This thesis is an example of an ear to loaf process:

A Preliminary Essential Data Set (PEDS) for Ear, Nose and Throat (ENT) diagnostics in Primary Health Care (PHC) was established by infologic modelling of existing tractates, between the specialist organisations of ENT and PHC, and four contemporary text-books on the subject (I). The PEDS was then compared to the aggregated data from a sample of case-files from a Swedish PHC centre. The quality of the individual medical record was found to be poor and not sufficient for follow-up and Quality Management (QM) purposes (II). The aggregated data from the case-file sample was processed by an inductive "expert" computer program that generated a decision-tree, based on the total number of decisions (diagnoses) in the data-base. This was nearly identical to the PEDS and somewhat less complicated. Infological modelling of the PEDS and the decision-tree resulted in the proposed Essential Data Set (EDS) for ENT diagnostics in PHC. The decision tree was "pruned" to achieve simplicity and ease of use (III). It was converted into a Computer-aided Decision Support System (CDSS) and put on the Internet using World Wide Web (WWW) tools (IV). This system was then implemented in the Skänninge PHC centre where an Electronic Medical Record System (EMRS) was in everyday use. Due to technical difficulties no integration between the two systems was possible. The CDSS was run on a computer outside the centre and this raised the question of secrecy and security (V). Prior to the implementation, and after a study period of four months attitudes towards, and the acceptance of, new Information Technology (IT) was explored by using focus group methodology (VI). It is important that those who are to use the system are intimately involved in its development. The results showed, that participation of the end-users during implementation is crucial for its acceptance. The need for a uniform and agreed terminology was obvious to facilitate co-operation and QM. The importance of nurses and physicians using the same terminology for documentation, was paramount.

Background and objective: Dyspepsia, peptic ulcer disease (PUD) and gastro-oesophageal reflux disease (GORD) involve a substantial cost to Swedish society. There is a lack of up-to-date nationwide cost estimates after 1985. This study was conducted to present a comprehensive and updated cost analysis and study the change over time of the national cost of these disorders. Design and setting: Primarily, data from National Swedish databases and secondly, data from databases from the County of Uppsala for 1997 were used for the calculations and estimations. Perspective: Swedish societal perspective. Results: The total cost to Swedish society of dyspepsia, PUD and GORD in 1997 was $US424 million, or $US63 per adult. Direct costs totalled $US258 million (61%) while indirect costs totalled $US166 million (39%). The highest proportions of costs were due to drugs and sick leave, these being 37 and 34%, respectively. Conclusions: The cost of dyspepsia and GORD is substantial for patients, health providers and society. Since 1985, drug costs have increased substantially while the cost of sick leave has decreased.

Objectives. To calculate the cost for patients with heart failure (HF) in a primary healthcare setting. Design. Retrospective study of all available patient data during a period of one year. Setting. Two healthcare centers in Linköping in the southeastern region of Sweden, covering a population of 19 400 inhabitants. Subjects. A total of 115 patients with a diagnosis of HF. Main outcome measures. The healthcare costs for patients with HF and the healthcare utilization concerning hospital days and visits to doctors and nurses in hospital care and primary healthcare. Results. The mean annual cost for a patient with HF was SEK 37 100. There were no significant differences in cost between gender, age, New York Heart Association functional class, and cardiac function. The distribution of cost was 47% for hospital care, 22% for primary healthcare, 18% for medication, 5% for nursing home, and 6% for examinations. Conclusion. Hospital care accounts for the largest cost but the cost in primary healthcare is larger than previously shown. The total annual cost for patients with HF in Sweden is in the range of SEK 5.0–6.7 billion according to this calculation, which is higher than previously known.Read More: http://informahealthcare.com/doi/abs/10.1080/02813430500197647

