Reasons for encounters, investigations, referrals, diagnoses and treatments in general practice in Sweden--a multicentre pilot study using electronic patient records.

摘要

OBJECTIVE: To investigate reasons for encounters, investigations, referrals, diagnoses and treatments in everyday general practice, using electronic patient records (EPR), and possible related differences concerning gender, socio-economic status (SES) and practice location. METHOD: Four Swedish primary care centres using EPR participated. Distributions of symptoms, investigations, diagnoses and prescribed drugs were registered. RESULTS: In 1055 encounters, the mean patient age was 53; 59% were women. The most common reasons for the encounter were musculoskeletal (21.5%) and respiratory (15.2%) symptoms. A total of 1534 diagnoses were coded, on average 1.5 per encounter. The predominant diagnostic groups, i.e. ICD-10 chapters, were musculoskeletal (17.2%) and respiratory (12.4%). The most common specific diagnoses were essential hypertension (8.1%) and acute upper respiratory infections (3.7%). A total of 1687 prescriptions were issued, on average 1.6 per encounter. The most frequent pharmaceutical groups were nervous (17.7%), respiratory system (16.2%), and cardiovascular (15.7%). The most frequent drugs were phenoxymethyl penicillin (3.7%), diclofenac (2.9%) and acetylsalicylic acid (2.5%). An average of 1.3 laboratory tests was performed per encounter. In 7.5% of encounters, radiology referrals were made; in 12.3% referrals were made to other specialists/therapists, while sick-list certificates were written in 11.7%. There were significant differences concerning symptoms, diagnoses and investigations between female and male patients, urban and rural practices and SES. CONCLUSION: The musculoskeletal, respiratory and circulatory systems predominated, both as reasons for the encounter and in the diagnoses, but with significant differences concerning gender, SES and practice location.