Obesity and its association with self-efficacy and metabolic risk factors by region of birth among 40-year-olds participating in the Swedish targeted health dialogues.

Objective: Targeted Health Dialogues (THD) is a public health intervention program that aims at preventing cardiovascular disease. THDs were implemented in the Swedish region Scania, in 2020, with the novelty of being conducted in a metropolitan area with a multiethnic population.This study investigated the prevalence of obesity among 40-year-old THD participants in Scania by region of birth, and its associations with self-efficacy and additional metabolic risk factors. Methods: Cross-sectional data were retrieved from measurements in the THDs. Study participants included 1831 40-year-olds. Differences in characteristics by region of birth were assessed using chi-squared and ANOVA tests. The associations between overweight, obesity, and high waist-hip ratio (WHR) and self-efficacy and metabolic risk factors (blood pressure, LDL cholesterol, plasma glucose) were assessed using binominal and ordinal logistic regression, adjusted for sex and education and tested for interactions by region of birth. Results: 35.1 % of the participants were overweight (BMI 25-29.9), and 18.7 % were obese (BMI ≥30) with the highest levels among participants born outside Sweden (p = 0.005). Abdominal obesity was also more prevalent among participants born outside Sweden (p = 0.002). Obesity was associated with increased odds of having low self-efficacy (OR per BMI-level: 1.48 (CI 1.24-1.76) and additional metabolic risk factors. No interactions with region of birth were detected. Conclusions: The prevalence of obesity differed between region of birth and obesity was associated with having low self-efficacy. These findings underline the need to customise lifestyle interventions in a multiethnic population to increase health equity.

Health determinants among participants in targeted health dialogues offered to all 40-year-old individuals in a metropolitan region of 1.4 million people.

OBJECTIVE: To examine cardiovascular risk factors in 40-year-old participants in the health screening program targeted health dialogues (THDs). DESIGN: Cross-sectional study. SETTING: 99 Swedish healthcare centers. INTERVENTION: Metabolic risk factors and health behaviors were assessed. THDs were provided. SUBJECTS: 1831 (62.3%) THD participants that consented to take part in the research project. MAIN OUTCOME MEASURES: (1) Prevalence of metabolic risk factors (blood pressure, LDL cholesterol, fasting plasma glucose, BMI, waist-hip ratio) and unhealthy behaviors (tobacco, alcohol, diet, physical activity) by sex, education, and place of birth. (2) Associations between different health behaviors and between the number of unhealthy behaviors and prevalence of metabolic risk factors. (3) THD participation by sociodemographics compared to age-matched controls. RESULTS: Men had a higher prevalence of all metabolic risk factors, excessive alcohol use and tobacco use than women. Lower educated individuals had a higher prevalence of metabolic risk factors (except for LDL cholesterol) and tobacco use than highly educated. Participants born outside Sweden had a higher prevalence of obesity, high waist-hip ratio, and tobacco use. Participants with 3-4 unhealthy behaviors had significantly higher prevalence of each of the metabolic risk factors except BMI. Women, highly educated and Swedish-born participants were slightly over-represented in the THDs. CONCLUSION: Considering the associations between unhealthy behaviors and metabolic risk factors, the THD method, covering lifestyle as well as objective health measures, may be an appropriate method for early identification of individuals at risk for future non-communicable diseases in the whole population with a specific focus on certain groups. CLINICALTRIALS.GOV: NCT04912739.

The study presents health determinants in 40-year-old targeted health dialogue (THD) participants in a Swedish metropolitan, multi-ethnic region.Only half of the men had normal blood pressure and less than 40% had a BMI < 25 kg/m².Having 3­4 unhealthy behaviors was associated with significantly higher prevalence of all metabolic risk factors (except BMI) compared to zero unhealthy behaviors.The predominance of female, highly educated and Swedish-born participants in THDs calls for a targeted outreach to certain population groups.

eVisits to primary care and subsequent health care contacts: a register-based study.

