| 1. |
- Andersson, Anne, 1966-, et al.
(författare)
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Adherence to adjuvant endocrine therapy after breast cancer in Sweden 2008-2010 : a nationwide survey
- 2019
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Ingår i: JOURNAL OF CLINICAL ONCOLOGY. - : American Society of Clinical Oncology. - 0732-183X. ; 37:15
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Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
- Background: In estrogen receptor (ER) positive early breast cancer (EBC) adjuvant endocrine therapy (AET) is crucial to reduce recurrence and mortality. Previous studies have shown that adherence to AET is lower than expected and could negatively affect outcome. Since the year of 2000, BC patients in Sweden are treated in accordance to national guidelines. Treatment is offered at a low cost for the patient. The aim of the study was to estimate the adherence to AET in Sweden by regions and age groups. Methods: Women with a first primary EBC diagnosis 2008-2010 were identified through the Swedish Cancer Registry (SCR). Individual tumour and treatment data were retrieved from the Swedish National Breast Cancer Registry (SNBCR). Patients with ER negative tumours, small tumours (≤ 10 mm) and metastatic disease was excluded from the study since there were no indication to AET. Likewise, were individuals with AET registered to be administered by a third part excluded. Dispensed treatment from pharmacies was obtained through the Swedish Prescription Registry and medication possession rate (MPR) was calculated as number of dispensed doses divided by treatment duration in days. Good adherence to treatment in a patient was set at MPR ≥ 80 %. Adherence was calculated for 3 and 5 years. Results: Twenty-one thousand sixteen (21 016) individuals with a first primary BC between 2008 and 2010 was identified through SCR of which 20 596 were registered in the SNBCR. A total of 10 176 met the inclusion criteria in the study. Adherence after 3 years was 88.0 % and after 5 years 82.5 %. Adherence differed between regions in Sweden and was positively associated with age at diagnosis between 41-74 years. Urban areas had a lower adherence than rural areas (80.7 % vs 83.6 %; p= <0.001). Conclusions: Adherence to AET in Sweden was good, although there were differences by age and urban and rural areas. Further studies are needed to identify factors affecting differences in adherence, with the purpose of initiate actions to increase adherence to AET in ER positive EBC patients.
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| 2. |
- Blomstedt, Yulia, et al.
(författare)
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Flawed conclusions on the Vasterbotten Intervention Program by San Sebastian et .al
- 2019
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Ingår i: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 19:1
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Tidskriftsartikel (refereegranskat)abstract
- An evaluation of Vasterbotten Intervention Programme (VIP) was recently conducted by San Sebastian et al. (BMC Public Health 19:202, 2019). Evaluation of health care interventions of this kind require 1) an understanding of both the design and the nature of the intervention, 2) correct definition of the target population, and 3) careful choice of the appropriate evaluation method. In this correspondence, we review the approach used by San Sebastian et al. as relates to these three criteria. Within this framework, we suggest important explanations for why the conclusions drawn by these authors contradict a large body of research on the effectiveness of the VIP.
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| 3. |
- Blomstedt, Yulia, et al.
(författare)
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Impact of a combined community and primary care prevention strategy on all-cause and cardiovascular mortality : a cohort analysis based on 1 million person-years of follow-up in Västerbotten County, Sweden, during 1990-2006
- 2015
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Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 5:12
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To evaluate the impact of the Västerbotten Intervention Programme (VIP) by comparing all eligible individuals (target group impact) according to the intention-to-treat principle and VIP participants with the general Swedish population.DESIGN: Dynamic cohort study.SETTING/PARTICIPANTS: All individuals aged 40, 50 or 60 years, residing in Västerbotten County, Sweden, between 1990 and 2006 (N=101 918) were followed from their first opportunity to participate in the VIP until age 75, study end point or prior death.INTERVENTION: The VIP is a systematic, long-term, county-wide cardiovascular disease (CVD) intervention that is performed within the primary healthcare setting and combines individual and population approaches. The core component is a health dialogue based on a physical examination and a comprehensive questionnaire at the ages of 40, 50 and 60 years.PRIMARY OUTCOMES: All-cause and CVD mortality.RESULTS: For the target group, there were 5646 deaths observed over 1 054 607 person-years. Compared to Sweden at large, the standardised all-cause mortality ratio was 90.6% (95% CI 88.2% to 93.0%): for women 87.9% (95% CI 84.1% to 91.7%) and for men 92.2% (95% CI 89.2% to 95.3%). For CVD, the ratio was 95.0% (95% CI 90.7% to 99.4%): for women 90.4% (95% CI 82.6% to 98.7%) and for men 96.8% (95% CI 91.7 to 102.0). For participants, subject to further impact as well as selection, when compared to Sweden at large, the standardised all-cause mortality ratio was 66.3% (95% CI 63.7% to 69.0%), whereas the CVD ratio was 68.9% (95% CI 64.2% to 73.9%). For the target group as well as for the participants, standardised mortality ratios for all-cause mortality were reduced within all educational strata.CONCLUSIONS: The study suggests that the VIP model of CVD prevention is able to impact on all-cause and cardiovascular mortality when evaluated according to the intention-to-treat principle.
