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author:("Ekman, anger")
1.  Medication Adherence: A Call for Action 
American heart journal  2011;162(3):412-424.
Poor adherence to efficacious cardiovascular related medications has led to considerable morbidity, mortality, and avoidable health care costs. This paper provides results of a recent think tank meeting in which various stakeholder groups representing key experts from consumers, community health providers, the academic community, decision-making government officials (FDA, NIH, etc), and industry scientists met to evaluate the current status of medication adherence and provide recommendations for improving outcomes. Below, we review the magnitude of the problem of medication adherence, prevalence, impact, and cost. We then summarize proven effective approaches and conclude with a discussion of recommendations to address this growing and significant public health issue of medication non adherence.
doi:10.1016/j.ahj.2011.06.007
PMCID: PMC3947508  PMID: 21884856
2.  The association between self-reported lack of sleep, low vitality and impaired glucose tolerance: a Swedish cross-sectional study 
BMC Public Health  2013;13:700.
Background
The increased incidence of impaired glucose tolerance (IGT), are serious public health issues, and several studies link sleeping disorders with increased risk of developing type 2 diabetes, impaired glucose tolerance and insulin resistance (IR). This study explore how self-reported lack of sleep and low vitality, are associated with IGT in a representative Swedish population.
Methods
A cross-sectional survey conducted in two municipalities in South-western Sweden. Participants aged 30–75 were randomly selected from the population in strata by sex and age. Altogether, 2,816 participants were surveyed with a participation rates at 76%. Participants with normal glucose tolerance (n=2,314), and those with IGT (n=213) were retained for analyses. The participants answered a questionnaire before the oral glucose tolerance test (OGTT). Associations for questions concerning sleeping disorders, vitality and IGT were analysed using logistic regression and were expressed as odds ratios (OR) with 95% CI.
Results
In men a statistically significant age-adjusted association was found between self-reported lack of sleep and IGT: OR 2.4 (95% CI: 1.1-5.4). It did not weaken after further adjustment for body mass index (BMI), smoking, education, and leisure time physical activity 2.3 (1.0-5.5, p=0.044). No such associations were found in females. Corresponding age-adjusted associations between low vitality and IGT in both men 2.8 (1.3-5.8), and women 2.0 (1.2-3.4) were successively lost with increasing adjustment.
Conclusions
Insufficient sleep seems independently associated with IGT in men, while low vitality was not independently associated with IGT neither in men nor women, when multiple confounders are considered. IGT should be considered in patients presenting these symptoms, and underlying mechanisms further explored.
doi:10.1186/1471-2458-13-700
PMCID: PMC3737019  PMID: 23902570
Impaired glucose tolerance; Fatigue; Sleeping disorders; Health conversation; Primary health care
3.  The association between self-rated health and impaired glucose tolerance in Swedish adults: A cross-sectional study 
Abstract
Objective
To investigate gender differences in the association between self-rated health (SRH) and impaired glucose tolerance (IGT) in subjects unaware of their glucose tolerance.
Design
A cross-sectional population-based study.
Setting
The two municipalities of Vara and Skövde in south-western Sweden.
Subjects
A total of 2502 participants (1301 women and 1201 men), aged 30–75, were randomly selected from the population.
Main outcome measures
IGT was regarded as the outcome measure and SRH as the main risk factor.
Results
The prevalence of IGT was significantly higher in women (11.9%) than in men (10.1%), (p = 0.029), as was the prevalence of low SRH (women: 35.4%; men: 22.1%, p = 0.006). Both men and women with low SRH had a poorer risk factor profile than those with high SRH, and a statistically significant crude association between SRH and IGT was found in both men (OR = 2.8, 95% CI 1.8–4.4) and women (OR = 1.5, 95% CI 1.0–2.2, p = 0.033). However, after controlling for several lifestyle factors and biomedical variables, the association was attenuated and remained statistically significant solely in men (OR = 2.3, 95% CI 1.2–4.3).
Conclusion
The gender-specific associations found between SRH and IGT suggest that SRH may be a better indicator of IGT in men than in women. Future studies should evaluate the utility of SRH in comparison with objective health measures as a potential aid to health practitioners when deciding whether to screen for IGT and T2DM.
doi:10.3109/02813432.2013.784541
PMCID: PMC3656394  PMID: 23621319
Gender; general practice; impaired glucose tolerance; self-rated health; Sweden
4.  Effects of person-centred care in patients with chronic heart failure: the PCC-HF study 
European Heart Journal  2011;33(9):1112-1119.
