Bacteriuria and vitamin D deficiency: a cross sectional study of 385 nursing home residents.

BACKGROUND: Up to half of elderly people at nursing homes have asymptomatic bacteriuria, and concentrations of 25-hydroxyvitamin D (25OHD) are generally low. Vitamin D is a modulator of the immune system and involved in protection of the epithelium in the urinary tract as well. The objective was to determine a possible association between bacteriuria and vitamin D deficiency among elderly people at nursing homes. METHODS: Cross-sectional study: Voided urine specimens and blood samples for cultivation and analysis of 25OHD were collected from elderly people at nursing homes in Sweden. Exclusion criteria were: urinary catheter, ongoing antibiotic treatment, incontinence or dementia too severe to provide a voided urine specimen or leave a blood sample, unwillingness to participate or terminal illness. Urine cultures and serum 25OHD concentrations were outcome measures and the association of bacteriuria with vitamin D deficiency was determined by logistic regression. RESULTS: Twenty-two nursing homes participated and 385 of 901elderly people provided voided urine specimens and blood samples. The mean age was 87 (SD 6.7), 69% women, 19% received vitamin D supplement, 13% had diabetes mellitus, and 54% were diagnosed with dementia. There was significant growth of potentially pathogenic bacteria in 32% (123/385) of voided urine specimens. Escherichia coli were present in 83% of positive urine cultures. The mean concentration of 25OHD in serum was 35 nmol/L (SD 21). Thirty-seven per cent (143/385) had 25OHD < 25 nmol/L, and 3.1% (12/385) 25OHD < 12.5 nmol/L. No association between bacteriuria and 25OHD < 25 nmol/L, OR 1.4 (0.86-2.3; p = 0.18) adjusted for age, gender, diabetes mellitus and dementia was found. However, if using 25OHD < 12.5 nmol/L as a cut-off for vitamin D deficiency the adjusted odds-ratio was 4.4 (1.1-17; p = 0.031). CONCLUSIONS: Bacteriuria and vitamin D deficiency was common. No association between bacteriuria and 25OHD < 25 nmol/L was found. If using 25OHD < 12.5 nmol/L as cut-off for vitamin D deficiency there was an association. However, this has to be interpreted with caution as causality cannot be evaluated as well as only few residents had 25OHD < 12.5 nmol/L.

More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment.

BACKGROUND: A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. METHODS: Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. RESULTS: The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. CONCLUSION: From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.

Vitamin D deficiency was common among nursing home residents and associated with dementia: a cross sectional study of 545 Swedish nursing home residents.

BACKGROUND: Residents of nursing homes may have low 25-hydroxyvitamin D (25OHD) concentrations. Associations between vitamin D and cognitive performance, dementia and susceptibility to infections are not clearly established. The aim of this study was to investigate the prevalence of vitamin D deficiency and to identify associated factors among residents of nursing homes for elderly. METHODS: In this cross-sectional study blood samples for analysis of 25OHD were collected from all participating residents of Swedish nursing homes for the elderly from January to March 2012. EXCLUSION CRITERIA: dementia too severe to collect a blood test, terminally ill or refusing participation. OUTCOME MEASURES: Serum 25OHD concentrations. Logistic regression to evaluate factors associated with vitamin D deficiency (25OHD < 25 nmol/L). RESULTS: Blood samples were obtained from 545 of 901 residents of 22 nursing homes. Mean age 86 years (SD 6.9), 68% were women. Prevalence of vitamin D supplementation 17%, dementia 55%, lack of appetite ≥3 months 45% and any antibiotic treatment during the last 6 months 30%. Serum 25OHD concentrations: mean 34 nmol/L (SD 21, median 27, range 4-125), 82% (448/545) had 25OHD < 50 nmol/L and 41% (224/545) had 25OHD < 25 nmol/L. Adjusted OR (95% CI; p-value) for possible predictors of vitamin D deficiency (25OHD < 25 nmol/L): vitamin D supplementation 0.075 (0.031-0.18; p < 0.001), lack of appetite ≥3 months 0.75 (0.50-1.1; p = 0.15), hours outdoors/week 0.99 (0.96-1.0; p = 0.62), Fitzpatrick skin phototype (4-6) 0.69 (0.44-1.1; p = 0.12); dementia 2.3 (1.5-3.4; p < 0.001) and antibiotics last 6 months 1.6 (1.1-2.6; p < 0.029), adjusted for age and gender. CONCLUSIONS: Vitamin D deficiency was common among nursing home residents and strongly associated with dementia. Regardless of causality or not, it is important to be alert for vitamin D deficiency in nursing homes residents with dementia. As expected vitamin D supplementation was associated with less vitamin D deficiency, however lack of appetite, staying outdoors and skin phototype were not significant predictors. Antibiotic treatments during the last 6 months were associated with vitamin D deficiency, potentially supporting the hypothesis that vitamin D deficiency is associated with infections.

