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1.  Primary Prevention of First-Ever Stroke in Primary Health Care: A Clinical Practice Study Based on Medical Register Data in Sweden 
Stroke Research and Treatment  2010;2010:468412.
Background. The aim of this study was to investigate whether established risk factors for stroke in patients admitted to health care for first-ever stroke had been detected and treated in primary health care. Methods. In a retrospective study in Nacka municipality, Stockholm County, Sweden, with about 70 000 inhabitants, we included all men and women admitted to health care due to first-ever stroke between October 1999 and March 2001. Data on 187 such patients, with a mean age of 75 years, were obtained from medical registers. Main outcome measures were detection and treatment of risk factors for stroke including hypertension, diabetes, atrial fibrillation, smoking, alcohol abuse, and overweight/obesity. Results. In a majority of patients seen in primary health care with hypertension and diabetes, those risk factors were detected and treated (75.6% and 75.0%, resp.). Fewer patients with atrial fibrillation received treatment (60.9%). Treatment of lifestyle factors was difficult to assess because of lack of data in the medical records. Conclusions. Primary prevention of stroke in primary health care needs to be improved, especially when atrial fibrillation and lifestyle-related risk factors are present. Health policies need to target not only the public, but also general practitioners and other health care professionals.
doi:10.4061/2010/468412
PMCID: PMC2915654  PMID: 20721332
2.  Reasons for and factors associated with issuing sickness certificates for longer periods than necessary: results from a nationwide survey of physicians 
BMC Public Health  2013;13:478.
Background
Physicians’ work with sickness certifications is an understudied field. Physicians’ experience of sickness certifying for longer periods than necessary has been previous reported. However, the extent and frequency of such sickness certification is largely unknown. The aims of this study were: a) to explore the frequency of sickness certifying for longer periods than necessary among physicians working in different clinical settings; b) to examine main reasons for issuing sickness certificates for longer periods than necessary; and c) to examine factors associated with unnecessary issued sickness certificates.
Methods
In 2008, all physicians living and working in Sweden (a total of 36,898) were sent an invitation to participate in a questionnaire study concerning their sick-listing practices. A total of 22,349 (60.6%) returned the questionnaire. In the current study, physicians reporting handling sickness certification consultations at least weekly were included in the analyses, a total of 12,348.
Results
The proportion of physicians reporting issuing sickness certificates for longer periods than actually necessary varied greatly between different types of clinics, with the highest frequency among those working at: occupational medicine, orthopedic, primary health care, and psychiatry clinics; and lowest among those working in: eye, dermatology, ear/nose/throat, oncology, surgery, and infection clinics. Logistic analyses showed that sickness certifying for longer periods than necessary due to limitations in the health care system was particularly common among physicians working at occupational medicine, orthopedic, and primary health care clinics. Sickness certifying for longer periods than necessary due to patient-related factors was much more common among physicians working at psychiatric clinics. In addition to differences between clinics, frequency of sickness certificates issued for longer periods than necessary varied by age, physicians’ experiences of different situations, and perceived problems.
Conclusions
This study showed that physicians issued sickness certificates for longer periods than actually necessary quite frequently at some types of clinics. Differences between clinics were to a large extent associated with frequency of problems, lack of time, delicate interactions with patients, and need for more competence.
doi:10.1186/1471-2458-13-478
PMCID: PMC3691717  PMID: 23679866
Sick leave; Sickness certification; Insurance medicine; Physician
3.  Is there a chilly climate? An educational environmental mixed method study in a chiropractic training institution 
Objective
The attitude towards gender in an educational environment has a significant impact on a student's behavior, sense of well-being, and academic performance. Our study aimed to explore the presence and extent of gender-related issues in a chiropractic undergraduate learning environment, which has been a scarcely researched topic in the literature.
Methods
The Perceived Chilly Climate Scale (PCCS) was used as the initial tool for screening the gender issues among undergraduates. The issues identified were explored further with a series of focus group interviews.
Results
The PCCS had an 83% response rate. The PCCS score (105/196) indicated the nonexistence of alarming gender-related issues. However, the PCCS score was significantly higher among female than male subjects, immigrants than nonimmigrants, and minorities than majority ethnic groups. Despite high ratings on the questionnaire quantitative findings, the focus groups indicated a good sense of equality, oppression-free environment, and no obvious signs of discrimination.