BACKGROUND: Evidence concerning health care use related to virtual visits is conflicting. More research has been called for regarding the effectiveness of text-based virtual visits (eVisits). Therefore, we investigated patient characteristics, diagnoses, and subsequent health care contacts after eVisits to primary care. METHODS: We conducted a register-based cohort study of eVisits to an all-virtual public primary care unit in Sweden and subsequent health care contacts within 14 days. Data for 2021 were acquired from the regional health care databases. Diagnoses were sorted into relevant diagnostic groups, such as skin diagnoses and respiratory tract diagnoses. Multiple logistic regression was performed with subsequent health care contact as the outcome variable and diagnostic group for the eVisit as the predictor variable. Analyses were adjusted for age, sex, and socioeconomic index. RESULTS: There were 5817 eVisits to a nurse and 4267 eVisits to a general practitioner (N = 10 084). Most patients were 20 to 39 years of age (41.8%). Skin diagnoses were most frequent (47.3%), followed by respiratory tract diagnoses (19.9%). Approximately one-fourth (25.8%) of the patients who completed an eVisit with a nurse or a general practitioner had a subsequent face-to-face visit within 14 days, mostly in primary care. Subsequent contacts were more frequent after an eVisit to a nurse than to a general practitioner. After an eVisit to a general practitioner, patients with infections (especially respiratory tract but also urinary tract) and unspecified diagnoses (especially skin-related) were more likely to require further health care contact compared to a group with various other diagnoses. CONCLUSIONS: eVisits to an all-virtual primary care unit may be appropriate for uncomplicated medical complaints. Nonetheless, the effectiveness of eVisits in terms of substitution of physical visits, and resource utilization in relation to the more complex care needs of a primary care population, should be further studied.

Inequity in access to digital public primary healthcare in Sweden: a cross-sectional study of the effects of urbanicity and socioeconomic status on utilization.

BACKGROUND: Social and geographical inequity in access to primary healthcare is an ongoing concern in Sweden. Digital care can potentially decrease geographical inequity. This study aimed to evaluate how urbanicity affects the utilization of a public digital primary healthcare service - PHC Online. METHODS: We performed an ecological cross-sectional study of 4,482 PHC Online visits grouped by 83 public primary healthcare centers. Multiple linear regression analysis was performed with PHC Online visits per 1,000 registered patients as the dependent variable and urbanicity (municipalities grouped by number of inhabitants), socioeconomic status (Care Need Index), and morbidity (Adjusted Clinical Groups) per primary healthcare center as independent variables. RESULTS: Utilization of PHC Online was more common among those of a younger age (median 32 years) and among women (65%). Urbanicity did not affect utilization. Lower socioeconomic status and higher morbidity had negative effects on utilization (B -3.289, p = 0.001, B -7.728, p = 0.045). CONCLUSIONS: Geographical differences based on urbanicity do not seem to affect the utilization of PHC Online. Further studies are needed to clarify a possible association to geographical barriers in access to primary healthcare, specifically accounting for factors associated with urbanicity and distance to physical clinics, and how age and sex affect such an association. Lower utilization of PHC Online in low socioeconomic status and high morbidity populations raises questions on the effect of digital primary care on equitable access to primary healthcare.

Clinical impact of medication reviews for community-dwelling patients in primary healthcare.

BACKGROUND: A high number of drug-related problems has previously been shown among community-dwelling patients in primary healthcare in Skåne County, Sweden. Medication reviews are one way to solve these problems, but their impact is largely dependent on the process. We aimed to evaluate medication reviews for community-dwelling patients regarding the clinical relevance of the pharmacists' recommendations, and their implementation by general practitioners. We also wanted to investigate if the general practitioners' tendency to act on drug-related problems was correlated to different factors of the process. METHODS: This was a cohort study, where patients in primary healthcare considered in need of a medication review were selected. Pharmacists identified drug-related problems and gave written recommendations on how to solve the problems to the general practitioner, via the medical record, and in addition in some cases via verbal communication. The clinical relevance of the recommendations was graded according to the Hatoum scale, ranging from one (adverse significance) to six (extremely significant). Descriptive statistics were used regarding the clinical relevance and the general practitioners´ tendency to act on drug-related problems. Multiple logistic regression analysis was used to examine the association between the tendency to act and different factors of the process. RESULTS: A total of 96.1% of the 384 assessed recommendations from the pharmacists were graded as significant or more for the patient (Hatoum grade 3 or higher). The general practitioners acted on 63.8% of the drug-related problems. Fewer recommendations per patient, as well as verbal communication in addition to written contact, significantly increased the general practitioners' tendency to act on a drug-related problem. No significant association was seen between the tendency to act and the clinical relevance of the recommendation. CONCLUSIONS: The high proportion of clinically relevant recommendations from the pharmacists in this study strengthens medication reviews as an important tool for reducing drug-related problems. Verbal communication between the pharmacist and the general practitioner is important for measures to be taken. Multiple recommendations for the same patient reduced their likelihood to of being addressed by the general practitioner.

