Swedish Primary Health Care Research Articles

Differences and time trends in drug treatment of atrial fibrillation in men and women and doctors’ adherence to warfarin therapy recommendations

Little is known about prescription trends in atrial fibrillation (AF) in primary health care in Sweden. The aim was to study time trends in pharmacotherapy, in men and women with AF. We also aimed at studying doctors' adherence to CHADS2 for prescribing warfarin. CHADS2 assesses stroke risk by presence of known risk factors, i.e., congestive heart failure, hypertension, age >75 years, diabetes, previous stroke and transient ischemic attack. Data were obtained from primary health care records that contained individual clinical data. In total, 371,036 patients were included in the sample from 2002, and 424,329 patients were included in the sample from 2007. The study population consisted of individuals aged 45+ years who were diagnosed with AF in 2002 (1,330 men and 1,096 women) and 2007 (2,748 men and 2,234 women). The pharmacotherapies prescribed in 2002 and 2007 were analyzed separately in men and women. Logistic regression was used to calculate the association between the CHADS2 score and prescribed warfarin treatment. Selective beta-blockers, anti-coagulant therapy and lipid-lowering drugs were prescribed more frequently in 2007 than in 2002. In 2007, antithrombotic and RAS-blocking agents were prescribed more frequently to men, whereas beta-1 selective beta-blockers were prescribed more frequently to women. There was no consistent association between the CHADS2 score and prescribed warfarin treatment. Pharmacotherapy of AF has improved over time, though CHADS2 guidelines need to be implemented systematically in primary health care in Sweden to decrease the risk of stroke and improve quality of life in patients with AF.

Bariatric Surgery and Long-term Cardiovascular Events

Obesity is a risk factor for cardiovascular events. Weight loss might protect against cardiovascular events, but solid evidence is lacking. To study the association between bariatric surgery, weight loss, and cardiovascular events. The Swedish Obese Subjects (SOS) study is an ongoing, nonrandomized, prospective, controlled study conducted at 25 public surgical departments and 480 primary health care centers in Sweden of 2010 obese participants who underwent bariatric surgery and 2037 contemporaneously matched obese controls who received usual care. Patients were recruited between September 1, 1987, and January 31, 2001. Date of analysis was December 31, 2009, with median follow-up of 14.7 years (range, 0-20 years). Inclusion criteria were age 37 to 60 years and a body mass index of at least 34 in men and at least 38 in women. Exclusion criteria were identical in surgery and control patients. Surgery patients underwent gastric bypass (13.2%), banding (18.7%), or vertical banded gastroplasty (68.1%), and controls received usual care in the Swedish primary health care system. Physical and biochemical examinations and database cross-checks were undertaken at preplanned intervals. The primary end point of the SOS study (total mortality) was published in 2007. Myocardial infarction and stroke were predefined secondary end points, considered separately and combined. Bariatric surgery was associated with a reduced number of cardiovascular deaths (28 events among 2010 patients in the surgery group vs 49 events among 2037 patients in the control group; adjusted hazard ratio [HR], 0.47; 95% CI, 0.29-0.76; P = .002). The number of total first time (fatal or nonfatal) cardiovascular events (myocardial infarction or stroke, whichever came first) was lower in the surgery group (199 events among 2010 patients) than in the control group (234 events among 2037 patients; adjusted HR, 0.67; 95% CI, 0.54-0.83; P < .001). Compared with usual care, bariatric surgery was associated with reduced number of cardiovascular deaths and lower incidence of cardiovascular events in obese adults.

The work environment impact scale – self-rating (WEIS-SR) evaluated in primary health care in Sweden

To develop a self-report alternative to the Work Environment Impact Scale (WEIS). First the novel instrument was used and evaluated by ten occupational therapists and 45~clients in primary health care. Then the instrument was used by 26~clients who participated in a rehabilitation programme in another primary health care district. The instrument was investigated in two steps. First content validity and utility were investigated through a questionnaire addressed to occupational therapists and their clients respectively. The response distribution was calculated by frequencies. Internal consistency was investigated. In the second step, a revised version of the instrument was investigated for test-retest reliability and internal consistency. The test-retest reliability was calculated by weighted kappa. The internal consistency of the WEIS-SR was calculated by means of Cronbach's alpha. In step one the content validity was good to moderately good, the utility was good, and the internal consistency was satisfactory (0.72). In step two the internal consistency was good (0.88/0.89) and the test-retest reliability was mostly good to moderate (0.35-0.78, median 0.61). The instrument will be further investigated in other populations and take into consideration additional psychometric properties such as sensitivity to change, predictive validity, and concurrent validity.

