Process evaluation of the CO-WORK-CARE model: Collaboration and a person-centred dialogue meeting for patients with common mental disorder in primary health care.

RATIONALE: To ensure optimal patient care based on evidence, it is crucial to understand how to implement new methods in practice. However, intervention studies often overlook parts of the implementation process. A comprehensive process evaluation is necessary to understand why interventions succeed or fail in specific contexts and to integrate new knowledge into daily practice. This evaluation examines the full implementation of the Co-Work-Care model in Swedish primary healthcare to identify strengths and weaknesses. AIM: This study aimed to evaluate the process of implementing the CO-WORK-CARE model that focuses on close collaboration and the use of a person-centred dialogue meeting in primary healthcare for patients on sick leave due to common mental disorders. METHOD: The CO-WORK-CARE model emphasises collaboration among the GP, rehabilitation coordinator and care manager, along with person-centred dialogue meetings involving employers. Following UK Medical Research Council guidelines, we conducted a process evaluation. Data from previous studies were reanalysed. We also analysed field notes and meeting notes using Malterud's qualitative method. RESULTS: The evaluation identified key facilitators for model implementation, including regular visits by facilitators and guidance from the research physician. Peer support meetings also bolstered implementation. However, challenges emerged due to conflicts with existing structures and limitations in person-centred dialogue meetings. CONCLUSION: Adapting the CO-WORK-CARE model to Swedish primary care is feasible and beneficial, with collaboration among the care manager, rehabilitation coordinator and GP and person-centred dialogue meetings. Thorough preparations, ongoing facilitator and peer support and integrated information enhanced implementation efficiency, despite challenges posed by existing structures.

Mild-to-Moderate Kidney Dysfunction and Cardiovascular Disease: Observational and Mendelian Randomization Analyses.

BACKGROUND: End-stage renal disease is associated with a high risk of cardiovascular events. It is unknown, however, whether mild-to-moderate kidney dysfunction is causally related to coronary heart disease (CHD) and stroke. METHODS: Observational analyses were conducted using individual-level data from 4 population data sources (Emerging Risk Factors Collaboration, EPIC-CVD [European Prospective Investigation into Cancer and Nutrition-Cardiovascular Disease Study], Million Veteran Program, and UK Biobank), comprising 648 135 participants with no history of cardiovascular disease or diabetes at baseline, yielding 42 858 and 15 693 incident CHD and stroke events, respectively, during 6.8 million person-years of follow-up. Using a genetic risk score of 218 variants for estimated glomerular filtration rate (eGFR), we conducted Mendelian randomization analyses involving 413 718 participants (25 917 CHD and 8622 strokes) in EPIC-CVD, Million Veteran Program, and UK Biobank. RESULTS: There were U-shaped observational associations of creatinine-based eGFR with CHD and stroke, with higher risk in participants with eGFR values <60 or >105 mL·min-1·1.73 m-2, compared with those with eGFR between 60 and 105 mL·min-1·1.73 m-2. Mendelian randomization analyses for CHD showed an association among participants with eGFR <60 mL·min-1·1.73 m-2, with a 14% (95% CI, 3%-27%) higher CHD risk per 5 mL·min-1·1.73 m-2 lower genetically predicted eGFR, but not for those with eGFR >105 mL·min-1·1.73 m-2. Results were not materially different after adjustment for factors associated with the eGFR genetic risk score, such as lipoprotein(a), triglycerides, hemoglobin A1c, and blood pressure. Mendelian randomization results for stroke were nonsignificant but broadly similar to those for CHD. CONCLUSIONS: In people without manifest cardiovascular disease or diabetes, mild-to-moderate kidney dysfunction is causally related to risk of CHD, highlighting the potential value of preventive approaches that preserve and modulate kidney function.

Anaemia in patients with self-reported use of iron supplements in the BAriatric surgery SUbstitution and nutrition study: A prospective cohort study.