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| 4. |
- Brunström, Mattias, et al.
(författare)
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From efficacy in trials to effectiveness in clinical practice : The Swedish Stroke Prevention Study
- 2016
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Ingår i: Blood Pressure. - : Informa UK Limited. - 0803-7051 .- 1651-1999. ; 25:4, s. 206-211
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Tidskriftsartikel (refereegranskat)abstract
- Blood pressure treatment has shown great efficacy in reducing cardiovascular events in randomized controlled trials. If this is effective in reducing cardiovascular disease in the general population, is less studied. Between 2001 and 2009 we performed an intervention to improve blood pressure control in the county of Vasterbotten, using Sodermanland County as a control. The intervention was directed towards primary care physicians and included lectures on blood pressure treatment, a computerized decision support system with treatment recommendations, and yearly feed back on hypertension control. Each county had approximately 255000 inhabitants. Differences in age and incidence of cardiovascular disease were small. During follow-up, more than 400000 patients had their blood pressure recorded. The mean number of measurements was eight per patient, yielding a total of 3.4 million blood pressure recordings. The effect of the intervention will be estimated combining the blood pressure data collected from the electronic medical records, with data on stroke, myocardial infarction and mortality from Swedish health registers. Additional variables, from health registers and Statistics Sweden, will be collected to address for confounders. The blood pressure data collected within this study will be an important asset for future epidemiological studies within the field of hypertension.
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| 5. |
- Haksari, Ekawaty L., et al.
(författare)
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Reference curves of birth weight, length, and head circumference for gestational ages in Yogyakarta, Indonesia
- 2016
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Ingår i: BMC Pediatrics. - : Springer Science and Business Media LLC. - 1471-2431. ; 16
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Tidskriftsartikel (refereegranskat)abstract
- Background: The birth weight reference curve to estimate the newborns at risk in need of assessment and monitoring has been established. The previous reference curves from Indonesia, approximately 8 years ago, were based on the data collected from teaching hospitals only with limited gestational ages. The aims of the study were to update the reference curves for birth weight, supine length and head circumference for Indonesia, and to compare birth weight curves of boys and girls, first child and later children, and the ones in the previous studies. Methods: Data were extracted from the Maternal-Perinatal database between 1998-2007. Only live singletons with recorded gestational ages of 26 to 42 weeks and the exact time of admission to the neonatal facilities delivered or referred within 24 h of age to Sardjito Hospital, five district hospitals and five health centers in Yogyakarta Special Territory were included. Newborns with severely ill conditions, congenital anomaly and chromosomal abnormality were excluded. Smoothening of the curves was accomplished using a third-order polynomial equation. Results: Our study included 54,599 singleton live births. Growth curves were constructed for boys (53.3%) and girls (46.7%) for birth weight, supine length, and head circumference. At term, mean birth weight for each gestational age of boys was significantly higher than that of girls. While mean birth weight for each gestational age of first-born-children, on the other hand was significantly lower than that of later-born-children. The mean birth weight was lower than that of Lubchenco's study. Compared with the previous Indonesian study by Alisyahbana, no differences were observed for the aterm infants, but lower mean birth weight was observed in preterm infants. Conclusions: Updated neonatal reference curves for birth weight, supine length and head circumference are important to classify high risk newborns in specific area and to identify newborns requiring attention.
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| 6. |
- Litorp, Helena, et al.
