Table A Baseline characteristics
of primary health care centres and ...
Table B Baseline characteristics of patients.
...
Figure A: Inclusion, exclusion, group
allocation, and ...
Figure B: Schematic view of the two balanced
clusters of general practitioners and ...
Short summary of a case: the what, how, and when
of a decision
Table A Baseline characteristics
of primary health care centres and general practitioners in intervention
and control groups
†Part of population aged >16 years (kSEK=1000 Swedish
Crowns). Table B Baseline characteristics
of patients. Values are numbers (percentages) unless stated otherwise
CCS=Canadian Cardiovascular Society classification system
of current angina pectoris symptoms.
No significant difference between intervention and control
groups for any parameter.
Figure A: Inclusion, exclusion, group
allocation, and follow up of the identified unselected cohort of patients
with coronary artery disease in Södertälje, as identified from
the patient registry of Stockholm County Council
Figure B: Schematic view of the two balanced
clusters of general practitioners and patients with coronary artery disease
(see tables A and B) to be randomised to intervention or control groups
Short summary of a case: the what, how, and when
of a decision
Dr Fredrik Anderson, a general practitioner at Lunda Primary Health
Care Centre, has as usual a fully booked day. His last patient for the
day is Oscar Berg, who is scheduled for a regular check of his diabetes
and hypertension. Just before preparing to leave, Oscar Berg mentions that
two months ago he had an episode of chest pain during heavy exercise.
Background—Lunda Primary Health Care Centre is located in a district
with many immigrants, high rates of unemployment, and a high need for social
services. Four general practitioners work at the centre; one position has
been vacant for a couple of months. Also based at the primary health care
centre are eight busy but highly competent district nurses, an efficient
secretarial service, and a small local laboratory. Cooperation with the
local hospital is rare, apart from referrals and telephone calls about
specific patients. Two half days a month are scheduled for continuing medical
education activities together with surrounding primary health care centres.
New scientific evidence on the effects of lipid lowering has been presented
in international medical journals. Eight months ago local guidelines on
secondary prevention in patients with coronary artery disease were distributed
to all general practitioners. During the past year five other guidelines
about different medical conditions have also been distributed to the general
practitioners.
Dr Fredrik Anderson is 45 years old, married, with three children.
He is a smoker and no longer has any time for exercise. He has been working
at Lunda Primary Health Care Centre for nine years. In the past year he
has also been the head of the centre. As a result of the vacant general
practitioner position and various reorganisations, he has been working
too much in recent months. He has not had any time for reading and reflection
either. He has never met Oscar Berg before. Oscar’s previous general practitioner
has left, and his new one has not yet begun working at the primary health
care centre.
Oscar Berg is a 62 year old divorced taxi driver. He smokes,
and he eats a lot of fast food. He has a medical history that includes
well controlled hypertension for five years, and he was diagnosed as having
diabetes two years ago. Three years ago he had strong chest pains during
a visit abroad, but he did not consult a doctor and has never told his
general practitioner about it. His available medical and laboratory records
give a blood pressure of 180/90 mm Hg, total cholesterol of 6.2 mmol/l,
low density lipoprotein cholesterol of 4.2 mmol/l, haemoglobin A1c
of 8.5%, and body mass index of 30 kg/m2.
Specific problem—This is formulated at the seminar in terms of
"What decision would you make if you stood in the position of Dr Anderson "
Example of aspects that could be discussed during the seminar:
· What—The local practice guidelines;
scientific evidence (the 4S study and so on).
· Context—Social and cultural
setting of Lunda Primary Health Care Centre and the surrounding health
care organisation; Dr Anderson’s workload; Oscar Berg’s current lifestyle
and medical history.
· Content—Dr Anderson’s and
Oscar Berg’s knowledge, attitudes, behaviour, ability to communicate, motivation,
and so on.
· Costs—Dr Anderson’s responsibility
for a balanced budget for the primary health care centre; his own increased
time commitment if he starts to motivate and further investigate Oscar
Berg; financial and time commitments for Oscar Berg.
· Ethics—The priority of this
problem compared with Dr Anderson’s other urgent issues.
· Who—Does Dr Anderson have
a responsibility to make a decision Are the guidelines applicable to Oscar
Berg
· Sense of coherence—Dr Anderson’s
sense of professional coherence and Oscar Berg’s sense of coherence as
a patient.
