Is it possible to characterize recurrent urinary stone formers who benefit from thiazide prophylaxis? Application of discrimination analysis

Twenty-three patients with recurrent urinary stones have been treated for 12-54 months with hydrochlorthiazide and 25 with placebo. Discrimination analysis was performed in order to distinguish patients with new stone formation (non-responders) from those without stone recurrence (responders) during the treatment. The discriminant function classified 16 out of 18 responders as such and 5 non-responders as such by using a combination of the three initial variables urinary pH, 24-h urine volume and serum phosphate. Eighteen other analysed variables and patient factors did not contribute to this discrimination. By using "leaving-one-out-technique", the probability for erroneously classifying a patient increased from 9 to 17%. Applying the discriminant function on the group receiving placebo, 92% of these patients were classified as responders to thiazide. It is concluded that discrimination analysis may give valuable information in characterizing patients who will benefit from a special therapy.

Learning to have less pain - is it possible? A one-year follow-up study of the effects of a personal construct group learning programme on patients with chronic musculoskeletal pain

A randomised controlled study with the objective to explore the effects of a group learning programme based on a phenomenological epistemology and personal construct theory. Main outcome measures were: experienced pain, pain coping strategies, absenteeism, disability pension and health care consumption. One hundred and twenty-one patients with chronic musculoskeletal pain and high absenteeism were included in this study. The intervention group (n=77) consisted of nine smaller groups with 6-10 persons in each and were counselled by health personnel with special training. The control group consisted of 44 persons. The learning programme emphasised awareness, possible relations between bodily symptoms, emotions, mind and life situation, and change of focus from pain and disability to resources and potentials. One year after the end of the learning programme (T3), patients in the intervention group reported significant pain reduction, increased pain-coping abilities and a higher reduction of health care consumption than the control group (P<0.05). Absenteeism was not significantly reduced compared to the control group, but there were fewer persons receiving disability pension in the intervention group at T3 (38 versus 59%) (P<0.05). This group-learning programme should be considered an important adjunct to the therapy of patients with chronic muscular pain.

A new, brief questionnaire (PEQ) developed in primary health care for measuring patients' experience of interaction, emotion and consultation outcome

BACKGROUND

A deepened understanding of patients' perspectives is essential in order to improve medical communication. By changing focus from patient satisfaction to patient experiences, more immediate, personal and affective responses may be captured.

OBJECTIVE

Our aim was to develop a new consultation-specific questionnaire on patient experiences.

METHODS

The questionnaire was developed in Norwegian primary care in three main phases. Phase 1: focus groups with patients in order to identify important aspects of patients' experiences, and their words and language when describing such experiences. Phase 2: a questionnaire survey with 110 items including 660 patients. Extensive testing resulted in a reduction to 25 items on six dimensions. Phase 3: a questionnaire survey with 25 items including 1092 patients. Psychometric analyses and feedback from patients and physicians involved dimensionality and tests of validity and reliability.

RESULTS

A final questionnaire was produced with 18 items on five dimensions: communication; emotions; short-term outcome; barriers; and relations with the auxiliary staff. The validity and reliability estimates were highly satisfactory. Three scales were skewed while two were more equally distributed. Forty-eight per cent of the patients described less than optimal communication experiences; some communication barriers were detected in 70% of the visits and less helpful experiences with the staff were reported in 55% of the visits. Twenty-four per cent of patients left with no positive feelings, and 48% scored low on the outcome scale (knowledge, perceived result).

CONCLUSIONS

The patient experience questionnaire (PEQ) emphasizes what patients value the most, i.e. interaction, emotions and outcome, and may represent a valuable tool for doctors who want feedback from their patients on the function of their doctor-patient relationships.

The patient perspective survey. Can consultations for complex health problems be enhanced?

BACKGROUND

Patients with complex health problems pose particular difficulties due to the interaction between psychosocial factors and physical disease. The aim of this study is to investigate the usefulness of a paper based instrument (the Patient Perspective Survey, or PPS) to enhance general practitioner-patient communication and patients' self reported coping skills.

METHODS

A previously validated questionnaire was modified and distributed to a self selected group of 21 GPs. They recruited 77 patients with complex health problems and asked them to complete a PPS questionnaire. The patients then returned for an extended consultation to discuss the results of the questionnaire with the GP. Patients and GPs subsequently completed PPS evaluation forms.

RESULTS

The PPS was useful for patients with chronic conditions with mixed physical and psychological components. It appeared to enhance the GP-patient relationship and gave patients a better understanding of their coping skills.

DISCUSSION

Patients with complex health problems can use paper based questionnaires to improve the quality of communication between themselves and their GPs.

Effectiveness of nystatin in polysymptomatic patients. A randomized, double-blind trial with nystatin versus placebo in general practice

BACKGROUND

Antifungal therapy has been claimed to be effective in polysymptomatic patients with diffuse symptoms from multiple body systems and even well defined diseases, traditionally not related to fungi. Hypersensitivity to fungus proteins and mycotoxins has been proposed as the cause.

METHODS

We conducted a 4-week randomized, double-blind, placebo-controlled study in 116 individuals selected by a 7-item questionnaire to determine whether the antifungal agent nystatin given orally was superior to placebo. At the onset of the study, the patients were free to select either their regular diet or a sugar- and yeast-free diet, which resulted in four different subgroups: nystatin + diet (ND); placebo + diet (PD); nystatin (N); and placebo (P).

RESULTS

Nystatin was significantly better than placebo in reduction of the overall symptom score (P < 0.003). In six of the 45 individually recorded symptoms, the improvement was significant (P < 0.01). All three active treatment groups reduced their overall symptom scores significantly (P < 0.0001), while the placebo regimen had no effect (P = 0.83). The benefit of diet was significant within both the nystatin (ND > N) and the placebo groups (PD > P).

CONCLUSIONS

Nystatin is superior to placebo in reducing localized and systemic symptoms in individuals with presumed fungus hypersensitivity as selected by a 7-item questionnaire. This superiority is probably enhanced even further by a sugar- and yeast-free diet.

Renal colic and recurrent urinary calculi. Management and prevention

BACKGROUND

Urinary calculi are a relatively common problem and up to 80% of patients with calculi who are untreated will experience one or more recurrences within five years.