Aims
Person-centred care (PCC) emphasizes a partnership in care between patients and healthcare professionals and is advocated by WHO as a key component of quality health care. We evaluated outcomes of PCC in hospitalized patients with chronic heart failure (CHF) with respect to the length of hospital stay (LOS), activities of daily living (ADL), health-related quality of life (HRQL) and 6-month readmission rate.
Methods and results
During 2008–2010, 248 consecutive patients hospitalized for symptoms of worsening CHF were enrolled in a controlled before and after designed study. A Usual care group (n= 123) was recruited according to pre-defined criteria to map usual CHF care and assess outcomes at five designated hospital wards. Based on the mapping, a panel of in-house clinicians and researchers developed measures aimed at aligning usual care with basic PCC principles. These measures were incorporated into a study protocol to guide care procedures at the same five wards. Person-centred care was then implemented at these wards and evaluated in 125 patients. Both length of hospital stay and 6-month readmission were extracted from patient records. Activities of daily living were evaluated at baseline and discharge and HRQL was evaluated at baseline and after 3 months. In the analysis of all patients, the LOS was reduced by 1 day (P= 0.16) while retaining ADL (P= 0.07). When PCC was fully implemented (per protocol analysis), LOS was reduced by 2.5 days (P= 0.01) and the ADL-level better preserved (P= 0.04). Health-related quality of life and time-to-first readmission did not differ.
Conclusion
In this proof-of-concept study, our findings suggest that a fully implemented PCC approach shortens hospital stay and maintains functional performance in patients hospitalized for worsening CHF, without increasing risk for readmission or jeopardizing patients' HRQL.
doi:10.1093/eurheartj/ehr306
PMCID: PMC3751966  PMID: 21926072
Patient-centred care; Chronic heart failure; Disease management programmes; Person-centered medicine; Person-centered care
5.  Everyday practices at the medical ward: a 16-month ethnographic field study 
Background
Modern hospital care should ostensibly be multi-professional and person-centred, yet it still seems to be driven primarily by a hegemonic, positivistic, biomedical agenda. This study aimed to describe the everyday practices of professionals and patients in a coronary care unit, and analyse how the routines, structures and physical design of the care environment influenced their actions and relationships.
Methods
Ethnographic fieldwork was conducted over a 16-month period (between 2009 and 2011) by two researchers working in parallel in a Swedish coronary care unit. Observations, informal talks and formal interviews took place with registered nurses, assistant nurses, physicians and patients in the coronary care unit. The formal interviews were conducted with six registered nurses (five female, one male) including the chief nurse manager, three assistant nurses (all female), two cardiologists and three patients (one female, two male).
Results
We identified the structures that either promoted or counteracted the various actions and relationships of patients and healthcare professionals. The care environment, with its minimalistic design, strong focus on routines and modest capacity for dialogue, restricted the choices available to both patients and healthcare professionals. This resulted in feelings of guilt, predominantly on the part of the registered nurses.
Conclusions
The care environment restricted the choices available to both patients and healthcare professionals. This may result in increased moral stress among those in multi-professional teams who work in the grey area between biomedical and person-centred care.
doi:10.1186/1472-6963-12-184
PMCID: PMC3409076  PMID: 22748059
Person-centered care; Moral stress; Interprofessional relationship; Professional-patient relations; Care environment; Care continuity.
6.  Impacts of patient characteristics on hospital care experience in 34,000 Swedish patients 
BMC Nursing  2012;11:8.
Background
Standardized patient surveys are widely used for assessing quality of healthcare from the patient perspective. An important purpose of such surveys is to identify disparities in care among different patient groups. The purpose of this study was to 1.) evaluate aspects of the validity of the adapted Swedish version of the Picker Patient Care Experience -15 (PPE-15) survey and 2.) examine the explanatory value of various socio-demographic and health characteristics in predicting patients’ care experiences.
Methods
A retrospective cross-sectional study design was used. Patients discharged from internal medicine wards at regional and university hospitals in different parts of Sweden during 2010 were invited to participate in the regularly administered national care-experience survey for hospital care. The internal validity of the PPE-15 was assessed with Cronbach’s alpha and item-scale correlations. Pearson product–moment correlation coefficients were used to compare PPE-15 total scores with overall care satisfaction ratings and Spearman correlation coefficients were used to compare PPE-15 total scores with various patient characteristics. Multiple linear regression analysis was performed to examine the influence of various patient characteristics on PPE-15 scores.