Conclusion
The educational environment of the institution concerned was conducive to equality. However, subtle but important gender-, ethnic-, and minority-related issues could be addressed to provide an enhanced educational environment to learners.
doi:10.7899/JCE-12-015
PMCID: PMC3604959  PMID: 23518905
Chiropractic; Education; Ethnic Groups; Gender Issues; Minority Groups
4.  Psychiatrists′ work with sickness certification: frequency, experiences and severity of the certification tasks in a national survey in Sweden 
Background
Many psychiatrists are involved in sickness certification of their patients; however, there is very limited knowledge about this aspect of their work. The objective of this study was to explore frequencies of problematic issues in the sickness certification tasks and experiences of severity regarding these problematic issues among psychiatrists.
Methods
A cross-sectional nationwide questionnaire study to all physicians in Sweden. The 579 specialists in psychiatry who answered the questionnaire, were under 65 years of age, worked mainly in psychiatric care, and had consultations involving sickness certification at least once a week were included.
Results
The frequency of problematic sickness certification consultations a few times per year or more often was considered by 87.3% of the psychiatrists; 11.7% handle such cases at least once a week. A majority (60.9%) reported ‘not having enough time with the patient’ at least once a week. The psychiatrists had access to several categories of professionals in their daily work. More than one third certified unnecessarily long sick-leave periods at least once a month due to waiting times for Social Insurance Office investigations or for treatments or investigations within health care.
Conclusion
The majority found it problematic to assess the level and duration of work incapacity, but also other types of problems like unnecessarily long sick-leave periods due to different types of waiting times. The findings have implications for different kinds of organisational and managerial support and training in sickness certification issues, like guidance to assess the level and duration of work incapacity.
doi:10.1186/1472-6963-12-362
PMCID: PMC3480832  PMID: 23075202
Sickness certification; Psychiatry; Sick leave; Physician
5.  Physicians who experience sickness certification as a work environmental problem: where do they work and what specific problems do they have? A nationwide survey in Sweden 
BMJ Open  2012;2(2):e000704.
Objectives
In a recent study, 11% of the Swedish physicians below 65 years dealing with sickness certification tasks (SCT) experienced SCT to a great extent as a work environment problem (WEP). This study aimed at exploring which SCT problems those physicians experienced and if these problems varied between general practitioners (GPs), psychiatrists, orthopaedists and physicians working at other types of clinics.
Design
A cross-sectional nationwide questionnaire study.
Setting
All physicians working in Sweden in 2008.
Participants
The 1554 physicians <65 years old, working in a clinical setting, having SCT and stating SCT to a great extent being a WEP.
Outcome measures
Frequency of possibly problematic situations or lack of time, reasons for sickness certifying unnecessarily long, experience of difficulties in contacts with sickness insurance offices, and severity of experienced problems.
Results
In all, 79% of this group of physicians experienced SCT as problematic at least once weekly, significantly higher proportion among GPs (p<0.001) and psychiatrists (p=0.005). A majority (at most 68.3%) experienced lack of time daily, when handling SCT, the proportion being significantly higher among orthopaedists (p=0.003, 0.007 and 0.011 on three respective items about lack of time). Among psychiatrists, a significantly higher proportion (p<0.001) stated wanting a patient coordinator. Also, GPs agreed to a higher extent (p<0.001) to finding 14 different SCT tasks as ‘very problematic’.
Conclusions
The main problem among physicians who experience SCT to a great extent as a WEP was lack of time related to SCT. The proportion of physicians experiencing problems varied in many aspects significantly between the different work clinics; however, GPs were among the highest in most types of problems. The results indicate that measures for improving physicians' sickness certification practices should be focused on organisational as well as professional level and that the needs in these aspects differ between specialties.
Article summary
Article focus
A study of the minority of physicians who state sickness certification tasks to a great extent being a work environment problem.
What problems do these physicians experience in relation to sickness certification?
Do the experienced problems vary with type of work clinic/specialty?
Key messages
A vast majority of these physicians experienced daily lack of time when handling sickness certification tasks.
About half of these physicians found it very problematic to assess level of work incapacity, to manage the two roles as the patient's physician and as a medical expert, and to provide the Social Insurance Office with more extensive sickness certificates.
