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Aim: To assess the predicative value of clinical judgement of endoscopic diagnosis in the dyspeptic patients among General Practitioners (GPs) Methods: 32 general practices included 233 patients with dyspepsia without alarm symptoms. All patients had an endoscopy performed within 2 weeks. Dyspepsia definition: Epigastric pain/discomfort with/without symptom of reflux. The study was conducted in the County of Aarhus, Denmark. Outcome measures: The GPs clinical judgement of endoscopic diagnosis, endoscopic diagnosis. Results: According to the GPs clinical judgments 36% had functional dyspepsia, 24% had ulcer, 40% had reflux/oesophagitis and 0.4% had malignant disease. The endoscopy revealed that 74% had functional dyspepsia, 7% had ulcer, 18 % had oesophagitis and 1.3% had malignant disease. The predicative values of the GPs clinical judgement were 80 % (67/84) for functional dyspepsia, 11% (6/55) for ulcer, 25% (23/93) for oesophagitis, 0% (0/1) for malignant disease and 30% (44/149) for all organic lesions (ulcer, oesophagitis or malignancy). The sensitivity of the GPs clinical judgement was 39 % (67/172 for functional dyspepsia, 38% (6/16) for ulcer, 55% (23/42) for oesophagitis, 0% (0/3) for malignant disease and 72% (44/61) for all organic lesions. The GPs assessed organic lesion three times more common than revealed by endoscopy, but even then ¼ of the organic lesion was overlooked. Concerning reflux/oesophagitis both predicative value and sensitivity was even lower despite reflux should be the easiest organic dyspeptic lesion to asses clinical. Conclusion: Clinical judgement of endoscopic diagnosis in the dyspeptic patients by GPs does not satisfactorily predict endoscopic verified diagnosis. -- page break -- The General Practitioners clinical judgementEndoscopic diagnosisPredicative value of clinical judgementSensitivity of clinical judgementFunctional dyspepsia36 % (84)74 % (172)80 % (67/84)39 % (67/172)Ulcer24 % (55)7 % (16)11 % (6/55)38 % (6/16)Oesophagitis40 % (93)18 % (42)25 % (23/93)55 % (23/42)Malignancy0.4 (1)1.3 % (3)0 % (0/1)0 % (0/3)All organic lesion (ulcer, oesophagitis or malignancy)74% (149)26 % (61)30 % (44/149)72% (44/61) Endoscopic diagnosisFunctional dyspepsiaNo functional dyspepsia Clinical judgementFunctional dyspepsia6717No functional dyspepsia10544 Total17261 Endoscopic diagnosisUlcerNo ulcer Clinical judgementUlcer649No ulcer10168 Total16217 Endoscopic diagnosisOesophagitisNo oesophagitis Clinical judgementOesophagitis2370No oesophagitis19121 Total42191 Endoscopic diagnosisOrganic lesionNo organic lesion Clinical judgementOrganic lesion44105No organic lesion1767 Total61172

Udgivelsesdato: 22. juni

Udgivelsesdato: Januar

OBJECTIVE - To examine the correlates of patient and provider attitudes toward insulin therapy. RESEARCH DESIGN AND METHODS - Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses. RESULTS - Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50-55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications. CONCLUSIONS - Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose-lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.

Udgivelsesdato: Januar

Background: Decision analyses conclude that empirical anti-secretory therapy is more cost-effective than endoscopy for managing patients with dyspepsia however RCTs including economic evaluation come to diverging results Aim: to compare the cost-effectiveness of two strategies for management of dyspepsia in primary care 1) endoscopy and 2) empirical proton pump inhibition (PPI) therapy. MethodsA prospective RCT designed to include prospective collection of economic resource data was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. 368 patients with dyspepsia were randomly assigned to treatment with omeprazol 40 mg for two weeks (n: 184) or endoscopy (n: 184). Main outcome measures: days free of dyspeptic symptoms and proportion of patients symptomatic after one year. Cost were estimated from patients' and GPs' questionnaire and from medical records. ResultsThe incremental cost effectiveness (CE) ratio for one day free of dyspeptic symptoms using the endoscopy strategy was €/day 300 compared with the PPI strategy. The incremental CE ratio for one patient free of dyspeptic symptoms after one year using the endoscopy strategy was € 13,600 based on the patients' evaluation. The PPI strategy was both cheaper and more effective when reflux was the predominant symptom. ConclusionEndoscopy was associated with a small, non-significant improvement in patients' health status compared with empirical PPI, but it was the more costly of the two strategies. The empirical PPI strategy was hence the more cost-effective strategy for managing patients with dyspepsia in general practice especially if reflux was the predominant symptom.

