967
Occasional
Survey
VARIATION IN ANNUAL INCIDENCE OF PRIMARY ACUTE PANCREATITIS IN
NOTTINGHAM, 1969-74
admitted to one or other of th,.Ý’1wo major hospitals. Neighbouring district general hospitals-Mansfield (14 miles north), Derby (16 miles west), Leicester (25 miles south), and Grantham (24 miles east)-seem very unlikely, for geographical reasons, to admit patients from Nottingham, and a deliberate search for such referrals had shown that they were very rare for another abdominal disease.2 The case-reports of all patients in whom pancreatitis was
diagnosed
J. B. BOURKE University Department of Surgery, General Hospital, Nottingham NGI 6HA
were sought primarily by searching the inpatient diagnostic indexes for the period 1969-74. This was supplemented by referral to a personal diagnostic index and postmortem reports for the same period.
Diagnostic Criteria
patients admitted to Nottingham hospitals with primary acute pancreatitis during the six years 1969-74 has been undertaken. The City of Nottingham and the four adjacent former urban districts had a population of 469 720
Summary
A review of the 202
in 1971, and an attempt was made to obtain details of all patients from within this defined population area. 134 of the 202 patients came from this area. The annual incidence varied by 4-fold throughout the six years of the survey from a peak incidence of 83·0 per million population in 1974 to a low incidence of 21·2 per million in 1970. There was no detectable pattern behind this variation and consideration of the individual figures did not suggest that any particular predisposing factor accounted for the variation. Spatial variation analysis is now being undertaken to see if population and environmental subgroups can be identified. INTRODUCTION
PRIMARY acute pancreatitis is a disease which results in hospital admission, and by careful inquiry it should be possible to obtain details of all patients with this disease in a particular area. The present study was confined to patients in their first attack of primary acute pancreatitis, for mortality is greatest in the inital attack.’ An attempt was made to obtain details of all Nottingham patients and the results are reported below. Use has also been made of the Nottingham defined population area2 of the department of community health of the University of Nottingham so that accurate annual incidence and mortality data could be calculated. METHOD
Patients In Nottingham the hospital service is based upon two district hospitals with limited facilities in smaller hospitals, and consequently all patients with acute pancreatitis should be
All case-reports were reviewed, and the diagnosis of acute pancreatitis was only accepted with a compatible clinical history, physical examination, and a greater than fourfold increase in serum-amylase level. Laparotomy and/or necropsy evidence were also accepted. Only patients with primary acute pancreatitis (i.e., in their first attack of pancreatitis) are included. Those with recurrent, chronic, traumatic, or postoperative pancreatitis were
excluded. The presence of associated factors such as gallstones was recorded. Some patients were not further investigated after recovery from the acute attack because the clinician decided not to pursue associated factors because of the patient’s age and/or
general debility. Calculation
of Incidence The City of Nottingham and the four former urban districts of Arnold, Beeston and Stapleford, Carlton, and West Bridgford had a population of 469 720 in 1971. This area lies within an approximate radius of 5 miles around the centre of Nottingham. This population has remained constant during the period of the survey, and the population figures for 1971 have been used in calculating incidence data for individual years. ’
RESULTS
During 1969-74, 202 patients were accepted on review as having had primary acute pancreatitis. Of these 202 patients, 134 came from within the Nottingham defined population area. Of the total series 36 out of 202 died (17.8%) while 26 out of 134 from within the Nottingham defined population area died (19.4%). The associated aetiological factors for the total and defined population areas are given in table i. Approximately half the patients had gallstones, a third had no detectable predisposing factors, and none of the remaining factors accounted for more than a tenth of the patients studied. The annual incidence and mortality rates of patients with primary acute pancreatitis within the defined popu-
TABLE I-ASSOCIATED AETIOLOGICAt. FACTORS IN PRIMARY ACUTF PANCREATITIS IN THE ’IO’1 AI AND THE NOTTINGHAM DEFINED POPULATION
AREA, 1969-74
968
Nottingham and cannot yet be explained. figures and the degree of variation are to those recorded by Trapnell and Duncomparable cant in the Bristol clinical area for 1961-67. Their peak incidence was 79.1per million in 1962 and the lowest incidence was 32.5per million in 1966. Trapnell and Duncan’s’O highest year is 2.4 times the incidence on the lowest year, while in Nottingham the highest year is 4 times the incidence in the lowest year. Any detailed comparison between these incidence figures is difficult since they represent 1961-67 in Bristol and 1969-74 in Nottingham and thus are discontinuous and drawn from different geographical areas. However the mean inci-
cal services in The absolute