· How—Can Dr Anderson use the
help of someone else at the primary health care centre (for example, a
district nurse) in the motivational work with Oscar Berg
· When—Urgency, importance,
and timing in the life of Oscar Berg and in the schedule of Dr Anderson.
Dr Anderson’s task—To advise against or to recommend and schedule
an investigational, treatment, or motivational plan for Oscar Berg; to
preserve or change the local organisation of Lunda Primary Health Care
Centre.
Details of inclusion and randomisation
Patient inclusion
Södertälje Primary Health Care and the department of medicine
at Södertälje Hospital provide health care to approximately 95
000 inhabitants in the southernmost part of Stockholm County, Sweden. No
registry exists that allows direct identification of all these patients.
However, the patient registry of Stockholm County Council allows identification
of all inpatients and outpatients visiting the department of medicine at
Södertälje Hospital. We could thus identify all patients in the
population who had visited Södertälje Hospital as inpatients
or outpatients during the preceding year with a diagnosis of coronary artery
disease (ICD-9 code 410-414); we identified 429 patients aged £
70 years with such a diagnosis and scrutinised their medical records.
Criteria for a confirmed diagnosis of coronary artery disease in the
patient record were: (1) A diagnosis of angina pectoris, either by objective
criteria on the basis of coronary angiography or a stress test or by a
clinical assessment on the basis of typical symptoms of angina pectoris
at exercise with or without electrocardiographic evidence of possible or
definite coronary insufficiency. (2) A diagnosis of myocardial infarction
based on either World Health Organization criteria or on unequivocal electrocardiographic
findings.
We excluded 106 patients—mainly as a result of miscoding and in a few
cases because of other life threatening diseases or because the patients
had moved out of the catchment area. Three hundred and twenty three patients
fulfilled the inclusion criteria. We had thus identified all the patients
in the population with a recent need for specialist care. We invited all
of these patients to participate in the study (January 1995); 68 patients
refused to participate, leaving 255 patients to be included in the study
(fig A).
A research nurse drew blood samples from all the patients—in the morning
after an overnight fast—at baseline and at two years from the start of
the study. We measured concentrations of total cholesterol, high density
lipoprotein cholesterol, low density lipoprotein cholesterol, and triglycerides.
The research nurse also gave patients a physical examination and interviewed
them.
Primary care physician groups
Södertälje Primary Health Care consists of 14 primary health
care centres. We divided these centres into two matched and balanced pairs,
taking into account geographic location, physician numbers, physician relationships,
patient volume, and the socioeconomic status of the patient populations.
The two groups contained 26 and 28 general practitioners, with an equal
sex and age distribution (table A; fig B). We distributed a questionnaire
about perceived knowledge and attitudes about risk factors and secondary
prevention of coronary artery disease to all general practitioners. We
found no differences between the two groups of general practitioners at
baseline.
Characteristic
No of general practitioners
Mean (SD) age (years)
No (%) women
No (%) specialised
in general medicine
No of physicians
with known relation to a physician in other group
No of included
patients
No of included
patients per physician (median (range))
No of primary health
care centres
No of primary health
care centres with:
1-3 physicians
4-5 physicians
>5 physicians
<5000 inhabitants
5000-9999 inhabitants
>10 000 inhabitants
Mean population
income†:
<150 kSEK
150-199 kSEK
>199 kSEK
Urban population
Mixed urban and
rural population
Characteristics
Mean (SD) age (years)
Female sex
Family history of
coronary artery disease
Diabetes
Hypertension
History of stroke
History of peripheral
artery disease
History of comorbidity
Smoking status:
Never smoked
Ex-smoker
Current smoker
Mean (SD) body mass
index (kg/m2)
Mean (SD) waist:hip
ratio
Mean (SD) systolic
blood pressure (mm Hg)
Mean (SD) diastolic
blood pressure (mm Hg)
Mean (SD) duration
of coronary artery disease (years)
History of myocardial
infarction
History of coronary
artery bypass graft surgery
History of percutaneous
coronary intervention
Current angina (n=250):
CCS 0
CCS 1
CCS 2
CCS 3
CCS 4
Use of cardiovascular
drugs:
Acetyl salicylic acid
bblockers
Lipid lowering drugs
Mean (SD) lipid concentrations
(mmol/l):
Total cholesterol
Triglycerides
High density lipoprotein
cholesterol
Low density lipoprotein
cholesterol
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