Frequency and severity of problems that general practitioners experience regarding sickness certification

Objective. Tasks involved in sickness certification constitute potential problems for physicians. The objective in this study was to obtain more detailed knowledge about the problems that general practitioners (GPs) experience in sickness certification cases, specifically regarding reasons for issuing unnecessarily long sick-leave periods. Design. A cross-sectional national questionnaire study. Setting. Primary health care in Sweden. Subjects. The 2516 general practitioners (GPs), below 65 years of age, who had consultations involving sickness certification every week. This makes it the by far largest such study worldwide. The response rate among GPs was 59.9%. Results. Once a week, half of the GPs (54.5%) found it problematic to handle sickness certification, and one-fourth (25.9%) had a patient who wanted to be sickness absent for some reason other than medical work incapacity. Issues rated as problematic by many GPs concerned assessing work capacity, prognosticating the duration of incapacity, handling situations in which the GP and the patient had different opinions on the need for sick leave, and managing the two roles as physician for the patient and medical expert in writing certificates for other authorities. Main reasons for certifying unnecessarily long sick-leave periods were long waiting times in health care and in other organizations, and younger and male GPs more often reported doing this to avoid conflicts with the patient. Conclusion. A majority of the GPs found sickness certification problematic. Most problems were related to professional competence in insurance medicine. Better possibilities to develop, maintain, and practise such professionalism are warranted.

Psychosocial stressors and depression at a Swedish primary health care centre. A gender perspective study

BackgroundPsychosocial stress may account for the higher prevalence of depression in women and in individuals with a low educational background. The aim of this study was to analyse the association between depression and socio-demographic data, psychosocial stressors and lifestyle circumstances from a gender perspective in a relatively affluent primary care setting.MethodsPatients, aged 18- 75 years, visiting a drop-in clinic at a primary care health centre were screened with Beck's Depression Inventory (BDI). The physicians used also targeted screening with BDI. A questionnaire on socio-demographic data, psychosocial stressors and use of alcohol and tobacco was distributed. Among patients, who scored BDI ≥10, DSM-IV-criteria were used to diagnose depression. Of the 404 participants, 48 men and 76 women were diagnosed with depression. The reference group consisted of patients with BDI score <10, 187 men and 93 women. Age-adjusted odds ratios (ORs) with 95% confidence intervals (CI) as being depressed were calculated for the psychosocial stressors and lifestyle circumstances, separately for men and women. Multiple logistic regression analyses were used to determine the age-adjusted main effect models for men and women.ResultsThe same three psychosocial stressors: feeling very stressed, perceived poor physical health and being dissatisfied with one's family situation were associated with depression equally in men and women. The negative predictive values of the main effect models in men and women were 90.7% and 76.5%, respectively. Being dissatisfied with one's work situation had high ORs in both men and women. Unemployment and smoking were associated with depression in men only.ConclusionsThree questions, frequently asked by physicians, which involve patient's family and working situation as well as perceived stress and physical health, could be used as depression indicators in early detection of depression in men and women in primary health care.

Total mortality among levothyroxine-treated women with atrial fibrillation in Swedish primary health care