lation area are given in table n for the period 1969-74. The incidence varied by fourfold throughout the six years of the survey but there was no detectable pattern behind this variation and consideration of the individual figures did not suggest that any particular predisposing factor accounted for the variation. DISCUSSION
No difference could be detected between the total Nottingham series and the defined population area group with respect to mortality and associated aetiological factors. Primary acute pancreatitis has a mortality of approximately 25%, but recent studies reported a mortality of 10.8% or less.6The mortality was 17.8% in the total Nottingham series, approximately mid-way between these figures. The associated aetiological factors which were found in this study (table I) were similar to other recent U.K. series.89 Unclassified patients in this study were typically of advanced age or poor physical condition, and the clinician in charge of the patient often did not investigate vigorously. If classification of these patients were possible many might have been added to the gallstone group. Alcohol as an aetiological factor was recorded in only 7% of patients: this contrasts with frequencies of 0% in Leeds in 1959,3 4-4% from Bristol for the period 1950-69,10 12.2% from Glasgow for 1960-70,8 and 23% for Edinburgh" for 1961-70. These retrospective studies may be criticised as recording too low a frequency of alcohol as an associated setiological factor since full and adequate prospective alcohol histories were not taken.8 In a prospective study for 1971-74 in Glasgow, Imrie and his coworkers9 found 23% of patients with alcoholassociated primary acute pancreatitis. It is likely that alcohol-associated primary acute pancreatitis may become more prevalent in the U.K. because the consumption of alcohol is rising. With time the U.K. associated stiological factors in primary acute pancreatitis may change from gallstones in about 50% of patients to become similar to continental European and North American acute pancreatitis with about 30% being alcohol-associated disease.12 It is most unlikely that patients from the local Nottingham area with an acute abdominal complaint would be admitted to neighbouring hospital medical centres such as Derby, Mansfield, Leicester, or Grantham which are at least fourteen miles away. Thus, all patients with primary acute pancreatitis from within the Nottingham defined population area should have been included in this survey. The fluctuation in the incidence of primary acute pancreatitis does not parallel the development of medi-
dence of 53.8 per million for Bristol for 1961-67 is of a similar order to the mean incidence of 47.5 per million for the Nottingham defined population area for 1969-74. Incidence figures for acute pancreatitis (acute pancreatitis and recurrent acute pancreatitis) ranged from 100 to 115 per million population for the period 1940-69 for Rochester, Minnesota.13 The much higher rates recorded in North America may reflect different diagnostic criteria or the importance of different xtiological factors such as alcohol. 12 1974 may have been a year with proportionately more acute pancreatitis in the United Kimgdom. Imrie and Blumgart 14 were impressed by the apparent increased number of patients in their practice in 1974 with primary acute pancreatitis and estimated their incidence as 100 per million population in Glasgow. The Nottingham defined population area incidence in 1974 was 83.0per million which was the highest for the six years studied. Comparison of similar annual incidence figures for Nottingham with data from Bristol and Glasgow might produce an early answer to the problem of the variation m annual incidence being due to normal fluctuation about a mean or to real difference. A spatial variation analysis" is being undertaken to see if various. population and environmental subgroups can be identified. It may be that this will provide further information about the xtiology of primary acute pancreatitis. Our current concept of associated xtiologica) factors such as gallstones and alcohol has helped in preventing subsequent attacks but we are still largely ignorant of what initiates the first attack. Death-rates vary from year to year and were as high as 19.1 per million in 1972 and as low as 2.1 per million in 1971 within the Nottingham area (table n). Trapnell and Duncan 10 in the Bristol area recorded a range of 5.7 to 11-7per million population. The mean mortality-rate was 9.0 per million in the Bristol area for the years 1961-67 and 9.2 per million in the Nottingham area during the period 1969-74. The Registrar General’s Statistical Review of England and Wales16 gives a mean yearly death-rate of 11.4 per million population for acute pancreatitis (LC.D. 577-0). Although, both Bristol and Nottingham have lower death-rates than the national average the difference is not statistically significant and may be accounted for by I.C.D. 577.0 containing all deaths from acute pancreatitis while the Nottingham and Bristol’" studies only refer to primary acute pancreatitis which is butcomponent part of I.C.D. 577.0. I thank the physicians and surgeons who have allowed me to study their patients; the medical-records departments of the Nomnpham hospitals for their cooperation; and Dr D. S. Miller, Mrs A C. Keigh-
969 J. S. Langman for allowing me to use their data for the Nottingham defined population area.
DESIGN
lev, and Prof. M.