A primary care lifestyle programme suitable for socioeconomically vulnerable groups - an observational study.

OBJECTIVE: To explore whether a primary health care (PHC) health promotion programme reaches and engages socioeconomically vulnerable groups in a community to the same extent as higher socioeconomic groups. DESIGN: Comparison of level of engagement and lifestyle improvements stratified by socioeconomic vulnerability level. SETTING: Hisingen PHC catchment area (130,000 inhabitants) Gothenburg, Sweden. PARTICIPANTS: Men and women aged 18-79, visiting any of the eight public PHC centres during an eight-month period 2007-2008, were presented with a short intervention health questionnaire and offered a health dialogue with a nurse, including a health profile, p-glucose and blood pressure check. Participants were classified according to four socioeconomic vulnerability factors: education, employment, ethnicity and living situation. RESULTS: Out of 3691 participants, 27% had low education (Hisingen community level 23%), 18% were unemployed (community level 22%), and 16% were born outside Scandinavia (community level 22%). At the one-year follow-up, 2121 (57%) attended. At baseline, 3% of the individuals in the sample had three out of four socioeconomic vulnerability factors, 17% had two vulnerability factors, 43% had one vulnerability factor, and 37% had no vulnerability factors. Improved biological markers were seen in all vulnerability groups (1-3) and odds ratios for improvement were significantly higher in the most socioeconomically vulnerable group for smoking and stress compared to the group with no vulnerability factors. CONCLUSION: Socioeconomically vulnerable groups were reached and lifestyle changes were accomplished to the same extent as in the higher socioeconomic groups in a PHC lifestyle intervention programme. KEY POINTS Primary care plays a major part in prevention of chronic diseases. However, non-pharmacological primary and secondary prevention is often less successful, especially concerning socioeconomically vulnerable groups. The health promoting intervention programme "Pro-Health" reached and engaged socioeconomically vulnerable groups. Participants from the socioeconomically vulnerable groups had comparable odds for lifestyle improvements after one year, compared to participants without vulnerability factors.

An eHealth Diary and Symptom-Tracking Tool Combined With Person-Centered Care for Improving Self-Efficacy After a Diagnosis of Acute Coronary Syndrome: A Substudy of a Randomized Controlled Trial.

BACKGROUND: Patients with cardiovascular diseases managed by a person-centered care (PCC) approach have been observed to have better treatment outcomes and satisfaction than with traditional care. eHealth may facilitate the often slow transition to more person-centered health care by increasing patients' beliefs in their own capacities (self-efficacy) to manage their care trajectory. eHealth is being increasingly used, but most studies continue to focus on health care professionals' logic of care. Knowledge is lacking regarding the effects of an eHealth tool on self-efficacy when combined with PCC for patients with chronic heart diseases. OBJECTIVE: The objective of our study was to investigate the effect of an eHealth diary and symptom-tracking tool in combination with PCC for patients with acute coronary syndrome (ACS). METHODS: This was a substudy of a randomized controlled trial investigating the effects of PCC in patients hospitalized with ACS. In total, 199 patients with ACS aged <75 years were randomly assigned to a PCC intervention (n=94) or standard treatment (control group, n=105) and were followed up for 6 months. Patients in the intervention arm could choose to use a Web-based or mobile-based eHealth tool, or both, for at least 2 months after hospital discharge. The primary end point was a composite score of changes in general self-efficacy, return to work or prior activity level, and rehospitalization or death 6 months after discharge. RESULTS: Of the 94 patients in the intervention arm, 37 (39%) used the eHealth tool at least once after the index hospitalization. Most of these (24/37, 65%) used the mobile app and not the Web-based app as the primary source of daily self-rating input. Patients used the eHealth tool a mean of 38 times during the first 8 weeks (range 1-118, SD 33) and 64 times over a 6-month period (range 1-597, SD 104). Patients who used the eHealth tool in combination with the PCC intervention had a 4-fold improvement in the primary end point compared with the control group (odds ratio 4.0, 95% CI 1.5-10.5; P=.005). This improvement was driven by a significant increase in general self-efficacy compared with the control group (P=.011). Patients in the PCC group who did not use the eHealth tool (n=57) showed a nonsignificant composite score improvement compared with those in the control group (n=105) (odds ratio 2.0, 95% CI 0.8-5.2; P=.14). CONCLUSIONS: We found a significant effect on improved general self-efficacy and the composite score for patients using an eHealth diary and symptom-tracking tool in combination with PCC compared with traditional care. TRIAL REGISTRATION: Swedish registry, Researchweb.org, ID NR 65 791.

