Med hjärtat i primärvården Staffan Nilsson, Med. Dr. lektor Distriktsläkare, specialist i allmänmedicin.

En presentation över ämnet: "Med hjärtat i primärvården Staffan Nilsson, Med. Dr. lektor Distriktsläkare, specialist i allmänmedicin."— Presentationens avskrift:

1 Med hjärtat i primärvården Staffan Nilsson, Med. Dr. lektor Distriktsläkare, specialist i allmänmedicin

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3 3 Problemlösningprocess i basgrupp 1. Utgångspunkt 2. Tänk fritt 3a. Gruppera 3b. Granska och värdera 4. Avgränsa frågeställningar 5. Precisera vad som behöver läras 6. Söka kunskap 7. Diskutera fakta 8. Diskutera de nya kunskaperna och egenvårdsmål Fortsatt problemlösning 9. Utvärdering

4 COR-PRIM study COR-PRIM study Problem-based learning in patient education after an event of coronary heart disease - a randomised study in primary care of long-term effects on self-care

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7 Sid 7 Hospital participation in COR-PRIM Not meeting the inclusion criteria Declined to participate Assessment eligibility at out- patient clinic: MI, Angina pectoris, PCI, CABG Written informed consent Baseline measurement Randomisation Patients allocated to control group(n=82) Home-sent patient information Patients allocated to experiment group (n=83) Problem-based learning Follow-up 1 1 year after randomisation Follow-up 1 1 year after randomisation Follow-up 2 3 years after randomisation Follow-up 2 3 years after randomisation Follow-up 3 5 years after randomisation Follow-up 3 5 years after randomisation

8 Sid 8 Material and methods Design: Randomised; two-group intervention study. Inclusion criteria: Men and women with CHD verified within 1 year before planned start of the study. Stable cardiac conditions and optimised cardiac medication; completed heart school (if joining); listed at one of six PHC. Exclusion criteria: Planned CABG; ongoing contact with heart failure clinic; disease with poor prognosis within 1 year; mental disease; abuse of alcohol etc; participation in other studies.

9 Sid 9 Measurements Base-line, 1, 3 and 5 years Blood pressure, smoking, BMI, waist measurement, serum lipids, Angina pectoris: Canadian Cardiovascular Society Functional Classification Scale (Campeau – 1976). Empowerment: SWE-CES 10 (Leksell – 2007). Self- efficacy: Self-Efficacy Scale - General, Nutrition and Physical exercise (Koskinen-Hagman et al. 1999, Swarzer & Renner 1999). Health related quality of life: EQ-5D (Burström 2002).

10 Sid 10 Measurements Base-line, 1, 3 and 5 years Physical exercise: Questionnaires (Prochaska et al. 2002; Kamwendo et al. 2004; IPAQ) Well-being: Questionnaire ‘Ladder of life’ (Cantril 1965). Patients’ beliefs about self-care/PBL-programme: Qualitative focus group interviews (Morgan 1996). Qualitative content analysis (Graneheim & Lundman 2004). Patients´ experiences of self-care: Reflective diary. Critical discourse analysis (Fairclough 1995).

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14 AMI, incidence and mortality/1000 Statin utilisation DDD/TID * Statin sales DDD/TID AMI, incidence and mortality/100 000 400 200 600 800 1000

15 Resultat Inga samband kunde påvisas mellan mängden sålda statiner och insjuknade eller dödlighet i akut hjärtinfarkt vid jämförelse mellan kommunerna. Resultaten antyder att andra preventiva åtgärder än ökad statinbehandling bör övervägas för att ytterligare minska sjukligheten i akut hjärtinfarkt. Slutsats

16 COR-PRIM study COR-PRIM study Problem-based learning in patient education after an event of coronary heart disease - a randomised study in primary care of long-term effects on self-care

17 V. Gronlund 1, A. Carlsson 2, P. Tingstrom 3, S. Nilsson 4, T. Jaarsma 5 and A. Karner 5 1 Finspang Health Care Center, Primary Health Care East Ostergotland, Council of Ostergotland, Norrkoping, Sweden, 2 Boxholm Health Care Center, Primary Health Care West Ostergotland, Council of Ostergotland, Motala, Sweden, 3 Linkoping University, Department of Medicine and Health, Linkoping, Sweden, 4 General Practice, Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Vikbolandet Health Care Center East County Primary Health Care, County Council of Ostergotland, Linköping, Sweden, 5 Linkoping University, Department of Social and Welfare Studies, Norrkoping, Sweden Findings Patients’ belief of self-care is influenced by their desire of a good life even though life seems fragile. Patients try to live up to the standard of health care prescription and advices. However, these achievements require behavior change and conscious boundaries, which are challenged by various obstacles such as fear of, overstrain and stress. Physical activity is considered as both a source to well-being and a necessity, but patients are uncertain and afraid for overstraining. A healthy diet is seen as important but the advices given are sometimes contradictory and create confusion. Medication is found important but not at the cost of all the side-effects. Patients also report that in order to believe in their ability and to be responsible for self-care, support from health care providers is expected. But at the same time the invaluable support and information is often not provided, creating uncertainty. Contact: Contact:Contact: victoria.gronlund@telia.com or doa@telia.comvictoria.gronlund@telia.com Contact: Contact:Contact: victoria.gronlund@telia.com or doa@telia.comvictoria.gronlund@telia.com Conclusions Patients’ beliefs about the concept of self-care are multifaceted compared to the health care definition There is a need to reconsider and assess what and how secondary preventive patient education should be performed after an event of coronary artery disease The desire for a good life - patients´ beliefs of self-care after a coronary event Introdution After a first coronary event there is an increased risk for a recurrent event. Despite that risk, 1/5 of the patients continue to smoke, 1/3 is obese and more than half of the patients have elevated blood pressure and total cholesterol. Secondary preventive self-care activities are needed to improve outcomes and the belief of patients plays a vital role in changing behavior.Methods The study design was qualitative. Twenty-five patients, including 10 women, mean age 65 years with stable coronary artery disease participated in four focus group interviews. Data were taped, transcribed and analyzed according to the conventional content analysis. ” Self-care does not only mean to take care of yourself. You can not just exercise and eat healthy, you have to enjoy it as well” Sweden Aim To examine patients' beliefs of self-care 6-12 months after a coronary Number of participants25 individuals, 10 women and 15 men Mean age65,2 Married or cohabiting76 % Former smokers56 % Current smokers4 % Retired60 %

18 Medicinering är viktig För att tro på sin förmåga och ansvara för egenvård, behöver man stöd från vårdgivare. Men detta behov av stöd och information tillgodoses ofta inte, vilket skapar osäkerhet. men inte på bekostnad av alla biverkningar.

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25 MCDonaldseffekt belastar akuter Dagens Medicin 2011-09-08 Gamla och multisjuka till akuten 53 100 vårdprogam och riktlinjer på google

26 Besöksorsaker och sjukdomar i primärvården -Övergående och ofarliga, cirka 50 % -Kroniska och långvariga, 30-40 % -Allvarliga och potentiellt livshotande, 10-15 %

27 Helhetssyn Kontinuitet Tillgänglighet

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31 Allmänläkares åtgärder vid bröstsmärta i förhållande till slutdiagnoskoronarsjukdom (IHD) förhållande till slutdiagnos koronarsjukdom (IHD)

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34 Sid 34 INTERCHEST

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40 Att göra Gamla Ingrid och alla de andra först som sist

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42 TACK!