Determinants related to gender differences in general practice utilization: Danish Diet, Cancer and Health Cohort

Women over 50 who use alcohol and their engagement with primary and preventative health services: a narrative review using a systematic approach

BACKGROUND

Women who are over 50 years are drinking alcohol in higher quantities and more frequently than in previous decades. Good engagement with primary care is crucial for women's physical and psychological health, particularly if they use alcohol. However, there is little known about the alcohol use of women over 50 and their use of primary care.

METHODS

A systematic search was conducted on six databases; CINAHL, Medline, PsycINFO, Academic Search Complete, EMBASE and Web of Science to identify literature on primary health care engagement of women 50 years and older (50+) who use alcohol. Titles and abstracts were reviewed and full texts were independently reviewed by two researchers. A narrative review, critical appraisal and synthesis of the eligible studies produced common themes and key findings.

RESULTS

After excluding 3822 articles, 13 articles were deemed eligible for the review. For this age group (50+), findings were: 1) women who drink heavily were less likely than men to attend General Practitioners (GPs), moderate drinkers were more likely than abstainers to attend mammogram screening, 2) GPs were less likely to ask questions or discuss alcohol with women than with men, 3) GPs offered less advice on alcohol to women than to men, and 4) less women than men received alcohol screening from their GP.

DISCUSSION

While women 50+ are drinking more, their alcohol use is underreported and insufficiently provided for in primary health. As women's life expectancy increases, improved GP engagement will benefit women's health and reduce future healthcare costs.

Sex and age differences in the use of analgesic drugs before and after primary total hip arthroplasty in 105,520 Danish patients

BACKGROUND

We examined analgesic drug use before and after total hip arthroplasty (THA) by sex and age, and impact of comorbidity in that context.

METHODS

Using Danish nationwide medical registries, we included 105,520 THA patients (1996-2018). We calculated prevalence of overall analgesic drug use and use of NSAIDs and opioids separately in four quarters before (-Q4 to -Q1) and after THA (Q1 to Q4). -Q4 and Q4 was compared using prevalence rate ratios (PRR) with 95% confidence interval (CI).

RESULTS

Among women, analgesic drug use was 46% in -Q4, 65% in Q1, but decreased to 31% in Q4 (PRR: 0.68 (CI: 0.67-0.69)). Among men, these numbers were 39% in -Q4, 62% in Q1, and 23% in Q4 (PRR: 0.61 (CI: 0.60-0.63)). Analgesic drug use was higher among older patients in all quarters except Q1. Analgesic drug use decreased from 40% in -Q4 to 25% in Q4 (PRR: 0.62 (CI: 0.59-0.64)) in patients <55 years, and from 44% to 30% in patients >85 years, (PRR: 0.67 (CI: 0.63-0.71)). Women used more NSAIDs and opioids than men. Older patients used more opioids compared to younger, while variation in NSAID use by age was small. Decrease in analgesic drug use from -Q4 to Q4 was least pronounced in patients with comorbidity history.

CONCLUSIONS

Women and older patients have higher prevalence of analgesic drug use before and after THA, and a smallest reduction in analgesic drug use from before to after THA. Comorbidity history modified these associations.

Help-seeking behaviour in primary care of men and women with a history of abuse: A Dutch cohort study

Background

Previous studies show an association between a history of abuse and higher care demand. However, studies in general practice regarding help-seeking behaviour by patients (mainly male patients) with a history of abuse are scarce.

Objectives

To analyse help-seeking behaviour in general practice of men and women with a history of abuse.

Methods

A cohort study using data from a Dutch primary care registration network from 2015 to 2019. We included all patients aged ≥ 18 years who indicated on a questionnaire that they did or did not have a history of abuse. We analysed differences in contact frequency, types of contact, reason for encounter and diagnoses between men and women with or without a history of abuse.

Results

The questionnaire had a response rate of 59% and resulted in 11,140 patients, of which 1271 indicated a history of abuse. Men and women with a history of abuse contact the general practitioner (GP) 1.5 times (95% CI 1.42–1.60) more often than men and women without a history of abuse, especially for psychological (rate ratio 1.97, 95% CI 1.79–2.17) and social (rate ratio 1.93, 95% CI 1.68–2.22) problems. Moreover, when diagnosed with a psychological or social problem, patients with a history of abuse contact the GP twice more often for these problems.