Results
The response rate was 66% (n = 34 603). Cronbach’s alpha was 0.87. The correlation between the PPE-15 total score and overall care satisfaction was high (0.62, p < 0.0001). Good self-rated health (SRH) and having Swedish as native language were associated with better care experiences and poorer experiences with greater healthcare utilization, higher age, functional impairment and being female. All examined characteristics, except language, were significant predictors in the regression model and SRH was the strongest predictor; however, the model explained only 7% of the total variance. Vulnerable patients (i.e. poor SRH and functional impairment) reported significantly less positive care experiences than did non-vulnerable patients (mean PPE-15 score 75 vs 85; p < 0.0001).
Conclusions
Our results supported the internal validity of the Swedish adapted version of the PPE-15. The explanatory value of the examined patient socio-demographic and health characteristics was low, suggesting the need for exploring other patient-related determinants of care experiences. Our findings also suggest a care paradox: patients in greatest need of hospital care are least satisfied with the quality of the care they receive.
doi:10.1186/1472-6955-11-8
PMCID: PMC3482554  PMID: 22697398
Patient-reported outcome; Self-rated health; Functional status; Frail; Care experience; Care disparity; Patient-centred care
7.  Patients with worsening chronic heart failure who present to a hospital emergency department require hospital care 
BMC Research Notes  2012;5:132.
Background
Chronic heart failure (CHF) is a major public health problem characterised by progressive deterioration with disabling symptoms and frequent hospital admissions. To influence hospitalisation rates it is crucial to identify precipitating factors.
To characterise patients with CHF who seek an emergency department (ED) because of worsening symptoms and signs and to explore the reasons why they are admitted to hospital.
Method
Patients (n = 2,648) seeking care for dyspnoea were identified at the ED, Sahlgrenska University Hospital/Östra. Out of 2,648 patients, 1,127 had a previous diagnosis of CHF, and of these, 786 were included in the present study with at least one sign and one symptom of worsening CHF.
Results
Although several of the patients wanted to go home after acute treatment in the ED, only 2% could be sent home. These patients were enrolled in an interventional study, which evaluated the acute care at home compared to the conventional, in hospital care. The remaining patients were admitted to hospital because of serious condition, including pneumonia/respiratory disease, myocardial infarction, pulmonary oedema, anaemia, the need to monitor cardiac rhythm, pathological blood chemistry and difficulties to communicate.
Conclusion
The vast majority of patients with worsening CHF seeking the ED required hospital care, predominantly because of co-morbidities. Patients with CHF with symptomatic deterioration may be admitted to hospital without additional emergency room investigations.
doi:10.1186/1756-0500-5-132
PMCID: PMC3315737  PMID: 22401538
Chronic heart failure; Hospitalisation; Deterioration; Emergency care
8.  Perceived Symptoms in People Living with Impaired Glucose Tolerance 
Nursing Research and Practice  2011;2011:937038.
The aim of the study was to identify symptoms in people with impaired glucose tolerance (IGT) and describe their experiences of living with the symptoms which they related to their condition. Twenty-one participants, from a cross-sectional population-based study, diagnosed as having IGT, were invited for an interview. The interviews were analyzed in two phases by means of a manifest and latent content analysis. The narratives included seven categories of symptoms (and more than 25 different symptoms) presented by the respondents. This study shows that symptoms such as the patient's own interpretation of different perceptions in the body must be considered, as well as signs and/or objective observations. Symptoms ought to be seen as complementary components in the health encounter and health conversation. The results of this study indicate that health professionals should increase their awareness of the balance between the implicit and the explicit bodily sensations that individuals communicate. Further studies are needed.
doi:10.1155/2011/937038
PMCID: PMC3169241  PMID: 21994845
9.  Views of patients with heart failure about their role in the decision to start implantable cardioverter–defibrillator treatment: prescription rather than participation 
Journal of Medical Ethics  2007;33(9):514-518.
Background
There is a shortage of reports on what potential recipients of implantable cardioverter–defibrillators (ICDs) need to be informed about and what role they can and want to play in the decision‐making process when it comes to whether or not to implant an ICD.
Aims
To explore how patients with heart failure and previous episodes of malignant arrhythmia experience and view their role in the decision to initiate ICD treatment.
