ethically complex area of medicine.

Risk of postpartum induced abortion in Finland: a register-based study

CONTEXT

Half of Finnish abortion patients already have children, and one in 10 pregnancies ending in abortions started within 12 months of a birth. Thus, many women may not practice contraception effectively during the postpartum period.

METHODS

Data from national registers were used to create ajoint data file on pregnancies occurring in Finland over the period 1987-1998. The abortion risk (the risk of a conception that leads to an induced abortion) and abortion ratio (the number of conceptions leading to abortions divided by the number leading to deliveries) were analyzed in follow-up periods after all live births to women younger than 45 (684,922), using hazard regression and logistic regression.

RESULTS

Pregnancies starting within eight months postpartum were more likely to end in abortion than were those starting later. Within the first eight months, the shorter the interval to the next pregnancy, the more likely the pregnancy was to end in abortion. Abortion risk was higher 6-18 months postpartum than at later periods and was highest at 6-8 months postpartum, particularly among unmarried women and teenagers. Between 1987-1988 and 1995-1996, the abortion risk within the first eight months postpartum rose significantly among women aged 25-29 and 30-34 (relative risks, 1.5 and 1.2, respectively). The abortion risk and abortion ratio were higher among teenagers than among women in other age-groups.

CONCLUSIONS

The findings are consistent with the hypothesis that contraceptive practice is less effective postpartum, suggesting room for improvement in postpartum contraceptive counseling in Finland.