Measures for improving physicians' sickness certification practices should be focused on organisational as well as professional levels and might need to differ between specialties.
Strengths and limitations of this study
The study was based on a questionnaire sent to all 37 000 physicians in a whole country, and the response rate (61%) could be regarded as relatively high.
Only one question about work environment was included.
doi:10.1136/bmjopen-2011-000704
PMCID: PMC3293140  PMID: 22382120
6.  Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems 
BMC Family Practice  2012;13:2.
Background
Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVÅ) and SNOMED CT.
Methods
Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed.
Results
417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions.
Conclusions
Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT.
Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.
doi:10.1186/1471-2296-13-2
PMCID: PMC3276441  PMID: 22230095
7.  Use and usefulness of guidelines for sickness certification: results from a national survey of all general practitioners in Sweden 
BMJ Open  2011;1(2):e000303.
Objectives
Diagnoses-specific sickness certification guidelines were recently introduced in Sweden. The aim of this study was to investigate to which extent general practitioners (GPs) used these guidelines and how useful they found them, 1 year after introduction.
Design
A cross-sectional questionnaire study. A comprehensive questionnaire about sickness certification practices in 2008 was sent to all physicians living and working in Sweden (n=36 898, response rate 60.6%). In all, 19.7% (n=4394) of the responders worked as GPs.
Setting
Primary healthcare in all Sweden.
Participants
The participating GPs who had consultations concerning sickness certification at least a few times a year (n=4278, 97%).
Main outcome measures
Descriptive statistics and prevalence ratios for the 11 questionnaire items about the use and usefulness of the sickness certification guidelines.
Results
A majority (76.2%) of the GPs reported that they used the guidelines. In addition, 65.4% and 43.5% of those GPs reported that the guidelines had facilitated their contacts with patients and social insurance officers, respectively. The guidelines also helped nearly one-third (31.5%) of the GPs to develop their competence and improve the quality of their management of sickness certification consultations (33.5%). About half experienced some problems when using the guidelines and 43.7% wanted better competence in using them. A larger proportion of non-specialists and of GPs with fewer sickness certification consultations had benefitted from the guidelines.
Conclusions
The national sickness certification guidelines implemented in Sweden were widely used by GPs already a year after introduction. Also, the GPs consider the guidelines useful in several respects, for example, in patient contacts and for competence development.
Article summary
Article focus
Sweden recently introduced national sickness certification guidelines. We investigated:
To what extent did the general practitioners use them 1 year later?
How useful did the general practitioners find them?
Key messages
Already after 1 year, most general practitioners used the guidelines and benefited extensively from them
Two-thirds of the general practitioners reported that the guidelines had facilitated their patient contacts and one-third that it facilitated their contacts with social insurance, other healthcare staff and employers
One-third stated that the guidelines had been helpful in competence development and improved the quality of their management of sickness certification cases
Strengths and limitations of this study
Strengths were the large study group and that all general practitioners in Sweden were included. Also, internationally this is the, so far, without comparison largest study of general practitioner's sickness certification practices. However, the non-response rate of 39% was a limitation, and we have no way of knowing if the non-responders differed with regard to use of the guidelines. However, only 11 of the 163 items in the questionnaire concerned the guidelines, why there is no reason to believe that no response was related to use of the guidelines.
doi:10.1136/bmjopen-2011-000303
PMCID: PMC3244659  PMID: 22189350
8.  Health problems and disability in long-term sickness absence: ICF coding of medical certificates 
BMC Public Health  2011;11:860.
Background
The purpose of this study was to test the feasibility of International Classification of Functioning, Disability and Health (ICF) and to explore the distribution, including gender differences, of health problems and disabilities as reflected in long-term sickness absence certificates.
Methods
A total of 433 patients with long sick-listing periods, 267 women and 166 men, were included in the study. All certificates exceeding 28 days of sick-listing sent to the local office of the Swedish Social Insurance Administration of a municipality in the Stockholm area were collected during four weeks in 2004-2005. ICD-10 medical diagnosis codes in the certificates were retrieved and free text information on disabilities in body function, body structure or activity and participation were coded according to ICF short version.
