| 1. |
- Högberg, Cecilia, et al.
(författare)
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Immunochemical faecal occult blood tests in primary care and the risk of delay in the diagnosis of colorectal cancer
- 2013
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Ingår i: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 31:4, s. 209-214
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Tidskriftsartikel (refereegranskat)abstract
- Objective. To evaluate the value, risks, and shortcomings of immunochemical faecal occult blood tests (iFOBTs) in the diagnosis of colorectal cancer (CRC) and adenomas with high-grade dysplasia (HGD) in patients initially presenting to primary care. Design. A retrospective population-based study. Setting and subjects. All 495 cases of CRC and adenomas with HGD diagnosed in the county of Jamtland, Sweden from 2005 to 2009. Results. Of 495 patients 323 (65%) initially presented to primary care. IFOBTs were performed in 215 of 323 (67%) patients. The sensitivity of iFOBT for CRC and adenomas with HGD was 88% (83% when patients with a history of rectal bleeding were excluded). Of 34 patients with anaemia found en passant, 10 had negative iFOBTs. Time to diagnosis was longer for patients with negative iFOBTs (p < 0.0005). Conclusion. IFOBT might be helpful in selecting which patients to refer for colonoscopy. However, iFOBT has a limited sensitivity as a diagnostic test for CRC and adenomas with HGD. Relying only on iFOBT for colonoscopy referral could delay diagnosis, especially for patients with anaemia found en passant.
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| 2. |
- Lekander, Ingrid, et al.
(författare)
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Hospital comparison of stroke care in Sweden : a register-based study
- 2017
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Ingår i: BMJ Open. - London, UK : BMJ Publishing Group Ltd. - 2044-6055. ; 7:9
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND AND PURPOSE: The objective of this study was to estimate the level of health outcomes and resource use at a hospital level during the first year after a stroke, and to identify any potential differences between hospitals after adjusting for patient characteristics (case mix).METHOD: Data from several registries were linked on individual level: seven regional patient administrative systems, Swedish Stroke Register, Statistics Sweden, National Board of Health and Welfare and Swedish Social Insurance Agency. The study population consisted of 14 125 patients presenting with a stroke during 2010. Case-mix adjusted analysis of hospital differences was made on five aspects of health outcomes and resource use, 1 year post-stroke.RESULTS: The results indicated that 26% of patients had died within a year of their stroke. Among those who survived, almost 5% had a recurrent stroke and 40% were left with a disability. On average, the patients had 22 inpatient days and 23 outpatient visits, and 13% had moved into special housing. There were significant variations between hospitals in levels of health outcomes achieved and resources used after adjusting for case mix.CONCLUSION: Differences in health outcomes and resource use between hospitals were substantial and not entirely explained by differences in patient mix, indicating tendencies of unequal stroke care in Sweden. Healthcare organisation of regions and other structural features could potentially explain parts of the differences identified.
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| 3. |
- Högberg, Cecilia, et al.
(författare)
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Use of faecal immunochemical tests common in patients with suspected colorectal cancer but unrelated to travel distance to secondary care : a population-based study from Swedish primary care
- 2022
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Ingår i: Scandinavian Journal of Primary Health Care. - : Taylor & Francis Group. - 0281-3432 .- 1502-7724. ; 40:4, s. 459-465
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Tidskriftsartikel (refereegranskat)abstract
- Background Evidence is increasing for the use of faecal immunochemical tests (FITs) for occult blood as diagnostic tools when colorectal cancer can be suspected. FITs have been used for this purpose in Swedish primary care since around 2005 despite absence of supporting guidelines. To our knowledge, the extent of this use has not been studied. Objective To investigate the use of FITs as diagnostic tools, and if the use was related to patient age, sex and travel time from primary care to diagnostic facilities in secondary care. Design Population-based retrospective study using data from electronic health records. Setting and subjects Patients >= 18 years that provided FITs in primary care in five Swedish health care regions during 2015. Driving times from their primary care centres to secondary care were calculated. Main outcome measures The proportion of patients that provided FITs was calculated for each region, different age intervals and grouped driving times. Results 18,913 patients provided FITs. The proportion of listed patients in the five regions that provided FITs increased with age: 0.86-1.2% for ages <65 years, 3.6-4.1% for ages 65-79 years and 3.8-6.1% for ages >= 80 years. Differences between the regions were small. There was no overall correlation between the proportion of patients that provided FITs and driving time to secondary care. Conclusion FITs were used extensively in Swedish primary care with a higher use in older age groups. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to secondary care.