BACKGROUND AND AIMS: After bariatric surgery, micronutrient deficiencies may lead to anaemia. To prevent post-operative deficiencies, patients are recommended lifelong micronutrient supplementation. Studies investigating the effectiveness of supplementation to prevent anaemia after bariatric surgery are scarce. This study aimed to investigate the relationship between nutritional deficiencies and anaemia in patients who report use of supplementation two years after bariatric surgery versus patients who do not. METHODS AND RESULTS: Obese (BMI≥35 kg/m2) individuals (n = 971) were recruited at Sahlgrenska University Hospital in Gothenburg, Sweden between 2015 and 2017. The interventions were Roux-en-Y gastric bypass (RYGB), n = 382, sleeve gastrectomy (SG), n = 201, or medical treatment (MT), n = 388. Blood samples and self-reported data on supplements were collected at baseline and two years post treatment. Anaemia was defined as haemoglobin <120 g/L for females and <130 g/L for males. Standard statistical methods, including a logistic regression model and a machine learning algorithm, were used to analyse data. The frequency of anaemia increased from baseline in patients treated with RYGB (3·0% vs 10·5%; p < 0·05). Neither iron-dependent biochemistry nor frequency of anaemia differed between participants who reported use of iron supplements and those who did not at the two-year follow-up. Low preoperative level of haemoglobin and high postoperative percent excessive BMI loss increased the predicted probability of anaemia two years after surgery. CONCLUSION: The results from this study indicate that iron deficiency or anaemia may not be prevented by substitutional treatment per current guidelines after bariatric surgery and highlights there is reason to ensure adequate preoperative micronutrient levels. TRIAL REGISTRATION: March 03, 2015; NCT03152617.

Trends in haemoglobin levels from 1968 to 2017 and association with hormonal contraceptives: observations from the population study of women in Gothenburg, Sweden.

AIM: To investigate trends in the haemoglobin (Hb) level in middle-aged Swedish women from 1968 to 2017 and to examine the potential association between Hb and the use of hormonal contraceptives (HCs). DESIGN: A prospective observational population study of representative 38- and 50-year-old women of Gothenburg, Sweden. SETTING: The population study of women in Gothenburg started in 1968-1969 and has continued since then with new examinations every 12 years, including both follow-ups and new recruited cohorts. The study consists of both physical examinations and questionnaires. SUBJECTS: Two thousand four hundred eighty-eight women aged 38 and 50 participated in the study from 1968 to 2017. STATISTICAL METHODS: Linear regression model analyses were used to analyse linear and non-linear trends in the level of Hb. Linear and logistic regression models were used to analyse possible associations between HC and Hb and possible associations between the use of HC and anaemia, respectively. MAIN OUTCOME MEASURES AND COVARIATES: Hb was measured in g/L. HC included any ongoing use of HC therapy. Covariates were smoking, body mass index (BMI), alcohol consumption and education. RESULTS: A non-linear U-shaped trend in mean Hb was seen in the two age groups, 38- and 50-years old. After adjusting for covariates, a significantly higher mean Hb was seen in the 2016-2017 examination compared to 1980-1981, 1992-1993 and 2004-2005. In 38-year-olds, using HC was associated with a reduced risk of anaemia (OR 0.35, 95% CI 0.13-0.75). In both age groups, the use of HC was significantly associated with having a higher Hb. CONCLUSIONS: Mean levels of Hb in middle-aged women of the general population seem to be increasing again after lower levels in the 1980s and 1990s. The use of HC was associated with having a higher Hb and a lower risk of anaemia in 38-year-old women.

Studies of trends in haemoglobin (Hb) in Swedish women are scarce, although many factors associated with Hb levels have changed during the last decades.The use of hormonal contraceptives was associated with higher Hb and decreased risk of anaemia in younger middle-aged women.This study shows there is a non-linear (U-formed) trend in mean Hb, with increasing values since 1992.

How can care managers strengthen health literacy among patients with common mental disorders? A qualitative study.

BACKGROUND: In order for persons with mental illness to be able to promote and preserve their health, sufficient knowledge about health is required. An effective means to improve the health of the patients is to strengthen their health literacy. The aim of this study was to explore how care managers work with health literacy in patients with common mental disorders to help them to better understand and manage their illness. METHOD: A qualitative study was conducted, using written reports from 25 care managers regarding meetings with patients with common mental disorders in the primary care in a Swedish region. The care managers' reports were coded based on Sörensen's four dimensions for the domain "health care" and analysed deductively through systematic text condensation according to Malterud. RESULTS: The care managers described how they worked strategically and continuously with follow-up and wanted to be responsive to the patients' stories. They confirmed the patients' feelings with the goal of creating increased interaction, thereby involving the patients in their own care. The care managers also worked actively to provide well-balanced care at an early stage. Using various tools such as self-assessment instruments, the care manager started from the patient's basic problem, gave support and discussed strategies based on the patient's condition and situation. CONCLUSIONS: The care managers used multifaceted health literacy interventions. They worked in a person-centred, strategic and encouraging manner based on the patient's unique conditions, where sensitivity and adapted information were important aspects. The aim of the interventions was for the patients to become knowledgeable, gain new insights and work independently with their own health.