Results
In 89.8% of the certificates there were descriptions of disabilities that readily could be classified according to ICF. In a reliability test 123/131 (94%) items of randomly chosen free text information were identically classified by two of the authors. On average 2.4 disability categories (range 0-9) were found per patient; the most frequent were 'Sensation of pain' (35.1% of the patients), 'Emotional functions' (34.1%), 'Energy and drive functions' (22.4%), and 'Sleep functions' (16.9%). The dominating ICD-10 diagnostic groups were 'Mental and behavioural disorders' (34.4%) and 'Diseases of the musculoskeletal system and connective tissue' (32.8%). 'Reaction to severe stress and adjustment disorders' (14.7%), and 'Depressive episode' (11.5%) were the most frequent diagnostic codes. Disabilities in mental functions and activity/participation were more commonly described among women, while disabilities related to the musculoskeletal system were more frequent among men.
Conclusions
Both ICD-10 diagnoses and ICF categories were dominated by mental and musculoskeletal health problems, but there seems to be gender differences, and ICF classification as a complement to ICD-10 could provide a better understanding of the consequences of diseases and how individual patients can cope with their health problems. ICF is feasible for secondary classifying of free text descriptions of disabilities stated in sick-leave certificates and seems to be useful as a complement to ICD-10 for sick-listing management and research.
doi:10.1186/1471-2458-11-860
PMCID: PMC3229614  PMID: 22078637
9.  Characteristics of Finnish and Swedish intensive care nursing narratives: a comparative analysis to support the development of clinical language technologies 
Journal of Biomedical Semantics  2011;2(Suppl 3):S1.
Background
Free text is helpful for entering information into electronic health records, but reusing it is a challenge. The need for language technology for processing Finnish and Swedish healthcare text is therefore evident; however, Finnish and Swedish are linguistically very dissimilar. In this paper we present a comparison of characteristics in Finnish and Swedish free-text nursing narratives from intensive care. This creates a framework for characterising and comparing clinical text and lays the groundwork for developing clinical language technologies.
Methods
Our material included daily nursing narratives from one intensive care unit in Finland and one in Sweden. Inclusion criteria for patients were an inpatient period of least five days and an age of at least 16 years. We performed a comparative analysis as part of a collaborative effort between Finnish- and Swedish-speaking healthcare and language technology professionals that included both qualitative and quantitative aspects. The qualitative analysis addressed the content and structure of three average-sized health records from each country. In the quantitative analysis 514 Finnish and 379 Swedish health records were studied using various language technology tools.
Results
Although the two languages are not closely related, nursing narratives in Finland and Sweden had many properties in common. Both made use of specialised jargon and their content was very similar. However, many of these characteristics were challenging regarding development of language technology to support producing and using clinical documentation.
Conclusions
The way Finnish and Swedish intensive care nursing was documented, was not country or language dependent, but shared a common context, principles and structural features and even similar vocabulary elements. Technology solutions are therefore likely to be applicable to a wider range of natural languages, but they need linguistic tailoring.
Availability
The Finnish and Swedish data can be found at: http://www.dsv.su.se/hexanord/data/.
doi:10.1186/2041-1480-2-S3-S1
PMCID: PMC3194173  PMID: 21992572
10.  Enriching a primary health care version of ICD-10 using SNOMED CT mapping 
Background
In 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.
Results
The 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.
Conclusions
It 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.
doi:10.1186/2041-1480-1-7
PMCID: PMC2908062  PMID: 20618919
12.  Self-rated health, symptoms of depression and general symptoms at 3 and 12 months after a first-ever stroke: a municipality-based study in Sweden 
BMC Family Practice  2007;8:61.
Background
Self-rated health is an important indicator of quality of life as well as a good predictor of future health. The purpose of the study was to follow up the self-rated health and the prevalence of symptoms of depression and general symptoms in a population of first-ever stroke patients 3 and 12 months after stroke.
Methods
All patients surviving their first-ever stroke and residing in Nacka municipality in Stockholm County Council were included using a multiple overlapping search strategy during an 18-month period (n = 187). Our study group comprised the 145 patients who survived the first 3 months after stroke. Three and 12 months after their stroke, the patients were assessed regarding self-rated health and general symptoms using parts of the Göteborg Quality of Life Instrument (GQLI), and regarding symptoms of depression using the Montgomery Asberg Depression Scale (MADRS-S).