Conclusion

Compared to men and women without a history of abuse, men and women with a history of abuse visit their GP more often, particularly for psychological and social problems.

The role of socio-demographic and health factors during COVID-19 in remote access to GP care in low-income neighbourhoods: a cross-sectional survey of GP patients

OBJECTIVES

Remote consultations were common in general practice during the COVID-19 pandemic. This approach may have affected access to GP care for people with low socio-economic status: this group has a high prevalence of chronic conditions and a higher mortality rate due to COVID-19. This study explores the association of sociodemographic and health factors with the decision to contact a GP practice, and care utilisation, among patients in low-income neighbourhoods in the Netherlands.

DESIGN

Cross-sectional survey study.

SETTING

General practice in low-income neighbourhoods in the Netherlands.

PARTICIPANTS

Patients from low-income neighbourhoods were selected from fourteen general practices on the basis of ethnic background, chronic disease or health literacy. Participants were stratified according to categories of these background characteristics to obtain equal numbers per category. A total of 213 surveys were retained for analysis.

MAIN OUTCOME MEASURES

Need for GP contact, decision to contact a GP practice, and GP service utilisation.

RESULTS

Forty-five percent (N = 88) of the participants experienced health problems for which they wished to consult their GP at the start of the outbreak of COVID-19. A majority of them (81%) had contact with a GP service. The need to contact the GP was significantly associated with financial difficulties (OR 2.20 CI (1.10 to 4.39)). An interaction effect was found of health literacy with concerns about COVID-19 with in respondents with low health literacy a significant association between concerns about COVID-19 and a need for a GP appointment (OR 5.33 CI (2.09 to 13.59)) and absence of a significant association in the higher health literacy group (OR 1.14 CI (0.51 to 2.56)) . Moreover, 56% (N = 74) of the participants received remote care at least one time during the first wave of COVID-19. Female participants used remote care more often (OR 3.22 CI (1.57 to 6.59)) and participants aged 50 and over used remote care less often (OR 0.46 CI (0.21 to 0.97)).

CONCLUSION

Many patients in low-income neighbourhoods were able to consult a GP, often remotely. However from the equity perspective, access to GP care should be safeguarded for patients with health problems, financial difficulties and low health literacy because of their greater need to consult a GP during times of crisis.

The Added Burden of Personality Disorder on Subsidized Australian Health Service Utilization Among Women With Mental State Disorder

This study aimed to investigate health service utilization among women with mental state disorder only (MSD-PD), mental state disorder plus personality disorder (MSD+PD), and controls in a population-based sample. Women (n = 635) from the Geelong Osteoporosis Study completed mental health assessments and were categorized into groups (MSD-PD, MSD+PD, controls). General practitioner (mental and non-mental health encounters) and specialized mental health service utilization was ascertained from data linkage to the Medicare Benefits Schedule, Australia (01/09/2008-31/12/2012). Negative binomial and binary logistic regression models were employed to assess health service utilization differences between groups. Results indicated that women with MSD+PD had more encounters of non-mental health service utilization than women with MSD-PD and controls. Age significantly modified these relationships: women with MSD+PD and MSD-PD had more encounters of health service utilization at midlife and in the seventh decade of life. No significant differences were found in the frequency of general practitioner mental health service utilization or specialized mental health service utilization between groups. These data suggest that the presence of co-occurring PD is associated with increased health service utilization among women with other common mental health problems. Healthcare providers should be vigilant to the presence of PD when establishing management plans with patients presenting with common mental health problems.

Feasibility and acceptability of breath research in primary care: a prospective, cross-sectional, observational study

OBJECTIVES

To examine the feasibility and acceptability of breath research in primary care.

DESIGN

Non-randomised, prospective, mixed-methods cross-sectional observational study.

SETTING

Twenty-six urban primary care practices.

PARTICIPANTS

1002 patients aged 18-90 years with gastrointestinal symptoms.

