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1.  Quality of sickness certification in primary health care: a retrospective database study 
BMC Family Practice  2013;14:48.
Background
In the period 2004–2009, national and regional initiatives were developed in Sweden to improve the quality of sickness certificates. Parameters for assessing the quality of sickness certificates in primary health care have been proposed. The aim of this study was to measure the quality of sickness certification in primary health care by means of assessing sickness certificates issued between 2004 and 2009 in Stockholm.
Methods
This was a retrospective study using data retrieved from sickness certificates contained in the electronic patient records of 21 primary health care centres in Stockholm County covering six consecutive years. A total number of 236 441 certificates were used in the current study. Seven quality parameters were chosen as outcome measures. Descriptive statistics and regression models with time, sex and age group as explanatory variables were used.
Results
During the study period, the quality of the sickness certification practice improved as the number of days on first certification decreased and the proportion of duly completely and acceptable certificates increased. Assessment of need for vocational rehabilitation and giving a prognosis for return to work were not significantly improved during the same period. Time was the most influential variable.
Conclusions
The quality of sickness certification practice improved for most of the parameters, although additional efforts to improve the quality of sickness certificates are needed. Measures, such as reminders, compulsory certificate fields and structured guidance, could be useful tools to achieve this objective.
doi:10.1186/1471-2296-14-48
PMCID: PMC3637144  PMID: 23586694
General practitioners; Sick leave; Sickness certificates; Quality indicators; Health care
2.  Knowledge of stroke risk factors among primary care patients with previous stroke or TIA: a questionnaire study 
BMC Family Practice  2010;11:47.
Background
Survivers of stroke or transient ischaemic attacks (TIA) are at risk of new vascular events. Our objective was to study primary health care patients with stroke/TIA regarding their knowledge about risk factors for having a new event of stroke/TIA, possible associations between patient characteristics and patients' knowledge about risk factors, and patients' knowledge about their preventive treatment for stroke/TIA.
Methods
A questionnaire was distributed to 240 patients with stroke/TIA diagnoses, and 182 patients (76%) responded. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/conditions ("distractors"). The patients were also asked whether they considered each disease/condition to be one of their own. Additional questions concerned the patients' social and functional status and their drug use. The t-test was used for continuous variables, chi-square test for categorical variables, and a regression model with variables influencing patient knowledge was created.
Results
Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%. Few patients considered the distractors as stroke/TIA risk factors (3-6%). Patients with a family history of cardiovascular disease, and patients diagnosed with carotid stenosis, atrial fibrillation or diabetes, knew these were stroke/TIA risk factors to a greater extent than patients without these conditions. Atrial fibrillation or a family history of cardiovascular disease was associated with better knowledge about risk factors, and higher age, cerebral haemorrhage and living alone with poorer knowledge. Only 56% of those taking anticoagulant drugs considered this as intended for prevention, while 48% of those taking platelet aggregation inhibitors thought this was for prevention.
Conclusions
Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. However, the knowledge level was low regarding diabetes as a risk factor and regarding the use of anticoagulants and platelet aggregation inhibitors for stroke/TIA prevention. Better teaching strategies for stroke/TIA patients should be developed, with special attention focused on diabetic patients.
doi:10.1186/1471-2296-11-47
PMCID: PMC2894756  PMID: 20550690
3.  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
4.  General practitioners' reasoning when considering the diagnosis heart failure: a think-aloud study 
Background
Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines.
Methods
Think-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines.
Results
Information about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument.
Conclusions
The clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way.
doi:10.1186/1471-2296-6-4
PMCID: PMC546006  PMID: 15651996
5.  The role of guidelines and the patient's life-style in GPs' management of hypercholesterolaemia 
Background
Recent Swedish and joint European guidelines on hyperlipidaemia stress the high coronary risk for patients with already established arterio-sclerotic disease (secondary prevention) or diabetes. For the remaining group, calculation of the ten-year risk for coronary events using the Framingham equation is suggested. There is evidence that use of and adherence to guidelines is incomplete and that tools for risk estimations are seldom used. Intuitive risk estimates are difficult and systematically biased. The purpose of the study was to examine how GPs use knowledge of guidelines in their decisions to recommend or not recommend a cholesterol-lowering drug and the reasons for their decisions.
Methods
Twenty GPs were exposed to six case vignettes presented on a computer. In the course of six screens, successively more information was added to the case. The doctors were instructed to think aloud while processing the cases (Think-Aloud Protocols) and finally to decide for or against drug treatment. After the six cases they were asked to describe how they usually reason when they meet patients with high cholesterol values (Free-Report Protocols). The two sets of protocols were coded for cause-effect relations that were supposed to reflect the doctors' knowledge of guidelines. The Think-Aloud Protocols were also searched for reasons for the decisions to prescribe or not to prescribe.
Results
According to the protocols, the GPs were well aware of the importance of previous coronary heart disease and diabetes in their decisions. On the other hand, only a few doctors mentioned other arterio-sclerotic diseases like stroke and peripheral artery disease as variables affecting their decisions. There were several instances when the doctors' decisions apparently deviated from their knowledge of the guidelines. The arguments for the decisions in these cases often concerned aspects of the patient's life-style like smoking or overweight- either as risk-increasing factors or as alternative strategies for intervention.
Conclusions
Coding verbal protocols for knowledge and for decision arguments seems to be a valuable tool for increasing our understanding of how guidelines are used in the on treatment of hypercholesterolaemia. By analysing arguments for treatment decisions it was often possible to understand why departures from the guidelines were made. While the need for decision support is obvious, the current guidelines may be too simple in some respects.
doi:10.1186/1471-2296-5-3
PMCID: PMC394323  PMID: 15113452
6.  Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study 
BMC Family Practice  2003;4:12.
Background
Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure.
Methods
Design: A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography. Setting: Primary health care and two cardiology outpatient clinics in Stockholm. Subjects: 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students. Main outcome measures: The assessed probability of heart failure for each case vignette, and the disagreement between the participants. The number of clinical variables (cues) indicative of heart failure in the case vignettes.
Results
The ten case vignettes with the least diverging assessments more often had increased relative cardiac volume and atrial fibrillation. No further specific clinical patterns could be found in subgroups of the case vignettes. The ten case vignettes with the most diverging assessments were those with an intermediate number of clinical variables. The case vignettes with the least diverging assessments more often represented patients with cardiac enlargement and atrial fibrillation.
Conclusion
Diagnosing mild heart failure is difficult, as these patients are not easy to characterise. In our study, a larger number of positive cues resulted in more diagnostic conformity among the participants, and the most important information was cardiac enlargement. The importance of more objective diagnostic methods in diagnosing suspected cases of heart failure should be emphasised.
doi:10.1186/1471-2296-4-12
PMCID: PMC222938  PMID: 14498999

Results 1-6 (6)