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1.  Obesity, High-Molecular-Weight (HMW) Adiponectin, and Metabolic Risk Factors: Prevalence and Gender-Specific Associations in Estonia 
PLoS ONE  2013;8(9):e73273.
Background
The metabolic consequences of obesity are associated with an imbalance of adipocytokines, e.g. adiponectin. However, some obese subjects remain metabolically healthy and have adiponectin levels similar to normal body weight subjects. Current estimates of the prevalence of obesity in Estonia have relied only on self-report data.
Objectives
To estimate the prevalence of obesity in Estonia, to test for associations between HMW adiponectin and metabolic risk factors and to test if HMW adiponectin levels differentiate metabolically healthy and metabolically unhealthy subjects.
Methods
We conducted a population-based cross-sectional multicentre study to gather history, examination and blood test results for 495 subjects aged 20–74. Metabolically healthy subjects were free from hypertension, dyslipidaemia, impaired glucose regulation and insulin resistance. Metabolically unhealthy subjects had at least one of these four metabolic abnormalities.
Results
The prevalence of obesity was 29% in men and 34% in women. HMW adiponectin was positively correlated with HDL cholesterol and negatively correlated with triglycerides, obesity, insulin resistance and blood glucose. This effect was driven by metabolically unhealthy subjects in men, but by both metabolically healthy and metabolically unhealthy subjects in women. Metabolically healthy women had higher HMW adiponectin levels than metabolically unhealthy women. 12% of all obese subjects were metabolically healthy, and their HMW adiponectin levels were similar to normal weight subjects.
Conclusions
Obesity is more prevalent in Estonian adults than previously thought. HMW adiponectin levels were associated with various metabolic risk factors in metabolically healthy women but not in metabolically healthy men. For both genders, HMW adiponectin differentiates metabolically healthy obese subjects from metabolically unhealthy obese subjects.
doi:10.1371/journal.pone.0073273
PMCID: PMC3767784  PMID: 24039900
2.  Satisfaction with Access to Health Services: The Perspective of Estonian Patients with Rheumatoid Arthritis 
The Scientific World Journal  2012;2012:257569.
In this cross-sectional study we explained the possible determinants of satisfaction with access to health services in patients with rheumatoid arthritis (RA). Of the 2000 randomly selected Estonian adult patients with RA, a total 1259 completed the survey. Regression analysis was used to analyse the predictors of patients' satisfaction with access to health services. Half of the respondents were satisfied with their access to health services. Factors that had a negative impact on satisfaction included pain intensity, longer waiting times to see the doctors, as well as low satisfaction with the doctors. Transportation costs to visit a rheumatologist and higher rehabilitation expenses also affected the degree of satisfaction. Patients who could choose the date and time at which they could visit the rheumatologist or who could visit their “own” doctor were more likely to be satisfied than patients whose appointment times were appointed by a healthcare provider.
doi:10.1100/2012/257569
PMCID: PMC3345532  PMID: 22593670
3.  Metabolic Syndrome in Estonia: Prevalence and Associations with Insulin Resistance 
Recently, it has been suggested that metabolic syndrome should be considered a premorbid condition in younger individuals. We evaluated the prevalence of metabolic syndrome in Estonia and compared the characteristic profiles between morbid metabolic syndrome (previously established diabetes, hypertension, or dyslipidaemia) and premorbid metabolic syndrome subgroups. Our study was a cross-sectional, population-based sample of the general population in Estonia aged 20–74 years (n = 495). Metabolic syndrome was diagnosed by National Cholesterol Education Program Adult Treatment Panel III criteria. Insulin resistance was estimated using the homeostasis model assessment (HOMA-IR). The crude and weighted prevalence of metabolic syndrome was 27.9% and 25.9%, respectively. Despite being significantly younger, the premorbid subgroup showed similar levels of insulin resistance as the morbid subgroup (mean HOMA-IR ± SD 2.73 ± 1.8 versus 2.97 ± 2.1, P = 0.5). The most important attribute of metabolic syndrome is insulin resistance, which already characterises metabolic syndrome in the early stages of its metabolic abnormalities.
doi:10.1155/2012/951672
PMCID: PMC3296151  PMID: 22518134
4.  The european primary care monitor: structure, process and outcome indicators 
BMC Family Practice  2010;11:81.
Background
Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.
There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care.
Methods
A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems).
Results
The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care.
Conclusions
A standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.
doi:10.1186/1471-2296-11-81
PMCID: PMC2975652  PMID: 20979612
5.  Seasonal variance of 25-(OH) vitamin D in the general population of Estonia, a Northern European country 
BMC Public Health  2009;9:22.
Background
Vitamin D has a wide variety of physiological functions in the human body. There is increasing evidence that low serum levels of this vitamin have an important role in the pathogenesis of different skeletal and extra-skeletal diseases. Vitamin D deficiency and insufficiency is common at northern latitudes. There are few population-based studies in the northern European region looking at the issue in a wider age group. We aimed to measure Vitamin D level in the general population of Estonia (latitude 59°N), a North-European country where dairy products are not fortified with vitamin D.
Methods
The study subjects were a population-based random selection of 367 individuals (200 women and 167 men, mean age 48.9 ± 12.2 years, range 25–70 years) from the registers of general health care providers. 25-(OH) vitamin D (25(OH)D) level and parathyroid hormone (PTH) were measured in summer and in winter. Additionally age, sex, body mass index (BMI) and self-reported sunbathing habits were recorded.