OBJECTIVE

This paper outlines the causes of urinary calculi and presents evidence for the less conventional treatment of renal colic with NSAIDs such as intramuscular diclofenac in preference to traditional pethidine injections. The paper also deals with ways to prevent recurrence of stone formation.

DISCUSSION

Effective treatment requires a clear understanding of the cause, and investigations need to be directed toward establishing this. Prevention is the cornerstone of management and requires patients to have a clear understanding of the problem. Follow up of these patients is essential.

Agency orientation and chronic musculoskeletal pain: effects of a group learning program based on the personal construct theory

OBJECTIVE

This study evaluated the effects of a group learning program on patients with chronic musculoskeletal pain and high absenteeism and investigates what characterizes those patients who may benefit from such a program. The learning program was based on personal construct theory. The theory included the following: (1) participation in an educational program is related to a favorable outcome across the outcome measures (pain, pain coping, management of daily life, absenteeism, and use of health care), (2) patients with high agency orientation (i.e., inner-directed) cope with their pain and manage daily life in a better manner than do patients with low agency orientation (i.e., outer-directed), and (3) patients with high personal control, measured in terms of agency orientation, in terms of health locus of control, or in both terms, will benefit more from the educational program than will patients with low personal control.

DESIGN

The study was a randomized controlled study.

PATIENTS

One hundred and sixteen patients with chronic musculoskeletal pain and high absenteeism answered a questionnaire before and after the intervention program. The intervention group (n = 61) consisted of nine subgroups geographically spread through the eastern part of Norway and met for four hours every 2 weeks from February 1997 to October 1997. A total of 12 meetings were held.

RESULTS

The intervention group reported a significantly higher score for the variable "management of everyday life" (p <0.005) and for the variable "health care consumption" (p <0.001) than did the control group. Patients with high agency orientation benefited more from the program with regard to pain reduction and improved pain coping than did those patients with low agency orientation (p <0.05). Patients with high agency orientation also reported less absenteeism than did those patients with low agency orientation (p <0.05).

Smoking cessation. A comparative, randomised study between management in general practice and the behavioural programme SmokEnders

OBJECTIVE

To compare the effectiveness of two different stop smoking interventions.

DESIGN

A randomised, controlled trial. Results based on intention to treat.

SETTING

Three towns in the south-eastern part of Norway.

INTERVENTIONS

Visits to GP for "practice as usual" (GP group) or participation in the behavioural programme SmokEnders (SE group) with follow-up 2 weeks, 2 months and 1 year after an agreed stopping date.

SUBJECTS

139 smokers recruited through open invitation.

MAIN OUTCOME MEASURE

Self-reported smoking stop rate 2 weeks, 2 months and 1 year after an agreed stopping date, completed with biochemical indicators by the 1-year registration.

RESULTS

Two weeks after the agreed cessation date, 10/70 (14%) of the GP group and 46/69 (67%) of the SE group had stopped smoking. After 2 months, 9/70 (13%) in the GP group and 37/69 (54%) in the SE group were non-smokers. One year after cessation 5/70 (7%) in the GP group and 21/69 (30%) in the SE group were non-smokers.

CONCLUSIONS

Both interventions were effective as measured by the smoking cessation rate. However, the intervention in the SE group was considerably more effective than in the GP group, which suffered from a sizeable number of drop-outs.

Is homeopathic 'immunotherapy' effective? A double-blind, placebo-controlled trial with the isopathic remedy Betula 30c for patients with birch pollen allergy

The objective of the study was to examine the effect of the homeopathic remedy Betula 30c vs. placebo for patients with birch pollen allergy. A double-blind, randomized, placebo-controlled trial was carried out. Tablets were given for 4 weeks during the birch pollen season. The setting was Oslo, Norway, May 1995. Patients were aged between 18 and 50 y; 32 patients received Betula 30c tablets and 34 patients received placebo tablets. The main outcome measure was the total score of 17 different allergy symptoms. Daily total scores were calculated, as well as differences and ratios between the run-in and the following time periods. Point estimates of the median difference between the experimental and placebo groups, with their 95% confidence intervals, were the main measure of effect. No statistically significant difference between the groups was found during the first and last period of May. However, from 8 to 18 May, a clinically interesting difference was revealed between the groups, those receiving Betula 30c having fewer and less serious symptoms. For some days these differences were statistically significant. Surprisingly, this group reported more aggravation from the tablets than did the placebo group. With a statistical power of 70% for a defined clinically interesting difference (25%), the present results indicate that treatment with Betula 30c during the pollen season deserves further attention.

Distance education. Part 3. Assessment of and feedback to students at a distance

INTRODUCTION

Assessment of students at distance, in a course with over 20 units (subjects), provides special challenges in providing timely, accurate and detailed feedback both formatively and summatively.

METHOD

A description of assessment practices including reflective journals, essays, critical appraisal of literature, case studies or teaching presentations in video and written format, clinical audits, and large research projects is provided. The impact of a multitude of criterion-referenced methods of students, teachers and administrative services as well as quality assurance issues are measured.

CONCLUSION

Students preferred multiple levels of formative and summative assessment using criterion referencing to exams. These methods were thought to be contextually relevant to clinical practice and examined knowledge, cognition and performance appropriately. Length of assessment task, difficulty with English as a second language and lack of detail or clarity on written feedback posed problems for a number of students. Quality assurance procedures have been put into place to rectify some of these problems.

Distance education. Part 5. Family medicine research at a distance. Guidelines for supervisors

INTRODUCTION

This paper recommends guidelines for the supervision of Masters degrees or similar postgraduate courses, in which research projects are supervised at a distance.

METHODS

The guidelines are based on the experiences of the authors with a five year old Masters of Family Medicine degree and a formative evaluation conducted by questionnaire survey among its students, graduates and supervisors.

RESULTS

It is important to establish ground rules for communication at an early point in the supervisory process. Supervisors need to take into account psychosocial, pedagogical and organisational aspects of their mentorship of students.

DISCUSSION

These guidelines are relevant to courses where there remains a strong one-to-one relationship between supervisors and students. In these cases, 'distance' need not be a barrier provided that both sides are aware of and committed to maintaining good patterns of communications with each other.

