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Andre, Malin
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Publications (10 of 13) Show all publications
Hammarberg, S. a., Hange, D., Andre, M., Udo, C., Svenningsson, I., Bjorkelund, C., . . . Westman, J. (2019). Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences. Scandinavian Journal of Primary Health Care, 37(3), 273-282
Open this publication in new window or tab >>Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences
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2019 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 37, no 3, p. 273-282Article in journal (Refereed) Published
Abstract [en]

Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Vastra Gotaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2019
Keywords
Primary care, family medicine, nursing interventions, coordinated care, psychiatry, patient care continuity, collaborative care
National Category
Health Care Service and Management, Health Policy and Services and Health Economy General Practice
Identifiers
urn:nbn:se:uu:diva-393834 (URN)10.1080/02813432.2019.1639897 (DOI)000482039500002 ()31286807 (PubMedID)
Available from: 2019-09-27 Created: 2019-09-27 Last updated: 2019-09-27Bibliographically approved
Björkelund, C., Svenningsson, I., Hange, D., Udo, C., Petersson, E.-L., Ariai, N., . . . Westman, J. (2018). Clinical effectiveness of care managers in collaborative care for patients with depression in Swedish primary health care: a pragmatic cluster randomized controlled trial. BMC Family Practice, 19, Article ID 28.
Open this publication in new window or tab >>Clinical effectiveness of care managers in collaborative care for patients with depression in Swedish primary health care: a pragmatic cluster randomized controlled trial
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2018 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 19, article id 28Article in journal (Refereed) Published
Abstract [en]

Background: Depression is one of the leading causes of disability and affects 10-15% of the population. The majority of people with depressive symptoms seek care and are treated in primary care. Evidence internationally for high quality care supports collaborative care with a care manager. Our aim was to study clinical effectiveness of a care manager intervention in management of primary care patients with depression in Sweden.

Methods: In a pragmatic cluster randomized controlled trial 23 primary care centers (PCCs), urban and rural, included patients aged >= 18 years with a new (< 1 month) depression diagnosis. Intervention consisted of Care management including continuous contact between care manager and patient, a structured management plan, and behavioral activation, altogether around 6-7 contacts over 12 weeks. Control condition was care as usual (CAU). Outcome measures: Depression symptoms (measured by Mongomery-Asberg depression score-self (MADRS-S) and BDI-II), quality of life (QoL) (EQ-5D), return to work and sick leave, service satisfaction, and antidepressant medication. Data were analyzed with the intention-to-treat principle.

Results: One hundred ninety two patients with depression at PCCs with care managers were allocated to the intervention group, and 184 patients at control PCCs were allocated to the control group. Mean depression score measured by MADRS-S was 2.17 lower in the intervention vs. the control group (95% CI [0.56; 3.79], p = 0.009) at 3 months and 2.27 lower (95% CI [0.59; 3.95], p = 0.008) at 6 months; corresponding BDI-II scores were 1.96 lower (95% CI [-0.19; 4.11], p = 0.07) in the intervention vs. control group at 6 months. Remission was significantly higher in the intervention group at 6 months (61% vs. 47%, p = 0.006). QoL showed a steeper increase in the intervention group at 3 months (p = 0.01). During the first 3 months, return to work was significantly higher in the intervention vs. the control group. Patients in the intervention group were more consistently on antidepressant medication than patients in the control group.

Conclusions: Care managers for depression treatment have positive effects on depression course, return to work, remission frequency, antidepressant frequency, and quality of life compared to usual care and is valued by the patients.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2018
Keywords
Depression, Primary care, Care manager, Collaborative care, Sick-leave, Quality-of-life
National Category
General Practice
Identifiers
urn:nbn:se:uu:diva-348117 (URN)10.1186/s12875-018-0711-z (DOI)000425172300001 ()29426288 (PubMedID)
Funder
Region Västra Götaland
Available from: 2018-04-11 Created: 2018-04-11 Last updated: 2018-04-11Bibliographically approved
Holst, A., Ginter, A., Bjorkelund, C., Hange, D., Petersson, E.-L., Svenningsson, I., . . . Svensson, M. (2018). Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: economic evaluation of a pragmatic randomised controlled study. BMJ Open, 8(11), Article ID e024741.
Open this publication in new window or tab >>Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: economic evaluation of a pragmatic randomised controlled study
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2018 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 11, article id e024741Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate the cost-effectiveness of a care manager (CM) programme compared with care as usual (CAU) for treatment of depression at primary care centres (PCCs) from a healthcare as well as societal perspective.