'In the end, I'm the one who has to do the job': Participant experience of a lifestyle intervention for patients with hypertension.

OBJECTIVE: Cardiovascular disease can be prevented through lifestyle changes, but such changes are often hard to attain. Text message interventions with lifestyle advice have shown small but promising effects. Our objective was to explore participant experience of a text message lifestyle intervention for patients with hypertension, and implications for future lifestyle interventions. DESIGN AND SUBJECTS: Fourteen participants were purposefully selected for telephone interviews after completion of a text message lifestyle intervention. A semi-structured interview guide with open-ended questions was used. Interviews were recorded and transcribed verbatim. The material was analyzed through systematic text condensation as described by Malterud, a data-driven analysis style that includes deductive elements. SETTING: Primary care in three regions in southern Sweden. RESULTS: The analysis resulted in three themes. 'Blood pressure and lifestyle, how seriously to take it?' revealed a remaining need for knowledge regarding to what extent lifestyle affects risk for cardiovascular disease. 'The text messages - a useful reminder in need of tailoring' described that the design of the intervention was satisfactory, but suggested improvements through increased individualization. Finally, 'Water off a duck's back or a kick in the pants - when does behavior change?' showed how some participants responded to the push to change while others did not, supplying material for further analysis in a framework of behavioral change theory. CONCLUSION: A key to adoption was advice that was applicable in daily life. Timing in relation to a diagnosis of hypertension or other motivational factors, and tailoring to prior knowledge, habits, and limitations could increase effectiveness.

Text message interventions with lifestyle advice for hypertension and cardiovascular disease have shown small effects, but effectiveness may be improved.Our qualitative analysis of patient experience revealed a remaining need for increased knowledge regarding blood pressure, lifestyle, and cardiovascular disease.Text message advice that was applicable in daily life, or perceived as new, seemed most useful to facilitate lifestyle change.Timing in relation to motivational factors and tailoring to individual habits and limitations could increase effectiveness of similar interventions.

Child and maternal benefits and risks of caseload midwifery - a systematic review and meta-analysis.

BACKGROUND: It has been reported that caseload midwifery, which implies continuity of midwifery care during pregnancy, childbirth, and the postnatal period, improves the outcomes for the mother and child. The aim of this study was to review benefits and risks of caseload midwifery, compared with standard care comparable to the Swedish setting where the same midwife usually provides antenatal care and the checkup postnatally, but does not assist during birth and the first week postpartum. METHODS: Medline, Embase, Cinahl, and the Cochrane Library were searched (Nov 4th, 2021) for randomized controlled trials (RCTs). Retrieved articles were assessed and pooled risk ratios calculated when possible, using random-effects meta-analyses. Certainty of evidence was assessed according to GRADE. RESULTS: In all, 7,594 patients in eight RCTs were included, whereof five RCTs without major risk of bias, including 5,583 patients, formed the basis for the conclusions. There was moderate certainty of evidence for little or no difference regarding the risk of Apgar ≤ 7 at 5 min, instrumental birth, and preterm birth. There was low certainty of evidence for little or no difference regarding the risk of perinatal mortality, neonatal intensive care, perineal tear, bleeding, and acute caesarean section. Caseload midwifery may reduce the overall risk of caesarean section. Regarding breastfeeding after hospital discharge, maternal mortality, maternal morbidity, health-related quality of life, postpartum depression, health care experience/satisfaction and confidence, available studies did not allow conclusions (very low certainty of evidence). For severe child morbidity and Apgar ≤ 4 at 5 min, there was no literature available. CONCLUSIONS: When caseload midwifery was compared with models of care that resembles the Swedish one, little or no difference was found for several critical and important child and maternal outcomes with low-moderate certainty of evidence, but the risk of caesarean section may be reduced. For several outcomes, including critical and important ones, studies were lacking, or the certainty of evidence was very low. RCTs in relevant settings are therefore required.

