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Lindblom S, Ivarsson C, Wändell P, Bergqvist M, Norrman A, Eriksson J, Lund L, Hagströmer M, Hasselström J, Sandlund C, Carlsson AC. Lifestyle counseling in patients with hypertension in primary health care and its association with antihypertensive pharmacotherapy. J Clin Hypertens (Greenwich) 2024; 26:816-824. [PMID: 38850281 PMCID: PMC11232439 DOI: 10.1111/jch.14852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 06/10/2024]
Abstract
The study aimed to investigate differences in hypertensive- and cardio-preventive pharmacotherapy depending on if patients with hypertension received lifestyle counseling or not, including the difference between men and women. Data from the Region Stockholm VAL database was used to identify all patients with a hypertension diagnosis and had visited a primary health care center within the past five years. Data included registered diagnoses, pharmacotherapy, and codes for lifestyle counseling. Logistic regression adjusted for age and comorbidity (diabetes, stroke, coronary heart disease, atrial fibrillation, gout, obesity, heart failure) was used, presenting results as odds ratios (OR) with 99% confidence interval (CI). The study included 130,030 patients with hypertension; 63,402 men and 66,628 women. Patients receiving recommended lifestyle counseling were more frequently treated with three or more hypertensive drugs: women OR 1.38 (1.31, 1.45) and men = 1.36 (1.30, 1.43); certain drug classes: calcium antagonists: women 1.09 (1.04, 1.14) and men 1.11 (1.06, 1.16); thiazide diuretics: women 1.26 (1.20, 1.34) and men 1.25 (1.19, 1.32); and aldosterone antagonists: women 1.25 (1.12, 1.41) and men 1.49 (1.34, 1.65). Patients receiving recommended level of lifestyle counseling with concomitant coronary heart disease, atrial fibrillation, diabetes, or stroke were more frequently treated with statins than those who did not. Further, recommended lifestyle counseling was significantly associated with anticoagulant treatment in patients with atrial fibrillation. Lifestyle counseling according to recommendations in national guidelines was significantly associated with a more thorough pharmacological treatment of hypertension, statins, and antithrombotic drugs as well as anticoagulants, in both men and women.
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Affiliation(s)
- Sebastian Lindblom
- Division of Family Medicine and Primary CareDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Women´s Health and Allied Health Professionals Theme Karolinska University HospitalStockholmSweden
| | | | - Per Wändell
- Division of Family Medicine and Primary CareDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
| | - Monica Bergqvist
- Division of NursingDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetStockholmSweden
| | - Anders Norrman
- Division of Family Medicine and Primary CareDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Academic Primary Health Care CentreStockholmSweden
| | - Julia Eriksson
- Division of BiostatisticsInstitute of Environmental MedicineKarolinska InstitutetStockholmSweden
| | - Lena Lund
- Division of Family Medicine and Primary CareDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Academic Primary Health Care CentreStockholmSweden
| | - Maria Hagströmer
- Academic Primary Health Care CentreStockholmSweden
- Division of PhysiotherapyDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Department of Health Promoting ScienceSophiahemmet UniversityStockholmSweden
| | - Jan Hasselström
- Division of Family Medicine and Primary CareDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Academic Primary Health Care CentreStockholmSweden
| | - Christina Sandlund
- Division of Family Medicine and Primary CareDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Academic Primary Health Care CentreStockholmSweden
- Division of PhysiotherapyDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
| | - Axel C Carlsson
- Division of Family Medicine and Primary CareDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Academic Primary Health Care CentreStockholmSweden
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Quester R, Björck S, Manhem K, Nåtman J, Andersson S, Hjerpe P. Improving cardiovascular control in a hypertensive population in primary care. Results from a staff training intervention. Scand J Prim Health Care 2024; 42:347-354. [PMID: 38456742 PMCID: PMC11003316 DOI: 10.1080/02813432.2024.2326470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE A pilot study to evaluate a staff training intervention implementing a nurse-led hypertension care model. DESIGN AND SETTING Clinical and laboratory data from all primary care centres (PCCs) in the Swedish region Västra Götaland (VGR), retrieved from regional registers. Intervention started 2018 in 11 PCCs. A total of 190 PCCs served as controls. Change from baseline was assessed 2 years after start of intervention. INTERVENTION Training of selected personnel, primarily in drug choice, team-based care, measurement techniques, and use of standardized medical treatment protocols. PATIENTS Hypertensive patients without diabetes or ischemic heart disease were included. The intervention and control groups contained approximately 10,000 and 145,000 individuals, respectively. MAIN OUTCOME MEASURES Blood pressure (BP) <140/90 mmHg, LDL-cholesterol (LDL-C) <3.0 mmol/L, BP ending on -0 mmHg (digit preference, an indirect sign of manual measuring technique), choice of antihypertensive drugs, cholesterol lowering therapy and attendance patterns were measured. RESULTS In the intervention group, the percentage of patients reaching the BP target did not change significantly, 56%-61% (control 50%-52%), non-significant. However, the percentage of patients with LDL-C < 3.0 mmol/L increased from 34%-40% (control 36%-36%), p = .043, and digit preference decreased, 39%-27% (control 41%-35%), p = 0.000. The number of antihypertensive drugs was constant, 1.63 - 1.64 (control 1.62 - 1.62), non-significant, but drug choice changed in line with recommendations. CONCLUSION Although this primary care intervention based on staff training failed to improve BP control, it resulted in improved cardiovascular control by improved cholesterol lowering treatment.