Distance education. Part 4. Supervision of family medicine research at a distance. A formative evaluation

INTRODUCTION

A survey on supervision of research projects was undertaken among current general practitioner students, recent graduates and supervisors of a Masters of Family Medicine degree. The aim was to describe and compare the experience of the three groups and, in particular, to identify the problems associated with distance supervision.

METHODS

A self-administered questionnaire survey was distributed to current students (n = 21), graduates (n = 16) and current supervisors (n = 7).

RESULTS

Forty out of 44 doctors returned completed questionnaires. Distance was a relatively minor barrier to successful supervision, provided that the student and supervisor established good communication patterns and were able to respond to each other with minimal delay. The commencement of the study and its final write-up were critical phases in the supervision process.

DISCUSSION

Communication, including emotional and psychological support, was at least as important as expert opinion in helping Masters students to successfully complete their research projects. Attention must be paid to establishing good understanding and regular means of communication at the beginning of the supervisory process.

[Words and language used by patients when describing consultation with general practitioners]

Increased knowledge of how patients express their experiences may help physicians to capture their patients' perceptions and agenda. The aim of the present study was to examine words and language used by patients when describing specific primary care consultation experiences. Six focus group sessions with a total of 31 patients were conducted shortly after a general practice consultation. All group sessions were audiotaped and analysed by qualitative ethnographic methodology. Seven distinct grammatical and verbal characteristics were found: The consultations were recited in the first person with little recollection of the doctors' talk or actions. Subjectivity was constantly underlined by the verbs "feel" or "think". When expressing negative emotions, the personal pronoun constantly was changed from the personal singular to the impersonal or plural form. Language tended to be evasive in connection with possible criticism. Negative emotions were diminished by the use of limiting expressions and modest wording. Non-committal expressions, with a wide range of possible meanings, were frequent, and were possible to decipher only by close attention to non-verbal cues. We conclude that doctors may capture more of their patients' hidden emotional messages in the consultation by increased awareness of specific verbal characteristics and non-verbal cues.

[What is the most important for the patient in the meeting with a general practitioner?]

Efficient medical communication depends on an understanding of the patient perspective. The purpose of this study was to characterise the most important consultation elements as perceived by primary care patients. The experience of 31 patients regarding their most recent medical encounter were recorded in six focus groups. All groups were audiotaped and analysed by qualitative methodology. Five consultation themes emerged spontaneously in all groups: Interaction between doctor and patient (e.g. communication, emotional experiences, and personal relationship with the doctor) and consultation outcome were the most important elements. Information, continuity of care, and time with the doctor were considered reasonably important. Six other themes received limited attention in a few groups only (e.g. availability, doctor's gender, time in the waiting room, auxiliary personnel, the clinical examination, and technical skills). Patients value the personal, attentive, and listening doctor. The feeling of not having to hurry during the consultation is more important than the actual number of minutes. Patients' level of emotional involvement and their specific expectations are often undisclosed. There are large individual differences with regard to the meaning of and need for information.

Patient satisfaction and quality of care at four diagnostic imaging procedures: mammography, double-contrast barium enema, abdominal ultrasonography and vaginal ultrasonography

The objective of this study was to measure patient satisfaction and to investigate the practical implications of monitoring the quality of care at four radiology procedures. A survey was conducted immediately after the examinations in eight radiology departments: 550 patients attending for mammography, 110 for double-contrast barium enema (DCBE), 97 for abdominal ultrasonography and 90 for vaginal ultrasonography. Outcome measures were seven questionnaire scales: pain, emotional distress, information received, staff's punctuality and technical ability, facilities, and general satisfaction. Response rate was 87 %. Multivariate regression analysis showed significant differences between procedures on all scales (p < 0.001). Differences considered to be of practical importance, i. e. >/= 7 scale points, were detected on five of the scales. Mammography and DCBE caused the most pain, and vaginal US and DCBE caused the most distress. The US procedures entailed dissatisfaction with information about the procedures. The DCBE patients recorded dissatisfaction with the staff's lack of punctuality, and these and the mammography patients recorded dissatisfaction with the facilities. The findings indicate a potential for improving patients' experiences. Several aspects of care, i. e. pain management, attention to the patient's emotional concerns, explanation of procedures, punctuality and quality of the facilities, can be improved.

[Spinal disorders in Norway--an epidemiological report]

Low back disorders are prevalent and induce large costs to the health services, the national insurance system and employers. This paper describes the prevalence of low back pain and low back work disability in the Norwegian population, and the incidence and duration of low back work disability in Aust-Agder county. Data from the Norwegian Health Survey 1995 and the registers of the National Insurance Administration are presented. 45% of women and 38% of men reported low back pain within a 14 day period. The prevalence of low back work disability was 1.9%. Low back disorders caused 13-17% of sickness absence, rehabilitation allowance and disability pensions in 1995. In Aust-Agder, the incidence of sickness absence caused by low back disorders was higher among men. In 16% of persons sick-listed due to low back pain without radiating symptoms, the sickness absence episode lasted for more than seven weeks. When radiating symptoms were present, the corresponding figure was 35%. The number of persons with low back disorders with radiating symptoms seems to have increased the most. Further research, preventive measures and guidelines for clinical work should focus on the group of persons who develop chronic low back work disability.

The importance of self-efficacy in cardiovascular risk factor change

SUBJECTS AND DESIGN

The study was based on the total patient sample (n = 110) of a randomized controlled trial comparing two intervention methods advising cardiovascular high-risk men of lifestyle changes in general practice. Behaviour and risk factor changes during the one-year intervention study were analysed using multiple regression and logistic regression analyses with the above-mentioned independent variables.

SETTING

Twenty-two general practice centres in the county of Hordaland, western Norway.

RESULTS

Self-efficacy of increased physical exercise was the only variable significantly related to exercise change. Age and self-efficacy were statistical significant predictors of smoking cessation success. None of the independent variables was statistically significantly related to blood pressure or cholesterol change. Educational level related negatively, although statistically insignificantly, with total risk change.

CONCLUSION

The study confirms the importance of self-efficacy in both human behaviour and motivation for behaviour change.

OBJECTIVES

The objectives of the study were to explore the impact of possible predictors for cardiovascular risk behaviour change, predictors such as education, age, self-efficacy, doctors' interpersonal skills, and number of appointments.

