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  • 1.
    Andre, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Anden, Annika
    Borgquist, Lars
    Rudebeck, Carl Edvard
    GPs' decision-making: perceiving the patient as a person or a disease2012In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, p. 38-Article in journal (Refereed)
    Abstract [en]

    Background: The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work.

    Methods: A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients.

    Results: 68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person.

    Conclusions: The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.

  • 2.
    Andre, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Linkoping Univ, Dept Med & Hlth Sci, Family Med, Linkoping, Sweden.
    Gröndal, Hedvig
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Sociology.
    Strandberg, Eva-Lena
    Lund Univ, Dept Clin Sci, Family Med, Malmo, Sweden.;Blekinge Cty Council, Blekinge Ctr Competence, Karlskrona, Sweden..
    Brorsson, Annika
    Lund Univ, Dept Clin Sci, Family Med, Malmo, Sweden.;Skane Reg, Ctr Primary Hlth Care Res, Malmo, Sweden..
    Hedin, Katarina
    Lund Univ, Dept Clin Sci, Family Med, Malmo, Sweden.;Kronoberg Cty Council, Dept Res & Dev, Vaxjo, Sweden..
    Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat2016In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, article id 56Article in journal (Refereed)
    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.

  • 3.
    André, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Löfvander, Monica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    A study of primary care physicians rating their immigrant patients' pain intensity2013In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 17, no 1, p. 132-139Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Few studies focus on how physicians evaluate pain in foreign-born patients with varying cultural backgrounds. This study aimed to compare pain ratings [visual analogue scale (VAS) 0-100] done by Swedish primary care physicians and their patients, and to analyse which factors predicted physicians' higher ratings of pain in patients aged 18-45 years with long-standing disabling back pain.

    METHODS:

    The two physicians jointly carried out the somatic and psychiatric diagnostic evaluations and alternated as consulting doctor or observer. One-third of the consultations were interpreted. Towards the end of the consultations, the patients rated their pain intensity 'right now' (patients' VAS). After the patient had left, the two physicians independently rated how much pain they thought the patient had, without looking at the patient's VAS score. The mean of the two doctors' VAS values (physicians' VAS) for each patient was used in the logistic regression calculations of odds ratios (OR) in main effect models for physicians' VAS above median (md) with patient's sex, education, origin, depression, psychosocial stress and pain sites as explanatory variables.

    RESULTS:

    Physicians' VAS values were significantly lower (md 15) than patients' VAS (md 66; women md 73, men md 52). The ratings showed no significant association with whether the physician was acting as consultant or observer. The higher physician VAS was only predicted by findings of multiple pain sites.

    CONCLUSIONS:

    Physicians appear to overlook psychological and emotional aspects when rating the pain of patients from other cultural backgrounds. This finding highlights a potential problem in multicultural care settings.

  • 4. Arvidsson, Eva
    et al.
    André, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Borgquist, Lars
    Andersson, David
    Carlsson, Per
    Setting priorities in primary health care - on whose conditions?: A questionnaire study2012In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, p. 114-Article in journal (Refereed)
    Abstract [en]

    Background: In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. Methods: Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. Results: Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. Conclusions: The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.

  • 5. Billstedt, E.
    et al.
    Skoog, I.
    Duberstein, P.
    Marlow, T.
    Hallstrom, T.
    André, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna.
    Lissner, L.
    Bjorkelund, C.
    Ostling, S.
    Waern, M.
    A 37-year prospective study of neuroticism and extraversion in women followed from mid-life to late life2014In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 129, no 1, p. 35-43Article in journal (Refereed)
    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.

  • 6.
    Björkelund, Cecilia
    et al.
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Gothenburg, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Box 454, S-40530 Gothenburg, Sweden..
    Svenningsson, Irene
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Gothenburg, Sweden..
    Hange, Dominique
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Gothenburg, Sweden..
    Udo, Camilla
    Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden..
    Petersson, Eva-Lisa
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Gothenburg, Sweden.;Narhalsan Res & Dev Primary Hlth Care, Reg Vastra Gotaland, Gothenburg, Sweden..
    Ariai, Nashmil
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Gothenburg, Sweden..
    Nejati, Shabnam
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Gothenburg, Sweden..
    Wessman, Catrin
    Univ Gothenburg, Sahlgrenska Acad, Hlth Metr Unit, Gothenburg, Sweden..
    Wikberg, Carl
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care, Gothenburg, Sweden..
    André, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Wallin, Lars
    Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Dept Hlth & Care Sci, Gothenburg, Sweden.;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Nursing, Stockholm, Sweden..
    Westman, Jeanette
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Family Med, Stockholm, Sweden..
    Clinical effectiveness of care managers in collaborative care for patients with depression in Swedish primary health care: a pragmatic cluster randomized controlled trial2018In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 19, article id 28Article in journal (Refereed)
    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.

  • 7.
    Gröndal, Hedvig
    et al.
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Sociology.
    Hedin, Katarina
    Strandberg, Eva Lena
    André, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Brorsson, Annika
    Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study2015In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 16, article id 81Article in journal (Refereed)
    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.

