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- af Winklerfelt Hammarberg, Sandra, et al.
(author)
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Clinical effectiveness of care managers in collaborative primary health care for patients with depression : 12-and 24-month follow-up of a pragmatic cluster randomized controlled trial
- 2022
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In: BMC Primary Care. - : Springer Nature. - 2731-4553. ; 23:1
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Journal article (peer-reviewed)abstract
- Background In previous studies, we investigated the effects of a care manager intervention for patients with depression treated in primary health care. At 6 months, care management improved depressive symptoms, remission, return to work, and adherence to anti-depressive medication more than care as usual. The aim of this study was to compare the long-term effectiveness of care management and usual care for primary care patients with depression on depressive symptoms, remission, quality of life, self-efficacy, confidence in care, and quality of care 12 and 24 months after the start of the intervention. Methods Cluster randomized controlled trial that included 23 primary care centers (11 intervention, 12 control) in the regions of Vastra Gotaland and Dalarna, Sweden. Patients >= 18 years with newly diagnosed mild to moderate depression (n = 376: 192 intervention, 184 control) were included. Patients at intervention centers co-developed a structured depression care plan with a care manager. Via 6 to 8 telephone contacts over 12 weeks, the care manager followed up symptoms and treatment, encouraged behavioral activation, provided education, and communicated with the patient's general practitioner as needed. Patients at control centers received usual care. Adjusted mixed model repeated measure analysis was conducted on data gathered at 12 and 24 months on depressive symptoms and remission (MADRS-S); quality of life (EQ5D); and self-efficacy, confidence in care, and quality of care (study-specific questionnaire). Results The intervention group had less severe depressive symptoms than the control group at 12 (P = 0.02) but not 24 months (P = 0.83). They reported higher quality of life at 12 (P = 0.01) but not 24 months (P = 0.88). Differences in remission and self-efficacy were not significant, but patients in the intervention group were more confident that they could get information (53% vs 38%; P = 0.02) and professional emotional support (51% vs 40%; P = 0.05) from the primary care center. Conclusions Patients with depression who had a care manager maintained their 6-month improvements in symptoms at the 12- and 24-month follow-ups. Without a care manager, recovery could take up to 24 months. Patients with care managers also had significantly more confidence in primary care and belief in future support than controls.
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| 2. |
- Björkelund, Cecilia, 1948, et al.
(author)
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Clinical effectiveness of care managers in collaborative care for patients with depression in Swedish primary health care: a pragmatic cluster randomized controlled trial
- 2018
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In: Bmc Family Practice. - : Springer Science and Business Media LLC. - 1471-2296. ; 19:1
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Journal article (peer-reviewed)abstract
- 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.
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| 5. |
- Gaziano, Liam, et al.
(author)
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Mild-to-moderate kidney dysfunction and cardiovascular disease : Observational and mendelian randomization analyses
- 2022
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In: Circulation. - : Wolters Kluwer. - 0009-7322 .- 1524-4539. ; 146:20, s. 1507-1517
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Journal article (peer-reviewed)abstract
- 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.
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| 6. |
- Hammarberg, Sandra af Winklerfelt, et al.
(author)
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Care managers can be useful for patients with depression but their role must be clear : a qualitative study of GPs' experiences
- 2019
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In: Scandinavian Journal of Primary Health Care. - : TAYLOR & FRANCIS LTD. - 0281-3432 .- 1502-7724. ; 37:3, s. 273-282
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Journal article (peer-reviewed)abstract
- 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 Vastra Gotaland 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.
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| 7. |
- Holst, Anna, et al.