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Affiliation(s)
- Rebecka Quester
- Närhälsan Bollebygd Health Care Centre, Bollebygd, Sweden
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Karin Manhem
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Department of Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Per Hjerpe
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Regionhälsan R&D Centre, Skaraborg Primary Care, Skövde, Sweden
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Hellgren M, Wennberg P, Hedin K, Jansson S, Nilsson S, Nilsson G, Wändell P, Bengtsson Boström K. Hypertension management in primary health care: a survey in eight regions of Sweden. Scand J Prim Health Care 2023; 41:343-350. [PMID: 37561134 PMCID: PMC10478603 DOI: 10.1080/02813432.2023.2242711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE To explore hypertension management in primary healthcare (PHC). DESIGN Structured interviews of randomly selected PHC centres (PHCCs) from December 2019 to January 2021. SETTING Seventy-six PHCCs in eight regions of Sweden. MAIN OUTCOME MEASURES Staffing and organization of hypertension care. Methods of measuring blood pressure (BP), laboratory tests, registration of co-morbidities and lifestyle advice at diagnosis and follow-up. RESULTS The management of hypertension varied among PHCCs. At diagnosis, most PHCCs (75%) used the sitting position at measurements, and only 13% routinely measured standing BP. One in three (33%) PHCCs never used home BP measurements and 25% only used manual measurements. The frequencies of laboratory analyses at diagnosis were similar in the PHCCs. At follow-up, fewer analyses were performed and the tests of lipids and microalbuminuria decreased from 95% to 45% (p < 0.001) and 61% to 43% (p = 0.001), respectively. Only one out of 76 PHCCs did not measure kidney function at routine follow-ups. Lifestyle, physical activity, food habits, smoking and alcohol use were assessed in ≥96% of patients at diagnosis. At follow-up, however, there were fewer assessments. Half of the PHCCs reported dedicated teams for hypertension, 82% of which were managed by nurses. There was a great inequality in the number of patients per tenured GP in the PHCCs (median 2500; range 1300-11300) patients. CONCLUSIONS The management of hypertension varies in many respects between PHCCs in Sweden. This might lead to inequity in the care of patients with hypertension.