Telemedicine in Swedish primary health care - a web-based survey exploring patient satisfaction.

BACKGROUND: Direct-to-consumer telemedicine (TM), with patients having access to a physician via video or text chat, has gradually been introduced into Swedish primary care during the last two decades. Earlier studies have concluded that patients were generally satisfied with TM and the satisfaction rate was consistently above 80% and comparable with in-person visits. Despite the number of studies looking at user experience, studies assessing what factors influence patient satisfaction are lacking. To further develop digital care, it is important to explore the patients' opinions of this relatively new phenomenon. The primary aim of this study was to explore patient opinions regarding satisfaction with TM-provided care, based on different age groups, sex, symptoms, and which type of health care professional they were assessed by. METHODS: The study was a quantitative web survey performed in 2020-2021 in which 688 patients using a TM provider in Southern Sweden responded. The results were analysed using Chi-2 test with the main outputs; satisfaction level and percentage that would use TM for similar symptoms in the future. RESULTS: The results from the survey population show that patients that were assessed by a doctor were more likely to intend to use TM in the future and were more satisfied with the visit than patients assessed by a nurse. Our results also show that patients older than 70 years of age were less likely to use TM again compared to the total population. CONCLUSION: This study shows that patient satisfaction with TM varied depending on the patient's age. The older patients were less satisfied than their younger equivalents. For patient satisfaction to be high, it was also crucial which health care provider the patient had been assessed by. The patients were more satisfied when assessed by a doctor than by a nurse. In addition, the study shows that patient satisfaction with TM was generally comparable to traditional care.

Trends in Remote Health Care Consumption in Sweden: Comparison Before and During the First Wave of the COVID-19 Pandemic.

BACKGROUND: Remote assessment of respiratory tract infections (RTIs) has been a controversial topic during the fast development of private telemedicine providers in Swedish primary health care. The possibility to unburden the traditional care has been put against a questionable quality of care as well as risks of increased utilization and costs. The COVID-19 pandemic has contributed to a changed management of patient care to decrease viral spread, with an expected shift in contact types from in-person to remote ones. OBJECTIVE: The main aim of this study was to compare health care consumption and type of contacts (in-person or remote) for RTIs before and during the COVID-19 pandemic. The second aim was to study whether the number of follow-up contacts after an index contact for RTIs changed during the study period, and whether the number of follow-up contacts differed if the index contact was in-person or remote. A third aim was to study whether the pattern of follow-up contacts differed depending on whether the index contact was with a traditional or a private telemedicine provider. METHODS: The study design was an observational retrospective analysis with a description of all index contacts and follow-up contacts with physicians in primary care and emergency rooms in a Swedish region (Skåne) for RTIs including patients of all ages and comparison for the same periods in 2018, 2019, and 2020. RESULTS: Compared with 2018 and 2019, there were fewer index contacts for RTIs per 1000 inhabitants in 2020. By contrast, the number of follow-up contacts, both per 1000 inhabitants and per index contact, was higher in 2020. The composition of both index and follow-up contacts changed as the share of remote contacts, in particular for traditional care providers, increased. CONCLUSIONS: During the COVID-19 pandemic in 2020, fewer index contacts for RTIs but more follow-up contacts were conducted, compared with 2018-2019. The share of both index and follow-up contacts that were conducted remotely increased. Further studies are needed to study the reasons behind the increase in remote contacts, and if it will last after the pandemic, and more clinical guidelines for remote assessments of RTI are warranted.

Attitudes, Barriers, and Concerns Regarding Telemedicine Among Swedish Primary Care Physicians: A Qualitative Study.

