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Abstract Background It is important to identify and evaluate cardiovascular risk factors at an early stage to address them accordingly. Among the younger population, the metabolic syndrome is less common than in older ages. However, each separate metabolic risk factor still has an additive effect on cardiovascular risk factor burden. Non-metabolic risk factors that occur in the younger population include family history, smoking, psychological distress and socioeconomic vulnerability. In 2021 a voluntary health intervention program was introduced in an urban area in Sweden where a cohort of 40-year-olds was invited for cardiovascular risk identification. The aim of this study was to identify how cardiovascular risk factors tend to aggregate in individuals participating in a voluntary health screening program and how the metabolic risk factors associate with non-metabolic cardiovascular risk factors. Methods This was a cross-sectional study with 1831 participants. Data from questionnaires and baseline measurements were used to calculate the prevalence of metabolic- (blood pressure, lipids, fasting plasma glucose, BMI, waist-hip ratio) and non-metabolic risk factors (family history of CVD, smoking, psychological distress, socioeconomic vulnerability) for CVD. SCORE2 was calculated according to the algorithm provided by the SCORE2 working group and ESC (European Society of Cardiology) Cardiovascular Risk Collaboration. Associations among each of the metabolic risk factors and non-metabolic risk factors were estimated using logistic regression and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Results More than half of the study population had at least one metabolic risk factor, and more than 1/3 was considered to be suffering from psychological distress. Furthermore, obesity or central obesity demonstrated individual associations with all of the non-metabolic risk factors in the study; smoking (1.49; 1.32–2.63), family history of CVD (1.41; 1.14–1.73), socioeconomic vulnerability (1.60; 1.24–2.07), and psychological distress (1.40; 1.14–1.72). According to SCORE2 25% of the men were at moderate risk (2.5–7.5%) of developing a cardiovascular event within 5–10 years, but only 2% of the women. Conclusions Obesity/central obesity should be a prioritized target in health screening programs. The non-metabolic risk factors, socioeconomic vulnerability, and psychological distress should not be ignored and addressed with adequate guidance to create health equity.

Background: Hypertension is an important cardiovascular risk factor with potentially harmful consequences. Home blood pressure monitoring is a promising method for following the effect of hypertension treatment. The use of technology-enabled care and increased patient involvement might contribute to more effective treatment methods. However, more knowledge is needed to explain the motivations and consequences of patients engaging in what has been called ‘do-it-yourself healthcare’. Aim: This study aimed to investigate patients’ experiences of home blood pressure monitoring through the theoretical frame of the Unified Theory of Acceptance and Use of Technology (UTAUT 2). Methods: The study had a qualitative design, with focus group interviews using the web-based platform Zoom. The data were analysed using qualitative deductive content analysis, inspired by Graneheim and Lundman. Results: The results are presented using the seven theoretical constructs of UTAUT 2: Performance Expectancy, Effort Expectancy, Social Influence, Facilitating Conditions, Hedonistic Motivation, Price Value and Habit. We found one overarching theme ‒ ‘It’s all about the feeling of security’. The patients were influenced by relatives or healthcare personnel and experienced the home monitoring process as being easy to conduct. The patients emphasised that the quality of the blood pressure monitor was more important than the price. Patients reported home monitoring of blood pressure as a feasible method to follow-up care of their hypertension. Discussion: This study indicates that among motivated patients, home blood pressure measurement entails minimal effort, increases security, and leads to better communication about blood pressure between healthcare personnel and patients.

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

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

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

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

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

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

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

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

Abstract Background Medication treatment can reduce morbidity but can also cause drug-related problems (DRPs). One method to identify and solve DRPs is medication reviews (MRs) that are aimed at increased patient safety and quality in drug treatment. In Skåne county, Sweden, a well-established multi-professional model for MRs in nursing homes is practiced. However, a demand for MRs regarding community-dwelling patients has emerged. These patients may be extra vulnerable since they have less supervision from healthcare personnel. AIM: To describe the community-dwelling patients in primary healthcare considered in need of an MR, as well as the outcomes of these pharmacist-led MRs. Methods Personnel from 14 primary healthcare centers selected patients for the MRs. Based on electronic medical records, the symptom assessment tool PHASE-20 (PHArmacotherapeutical Symptom Evaluation 20 questions) and medication lists, pharmacists conducted MRs and communicated adjustment suggestions via the medical record to the general practitioners (GPs). Results A total of 109 patients were included in the study and 90.8% (n = 99) of the patients were exposed to at least one DRP, with an average of 3.9 DRPs per patient. Patients with impaired renal function (glomerular filtration rate, GFR