Mammography: influence of departmental practice and women's characteristics on patient satisfaction: comparison of six departments in Norway

OBJECTIVE

To investigate how departmental practice and women's characteristics are related to low patient satisfaction with mammography.

DESIGN

Survey of patients by means of self administered questionnaires before and after mammography.

PATIENTS

488 women (89% of those invited), aged 23-86 years, at six departments.

MAIN OUTCOME MEASURES

Low level of satisfaction measured on psychometric scales of physical pain, psychological distress, staff punctuality and technical skills, information provided, and physical surroundings.

RESULTS

Satisfaction varied by department on the scales for pain, punctuality, information, and surroundings. After adjustment for women's characteristics an attributable risk of negative outcome by department was identified on the scales for pain, distress, punctuality, information, and surroundings. Adjusted odds ratio (ORs) ranged from 0.3 (95% confidence interval (95% CI) 1.2 to 6.0) on the pain scale, to 6.0 (2.9 to 12.3) on the punctuality scale. After adjustment for confounding variables, higher risk of dissatisfaction was associated with age < 50, nervousness about mammography, expected pain, lack of knowledge about mammography, and distrust in mammography (adjusted OR (95% CI) ranged from 1.6 (1.0 to 2.7) to 3.7 (2.0 to 7.3)).

CONCLUSION

Departmental practices differed for breast compression, information, punctuality, and facilities and were associated with a low level of satisfaction irrespective of patient characteristics. Women's lack of knowledge about mammography and distrust in the procedure were confirmed as risk factors for dissatisfaction. All these factors might be helped by training the staff, improving facilities, and informing the women.

Complex health problems in general practice: do we need an instrument for consultation improvement and patient involvement? Theoretical foundation, development and user evaluation of the Patient Perspective Survey (PPS)

BACKGROUND AND OBJECTIVES

Many patients in general practice present with complex health problems. It is argued that the GP who is in a prime position to counsel patients with such problems, will, however, often perceive a lack of tools to manage them. The aim of the present study was to develop a novel instrument in terms of a patient-administered questionnaire, the Patient Perspective Survey (PPS), designed to enhance the quality of clinical communication in the consultation. It is based on a biopsychosocial patient perspective, patient centredness, patient resources, involvement and coping, and quality of life orientation.

METHODS

Development of the PPS has included comprehensive literature research, discussions and advice, during several phases, from groups of GPs, patients, broad panels of experts and testing in pilot studies. After many revisions, a 102-item version, consisting of a main somatic, mental and social domain axis, was evaluated by GPs and patients in 213 consultations.

RESULTS

The basic idea, theoretical elements and purpose of the PPS appeared in general to be well accepted. Seventy-five to eighty-five per cent of the patients found the questions relevant and easy to understand and there were high positive scorings regarding influence on the doctor-patient relationship, communication, resource and coping aspects, occurrence of new information and general satisfaction with the consultation. Similar scorings were obtained from the GPs' evaluation. Both parties agreed that there is a need for a shorter and more specific PPS version, and that the resource and coping dimension should be even more extended.

CONCLUSIONS

We consider it well documented that there is a need for this new instrument to deal with complex health problems in general practice, and that it has promising potentials for consultation improvement.

Antibiotic treatment of patients with mucosal thickening in the paranasal sinuses, and validation of cut-off points in sinus CT

We compared the efficacy of penicillin V and amoxycillin treatment with placebo in 70 adult patients from Norwegian family practice with a clinical diagnosis of acute sinusitis and mucosal thickening on CT, but without fluid level or total opacification. The study was randomized and double-blind. Three different outcomes were evaluated; subjective status after 10 days of treatment, difference in clinical score between day 0 and day 10, and duration of the illness episode. Amoxycillin and penicillin V gave no better response to treatment than placebo, evaluated by all three outcome measures. The median duration of the sinusitis episode was 10 days in the amoxycillin- and placebo groups and 13 days in the penicillin-V group. In patients with a clinical diagnosis of acute sinusitis, fluid level and total opacification on CT are good criteria to differentiate between groups of patients that need or do not need antibiotic treatment.

[Effects of a health-education approach on health behavior, consultation satisfaction and psychological well being]

78 patients were recruited from a local occupational health clinic service and from general practices. They were allocated randomly to either an intervention group (40 patients) for a patient-centred approach to health care, or to a control group (38 patients) for conventional care. The patients were free to express their attitudes to health-related behaviour and to suggest behaviour changes. Emphasis was placed on the doctor being an active listener, with an understanding and sympathetic approach to the patient. 27 of the 40 patients in the intervention group suggested initiating change. After six weeks 24 patients reported having accomplished changes. There was a more significant reduction in the use of tobacco in the intervention group (p = 0.05) than in the control group. The patients' evaluation of the two approaches was the same, except for four patients in the intervention group, who felt provoked. Psychological well-being was measured using the Goldberg General Health Questionnaire, 28 item version (GHQ-28). In the control group there was a significant improvement in the GHQ-28 score (p = 0.022) after six weeks; the intervention group showed a near-significant improvement (p = 0.068) after 12 weeks. There was no significant difference in the change in GHQ-28 score between the groups. A patient-centred approach to health care may have potential for changing attitudes to health-related behaviour and bringing about actual behaviour changes. Further research with more extensive material is needed to confirm both this, and the effects on psychological well-being.

Salt restriction: effects on lipids and insulin production in hypertensive patients

The object of the study was to evaluate blood pressure, insulin and glucose metabolism, and serum lipids in hypertensive patients, during 8 weeks on a moderately salt-restricted diet. A double-blind, cross-over study was conducted with hypertensive patients following a moderately salt-restricted diet. Patients were randomised to sodium capsules in one period and placebo capsules during the other period. After a 1-month run-in period, 13 males and three females with mild to moderate essential hypertension (mean age 50 years) complied with a salt-reduced diet. They were randomized to a salt-supplemented group (5 capsules of 10 mmol sodium per capsule) or a salt reduced diet group (5 capsules of placebo) with cross-over after 8 weeks. Serum insulin, insulin C-peptide, and glucose were measured, fasting and 30 min after a 75-g glucose load. Serum lipids and lipoproteins constituting an atherogenic index were measured, along with blood pressure and 24-h urine excretion of sodium and chloride. Non-significant reductions of systolic and diastolic blood pressure (4 mmHg, p = 0.06, and 2 mmHg, p = 0.13, respectively) were observed during the reduced-salt period. The changes observed for fasting insulin, insulin C-peptide, glucose, serum lipids and the atherogenic index were also non-significant. It is concluded that moderate salt restriction seems not to adversely influence insulin resistance or serum lipids in hypertensive patients.