MAIN OUTCOME MEASURES

During the first 6 months of the study (phase 1), feasibility of patient enrolment using face-to-face, telephone or SMS-messaging (Short Message Service) enrolment strategies, as well as processes for breath testing at local primary care practices, were evaluated. A mixed-method iterative study design was adopted and outcomes evaluated using weekly Plan-Do-Study-Act cycles, focus groups and general practitioner (GP) questionnaires.During the second 6 months of the study (phase 2), patient and GP acceptability of the breath test and testing process was assessed using questionnaires. In addition a 'single practice' recruitment model was compared with a 'hub and spoke' centralised recruitment model with regards to enrolment ability and patient acceptability.Throughout the study feasibility of the collection of a large number of breath samples by clinical staff over multiple study sites was evaluated and quantified by the analysis of these samples using mass spectrometry.

RESULTS

1002 patients were recruited within 192 sampling days. Both 'single practice' and 'hub and spoke' recruitment models were effective with an average of 5.3 and 4.3 patients accrued per day, respectively. The 'hub and spoke' model with SMS messaging was the most efficient combined method of patient accrual. Acceptability of the test was high among both patients and GPs. The methodology for collection, handling and analysis of breath samples was effective, with 95% of samples meeting quality criteria.

CONCLUSIONS

Large-scale breath testing in primary care was feasible and acceptable. This study provides a practical framework to guide the design of Phase III trials examining the performance of breath testing in primary care.

Healthcare Utilization and Knee Osteoarthritis Symptoms among Urban Older Malaysian

Knee osteoarthritis (OA) is a prevalent chronic disorder in the older population. While timely management is important to minimize the consequences of knee OA, information on the utilization of healthcare services among this population remains limited. Therefore, the objectives of this study were to determine the healthcare utilization and its associated factors in older persons with knee OA. Cross-sectional data from 1073 participants aged 60 years and above from the Malaysian Elders Longitudinal Research (MELoR) study were included. The utilization rate of healthcare services was quantified. Factors related to the utilization of healthcare services were determined using logistic regression analysis. Healthcare utilization among participants with knee OA was significantly higher than those without knee OA (p < 0.01). Outpatient usage was higher (p < 0.01) in comparison to inpatient and pharmacotherapy. Being married and having an income were significantly associated with seeking outpatient care (OR: 11.136, 95% CI: 1.73–52.82, p < 0.01) and pharmacotherapy (OR: 10.439, 95% CI: 1.187–91.812, p < 0.05), while females were less likely to utilize inpatient care services (OR: 0.126, 95% CI: 0.021–0.746, p < 0.05). The higher rate of healthcare utilization among older persons with knee OA indicates the increased healthcare needs of this population, who are commonly assumed to suffer from a benign disease.

Should GPs ask patients about their financial concerns? Exploration through collaborative research

Objective: Health services should arguably be concerned about the financial situation of patients since health problems can cause financial concerns, which in turn can cause health problems. In this study, we explored the role of the general practitioner (GP) as a potential early discoverer of financial problems who can refer at-risk patients to financial counselling services.Design: A collaborative health service research experiment. For four weeks, GPs asked their patients predefined questions about financial concerns and health, by anonymous data mapping. GPs shared their experiences with the researchers after the experiment.Setting: One GP office in Norway.Subjects: A total of 565 patients were included in data mapping by 8 GPs.Main outcome measures: Patient prevalence data and GPs experimental data of patients' health problems that caused financial concerns and financial concerns that affected patients' health.Results: Of 565 GP patients, 11% (n = 63) indicated that they had health problems causing them financial concerns, or vice versa; 9% of patients reported health problems causing financial concerns and 8% of patients reported financial concerns that affected their health. Through the data mapping experiment GPs became aware of financial concerns of their patients and by this expanded and improved their therapeutic toolbox. Several months after the experiment the GPs reported that more patients received financial counselling since the GPs asked their patients about financial problems more often than before and because the patients had heard that GPs cared about such problems.Conclusion: Our results suggest that GPs can be early discoverers of financial problems interacting with their patients' health. When there are no clear medical explanations for the health problems that prompted the consultation, the best therapy may thus be financial counselling.Key pointsMany people live on the edge of financial ruin and struggle to keep track of their finances, but limited research exists that investigates associations between finance and health.In a collaborative health services research experiment 11% of the patients at a Norwegian GP office had health problems that caused them financial concerns, or vice versa.GPs found it helpful to ask patients about their financial concerns when no clear medical explanations for their health problems was found. Then free financial counselling services could be offered.