REFERENCES
1. Trapnell, J. E. Clins Gastroent. 1972, 1, 147. 2. Miller, D. S., Keighley, A. C., Langman, M. J. S. Lancet, 1974, ii, 691. 3. Pollock, A. V. Br. med. J. 1959, i, 6 4. Efron, G. Br. J. Surg. 1966, 53, 702. 5. Trapnell, J. E. Ann. R. Coll. Surg. 1966, 38, 265. 6. Condon, J. R., Knight, M., Day, J. L. Br. J. Surg. 1973, 60, 509. 7 Trapnell, J. E., Rigby, C. C., Talbot, C. H., Duncan, E. H. L. ibid. 1974, 61, 177. 8. Imrie, C. W. ibid. 1974, 61, 539. 9. Imrie, C. W., Frew, E. M. S., Lloyd
Jones, W., Blumgart, L. H. Gut, 1975, 16, 406. 10. Trapnell, J. E., Duncan, E. H. L. Br. med. J. 1975, ii, 179. 11. Gillespie, W. J. Br. J. Surg. 1973, 60, 63. 12 White, T. T. Pancreatitis. London, 1966. 13. O’Sullivan, J. N., Nobrega, F. T., Morlock, C. G., Brown, A. L. Jr., Bartholomew, L. G. Gastroenterology, 1972, 62, 373. 14. Imrie, C. W., Blumgart, L. H. Br. med. J. 1974, iii, 626. 15. Bourke, J. B., Ebdon, D. S., Giggs, J. A. Unpublished. 16. Registrar General’s Statistical Review of England and Wales for the year 1969: part 1, medical tables. H.M. Stationery Office. 1971.
Public Health MASS SCREENING FOR HYPERTENSION IN COPENHAGEN SUPERMARKETS A. TYBIAERG HANSEN
PETER SCHNOHR Medical Department B,
Rigshospitalet, DK-2100 Copenhagen, Denmark
its "heart week" in February, the Danish Heart Foundation 1975, drew the attention of the public to the problem of heartdisease with special reference to high blood-pressure; and 24 377 people attending supermarkets in Copenhagen took advantage of an offer to have their bloodpressure checked. There was a small charge for measurement, but the supermarket owners usually paid the fee on behalf of their customers. This unconventional approach to blood-pressure screening proved to be
During
Summary
cheap, straightforward, and acceptable to the public. 23% of people measured were referred to their general practitioners for further evaluation. INTRODUCTION
HYPERTENSION is
condition which is often inadequately treated. The major
a common
undetected, untreated, problems in controlling high blood-pressure are getting the symptom-free as well as the symptomatic hypertenor
sives to their doctors and
motivating them to lifelong follow-up and, probably, lifelong treatment. To meet this challenge more information should be given to the public. During one week in February, 1975, the Danish Heart Foundation organised a campaign, the main purpose of which was to inform the public about the importance of regular blood-pressure measurements as a health check and in the prevention of disease. Other purposes of the campaign were to increase the doctors’ interest in the follow-up and treatment of hypertension and to investigate the possibility of measuring bloodpressure in large numbers of people in an easy, quick, and inexpensive way which would be accepted by people accustomed
Each year the Danish Heart Foundation holds a "heart week" with the main purpose of informing the public about what is known about the prevention (or, more correctly perhaps, postponement) of ischaemic heart-disease. The theme this year was arterial blood-pressure. 300 000 copies of an easy-toread pamphlet with illustrations were printed and distributed, mainly through supermarkets, schools, doctors, and members of the Foundation. Besides using posters and advertisements, the Foundation organised blood-pressure measurements in several cities in Denmark. In Copenhagen thirteen supermarkets were contacted all of which showed great interest in helping with this information and screening programme. The largest supermarket had approximately 125 000 customers a week, the smallest 10 000 to 15 000. The Foundation decided that 2 D. kr. (1 D. kr.=8p=18 cents) should be paid by each person screened. For this they would also receive the bloodpressure pamphlet. In only two supermarkets did the customers in fact pay for themselves, because the other supermarket owners offered to make the contributions. The blood-pressures were measured mostly by medical students but also by nurses and laboratory technicians; altogether some 90 persons were involved. The blood-pressure was measured in either arm with the subject seated just after standing in a line for 2-10 min. The public was informed of this screening through newspapers some days before the "heart week". The blood-pressure measurements were performed on five consecutive workdays, on the first four from 3-30 to 5’30 P.M. and on the fifth from 4.00 to 8.00 P.M. Every person measured received, in addition to the blood-pressure pamphlet, a card with the blood-pressure values. If the systolic blood-pressure was more than or equal to the age+ 110 (and this sum exceeded 145) and/or the diastolic blood-pressure was 100 mm Hg or more for all ages, the person screened was advised to contact his or her general practitioner for further evaluation.
