Departement of Family medicine

Objective-To examine the relation between general practitioners' knowledge about their patients and the use of resources in consultations. Design-A cross sectional evaluation of consultations. Setting and subjects-A representative sample of 133 Norwegian general practitioners were each asked to record 30 consecutive consultations. 131 did so, and of 3990 possible registrations, 3918 (98%) were evaluated. Main outcome measures-The influence, as assessed by the doctor, of accumulated knowledge on the use of laboratory tests, expectant management, prescriptions, sickness certification, referrals, and time spent in the consultation. Results-Accumulated knowledge was a substantial factor in saving time, especially in consultations with children, the elderly, patients with psychosocial problems, and those with chronic diseases. It also influenced the overali use of laboratory tests, expectant management, sickness certification, and referrals, and to a lesser degree the use of medication. Conclusion-The findings imply strong but complex associations between accumulated knowledge and the use of resources in the consultation.

Objective-To evaluate the influence of continuity of care on patient satisfaction with consultations. Design-Direct and episodic specific evaluation of patient satisfaction with recent consultation. Setting and subjects-A representative sample of 3918 Norwegian primary care patients were asked to evaluate their consultations by filling in a questionnaire. The response rate was 78%. Main outcome measures-The patient's overali satisfaction with the consultation was rated on a six point scale. Continuity of care was recorded as the duration and intensity of the present patient-doctor relationship and as patients' perception ofthe present doctor being their personal doctor or not. Results-The multivariate analysis indicated that an overali personal patient-doctor relationship increased the odds of the patient being satisfied with the consultation sevenfold (95% confidence interval 4 9 to 9.9) as compared with consultations where no such relationships existed. The duration of the patient-doctor relationship had a weak but significant association with patient satisfaction, while the intensity of contacts showed no-such association. Conclusion-Personal, continuous care is linked with patient satisfaction. If patient satisfaction is accepted as an integral part of quality health care, reinforcing personal care may be one way of increasing this quality.

Folgering HTM, van der Heide S, et al. House dust mite avoidance measures improve peak flow and symptoms in patients with allergy but without asthma: a possible delay in the manifestation of clinical asthma? J Allergy Clin Immunol 1997;100:313-9. 3 Cloosterman SGM, Schermer TRJ, Bijl-Hofland I, Van der Heide S, Brunekreef B, Van den Elshout FJJ, et al. Effects of house-dust mite avoidance measures on Der p 1 concentrations and clinical condition of mild adult housedust mite allergic asthmatic patients using no inhaled steroids. Clin Exp Allergy (in press). 4 Ehnert B, Lau-Schadendorf S, Weber A, Buettner P, Schou C, Wahn U. Reducing domestic exposure to dust mite allergen reduces bronchial hyperreactivity in sensitive children with asthma. J Allergy Clin Immunol 1992;90:135-8. 5 Schönberger HJAM, van Schayck CP. Prevention of asthma in genetically predisposed children in primary care. From clinical efficacy to a feasible intervention programme.

