RESUMEN
OBJECTIVE: To describe the use and level of HbA1c in a large unselected Type 2 diabetic population in Denmark. In addition, to describe the characteristics of the patients and the general practitioners in relation to the monitoring of HbA1c. DESIGN: Data were collected from public data files for the period January 1993 to December 1997. SETTING: The County of Vejle with a background population of 342,597 citizens, 303,250 of whom were listed with participating general practitioners. PATIENTS: The Type 2 diabetic population alive and resident in the county on 1 January 1997. RESULTS: In a population of 4438 Type 2 diabetics, 73% had a minimum of one annual HbA1c measurement in 1997. No HbA1c measurement was associated with a long history of diabetes, diet treatment or old age. Poor glycaemic regulation was found in 65% of the Type 2 diabetics in 1997. Poor glycaemic regulation was associated with tablet or insulin treatment, age under 70 years and long history of diabetes. The interpractice variation was huge. CONCLUSION: The quality of HbA1c monitoring of Type 2 diabetics needs to be improved. Possibilities for improvement seem to be present.
Asunto(s)
Diabetes Mellitus Tipo 2/sangre , Pruebas Diagnósticas de Rutina/estadística & datos numéricos , Hemoglobina Glucada/análisis , Pautas de la Práctica en Medicina/estadística & datos numéricos , Anciano , Dinamarca , Diabetes Mellitus Tipo 2/dietoterapia , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Medicina Familiar y Comunitaria/normas , Medicina Familiar y Comunitaria/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de la Atención de Salud , Sistema de RegistrosRESUMEN
Phenprocoumon, whose elimination half-time is 144 hours, has been the traditional oral anticoagulant of choice in Europe. However, today's most widely used drug is warfarin, whose elimination half-time is 40 hours. This study aims to evaluate a method for safe transition from phenprocoumon to warfarin, which is sometimes required. Hence, the large difference in their elimination rates may on occasion lead to serious overdosage upon transition from one drug to the other. According to average equipotent doses, a stepwise increase in warfarin dose was calculated based on the elimination half-times of the two drugs. The dosage scheme was subsequently tested in a pilot study including 35 patients. The conversion scheme was then adjusted based on the results from the pilot study. The new scheme was tested in 69 patients. The transition factor was 2.3, which implies that equipotency was achieved when the warfarin dose was 2.3 times larger than the phenprocoumon dose (in mg). This scheme proved optimal for 75% of the patients. However, the dose had to be adjusted individually in the remaining 25% of the patients to a level corresponding to the measured international normalised ratios. No patients experienced haemorrhages or thromboembolic complications during the period of changeover. In conclusion, the proposed scheme for changing medication from phenprocoumon to warfarin is safe and convenient.
Asunto(s)
Anticoagulantes/administración & dosificación , Fenprocumón/administración & dosificación , Warfarina/administración & dosificación , Administración Oral , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Anticoagulantes/farmacocinética , Semivida , Humanos , Persona de Mediana Edad , Fenprocumón/efectos adversos , Fenprocumón/farmacocinética , Proyectos Piloto , Tiempo de Protrombina , Seguridad , Warfarina/efectos adversos , Warfarina/farmacocinéticaRESUMEN
There is no tradition for sharing the responsibility for episodes of care between the primary and secondary sectors in the Danish health care system. Concurrently with increased international experience with shared care programmes, there is also a growing interest in Denmark in cooperation between the sectors. Based on literature research, shared care programmes are presented as a method of ensuring continuity and quality in treatment of chronic diseases. Experiences in the areas of diabetes, asthma, rheumatoid arthritis, and cancer are described. It is concluded that the Danish health care system is well prepared for the implementation of shared care programmes; there are only few sources of payment in the system, and an extensive continuing medical education system ensures that general practitioners can participate in relevant education. The implementation of shared care programmes in Denmark should be followed by scientific evaluation and documentation of the quality of the treatment programmes.
Asunto(s)
Medicina Familiar y Comunitaria , Sector de Atención de Salud , Atención a la Salud , Dinamarca , Servicios Hospitalarios Compartidos , Hospitales , Humanos , Relaciones Interprofesionales , Registro Médico Coordinado , Modelos Organizacionales , Derivación y Consulta , Programas Médicos RegionalesRESUMEN
The randomized controlled trial (RCT) may have considerable limitations in clinical research. Lacking the possibility of blinding impairs the internal validity of the trials. The external validity is often impaired, as results of RCTs obtained in an ideal situation, may be difficult to generalize to a clinical routine situation. Pragmatic randomized trials move from ideal situations towards routine situations, and by modifying the design it is possible to reduce selection bias due to patient and physician preferences. Quasi-experimental studies have varying degrees of problems with internal validity but are necessary contributions to our knowledge of the effect of treatment in clinical routine situations. Limitations of the usefulness of RCTs as well as pragmatic and quasi-experimental studies in clinical research make it necessary to recognise that different methods complement one another. Research in development of RCTs and new methods in clinical research should be encouraged.