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| 4. |
- Högberg, Cecilia, et al.
(författare)
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Diagnosing colorectal cancer in primary care : cohort study in Sweden of qualitative faecal immunochemical tests, haemoglobin levels, and platelet counts
- 2020
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Ingår i: British Journal of General Practice. - London : Royal College of General Practitioners. - 0960-1643 .- 1478-5242. ; 70:701, s. E843-E851
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Tidskriftsartikel (refereegranskat)abstract
- Background Colorectal cancer (CRC) diagnostics are challenging in primary care and reliable diagnostic aids are desired. Qualitative faecal immunochemical tests (FITs) have been used for suspected CRC in Sweden since the mid-2000s, but evidence regarding their effectiveness is scarce. Anaemia and thrombocytosis are both associated with CRC. Aim To evaluate the usefulness of qualitative FITs requested for symptomatic patients in primary care, atone and combined with findings of anaemia and thrombocytosis, in the diagnosis of CRC. Design and setting A population-based cohort study using electronic health records and data from the Swedish Cancer Register, covering five Swedish regions. Method Patients aged >= 18 years in the five regions who had provided FITs requested by primary care practitioners from 1 January 2015 to 31 December 2015 were identified. FIT and blood-count data were registered and all CRC diagnoses made within 2 years were retrieved. Diagnostic measurements were calculated. Results In total, 15 789 patients provided FITs (four different brands); of these patients, 304 were later diagnosed with CRC. Haemoglobin levels were available for 13 863 patients, and platelet counts for 10 973 patients. Calculated for the different FIT brands only, the sensitivities for CRC were 81.6%-100%; specificities 65.7%-79.5%: positive predictive values 4.7%-8.1%; and negative predictive values 99.5%-100%. Calculated for the finding of either a positive FIT or anaemia, the sensitivities increased to 88.9-100%. Adding thrombocytosis did not further increase the diagnostic performance. Conclusion Qualitative FITs requested in primary care seem to be useful as rule in tests for referral when CRC is suspected. A negative FIT and no anaemia indicate a low risk of CRC.
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| 5. |
- Högberg, Cecilia, et al.
(författare)
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Could it be colorectal cancer? : general practitioners' use of the faecal occult blood test and decision making - a qualitative study
- 2015
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Ingår i: BMC Family Practice. - : BioMed Central. - 1471-2296. ; 16:1, s. 153-161
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Abdominal complaints are common reasons for contacting primary care physicians, and it can be challenging for general practitioners (GPs) to identify patients with suspected colorectal cancer (CRC) for referral to secondary care. The immunochemical faecal occult blood test (iFOBT) is used as a diagnostic aid in primary care, but it is unclear how test results are interpreted. Studies show that negative tests are associated with a risk of delayed diagnosis of CRC and that some patients with positive tests are not investigated further. The aim of this study was to explore what makes GPs suspect CRC and to investigate their practices regarding investigation and referral, with special attention on the use of iFOBTs.METHOD: Semi-structured individual interviews were conducted with eleven purposely selected GPs and registrars in Region Jämtland Härjedalen, Sweden, and subjected to qualitative content analysis.RESULTS: In the analysis of the interviews four categories were identified that described what made the physicians suspect CRC and their practices. Careful listening-with awareness of the pitfalls: Attentive listening was described as essential, but there was a risk of being misled by, for example, the patient's own explanations. Tests can help-the iFOBT can also complicate the diagnosis: All physicians used iFOBTs to various extents. In the absence of guidelines, all found their own ways to interpret and act on the test results. To refer or not to refer-safety margins are necessary: Uncertainty was described as a part of everyday work and was handled in different ways. Common vague symptoms could be CRC and thus justified referral with safety margins. Growing more confident-but also more humble: With increasing experience, the GPs described becoming more confident in their decisions but they were also more cautious.CONCLUSIONS: Listening carefully to the patient's history was essential. The iFOBT was frequently used as support, but there were considerable variations in the interpretation and handling of the results. The diagnostic process can be described as navigating uncertain waters with safety margins, while striving to keep the patient's best interests in mind. The iFOBT may be useful as a diagnostic aid in primary care, but more research and evidence-based guidelines are needed.