to
free medical
care.
SOME RESULTS AND REMARKS
public showed a great interest in this blood-pressure screening. Some of the supermarkets had almost twice as many customers during the screening hours compared with numbers in the same hours in other weeks. All in all 24 377 persons (13 747 women and 10 630 men) were checked. 6% were aged 19 or less; 26% were 20-39; 43% were 40-59; and 25% were 60 The
years of age
or more. The total percentage of women and men corresponded well to the total sex-distribution in Copenhagen, unlike the distribution of patients seen in general practice where women are over-represented. Several women mentioned that "they couldn’t drag their husbands to the physician", but that the men were willing to visit the supermarket and have their blood-pressure checked there. The sample measured under-represented Copenhagen residents below the age of 30 and above 70, and over-represented the other age-
groups. Each member of the screening team did 22 measurements an hour on the average, ranging from 18 to 30. The cost of this screening, including payments to the students ($7 an hour), transport, pamphlets, cards, and other materials was$12 000 or 49 cents per measurement. The income was$7700, so the cost to the Danish Heart Foundation was$4300 (about 18 cents per measurement, 11 cents of which was for the blood.-pressure pamphlet). The attendance-rate was approximately the same in the supermarkets where people themselves had to pay compared with the supermarkets where the measurements were free.
Occasional
Survey
VARIATION IN ANNUAL INCIDENCE OF PRIMARY ACUTE PANCREATITIS IN
NOTTINGHAM, 1969-74
admitted to one or other of th,.Ý’1wo major hospitals. Neighbouring district general hospitals-Mansfield (14 miles north), Derby (16 miles west), Leicester (25 miles south), and Grantham (24 miles east)-seem very unlikely, for geographical reasons, to admit patients from Nottingham, and a deliberate search for such referrals had shown that they were very rare for another abdominal disease.2 The case-reports of all patients in whom pancreatitis was
diagnosed
J. B. BOURKE University Department of Surgery, General Hospital, Nottingham NGI 6HA
were sought primarily by searching the inpatient diagnostic indexes for the period 1969-74. This was supplemented by referral to a personal diagnostic index and postmortem reports for the same period.
Diagnostic Criteria
patients admitted to Nottingham hospitals with primary acute pancreatitis during the six years 1969-74 has been undertaken. The City of Nottingham and the four adjacent former urban districts had a population of 469 720
Summary
A review of the 202
in 1971, and an attempt was made to obtain details of all patients from within this defined population area. 134 of the 202 patients came from this area. The annual incidence varied by 4-fold throughout the six years of the survey from a peak incidence of 83·0 per million population in 1974 to a low incidence of 21·2 per million in 1970. There was no detectable pattern behind this variation and consideration of the individual figures did not suggest that any particular predisposing factor accounted for the variation. Spatial variation analysis is now being undertaken to see if population and environmental subgroups can be identified. INTRODUCTION
PRIMARY acute pancreatitis is a disease which results in hospital admission, and by careful inquiry it should be possible to obtain details of all patients with this disease in a particular area. The present study was confined to patients in their first attack of primary acute pancreatitis, for mortality is greatest in the inital attack.’ An attempt was made to obtain details of all Nottingham patients and the results are reported below. Use has also been made of the Nottingham defined population area2 of the department of community health of the University of Nottingham so that accurate annual incidence and mortality data could be calculated. METHOD
Patients In Nottingham the hospital service is based upon two district hospitals with limited facilities in smaller hospitals, and consequently all patients with acute pancreatitis should be
All case-reports were reviewed, and the diagnosis of acute pancreatitis was only accepted with a compatible clinical history, physical examination, and a greater than fourfold increase in serum-amylase level. Laparotomy and/or necropsy evidence were also accepted. Only patients with primary acute pancreatitis (i.e., in their first attack of pancreatitis) are included. Those with recurrent, chronic, traumatic, or postoperative pancreatitis were