Why are some doctors high-prescribers of benzodiazepines and minor opiates? A qualitative study of GPs in Norway

BACKGROUND

Registration studies have shown great variations in prescribing volume and prescribing patterns of benzodiazepines (BZDs) and minor opiates among GPs.

OBJECTIVES

We aimed to form a basis for hypotheses and build theories about prescribing, in order to investigate how high-prescribing doctors can legitimize their own prescribing pattern.

METHODS

A qualitative interview study of doctors with previously known high, medium and low prescribing volumes was performed. The interpretation focused on the doctors' self-explanations and how they influence their daily decision of prescribing.

RESULTS AND CONCLUSIONS

It was a striking feature that many of the attitudes towards the drugs were common both within and between the three groups of prescribers. All doctors regarded the task of prescribing as difficult, and the great majority strongly advocated restriction in prescribing. In order to cope with daily practice and to live with high prescribing volumes, doctors make use of effective working strategies. These strategies, of ascribing responsibility to the previous doctor, to patient autonomy and responsibility, to the patient's age and to concomitant diseases, are described in this study. An allocation of responsibility to other persons or circumstances delimits the doctors' professional discretion in this matter. Striking differences between prescriber groups were not found in the analysis, but when all small tendencies in all steps of the decision-making process were added, a clear trend was revealed.

[Re-education and new education. Evaluation of a training program for occupational health services' personnel aimed for employees with chronic musculoskeletal pain]

Chronic musculoskeletal pain can be perceived as resulting from lack of control and coping in relation to both internal and external demands. Persons with chronic musculoskeletal pain are repetitive users of the occupational and primary health care services, and it seems that traditional medical treatment and physiotherapy are of little help. Health personnel may gain from learning teaching and counselling methods that might enable them to deal with the complexity of the patient's pain. 23 occupational personnel from different professions we invited to participate in a 150 hour training programme based on experience- and process-oriented teaching and counselling methods. After the training programme the participants counselled groups of employees with chronic musculoskeletal pain. Four left the programme after the first workshop. The remaining group felt more competent in meeting persons with chronic pain. When, in stead of giving traditional advice, they used counselling methods and focused on interaction and communication, and on helping the person in pain to find her/his own solutions, they also experienced a change of role in their relationship with these persons.

[Can chronic musculoskeletal pain be reduced by education? Results from an educational test model]

An attempt was made to rehabilitate 67 employees with chronic musculoskeletal pain at 20 different work sites in Norway by means of an educational model. Nine groups were each counselled by two specially trained occupational health personnel. They met for 2-3 hours during working hours at intervals of two to three weeks for one year. Key words in the educational model are: Change of focus from pain and disability to resources and potentials, Higher degree of self-awareness, Development of inner authority. The results indicate that group participation reduces pain and dysfunction and increases everyday coping abilities. In this uncontrolled study 41% had less pain (p = 0.025), 68% coped better with the pain (p < 0.001) and 56% coped better with their everyday life (p < 0.001). Absenteeism was reduced by 28% (p = 0.039) and the need for physiotherapy decreased (p = 0.06).

A new instrument to measure patient satisfaction with mammography. Validity, reliability, and discriminatory power

OBJECTIVES

The benefit of mammography depends on repeated use. Therefore, surveying the mammographic quality as judged by the users addresses an important topic. The authors assess the practicality, validity, reliability, and discriminatory power of a new, brief, multidimensional questionnaire for measuring patient satisfaction with mammography. Items measuring discomfort and attitudes toward repeat adherence were included.

METHODS

A self-administered questionnaire was given to women from six radiology departments in Norway. Four hundred eighty-eight out of 550 women referred for screening or diagnostic mammography were included. Seventy-seven patients also completed the test/retest study, and 44 women additionally completed an Australian questionnaire. Scores for patient satisfaction on the structure, process, discomfort, and general satisfaction scales of the questionnaire were used as the main outcome measures.

RESULTS

Response rate was 89%, and rate of completion was more than 95%. Strict psychometric criteria for construct validity and reliability were satisfied. Because lower levels of satisfaction were detectable with the new questionnaire but not with the Australian questionnaire and because an acceptable degree of variability in response was detected, support for discriminatory power was found.

CONCLUSIONS

The discomfort dimension contributed substantially to validity and discriminatory power. Patient behavior with time may be monitored with the new questionnaire, thus representing a valuable tool for scientific and practical purposes.

Effectiveness of two preventive interventions for coronary heart disease in primary care

OBJECTIVES

1. To compare a patient-centred, self-directive intervention with conventional care; 2. To evaluate longitudinal within-group changes of coronary heart disease risk.

METHODS

Risk factor changes were evaluated in 110 men with high coronary heart disease risk attending a one year intervention study in general practice. The 22 participating general practice centres were randomly allocated to follow either a patient-centred, self-directive intervention or a conventional approach.

RESULTS

No significant between-group differences were found in any single risk factor or in the combined risk of coronary heart disease. The improvement of total risk from screening time to conclusion of the study corresponded with changes of relative risks of CHD to 0.64 (95% CI: 0.54-0.77) and 0.65 (0.54-0.77) in the patient-centred, self-directive and the conventional care group respectively (p < 0.0001 in both groups).

CONCLUSION

Everyday general practice clinical work seems as efficacious as a specific intervention method based on currently advocated behaviour change principles.