Objective - The aim of the present study was to describe patients considered to have had heart failure (HF), or were being treated for HF, in a defined area in primary health care, e.g. diagnostic procedures, aetiologic diseases and management, and to evaluate whether there is a difference between the genders. Design - Descriptive retrospective investigation. Setting - ┼tvidaberg community situated in southeast Sweden, 12 400 inhabitants. Patients - 256 patients treated for symptomatic HF. Main outcome measures - Prevalence, aetiology, diagnostic procedures and management of HF and differences between the genders. Results - The diagnosis of HF was based on an objective evaluation of cardiac function in only 31% of the patients. Ischaemic heart disease (IHD) was the predominant associated disease, followed by hypertension. Therapy included diuretics (84%), angiotensin converting enzyme (ACE) inhibitors (56%) and digoxin (40%). Only 52% had optimal doses of ACE inhibitors. Women had a significantly higher mean age and their diagnoses were based on an objective diagnostic test (echocardiography) in only 20%. Women were prescribed ACE inhibitors to a lesser extent (43%) than men (64%) and with a lower optimal dose (44% versus 56% in men). Conclusion - There is still room for improvement in the management of HF in primary health care, especially in women, where the diagnosis is not generally based on an objective evaluation of cardiac function and where the treatment to a lesser extent than in men includes ACE inhibitors.

Objectives: The principle of achieving the most cost-effective level of care in relation to needs is an essential aim for all health care systems. However, it is not certain that the corresponding knowledge and attitudes with respect to the appropriate level of care for different symptoms can be found in the general population. There may be age-related differences in illness behaviour that manifest in ‘overutilisation’ of the system. We studied illness behaviour with regard to attitudes and inclination to seek care for different symptoms at various levels in the health care system.Methods: The study group consisted of a random selection of 296 persons, born in the 1940s, ′50s and ′60s, and living in a defined region in Sweden. In a questionnaire they had to choose between different levels of care for twelve symptom descriptions with varying degrees of severity. The answers were scored according to the level of care, adequacy and overutilisation.Results: The vast majority of participants chose an adequate level of care. However, overutilisation was found, particularly among women born in the 1960s and to some extent among men born in the 1940s. These two groups together constituted about 70% of all the individuals who tended to overutilise the health care in their expressed preferences.Conclusions: These individuals do not receive cost-effective care, or the most adequate care with regard to their needs. The results indicate, however, that the problem was more a question of attitude rather than a lack of knowledge and information.

A diagnosis-prescribing study was performed in 5 Swedish counties during 1 week in November in 2000 and repeated in 2002. The aim of the present study was to analyse data for children 0-15 y of age who consulted a general practitioner with symptoms of an infection. During the 2 weeks studied, 4049 children were consulted. Respiratory tract infections (RTI) were the predominant diagnoses, above all among the youngest children, while the proportion of urinary tract infections and skin infections increased with increasing age. Between the y 2000 and 2002, the proportion of children allocated the diagnosis streptococcal tonsillitis and pneumonia decreased (p<0.01 and p<0.001, respectively) while the proportion of common cold increased (p <0.001). Antibiotic prescribing decreased from 55% to 48% (p <0.001) for respiratory infections between the years studied. The only significant changes in type of antibiotics prescribed were the increase of isoxazolylpenicillins (p<0.001) used for skin infection and the decrease of macrolides (p=0.001). A diagnostic test was used in more than half of the consultations. Of children allocated a RTI diagnosis, 36% were prescribed antibiotics when a C-reactive protein test was performed compared to 58% in those not tested. Further studies are needed in general practice to determine the optimal use of near-patient tests in children with RTI. © 2005 Taylor & Francis.

In Sweden, a change of the legislation for sickness absence became effective on 1st October, 1995. The purpose of the change was to reduce costs for sickness absence by exclusion of non-medical criteria for sick-listing, more part-time sick-listing and faster rehabilitation. This study was conducted in order to describe and analyse certification practice of various physician categories, before and after the change in legislation. Thirty-one thousand seven hundred and thirty certificates for sickness absence, collected by the local offices of the National Social Insurance Board in eight Swedish counties, fulfilled the inclusion criteria. The number of certificates decreased temporarily. The number of certified net days, i.e. crude days multiplied by degree, tended to increase and there was no shift from full to partial sick-listing during the period. There were small changes regarding case mix, i.e. patient characteristics, and sick-listing physician category. The results were almost unchanged when these small changes were taken into account. General practitioners issued significantly shorter periods of sick-leave than the other categories both years. The goals of the legislative change were thus not met. The result of the study indicates that other factors than the legislation may be more important for physicians' practice. ⌐ 2002 Elsevier Science Ireland Ltd. All rights reserved.