excluded. The presence of associated factors such as gallstones was recorded. Some patients were not further investigated after recovery from the acute attack because the clinician decided not to pursue associated factors because of the patient’s age and/or
general debility. Calculation
of Incidence The City of Nottingham and the four former urban districts of Arnold, Beeston and Stapleford, Carlton, and West Bridgford had a population of 469 720 in 1971. This area lies within an approximate radius of 5 miles around the centre of Nottingham. This population has remained constant during the period of the survey, and the population figures for 1971 have been used in calculating incidence data for individual years. ’
RESULTS
During 1969-74, 202 patients were accepted on review as having had primary acute pancreatitis. Of these 202 patients, 134 came from within the Nottingham defined population area. Of the total series 36 out of 202 died (17.8%) while 26 out of 134 from within the Nottingham defined population area died (19.4%). The associated aetiological factors for the total and defined population areas are given in table i. Approximately half the patients had gallstones, a third had no detectable predisposing factors, and none of the remaining factors accounted for more than a tenth of the patients studied. The annual incidence and mortality rates of patients with primary acute pancreatitis within the defined popu-
TABLE I-ASSOCIATED AETIOLOGICAt. FACTORS IN PRIMARY ACUTF PANCREATITIS IN THE ’IO’1 AI AND THE NOTTINGHAM DEFINED POPULATION
AREA, 1969-74
968
Nottingham and cannot yet be explained. figures and the degree of variation are to those recorded by Trapnell and Duncomparable cant in the Bristol clinical area for 1961-67. Their peak incidence was 79.1per million in 1962 and the lowest incidence was 32.5per million in 1966. Trapnell and Duncan’s’O highest year is 2.4 times the incidence on the lowest year, while in Nottingham the highest year is 4 times the incidence in the lowest year. Any detailed comparison between these incidence figures is difficult since they represent 1961-67 in Bristol and 1969-74 in Nottingham and thus are discontinuous and drawn from different geographical areas. However the mean inci-
cal services in The absolute
lation area are given in table n for the period 1969-74. The incidence varied by fourfold throughout the six years of the survey but there was no detectable pattern behind this variation and consideration of the individual figures did not suggest that any particular predisposing factor accounted for the variation. DISCUSSION
No difference could be detected between the total Nottingham series and the defined population area group with respect to mortality and associated aetiological factors. Primary acute pancreatitis has a mortality of approximately 25%, but recent studies reported a mortality of 10.8% or less.6The mortality was 17.8% in the total Nottingham series, approximately mid-way between these figures. The associated aetiological factors which were found in this study (table I) were similar to other recent U.K. series.89 Unclassified patients in this study were typically of advanced age or poor physical condition, and the clinician in charge of the patient often did not investigate vigorously. If classification of these patients were possible many might have been added to the gallstone group. Alcohol as an aetiological factor was recorded in only 7% of patients: this contrasts with frequencies of 0% in Leeds in 1959,3 4-4% from Bristol for the period 1950-69,10 12.2% from Glasgow for 1960-70,8 and 23% for Edinburgh" for 1961-70. These retrospective studies may be criticised as recording too low a frequency of alcohol as an associated setiological factor since full and adequate prospective alcohol histories were not taken.8 In a prospective study for 1971-74 in Glasgow, Imrie and his coworkers9 found 23% of patients with alcoholassociated primary acute pancreatitis. It is likely that alcohol-associated primary acute pancreatitis may become more prevalent in the U.K. because the consumption of alcohol is rising. With time the U.K. associated stiological factors in primary acute pancreatitis may change from gallstones in about 50% of patients to become similar to continental European and North American acute pancreatitis with about 30% being alcohol-associated disease.12 It is most unlikely that patients from the local Nottingham area with an acute abdominal complaint would be admitted to neighbouring hospital medical centres such as Derby, Mansfield, Leicester, or Grantham which are at least fourteen miles away. Thus, all patients with primary acute pancreatitis from within the Nottingham defined population area should have been included in this survey. The fluctuation in the incidence of primary acute pancreatitis does not parallel the development of medi-