Results
Self-rated health was rated as very good or rather good by 62% at 3 months after stroke and by 78% at 12 months after stroke. More than half of the patients suffered from symptoms of depression, with no significant improvement at 12 months. The most common general symptoms at 3 months after stroke were fatigue, sadness, pain in the legs, dizziness and irritability. Fatigue and sadness were still common at 12 months. Twelve months after stroke the prevalences of crying easily, irritability, impaired concentration, nausea and loss of weight were significantly lower.
Conclusion
The majority of patients rated their health as rather good or very good at 3 and 12 months after stroke. However, the majority suffered from fatigue and from symptoms of depression after both 3 and 12 months. In continued care of stroke survivors, it is important to consider the fact that many patients who rate their health as good may nevertheless have symptoms of depression, and some of them may benefit from anti-depressive treatment.
doi:10.1186/1471-2296-8-61
PMCID: PMC2174472  PMID: 17941995
13.  Mapping the categories of the Swedish primary health care version of ICD-10 to SNOMED CT concepts: Rule development and intercoder reliability in a mapping trial 
Background
Terminologies and classifications are used for different purposes and have different structures and content. Linking or mapping terminologies and classifications has been pointed out as a possible way to achieve various aims as well as to attain additional advantages in describing and documenting health care data.
The objectives of this study were:
• to explore and develop rules to be used in a mapping process
• to evaluate intercoder reliability and the assessed degree of concordance when the 'Swedish primary health care version of the International Classification of Diseases version 10' (ICD-10) is matched to the Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT)
• to describe characteristics in the coding systems that are related to obstacles to high quality mapping.
Methods
Mapping (interpretation, matching, assessment and rule development) was done by two coders. The Swedish primary health care version of ICD-10 with 972 codes was randomly divided into an allotment of three sets of categories, used in three mapping sequences, A, B and C. Mapping was done independently by the coders and new rules were developed between the sequences. Intercoder reliability was measured by comparing the results after each set. The extent of matching was assessed as either 'partly' or 'completely concordant'
Results
General principles for mapping were outlined before the first sequence, A. New mapping rules had significant impact on the results between sequences A - B (p < 0.01) and A - C (p < 0.001). The intercoder reliability in our study reached 83%. Obstacles to high quality mapping were mainly a lack of agreement by the coders due to structural and content factors in SNOMED CT and in the current ICD-10 version. The predominant reasons for this were difficulties in interpreting the meaning of the categories in the current ICD-10 version, and the presence of many related concepts in SNOMED CT.
Conclusion
Mapping from ICD-10-categories to SNOMED CT needs clear and extensive rules. It is possible to reach high intercoder reliability in mapping from ICD-10-categories to SNOMED CT. However, several obstacles to high quality mapping remain due to structure and content characteristics in both coding systems.
doi:10.1186/1472-6947-7-9
PMCID: PMC1876209  PMID: 17472757
14.  The cost of monitoring warfarin in patients with chronic atrial fibrillation in primary care in Sweden 
Background
Warfarin is used for the prevention of stroke in chronic atrial fibrillation. The product has a narrow therapeutic index and to obtain treatment success, patients must be maintained within a given therapeutic range (International Normalised Ratio;INR). To ensure a wise allocation of health care resources, scrutiny of costs associated with various treatments is justified. The objective of this study was to estimate the health care cost of INR controls in patients on warfarin treatment with chronic atrial fibrillation in primary care in Sweden.
Methods
Data from various sources were applied in the analysis. Resource consumption was derived from two observational studies based on electronic patient records and two Delphi-panel studies performed in two and three rounds, respectively. Unit costs were taken from official databases and primary health care centres.
Results
The mean cost of one INR control was SEK 550. The mean costs of INR controls during the first three months, the first year and during the second year of treatment were SEK 6,811, SEK 16,244 and SEK 8,904 respectively.
Conclusion
INR controls of patients on warfarin treatment in primary care in Sweden represent a substantial cost to the health care provider and they are particularly costly when undertaken in home care. The cost may however be off-set by the reduced incidence of stroke.
doi:10.1186/1471-2296-8-6
PMCID: PMC1820599  PMID: 17324260
15.  Resource consumption and management associated with monitoring of warfarin treatment in primary health care in Sweden 
BMC Family Practice  2006;7:67.