The impact of sex and gender on immunotherapy outcomes

Immunotherapies are often used for the treatment, remission, and possible cure of autoimmune diseases, infectious diseases, and cancers. Empirical evidence illustrates that females and males differ in outcomes following the use of biologics for the treatment of autoimmune diseases, e.g., rheumatoid arthritis (RA), infectious diseases, e.g., influenza, and solid tumor cancers. Females tend to experience more adverse reactions than males following the use of a class of biologics referred to as immunotherapies. For immunotherapies aimed at stimulating an immune response, e.g., influenza vaccines, females develop greater responses and may experience greater efficacy than males. In contrast, for immunotherapies that repress an immune response, e.g., tumor necrosis factor (TNF) inhibitors for RA or checkpoint inhibitors for melanoma, the efficacy is reportedly greater for males than females. Despite these differences, discrepancies in reporting differences between females and males exist, with females have been historically excluded from biomedical and clinical studies. There is a critical need for research that addresses the biological (i.e., sex) as well as sociocultural (i.e., gender) causes of male-female disparities in immunotherapy responses, toxicities, and outcomes. One-size-fits-all approaches to immunotherapies will not work, and sex/gender may contribute to variable treatment success, including adherence, in clinical settings.

Factors Associated with Utilization of Primary and Specialist Healthcare Services by Elderly Cardiovascular Patients in the Republic of Serbia: A Cross-Sectional Study from the National Health Survey 2013

The European Health Interview Survey (EHIS) is run every 5 years to examine how people experience and rank their health, how they care about their health, and to what extent they use the healthcare services. We identified the sub-population of special interest, i.e., cardiovascular disease (CVD) patients older than 65 years, in this cross-sectional study from the Serbian national survey of population health (2568 persons from a total of 15,999 subjects surveyed). We performed univariable and multivariable logistic regression analysis to assess the correlation between the healthcare system utilization and identified demographic, geographic, socio-economic, and self-rated factors. The most important factor for the utilization of the primary and the specialist healthcare services by elderly CVD patients is the region where one lives (Southern and Eastern Serbia OR = 2.44, 95% CI = 1.58-3.77/Belgrade OR = 1.75, 95% CI = 1.32-2.30). Age is another factor, where the 65 to 74 years old CVD patients utilize healthcare services the most. Higher education (OR = 1.80, 95% CI = 1.31-2.47), being a part of the highest Wealth Index group (OR = 1.62, 95% CI = 1.10-2.40), having very poor health status (OR = 3.02, 95% CI = 1.41-6.47), and presence of long-term illness (OR = 1.49, 95% CI = 1.16-1.92), play an important role in the utilization of the specialist care only.

Time from incident primary cancer until recurrence or second primary cancer: Risk factors and impact in general practice

OBJECTIVE

Specialised follow-up care after cancer treatment is changing towards increased involvement of general practice. To ensure timely detection of new cancer events, knowledge is warranted on the timing of cancer recurrence (CR) and second primary cancer (SPC), including risk factors for CR.

METHODS

This population-based register study included 67,092 patients diagnosed with malignant melanoma, bladder, lung, ovarian, endometrial, colorectal and breast cancer in Denmark in 2008-2016. The time from primary cancer to CR or SPC and risk factors for prolonged time to CR were analysed and stratified on sex and primary cancer type.

RESULTS

Cancer recurrence proportions ranged from 6% to 35%. The risk of CR increased profoundly within the first 3 years and then levelled off, except for breast cancer. A total of 3%-6% of patients had SPC, with monotonously increasing cumulative incidence proportions. Besides primary tumour characteristics, lower educational level, living alone and comorbidity were associated with earlier CR. For example, in female malignant melanoma, HRs and 95% confidence intervals were 0.47 (0.37-0.61) for high educational level, 1.40 (1.16-1.68) for living alone and 2.38 (1.53-3.70) for high comorbidity.

CONCLUSION

The results may inform stratified risk assessment in decision of frequency, location and duration of post-cancer follow-up care.