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| 6. |
- Benckert, Martin, et al.
(författare)
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Improved metabolic health among the obesein six population surveys 1986 to 2009 : the Northern Sweden MONICA study
- 2015
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Ingår i: BMC Obesity. - : BioMed Central. - 2052-9538. ; 2:7
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundThe incidence of CVD is decreasing in spite of increasing BMI in the population. We examined trends in metabolic health among overweight and obese individuals and the influence of lifestyle and socioeconomic status. Six cross sectional population surveys in the Northern Sweden MONICA Study between 1986 and 2009. 8 874 subjects 25 to 64 years participated (74% participation rate). Metabolic health was defined as a total cholesterol level below 5.0 mmol/l, blood pressure below 140/90 mmHg and not having diabetes. In 2009 the age span 25 to 74 years was studied.ResultsThe prevalence of metabolic health among obese subjects increased by 7.9 % per year (95% confidence interval 5.4; 10.5), reaching 21.0% in 2009. The corresponding figures for overweight subjects were 5.9% per year (4.6; 7.3), reaching 18% in 2009, whereas for the normal-weight subjects, the increase was 6.2% per year (5.3; 7.2), reaching 39% in 2009. The prevalence of metabolic health among subjects with abdominal obesity increased by 5.8% (4.6; 7.0) per year, reaching 17.3% in 2009. Among those with no abdominal obesity the increase was 6.2% (5.2; 7.1), reaching 38% in 2009 (p = <0.001 for all groups). Only among non-obese men and obese women did the increase continue between 2004 and 2009. In the other groups a slight decline or levelling off was noted.In 2009 women had a 27% higher prevalence of metabolic health than men. The prevalence of metabolic health among the obese was 19.8% which declined to 15.8% if subjects treated for hypertension or hypercholesterolemia were classified as not healthy. Overweight and obese subjects were less often metabolically healthy (odds ratio 0.54 and 0.59 respectively) compared with normal-weight subjects, independent of sex and age as were subjects with abdominal obesity (odds ratio 0.52). Adjustments for smoking, physical activity and education level did not influence any estimates.ConclusionsThis report shows a large increase in prevalence of metabolic health from 1986 to 2009 for all anthropometric categories. Metabolic health remains considerably less prevalent among overweight and obese subjects than among those with normal weight.