Is the quality of primary healthcare services influenced by the healthcare centre's type of ownership?-An observational study of patient perceived quality, prescription rates and follow-up routines in privately and publicly owned primary care centres.

BACKGROUND: Primary healthcare in Sweden has undergone comprehensive reforms, including freedom of choice regarding provider, freedom of establishment and increased privatisation aiming to meet demands for quality and availability. In this system privately and publicly owned primary care centres with different business models (for-profit vs non-profit) coexist and compete for patients, which makes it important to study whether or not the type of ownership influences the quality of the primary healthcare services. METHODS: In this retrospective observational study (April 2011 to January 2014) the patient perceived quality, the use of antibiotics and benzodiazepine derivatives, and the follow-up routines of certain chronic diseases were analysed for all primary care centres in Region Västra Götaland. The outcome measures were compared on a group level between privately owned (n = 86) and publicly owned (n = 114) primary care centres (PCC). RESULTS: In comparison with the group of publicly owned PCCs, the group of privately owned PCCs were characterized by: a smaller, but continuously growing share of the population served (from 32 to 36%); smaller PCC population sizes (avg. 5932 vs. 9432 individuals); a higher fraction of PCCs located in urban areas (57% vs 35%); a higher fraction of listed citizens in working age (62% vs. 56%) and belonging to the second most affluent socioeconomic quintile (26% vs. 14%); higher perceived patient quality (82.4 vs. 79.6 points); higher use of antibiotics (6.0 vs. 5.1 prescriptions per 100 individuals in a quarter); lower use of benzodiazepines (DDD per 100 patients/month) for 20-74 year olds (278 vs. 306) and >74 year olds (1744 vs.1791); lower rates for follow-ups of chronic diseases (71.2% vs 74.6%). While antibiotic use decreased, the use of benzodiazepines increased for both groups over time. CONCLUSIONS: The findings of this study cannot unambiguously answer the question of whether or not the quality is influenced by the healthcare centre's type of ownership. It can be questioned whether the reform created conditions that encouraged quality improvements. Tendencies of an (unintended) unequal distribution of the population between the two groups with disparities in age, socio-economy and geography might lead to unpredictable effects. Further studies are necessary for evidence-informed policy-making.

Effective teamwork in primary healthcare through a structured patient-sorting system - a qualitative study on staff members' conceptions.

BACKGROUND: Primary healthcare meets increased demands from an aging population concerning quality and availability while concurrently dealing with a growing shortage of general practitioners and imperfect efficiency in healthcare processes. Reorganization and team development can improve quality and performance but projects in primary care frequently do not attain the targeted results. By developing and introducing a structured patient-sorting system a primary healthcare centre in Western Sweden increased its access rate significantly and employed its medical professionals more efficiently. The aim of this study was to explore staff members' conceptions of the structured patient-sorting system in order to gain an inside perspective on this project. METHODS: In this qualitative study 16 interviews were conducted over a period of two years and data was analysed using a phenomenographic approach to identify the various conceptions of the eleven participants. RESULTS: Three categories of description were identified: The system was conceptualized as 1) a framework for the development of patient-centred processes that were clear and consistent, 2) a promotor of professional development and a shared ideal of cooperative practice and 3) a common denominator and catalyst in conflict management. CONCLUSIONS: This study demonstrates that the introduction of a structured patient-sorting system makes it possible for several important change processes to take place concurrently: improvement of healthcare processes, empowerment of professionals and team development. It therefore indicates the importance of an appropriate, contextualized framework to support multiple concomitant quality improvement processes. Knowledge from this study can be used to assist and improve future implementations in primary healthcare centres.

Primary healthcare in transition--a qualitative study of how managers perceived a system change.