Background

Experience from work with priority setting in health and medical care indicates that the ethical guidelines that are at the heart of Swedish Parliament’s principles for priority  setting  are difficult  to implement  into practical  clinical  decision- making. The same can be said of the model for priority setting drawn up by the Swedish National Board of Health and Welfare in the national guidelines  for care and treatment. For this reason, we need more knowledge on how principles for priority setting and related concepts are perceived by medical care personnel, the relevance of these concepts, and if there are other aspects that also impact the priority setting situation.  We also need to develop  new work methods  to meet Parliament’s intentions with priority setting in health and medical care.

To contribute  to the development  of new  work  methods,  we chose  to study priority setting in primary care practice. Our primary purpose was to describe the way in which general practitioners and district nurses perceive the concepts severity  of  illness,  benefit  and  cost-effectiveness  when  they  rank  priority  for individual patients. Our secondary purpose was to compare medical personnel’s perception of the concepts severity of illness, benefit and cost-effectiveness with the definitions  of these  concepts  in the model  for vertical  priority  setting  as established by the National Board of Health and Welfare.

Methods

Focus group interviews as a source of data collection was selected as the method since the study was explorative and the intention was to obtain as many aspects as possible pertaining  to priority setting concepts.  The method is suitable for collecting a large amount of information within a previously unexplored subject. Interviews were conducted with eight groups of physicians and nurses from four different primary care centers. The respondents  selected had participated  in a prospective  study  on  practical  priority  setting,  i.e.  they  had  experience  of implementing the concepts severity of illness, benefit, and cost-effectiveness in setting priorities in their daily work.

Results and Conclusions

Both  the  physicians  and  nurses  expressed  a  simplified  interpretation  of  the concepts severity of illness and benefit. One example of such simplification was that many nurses said that when ranking the severity of a condition, they based their decision on how imperative  it was for the patient to see a physician.  A

common response was that the concepts could be assessed from both patient and staff perspectives  but that these assessments  could differ. When asked to set priorities according to a specific template, respondents said that it was easier to rank patients with an acute condition that had a tangible effect on function and that could be immediately treated, than to rank patients according to factors that were a risk to their future health. This means that priority judgements based on knowledge of a patient category were perceived as uncertain and more difficult to use than direct personal experience of treating an individual patient. This was discussed, above all, by the physicians. Respondents gave several examples of actions taken despite that medical staff did not feel that there was any benefit to the patient.

In a comparison  of how these three concepts  are described  in the model for priority setting on the policy level drawn up by the National Board of Health and Welfare and how medical personnel implemented the concepts, we found both similarities and dissimilarities.

A model based on these concepts can be of use in priority setting in primary care, but it must be supplemented  and improved  to be applicable  to ranking patients  in day-to-day  medical  care. Supplements  that may be necessary  are; clarification that a combination of medical and patient perspectives is intended, clarification of how to use the concept cost-effectiveness, and the addition of a time factor and factors related to the individual patient. There is also a need for a more  structured  way  of working  with evidence-based  care.  We also  need  to clarify the differences between setting priorities for patient categories and for individual patients in day-to-day medical care.

In our opinion, the model for priority setting on the patient category level can be improved  to  be  more  applicable  as  a  template  for  decision-making  on  the individual patient level, however a supplementary  model may be necessary to support priority setting on the individual level.