Title: Clinical Efficacy of Proton Pump Inhibitor versus Prompt Endoscopy for Management of People with Dyspepsia: A Randomized Clinical Trial in General Practice. Purpose: To compare the clinical efficacy of two strategies for management of dyspepsia in general practice in a RCT design. Setting: June 2000 to August 2002, 41 GPs, Aarhus County, Denmark Methods: 368 people with dyspepsia (epigastric pain/discomfort, no alarm symptoms) were randomly assigned to treatment with omeprazol 40 mg/day for two weeks (PPI group, n:185) or endoscopy (endoscopy group, n:183). Due to migration, cancer, or death 25 were excluded.Outcome measures: Dyspeptic symptoms after 1 year and endoscopies in PPI group (GPs and patients' questionnaires). Use of PPI, sick leaves, visit to GPs and patients' satisfaction (patients' questionnaires).Results: We found no base line difference in age, symptoms, and use of PPI between the groups. The questionnaire response rates after 1 year were 91.3% for GPs and 86.9% for patients. After 1 year the GPs assessed whether the patients primary symptom at inclusion had improved, and 75.6% in the PPI group and 83.6% in the endoscopy group had improvement in their dyspeptic symptoms (2; P: 0.08). Pain/discomfort was the primary symptom at inclusion in 63.7% of the cases, and 74.1% in the PPI group, and after 1 year 85.7% in the endoscopy group had improvement in their pain/discomfort symptoms (2; P: 0.03). After 1 year the patients assessed whether they had of upper GI symptom regardless of the primary symptom at inclusion. The patients assessed 23.6% in the PPI group and 20.1% in the endoscopy group were free of symptoms after 1 year (2; P: 0.47). When pain/discomfort was the primary symptom at inclusion 20.4% in the PPI group and 35.4% in the endoscopy group were free of symptoms after 1 year (2; P: 0.05). The patients reported 31.8% in the PPI group and 42.6% in the endoscopy group used PPI after 1 year (2; P: 0.08). In the PPI group 35.7% had secondary endoscopy performed. We found no differences between the two strategies in respect to sick leaves, dyspeptic contacts to GP or patients' satisfaction. Conclusions: Prompt endoscopy was superior to proton pump inhibitor concerning symptom improvement in management of dyspepsia in general practice when pain/discomfort was the primary symptom. There were no differences between the two strategies in respect to sick leaves, dyspeptic contacts to GP or patients' satisfaction. Table1GPs and patients assessment of dyspeptic symptoms after 1 year. 20 of the GPs and 40 of the patients assessed other primary symptom than reflux or pain/discomfort at inclusion. All value in percentages. Chi-square used for all p-values Primary symptom at inclusionAll N(GP): 310N(pat): 298Pain/discomfortn(GP): 206n (pat): 154Reflux n(GP):84 n(pat):104PPIEndoscopyPPPIEndoscopyPPPIEndoscopyPGPs after 1 yearDyspepticsymptoms improved74.185.70.0479.277.10.9375.683.60.08Patientsafter 1 yearNo dyspepticsymptoms20.833.80.0717.914.60.6520.1 23.60.47

Er vi tilbageholdende med at initiere insulinbehandling? Hos type 2-diabetikere vil det være et rationelt tiltag, når der ikke længere kan opnås en acceptabel glykæmisk kontrol med livsstilsændringer og perorale antidiabetika.