Background
Warfarin is used for the prevention and treatment of various thromboembolic complications. It is an efficacious anticoagulant, but it has a narrow therapeutic range, and regular monitoring is required to ensure therapeutic efficacy and at the same time avoid life-threatening adverse events. The objective was to assess management and resource consumption associated with patient monitoring episodes during warfarin treatment in primary health care in Sweden.
Methods
Delphi technique was used to systematically explore attitudes, demands and priorities, and to collect informed judgements related to monitoring of warfarin treatment. Two separate Delphi-panels were performed in three and two rounds, respectively, one concerning tests taken in primary health care centres, involving 34 GPs and 10 registered nurses, and one concerning tests taken in patients' homes, involving 49 district nurses.
Results
In the primary health care panel 10 of the 34 GPs regularly collaborated with a registered nurse. Average time for one monitoring episode was estimated to 10.1 minutes for a GP and 21.4 minutes for a nurse, when a nurse assisted a doctor. The average time for monitoring was 17.6 minutes for a GP when not assisted by a nurse. Considering all the monitoring episodes, 11.6% of patient blood samples were taken in the individual patient's home. Average time for such a monitoring episode was estimated to 88.2 minutes. Of all the visits, 8.2% were performed in vain and took on average 44.6 minutes. In both studies, approximately 20 different elements of work concerning management of patients during warfarin treatment were identified.
Conclusion
Monitoring of patients during treatment with warfarin in primary health care in Sweden involves many elements of work, and demands large resources, especially when tests are taken in the patient's home.
doi:10.1186/1471-2296-7-67
PMCID: PMC1654161  PMID: 17096858
16.  Clinical categories of patients and encounter rates in primary health care – a three-year study in defined populations 
BMC Public Health  2006;6:35.
Background
The objective was to estimate the proportion of inhabitants with a diagnosis-registered encounter with a general practitioner, and to elucidate annual variations of clinical categories of patients in terms of their individual comorbidity.
Methods
A three-year retrospective study of encounter data from electronic patient records, with an annual-based application of the Johns Hopkins Adjusted Clinical Groups (ACG) system. Data were retrieved from every patient with a diagnosis-registered encounter with a GP during the period 2001–2003 at 13 publicly managed primary health care centres in Blekinge county, southeastern Sweden, with about 150000 inhabitants. Main outcome measures: Proportions of inhabitants with a diagnosis-registered encounter, and ranges of the annual proportions of categories of patients according to ACGs.
Results
The proportion of inhabitants with a diagnosis-registered encounter ranged from about 64.0% to 90.6% for the primary health care centres, and averaged about 76.5% for all inhabitants. In a three-year perspective the average range of categories of patients was about 0.4% on the county level, and about 0.9% on the primary health care centre level. About one third of the patients each year had a constellation of two or more types of morbidity.
Conclusion
About three fourths of all inhabitants had one or more diagnosis-registered encounters with a general practitioner during the three-year period. The annual variation of categories of patients according to ACGs was small on both the county and the primary health care centre level. The ACG system seems useful for demonstrating and predicting various aspects of clinical categories of patients in Swedish primary health care.
doi:10.1186/1471-2458-6-35
PMCID: PMC1431523  PMID: 16483353
17.  The importance of comorbidity in analysing patient costs in Swedish primary care 
BMC Public Health  2006;6:36.
Background
The objective was to explore the usefulness of the morbidity risk adjustment system Adjusted Clinical Groups® (ACG), in comparison with age and gender, in explaining and estimating patient costs on an individual level in Swedish primary health care. Data were retrieved from two primary health care centres in southeastern Sweden.
Methods
A cross-sectional observational study. Data from electronic patient registers from the two centres were retrieved for 2001 and 2002, and patients were grouped into ACGs, expressing the individual combination of diagnoses and thus the comorbidity. Costs per patient were calculated for both years in both centres. Cost data from one centre were used to create ACG weights. These weights were then applied to patients at the other centre. Correlations between individual patient costs, age, gender and ACG weights were studied. Multiple linear regression analyses were performed in order to explain and estimate patient costs.
Results
The variation in individual patient costs was substantial within age groups as well as within ACG weight groups. About 37.7% of the individual patient costs could be explained by ACG weights, and age and gender added about 0.8%. The individual patient costs in 2001 estimated 22.0% of patient costs in 2002, whereas ACG weights estimated 14.3%.