BACKGROUND: Primary healthcare in Sweden has undergone widespread reforms in recent years, including freedom of choice regarding provider, freedom of establishment and increased privatisation. The key aims of the reforms were to strengthen the role of the patient and improve performance in terms of access and responsiveness. The aim of this study was to explore how managers at publicly owned primary healthcare centres perceived the transition of the primary healthcare system and the impact it has had on their work. METHODS: In this qualitative study, 24 managers of publicly owned primary healthcare centres in the metropolitan region of Gothenburg were recruited. Semi-structured interviews were conducted and data were analysed using content analysis inspired by Silverman. RESULTS: The analysis revealed two core themes: The transition is perceived as a rapid change, enforced mainly through financial incentives and Prioritisation conflicts arise between patient groups with different needs, demands and levels of empowerment. The transition has produced powerful and rapid effects that were considered to be both positive and negative. While the new financial incentives were seen as a driving force and a tool for change, they also became a stress factor due to uncertainty, competition with other primary healthcare centres and negative feelings associated with staff cutbacks. The shift in power towards the patient improved access and service but also led to more patients with unreasonable demands. Managers found it difficult to prioritise correctly between patient groups with different needs, demands and levels of empowerment and they were concerned about potentially negative effects on less empowered patients, e.g. multi-morbid patients. Managers also experienced shortcomings in their change management skills. CONCLUSIONS: This qualitative study shows the complexity of the system change and describes the different effects and perceptions of the transition from a manager's perspective. This suggests a need for improved follow-up and control in order to monitor and govern system changes and ensure development towards a more effective and sustainable primary healthcare system.

Improved prediction of COPD in at-risk patients using lung function pre-screening in primary care: a real-life study and cost-effectiveness analysis.

BACKGROUND: The importance of identifying chronic obstructive pulmonary disease (COPD) at an early stage is recognised. Improved and easily accessible identification of individuals at risk of COPD in primary care is needed to select patients for spirometry more accurately. AIMS: To explore whether use of a mini-spirometer can predict a diagnosis of COPD in patients at risk of COPD in primary care, and to assess its cost-effectiveness in detecting patients with COPD. METHODS: Primary care patients aged 45-85 years with a smoking history of >15 pack-years were selected. Data were collected on the Clinical COPD Questionnaire (CCQ), Medical Research Council (MRC) dyspnoea scale and smoking habits. Lung function (forced expiratory volume in 1 and 6 s; FEV1 and FEV6, respectively) was measured by mini-spirometer (copd-6), followed by diagnostic standard spirometry (COPD diagnosis post-bronchodilation ratio of FEV1 to forced vital capacity (FVC) <0.7). Time consumed was recorded. Univariate logistic regression and receiver operating characteristic (ROC) curves were used. RESULTS: A total of 305 patients (57% females) of mean (SD) age 61.2 (8.4) years, mean (SD) total CCQ 1.0 (0.8) and mean (SD) MRC 0.8 (0.8) were recruited from 21 centres. COPD was diagnosed in 77 patients (25.2%) by standard diagnostic spirometry. Using the copd-6 device, mean (SD) FEV1/FEV6 was 68 (8)% in patients with COPD and 78 (10)% in patients without COPD. Sensitivity and specificity at a FEV1/FEV6 cut-off of 73% were 79.2% and 80.3%, respectively. The area under the ROC curve was 0.84. Screening with the copd-6 device significantly predicted COPD. Gender, CCQ, and MRC were not found to predict COPD. CONCLUSIONS: Using the copd-6 as a pre-screening device, the rate of COPD diagnoses by standard diagnostic spirometry increased from 25.2% to 79.2%. Although the sensitivity and specificity of the copd-6 could be improved, it might be an important device for prescreening of COPD in primary care and may reduce the number of unnecessary spirometric tests performed.

Adherence to lipid-lowering guidelines for secondary prevention and potential reduction in CVD events in Swedish primary care: a cross-sectional study.