Background: Physicians have a central role as gatekeepers to the social security system, including sick-listing. Variation in physicians' sick-listing practices has been demonstrated in several studies. The objective of this study was to determine whether local structural factors affect sick-listing practice. Methods: A total of 57 563 consecutive sick-listing certificates, issued during 4 months in 1995 and 2 months in 1996, were collected from the local branches of the National Social Insurance Office in eight Swedish counties. County code, local community population size and presence of a hospital in the area were used as indicators of local structural factors. Length of the sick-listing certificates and of the sick-listing episodes were used as outcome variables. Results: After ajustment for the influence of category of issuing physician, patients' age, sex and diagnosis ('case mix'), and type of certificate there was a large variation of the length of the sick-listing certificates and of the sick-listing episodes between counties, between communities of various size and between communities with or without a hospital in the area. All these factors were independently and significantly correlated to the length of the certificate and of the sick-listing episode. Conclusions: The results support the hypothesis that physicians' sick-listing practice is influenced by local structural factors. © The Author 2005. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Objective. A national change in infant feeding recommendations was proposed in 1996 in Sweden: a slow introduction to gluten during weaning was stressed, the recommendation being introduction at 4 instead of 6 months of age. The aim of the present study was to compare the prevalence of celiac disease in healthy young children born before and after the new feeding recommendations in 1996. Material and methods. Sera from 679 children at a median age of 2.9 years (range 2.5-4.2 years) born between January 1996 and November 1997 were investigated with IgA-antigliadin antibodies (AGA) and IgA-endomysial autoantibodies (EMA) and compared with 690 age-matched children born between July 1992 and June 1993. Children with a positive test for EMA and AGA or EMA only were re-tested, and if positive at follow up, investigated with intestinal biopsy. Results. At baseline, 2.2% (15/679) children were positive for EMA and another 0.6% (4/679) for both EMA and AGA. One child refused to be re-tested and eight children were still EMA positive at follow-up. Intestinal biopsy was performed in seven children (one declined biopsy), of whom three showed total villous atrophy. Two children with EMA titers 1:640, respectively, refused further participation in the study, but were strongly suspected to have celiac disease. In total, 0.7% (5/679) (95% confidence interval (CI) = 0.1-1.4%) were considered to have celiac disease compared with 1.3% (9/690) (95% CI = 0.4-2.2%) in the control group (p = 0.4217). In addition, 0.3% of the children were diagnosed with symptomatic celiac disease compared with 0.7% in controls (p = 0.0134). Conclusions. The prevalence of symptomatic celiac disease declined after the infant dietary recommendations were introduced in 1996, but we could not find any difference in undiagnosed celiac disease between the screened children born before and those born after 1996. © 2006 Taylor & Francis.

The present thesis gives an account of the scheduled transformation of a combined Hospital and Primary Health Care institution, Nosokomio Neapolis, in a semi-rural community on Crete to an integrated population health research and development (R&D) centre by relatively minor organisational updatings and focused scientific studies with academic and political support and supervision. This process has engaged the whole local team, and the thesis is concerned with some of its bearing "Ariadne threads". First, the health systems perspective and framework of the Nosokomio Neapolis are described, including opportunities and scope of the directed, needs-and-outcome-oriented R&D undertaken also outside the focus of the present thesis, e.g. osteoporosis, cardiovascular diseases and accidents (I).

Then, and new to Greece, three different and complementary lines are drawn concerning primary health care (PHC) quality assurance research in the three ages and with an epidemiological, risk factor and staff emphasis, respectively. The first of them is the primary prevention sector of immunisation in Cretan schoolchildren, where insufficient levels were found and measures of improvement implemented (II). The second concerns the determination of hepatitis A, B, and C markers and assessment of immunisation status in the Neapolis prison inmates and staff, and showing that both are high risk groups, where secondary and tertiary preventive measures are highly warranted (III). In the third age, research focused upon staff capacity regarding PHC physicians' level of knowledge and patterns of practices related to dementia in two European Regions; Crete, Greece and OstergOtland, Sweden. This is predominantly a tertiary preventive sector, where the care organisation is instrumentaL The study showed in the younger Greek PHC physicians a need for quality improvement, in particular in relation to Alzheimer's disease (IV).

The final, fifth and sixth papers give an overview of the decisive step out to society, by a specially designed questionnaire, in order to achieve community involvement: a vital requirement for population participation and shar-ingjn the decentralised work towards Health For All by year 2000 and beyond (V - VI). The general conclusion of the thesis is that the new policies of small-areas action R&D in the community are both needed and relevant in the primary health care of Cretan and other Mediterranean areas.