Patients and methods
A qualitative content analysis of semistructured interviews was used. The study population consisted of 31 outpatients with moderate heart failure at the time of their first ICD implantation.
Setting
The study was performed at Sahlgrenska University Hospital, Göteborg, Sweden.
Results
None of the respondents had discussed the alternative option of receiving treatment with anti‐arrhythmic drugs, the estimated risk of a fatal arrhythmia, or the expected time of survival from heart failure in itself. Even so, very little criticism was directed at the lack of information or the lack of participation in the decision‐making process. The respondents felt that they had to rely on the doctors' recommendation when it comes to such a complex and important decision. None of them regretted implantation of the ICD.
Conclusions
The respondents were confronted by a matter of fact. They needed an ICD and were given an offer they could not refuse, simply because life was precious to them. Being able to give well‐informed consent seemed to be a matter of less importance for them.
doi:10.1136/jme.2006.017723
PMCID: PMC2598204  PMID: 17761818
10.  Relationship between blood pressure levels and adherence to medication in patients with chronic heart failure: How come? 
Objective:
To investigate whether change in objective signs during up-titration of angiotensin-converting enzyme (ACE)-inhibitors in patients with chronic heart failure affect perception of information about medicines and subjective activities such as self-care.
Methods:
Consecutive patients referred for up-titration of ACE-inhibitors were included. Patients were given the Satisfaction with Information about Medicines Scale and the European Heart Failure Self-Care Behaviour Scale at their first visit and when the target dose was reached. Blood pressure, pulse and s-creatinine were measured at each visit.
Results:
Relationships were found between change in systolic (r = 0.224, p = 0.044) and diastolic (r = 0.361, p = 0.001) blood pressure and change in self-care scores and were also observed at baseline (r = 0.324, 0.398, p = 0.001, 0.000) and follow-up (r = 0.317, 0.253, p = 0.004, 0.022). Diastolic blood pressure correlated with the “potential problem of medication” score (r= −0.263, p = 0.007).
Conclusion:
Patients with a more advanced disease usually have a lower blood pressure. Hence, the relationship between blood pressure and self-care scores might indicate that patients are more motivated to adhere to prescriptions the more advanced the stage of their disease.
PMCID: PMC2672438  PMID: 19436649
blood pressure; chronic heart failure; adherence; scales
11.  Symptom recognition and health care seeking among immigrants and native Swedish patients with heart failure 
BMC Nursing  2008;7:9.
Background
It is not known what patient perceptions or beliefs lead to beneficial decisions or response patterns in symptom interpretation among heart failure (HF) patients, especially immigrants. The aim of this study was to explore and compare symptom recognition and health care seeking patterns among immigrants and native Swedes with HF.
Methods
The study used a qualitative design. Semi-structured interviews were conducted with 42 patients with HF, of whom 21 were consecutively selected immigrants and 21 were randomly selected Swedish patients. The interviews were analysed using content analysis.
Results
A majority of the immigrant patients sought health care for symptoms and signs, such as breathing difficulties, fatigue and swelling. Twice as many immigrants as Swedes were unaware of "what the illness experience entailed" and which symptoms indicated worsening of HF.
Conclusion
The symptoms that patients sought care for, were similar among immigrants and Swedes. However, when interpreting symptoms more immigrants were unaware of the connection between the symptoms/signs and their HF condition. More tailored educational interventions might improve recognition of worsening symptoms in immigrant patients with chronic heart failure.
doi:10.1186/1472-6955-7-9
PMCID: PMC2447827  PMID: 18590538
12.  A cost-effectiveness study of cost of care and health consequences for two modes of treatment for patients with hip fractures 
Objective
To perform an economic evaluation of two treatment approaches in participants with an acute hip fracture.
Design
A cost-effectiveness analysis was performed to compare an intervention treatment (treatment A) with standard care (treatment B). The intervention treatment was an integrated care pathway (ICP). Participants were selected consecutively and the treatment study used a before-and-after design.
Setting
An orthopaedic ward at a hospital southwest of Sweden.
Participants
112 independently living participants, aged 65 years or older and admitted to hospital with a hip fracture, were included. The exclusion criteria were pathological fracture and severe intellectual impairment (Pfeiffer's test <3 points).
The main outcome was hospital's total treatment costs for each participant undergoing surgery for a hip fracture, where effectiveness was measured using the Katz ADL index.