Associations between alcohol and liver enzymes are modified by coffee, cigarettes, and overweight in a Swedish female population.

PURPOSE: To examine whether positive associations between alcohol and liver enzymes were modified by coffee consumption, smoking, or weight status in a female population. METHODS: Regular consumption of beer, wine, and spirits was assessed in a representative cohort of 1462 Swedish women aged 38-60 in 1968, and re-assessed in 1974. In 1980, gamma-glutamyltransferase (GGT) and aspartase transaminase (AST) were measured in 1130 women. Exposures were averaged over values obtained in 1968 and 1974. Multivariable linear regression linked total ethanol intake to log-transformed enzyme values, including interactions by coffee, smoking, and overweight in mutually adjusted models. RESULTS: Coffee consumption significantly modified the association between ethanol intake and liver enzymes. One g/day higher ethanol intake was associated with 5.5 (3.5, 7.5)% higher values of GGT, and 1.2 (0.4, 2.1)% higher values of AST in women consuming 0-1 cups of coffee per day, while smaller or no effects were observed in women consuming ≥2 cups/day. Synergistic interactions were observed for ethanol and smoking, and for ethanol and overweight. Average alcohol-related effects on GGT in smokers and non-smokers were given by 3.8 (2.7, 4.9)% and 2.1 (0.9, 3.2)% per g ethanol/day, and by 0.9 (0.4, 1.4)% and 0.2 (-0.3, 0.7)% for AST. Similarly, in overweight women, 1 g/day higher ethanol intake was associated with 4.3 (3.0, 5.6)% higher GGT compared to 1.6 (0.7, 2.5)% in non-overweight women. CONCLUSIONS: The results suggest that coffee consumption reduces the enzyme-raising effect of ethanol in the presence of synergistic interactions with smoking and overweight, specifically in women.

Increased use of analgesics in midlife women but no association with mental stress: observations from the Prospective Population Study of Women in Gothenburg.

BACKGROUND: The study is part of the ongoing Prospective Population Study of Women in Gothenburg, Sweden, initiated in 1968-1969 with the aim of characterising a total population of women who were representative of middle-aged females. The aim of the present study was to investigate the prevalence of actual analgesic use (prescribed and self-medication) and the possible association with perceived mental stress among women aged 38 and 50 years, respectively, in the Population Study of Women. METHODS: Two different cohorts of population-based samples of 38- and 50-year-old women examined in 2004-2005 and 2016-2017, respectively, were eligible participants. The women were representative for their age cohort at the time of the examinations. Use of medicines and especially analgesics, as well as perceived mental stress, was registered. Changes in medicine use among 38- and 50-year-old women between 2004 and 2005 and 38- and 50-year-old women in 2016-2017 were studied. Data were analysed using logistic regression. Use of analgesics and mental stress were analysed controlling for lifestyle factors, use of other medicines and pain. RESULTS: The overall sample size across the time periods was 1,073 individuals. The frequency of analgesic use in 38- and 50-year-old women was about 26% in 2004-2005 and 58% in 2016-2017. 28% of women who reported high mental stress in 2004-2005 used analgesics, compared to 60% in 2016-2017. There were no associations between self-perceived mental stress and the use of analgesics. CONCLUSION: The higher use of analgesics among midlife women in 2016-2017 is in line with global findings and could be due to increased availability in Sweden of over the counter medicines. The impact of mental stress on analgesic use found previously by other researchers was not confirmed. However, medicine use as a potential coping strategy is an important public health issue that needs to be further explored.

Forty-four-year longitudinal study of stroke incidence and risk factors - the Prospective Population Study of Women in Gothenburg.