Risk Factors for Unruptured Intracranial Aneurysms and Subarachnoid Hemorrhage in a Prospective Population-Based Study

Background and Purpose- We wanted to evaluate potential risk factors for unruptured intracranial aneurysms (UIAs) and aneurysmal subarachnoid hemorrhage (aSAH) in a large, prospective study of the general population with risk factors collected before the detection of UIA or aSAH. Methods- All residents ≥20 years were invited to the HUNT (The Nord-Trøndelag Health Study). In this study, 89 951 participants were included. The study included standardized measurements of blood pressure and self-administered questionnaires. Cases of UIA and aSAH from 1999 to 2014 were identified using hospital records and the Norwegian Cause of Death Register. Hazard ratios with CIs were estimated using Cox regression analysis. Results- The detection rate of UIA was 8.2 per 100 000 person-years (97 patients). Current smoking (hazard ratio, 4.1; 95% CI, 2.4-7.1) and female sex (hazard ratio, 2.8; 95% CI, 1.7-4.5) were associated with markedly increased risk of UIA, but we found no association with systolic blood pressure (P for trend 0.62). The incidence of aSAH was 9.9 per 100 000 person-years (117 patients). The most important risk factors for aSAH were current smoking, female sex and increasing blood pressure (P for trend 0.006 for systolic blood pressure). Conclusions- In contrast to previous studies on risk factors of UIA, we found no association with systolic blood pressure. However, there was a strong association between systolic blood pressure and aSAH in the same population. Current smoking and female sex were associated with both diseases.

Prevalence and predictors of having no general practitioner - analysis of the German health interview and examination survey for adults (DEGS1)

BACKGROUND

Although patients in Germany are generally free to choose their primary healthcare provider, this role should mainly be assumed by general practitioners (GPs). While some predictors of the frequency of use of GP services have been reported in international studies, there is still a lack in knowledge what could deter people from contacting a GP in Germany. To improve healthcare, it is important to identify characteristics of people without a GP.

METHODS

This cross-sectional analysis was based on the first wave of the "German Health Interview and Examination Survey for Adults" (DEGS1) conducted by the Robert Koch Institute in 2008-2011. Descriptive analyses and multiple logistic regression by gender were performed to analyze the association between having no GP and age, gender, residential area, socioeconomic status (SES), marital status, working hours per week, general state of health, chronic diseases and health insurance.

RESULTS

Overall, 9.5% (95% confidence interval (CI): 8.4-10.7) of the 7755 participants stated to have no GP, more often men (11.4%) than women (7.6%). Life in urban areas (big cities vs. rural: adjusted odds ratio (aOR): 2.9, 95% CI: 2.1-3.9), younger age (18-29 years vs. 65-79 years: aOR: 4.4, 95% CI: 2.5-7.7) and the presence of chronic diseases (yes vs. no: aOR: 0.4, 95% CI: 0.3-0.6) showed significant associations of not having a GP. For men, the type of health insurance (private vs. statutory: aOR: 2.1, 95% CI: 1.5-3.0; other vs. statutory: aOR: 2.1, 95% CI: 1.4-3.1) and for women, SES (low vs. medium: aOR: 1.8, 95% CI: 1.2-2.7; high vs. medium: aOR: 2.1, 95% CI: 1.4-3.0) increased the risk of having no GP.

CONCLUSIONS

Our analysis offers new insights into the use of GPs in Germany and revealed differences between men and women. Public health strategies regarding access to a GP have to focus on men and on women with a low SES. Further analyses are needed to determine whether men with private health insurance prefer to consult a specialist rather than a GP. For young adults, improving the transition process from a pediatrician to a GP could fill a gap in health care.

The Effect of Text Messaging on Medication Adherence After Outpatient Knee Arthroscopy: A Randomized Controlled Trial

PURPOSE

The purpose of this project was to examine if text message reminders can increase postoperative adherence to treatment with acetaminophen among outpatients undergoing arthroscopic knee surgery.

DESIGN

A nonblinded randomized control trial.

METHODS

In this study, 187 patients were randomized to either an intervention group (text message reminders) or a control group (no text message reminders). On the fourth postoperative day, all patients received an electronic questionnaire concerning (1) adherence to treatment with acetaminophen (main outcome), (2) pain intensity, and (3) unscheduled health care contacts.