Objective To evaluate the feasibility of a randomized controlled pilot study with lifestyle-promoting text messages as a treatment for hypertension in primary care. Design Randomized controlled pilot trial. Setting Three primary health care centers in southern Sweden. Subjects Sixty patients aged 40–80 years with hypertension were included. Main outcome measures Feasibility of the pilot study, i.e. recruitment rate, dropout rate and eligibility criteria. Secondary outcomes were change in blood pressure and other cardiovascular risk factors. Methods Thirty participants were randomized to the intervention group with four lifestyle-promoting text messages sent every week for six months. The control group received usual care. The baseline and follow-up visits for all 60 patients included measurements of blood pressure, anthropometrics, blood tests and a self-reported questionnaire. Results All feasibility criteria (recruitment rate (≥55%), dropout rate (≤15%) and eligibility (60 eligible patients during the four-month inclusion period) for the pilot study were fulfilled. This means that a larger study with a similar design may be conducted. After six months, there were no significant improvements in cardiovascular risk factors. However, we found favorable trends for all secondary outcomes in the intervention group as compared to the control group. Conclusion Lifestyle modification in patients with hypertension is important to reduce cardiovascular risk. However, primary healthcare has limited resources to work with modifying lifestyle habits. This is the first pilot study to test the feasibility of text message-based lifestyle intervention in patients with hypertension in Swedish primary healthcare. Whether significant improvement in cardiovascular risk factors may be achieved in a larger study population remains to be evaluated.Key points This pilot randomized controlled trial (RCT) is the first study to evaluate the feasibility of text message-based lifestyle advice to patients with hypertension in Swedish primary healthcare. •All feasibility criteria for the pilot study were fulfilled. This outcome means that a larger study with a similar design may be conducted. •The study was not powered to find significant changes in cardiovascular risk factors. Nevertheless, after six months we found favorable trends for all secondary outcomes in the intervention group compared to control. •If a future larger study can show significant results, this intervention could serve as a useful tool in everyday primary healthcare.

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

Objective: The elderly are an increasing group and large consumers of care in Sweden. Development of mobile information technology shows promising results of interventions for prevention and treatment of chronic diseases. Exploring the elderly patients’ beliefs, attitudes, experiences and expectations of e-health services helps us understand the factors that influence adherence to such tools in primary care. Material and methods: We conducted focus group interviews with 15 patients from three primary health care centers (PHCCs) in Southern Sweden. Data were analysed with thematic content analysis with codes and categories emerged from data during analysis. Results: We found one comprehensive theme: ‘The elderly’s ambivalence towards e-health: reluctant curiosity, a wish to join and need for information and learning support’. Eight categories emerged from the text during analysis: ‘E-health – a solution for a non-existing problem?’, ‘The elderly’s experiences of e-health’, ‘Lack of will, skills, self-trust or mistrust in the new technology’, ‘Organizational barriers’, ‘Wanting and needing to move forward’, ‘Concerns to be addressed for making e-health a good solution’, ‘Potential advantages with e-health versus ordinary health care’ and ‘Need for speed, access and correct comprehensive information’. Conclusions: Elderly patients in Sweden described feelings of ambivalence towards e-health, raising concerns as accessibility to health care, mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.Key points Exploring the elderly patients’ beliefs, experiences, attitudes and expectations of the fast developing e-health services helps us understand the factors that influence adherence to such tools in primary care. Elderly patients in Sweden reported ambivalence and different experiences and attitudes towards e-health, raising concerns as accessibility to health care, costs and mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

Objectives To explore staff experiences of working with a digital communication platform implemented throughout several primary healthcare centres in Sweden.Design A descriptive qualitative approach using focus group interviews. Qualitative content analysis was used to code, categorise and thematise data.Setting Primary healthcare centres across Sweden, in both rural and urban settings.Participants A total of three mixed focus groups, comprising 19 general practitioners and nurses with experience using a specific digital communication platform.Results Five categories emerged: ‘Fears and Benefits of Digital Communication’, ‘Altered Practice Workflow’, ‘Accepting the Digital Society’, ‘Safe and Secure for Patients’ and ‘Doesn't Suit Everyone and Everything’. These were abstracted into two comprehensive themes: ‘Adjusting to a novel medium of communication’ and ‘Digitally filtered primary care’, describing how staff experienced integrating the software as a useful tool for certain clinical contexts while managing the communication challenges associated with written communication.Conclusions Family medicine staff were ambivalent concerning the use of digital communication but, after a period of adjustment, it was seen as a useful communication tool especially when combined with continuity of care. Staff acknowledged limitations regarding use by inappropriate patient populations, information overload and misinterpretation of text by both staff and patients.