dence of 53.8 per million for Bristol for 1961-67 is of a similar order to the mean incidence of 47.5 per million for the Nottingham defined population area for 1969-74. Incidence figures for acute pancreatitis (acute pancreatitis and recurrent acute pancreatitis) ranged from 100 to 115 per million population for the period 1940-69 for Rochester, Minnesota.13 The much higher rates recorded in North America may reflect different diagnostic criteria or the importance of different xtiological factors such as alcohol. 12 1974 may have been a year with proportionately more acute pancreatitis in the United Kimgdom. Imrie and Blumgart 14 were impressed by the apparent increased number of patients in their practice in 1974 with primary acute pancreatitis and estimated their incidence as 100 per million population in Glasgow. The Nottingham defined population area incidence in 1974 was 83.0per million which was the highest for the six years studied. Comparison of similar annual incidence figures for Nottingham with data from Bristol and Glasgow might produce an early answer to the problem of the variation m annual incidence being due to normal fluctuation about a mean or to real difference. A spatial variation analysis" is being undertaken to see if various. population and environmental subgroups can be identified. It may be that this will provide further information about the xtiology of primary acute pancreatitis. Our current concept of associated xtiologica) factors such as gallstones and alcohol has helped in preventing subsequent attacks but we are still largely ignorant of what initiates the first attack. Death-rates vary from year to year and were as high as 19.1 per million in 1972 and as low as 2.1 per million in 1971 within the Nottingham area (table n). Trapnell and Duncan 10 in the Bristol area recorded a range of 5.7 to 11-7per million population. The mean mortality-rate was 9.0 per million in the Bristol area for the years 1961-67 and 9.2 per million in the Nottingham area during the period 1969-74. The Registrar General’s Statistical Review of England and Wales16 gives a mean yearly death-rate of 11.4 per million population for acute pancreatitis (LC.D. 577-0). Although, both Bristol and Nottingham have lower death-rates than the national average the difference is not statistically significant and may be accounted for by I.C.D. 577.0 containing all deaths from acute pancreatitis while the Nottingham and Bristol’" studies only refer to primary acute pancreatitis which is butcomponent part of I.C.D. 577.0. I thank the physicians and surgeons who have allowed me to study their patients; the medical-records departments of the Nomnpham hospitals for their cooperation; and Dr D. S. Miller, Mrs A C. Keigh-
969 J. S. Langman for allowing me to use their data for the Nottingham defined population area.
DESIGN
lev, and Prof. M.
REFERENCES
1. Trapnell, J. E. Clins Gastroent. 1972, 1, 147. 2. Miller, D. S., Keighley, A. C., Langman, M. J. S. Lancet, 1974, ii, 691. 3. Pollock, A. V. Br. med. J. 1959, i, 6 4. Efron, G. Br. J. Surg. 1966, 53, 702. 5. Trapnell, J. E. Ann. R. Coll. Surg. 1966, 38, 265. 6. Condon, J. R., Knight, M., Day, J. L. Br. J. Surg. 1973, 60, 509. 7 Trapnell, J. E., Rigby, C. C., Talbot, C. H., Duncan, E. H. L. ibid. 1974, 61, 177. 8. Imrie, C. W. ibid. 1974, 61, 539. 9. Imrie, C. W., Frew, E. M. S., Lloyd
Jones, W., Blumgart, L. H. Gut, 1975, 16, 406. 10. Trapnell, J. E., Duncan, E. H. L. Br. med. J. 1975, ii, 179. 11. Gillespie, W. J. Br. J. Surg. 1973, 60, 63. 12 White, T. T. Pancreatitis. London, 1966. 13. O’Sullivan, J. N., Nobrega, F. T., Morlock, C. G., Brown, A. L. Jr., Bartholomew, L. G. Gastroenterology, 1972, 62, 373. 14. Imrie, C. W., Blumgart, L. H. Br. med. J. 1974, iii, 626. 15. Bourke, J. B., Ebdon, D. S., Giggs, J. A. Unpublished. 16. Registrar General’s Statistical Review of England and Wales for the year 1969: part 1, medical tables. H.M. Stationery Office. 1971.