FINDINGS

Data were available from 134 patients (intervention group, n = 70; control group, n = 64). No significant differences between groups were found regarding the median number of missed acetaminophen doses (1 vs 2.5; P = .06), pain intensity at rest and during walking, or the number of unscheduled health care contacts (7 vs 4; P = .35).

CONCLUSIONS

A nonsignificant trend toward an increased medication adherence of acetaminophen was found.

Determinants of having no general practitioner in Germany and the influence of a migration background: results of the German health interview and examination survey for adults (DEGS1)

BACKGROUND

It is aspired in the German healthcare system that general practitioners (GPs) act as initial contact for patients and guide through at all steps of medical treatment. This study aims at identifying factors associated with the odds of having no GP within the general population and especially among people with migration background.

METHODS

This cross-sectional analysis was based on the "German Health Interview and Examination Survey for Adults" (DEGS1) conducted by the Robert Koch Institute. Descriptive analyses as well as multiple logistic regression models were performed to analyse the impact of a migration background, age, gender, residential area, socioeconomic status (SES) and other factors on having no GP among 7755 participants.

RESULTS

9.5% of the total study population and 14.8% of people with a migration background had no GP, especially men, adults living in big cities and without chronic diseases. The odds of not having a GP were higher for people with a two-sided migration background (aOR: 1.90, 95% CI: 1.42-2.55). Among the population with a migration background, particularly young adults, men, people living in big cities and having a private health insurance showed higher odds to have no GP.

CONCLUSIONS

It is necessary to investigate the causes of the differing utilization of healthcare of people with a migration background and, if necessary, to take measures for an equal access to healthcare for all population groups. Further research needs to be done to evaluate how to get young people into contact with a GP.

Alcohol, tobacco and health care costs: a population-wide cohort study (n = 606 947 patients) of current drinkers based on medical and administrative health records from Catalonia

Background

Most cost of illness studies are based on models where information on exposure is combined with risk information from meta-analyses, and the resulting attributable fractions are applied to the number of cases.

Methods

This study presents data on alcohol and tobacco use for 2011 and 2012 obtained from a routine medical practice in Catalonia of 606 947 patients, 18 years of age and older, as compared with health care costs for 2013 (all costs from the public health care system: primary health care visits, hospital admissions, laboratory and medical tests, outpatient visits to specialists, emergency department visits and pharmacy expenses). Quasi-Poisson regressions were used to assess the association between alcohol consumption and smoking status and health care costs (adjusted for age and socio-economic status).

Results

Resulting health care costs per person per year amounted to 1290 Euros in 2013, and were 20.1% higher for men than for women. Sex, alcohol consumption, tobacco use and socio-economic status were all associated with health care costs. In particular, alcohol consumption had a positive dose-response association with health care costs. Similarly, both smokers and former smokers had higher health care costs than did people who never smoked.

Conclusions

Alcohol and tobacco use had modest and large impacts respectively on health care costs, confirming the results of previous ecological modelling analyses. Reductions of alcohol consumption and smoking through public policies and via early identification and brief interventions would likely be associated with reductions in health care costs.

Time trend occurrence of duodenal intraepithelial lymphocytosis and celiac disease in an open access endoscopic population

BACKGROUND

Duodenal intraepithelial lymphocytosis (DIL) is a histological finding characterized by the increase of intraepithelial CD3T-lymphocytes over the normal value without villous atrophy, mostly associated to coeliac disease (CD), Helicobacter pylori (Hp) gastritis and autoimmune diseases.

OBJECTIVE

To assess the occurrence of DIL, CD and Hp gastritis in an endoscopic population over a 13 year period.

METHODS

From 2003 to 2015 we included adult patients who consecutively underwent oesophago-gastro-duodenoscopy (OGD) with duodenal biopsies assessing the overall and annual occurrence of DIL and CD and the prevalence of Hp gastritis.