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Affiliation(s)
- Mikko Hellgren
- University Health Care Research Centre, Örebro University Hospital, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Patrik Wennberg
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Katarina Hedin
- Futurum, Jönköping, Region Jönköping County, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Stefan Jansson
- University Health Care Research Centre, Örebro University Hospital, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Nilsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Gunnar Nilsson
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Per Wändell
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Huddinge, Sweden
| | - Kristina Bengtsson Boström
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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Mourtzinis G, Manhem K, Kahan T, Schiöler L, Isufi J, Ljungman C, Andersson T, Hjerpe P. Socioeconomic status affects achievement of blood pressure target in hypertension: contemporary results from the Swedish primary care cardiovascular database. Scand J Prim Health Care 2021; 39:519-526. [PMID: 34818121 PMCID: PMC8725880 DOI: 10.1080/02813432.2021.2004841] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the relation between socioeconomic status and achievement of target blood pressure in hypertension. DESIGN Retrospective longitudinal cohort study between 2001 and 2014. SETTING Primary health care in Skaraborg, Sweden. SUBJECTS 48,254 patients all older than 30 years, and 53.3% women, with diagnosed hypertension. MAIN OUTCOME MEASURES Proportion of patients who achieved a blood pressure target <140/90 mmHg in relation to the country of birth, personal disposable income, and educational level. RESULTS Patients had a lower likelihood of achieving the blood pressure target if they were born in a Nordic country outside Sweden [risk ratio 0.92; 95% confidence interval (CI) 0.88-0.97], or born in Europe outside the Nordic countries (risk ratio 0.87; 95% CI 0.82-0.92), compared to those born in Sweden. Patients in the lowest income quantile had a lower likelihood to achieve blood pressure target, as compared to the highest quantile (risk ratio 0.93; 95% CI 0.90-0.96). Educational level was not associated with outcome. Women but not men in the lowest income quantile were less likely to achieve the blood pressure target. There was no sex difference in achieved blood pressure target with respect to the country of birth or educational level. CONCLUSION In this real-world population of primary care patients with hypertension in Sweden, being born in a foreign European country and having a lower income were factors associated with poorer blood pressure control.KEY POINTSThe association between socioeconomic status and achieving blood pressure targets in hypertension has been ambiguous.•In this study of 48,254 patients with hypertension, lower income was associated with a reduced likelihood to achieve blood pressure control.•Being born in a foreign European country is associated with a lower likelihood to achieve blood pressure control.•We found no association between educational level and achieved blood pressure control.
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Affiliation(s)
- Georgios Mourtzinis
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg; and Sahlgrenska University Hospital, Gothenburg, Sweden
- CONTACT Georgios Mourtzinis Department of Medicine and Emergency, Sahlgrenska University Hospital, Göteborgsvägen 31, Mölndal, 431 80, Sweden
| | - Karin Manhem
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg; and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Linus Schiöler
- Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jetish Isufi
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg; and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Charlotta Ljungman
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg; and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tobias Andersson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Närhälsan Norrmalm Health Centre, Skövde, Sweden
| | - Per Hjerpe
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Närhälsan Norrmalm Health Centre, Skövde, Sweden
- R&D Centre Skaraborg Primary Care, Skövde, Sweden
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Burnier M, Prejbisz A, Weber T, Azizi M, Cunha V, Versmissen J, Gupta P, Vaclavik J, Januszewicz A, Persu A, Kreutz R. Hypertension healthcare professional beliefs and behaviour regarding patient medication adherence: a survey conducted among European Society of Hypertension Centres of Excellence. Blood Press 2021; 30:282-290. [PMID: 34392741 DOI: 10.1080/08037051.2021.1963209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Little is known on the beliefs, perceptions and practices of hypertension specialists in addressing non-adherence to therapy. Therefore, a survey was undertaken amongst healthcare professionals (HCPs) managing hypertension in the European Society of Hypertension (ESH) Centres of Excellence. MATERIALS AND METHODS Cross-sectional data were obtained between December 2020 and April 2021 using an online anonymous structured questionnaire including 26 questions/136 items, that was sent to all ESH Excellence centres. RESULTS Overall 67 from 187 centres (37.3%) responded and 200 HCPs from 30 countries answered the questionnaire. Participants (60% men) were mainly physicians (91%) and nurses (8%) from University hospitals (77%). Among physicians, 83% had >10 years professional experience. Average time dedicated to discuss medications was 1-5 min in 48% and 6-10 min in 29% of cases. Interviews with patients about adherence were the most frequently used assessment method. Chemical detection of medications in urine was available in 36% of centres. One third of physicians involved their patients regularly in treatment decisions. The most frequent methods to improve adherence included simplification of medication therapy, more frequent visits, and home blood pressure monitoring. CONCLUSIONS The level of implementation of tools to detect and improve adherence in hypertension management by HCPs in ESH excellence centres is low. Structured educational activities focussing on adherence management and access to the newest objective measures to detect non-adherence might improve these deficits.