Design: Cost-effectiveness analysis.

Setting: 23 PCCs in two Swedish regions.

Participants: Patients with depression (n=342).

Main outcome measures: A cost-effectiveness analysis was applied on a cluster randomised trial at PCC level where patients with depression had 3 months of contact with a CM (11 intervention PCCs, n=163) or CAU (12 control PCCs, n=179), with follow-up 3 and 6 months. Effectiveness measures were based on the number of depression-free days (DFDs) calculated from the Montgomery-angstrom sberg Depression Rating Scale-Self and quality-adjusted life years (QALYs).

Results were expressed as the incremental cost-effectiveness ratio: Cost/QALY and Cost/DFD. Sampling uncertainty was assessed based on non-parametric bootstrapping.

Results: Health benefits were higher in intervention group compared with CAU group: QALYs (0.357 vs 0.333, p<0.001) and DFD reduction of depressive symptom score (79.43 vs 60.14, p<0.001). The mean costs per patient for the 6-month period were Euro368 (healthcare perspective) and Euro6217 (societal perspective) for the intervention patients and Euro246 (healthcare perspective) and Euro7371 (societal perspective) for the control patients (n.s.). The cost per QALY gained was Euro6773 (healthcare perspective) and from a societal perspective the CM programme was dominant.

Discussion: The CM programme was associated with a gain in QALYs as well as in DFD, while also being cost saving compared with CAU from a societal perspective. This result is of high relevance for decision-makers on a national level, but it must be observed that a CM programme for depression implies increased costs at the primary care level.

Keywords
depression, primary care, care manager, collaborative care, health economic analysis, intervention
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-374130 (URN)10.1136/bmjopen-2018-024741 (DOI)000454740400145 ()30420353 (PubMedID)
Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-01-18Bibliographically approved
Wikberg, C., Westman, J., Petersson, E.-L., Larsson, M. E., André, M., Eggertsen, R., . . . Bjorkelund, C. (2017). Use of a self-rating scale to monitor depression severity in recurrent GP consultations in primary care - does it really make a difference?: A randomised controlled study. BMC Family Practice, 18, Article ID 6.
Open this publication in new window or tab >>Use of a self-rating scale to monitor depression severity in recurrent GP consultations in primary care - does it really make a difference?: A randomised controlled study
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2017 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 18, article id 6Article in journal (Refereed) Published
Abstract [en]