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| 7. |
- Högberg, Cecilia, 1953-
(författare)
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Diagnosing colorectal cancer in primary care : the value of symptoms, faecal immunochemical tests, faecal calprotectin and anaemia
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Colorectal cancer (CRC) is the third most common cancer in men and the second most common in women worldwide. Adenomas can be precursors to CRC, and inflammatory bowel disease (IBD) can present with the same symptoms as CRC. The majority of patients with CRC initially consult primary care. Symptoms associated with CRC are also common among primary care patients, but seldom caused by any significant disease. Reliable diagnostic aids would be helpful in deciding which patients to refer. Faecal immunochemical tests (FITs) are commonly used for this purpose in primary care in Sweden, but there is little evidence to support this use. Faecal calprotectin (FC) has been suggested as an additional test.Aim: To explore how doctors in primary care investigate patients with suspected CRC, the value of FITs, symptoms and presence of anaemia in diagnosing CRC and adenomas in primary care, and whether FC tests could contribute to diagnosis.Methods: Three studies (1-3) were carried out in Region Jämtland Härjedalen, Sweden. There was no screening programme for CRC. We used a point of care qualitative dip-stick 3-sample FIT with a cut-off of 25-50μg haemoglobin/g faeces, and a calprotectin enzyme-linked immunosorbent assay (ELISA) test with a cut-off of 100 μg/g faeces. 1: A retrospective, population-based study including all patients diagnosed with CRC or adenomas with high-grade dysplasia (HGD) during the period 2005-2009 that initially consulted primary care. Symptoms, FIT results, anaemia and time to diagnosis were retrieved from medical records. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated from FIT results at the region’s health centres 2008- 2009. (Paper I.) 2: A prospective cohort study including consecutive patients where primary care doctors requested FITs and/or FC tests, at four health centres, from 30 Jan 2013 to 31 May 2014. FITs, FC tests, haemoglobin and iron deficiency tests were analysed; patients and doctors answered questionnaires about symptoms. Patients were examined with bowel imaging or followed for two years. Findings of CRC, adenomas with HGD, adenomas with low grade dysplasia (LGD) ≥1 cm and IBD were registered. (Papers II and III.) 3: A qualitative study of interviews with eleven primary care doctors. We explored what made them suspect CRC, and their practices regarding investigation and referral with particular attention to their use of FITs. Qualitative content analysis with an inductive approach was used for the analysis. (Paper IV.)Results: 1: Paper I: Of 495 patients 323 (65.3%) started the investigation in primary care. FITs were analysed in 215. In 23 cases with CRC, FITs were negative; 15 (65.2%) had anaemia. In 33 cases with CRC, FITs were performed due to asymptomatic anaemia; 10 (30.3%) had negative FITs. The time from start of investigation, to the diagnosis of CRC or adenomas with HGD, was significantly longer for patients with negative FITs.2: 377 patients (9 diagnosed with CRC, 10 with IBD) were included. Paper II: Concordance of positive answers about symptoms from patients and doctors was generally low. Rectal bleeding (recorded by 43.5% of patients and 25.6% of doctors) was the only symptom related to CRC and IBD. The FIT showed a better PPV than rectal bleeding for CRC and IBD. When patients recorded rectal bleeding, the FIT had a PPV of 22.6% and a NPV of 98.9% for CRC and IBD. Paper III: The best test for detecting CRC and IBD was the combination of a positive FIT and/or anaemia with a sensitivity, specificity, PPV and NPV of 100%, 61.7%, 11.7% and 100% respectively. The FC test had no additional value to the FIT alone. The sensitivity, specificity, PPV and NPV of the FIT for CRC in study 1 was estimated at 88.4%, 73.3%, 6.2% and 99.7% respectively. In study 2, corresponding figures were 88.9%, 67.4%, 6.3% and 99.6% respectively.3: Paper IV: We identified four categories: “Careful listening – with awareness of the pit-falls”, “tests can help – the FIT can also complicate the diagnosis”, “to refer or not to refer – safety margins are necessary”, and “growing more confident – but also more humble”. All doctors had found their own way to handle FIT results in the absence of guidelines.Conclusion: The diagnostic process when suspecting CRC can be described as navigating uncertain waters with safety margins. FITs were often used by primary care doctors but with considerable variations in interpretation and handling of results. Rectal bleeding was the only symptom related to CRC and IBD, but the FIT showed a better PPV than rectal bleeding. The combination of a negative FIT and no anaemia may be useful as a rule-out test when CRC is suspected in primary care, and this potentially also applies when patients present with rectal bleeding. Further studies are needed to confirm this and to determine the optimal FIT cut-off value for this use.
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| 8. |
- Högberg, Cecilia, et al.
