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Biomedical subjects

I Hetlevik

Publications and source records attributed to I Hetlevik.

17 recordsLinked to original sources
PubMed2001

[Blood pressure records in general practice--expectations and reality].

BACKGROUND: The effect of antihypertensive medication on cardiovascular diseases is based on results achieved in prospective and controlled clinical studies. Comparable results in clinical practice can be achieved only when the quality of management for subjects with high blood pressure is comparable with the quality achieved in clinical studies. MATERIAL AND METHODS: This study consists of two parts; an attempt to implement an computer-based clinical decision support system for management of hypertension in primary health care in two counties in Norway, and a questionnaire survey among doctors in primary care and specialists in internal medicine in hospitals in other counties. We asked what they expected would be the result of the specific implementation strategy for the computer-based program. The objectives were to evaluate the results of the implementation strategy and to compare these results with expectations expressed in the filled-in questionnaires by doctors without any obligations to the main study. RESULTS: A total of 175 doctors were invited to implement the clinical decision support system. 85% responded; 44% of these, or 37% of the invited doctors, were willing to participate. After 12 months with recurrent visits by one of the authors, only six out of 74 doctors participating in the intervention study still used the program. The questionnaire were completed and returned by 203 doctors, who expected that 55% of the invited doctors would accept the invitation following the implementation strategy used. In general the validity of the information given by the questionnaire was poor and unreliable. INTERPRETATION: We conclude that introduction of a computer-based clinical decision support system is difficult in a busy primary care setting. Availability and simplicity are crucial requirements, and doctors would need financial compensation if they were to use such a system.

Adult↗
PubMed2000

[Pharmacological prevention of cardiovascular diseases in general practice].

BACKGROUND: In this paper the Norwegian College of General Practitioners, Working Group on Hypertension report recommendations for primary preventive drug treatment of elevated cardiovascular risk. MATERIAL AND METHODS: Updated metaanalyses and randomised controlled trials are the main basis for the recommendations. The purpose of treating hypertension is prevention of cardiovascular diseases. Drug treatment with documented effect on morbidity and mortality is therefore recommended. We have also evaluated the cost effectiveness of drug treatment. RESULTS: An estimate of the total risk of future cardiovascular disease is a necessary basis for treatment decisions. This paper presents tools for estimating total cardiovascular risk. Drug treatment is recommended if ten-year risk exceeds 20% or blood pressure equals or exceeds 170/100 mmHg. Drug treatments include antihypertensive, antithrombotic, antidiabetic and lipid-lowering drugs with documented effect on hard endpoints. Aspirin, thiazides, betablockers, metformin, calcium blockers, ACE inhibitors and statins are all drugs with documented effects on significant endpoints, but the costs of these treatments differ substantially. INTERPRETATION: Drug treatment to prevent cardiovascular disease should be recommended for patients at significant risk of cardiovascular disease. Drugs with documented effect on morbidity and mortality should be used. Considerations of costs are important in treatment decisions.

Adult↗
PubMed2000

[Life style advice provided by primary health care to prevent cardiovascular diseases].

BACKGROUND: The Working Group on Hypertension of the Norwegian College of General Practitioners reports in this paper on the documentation on behavioural advice in the prevention of cardiovascular disease. Emphasis is given to hypertension. MATERIAL AND METHODS: The recommendations are mainly based on updated metaanalyses and randomised controlled trials. Hypertension is treated to prevent cardiovascular disease; that is why we put emphasis on documentation with significant end points. The validity of the documentation for general practice is assessed. We have also assessed whether certain methods or theories for behavioural change could be helpful to the general practitioner. RESULTS: The value of advice against smoking, dietary advice (increased intake of grain products, vegetables, fruit, poultry and fish), and advice about exercise are well documented and applicable in general practice. Respect for the patient's autonomy and interest in the patients and their health-related habits seem to be important factors for improving doctor's chances of influencing patient behaviour. INTERPRETATION: The value of life-style advice is well documented and should play an important role in clinical strategies to prevent cardiovascular disease in high-risk patients.

Antioxidants↗
PubMed2000

Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system.