  • 8.
    Hammarberg, Sandra af Winklerfelt
    et al.
    Karolinska Inst, Div Family Med & Primary Care, Dept Neurobiol Care Sci & Soc, Alfred Nobels Alle 23, S-14152 Stockholm, Sweden;Stockholm Cty Council, Acad Primary Hlth Care Ctr, Stockholm, Sweden.
    Hange, Dominique
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Primary Hlth Care,Dept Publ Hlth & Community Med, Gothenburg, Sweden.
    Andre, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Udo, Camilla
    Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden;Ctr Clin Res Dalarna, CKF, Falun, Sweden.
    Svenningsson, Irene
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Primary Hlth Care,Dept Publ Hlth & Community Med, Gothenburg, Sweden;Narhalsan Res & Dev Primary Hlth Care, Gothenburg, Sweden.
    Bjorkelund, Cecilia
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Primary Hlth Care,Dept Publ Hlth & Community Med, Gothenburg, Sweden.
    Petersson, Eva-Lisa
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Primary Hlth Care,Dept Publ Hlth & Community Med, Gothenburg, Sweden;Narhalsan Res & Dev Primary Hlth Care, Gothenburg, Sweden.
    Westman, Jeanette
    Karolinska Inst, Div Family Med & Primary Care, Dept Neurobiol Care Sci & Soc, Alfred Nobels Alle 23, S-14152 Stockholm, Sweden;Stockholm Cty Council, Acad Primary Hlth Care Ctr, Stockholm, Sweden;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Nursing, Stockholm, Sweden.
    Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences2019In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 37, no 3, p. 273-282Article in journal (Refereed)
    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.

  • 9. Hedin, K
    et al.
    André, M
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Brorsson, A
    Gröndal, Hedvig
    Soares, J
    Strandberg, EL
    Mölstad, S
    Studie över faktorer som påverkar läkares beteende vid förskrivning av antibiotika2014Report (Other academic)
  • 10. Hedin, Katarina
    et al.
    Strandberg, Eva Lena
    Gröndal, Hedvig
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Sociology.
    Brorsson, Annika
    Thulesius, Hans
    André, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Management of patients with sore throats in relation to guidelines: An interview study in Sweden2014In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 32, no 4, p. 193-199Article in journal (Refereed)
    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.

  • 11.
    Holst, Anna
    et al.
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Primary Hlth Care, Gothenburg, Sweden.
    Ginter, Annika
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Hlth Metr, Gothenburg, Sweden.
    Bjorkelund, Cecilia
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Primary Hlth Care, Gothenburg, Sweden.
    Hange, Dominique
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Primary Hlth Care, Gothenburg, Sweden.
    Petersson, Eva-Lisa
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Primary Hlth Care, Gothenburg, Sweden;Reg Vastra Gotaland, Narhalsan Res & Dev Primary Hlth Care, Gothenburg, Sweden.
    Svenningsson, Irene
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Primary Hlth Care, Gothenburg, Sweden;Reg Vastra Gotaland, Narhalsan Res & Dev Primary Hlth Care, Gothenburg, Sweden.
    Westman, Jeanette
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Family Med, Stockholm, Sweden.
    Andre, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Wikberg, Carl
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Primary Hlth Care, Gothenburg, Sweden.
    Wallin, Lars
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Nursing, Stockholm, Sweden;Univ Gothenburg, Sahlgrenska Acad, Dept Hlth & Care Sci, Gothenburg, Sweden.
    Moller, Christina
    Reg Vastra Gotaland, Narhalsan, Primary Hlth Care Head Off, Hisings Backa, Sweden.
    Svensson, Mikael
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Publ Hlth & Community Med Hlth Metr, Gothenburg, Sweden.
    Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: economic evaluation of a pragmatic randomised controlled study2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 11, article id e024741Article in journal (Refereed)
    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.

  • 12.
    Strandberg, Eva Lena
    et al.
    Lund Univ, Dept Clin Sci Malmo Family Med, Malmo, Sweden.;Blekinge Cty Council, Blekinge Ctr Competence, Karlskrona, Sweden..
    Brorsson, Annika
    Lund Univ, Dept Clin Sci Malmo Family Med, Malmo, Sweden.;Ctr Primary Hlth Care Res, Malmo, Skane Region, Sweden..
    André, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Linkoping Univ, Dept Med & Hlth Sci Family Med, Linkoping, Sweden..
    Gröndal, Hedvig
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Sociology.
    Molstad, Sigvard
    Lund Univ, Dept Clin Sci Malmo Family Med, Malmo, Sweden..
    Hedin, Katarina
    Lund Univ, Dept Clin Sci Malmo Family Med, Malmo, Sweden.;Reg Kronoberg, Dept Res & Dev, Vaxjo, Sweden..
    Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden2016In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, article id 78Article in journal (Refereed)
    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.

  • 13.
    Wikberg, C.
    et al.
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care Publ Hlth & Community, Gothenburg, Sweden..
    Westman, J.
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Family Med, Stockholm, Sweden..
    Petersson, E-L
    Larsson, M. E. H.
    Narhalsan Res & Dev Primary Hlth Care, Reg Vastra Gotaland, Gothenburg, Sweden.;Univ Gothenburg, Inst Neurosci & Physiol, Dept Hlth & Rehabil, Unit Physiotherapy, Gothenburg, Sweden..
    André, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Eggertsen, R.
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care Publ Hlth & Community, Gothenburg, Sweden.;Narhalsan Res & Dev Primary Hlth Care, Reg Vastra Gotaland, Gothenburg, Sweden..
    Thorn, J.
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care Publ Hlth & Community, Gothenburg, Sweden.;Narhalsan Res & Dev Primary Hlth Care, Reg Vastra Gotaland, Gothenburg, Sweden..
    Agren, H.
    Univ Gothenburg, Inst Neurosci & Physiol, Gothenburg, Sweden..
    Bjorkelund, C.
    Univ Gothenburg, Sahlgrenska Acad, Inst Med, Dept Primary Hlth Care Publ Hlth & Community, Gothenburg, Sweden..
    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 study2017In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 18, article id 6Article in journal (Refereed)
    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.

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