Atrialfibrillation (AF) is equally common amongmen andwomen of Western populations [1], but women develop AF around five years later than men [2], and show less favorable outcomes with higher relative mortality and a higher risk of stroke [3]. Women have a higher prevalence of hypothyroidism and levothyroxine treatment [4], and this treatment could possibly be cardiotoxic in patients with heart disease [5]. Earlier studies have shown conflicting results, with no increased morbidity or mortality [6], increased cardiovascular morbidity [7], and a higher mortality among women with levothyroxine treatment [8]. Our aimwas to study if levothyroxine treatment amongwomen is associatedwithhigher totalmortality or not. The study used individual-level patient data from a total of 75 primary health care centers (PHCC) (n=1,098,420). The data was linked to individual-level data on age, gender, education and marital status for all people registered in Sweden [9], and the Cause of Death Register [10]. The study included women with established atrial fibrillation between 2001 and 2007, identified by the presence of the ICD-10 code for AF in patients' medical records. Cardiovascular disorders and diabetes were used as covariates. Altogether 5642 women≥45 years of age at the time of diagnosis were included, 907 with a concomitant prescription of levothyroxine and 4735 without. Ethical permissionswere achieved at Karolinska Institutet and at the University of Lund. Death was registered from notification of AF diagnosis until 31 December, 2007. Age was dichotomized into 45–79 and ≥80 years. Educational attainment, marital status and drugs prescribed at PHCCs during the assessment period were recorded. Prescription of antithrombotic drugs was coded as no treatment, anti-platelet treatment only, or anticoagulant treatment. Differences in means and distributions were calculated using Student's t-test, chi-square analysis and Fisher's exact test. Follow-up analyses were performed using Cox regression, with time being defined as years from inclusion to death, or to censoring at the end of the followup period. Analyses were performed using separate models for those below 80 and those 80 years of age or older, respectively. In the models we included factors showing significant results in either age-group. A p value b0.05 was considered to be statistically significant. Table 1 shows the characteristics of the sample, divided by the presence of levothyroxine treatment or not. Mean follow-up time was 3.5 years (SD 2.1), in total 3200 person-years. Difference of prescription of pharmacological between the groups was found for anticoagulant agents, specific anti-arrhythmic agents, non-selective beta-blockers, sotalol, and lipid-lowering drugs being more common among younger, and antiplatelet agents, all diuretics and loop-diuretics among older women. Table 2 shows models of Cox' regression, stratified by age group, with diagnoses, prescribed drugs in separate models, and full model with them combined and with also socio-economic factors included. When combining age groups, levothyroxine treatment was associated with a lower mortality when adjusting for co-morbidities, prescribed drugs and socio-economic factors (HR 0.76, 95% CI 0.58–0.99).

Reporting systems, reporting rates and completeness of data reported from primary healthcare to a Swedish quality register – The National Diabetes Register

Objective The aims of this paper were to study the reporting rate and completeness of data reported from primary healthcare centres (PHCCs) in Sweden to the Swedish National Diabetes Register (NDR), with a special attention on the relation between these measures and the reporting system used by the PHCCs. Method A national survey conducted in Swedish primary healthcare covering the year 2006. A questionnaire was used to collect data from 523 PHCCs. Data on 87,099 adult diabetic patients attending these PHCCs and reported to the NDR were obtained from the register. In Sweden, participation in the NDR is voluntary. The data were reported through the Internet, either online using a web-based system or by direct transmission. The main outcome measures were reporting rate and completeness of reported data. Results Of the 523 PHCCs, almost two-thirds had reported <75% of their diabetic patients to the NDR. The lowest reporting rate was found among the largest PHCCs, while the highest was found among small PHCCs ( p < 0.001). Reasons given for not reporting data to the NDR were lack of time and lack of personnel resources. Altogether, 73.1% of the PHCCs reported data to the NDR online using a web-based system, 20.5% used direct transmission and 6.3% used both systems. The PHCCs that reported data through direct transmission systems reported almost 70% of their diabetic patients to the NDR, while PHCCs using web-based systems reported 54% of their diabetic patients to the NDR. Adjusted for other factors, using direct transmission increased the reporting rate by 13.0 percentage points. However, the web-based system contributed to a higher completeness of data than the direct transmission system. Conclusions A direct transmission system facilitates a high reporting rate to the register at the expense of lower completeness of the reported data.