prescribing data into traffic-light categories; a tool for evaluating treatment quality in primary care. Family Practice 2001; 18: 528-533. Background. Prescribing feedback based on aggregated data alone does not give the information needed to improve treatment quality. Objectives. Our aim was to develop a new method, or tool, of presenting prescribing feedback which, combined with guideline recommendations, makes it possible for doctors to judge their own prescribing as good or bad. Methods. Asthma was chosen as a disease model, as treatment recommendations are readily available published as national and international guidelines. Four mean daily dosage intervals of inhaled short-acting β-agonists and four mean daily dosage intervals of inhaled steroids were combined into a 4 × 4 matrix. This matrix of 16 combined dosage boxes was presented to 68 Norwegian GPs participating in peer review groups. As a first step, the GPs in the groups reached consensus on what they considered to be appropriate and inappropriate combined dosage intervals of these drugs based on national guideline recommendations and their joint clinical experience. Accordingly, traffic-light colours, green and red, were assigned to the combined dosage boxes in the matrix. Treatments in boxes difficult to judge were coloured yellow. During a 1-year period prior to the consensus meetings, the dispensed inhaled short-acting β-agonists and inhaled steroids of each of the doctors' patients were recorded at the local pharmacies. As a second step in developing the new method, the number of patients treated within each of the coloured boxes was presented to the GPs in the peer review groups. These combined presentations provided an overview to the whole group, and individually to each GP, of how many patients were actually given appropriate or inappropriate treatment according to their own agreed upon standard. Results. The GPs categorized 34% of 1122 evaluated patients receiving inhaled short-acting β-agonists or inhaled steroids as treated inappropriately during the 1-year registration period. Appropriate treatment was given to 47% of the patients, and in 19% of the cases the treatment was difficult to evaluate. Conclusions. A method has been developed enabling GPs to categorize prescribing information into good (green), bad (red) and difficult to judge (yellow) treatment qualities, based on guideline recommendations and clinical experience. The actual prescribing data for each GP were labelled according to the same colour scheme, thus revealing to each GP his or her own actual prescribing compared with their own treatment standard, yielding information and motivation for quality improvement efforts.

Insight into patients' priorities with respect to health care should complement the views of professionals and policy makers on what is thought to be appropriate health care. To determine the strengths and weaknesses of general practice care from patients' perspectives written surveys were performed among patients in Denmark,

Purpose: To analyze associations among the negative life experiences and health-care-seeking of adolescents during the 12 months before the study. Methods: Cross-sectional questionnaire study among 10th-year students at all secondary schools in Oslo. Results: In 2000 and in 2001, 7329 (88%) of Oslo's 8316 secondary-school students responded to the questionnaire. Some contacts with primary health care during the previous year were reported by 71% of respondents, and 6% had seen a mental health practitioner (psychologist or psychiatrist). Health care utilization was not correlated with the family's financial situation as reported by the student (boys ϭ 1019; girls ϭ 1258), or with a parent's unemployment (boys ϭ 253; girls ϭ 325). The 2112 boys (59% of all) and 2378 girls (64%) who reported feeling strong pressure from others to succeed, had more contacts with all primary health care services. Girls, but not boys, who reported being bullied by others reported more psychologist or psychiatrist visits than did their nonbullied peers. Exposure to physical violence was associated with a significant increase in visits to the School Health Service, family physician, and emergency medical service, and was related to more than doubling the probability of visiting a mental health practitioner. Being sexually violated during the previous year increased the likelihood of boys visiting mental health practitioner more than four times (odds ratio [OR] 4.6; 95% confidence interval [CI] 1.7-12.2); and visiting School Health Service by nearly four times, (OR 3.7; 95% CI 1.0-13.5). Conclusion: Variation in adolescent health care seeking can, by and large, be predicted by negative life experiences.

Objective-To assess the efficacy of near-to-patient laboratory testing in diagnosing group A beta haemolytic streptococci throat infection in adults, alone and in conjunction with the doctor's clinical judgement. Setting and subjects-174 primary care patients with a sore throat, of which 59 (34%) were identified as having group A streptococci. Main outcome measures-The erythrocyte sedimentation rate, leucocyte count, and C-reactive protein, and a specific streptococcal immunological assay were evaluated separately and in conjunction with the doctor's clinical diagnosis. The presence of GAS throat infection, the reference standard, was defined as those patients presenting with a chief complaint of sore throat and having a positive GAS culture or a four-fold or more increase or fall of AST or ADNase B serum levels during a four-week observation period. Results-The discriminatory ability of the sedimentation rate was not satisfactory and added little useful clinical information. Leucocytes and C-reactive protein both yielded clinically significant information and had similar test characteristics. The immunological test had the best characteristics of the tests evaluated. Conclusion-Near-to-patient testing, except the erythrocyte sedimentation rate, may, in addition to the clinical evaluation, contribute to the differential diagnosis of streptococcal pharyngitis in adults.