OBJECTIVE: To assess stroke incidence over 44 years and association with risk factors. To study total stroke incidence at 60-82 years of age and risk factors. DESIGN: Prospective population study. SETTING: Gothenburg, Sweden, with ∼450,000 inhabitants. SUBJECTS: A representative sample of a general population of women (1462 in total) in 5 age strata aged 38-60 years in 1968-1969 (the Population Study of Women in Gothenburg, PSWG) were followed up to the ages of 82-104 years in 2012. Further, analysis was also performed for the age interval 60-82 years. MAIN OUTCOME MEASURES: Incidence of total stroke (TS), ischaemic (IS), haemorrhagic (HS), non-specified (NS) and fatal (FS) strokes and association with baseline classic risk factors (such as hypertension, atrial fibrillation, low physical activity, diabetes, high waist-hip-ratio, hyperlipidaemia, smoking), low education, mental stress, pre-eclampsia and oral health as expressed by loss of teeth and bone score. Blood pressure in levels 1-3 according to modern guidelines. Associations with atrial fibrillation, diabetes and myocardial infarction shown in survival analyses. The five cohorts contributed to risk time data concerning associations with TS in the 60-82 age interval from the examination performed when they were 60. RESULTS: Three hundred and thirty-seven (23%) women had a first-ever stroke, 64 (19%) fatal. TS was associated with physical inactivity, high triglycerides and low education in multivariable analysis. The main sub-type IS was associated with systolic blood pressure, physical inactivity and low education. Pre-eclampsia showed association with IS only in the univariable analysis. FS was associated with systolic blood pressure and smoking. During 60-82 years of age, having <20 teeth (HR 1.74, CI 1.25-2.42), diabetes (HR 2.28 CI 1.09-4.76), WHR (HR 1.29 per 0.1 units CI 1.01-1.63), systolic blood pressure (HR 1.11 per 10 units CI 1.04-1.18) and smoking (HR 1.57, CI 1.14-2.16), were associated with TS in the combined five cohorts. CONCLUSIONS: Several classic risk factors showed independent associations with stroke. Vulnerability factors as low education and oral health, reflected by loss of teeth, also showed association with stroke. All these factors are possible to target in primary care preventive interventions.Key PointsStroke is a common disease and the risk of stroke is a key issue demanding preventive strategies in primary health care. The present prospective population study of women showsOut of 1460 women, almost a quarter got a stroke. The stroke incidence 60-82 years of age was rather stable between the first four age cohorts but somewhat lower in the latest cohort, born 1930.Hypertension, low physical activity, low education and high triglyceride levels but not cholesterol were associated with stroke in women.Low education and loss of teeth are vulnerability factors that should need particular attention.

Promoting health literacy and sense of coherence in primary care patients with long-term impaired work ability-a pilot study.

OBJECTIVE: Evaluate feasibility, partnerships, and study design of intervention to minimise sick leave. DESIGN AND SETTING: The design was a pilot single arm intervention study in primary health care. Outcome measures at follow-ups for each participant were compared with baseline data for the same person. SUBJECTS: Twenty primary health care patients with recurrent or long-term sick leave or health-related unemployment. INTERVENTION: Patient education through interactive study groups that met half a day a week for eight subsequent weeks. Groups were led by experienced but not medically trained facilitators. The intervention was designed to improve participant health literacy, sense of coherence, health-related quality of life, and patient involvement in healthcare. MAIN OUTCOME MEASURES: Primary outcome was the level of sick leave. Sick leave data were obtained from medical records when available, otherwise patient reported. Secondary outcomes regarding health literacy, sense of coherence, and health-related quality of life were measured with validated questionnaires at baseline and follow-ups. RESULTS: Level of sick leave decreased significantly and participation in work preparatory activities increased during follow-up. Health literacy, sense of coherence (subscale sense of meaningfulness), and health-related quality of life (subscale social functioning) showed statistically significant improvement. Intervention, partnerships, and study design were feasible. CONCLUSION: An educational programme, conducted in cooperation between primary health care and partners outside the healthcare system, was feasible and showed an impact on sick leave, health literacy, sense of coherence, and health-related quality of life.KEY FINDINGSA pilot study to evaluate an educational programme with study groups conducted in cooperation between primary health care and partners outside the healthcare system showed good feasibility.Sick leave decreased significantly six months after baseline.Health literacy, sense of coherence (subscale sense of meaningfulness), and health-related quality of life (subscale social function) improved significantly 6 months after baseline.

How can a care manager at the primary care centre support foreign-born female patients suffering from common mental disorders? - An interview study.