Conclusion
ACGs was an important factor in explaining and estimating individual patient costs in primary health care. Costs were explained to only a minor extent by age and gender. However, the usefulness of the ACG system appears to be sensitive to the accuracy of classification and coding of diagnoses by physicians.
doi:10.1186/1471-2458-6-36
PMCID: PMC1459136  PMID: 16483369
18.  Occurrence and quality of anticoagulant treatment of chronic atrial fibrillation in primary health care in Sweden: a retrospective study on electronic patient records 
Background
Chronic atrial fibrillation is a prevalent cardiac disorder. The literature indicates varying proportions of those treated with anticoagulants, and varying intensity of anticoagulation. Electronic patient records are providing us with clinical data concerning management of anticoagulant treatment in real-life practice that is useful for audits. We aimed to assess warfarin treatment for chronic atrial fibrillation in primary health care with regard to prevalence, incidence, the proportion treated and the quality of anticoagulation control.
Methods
Five primary health care centres in Stockholm with a registered population of 75146 participated in a one-year retrospective study of electronic patient records up until May 2000. All patients over 18 years of age with an encounter labelled 'Atrial fibrillation' were identified, and all records of patients on warfarin treatment were manually reviewed. Main outcome measures were number of patients with chronic atrial fibrillation, number of patients on wafarin treatment, and time within the therapeutic prothrombin range.
Results
In total, 419 patients had chronic atrial fibrillation, giving a prevalence of 0.60% (age-adjusted 0.62%), the age group 65 years or older accounted for 91.6%, and 50.1% were women. Out of these, 50.4% (211 patients) were established on warfarin treatment for chronic atrial fibrillation (0.28% of the population), and there was a predominance of men (p = 0.02). Fifty-four patients started treatment with warfarin for chronic atrial fibrillation (0.07% of the population). Among 25 randomly selected patients on established treatment, the proportion of time within the therapeutic range was 70.2%. Among 24 randomly selected patients starting treatment, the proportion of time with therapeutic values was 54.2% and 66.9% the first and second months of treatment, respectively.
Conclusions
Chronic atrial fibrillation is common among the elderly in primary health care, and about half of these patients are treated with warfarin. It appears to be under-diagnosed, and may also be under-treated. About two thirds of treatment time is spent within the therapeutic range, and further improvement of the quality of anticoagulation control with warfarin may therefore be hard to achieve.
doi:10.1186/1472-6904-4-1
PMCID: PMC368440  PMID: 15028124
anticoagulant treatment; atrial fibrillation; primary health care; prevalence; quality assurance
19.  Anticoagulant treatment in primary health care in Sweden – prevalence, incidence and treatment diagnosis: a retrospective study on electronic patient records in a registered population 
Background
The indications for warfarin treatment in primary health care are increasing. An undertreatment with warfarin is reported in the prevention of embolic stroke in patients with chronic atrial fibrillation, and can be suspected for other indications. Information on the prevalence and incidence of diseases treated with warfarin would reveal useful data for audits concerning management of anticoagulant treatment. We aimed to assess warfarin treatment in primary health care with regard to prevalence, incidence, treatment diagnosis and patient characteristics.
Methods
A one-year retrospective study of electronic patient records up to May 2000 in primary health care in Stockholm, Sweden. Five primary health care centres with a registered population of 75 146. Main outcome measures were prevalence, incidence and treatment diagnosis.
Results
Five hundred and seven patients, mean age 71.9 years, were on warfarin treatment. The prevalence was 0.67% (age-adjusted 0.75%), and it was significantly higher for men (0.78%) than for women (0.58%) (p = 0.01). In the age group 75–84 years the prevalence was 4.54%. The most prevalent treatment diagnosis was chronic atrial fibrillation (0.28%), which was more predominant for males (p = 0.02), followed by cerebrovascular disease (0.13%) and deep venous thrombosis (0.13%). The yearly incidence of warfarin treatment was 0.17%, with chronic atrial fibrillation as the predominant treatment diagnosis.
Conclusion
Warfarin treatment in primary health care is prevalent among the elderly. Chronic atrial fibrillation is the main treatment diagnosis. There is a gender difference favouring men in general and chronic atrial fibrillation as the treatment diagnosis.
doi:10.1186/1471-2296-4-3
PMCID: PMC156632  PMID: 12675952

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