The health of women has risen to a priority position in medical research. Comparative studies of female morbidity are called for as an intermediary stage for generation of hypotheses and design of deeper studies of determinants, such as social, ecological, and individual factors. In previous studies, we have noted differences in female hospitalization between Heraklion in Greece and Linköping in Sweden. They were related to age and to urban versus rural dwelling, and fit projections for a more archaic and a more technocratic society, respectively. This paper aims at showing how the study of women's health may proceed from relevant hospitalization observations to the next level, of exploring already available indicators of self‐perceived health in elderly females.

Handbokens målgrupper är framför allt allmänläkare och läkare under allmäntjänstgöring och specialistutbildning samt medicine studerande. Den används som uppslagsverk av alla kategorier av sjukvårdspersonal såväl i öppen som sluten vård. Den här utgåvan inleds med kostnadsjämförelser mellan olika sorters terapier vid vanliga sjukdomar

An interdisciplinary research group entitled ”Twincities Research Group” has been initiated at Linköping University. The term twin cities refer to the Swedish cities Linköping and Norrköping, neighbours that are nearly equal in size. These two cities, located within a distance of only 40 km, are governed by the same county council and consequently have the same health care structure. However, health is remarkably different in these twin cities. The comparison of public health in these two cities during the development from the industrial to the post-industrial era has a design similar to classical experiments with a control and an experiment group, since the social history and the socio-economic structures of the cities are radically different. Through an interdisciplinary research design including historical, epidemiological and clinical competence we have a unique opportunity to increase our understanding of how social environment may affect public health.

The Faculty of Health Sciences, Linköping, Sweden, started the reformedmedical curriculum in 1986. Problem-based Learning as an educational method was introduced into the entire curriculum. It was a response to requests for community-orientation by increasing the involvement of general practice. A new extensive communication skills training - the 'Strand', a new form of examination- 'phase examination', and recurrent clerkships in general practice in the clinical phase were also introduced. The medical cuniculum, with its focus on general practice, together with these innovations are presented in a case report of its implementation and development.

The similarities between quality assurance and problem-based learning, as processes and methods, are also identified, described and discussed.

Two of the innovations where general practice is a main contributor, namely, the clerkships in general practice and the phase examination 1 and 2 have been evaluated. Of the 115 students, in semester six to nine in the autumn of 1992, 74% filled in the clerkship evaluation questionnaire. The overall rating was very positive. Regression analysis of the rated variables showed that the quality of the tutoring was the strongest determinator of the overall rating. No decline in the students' ratings in the latter semesters was found.

A qualitative study was made on all free comments made by the same study group in the same questionnaires. This study identified an area not covered in the quantitative evaluation, the important elements of the student-tutor relationship.

The 'phase examinations' have been found to be a valid assessment ofcommunication skills, integrative knowledge and the search for scientificinformation. The use of general practitioners as assessors has strengthened the role of general practice in the curriculum.

Objective: To investigate the clinical logistics of laboratory routines at primary health care centres (PHCs). Design and methods: Prospective registration was carried out for each PHC using questionnaires during 2-week intervals between the end of November 2001 and mid-January 2002. The study included 9 PHCs in the county of Östergötland and 4 in the county of Jönköping, Sweden, with different numbers of blood tests analysed using point-of-care testing (POCT). Data for B-glucose, HbA1c, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), thyroid-stimulating hormone (TSH), T4, cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides were collected. Main outcome measures were median time from sampling to available test result (TATa) and median time from sampling to clinical decision (TATd), and the proportion of patients informed of the outcome of the blood test in question during the sampling occasion. Results: A total of 3542 samples were collected. The median TATa showed that B-glucose, ESR and CRP were immediately analysed at all 13 PHCs. For the other tests, TATa varied from immediately to about two days. The median TATd varied from immediately to about a week. When POCT was used, 30% of the patients were informed about the outcome of the test during the sampling occasion. Conclusion: POCT has a limited effect on the clinical logistics in PHCs.