Applying the RE-AIM framework to evaluate two implementation strategies used to introduce a tool for lifestyle intervention in Swedish primary health care

The aim of this study was to evaluate two implementation strategies for the introduction of a lifestyle intervention tool in primary health care (PHC), applying the RE-AIM framework to assess outcome. A computer-based tool for lifestyle intervention was introduced in PHC. A theory-based, explicit, implementation strategy was used at three centers, and an implicit strategy with a minimum of implementation efforts at three others. After 9 months a questionnaire was sent to staff members (n= 159) and data from a test database and county council registers were collected. The RE-AIM framework was applied to evaluate outcome in terms of reach, effectiveness, adoption and implementation. The response rate for the questionnaire was 73%. Significant differences in outcome were found between the strategies regarding reach, effectiveness and adoption, in favor of the explicit implementation strategy. Regarding the dimension implementation, no differences were found according to the implementation strategy. A theory-based implementation strategy including a testing period before using a new tool in daily practice seemed to be more successful than a strategy in which the tool was introduced and immediately used for patients.

Perception of budgetary control: a study of differences across managers in Swedish public primary healthcare related to professional background and sex

The composition of managers in Swedish public primary care centres has changed since the mid-1990s, favouring nurses and female managers. In parallel, health-care professionals have become more involved in the management structure and many have experienced an increased demand for cost containment. There is limited empirical evidence about how managers with different professional backgrounds perceive tight budgetary control. To examine whether perceptions of tight budgetary control across managers in Swedish public primary care are related to personal characteristics such as professional background and sex. A questionnaire measuring perception of tight budgetary control was administered to all (636) identified managers in Swedish public primary care centres (response rate was 59%). Differences between groups were analysed through logistic regression and factor analysis. Nurses and other non-physicians perceived the budgetary control to be tighter than did physicians and female physicians perceived the budgetary control to be tighter than did male physicians. Results suggest that nurses were more committed to the budgetary control system and county council objectives than physicians. The impact of these differences are uncertain, however, nurses' capacity to influence primary care services may be more limited compared with physicians because of their lower professional status.

Effects of Structured Follow-Up and of More Effective Acid Inhibitory Treatment in the Management of GORD Patients in a Swedish Primary-Care Setting

Despite the high prevalence of gastro-oesophageal reflux disease (GORD) and the documented impact of GORD symptoms on individual health-related quality of life (HR-QOL) and on socioeconomic factors, structured management of GORD has had a low priority in Swedish routine primary health care. The primary objective of this study (IMPROVE) was to evaluate the effects of a structured follow-up and management regimen for primary-care GORD patients with symptomatic breakthrough despite standard proton pump inhibitor (PPI) treatment. Patients received either an increased dose of current PPI treatment or were switched to the more effective acid inhibitor esomeprazole. GORD patients with symptomatic breakthrough despite standard PPI treatment were identified through medical records and by a postal survey using the GERD Impact Scale (GIS) questionnaire. Patients rated the severity and frequency of GORD symptoms, general health status (EuroQol Group 5-Dimension Self-Report Questionnaire) and the impact of GORD symptoms on work productivity (Work Productivity and Activity Impairment) before and 4 weeks following randomization to open-label treatment with either increased acid suppressive therapy or an adjusted, higher dosage of the PPI previously used. The patients' valuation, in monetary terms, of the treatment they received pre-study versus the treatment given during the study was documented through willingness-to-pay (WTP) questions. Following more effective acid suppression, 66.3% of the study population experienced complete relief of heartburn, with no difference between the groups; HR-QOL was restored to a level comparable to that of a normal Swedish population and ability to work efficiently was significantly improved. Access to a better acid suppressive treatment was highly valuable to the patients in terms of WTP. An improved GORD management strategy including structured follow-up of treatment given and initiation of more effective acid inhibitor therapy when symptoms persist will be of great benefit to GORD patients. [ClinicalTrials.gov Identifier: NCT00272701].

Referral to an Electronic Screening and Brief Alcohol Intervention in Primary Health Care in Sweden: Impact of Staff Referral to the Computer

The aim of this paper was to evaluate whether primary health care staff's referral of patients to perform an electronic screening and brief intervention (e-SBI) for alcohol use had a greater impact on change in alcohol consumption after 3 month, compared to patients who performed the test on their own initiative. Staff-referred responders reported reduced weekly alcohol consumption with an average decrease of 8.4 grams. In contrast, self-referred responders reported an average increase in weekly alcohol consumption of 2.4 grams. Staff-referred responders reported a 49% reduction of average number of heavy episodic drinking (HED) occasions per month. The corresponding reduction for self-referred responders was 62%. The differences between staff- and self-referred patient groups in the number who moved from risky drinking to nonrisky drinking at the followup were not statistically significant. Our results indicate that standalone computers with touchscreens that provide e-SBIs for risky drinking have the same effect on drinking behaviour in both staff-referred patients and self-referred patients.