OBJECTIVES: The protective effect of lipid-lowering treatment for secondary prevention after coronary heart disease (CHD) has been well documented. Current guidelines recommend a target level for low-density lipoprotein cholesterol (LDL-C) of ≤1.8 mmol/L. The aim was to describe lipid-lowering treatment patterns and to provide an estimate of the potential reductions in cardiovascular disease (CVD) events with improved adherence to guidelines. DESIGN: Cross-sectional. SETTING: Primary care in a large Swedish region. PARTICIPANTS: 37 120 patients with CHD in a Swedish regional primary care quality register (QregPV), by 31 December 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of patients on statin treatment and proportion of patients achieving LDL-C ≤1.8 mmol/L. Estimated number of CVD events calculated for (1) current treatment, (2) improved treatment and (3) lowered LDL-C, based on applying rate reductions from meta-analyses of randomised trials to the potentially undertreated population. Risk estimation modelling was based on 52 042 patients in the same register on January 2011 followed for 5 years. RESULTS: Of 37 120 patients, 18% reached LDL-C ≤1.8 mmol/L and 32% were not on statin treatment. Based on individual risks, the estimated number of CVD events in the study group over 5 years was 9209/37 120. If all patients without a statin or with less potent statin treatment were given atorvastatin 80 mg, an estimated reduction of CVD events by 14% (7901 vs 9209) was seen. If all patients achieved LDL-C ≤1.8 mmol/L, the number of events was estimated to be reduced by 18% (7577 vs 9209). CONCLUSION: One-third of patients with CHD in primary care were not on lipid-lowering treatment. Based on the assumption that included patients would react to statin therapy the same way as the patients in randomised trials, improved adherence to treatment guidelines could lead to a substantial reduction in new CVD events.

Association between CD14 polymorphisms and serum soluble CD14 levels: effect of atopy and endotoxin inhalation.

BACKGROUND: A prerequisite for activation of the innate immune response by endotoxin is its binding to CD14. OBJECTIVE: The aim of this study was to evaluate the role of CD14 polymorphisms, atopy, and inhaled endotoxin in modulating serum CD14 levels. METHODS: Healthy volunteers (n = 88) were genotyped for CD14 polymorphisms at the -1619, -1359, and -159 loci, relative to the transcription start site. Subjects inhaled 20 mug of endotoxin, and white blood cell, C-reactive protein, LPS-binding protein, and soluble CD14 (sCD14) levels were measured before and after exposure. RESULTS: Homozygotes for the -1619G, -1359G, and -159T alleles had higher baseline levels of sCD14 than carriers of the CD14/-1619AA (P = .015), -1359GT/TT (P = .015), or -159CC (P = 0.017) genotypes. sCD14 levels increased within 24 hours of endotoxin inhalation (P < .0001 for all biomarkers); however, the association between CD14 polymorphisms and sCD14 levels was no longer present after exposure. The atopic status of an individual did not alter these associations. CD14 polymorphisms were not associated with levels of white blood cells, C-reactive protein, and LPS-binding protein before or after endotoxin challenge. CONCLUSION: These data suggest that CD14 promoter polymorphisms and inhaled endotoxin modulate sCD14 levels.

A feasible lifestyle program for early intervention in patients with chronic obstructive pulmonary disease (COPD): a pilot study in primary care.

AIM: To evaluate the feasibility of a lifestyle program for early intervention in patients with COPD in a primary care population. METHODS: The study was performed in a Primary Health Care Centre in Western Sweden. During a four-week period, all smokers between 40-70 years of age were invited to answer a questionnaire and to perform spirometry. The intervention program included a specially designed smoking cessation program and programs for physical activity and diet. RESULTS: 84 smokers were included. 42% fulfilled the criteria for COPD. All of the COPD patients were in GOLD stage I and II. Among the COPD subjects, 38% were underweight and 56% had a low fat-free mass - both together indicating malnutrition and the need for nutritional treatment. By the end of the intervention program, 47% of the COPD patients had stopped smoking. CONCLUSIONS: The intervention program was feasible and effective with a very high smoking cessation rate.

Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial.