BACKGROUND: Difficulty in communicating can lead to stressful situations both for foreign-born female patients suffering from common mental disorders (CMDs) and for the health care professionals. AIM: The aim of the study was to explore how foreign-born female patients with CMDs experienced their health care encounters and how they perceived a care manager could be a support during their illness, as well as to explore the care managers' perceptions and experiences concerning this group. METHODS: A qualitative method with semi-structured interview was chosen. The data were analysed with systematic text condensation. The study was conducted in primary care in western Sweden. Eight Persian-speaking female patients were recruited by the snowball method and participated in the study. Furthermore, nine care managers participated. RESULTS: Foreign-born female patients felt shame and anxiety because of language difficulties, interpreter presence, mental illness, and feelings of dependency. The care managers and the patients felt that physical meetings, access to translated assessment scales and female telephone interpreters, and early and continuous contact and access to health care personnel with a similar cultural background could facilitate communication. CONCLUSION: In order to facilitate mutual understanding and knowledge, accessibility and continuity of health care are needed to enable foreign-born female patients with CMD to support their own health development. Female interpreters, telephone interpreting, translated scales, and telephone contacts combined with face-to-face visits could facilitate communication.

Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: 12-month economic evaluation of a pragmatic randomised controlled trial.

OBJECTIVES: To study the cost-effectiveness of a care manager organization for patients with mild to moderate depression in Swedish primary care in a 12-month perspective. METHODS: Cost-effectiveness analysis of the care manager organization compared to care as usual (CAU) in a pragmatic cluster randomised controlled trial including 192 individuals in the care manager group and 184 in the CAU group. Cost-effectiveness was assessed from a health care and societal perspectives. Costs were assessed in relation to two different health outcome measures: depression free days (DFDs) and quality adjusted life years (QALYs). RESULTS: At the 12-month follow-up, patients treated at the intervention Primary Care Centres (PCCs) with a care manager organization had larger health benefits than the group receiving usual care only at control PCCs. Mean QALY per patient was 0.73 (95% CI 0.7; 0.75) in the care manager group compared to 0.70 (95% CI 0.66; 0.73) in the CAU group. Mean DFDs was 203 (95% CI 178; 229) in the care manager group and 155 (95% CI 131; 179) in the CAU group. Further, from a societal perspective, care manager care was associated with a lower cost than care as usual, resulting in a dominant incremental cost-effectiveness ratio (ICER) for both QALYs and DFDs. From a health care perspective care manager care was related to a low cost per QALY (36,500 SEK / €3,379) and DFD (31 SEK/€3). LIMITATIONS: A limitation is the fact that QALY data was impaired by insufficient EQ-5D data for some patients. CONCLUSIONS: A care manager organization at the PCC to increase quality of care for patients with mild-moderate depression shows high health benefits, with no decay over time, and high cost-effectiveness both from a health care and a societal perspective. Trial registration details: The trial was registered in ClinicalTrials.com ( https://clinicaltrials.gov/ct2/show/NCT02378272 ) in 02/02/2015 with the registration number NCT02378272. The first patient was enrolled in 11/20/2014.

The care manager meeting the patients' unique needs using the care manager model-A qualitative study of experienced care managers.

BACKGROUND: Implementation of a care manager in a collaborative care team in Swedish primary care via a randomized controlled trial showed successful outcome. As four years have elapsed since the implementation of care managers, it is important to gain knowledge about the care managers' long-term skills and experiences. The purpose was to examine how long-term experienced care managers perceived and experienced their role and how they related to and applied the care manager model. METHOD: Qualitative study with a focus group and interviews with nine nurses who had worked for more than two years as care managers for common mental disorders. The analysis used Systematic Text Condensation. RESULTS: Four codes arose from the analysis: Person-centred; Acting outside the comfort zone; Successful, albeit some difficulties; Pride and satisfaction. The care manager model served as a handrail for the care manager, providing a trustful and safe environment. Difficulties sometimes arose in the collaboration with other professionals. CONCLUSION: This study shows that long-term experience of working as a care manager contributed to an in-depth insight and understanding of the care manager model and enabled care managers to be flexible and act outside the comfort zone when providing care and support to the patient. A new concept emerged during the analytical process, i.e. the Anchored Care Manager, which described the special competencies gained through experience. TRIAL REGISTRATION: NCT02378272  Care Manager-Coordinating Care for Person Centered Management of Depression in Primary Care (PRIM-CARE).

The experiences of care managers and rehabilitation coordinators of a primary care intervention to promote return to work for patients with common mental disorders: a qualitative study.