Aim: To compare the effect of two strategies for management of dyspepsia. Evaluation based on GP's assessment after two weeks and patients assessment after three months. Design: Prospective randomised controlled trial in general practice Methods: 357 patients with dyspepsia where the general practitioner (GP) finds indication for treatment with antisecretory therapy and/or diagnostic Helicobacter Pylori test were included in general practice between June 2000 and June 2002. Patients the GP want to refer to endoscopy were not included. Dyspepsia definition: persistent or recurrent pain or discomfort centred in the upper abdomen with or without nausea, vomiting, heartburn, acid regurgitation, early satiety or bloating. Patients were initially treated according to one of two management strategies. The patient was the unit of randomisation.Strategy 1: Proton pump inhibitor (40 mg omeprazol) for two weeks. If symptoms were unchanged after to weeks => referral to endoscopy. Later recurrence of symptoms => endoscopy (> 45 year) or management strategy according to helicobacter pylori status and/or clinical reflux (< 45 year)Strategy 2: Immediate referral to endoscopyOutcome measures: Symptoms, self rated health status (SF-36), drug consumption and use of health care services (visits to GP, out-patient clinics, hospitalisations).GP's and patients responded on questionnaires at inclusion and after 1 year. Additional questionnaires were answered by the GP's after 2 weeks and the patients after 3 months. Results: Response rate GPs after two weeks were 92% (330/357). Response rate patients after three months were 71% (252/357). There were no significant difference between the groups randomised to strategy 1(PPI group) and strategy 2 (endoscopy group) concerning, age, gender, duration of dyspepsia, dyspeptic episodes, main symptom, previous contact to general practice, previous gastroscopia, use of antacids or NSAID's, Helicobacter Pylori status and mental/physical well being (SF-36 measurement scale) (Table 1). After two weeks the GPs assessed 46 % of the patients to be free of symptoms in PPI group and 21 % free of symptoms in endoscopy group (figure 1). After three months the patient assessed 16 % to be free of symptoms in PPI group and 24 % free of symptoms in endoscopy group (figure 2). There was no difference in use of PPI between the groups after three months (figure 3) ConclusionIn management of dyspepsia therapy does have a better short term effect than endoscopy concerning symptom relief, but after 3 months the endoscopy strategy had a better effect than PPI concerning symptom relief

INTRODUCTION: Both physical and psychosocial workplace factors are considered risk factors for low back pain (LBP). However, today, no consensus has been reached regarding the exact role of these factors in the genesis of LBP. MATERIAL AND METHODS: Questionnaire data were collected at baseline for 1,397 (and after five years for 1,163) men and women aged 31-50 years at baseline. LBP (any LBP within the past year; LBP < or = 30 days in total during the past year; LBP > 30 days in total during tha past year) was analysed in relation to physical workload (sedentary, light physical, and heavy physical work) using logistic regression and controlling for age, gender, and social group. The proportions af workers changing between the workload groups over the five-year period were analysed in relation to LBP status. RESULTS: A baseline no statistically significant differences in LBP outcomes were found for workers exposed to sedentary, light physical, or heavy physical work. This was true for both genders and all age and social groups. At follow-up these was a statistically significant dose-response association between any LBP and long-standing LBP during the past year and increasing physical workload at baseline, also after controlling for age, gender and social group. Subjects with a heavy physical workload at baseline changed significantly more often to sedentary work, if they had experienced LBP for more than 30 days out of the past year. DISCUSSION: Having a sedentary job might have a protective or neutral effect in relation to LBP, whereas having a heavy physical job constitutes a significant risk factor. Because og migration between exposure groups (the "healthy worker" effect), longitudinal studies are necessary for investigating the associations between physical workload and LBP. Udgivelsesdato: 2002-May-20

Udgivelsesdato: 2002-Jan-7

INTRODUCTION: We investigated the impact of general health screenings and discussions with general practitioners on the cardiovascular risk profile of the population. MATERIAL AND METHODS: A population-based, randomised, controlled, 5-year follow-up trial conducted in a primary care setting. In total 2000 randomly selected men and women, aged 30-50 years, from family practices in the district of Ebeltoft, Denmark. Of these persons, 1507 (75.4%) agreed to participate, and were randomised into: (1) a control group who did not receive health screenings; (2) an intervention group that received two health screenings; or (3) an intervention group that received both the two screenings and a 45-minute follow-up consultation annually with their general practitioner. All were followed up after 5 years by questionnaires and health screenings. The outcome measures were: cardiovascular risk score (CRS), body mass index (BMI), blood pressure, serum cholesterol, carbon monoxide in expiratory air, and use of tobacco. RESULTS: After 5 years, the CRS, BMI, and serum cholesterol levels were lower in the intervention groups, as compared with the control group. The improved outcome was greater in the baseline risk groups. The number of persons with elevated CRS in the intervention groups was about half the number of persons with elevated CRS in the control group. The difference was not a result of medication use. There was no difference between the group that received consultations after the screenings and the group that had health screenings alone. DISCUSSION: Systematic health screenings reduce the cardiovascular risk score in a middle-aged population. After 5 years of follow-up, the number of persons at elevated cardiovascular risk was about half the expected. The impact of intervention is higher in at-risk individuals. Planned consultations about health did not appear to improve the cardiovascular profile of the study population. Udgivelsesdato: 2002-Jun-17