(författare)
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Patient-reported and doctor-reported symptoms when faecal immunochemical tests are requested in primary care in the diagnosis of colorectal cancer and inflammatory bowel disease : a prospective study
- 2020
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Ingår i: BMC Family Practice. - : BioMed Central. - 1471-2296. ; 21:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Rectal bleeding and a change in bowel habits are considered to be alarm symptoms for colorectal cancer and they are also common symptoms for inflammatory bowel disease. However, most patients with these symptoms do not have any of these diseases. Faecal immunochemical tests (FITs) for haemoglobin are used as triage tests in Sweden and other countries but little is known about the symptoms patients have when FITs are requested.Objective: Firstly, to determine patients’ symptoms when FITs are used as triage tests in primary care and whether doctors record the symptoms that patients report, and secondly to evaluate the association between symptoms, FIT results and possible prediction of colorectal cancer or inflammatory bowel disease.Methods and materials: This prospective study included 364 consecutive patients for whom primary care doctors requested a FIT. Questionnaires including gastrointestinal symptoms were completed by patients and doctors.Results: Concordance between symptoms reported from patients and doctors was low. Rectal bleeding was recorded by 43.5% of patients versus 25.6% of doctors, FITs were negative in 58.3 and 52.7% of these cases respectively. The positive predictive value (PPV) of rectal bleeding recorded by patients for colorectal cancer or inflammatory bowel disease was 9.9% (95% confidence interval [CI] 5.2–14.7); for rectal bleeding combined with a FIT the PPV was 22.6% (95% CI 12.2–33.0) and the negative predictive value (NPV) was 98.9% (95% CI 96.7–100). For patient-recorded change in bowel habits the PPV was 6.1% (95% CI 2.4–9.8); for change in bowel habits combined with a FIT the PPV was 18.2% (95% CI 9.1–30.9) and the NPV 100% (95% CI 90.3–100).Conclusions: Doctors should be aware that, during consultations, they do not record all symptoms experienced by patients. FITs requested in primary care, when found positive, may potentially be of help in prioritising referrals, also when patients present with rectal bleeding or change in bowel habits.
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| 9. |
- Lööv, Anna, 1990-, et al.
(författare)
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Diagnostic accuracy for colorectal cancer of a quantitative faecal immunochemical test in symptomatic primary care patients : a study protocol
- 2022
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Ingår i: Diagnostic and prognostic research. - : BioMed Central (BMC). - 2397-7523. ; 6:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: There is increasing evidence supporting the use of faecal immunochemical tests (FIT) in patients reporting symptoms associated with colorectal cancer (CRC), but most studies until now have focused on selected subjects already referred for investigation. We therefore set out to determine the accuracy and predictive values of FIT in a primary care population.METHOD: A prospective, multicentre, single-gated comparative diagnostic study on quantitative FIT in patients aged 40 years and above presenting in primary care with symptoms associated with CRC will be conducted. Patients representing the whole spectrum of severity of such symptoms met with in primary care will be eligible and identified by GPs. Participants will answer a short form on symptoms during the last month. They will provide two faecal samples from two separate days. Analyses will be performed within 5 days (QuikRead go®, Aidian Oy). The analytical working range is 10-200 μg Hb/g faeces. Reference test will be linked to the Swedish Colorectal Cancer Registry up to 2 years after inclusion. Accuracy, area under ROC curves, and predictive values will be calculated for one FIT compared to the highest value of two FIT and at cutoff < 10, 10-14.9, 15-19.9 and ≥ 20 μg Hb/g faeces. Subgroup analyses will be conducted for patients with anaemia and those reporting rectal bleeding. A model-based cost-effectiveness analysis based on the clinical accuracy study will be performed. Based on previous literature, we hypothesized that the sensitivity of the highest value of two FIT at cutoff 10 μg Hb/g faeces will be 95% (95% CI + / - 15%). The prevalence of CRC in the study population was estimated to be 2%, and the rate of non-responders to be 1/6. In all, 3000 patients will be invited at 30 primary care centres.DISCUSSION: This study will generate important clinical real-life structured data on accuracy and predictive values of FIT in the most critical population for work-up of CRC, i.e. patients presenting with at times ambiguous symptoms in primary care. It will help establish the role of FIT in this large group.
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| 10. |
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