Results
The mean serum 25(OH)D concentration in winter was 43.7 ± 15 nmol/L and in summer 59.3 ± 18 nmol/L (p < 0.0001). In winter 73% of the subjects had 25(OH)D insufficiency (25(OH)D concentration below 50 nmol/L) and 8% had deficiency (25(OH)D below 25 nmol/L). The corresponding percentages in summer were 29% for insufficiency and less than 1% for deficiency. PTH reached a plateau at around 80 nmol/L. BMI and age were inversely associated with 25(OH)D, but lost significance when adjusted for sunbathing habits. A difference in the seasonal 25(OH)D amplitude between genders (p = 0.01) was revealed.
Conclusion
Vitamin D insufficiency is highly prevalent throughout the year in a population without vitamin D dairy fortification living at the latitude of 59°N.
doi:10.1186/1471-2458-9-22
PMCID: PMC2632995  PMID: 19152676
6.  Predictors of quality of life of patients with type 2 diabetes 
Background
Researchers have shown that patients with type 2 diabetes have a lower quality of life than the general population and also somewhat lower than patients with other chronic diseases. Thus one of the most important outcomes of treatment is optimizing the quality of life of the patient. This study examines the factors that most strongly influence the quality of life of patients with type 2 diabetes.
Methods
200 patients with type 2 diabetes were studied in Estonia in 2004–2005. A patient blood sample, taken during a visit to the family doctor, was collected. The family doctor also provided data on each patient’s body mass index (BMI), blood pressure, and medications for treatment of type 2 diabetes. Patients completed a SF-36 during a doctor visit, and also a special questionnaire which we provided to study their awareness about diabetes type 2.
Results
The mean age of the respondents was 64.7 (±11.1) years and the mean duration of the diabetes was 7.5 (±1.8) years. Logistic regression analysis showed that quality of life was most significantly affected by awareness of the complications and risk-factors of diabetes, and by the age, duration of the disease, and BMI of the patient. Patients who were less aware had a significantly higher quality of life score (p < 0.001 in all cases). The age and BMI of the patients as well as the duration of the diabetes all lowered the score of the quality of life.
Conclusions
The results suggest that the main challenges for physicians in management of diabetes type 2 are modifying patient BMI and patient awareness.
PMCID: PMC2770386  PMID: 19920940
diabetes type 2; quality of life; SF-36; awareness of patients; body mass index
7.  Family doctors' knowledge and self-reported care of type 2 diabetes patients in comparison to the clinical practice guideline: cross-sectional study 
BMC Family Practice  2006;7:36.
Background
It is widely believed that providing doctors with guidelines will lead to more effective clinical practice and better patient care. However, different studies have shown contradictory results in quality improvement as a result of guideline implementation. The aim of this study was to compare family doctors' knowledge and self-reported care of type 2 diabetes patients with recommendation standards of the clinical practice guideline.
Methods
In April 2003 a survey was conducted among family doctors in Estonia. The structured questionnaire focused on the knowledge and self-reported behavior of doctors regarding the guideline of type 2 diabetes. The demographic and professional data of the respondents was also provided.
Results
Of the 354 questionnaires distributed, 163 were returned for a response rate of 46%. Seventy-six percent of the responded doctors stated that they had a copy of the guideline available while 24% reported that they did not. Eighty-three percent of the doctors considered it applicable and 79% reported using it in daily practice. The doctors tended to start treatment with medications and were satisfied with treatment outcomes at higher fasting blood glucose levels than the levels recommended in the guideline. Doctors' self-reported performance of the tests and examinations named in the guideline, which should be performed within a certain time limit, varied from overuse to underuse. Blood pressure, serum creatinine, eye examination and checking patients' ability to manage their diabetes were the best-followed items while glycosylated hemoglobin and weight reduction were the most poorly followed. Doctors' behavior was not related to the fact of whether they had the guideline available, whether they considered it applicable, or whether they actually used it.
Conclusion
Doctors' knowledge and self-reported behavior in patient follow-up of type 2 diabetes is very variable and is not related to the reported availability or usage of the guideline. Practice guidelines may be a useful source of information but they should not be overestimated.
doi:10.1186/1471-2296-7-36
PMCID: PMC1513575  PMID: 16776847
8.  Family doctors' involvement with families in Estonia 
BMC Family Practice  2004;5:24.
Background
Family doctors should care for individuals in the context of their family. Family has a powerful influence on health and illness and family interventions have been shown to improve health outcomes for a variety of health problems. The aim of the study was to investigate the Estonian family doctors' (FD) attitudes to the patients' family-related issues in their work: to explore the degree of FDs involvement in family matters, their preparedness for management of family-related issues and their self-assessment of the ability to manage different family-related problems.
Methods
A random sample (n = 236) of all FDs in Estonia was investigated using a postal questionnaire. Altogether 151 FDs responded to the questionnaire (response rate 64%), while five of them were excluded as they did not actually work as FDs.
Results
Of the respondents, 90% thought that in managing the health problems of patients FDs should communicate and cooperate with family members. Although most of the family doctors agreed that modifying of the health damaging risk factors (smoking, alcohol and drug abuse) of their patients and families is their task, one third of them felt that dealing with these problems is ineffective, or perceived themselves as poorly prepared or having too little time for such activities. Of the respondents, 58% (n = 83) were of the opinion that they could modify also relationship problems.
Conclusions
Estonian family doctors are favourably disposed to involvement in family-related problems, however, they need some additional training, especially in the field of relationship management.
doi:10.1186/1471-2296-5-24
PMCID: PMC526768  PMID: 15504236

Results 1-8 (8)