BACKGROUND: Physiotherapists and general practitioners (GPs) both act as primary assessors for patients with musculoskeletal disorders in primary care. Previous studies have shown that initial triaging to physiotherapists at primary healthcare centres has advantages regarding efficiency in the work environment and utilization of healthcare. In this study, we aimed primarily to determine whether triaging to physiotherapists affects the progression of health aspects over time differently than traditional management with initial GP assessment. The secondary aim was to determine whether triaging to physiotherapists affects patients' attitudes of responsibility for musculoskeletal disorders. METHODS: This was a pragmatic trial where both recruitment and treatment strategies were determined by clinical, not study-related parameters, and was initiated at three primary care centres in Sweden. Working-age patients of both sexes seeking primary care for musculoskeletal disorders and nurse assessed as suitable for triaging to physiotherapists were randomized to initial consultations with either physiotherapists or GPs. They received self-assessment questionnaires before the initial consultation and were followed up at 2, 12, 26 and 52 weeks with the same questionnaires. Outcome measures were current and mean (3 months) pain intensities, functional disability, risk for developing chronic musculoskeletal pain, health-related quality of life and attitudes of responsibility for musculoskeletal conditions. Trends over time were analysed with a regression model for repeated measurements. RESULTS: The physiotherapist-triaged group showed significant improvement for health-related quality of life at 26 weeks and showed consistent but nonsignificant tendencies to greater reductions of current pain, mean pain in the latest 3 months, functional disability and risk for developing chronic pain compared with traditional management. The triage model did not consistently affect patients' attitudes of responsibility for musculoskeletal disorders. CONCLUSIONS: Triaging to physiotherapists for primary assessment in primary care leads to at least as positive health effects as primary assessment by GPs and can be recommended as an alternative management pathway for patients with musculoskeletal disorders. CLINICALTRIALSGOV IDENTIFIER: NCT148611.

Low socio-economic status, smoking, mental stress and obesity predict obstructive symptoms in women, but only smoking also predicts subsequent experience of poor health.

This study was conducted among female subjects to assess the possible association between selected risk factors and lung function as well as airway symptoms in a 32-year perspective. The Prospective Population Study of Women was initiated in 1968-1969 in Göteborg, Sweden (population about 450,000) with follow-ups in 1974-1975, 1980-1981, 1992-1993 and 2000-2001. Women born in 1930, representative of women of the same age in the general population in 1968, were selected. Initially, 372 participants were included in the cohort. In 2000-2001, 231 of these women (73%), now 70 years old, underwent lung function tests. The main outcome measures were lung function values, airway symptoms and health outcome in 2000-2001 in relation to self-reported exposures in 1968-1969 including smoking status. Smoking in 1968-1969 was associated with self-reported chronic bronchitis, obstructive symptoms and poor health 32 years later as well as lower lung function values, compared to non-smokers. Obesity, low socio-economic status and self-reported mental stress in 1968-1969 were associated with obstructive symptoms 32 years later. There are only a few longitudinal studies concerning women's health problems in this field and epidemiological studies of lung function impairment in women and risk factors in a long-term perspective are scarce. The results of the study suggest that life-style factors such as mental stress, obesity and smoking among women are related to airway symptoms and also quality of life many years later.

A sense of increased living space after participating in multimodal rehabilitation.

PURPOSE: The aim was to explore and describe experiences of change related to multimodal rehabilitation (MMR) in participants suffering from persistent musculoskeletal-related pain, in order to increase knowledge about the impact of the rehabilitation. METHODS: Participants in MMR from an outpatient rehabilitation unit in primary care in Sweden were recruited for interviews about any kind of change they experienced that they thought were related to their participation in the MMR. Systematic text condensation according to Malterud was used to analyze the data. RESULTS: A total of 14 participants were interviewed. The interview analysis resulted in four categories in which the participants described their experience of change related to the MMR: a new desire for participation, increased embodied knowledge, a stronger sense of feeling empowered and regained hope. The categories interacted and from these categories, one theme emerged: a sense of increased living space. CONCLUSION: According to these results, it is important to have various entrances to enhance change and to be aware of how these changes interact and can reinforce each other in order to facilitate the participants' empowerment processes toward a sense of increased living space. Implications for rehabilitation The efforts in MMR should be coordinated to be mutually reinforcing as changes in one area could facilitate in others and thus facilitate the participants' empowerment processes. Participants experience change after MMR in areas that standardized assessment questionnaires do not capture and consequently it would be useful to let the participants answer an open question about perceived changes together with standardized questionnaires.

Physiotherapy in Primary Care Triage - the effects on utilization of medical services at primary health care clinics by patients and sub-groups of patients with musculoskeletal disorders: a case-control study.