OBJECTIVES: To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. METHODS: Randomized study with health center as unit. General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group. Main outcome measures were group differences in fractions of patients without registrations (process evaluation) and mean group differences for the same variables (patient outcome evaluation). RESULTS: Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking (intervention group, 82.6%; control group 94.5%), body mass index (78.2% vs. 93.0%), and sufficient registrations for calculation of risk score for myocardial infarction (91.1% vs. 98.3%); all during 18 months. Large center variations were shown for all variables. The only statistically significant group difference was -2.3 mm Hg (95% CI, -3.8, -0.8) in diastolic blood pressure in favor of the intervention group. Statistically insignificant differences in favor of the intervention group were HbA1c, -0.1% (95% CI, -0.4, 0.1), systolic blood pressure, -1.2 mm Hg (95% CI, -4.4, 2.0). Statistically insignificant differences in favor of the control group were fractions of smokers, +3.0% (95% CI, -4.0, 10.0), body mass index, +0.3 kg/m2 (95% CI, -0.8, 1.4), risk score in female +0.1 (95% CI, -5.1, 5.2), and risk score in male +2.6 (95% CI, -14.2, 19.5). CONCLUSIONS: Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.

Aged↗
PubMed1999

Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system.

OBJECTIVE: To evaluate the implementation of clinical guidelines for hypertension in general practice by use of a computer-based clinical decision support system (CDSS) and a specific implementation strategy. Evaluation of patient outcome. DESIGN: Randomised study with health centres as units. The intervention group had the CDSS installed and made ready for use, doctors and assistants were trained and received a user-manual, the doctors were offered telephone repetitions, a seminar in risk intervention and, at the same seminar, further demonstration of the CDSS. The doctors received baseline registrations with information of how they treated their own hypertensive patients, and use of the CDSS was checked repeatedly. SETTING: General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. PARTICIPANTS: Seventeen health centres with 24 doctors and 984 patients in the intervention group. Data from 879 patients used in the final analyses. Twelve health centres with 29 doctors and 1255 patients in the control group. Data from 1119 patients used in the final analyses. MAIN OUTCOME MEASURES: After an intervention period of 18 months, group differences in level of systolic and diastolic blood pressure, serum cholesterol, body mass index, and risk score for myocardial infarction were calculated, as well as group differences in fractions of smokers. RESULTS: Significant group difference in favour of intervention group: diastolic blood pressure 1 mmHg (95% CI -1.89, -0.17). However, a significant baseline difference in systolic blood pressure in favour of control group of 2.7 mmHg (95% CI 1.0, 4.5) had been reduced to 1.2 mmHg (95% CI -0.6, 3.0) after intervention. CONCLUSION: Implementation of clinical guidelines in the treatment of hypertensive patients in general practice by means of a CDSS and several other procedures for implementation did not affect patient outcome in any clinically significant way.

Decision Making, Computer-Assisted↗
PubMed1998

[Drugs in the treatment of asymptomatic risk conditions--better documentation is required].

This paper points to the dilemmas posed by the lack of longitudinal studies of morbidity and mortality, or of side-effects, of several drugs widely used in treatment of asymptomatic risk factors. New drugs and new indications make large groups eligible for treatment, i.e. for mildly elevated blood pressure or cholesterol levels, impaired glucose tolerance and risk of osteoporosis. The treatment of people with asymptomatic elevated risk factors differs in point of principle from the treatment of diseases, symptoms or complaints: The patient has no subjective feeling about his or her condition; the health risk is usually lower; there are no good evaluation measures for the treatment; and the risk that side-effects outweigh the benefits is greater. This makes high quality treatment and good information to patients even more important than in ordinary practice. More knowledge about effects with regard to morbidity and mortality and about long-term side-effects is necessary. Doctors should prefer drugs for which the effects are documented, and give patients with the highest health risk top priority.

Drug Information Services↗
PubMed1998

Implementing clinical guidelines in the treatment of hypertension in general practice.

Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies. This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. We carried out a randomized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway (population 380000). A total of 17 health centres were included, with 24 doctors and 984 patients in the intervention group. Data from 887 patients was used in the analyses. There were 12 health centres with 29 doctors and 1255 patients in the control group. Data from 1127 control patients was used in the analyses. The main outcome measures were doctor's behaviour, measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension. The aim of the intervention was to lower the fractions of patients without registrations. However, there were no clinically significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure (intervention group 14.3%, control group 14.2%) or serum cholesterol (62.3% vs. 56.8%) during 12 months, nor, during 18 months, for fractions of patients without a registration of cigarette smoking (82.9% vs. 87.1%), cardiovascular inheritance (79.5% vs. 73.4%) and body mass index (81.5% vs. 89.2%). One or several variables necessary for calculation of risk score for myocardial infarction were missing in 91.7% of patients in the intervention group and 91.9% of patients in the control group. Large centre variations were shown for all variables. Implementation of clinical guidelines in the treatment of hypertensive patients in general practice, by means of a CDSS and several procedures for implementation did not result in clinically significant changes in the doctors' behaviour. Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures.