BACKGROUND: In an earlier study, PRIM-CARE RCT, a care manager implementation at the primary care centre showed improved return to work and reduced sick leave for patients with CMD. To further improve return to work, the project Co-Work-Care added a person-centered dialogue meeting between the patient, the employer and the rehabilitation coordinator, preceded by an increased collaboration between care manager, rehabilitation coordinator and GP. In this first qualitative study of the Co-Work-Care project, we explored how care managers and rehabilitation coordinators experienced the Co-Work-Care model. The purpose of this study was to explore care managers' and rehabilitation coordinators' perceptions and experiences of a close collaboration and the use of the person-centred dialogue meeting. METHODS: From an ongoing RCT with 20 primary care centres, care managers (CMs) (n = 13) and rehabilitation coordinators (RCs) (n = 12) participated in a qualitative study with focus groups. The study was conducted in the primary health care in a Swedish region. The data was analysed with Systematic Text Condensation by Malterud. RESULTS: Seven codes describing the participants' experiences of the Co-Work-Care model were identified: 1) The importance of collaboration at the primary care centre, 2) Collaboration and division of roles between the RC and the CM, 3) Collaboration with the General practitioner (GP), 4) The person-centred dialogue meeting, 5) Initiating the person-centred dialogue meeting, 6) The person-centred dialogue meeting to improve collaboration with the employer, and 7) The person-centred dialogue meeting to teach about the return to work process. CONCLUSION: The increased collaboration within the Co-Work-Care model created a common picture and understanding of the patient's situation. The person-centred dialogue meeting in the rehabilitation process became a bridge between the employer and the patient. TRIAL REGISTRATION: NCT03250026 (registered August 15, 2017).

Impact of changes in physical activity or BMI on risk of heart failure in women - the prospective population study of women in Gothenburg.

Objective: To longitudinally evaluate the impact of change in physical activity or change in body mass index (BMI) over time on the risk of developing heart failure (HF) in women without a previous diagnosis of HF.Design and setting: Longitudinal, observational, prospective study of women in Gothenburg, Sweden. Data on BMI and level of physical activity were collected from examinations 1968-1992 and hospital diagnoses and mortality data were ascertained from 1980 to 2012.Subjects: Data were obtained from 1749 women included in the Prospective Population Study of Women in Gothenburg.Main outcome measures: Hazard ratio (HR) for HF was calculated, using a Cox regression model.Results: Women with stable high physical activity during 1968-1980 and 1980-1992 reduced their risk of subsequent HF compared to the non-active women (for 1968-1980 HR 0.66, 95% Confidence Interval (CI) 0.44-0.99 and for 1980-1992 HR 0.47, 95% CI 0.29-0.74). Women with increasing levels of physical activity during 1980-1992 reduced their risk of HF compared to the non-active women (HR 0.40, 95% CI 0.22-0.72). Increase in BMI from overweight to obesity during 1968-1980 predicted increased risk of developing HF (HR 1.93, 95% CI 1.18-3.14).Conclusions: Reduced risk of future HF in healthy women may be achieved by remaining physically active from young middle age and throughout life or by increasing the level of physical activity. This is particularly important for sedentary women in middle age. The role of physical activity in preventing the development of obesity must be taken into account.Key pointsA sedentary lifestyle and obesity are risk factors for developing heart failure (HF) in women.The risk of developing HF may be reduced by increasing the level of activity in sedentary middle-aged women.For younger women, avoiding obesity is most important to reduce the risk of later HF.Primary care has a key role in guiding women towards the most effective lifestyle changes to prevent development of HF.

Equalization of four cardiovascular risk algorithms after systematic recalibration: individual-participant meta-analysis of 86 prospective studies.

AIMS: There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after 'recalibration', a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied. METHODS AND RESULTS: Using individual-participant data on 360 737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham risk score (FRS), Systematic COronary Risk Evaluation (SCORE), pooled cohort equations (PCE), and Reynolds risk score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at 'high' 10 year CVD risk. Original risk algorithms were recalibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before recalibration, FRS, SCORE, and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, whereas RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high risk. By contrast, recalibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with recalibrated algorithms. CONCLUSION: Before recalibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple recalibration nearly equalized their performance and improved modelled targeting of preventive action to clinical need.

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences.

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 Västra Götaland 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. KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs' experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

Waist-to-hip ratio but not body mass index predicts liver cirrhosis in women.