Background: Little information is available about whether the use of self-assessment instruments in primary care affects depression course and outcome. The purpose was to evaluate whether using a depression self-rating scale in recurrent person-centred GP consultations affected depression severity, quality of life, medication use, and sick leave frequency. Methods: Patients in the intervention group met their GP regularly at least 4 times during the 3 months intervention. In addition to treatment as usual (TAU), patients completed a self-assessment instrument (Montgomery-Asberg Depression Rating Scale) on each occasion, and then GPs used the completed instrument as the basis for a person-centred discussion of changes in depression symptoms. The control group received TAU. Frequency of visits in the TAU arm was the result of the GPs' and patients' joint assessments of care need in each case. Depression severity was measured with Beck Depression Inventory-II (BDI-II), quality of life with EQ-5D, and psychological well-being with the General Health Questionnaire-12 (GHQ-12). Data on sick leave, antidepressant and sedatives use, and care contacts were collected from electronic patient records. All variables were measured at baseline and 3, 6, and 12 months. Mean intra-individual changes were compared between the intervention and TAU group. Results: There were no significant differences between the intervention and control group in depression severity reduction or remission rate, change in quality of life, psychological well-being, sedative prescriptions, or sick leave during the whole 12-month follow-up. However, significantly more patients in the intervention group continued antidepressants until the 6 month follow-up (86/125 vs 78/133, p < 0.05). Conclusions: When GPs used a depression self-rating scale in recurrent consultations, patients more often continued antidepressant medication according to guidelines, compared to TAU patients. However, reduction of depressive symptoms, remission rate, quality of life, psychological well-being, sedative use, sick leave, and health care use 4-12 months was not significantly different from the TAU group. These findings suggest that frequent use of depression rating scales in person-centred primary care consultations has no further additional effect on patients' depression or well-being, sick leave, or health care use.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2017
Keywords
Depression, Primary care, Self-assessment instrument, Adherence, Sick-leave, Quality-of-life
National Category
General Practice
Identifiers
urn:nbn:se:uu:diva-319658 (URN)10.1186/s12875-016-0578-9 (DOI)000397340300001 ()28103816 (PubMedID)
Available from: 2017-04-07 Created: 2017-04-07 Last updated: 2018-01-13Bibliographically approved
Strandberg, E. L., Brorsson, A., André, M., Gröndal, H., Molstad, S. & Hedin, K. (2016). Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden. BMC Family Practice, 17, Article ID 78.
Open this publication in new window or tab >>Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden
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2016 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, article id 78Article in journal (Refereed) Published
Abstract [en]

Background: Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care. Methods: Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners' audit registrations. Qualitative data were collected through observations and semi-structured interviews. Results: From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner's diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual. Conclusions: Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses' triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

Keywords
Mixed methods design, Antibiotic prescribing, Guidelines, Implementation, Primary care
National Category
General Practice
Identifiers
urn:nbn:se:uu:diva-300448 (URN)10.1186/s12875-016-0494-z (DOI)000379800700003 ()27430895 (PubMedID)
Funder
Public Health Agency of Sweden
Available from: 2016-08-09 Created: 2016-08-09 Last updated: 2018-01-10Bibliographically approved
Andre, M., Gröndal, H., Strandberg, E.-L., Brorsson, A. & Hedin, K. (2016). Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat. BMC Family Practice, 17, Article ID 56.
Open this publication in new window or tab >>Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat
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2016 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, article id 56Article in journal (Refereed) Published
Abstract [en]

Background: Uncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines.

Methods: An interview study was conducted among a strategic sample of 25 general practitioners (GPs).

Results: All GPs mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, "Adherence to guidelines", and three were idiosyncratic: "Clinical picture and C-reactive protein (CRP)", "Expanded control", and "Unstructured". The residual uncertainty differed for the different strategies: in the strategy "Adherence to guidelines" and " Clinical picture and CRP" uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy " Expanded control" uncertainty was balanced based on expanded control; and in the strategy "Unstructured" uncertainty prevailed in spite of redundant examination and anamnesis.

Conclusion: The majority of the GPs avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPs did not manage to cope with uncertainty or had to put in excessive work to control uncertainty.

Keywords
Uncertainty, General practitioners, Sore throat, Guideline, C-reactive protein, Qualitative research
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-298088 (URN)10.1186/s12875-016-0452-9 (DOI)000375989200001 ()27188438 (PubMedID)
Available from: 2016-06-29 Created: 2016-06-29 Last updated: 2017-11-28Bibliographically approved
Gröndal, H., Hedin, K., Strandberg, E. L., André, M. & Brorsson, A. (2015). Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study. BMC Family Practice, 16, Article ID 81.
Open this publication in new window or tab >>Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study
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2015 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 16, article id 81Article in journal (Refereed) Published
Abstract [en]

Background: Excessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2-4 Centor criteria present and antibiotics were recommended if the test was positive. C-reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies. Methods: From a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used. Results: The use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection. Conclusions: Inappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.