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Affiliation(s)
- Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Thomas Weber
- Cardiology Department, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Michel Azizi
- INSERM, CIC1418, Université de Paris, Paris, France.,Hypertension Department and DMU CARTE, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | | | - Jorie Versmissen
- Departments of Internal Medicine and Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pankaj Gupta
- The Department of Chemical Pathology and Metabolic Diseases, Leicester Royal Infirmary, Leicester, UK
| | - Jan Vaclavik
- Department of Internal Medicine and Cardiology, Ostrava University Hospital, Ostrava, Czech Republic.,Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Reinhold Kreutz
- Institute of Clinical Pharmacology and Toxicology, Humboldt-Universität zu Berlin, Berlin, Germany
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Hoffmann M, Nilsson PM, Ahlner J, Dahllöf B, Fredrikson M, Säljö R, Kjellgren KI. Do patients or their physicians more accurately assess long-term risk associated with hypertension? A population-based study. Scand J Prim Health Care 2020; 38:166-175. [PMID: 32362222 PMCID: PMC8570735 DOI: 10.1080/02813432.2020.1753345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective: To compare the assessments of 10-year probability by patients and their physicians of cardiovascular complications of hypertension with actual outcomes.Design: Patients with uncomplicated hypertension treated with at least one antihypertensive drug at inclusion were followed for 10 years through mandatory national health registers.Setting: 55 primary health care centres, 11 hospital outpatient clinics in SwedenPatients: 848 patient, 212 physicians.Main outcome measures: Patients and physicians estimated the probability of hypertension-related complications with treatment (death, heart failure, acute myocardial infarction/AMI, and stroke) for each patient in 848 pairs. Estimates were compared with the clinical outcomes 10 years later using data from the Mortality Register and the National Patient Register.Results: Patients were significantly better (p < 0.001) than their physicians in estimating the average probability of heart failure compared with actual outcome data (14% vs. 24%, outcome 15%), AMI (16% vs. 26%, outcome 8%), and stroke (15% vs. 25%, outcome 11%). Patients were significantly worse (p < 0.001) at estimating the average probability of death (10% vs. 18%, actual outcome 20%). Neither the patients nor the physicians were able to distinguish reliably between low-risk and high-risk patients after adjustment for age and sex.Conclusions: Patients were better than their physicians in estimating the average probability of morbidity due to hypertension. Both the patients and their attending physicians had difficulty in estimating the individual patient's risk of complications. The results support the use of evidence-based tools in consultations for assessing the risk of cardiovascular complications associated with hypertension.Key points • Shared decision making relies on a common understanding of risks and benefits. Tools for risk assessment of hypertension have been introduced in the last two decades. • Without tools for risk assessment, both patients and physicians had difficulties in estimating the individual patient's risk of cardiovascular morbidity. • Patients were better than physicians in estimating actual average cardiovascular morbidity due to hypertension during a follow-up of 10 years. • The results support the use of evidence-based tools in consultations for assessing the risk of cardiovascular complications associated with hypertension.
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Affiliation(s)
- Mikael Hoffmann
- The NEPI Foundation, Department of Medical and Health Sciences, Division of Drug Research, Linköping University, Linköping, Sweden;
- CONTACT Mikael Hoffmann The NEPI Foundation, Department of Medical and Health Sciences, Division of Drug Research, Linköping University, Linköping, SE-581 83, Sweden
| | - Peter M. Nilsson
- Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Malmö, Sweden;
| | - Johan Ahlner
- Department of Medical and Health Sciences, Division of Drug Research, Linköping University, Linköping, Sweden;
| | - Björn Dahllöf
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden;
| | - Roger Säljö
- Department of Education, Communication and Learning, University of Gothenburg, Gothenburg, Sweden
| | - Karin I. Kjellgren
- Department of Medical and Health Sciences, Division of Drug Research, Linköping University, Linköping, Sweden;
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Midlöv P, Nilsson PM, Bengtsson U, Hoffmann M, Wennersten A, Andersson U, Malmqvist U, Steen Carlsson K, Ranerup A, Kjellgren K. PERson-centredness in hypertension management using information technology (PERHIT): a protocol for a randomised controlled trial in primary health care. Blood Press 2019; 29:149-156. [DOI: 10.1080/08037051.2019.1697177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Patrik Midlöv
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Peter M. Nilsson
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ulrika Bengtsson
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Mikael Hoffmann
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - André Wennersten
- Clinical Studies Sweden – Forum South, Skåne University Health Care, Lund, Sweden
| | - Ulrika Andersson
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ulf Malmqvist
- Clinical Studies Sweden – Forum South, Skåne University Health Care, Lund, Sweden
| | | | - Agneta Ranerup
- Department of applied IT, University of Gothenburg, Gothenburg, Sweden
| | - Karin Kjellgren
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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