Quantitative C-reactive protein (CRP) measurement has become increasingly valuable as a test for rapid diagnosis of infections in hospital medicine. CRP has not obtained the same importance in primary health care. This has, at least partly, been due to methodological difficulties, with no simple or rapid tests with quantitative results available. A new immunometric semi-quantitative assay, NycoCardrM CRP, has recently been developed. CRP was analysed at the local health centres by the new assay in 288 consultations where patients came because of infections. Parallel CRP values were obtained by an established reference method. The two procedures had an acceptable correlation (r = 0.85). The primary care doctors also registered the clinical information they obtained from each CRP result. CRP was helpful in indicating the presence, or absence of bacterial infection in more than half the consultations due to new infections. CRP was thought to yield more clinical information than the erythrocyte sedimentation rate in almost every case.

Background: Millions of patients are prescribed drugs for sexually transmitted infections (STIs) in developing countries each year, yet the treatment effect of these prescriptions is largely unknown. Objectives: To determine if the prescribing of erythromycin and ceftriaxone to pregnant women with STI symptoms leads to a reduction in the prevalence among these women of chlamydia and gonorrhoea, respectively. Methods: We compared the prevalence of chlamydia among 116 pregnant women who had been prescribed erythromycin for a history of STI symptoms in their current pregnancy with the prevalence in a control group of 557 pregnant women who had not been prescribed this drug. Similarly we compared the prevalence of gonorrhoea among 110 pregnant women who had and 561 women who had not been prescribed ceftriaxone. Results: There was no significant difference in the prevalence of chlamydia among the women who had and the women who had not been prescribed erythromycin four times daily for 10 days (7% v 8%). Contrarily, none of the women who had been prescribed a single dose of ceftriaxone had gonorrhoea, whereas 4% of the women who had not had this drug prescribed did have gonorrhoea. Conclusions: The prescribing of erythromycin seems to have had a limited effect on chlamydia in this population, whereas the prescribing of ceftriaxone led to the curing of gonorrhoea. Ceftriaxone is provided as a single dose injection at the point of care, and the differential effectiveness between the two drugs may reflect low compliance with the complex erythromycin regimen. Interventions to increase compliance could improve cure rates. The use of a simpler drug regimen should be considered when low compliance is likely.

Preface "Improving public health control of sexually transmitted diseases in Botswana" is one of the institutional collaboration projects financed by the Health Sector Agreement between Norway and Botswana. The project has two main components; an epidemiological study and an economic evaluation.

We examined an instrument-free test for C-reactive protein (CRP) in whole blood. The NycoCard CRP Whole Blood test uses a cell-solubilizing dilution liquid, a membrane-bound antibody that binds CRP, and a gold-conjugated antibody for making visible the bound CRP. We obtained essentially identical dose-response curves in citrate-, heparin-, and EDTA-treated blood. CVs were 6.7-12.5% within series and 10.1-14.7% between series. The detection limit was 12 mg/L. Intralipid added to blood increased measured CRP by 10-20%, whereas no change was seen with added bilirubin, added serum amyloid P component, or the presence of rheumatoid factor. In 234 patients' blood samples the results of the NycoCard Whole Blood test correlated well (r = 0.96) with those of a turbidimetric serum method. The test allows reliable measurement of CRP from a small volume of whole blood (25 microL) without using expensive equipment; it should be useful for decentralized testing in hospital departments, emerge...

relationship between a woman and her clinician should be built on trust, and the benefits and the risks of a procedure such as an episiotomy must be openly discussed to ensure truly informed consent. The reexamination of the use of episiotomy that has occurred over the past 20 years underscores both the important role of systematic reviews in stimulating research and an often unappreciated issue in assessing procedures: what should be done with long standing procedures that have never been assessed using an evidence based approach. An important next step with episiotomy is to assess the relevant benefits of the midline versus the mediolateral technique. Randomised controlled trials should be conducted soon and their results disseminated broadly for the benefit of mothers and their children throughout the world.

It is difficult to put research findings into clinical practice by either guidelines or prescription feedback. To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups. 199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the pro...