Keywords
Near-patient tests, Sore throat, Guidelines, Decision-making, Qualitative interview study
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-259091 (URN)10.1186/s12875-015-0285-y (DOI)000357305200001 ()26141740 (PubMedID)
Available from: 2015-07-28 Created: 2015-07-27 Last updated: 2017-12-04Bibliographically approved
Billstedt, E., Skoog, I., Duberstein, P., Marlow, T., Hallstrom, T., André, M., . . . Waern, M. (2014). A 37-year prospective study of neuroticism and extraversion in women followed from mid-life to late life. Acta Psychiatrica Scandinavica, 129(1), 35-43
Open this publication in new window or tab >>A 37-year prospective study of neuroticism and extraversion in women followed from mid-life to late life
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2014 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 129, no 1, p. 35-43Article in journal (Refereed) Published
Abstract [en]

Objective: Personality traits are presumed to endure over time, but the literature regarding older age is sparse. Furthermore, interpretation may be hampered by the presence of dementia-related personality changes. The aim was to study stability in neuroticism and extraversion in a population sample of women who were followed from mid-life to late life.

Method: A population-based sample of women born in 1918, 1922 or 1930 was examined with the Eysenck Personality Inventory (EPI) in 1968-1969. EPI was assessed after 37years in 2005-2006 (n=153). Data from an interim examination after 24years were analysed for the subsample born in 1918 and 1922 (n=75). Women who developed dementia at follow-up examinations were excluded from the analyses.

Results: Mean levels of neuroticism and extraversion were stable at both follow-ups. Rank-order and linear correlations between baseline and 37-year follow-up were moderate ranging between 0.49 and 0.69. Individual changes were observed, and only 25% of the variance in personality traits in 2005-2006 could be explained by traits in 1968-1969.

Conclusion: Personality is stable at the population level, but there is significant individual variability. These changes could not be attributed to dementia. Research is needed to examine determinants of these changes, as well as their clinical implications.

Keywords
neuroticism, extraversion, eysenck personality inventory, longitudinal, old-age
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-216043 (URN)10.1111/acps.12093 (DOI)000328209400005 ()
Available from: 2014-01-20 Created: 2014-01-17 Last updated: 2017-12-06Bibliographically approved
Hedin, K., Strandberg, E. L., Gröndal, H., Brorsson, A., Thulesius, H. & André, M. (2014). Management of patients with sore throats in relation to guidelines: An interview study in Sweden. Scandinavian Journal of Primary Health Care, 32(4), 193-199
Open this publication in new window or tab >>Management of patients with sore throats in relation to guidelines: An interview study in Sweden
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2014 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 32, no 4, p. 193-199Article in journal (Refereed) Published
Abstract [en]

Objective. To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews. Design. Qualitative content analysis was used to analyse semi-structured interviews. Setting. Swedish primary care. Subjects. A strategic sample of 25 GPs. Main outcome measures. Perceived management of sore throat patients. Results. It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs. Conclusion. This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.

Keywords
General practice, general practitioners, guidelines, qualitative research, sore throat, Sweden
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-241429 (URN)10.3109/02813432.2014.972046 (DOI)000346108700008 ()25363143 (PubMedID)
Available from: 2015-01-16 Created: 2015-01-12 Last updated: 2017-12-05Bibliographically approved
Hedin, K., André, M., Brorsson, A., Gröndal, H., Soares, J., Strandberg, E. & Mölstad, S. (2014). Studie över faktorer som påverkar läkares beteende vid förskrivning av antibiotika. Lunds universitet
Open this publication in new window or tab >>Studie över faktorer som påverkar läkares beteende vid förskrivning av antibiotika
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2014 (Swedish)Report (Other academic)
Place, publisher, year, edition, pages
Lunds universitet: , 2014
Series
Rapport till Folkhälsomyndigheten
National Category
General Practice
Identifiers
urn:nbn:se:uu:diva-245071 (URN)
Available from: 2015-02-24 Created: 2015-02-24 Last updated: 2018-01-11
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