RESULTS

160 (2.3%) patients with DIL and 275 (3.9%) with CD were detected among 7001 patients. CD occurrence was higher from 2003 to 2011, while since 2012 DIL occurrence gradually increased significantly compared to CD (p = 0.03). DIL patients were more frequently female (p = 0.0006) and underwent OGD more frequently for dyspepsia (p = 0.002) and for indications not related to gastrointestinal symptoms than CD patients (p = 0.0003). Hp gastritis occurred similarly in CD and DIL patients but the latter had higher frequency of atrophic body gastritis (p = 0.005).

CONCLUSIONS

DIL is a condition increasing in the general endoscopic population mainly diagnosed by chance. Concomitant gastric histological evaluation is able in one third of DIL patients to identify associated possible causes of DIL, such as Hp and atrophic gastritis.

Association of bariatric surgery with risk of acute care use for hypertension-related disease in obese adults: population-based self-controlled case series study

BACKGROUND

Hypertension carries a large societal burden. Obesity is known as a risk factor for hypertension. However, little is known as to whether weight loss interventions reduce the risk of hypertension-related adverse events, such as acute care use (emergency department [ED] visit and/or unplanned hospitalization). We used bariatric surgery as an instrument for investigating the effect of large weight reduction on the risk of acute care use for hypertension-related disease in obese adults with hypertension.

METHODS

We performed a self-controlled case series study of obese patients with hypertension who underwent bariatric surgery using population-based ED and inpatient databases that recorded every bariatric surgery, ED visit, and hospitalization in three states (California, Florida, and Nebraska) from 2005 to 2011. The primary outcome was acute care use for hypertension-related disease. We used conditional logistic regression to compare each patient's risk of the outcome event during sequential 12-month periods, using pre-surgery months 13-24 as the reference period.

RESULTS

We identified 980 obese patients with hypertension who underwent bariatric surgery. The median age was 48 years (interquartile range, 40-56 years), 74% were female, and 55% were non-Hispanic white. During the reference period, 17.8% (95% confidence interval [CI], 15.4-20.2%) had a primary outcome event. The risk remained unchanged in the subsequent 12-month pre-surgery period (18.2% [95% CI, 15.7-20.6%]; adjusted odds ratio [aOR] 1.02 [95% CI, 0.83-1.27]; P = 0.83). In the first 12-month period after bariatric surgery, the risk significantly decreased (10.5% [8.6-12.4%]; aOR 0.58 [95% CI, 0.45-0.74]; P < 0.0001). Similarly, the risk remained significantly reduced in the 13-24 months after bariatric surgery (12.9% [95% CI, 10.8-15.0%]; aOR 0.71 [95% CI, 0.57-0.90]; P = 0.005). By contrast, there was no significant reduction in the risk among obese patients who underwent non-bariatric surgery (i.e., cholecystectomy, hysterectomy, spinal fusion, or mastectomy).

CONCLUSIONS

In this population-based study of obese adults with hypertension, we found that the risk of acute care use for hypertension-related disease decreased by 40% after bariatric surgery. The data provide the best evidence on the effectiveness of substantial weight loss on hypertension-related morbidities, underscoring the importance of discussing options for weight reduction when treating obese patients with hypertension.

Pain-related unscheduled contact with healthcare services after outpatient surgery

This prospective, observational study explored the need for pain-related unscheduled contact with healthcare services after outpatient surgery. We hypothesised that 10% of outpatients would have pain-related unscheduled contact with healthcare services, and that the incidence would differ depending on the type of surgical procedure. In total, 905 patients who had undergone one of five common outpatient surgical procedures (knee or shoulder arthroscopy, surgical correction of hallux valgus, laparoscopic cholecystectomy or laparoscopic gynaecological procedures) completed an electronic questionnaire one week and eight weeks after surgery. Data from 732 patients (81%) were available for analysis. Within the first eight weeks after surgery, 150 patients (20.5%) had made unscheduled contact with healthcare professionals, in 247 cases due to pain that was most frequent in the first postoperative week. Risk factors were female sex, unemployment and laparoscopic cholecystectomy. The most frequent healthcare contact was with the general practitioner (46.4%), and the most frequent outcome was further information and guidance (41.2%). We have demonstrated that a minority of patients still needed to make contact with health services after outpatient surgery, most often due to inadequate pain management. This finding should be considered when planning postoperative monitoring and care, and developing postoperative patient education.