Public Health MASS SCREENING FOR HYPERTENSION IN COPENHAGEN SUPERMARKETS A. TYBIAERG HANSEN
PETER SCHNOHR Medical Department B,
Rigshospitalet, DK-2100 Copenhagen, Denmark
its "heart week" in February, the Danish Heart Foundation 1975, drew the attention of the public to the problem of heartdisease with special reference to high blood-pressure; and 24 377 people attending supermarkets in Copenhagen took advantage of an offer to have their bloodpressure checked. There was a small charge for measurement, but the supermarket owners usually paid the fee on behalf of their customers. This unconventional approach to blood-pressure screening proved to be
During
Summary
cheap, straightforward, and acceptable to the public. 23% of people measured were referred to their general practitioners for further evaluation. INTRODUCTION
HYPERTENSION is
condition which is often inadequately treated. The major
a common
undetected, untreated, problems in controlling high blood-pressure are getting the symptom-free as well as the symptomatic hypertenor
sives to their doctors and
motivating them to lifelong follow-up and, probably, lifelong treatment. To meet this challenge more information should be given to the public. During one week in February, 1975, the Danish Heart Foundation organised a campaign, the main purpose of which was to inform the public about the importance of regular blood-pressure measurements as a health check and in the prevention of disease. Other purposes of the campaign were to increase the doctors’ interest in the follow-up and treatment of hypertension and to investigate the possibility of measuring bloodpressure in large numbers of people in an easy, quick, and inexpensive way which would be accepted by people accustomed
Each year the Danish Heart Foundation holds a "heart week" with the main purpose of informing the public about what is known about the prevention (or, more correctly perhaps, postponement) of ischaemic heart-disease. The theme this year was arterial blood-pressure. 300 000 copies of an easy-toread pamphlet with illustrations were printed and distributed, mainly through supermarkets, schools, doctors, and members of the Foundation. Besides using posters and advertisements, the Foundation organised blood-pressure measurements in several cities in Denmark. In Copenhagen thirteen supermarkets were contacted all of which showed great interest in helping with this information and screening programme. The largest supermarket had approximately 125 000 customers a week, the smallest 10 000 to 15 000. The Foundation decided that 2 D. kr. (1 D. kr.=8p=18 cents) should be paid by each person screened. For this they would also receive the bloodpressure pamphlet. In only two supermarkets did the customers in fact pay for themselves, because the other supermarket owners offered to make the contributions. The blood-pressures were measured mostly by medical students but also by nurses and laboratory technicians; altogether some 90 persons were involved. The blood-pressure was measured in either arm with the subject seated just after standing in a line for 2-10 min. The public was informed of this screening through newspapers some days before the "heart week". The blood-pressure measurements were performed on five consecutive workdays, on the first four from 3-30 to 5’30 P.M. and on the fifth from 4.00 to 8.00 P.M. Every person measured received, in addition to the blood-pressure pamphlet, a card with the blood-pressure values. If the systolic blood-pressure was more than or equal to the age+ 110 (and this sum exceeded 145) and/or the diastolic blood-pressure was 100 mm Hg or more for all ages, the person screened was advised to contact his or her general practitioner for further evaluation.
to
free medical
care.
SOME RESULTS AND REMARKS
public showed a great interest in this blood-pressure screening. Some of the supermarkets had almost twice as many customers during the screening hours compared with numbers in the same hours in other weeks. All in all 24 377 persons (13 747 women and 10 630 men) were checked. 6% were aged 19 or less; 26% were 20-39; 43% were 40-59; and 25% were 60 The
years of age
or more. The total percentage of women and men corresponded well to the total sex-distribution in Copenhagen, unlike the distribution of patients seen in general practice where women are over-represented. Several women mentioned that "they couldn’t drag their husbands to the physician", but that the men were willing to visit the supermarket and have their blood-pressure checked there. The sample measured under-represented Copenhagen residents below the age of 30 and above 70, and over-represented the other age-
groups. Each member of the screening team did 22 measurements an hour on the average, ranging from 18 to 30. The cost of this screening, including payments to the students ($7 an hour), transport, pamphlets, cards, and other materials was$12 000 or 49 cents per measurement. The income was$7700, so the cost to the Danish Heart Foundation was$4300 (about 18 cents per measurement, 11 cents of which was for the blood.-pressure pamphlet). The attendance-rate was approximately the same in the supermarkets where people themselves had to pay compared with the supermarkets where the measurements were free.