BACKGROUND: Being overweight can lead to fatty liver and end-stage liver disease. In men, higher body mass index is associated with higher risk of developing liver cirrhosis. The extent of association between overweight and liver cirrhosis in women is not fully elucidated. AIMS: This study aimed to investigate the association between overweight and liver cirrhosis in women, taking into account different measures of adipose tissue distribution. METHODS: A cohort of 1462 middle-aged women was followed over 40 years. Cases of liver cirrhosis were identified by linkage to Hospital Discharge and Death Certificate registries. The hazard ratios for different anthropometric measures and liver cirrhosis were obtained by Cox proportional hazard regression, using propensity score methods to adjust for important confounders. RESULTS: During 48,062 person-years of follow-up, 11 cases of liver cirrhosis were identified. The incidence rate in women with waist-to-hip ratio ≥ 0.8 was 131.8 (48.1-287.0), compared to 12.0 (3.9-28.1) in women with a lower ratio. A waist-to-hip ratio ≥ 0.8 was associated with an increased risk of liver cirrhosis, the hazard ratio being 5.8 (95% confidence interval 1.6-21.4). No association between body mass index and liver cirrhosis was found and the hazard ratio for body mass index >25 was 1.8 (0.5-5.8). CONCLUSION: In women, an unfavorable adipose tissue distribution is more important for development of liver cirrhosis than total body fat per se. When assessing the risk for development of liver cirrhosis in women, waist-to-hip ratio is a better predictor than body mass index.

Clinical effectiveness of care managers in collaborative care for patients with depression in Swedish primary health care: a pragmatic cluster randomized controlled trial.

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. TRIAL REGISTRATION: Identifier: NCT02378272 . February 2, 2015. Retrospectively registered.

Socioeconomic disparities in physical activity among Swedish women and trends over time - the population study of women in Gothenburg.

OBJECTIVE: To explore secular trends in physical activity in relation to socioeconomic position in middle-aged women, with focus on whether the social gaps have become wider, narrower, or remain unchanged. DESIGN: Cohort comparisons between two representative samples of women, recruited in 1980-81 and 2004-05 as a part of the Population Study of Women in Gothenburg. SETTING: Gothenburg, the second largest city of Sweden, with ≈ 450 000 inhabitants. SUBJECTS: Population-based cohorts of 38- and 50-year-old women, invited in 1980-81 and 2004-05 to free health examinations. The study population in 1980 was n = 477, 38- and 50-year-old women born in 1930 (n = 355) and 1942 (n = 122), and in 2004 n = 500, 38- and 50-year- old women born in 1966 (n = 207) and 1954 (n = 293). MAIN OUTCOME MEASURE: Physical activity at work and leisure time. Socioeconomic position was defined based on socio-occupational group and level of education. Physical activity during work and leisure time was based on questionnaires. RESULTS: On average 38- and 50-year-old women were more physically active at work and leisure time in 2004-05 compared to 1980-81; odds ratio (OR) for increase over time for physical activity at work for 38-year-olds: 2.59, (95% confidence interval (CI) 1.65-4.07), and for 50-year-olds: OR 2.09 (1.52-2.88); OR for increase physical activity leisure time in 38-year-olds: 1.93 (1.25-2.98), and in 50-year-olds 2.04 (1.49-2.79). There were no significant differences between socioeconomic groups in physical activity levels changes over time. CONCLUSION: Women in different socioeconomic groups improved their physical activity at work and leisure time to the same extent from 1980 to 2004, indicating that the socioeconomic gap in physical activity is neither increasing nor decreasing. Key Points  The gap in physical activity levels between socioeconomic groups seems to have remained stable for middle-aged women the last 25 years. • However, women were more physically active in 2004 at work and during leisure time, independent of socioeconomic position, compared to 1980. • It remains a great challenge to create structures that enable these behaviours for all social groups.

Creating a safety net for patients with depression in primary care; a qualitative study of care managers' experiences.

OBJECTIVE: The aim of this study was to explore nurses' experiences and perceptions of working as care managers at primary care centers. DESIGN: Qualitative, focus group study. Systematic text condensation was used to analyze the data. SETTING: Primary health care in the region of Västra Götaland and region of Dalarna in Sweden. SUBJECTS: Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support. MAIN OUTCOME MEASURES: The nurses' experiences and perceptions of working as care managers at primary care centers. RESULTS: The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression. CONCLUSION: The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care. Key Points The care managers described their role as an additional support to the already existing care at the primary care center. • They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression. • Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful. • Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.