Improving quality of care for children with asthma by learning with an interactive approach: a prospective randomized controlled study in 14 Swedish primary health care centers

Eight to 10% of children in Sweden have asthma. The majority of these children are followed and treated in primary health care centers (PHCs). Many studies show poor compliance to written guidelines [1,2]. The purpose of this study was to evaluate whether or not the method of interactive case-based education [3] combined with audit/feedback [4], leads to a better quality of care for children with asthma, according to quality indicators from Local Practice Guidelines (LPG) [5]. We collected data from children aged 6 months to 16 years with asthma, obstructive bronchitis or cough, attending 14 PHCs in northern Stockholm. Medical records of 20 children diagnosed with asthma were randomly selected in each PHC. Medical records of 20 children diagnosed with obstructive bronchitis or cough were also included to evaluate if these children fulfilled the diagnostic criteria of asthma. A questionnaire was addressed to general practitioners (GPs) and nurses regarding knowledge and competence in asthma management, educational needs and interest, and current equipment and routines at their PHC. The 14 PHCs were matched by pairs. Seven PHCs received the educational intervention, while 7 PHCs had this intervention only after completion of the study. Medical records were scrutinized in order to identify the following quality indicators: diagnosis on the basis of the criteria delineated in the LPGs: performance of spirometry, assessing exposure to tobacco smoke, prescription of inhaled corticosteroids, patient education and routine follow-up. The second evaluation of the medical records and questionnaire were scheduled six months after the intervention, to allow time to change behaviour. GPs and nurses from the intervention group participated in three interactive educational meetings [3] led by an allergologist and a nurse. The first two meetings used case-based learning approaches, focusing on the specific needs of each PHC and the third meeting was based on audit/ feedback [4] to discuss the results obtained and address the problems identified in the first analysis of data from the participating PHCs. Preliminary baseline data reveals that 50% of children with asthma from school age are treated with inhaled corticosteroids, prescribed by the GPs. Few patients had a spirometry test and few had received asthma education. Exposure to tobacco smoke was rarely discussed. Most children had only one visit to the PHC. Fifty per cent of the children had a planned follow-up, usually by referral to the local paediatric outpatient clinic. Twenty per cent of the preschool children had under-diagnosed asthma. This initial analysis shows that there are many care gaps in children’s asthma management, and that educational interventions have the potential to help address these gaps.

Visualization of disease distribution with SNOMED CT and ICD-10.

Methods for presentation of disease and health problem distribution in a health care environment rely among other things on the inherent structure of the controlled terminology used for coding. In the present study, this aspect is explored with a focus on ICD-10 and SNOMED CT. The distribution of 2,5 million diagnostic codes from primary health care in the Stockholm region is presented and analyzed through the "lenses" of ICD-10 and SNOMED CT. The patient encounters, originally coded with a reduced set of ICD-10 codes used in primary health care in Sweden, were mapped to SNOMED CT concepts through a mapping table. The method used for utilizing the richer structure of SNOMED CT as compared to ICD-10 is presented, together with examples of produced disease distributions. Implications of the proposed method for enriching a traditional classification such as ICD-10 through mappings to SNOMED CT are discussed.

The Swedish National Survey of the Quality and Organization of Diabetes Care in Primary Healthcare—Swed-QOP

Aim To describe the quality and organization of diabetes care in primary healthcare in Sweden regarding resources and ways of working. Method A questionnaire was used to collect data from all 921 primary healthcare centres (PHCCs) in Sweden. Of these, 74.3% ( n = 684) responded to the questionnaire covering list size of the PHCCs, number of diabetic patients, personnel resources and ways of working. Results The median list size reported from the PHCCs was 9,000 patients, 294 of whom were diabetic patients. The majority (72%) of PHCCs had diabetes-responsible general practitioners (GPs) and almost all (97%) had diabetes specialist nurses (DSNs) with some degree of postgraduate education in diabetes. The PHCCs reported that they used regional/local diabetes guidelines (93%), were engaged in call-recall diabetic reviews by GP(s) (66%) and DSN(s) (89%), checked that patients had participated in the reviews by GP(s) (69%) and DSN(s) (78%), arranged group education programmes (23%) and reported data to a National Diabetes Register (82%). Conclusions The presence of diabetes-responsible GP(s) and DSN(s) who use guidelines may contribute to good and equal quality of care. It is, however, necessary to improve the call-recall system and there is an urgent need for all diabetic patients to receive patient education.