(författare)
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The effects of previous cesarean deliveries on severe maternal and adverse perinatal outcomes at a university hospital in Tanzania
- 2016
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Ingår i: International Journal of Gynecology & Obstetrics. - : Wiley. - 0020-7292 .- 1879-3479. ; 133:2, s. 183-187
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To investigate if multiparous individuals who had undergone a previous cesarean delivery experienced an increased risk of severe maternal outcomes or adverse perinatal outcomes compared with multiparous individuals who had undergone previous vaginal deliveries. Methods: An analytical cross-sectional study at a university hospital in Dar es Salaam, Tanzania, enrolled multiparous participants of at least 28 weeks of pregnancy between February 1 and June 30, 2012. Data were collected from patients' medical records and the hospital's obstetric database. Odds ratios (OR) and 95% confidence intervals (Cl) were calculated to compare outcomes among patients who had or had not undergone previous cesarean deliveries. Results: A total of 2478 patients were enrolled. A previous cesarean delivery resulted in no increase in the risk of severe maternal outcomes (OR0.86, 95% CI 0.58-1.26; P = 0.46), and decreased risk of stillbirth (OR 0.42, 95% CI 0.29-0.62, P < 0.001), and intrapartum stillbirth and neonatal distress (OR 0.58, 95% CI 038-0.87, P = 0.007). Conclusion: Previous cesarean delivery was not a risk factor for severe maternal outcomes or adverse perinatal outcomes. The present study was conducted at a referral institution, where individuals with previous cesarean deliveries may constitute a healthy group. Additionally, there could be differences between the study groups in terms of healthcare-seeking behavior, referral mechanisms, intrapartum monitoring, and clinical decision making.
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| 7. |
- Mgaya, Andrew H, 1977-, et al.
(författare)
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Criteria-based audit to improve quality of care of foetal distress : standardising obstetric care at a national referral hospital in a low resource setting, Tanzania
- 2016
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Ingår i: BMC Pregnancy and Childbirth. - : Springer Science and Business Media LLC. - 1471-2393 .- 1471-2393. ; 16
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting.METHODS: During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate.RESULTS: In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients.CONCLUSION: The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.
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| 8. |
- Mgaya, Andrew Hans
(författare)
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Improving the quality of caesarean section in a low-resource setting : An intervention by criteria-based audit at a tertiary hospital, Dar es Salaam, Tanzania
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes.This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process. In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.
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| 9. |
- Mgaya, Andrew H., et al.
(författare)
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Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting
- 2019
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Ingår i: International Journal of Gynecology & Obstetrics. - : Wiley-Blackwell. - 0020-7292 .- 1879-3479. ; 144:2, s. 199-209
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To evaluate the impact of a criteria‐based audit (CBA) of obstructed labor and fetal distress on cesarean delivery and perinatal outcomes.Methods: A cross‐sectional study was performed at a tertiary referral hospital in Tanzania. Data were collected before and after CBA (January 2013–November 2013 and July 2015–June 2016). Outcomes of fetal distress (baseline CBA, n=248; re‐audit, n=251) and obstructed labor (baseline CBA, n=260; re‐audit n=250) were assessed using a checklist. Additionally, 27 960 parturients were assessed using the Robson classification.Results: Perinatal morbidity and mortality decreased from 42 of 260 (16.2%) to 22 of 250 (8.8%) among patients with obstructed labor after CBA (P=0.012). Cesarean delivery rate decreased for referred term multiparas with induced labor or prelabor cesarean delivery (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09–0.82). Cesarean delivery rate for preterm pregnancies increased among both referred (OR 1.28, 95% CI 1.02–1.63) and non‐referred (OR 2.78, 95% CI 1.98–3.90) groups. Neonatal distress rate decreased for referred term multiparas (OR 0.72, 95% CI 0.56–0.92), referred preterm pregnancies (OR 0.32, 95% CI 0.25–0.39), and non‐referred preterm pregnancies (OR 0.26, 95% CI 0.18–0.36).Conclusion: Use of CBA reduced poor perinatal outcomes of obstructed labor and increased uptake of cesarean delivery.
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| 10. |
- Mgaya, Andrew, et al.
(författare)
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Improving Standards of Care in Obstructed Labour : A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania
- 2016
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Ingår i: PLOS ONE. - : Public library science. - 1932-6203. ; 11:11
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Tidskriftsartikel (refereegranskat)abstract
- Objective: In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. Methods: A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. Results: Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion: A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.
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