[Diclofenac in the short-term prevention of recurrent colic from ureteral calculi. A placebo controlled double-blind study]

We have conducted a double-blind randomised placebo controlled trial with oral diclofenac to study the prophylactic effect on recurrence of renal colic and rate of spontaneous stone expulsion. 41 patients were given 50 mg oral diclofenac three times a day for seven days after being discharged for a colic episode from Oslo Emergency Hospital and 39 patients were given matching placebo tablets. The number of new ureteral colic episodes per accumulated patient treatment days was 64/287 in the diclofenac group and 119/273 in the placebo group (p < 0.01). The difference was greatest during the first four days of treatment. A similar trend was found for pain intensity, with the greatest difference on day one. There was no difference in reported type or frequency of side effects in the two treatment groups. Stone expulsion rate was almost identical. The effect of the treatment was not affected by fluid intake. Re-admission rates to Oslo Emergency Hospital or other hospitals were 10 and 67% (p < 0.001).

[Urolithiasis in clinical practice. Occurrence, etiology, investigation and preventive treatment]

The author reviews the epidemiological, etiological aspects of stone disease of the urinary tract, and prophylactic treatment. The occurrence of urolithiasis has increased considerably since the second world war and now affects 10% of the adult male and 4% of the adult female population. In Norway the yearly incidence of patients presenting with urinary stone colic in general practice is two per 1,000 inhabitants. Urinary calculi form when the concentration of the crystal-forming substances such as calcium oxalate, calcium phosphate, uric acid and cystine exceed their solubility. Important risk factors for stone formation are low fluid intake and high consumption of animal protein. Etiological examination and stone prophylactic treatment should reflect the most prevalent types of stone disease. An examination programme that probably can reveal one or several causes of the stone disease in about 60-70% of the patients is described. The recommended examinations car be performed in general practice. Prophylactic treatment in terms of dietary advice and fluid intake is suggested. In patients with a high recurrence rate of stone formation prophylactic drug treatment with tiazid or alluopurinol should be considered. The beneficial effect of the treatment is well documented.

CT findings in general practice patients with suspected acute sinusitis

PURPOSE

To study CT findings in general practice patients with a clinical diagnosis of acute sinusitis, and to examine the interobserver variation between 2 radiologists with regard to their CT evaluation.

MATERIAL AND METHODS

Two hundred and one patients were examined with coronal CT images of the paranasal sinuses within 2 days of the clinical diagnosis. Patients with chronic sinusitis were excluded. Fluid level or total opacification of any sinus were used as evidence of sinusitis.

RESULTS

One hundred and twenty-seven (63%) patients had fluid level or total opacification in a sinus region, most in more than one region. One hundred and fifteen had CT signs of sinusitis in the ethmoid region, 84 in the maxillary, 18 in the frontal, and 10 in the sphenoid. Forty-nine patients had a negative Ct. In the evaluation of interobserver agreement, the overall assessment of the CT yielded a kappa value of 0.70.

CONCLUSION

The study demonstrated great variation in the CT findings in general practice patients with suspected acute sinusitis. More than one sinus region was affected in most patients in whom sinusitis was confirmed by CT imaging; the most common combination was ethmoid and maxillary sinuses. The interobserver agreement was substantial.

Life style intervention in general practice: effects on psychological well-being and patient satisfaction

The objectives of this study were to: (1) study if an opportunistic screening of coronary heart disease (CHD) risk factors among male attenders in general practice (GP) influenced the overall subjective satisfaction with life of persons labelled 'high risk' compared to other screened persons; (2) compare psychological well-being and patient satisfaction in a patient centred and self-directive (PCSD) intervention with conventional care (CC); and (3) evaluate patient satisfaction and psychological well-being among subjects with high CHD risk during a one year intervention study. Effects of 'labelling' were evaluated in 115 subjects with high CHD risk in comparison with a low risk reference population. The 22 participating GP centres were randomly allocated to follow either a PCSD intervention or a CC approach. An overall satisfaction with life question was employed and psychological well-being were measured using the General Health Questionnaire (20 item version). Satisfaction measures on health care aspects were also included. No difference of change between the high risk and the reference population was found concerning satisfaction with life after screening. No significant difference of change was found within or between the PCSD and the CC group concerning emotional well-being or overall satisfaction with life during one year intervention. Satisfaction with the care received was significantly better in the CC group as compared with the PCSD group (p = 0.02). Satisfaction with own efforts for improving health was, however, more pronounced in the PCSD group (p = 0.01). A substantial number (n = 61) of the participants reported distaste of being reminded of the risk of heart disease and no more than 60 of the participants were satisfied with their own efforts for improving health. Although no significant change of satisfaction with life and emotional well-being due to screening or intervention could be detected, clinicians should be aware that encouraging patients to change life style may lead to patients' annoyance of being reminded of the risk of disease and dissatisfaction with their own efforts. Increasing patient responsibility and self-determination may improve their satisfaction with their own efforts, but reduce satisfaction with medical care.

A new measure of patient satisfaction with mammography. Validation by factor analytic technique

BACKGROUND AND OBJECTIVES

The success of national breast screening programmes hinges on women's adherence. By monitoring patients' perceptions, potential barriers to attendance may be detected, measured and possibly alleviated. Consequently a new questionnaire MGQ, measuring patients' experience of and satisfaction with mammography, has been developed. As discomfort is a predictor of non-attendance, a dimension measuring physical and psychological discomfort was included.

METHODS

The internal structure of observed variables was tested using factor analysis as part of the validation process. The study was conducted in six radiological departments in Norway including 550 patients presenting for mammography. The analysis suggested eight factors explaining 56.7% of the variance.

RESULTS

Construct validity was supported since the factor scales covered all hypothesized dimensions and all but one subdimension. The factors were internally consistent and externally independent, indicating that distinct aspects of patients' experience with mammography may be assessed and thus possibly improved.

CONCLUSIONS

A relationship between pain and re-attendance was suggested as pain and worries about the next mammography belonged to the same factor. This underlines the importance of including a discomfort dimension when monitoring patient satisfaction with mammography.

Intramuscular diclofenac versus intravenous indomethacin in the treatment of acute renal colic

OBJECTIVE

We have conducted a clinical trial to compare the pain-relieving effect and safety of diclofenac administered intramuscularly to indomethacin given intravenously.

METHODS

The study was designed as a randomized single-blind trial. It was carried out at Oslo Emergency Hospital (outpatient setting or stay < 24 h). 41 patients with a mean age of 41.6 years received 75 mg diclofenac and 42 patients with a mean age of 45.2 years were given 50 mg indomethacin. The two groups were similar in regard to baseline characteristics except gender distribution.