Experiences of the new role of advanced practice nurses in Swedish primary health care—A qualitative study

Experiences of the new role of advanced practice nurses in Swedish primary health care-A qualitative study The aim of this study was to investigate and describe the experiences of the first advanced practice nurses (APNs), a new profession for Swedish health care, and of their supervising general practitioners (GPs), regarding the new role and scope of practice of APNs in primary health care. Individual interviews were conducted with the four first APNs and one focus group interview was conducted with five supervising physicians. The material was transcribed verbatim and analysed using latent content analysis. The respondents expressed confidence and trust in the new role of APNs. Some opposition to this new role from the GPs and other colleagues was observed, but was nonetheless overcome. The experiences of the APN role indicate that the new role is clearly demarcated from the role of physicians. The APNs were considered an extra resource for both the GPs and other nurses, which contributed to an increased availability of care for patients. The APN role requires an explicit definition and demarcation in relation to responsibility and roles among colleagues. Further development of the APN role presupposes the right to prescribe medication and order treatments, as well as an evaluation of patient, organizational and inter-professional perspectives on the matter.

Enriching a primary health care version of ICD-10 using SNOMED CT mapping.

BackgroundIn order to satisfy different needs, medical terminology systems must have richer structures. This study examines whether a Swedish primary health care version of the mono-hierarchical ICD-10 (KSH97-P) may obtain a richer structure using category and chapter mappings from KSH97-P to SNOMED CT and SNOMED CT's structure. Manually-built mappings from KSH97-P's categories and chapters to SNOMED CT's concepts are used as a starting point.ResultsThe mappings are manually evaluated using computer-produced information and a small number of mappings are updated. A new and poly-hierarchical chapter division of KSH97-P's categories has been created using the category and chapter mappings and SNOMED CT's generic structure. In the new chapter division, most categories are included in their original chapters. A considerable number of concepts are included in other chapters than their original chapters. Most of these inclusions can be explained by ICD-10's design. KSH97-P's categories are also extended with attributes using the category mappings and SNOMED CT's defining attribute relationships. About three-fourths of all concepts receive an attribute of type Finding site and about half of all concepts receive an attribute of type Associated morphology. Other types of attributes are less common.ConclusionsIt is possible to use mappings from KSH97-P to SNOMED CT and SNOMED CT's structure to enrich KSH97-P's mono-hierarchical structure with a poly-hierarchical chapter division and attributes of type Finding site and Associated morphology. The final mappings are available as additional files for this paper.

Validation of ACG Case-mix for equitable resource allocation in Swedish primary health care

BackgroundAdequate resource allocation is an important factor to ensure equity in health care. Previous reimbursement models have been based on age, gender and socioeconomic factors. An explanatory model based on individual need of primary health care (PHC) has not yet been used in Sweden to allocate resources. The aim of this study was to examine to what extent the ACG case-mix system could explain concurrent costs in Swedish PHC.MethodsDiagnoses were obtained from electronic PHC records of inhabitants in Blekinge County (approx. 150,000) listed with public PHC (approx. 120,000) for three consecutive years, 2004-2006. The inhabitants were then classified into six different resource utilization bands (RUB) using the ACG case-mix system. The mean costs for primary health care were calculated for each RUB and year. Using linear regression models and log-cost as dependent variable the adjusted R2 was calculated in the unadjusted model (gender) and in consecutive models where age, listing with specific PHC and RUB were added. In an additional model the ACG groups were added.ResultsGender, age and listing with specific PHC explained 14.48-14.88% of the variance in individual costs for PHC. By also adding information on level of co-morbidity, as measured by the ACG case-mix system, to specific PHC the adjusted R2 increased to 60.89-63.41%.ConclusionThe ACG case-mix system explains patient costs in primary care to a high degree. Age and gender are important explanatory factors, but most of the variance in concurrent patient costs was explained by the ACG case-mix system.