BACKGROUND: Primary Care Triage is a patient sorting system used in some primary health care clinics (PHCCs) in Sweden where patients with musculoskeletal disorders (MSD) are triaged directly to physiotherapists. The purpose of this study was to investigate whether sorting/triaging patients seeking a PHCC for MSD directly to physiotherapists affects their utilization of medical services at the clinic for the MSD and to determine whether the effects of the triaging system vary for different sub-groups of patients. METHODS: A retrospective case-control study design was used at two PHCCs. At the intervention clinic, 656 patients with MSD were initially triaged to physiotherapists. At the control clinic, 1673 patients were initially assessed by general practitioners (GPs). The main outcome measures were the number of patients continuing to visit GPs after the initial assessment, the number of patients receiving referrals to specialists/external examinations, doctors' notes for sick-leave or prescriptions for analgesics during one year, all for the original MSD. RESULTS: Significantly fewer patients triaged to physiotherapists required multiple GP visits for the MSD or received MSD-related referrals to specialists/external examinations, sick-leave recommendations or prescriptions during the following year compared to the GP-assessed group. This applies to all sub-groups except for the group with lower extremity disorders, which did not reach significance for either multiple GP visits or sick-leave recommendations. CONCLUSIONS: The reduced utilization of medical services by patients with MSD who were triaged to physiotherapists at a PHCC is likely due to altered management of MSD with initial assessment by physiotherapists.

Person-centred care after acute coronary syndrome, from hospital to primary care - A randomised controlled trial.

AIM: To evaluate if person-centred care can improve self-efficacy and facilitate return to work or prior activity level in patients after an event of acute coronary syndrome. METHOD: 199 patients with acute coronary syndrome < 75 years were randomly assigned to person-centred care intervention or treatment as usual and followed for 6 months. In the intervention group a person-centred care process was added to treatment as usual, emphasising the patient as a partner in care. Care was co-created in collaboration between patients, physicians, registered nurses and other health care professionals and documented in a health plan. A team-based partnership across three health care levels included transparent knowledge about the disease and medical state to achieve agreed goals during recovery. Main outcome measure was a composite score of changes in general self-efficacy ≥ 5 units, return to work or prior activity level and re-hospitalisation or death. RESULTS: The composite score showed that more patients (22.3%, n=21) improved in the intervention group at 6 months compared to the control group (9.5%, n=10) (odds ratio, 2.7; 95% confidence interval: 1.2-6.2; P=0.015). The effect was driven by improved self-efficacy ≥ 5 units in the intervention group. Overall general self-efficacy improved significantly more in the intervention group compared with the control group (P=0.026). There was no difference between groups on re-hospitalisation or death, return to work or prior activity level. CONCLUSION: A person-centred care approach emphasising the partnership between patients and health care professionals throughout the care chain improves general self-efficacy without causing worsening clinical events.

Work-related symptoms and inflammation among sewage plant operatives.

Sewage operatives at five sewage treatment plants (n = 59) and controls not exposed to sewage (n = 55) were examined to determine work-related symptoms and inflammatory responses. Symptoms were elicited using a questionnaire, and spirometry was performed. Inflammatory markers were determined in blood and nasal lavage. Workplace endotoxin and hydrogen sulfide were measured and adeno- and enterovirus antibodies were evaluated in blood. Gastrointestinal and airway symptoms, joint pains, unusual tiredness, and toxic pneumonitis were more common among operatives, and the proportion of blood neutrophils was higher among operatives as compared with controls. A relationship was found between several reported symptoms and the inflammatory markers. Hydrogen sulfide levels were very low. Endotoxin levels were generally low, but high at some work sites.

Patients' experience of being triaged directly to a psychologist in primary care: a qualitative study.

BACKGROUND: In a primary health-care centre (PHCC) situated in a segregated area with low socio-economic status, 'primary care triage' has increased efficiency and accessibility. In the primary-care triage, the nurse sorts the patient to the appropriate PHCC profession according to described symptoms. Aim The aim of this study was to examine the patients' experience of being triaged directly to a psychologist for assessment. METHOD: Interviews were conducted with 20 patients and then analysed using qualitative content analysis. FINDINGS: The results show that patients contacting the PHCC for mental health issues often are active agents with their own intent to see a psychologist, not a doctor, as a first-hand choice when contacting the PHCC. Seeking help for mental health issues is described as a sensitive issue that demands building up strength before contacting. The quick access to the preferred health-care professional is appreciated. The nurse was perceived as a caring facilitator rather than a decision maker. It is the patient's wish rather than the symptoms that directs the sorting. The patients' expectations when meeting the psychologist were wide and diverse. The structured assessment sometimes collided and sometimes united with these expectations, yielding different outcome satisfaction. The results could be seen in line with the present goal to increase patients' choice in the health-care system. The improved accessibility to the psychologist seems to meet community expectations. The results also indicate a need for providing more prior information about the assessment and potential outcomes.