RESULTS

Statistically significant reduction in pain intensity was achieved after 5 min in the diclofenac group (p < 0.01), and after 10 min in the indomethacin group (p < 0.01). The probability of having pain after 1 h was 52% in the indomethacin group and 37% in the diclofenac group (p = 0.11). Rescue medication with pethidine after 2 h was given in 9 and 5 patients, respectively. Four patients in the diclofenac group reported one occurrence of adverse effect each, while 9 patients on indomethacin experienced 14 occurrences, mainly dizziness and nausea.

CONCLUSION

These findings together with a simpler mode of administration indicate that diclofenac may be preferred in the analgesic treatment of renal colic.

Predictors of enhanced well-being after coronary artery bypass surgery

OBJECTIVES

To assess patients' perception of the therapeutic outcome after coronary artery bypass surgery, and to find predictors for increased well-being.

DESIGN

Self-administered questionnaires (Family APGAR and GHQ-30) were completed on admission and at the follow-up after 12 months, together with functional classification according to the NYHA index.

SETTING

Ullevål University Hospital, Oslo, Norway, 1990-1992.

SUBJECTS

Two hundred and thirteen patients with stable angina admitted for elective coronary artery bypass surgery.

INTERVENTION

Elective coronary artery bypass surgery.

MAIN OUTCOME MEASURES

Improved physical and psychosocial functioning after one year.

RESULTS

One hundred and ninety-seven (92%) patients improved their NYHA class, while it remained stable or declined in 16 (8%) patients. Significantly fewer patients with mental distress were found at the follow-up than at the baseline examination (49 patients [23%] versus 80 patients [38%], respectively, P < 0.0001). One hundred and forty-six patients (69%) reported enhanced psychosocial well-being, while it was reduced (n = 60) or unchanged (n = 7) in 67 patients (31%). Predictors for improved psychosocial well-being following coronary artery bypass surgery were mental distress before surgery (odds ratio 2.8) and being a male patient (odds ratio 2.8).

CONCLUSIONS

The majority of the patients reported significant improvement in their physical and psychosocial functioning one year after coronary artery bypass surgery. Mental distress and male sex were significant predictors of enhanced well-being. Questionnaires on psychosocial well-being such as the GHQ-30 may, in addition to health status measurements, offer additional useful information when coronary artery bypass surgery is considered.

Oral diclofenac in the prophylactic treatment of recurrent renal colic. A double-blind comparison with placebo

We have conducted a double-blind, randomized, placebo-controlled trial with oral diclofenac to study the prophylactic effect on renal colic recurrence and spontaneous stone expulsion rate. Forty-one patients were given 50 mg oral diclofenac 3 times a day for 7 days after being discharged for a colic episode from Oslo Emergency Hospital (< 24 h stay) and 39 patients were given matching placebo tablets. The number of new renal colic episodes per accumulated patient treatment days was 64/287 in the diclofenac group and 119/273 in the placebo group (p < 0.01). This difference was greatest during the first 4 treatment days. A similar trend was found for pain intensity (0-10 cm VAS) with the greatest difference on day 1 (4.3 vs. 2.8, p = 0.05). Side effects, mainly gastrointestinal, were reported for 14% of the treatment days in both treatment groups. Stone expulsion rate was almost identical (28 vs. 29 days), regardless of stone size. Readmission rate to Oslo Emergency Hospital/other hospitals were 10 and 67% (p < 0.001). In conclusion, oral treatment with diclofenac was effective as short-term prophylaxis of new colic episodes, especially during the first 4 days, and reduces the number of hospital readmissions significantly. The stone passage rate appears not to be affected.

[Do physicians know if their patients are satisfied? A study in general practice carried out by medical students]

A doctor's ability to assess to what degree his patients are satisfied may indicate how well the patient and the doctor communicate. The main intention of this study was to evaluate the doctor's ability to register a patient's level of satisfaction after a consultation. 19 doctors from six medical centres in Eastern Norway participated. In 50% of the 216 consultations the doctors were able to state exactly how satisfied the patients were. In most of the cases with a mismatch between the doctor's and his patient's ratings the patients were more satisfied than the doctors realized. In some of these cases, however, the doctors failed to observe that the patients were dissatisfied. Male doctors were able to state the patients' level of satisfaction more accurately than female doctors were. Doctors with more experience were also more accurate in their assessments. The method of research used in this area can be problematic. A more reliable and valid questionnaire should be developed.

Salt restriction in hypertension--the effect of dietary advice and self monitoring of chloride concentration in urine

The aims of this present study were firstly to examine whether diet compliance and blood pressure effect could be enhanced by self monitoring with a titrator strip (Quantab 1176) measuring the urine chloride concentration. This was achieved by an open, randomized parallel group design. The study also sought to evaluate the blood pressure effect of a moderately salt restricted diet by using a pre-test-post-test design with a run-in period and controlling for relevant confounding factors (weight, training and alcohol consumption). Furthermore, the study aims were to validate the measurement of chloride concentration in the morning urine by the Quantab titrator strip. We compared Quantab 1176 measurement of chloride concentration in the morning urine with 24 h sodium excretion, determined by the clinical chemical laboratory, was performed. Twenty men and 14 women (mean age 53 years) with essential hypertension (mean: 165/96 mmHg) were observed during a run-in period of 4 weeks before randomization to either dietary advice combined with self monitoring of morning urine chloride concentration for 12 weeks, or dietary advice alone. The reduction in diastolic blood pressure of 6 mmHg was not different in the two groups (between groups p = 0.44). Within group changes of systolic blood pressure were 10 mmHg and 6 mmHg (p = 0.006 and p = 0.04) in the diet plus Quantab group, and the diet only group respectively (between groups p = 0.30). No significant difference in 24 h sodium excretion could be detected between the groups. The morning urine chloride concentration correlated moderately to the 24 h urine sodium excretion (r = 0.66, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Salt restriction and increased insulin production in hypertensive patients

The present study was performed to evaluate glucose metabolism, serum lipids and sympathetic activity during 12 weeks of a moderate salt restricted diet in hypertensive patients. The study was designed as a pre-test-post-test study. All patients from a controlled trial evaluating self-monitoring of urine chloride concentration as a remedy for enhancing diet compliance and blood pressure effect were included. Twenty male patients and 14 female patients with essential hypertension (mean age 53 years) were randomized to a self monitoring diet group and a diet only group. They were exposed to a moderately salt restricted diet during 12 weeks. Fasting serum insulin C-peptide, glucose, HbA1c, total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were measured along with 24 h urine excretion of adrenaline, noradrenaline and vanillylmandelic acid (VMA). As a result, insulin C-peptide increased by 40% (p = 0.0001) whereas glucose rose by 6% (p = 0.02). Total cholesterol, LDL-cholesterol and HDL-cholesterol concentration were reduced by 6% (p = 0.001), 12% (p = 0.008) and 11% (p = 0.004) respectively. HbA1c, serum triglycerides, total/HDL-cholesterol ratio, urine catecholamines and VMA were unchanged during the trial. It is concluded that salt restriction may increase insulin resistance in hypertensive patients.