Results
The main result was a 40% reduction for each participant in the average total cost for treatment A € 9,685 vs. € 16,002 for treatment B (p=0.000). Moreover, effectiveness was significantly improved. The cost-effectiveness ratio for treatment A was € 14,840 vs. € 31,908 for treatment B. In addition, 75% of the participants in treatment A were successfully rehabilitated vs. 55% in treatment B.
Conclusion
The use of an ICP was cost-effective, with the greatest reduction in hotel costs. A longer hospital stay was related to more investigation costs, which appeared to be unrelated to the participants' medical condition. The cost of developing the ICP had already been covered after three participants. No 30-day re-admission was recorded in either group and the one-year mortality rate was 16% in both groups.
PMCID: PMC2430299
hospital care; health care cost; integrated care pathway; Sweden
13.  Worsening chronic heart failure and the link to frequent hospital admissions and need of specialist care 
Background
Worsening chronic heart failure (CHF) is largely characterised by disabling symptoms, poor quality of life, frequent hospital admissions and need of specialist care. Lack of alternative care results in involuntary hospitalisation.
Aim
In a pilot study evaluate home care (HC) versus conventional care (CC) in relation to medical safety, health-related quality of life (HRQL) and cost-utility in patients with worsening CHF.
Method
Thirty-one patients with deteriorating CHF were randomised to HC or CC when seeking medical attention at hospital. Patients in the HC group were discharged from the hospital and were followed-up in their homes by a specialist nurse. Patients in the control group were treated in hospital with usual care. Follow-ups were conducted for both groups, 1, 4, 8 and 12 months after inclusion in the study. Health-related quality of life assessed by EuroQol-5D VAS, Standard Gamble technique, SF-36 and Kansas City cardiomyopathy Questionnaire. All health care related costs were assessed and cost utility analysis was performed to compare cost/QALYs between groups.
Results
There was no significant difference in clinical events, adverse events or in HRQL. The total cost related to CHF was lower in the HC group after 12 months. Median direct health care related costs in HC were € 1122 and in CC € 5670 (p 0.05). Cost/QALYs ranged € 74–580 in HC compared to CC € 289–1013, calculated from each follow-up. The cost utility ratio was (CC/HC) 2.55 (SG) and 2.65 (VAS).
Conclusion
Reductions in cost of care for selected patients with CHF eligible for hospital care might be achieved by a very early discharge from hospital followed by home visits. More importantly, HC seems to be safe and no difference was found in HRQL between two groups. This pilot study provides clinicians with useful information in their decisions concerning CHF patient management, who are reluctant to hospitalisation.
PMCID: PMC2430295
chronic heart failure; healthcare cost; quality-adjusted life years; home care; cost-utility analysis; safety
14.  The integrated care pathway reduced the number of hospital days by half: a prospective comparative study of patients with acute hip fracture 
Background
The incidence of hip fracture is expected to increase during the coming years, demanding greater resources and improved effectiveness on this group of patients. The aim of the present study was to evaluate the effectiveness of an integrated care pathway (ICP) in patients with an acute fracture of the hip.
Methods
A nonrandomized prospective study comparing a consecutive series of patients treated by the conventional pathway to a newer intervention. 112 independently living patients aged 65 years or older admitted to the hospital with a hip fracture were consecutively selected. Exclusion criteria were pathological fracture and severe cognitive impairment. An ICP was developed with the intention of creating a care path with rapid pre-operative attention, increased continuity and an accelerated training programme based on the individual patient's prerequisites and was used as a guidance for each patient's tailored care in the intervention group (N = 56) The main outcome measure was the length of hospital stay. Secondary outcomes were the amount of time from the emergency room to the ward, to surgery and to first ambulation, as well as in-hospital complications and 30-day readmission rate.
Results
The intervention group had a significantly shorter length of hospital stay (12.2 vs. 26.3 days; p < 0.000), a shorter time to first ambulation (41 vs. 49 h; p = 0.01), fewer pressure wounds (8 vs. 19; p = 0.02) and medical complications (5 vs. 14; p = 0.003) than the comparison group. No readmissions occurred within 30 days post-intervention in either group.
Conclusion
Implementing an ICP for patients with a hip fracture was found to significantly reduce the length of hospital stay and improve the quality of care.
doi:10.1186/1749-799X-1-3
PMCID: PMC1634996  PMID: 17150123

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