Adult↗
PubMed1997

Fifteen years with clinical guidelines in the treatment of hypertension--still discrepancies between intentions and practice.

OBJECTIVE: To assess physicians' current adherence to the Norwegian clinical guidelines for the treatment of hypertension. DESIGN: Descriptive, retrospective registration of information from patient records of one specified year. In addition, mailed questionnaire to examine the representativeness of the participating doctors. SETTING: General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. PATIENTS: In one year 2468 patients were registered with the diagnosis of hypertension in the records of 56 general practitioners. The patients were 57% women and 43% men; 41% were 70 years or older. MAIN OUTCOME MEASURES: Levels of blood pressure in accordance with the recommendations of the Norwegian clinical guidelines for hypertension. Fractions of patients with a measured blood pressure and serum cholesterol in one year. RESULTS: At least one blood pressure was recorded in 95% of the hypertensive patients during the specified year. The systolic blood pressure was 140 mmHg or less in 25% and 160 mmHg or less in 65%, while the diastolic blood pressure was 90 mmHg or less in 61%. According to the Norwegian clinical guidelines for systolic blood pressure, 29% of the women and 21% of the men were above recommended levels for treatment. With respect to the diastolic blood pressure, the figures were 38% for women and 40% for men. Patients under 60 years of age were often not treated according to the recommendations. Serum cholesterol was not recorded during the specified year in 68% of the total group, nor in 55% of patients aged 65 years or younger. CONCLUSION: There are still major discrepancies between current practice and the intentions laid down in the Norwegian clinical guidelines. A discussion of alternative methods for implementation and for evaluation of the efficacy of clinical guidelines is needed.

Adult↗
PubMed1997

Treatment of diabetes mellitus--physicians' adherence to clinical guidelines in Norway.

OBJECTIVE: To assess general practitioners' current adherence to the Norwegian clinical guidelines for the treatment of diabetes mellitus. DESIGN: Descriptive, retrospective registration of information from patient records of one year; 7 November 1993 to 7 November 1994. In addition, mailed questionnaire to examine the representativeness of the participating doctors. SETTING: General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. PARTICIPANTS: In one year 1119 patients were registered with the diagnosis of diabetes mellitus in the records of 56 general practitioners. The patients were 53% women and 47% men; 51% were 70 years or older. MAIN OUTCOME MEASURES: Levels of HbA1c and blood pressure in accordance with the recommendations of the Norwegian clinical guidelines for diabetes mellitus. Fractions of patients with a measured HbA1c, blood pressure, and serum cholesterol in one year. RESULTS: At least one HbA1c was recorded in 77% of the diabetic patients during the specified year. In patients under 70 years of age, 56% had HbA1c above the recommended treatment level of 7.5%. In patients 70 years of age or older, 36% were above the recommended limit of 8.5%. At least one blood pressure was recorded in 79% of the patients during the specified year. In patients under 70 years of age, 53% had a systolic blood pressure above the recommendations of 140 mmHg, and 22% had a diastolic blood pressure above the recommendations of 90 mmHg. Serum cholesterol was not recorded during the specified year in 75% of the patients. CONCLUSION: There are still major discrepancies between current practice and the intentions laid down in the Norwegian clinical guidelines. A discussion of alternative methods for implementation and evaluation of the efficacy of clinical guidelines is needed.

Adult↗
PubMed1994

[What attitude do physicians have towards risk?].

Results of medical research provide physicians with knowledge on how to reduce risk, and are probably the main source of such knowledge. The results are usually presented in terms of relative risk reduction. However, when treating the individual patient, the most important question will be how beneficial the treatment is for this particular patient, that is to say, the absolute reduction of risk. 91 Norwegian general practitioners who participated in a symposium on hypertension were presented with results from a recent study of treatment of this condition. Most of the doctors placed a different interpretation when the same information was presented in two different ways, i.e.: as relative reduction and absolute reduction of risk. They evaluated the results stated in terms of relative risk reduction as far better than the same results when stated as absolute risk reduction. This may influence the degree of treatment of hypertension in general practice.

Attitude of Health Personnel↗