Assessment of coronary heart disease risk, I. A postal inquiry among primary care physicians

The purpose of the present study was to examine general practitioners' abilities to make a correct estimation of the risk of coronary heart disease (CHD). A 10% random sample of Norwegian primary care physicians (n = 288) received a questionnaire that presented 10 case histories containing information about five CHD risk factors. The respondents' risk estimation was compared with a composite score computed from epidemiologic data. The observed general tendency was towards underestimating the CHD risk. However, 'high-risk' histories were recognized as CHD risk persons. Assessment of CHD risk due to multiple marginal abnormalities was only exceptionally correct. Hypercholesterolaemia and hypertension in men were acknowledged as contributing to clinically significant CHD risk only by a minority of GPs. Heavy smoking and a positive family history were associated with a more accurate estimation of CHD risk. Forty per cent of the physicians did not recognize the sex dependency of cholesterol as a CHD risk factor. None of the physician characteristics could predict variation in correct risk assessment.

Assessment of coronary heart disease risk, II. A clinical multicentre study of general practitioners' risk assessment

The objectives of the present study were: (i) to compare clinical assessment of coronary heart disease (CHD) risk with risk estimation faced with simulated, written case histories; (ii) to observe the risk assessment performed by general practitioners (GPs) in their clinical setting. Thirty-one GPs participating in a multicentre study were asked to invite 20 consecutive male patients aged 30-59 years to an opportunistic screening of CHD risk factors. They assessed the risk status of these patients and of 10 written case histories containing information about corresponding CHD risk factors. A composite 'infarction score' computed from epidemiologic data was used as a gold standard. Diagnostic performance in the clinical setting was compared with that in the simulated setting by Pearson's correlation. A weak, but statistically significant positive correlation was demonstrated when comparing correct estimation in the two settings. No correlation was found for over- and underestimation. Sensitivity was increased faced with clinical patients at the sacrifice of specificity compared to the simulated setting. The impact of a positive family history on clinical assessment parallels the epidemiological estimate. Due to lack of sensitivity, the other factors had a lower impact on risk estimation than an epidemiological estimate would presuppose. We advocate the application of a formal risk estimation to improve risk assessment accuracy. The synergistic effect of multiple risk factors should be emphasized in medical training to improve the clinical risk estimation.

Referrals for radiological examination of the large bowel. Pre-radiological examinations, tests and referral letters

The aims of the present study were to assess the frequency of examinations or tests before referral for a barium enema, to identify predictors for the use of such examinations or tests and to evaluate the quality of the referral letters. 1852 patients completed a questionnaire on symptoms and examinations or tests performed before referral. Symptoms, examination procedures, laboratory data and reason for referral were registered in 1781 referral letters and were compared with the information given by the patients. Serum haemoglobin was measured in 76%, per-rectal examination in 45%, faecal occult blood tests in 37% and proctosigmoidoscopy in only 16% of the patients. High age was a significant predictor for all examinations, and patients with rectal bleeding and rectal pain were more often examined rectally, although this was omitted in several patients with such symptoms. All evaluated information was reported significantly more frequently by the patients than by the doctors in the referral letters. The very low figures for rectal examinations and the lack of completeness and adequacy of the information in the referral letters underline the need for efforts to change doctors' behaviour when investigating and referring patients with possible colorectal disease.

Referrals for double-contrast barium examination. Factors influencing the probability of finding polyps or cancer

Predictors of the radiologic detection of colorectal polyps or cancer were studied in 1852 patients referred from primary health care for a double-contrast barium enema. Significant polyp predictors were age 40-79 years (odds ratio (OR), 2.4-5.0) and rectal bleeding (OR, 1.8). Previous colorectal neoplasm, familial history of cancer in general, and male sex were nearly significant predictors of polyps. Significant cancer predictors were age > or = 60 years (OR, 8.6-27.8), rectal bleeding (OR, 2.7), loss of weight (OR, 2.6), and male sex (OR, 2.2). Fatigue and abdominal pain were nearly significant negative predictors for cancer. No association was found between patient delay and the detection of polyps or cancer. Physician delay was significantly shorter in patients with cancer than in cancer-free patients. Age was the most important predictor for the detection of both polyps and cancer, more important than symptoms and history, including family history.

[Chloramphenicol eyedrops in acute bacterial conjunctivitis. A comparison of 2 dosage regimes in general practice]

Acute bacterial conjunctivitis is a prevalent infection in the population. Topically applied chloramphenicol has been the most frequently used treatment on this indication. The recommended dosage of 0.5% eye drops has been one drop hourly/every two hours for three days, thereafter every 4-6 hours. This dosage is not based on scientific documentation. We have conducted a clinical trial in general practice to compare the standard dosage with a simplified dose regimen. 77 patients were allocated to the regimen described above and 75 patients were instructed to use the drops four times a day. Mean duration until complete healing of all symptoms was 4.4 days (median 4; 95%-confidence interval (CI) 4-5) and 4.8 days (median 5; CI 4-5) in the two groups. The proportion of completely cured patients after nine days of treatment was 95% and 88% respectively; after four days corresponding percentages were 61% and 44% (p < 0.05). For other clinical variables the differences were small and not statistically significant. Compliance was significantly better for the simplified regimen (p < 0.001). The study indicates that the simplified dose regimen may be preferable in clinical practice.