(author)
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Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care : economic evaluation of a pragmatic randomised controlled study
- 2018
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In: BMJ Open. - : BMJ. - 2044-6055. ; 8:11
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Journal article (peer-reviewed)abstract
- Objective: To evaluate the cost-effectiveness of a care manager (CM) programme compared with care as usual (CAU) for treatment of depression at primary care centres (PCCs) from a healthcare as well as societal perspective.Design: Cost-effectiveness analysis.Setting: 23 PCCs in two Swedish regions.Participants: Patients with depression (n=342).Main outcome measures: A cost-effectiveness analysis was applied on a cluster randomised trial at PCC level where patients with depression had 3 months of contact with a CM (11 intervention PCCs, n=163) or CAU (12 control PCCs, n=179), with follow-up 3 and 6 months. Effectiveness measures were based on the number of depression-free days (DFDs) calculated from the Montgomery-angstrom sberg Depression Rating Scale-Self and quality-adjusted life years (QALYs).Results were expressed as the incremental cost-effectiveness ratio: Cost/QALY and Cost/DFD. Sampling uncertainty was assessed based on non-parametric bootstrapping.Results: Health benefits were higher in intervention group compared with CAU group: QALYs (0.357 vs 0.333, p<0.001) and DFD reduction of depressive symptom score (79.43 vs 60.14, p<0.001). The mean costs per patient for the 6-month period were Euro368 (healthcare perspective) and Euro6217 (societal perspective) for the intervention patients and Euro246 (healthcare perspective) and Euro7371 (societal perspective) for the control patients (n.s.). The cost per QALY gained was Euro6773 (healthcare perspective) and from a societal perspective the CM programme was dominant.Discussion: The CM programme was associated with a gain in QALYs as well as in DFD, while also being cost saving compared with CAU from a societal perspective. This result is of high relevance for decision-makers on a national level, but it must be observed that a CM programme for depression implies increased costs at the primary care level.
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| 8. |
- Petersson, Eva-Lisa, et al.
(author)
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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
- 2024
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In: Scandinavian Journal of Caring Sciences. - 0283-9318 .- 1471-6712. ; 38:3, s. 602-613
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Journal article (peer-reviewed)abstract
- 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.
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| 9. |
- Svenningsson, Irene, 1957, et al.
(author)
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Creating a safety net for patients with depression inprimary care: a qualitative study of care managers’ experiences
- 2018
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In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 36:4, s. 355-362
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Journal article (peer-reviewed)abstract
- 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. Malterud’s method of systematic text condensation was used to analyse 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 in the method.Main outcome measures: The nurses’s 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.
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| 10. |
- Svenningsson, Irene, 1957, et al.
(author)
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Process evaluation of a cluster randomised intervention in Swedish primary care: using care managers in collaborative care to improve care quality for patients with depression
- 2019
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In: Bmc Family Practice. - : Springer Science and Business Media LLC. - 1471-2296. ; 20
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Journal article (peer-reviewed)abstract
- BackgroundThe collaborative care model with a care manager has previously generated beneficial results for patients with depression in terms of decreased burden of depression symptoms. A care manager function has been tested in Sweden in the PRIM-CARE RCT with successful results. The aim of the present study was to evaluate the process of implementing care managers in collaborative care for patients with depression in Swedish primary health care in the PRIM-CARE RCT.MethodsThe study followed UK Medical Research Council guidance for process evaluation.Field notes from the implementation of the PRIM - CARE RCT were used, as well as data collected from five focus group discussions with General Practitioners (n=29) and three focus group discussions with care managers (n=11). Data were analysed with content analysis.ResultsTraining sessions, careful preparation and extensive initial support to the care manager and staff at the Primary Care Centres were important ingredients in the implementation. The close access to facilitators, the recurrent peer support meetings, and the weekly newsletter strengthened the care manager function.ConclusionsA complex intervention adapted to the Swedish primary care context focusing on a care manager function for patients with depression could be performed through a stepwise implementation process. Financial support from the health care regions included in the study helped to reduce the impact of identified barriers. This process evaluation has revealed new and important knowledge for primary care development concerning infrastructure and organization building, knowledge sharing, and facilitating factors and barriers.Trial registrationNCT02378272 Care Manager - Coordinating Care for Person Centered Management of Depression in Primary Care (PRIM - CARE). Registered March 4 2015. Retrospectively registered.
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