PURPOSE: The primary care physician's traditional patient contacts are challenged by the rapidly accelerating digital transformation. In a quantitative survey analysis based on the theory of planned behavior, we found high behavioral intention to use telemedicine among Swedish primary care physicians, but low reported use. The aim of this study was to further examine the physicians' experiences regarding telemedicine, with a focus on possible explanations for the gap between intention and use, through analysis of the free-text comments supplied in the survey. MATERIAL AND METHODS: The material was collected through a web-based survey which was sent out to physicians at 160 primary health care centers in southern Sweden from May to August 2019. The survey covered four areas: general experiences of telemedicine, digital contacts, chronic disease monitoring with digital tools, and artificial intelligence. A total of 100 physicians submitted one or more free-text comments. These were analyzed using qualitative content analysis with an inductive approach. RESULTS: The primary care physicians expressed attitudes towards telemedicine that focused on clinical usefulness. Barriers to use were the loss of personal contact with patients and a deficient technological infrastructure. The major concerns were that these factors would result in patient harm and an increased workload. The connection between intention and use postulated by the theory of planned behavior was not applicable in this context, as external factors in the form of availability and clinical usefulness of the specific technology were major impediments to use despite a generally positive attitude. CONCLUSION: All telemedicine tools must be evaluated regarding clinical usefulness, patient safety, and effects on staff workload, and end users should be included in this process. Utmost consideration is needed regarding how to retain the benefits of personal contact between patient and provider when digital solutions are introduced.

The Impact of Medication Reviews Conducted in Primary Care on Hospital Admissions and Mortality: An Observational Follow-Up of a Randomized Controlled Trial.

BACKGROUND: Drug-related problems among the elderly population are common and increasing. Multi-professional medication reviews (MR) have arisen as a method to optimize drug therapy for frail elderly patients. Research has not yet been able to show conclusive evidence of the effect of MRs on mortality or hospital admissions. AIM: The aim of this study was to assess the impact of MRs' on hospital admissions and mortality after six and 12 months in a frail population of 369 patients in primary care in a cohort from a randomized controlled study. METHODS: Patients were blindly randomized to an intervention group (receiving MRs) and a control group (receiving usual care). Descriptive data on mortality and hospital admissions at six and 12 months were collected. Survival analysis was performed for time to death and time to the first hospital admission within 12 months. RESULTS: An observational follow-up was performed in a cohort of 369 patients, previously randomized to an intervention group (182) and a control group (187). Most of the patients (75%) were females and lived in nursing homes. At six months, 50 patients of the baseline population (27%) in the control group had been admitted to hospital at least once, compared to 40 patients (21%) in the intervention group. At 12 months, the percentage had increased to 70 (37%) in the control group compared to 53 (29%) in the intervention group. Compared to usual care, we found that MRs reduced the risk of hospital admissions within 12 months by 42% (HR = 0.58, 95% CI 0.37-0.92, p=0.021), but found no difference in mortality (HR = 1.12, 95% CI 0.78-1.61, p=0.551) between the groups. CONCLUSION: We suggest that MRs should be recommended in the care of frail elderly patients with expected benefits on delayed hospital admissions. The study is registered at ClinicalTrials.gov, registration number NCT04040855, Unique Protocol ID 2018/8.

The nutritional situation in Swedish nursing homes - a longitudinal study.

Poor nutritional status is widespread among the elderly and is associated with increased morbidity and mortality. The aim of this study was to longitudinally describe the nutritional status in elderly people living in nursing homes. Nutritional status was recorded longitudinally in elderly people living in 11 different nursing homes in Sweden. Participants were examined at baseline by specially trained nurses who also assisted with questionnaires and collected data for current medical treatment from patient records. Nutritional status was evaluated at baseline and after 24 months with the mini nutritional assessment (MNA). The study included 318 subjects. The mean age of the participants was 85.0 years (range 65-101). At baseline, 41.6% were well nourished, 40.3% at risk of malnutrition, and 17.7% malnourished according to the MNA. Survival was significantly lower in the malnourished group. After 24 months, almost half of the population had died. The group of participants who survived at 24 months represents a population of better nutritional state, where 10.6% were malnourished at baseline increasing to 24.6% after 24 months. After 24 months, 38.7% of the participants showed a decline in nutritional state. The group with deteriorating MNA scores had higher weight, BMI values, and a higher hospitalization rate. The prevalence of malnutrition in nursing home residents increased over time and it is important to evaluate nutritional state regularly. Nutritional interventions should be considered in better nourished groups, as well as in malnourished individuals, to prevent a decline in nutritional state.