Adequacy of diagnosis and treatment of chronic heart failure in primary health care in Sweden

We performed an observational multicentre study to obtain information of the diagnostic tools and treatments currently used in patients with chronic heart failure (CHF) in primary health care (PHC) in Sweden. Data were collected from 2093 patients in 158 randomly selected PHC centres. The mean age was 79 years. The dominating aetiology of HF was hypertension and/or ischaemic heart disease. Diagnosis was based on symptoms and/or ECG and/or chest X-ray in 69% of the patients. Treatment with a renin-angiotensin system (RAS) blocker was ongoing in 74% of the patients, but only 37% had > or = 50% of the recommended target dose. In 68%, treatment with a beta-blocker (BB) was present, but only 31% had > or = 50% of the recommended target dose. Only 42% of the patients were on treatment with an RAS blocker and a BB and only 20% had > or = 50% of the recommended target dose. The diagnostic criteria for CHF according to the European Society of Cardiology were fulfilled in only approximately 30% of the patients. In addition, evidenced-based treatments to reduce morbidity and mortality were markedly underused, particularly regarding dosing. Our findings may reflect the patients' high age and the presence of important co-morbidities.

Does patient education facilitate diabetic patients’ possibilities to reach national treatment targets?

Objective. To describe how patient education is arranged in Swedish primary healthcare (PHC) and to assess whether the type of patient education and individual goal setting have an impact on diabetic patients’ possibilities of reaching national treatment targets. Design. A Swedish national survey. Setting. Swedish PHC. Subjects. Data from 485 primary healthcare centres (PHCCs) and 91 637 diabetic patients reported by the PHCCs to the National Diabetes Register in 2006. Main outcome measures. Description of how patient education is arranged, HbA1c, body mass index, cholesterol, blood pressure, and physical activity. Results. Of the PHCCs that reported how they performed the individual counselling, 50% reported checklist-driven counselling and 8% individualized counselling based on patients’ needs. A total of 105 PHCCs reported that they arranged group education. Of these, 67% used pre-planned programmes and 9% individualized the programme to the patients’ needs. The majority of PHCCs (96%) reported that they set individual goals (HbA1c, blood pressure, lipids, and lifestyle). A minority of the PHCCs (27%) reported that the patients were involved in the final decision concerning their goals. Individual goal-setting facilitated patients’ possibilities of reaching treatment targets. Goal-setting, list size of PHCCs, and personnel resources explained a variance of 2.1–5.7%. Neither individual counselling (checklist-driven or individualized to patients’ needs) nor group education had an impact on patients’ possibilities of reaching the targets. Conclusion. The current study indicates that improvement is needed in patient education in PHC to facilitate diabetic patients’ possibilities of reaching national treatment targets.

Primary care patients’ attitudes to priority setting in Sweden

Objective. To analyse attitudes to priority setting among patients in Swedish primary healthcare. Design. A questionnaire was given to patients comprising statements on attitudes towards prioritizing, on the role of politicians and healthcare staff in prioritizing, and on patient satisfaction with the outcome of their contact with primary healthcare (PHC). Settings. Four healthcare centres in Sweden, chosen through purposive sampling. Participants. All the patients in contact with the health centres during a two-week period in 2004 (2517 questionnaires, 72% returned). Main outcomes. Patient attitudes to priority setting and satisfaction with the outcome of their contact. Results. More than 75% of the patients agreed with statements like “Public health services should always provide the best possible care, irrespective of cost”. Almost three-quarters of the patients wanted healthcare staff rather than politicians to make decisions on priority setting. Younger patients and males were more positive towards priority setting and they also had a more positive view of the role of politicians. Less than 10% of the patients experienced some kind of economic rationing but the majority of these patients were satisfied with their contact with primary care. Conclusions. Primary care patient opinions concerning priority setting are a challenge for both politicians and GPs. The fact that males and younger patients are less negative to prioritizing may pave the way for a future dialogue between politicians and the general public.