CPF and KCP Annual report 2019 by Akademiskt primärvårdscentrum

Overview

Competence Center for Primary Healthcare in Skåne

In numbers 11 PRIMARY CARE IN-SERVICE TRAINING UNIT 12 In-service training 14 Workplace training, VFU 15 Trainee physicians (AT) 16 Resident physicians (ST) 17 Health & Culture 22 New appointments and education benefits for nurses 25 Diabetes coordinators 26 Family medicine consultants AKO 28 KNOWLEDGE CENTER FOR MIGRATION AND HEALTH 36 KNOWLEDGE CENTER FOR CHILD HEALTHCARE 44 KNOWLEDGE CENTER FOR WOMEN’S HEALTH 46 Common Screening 48

Introduction Organisation Vision Management & Mission

04 06 07 08

CONTENTS

Center for Primary Healthcare Research

In numbers 61 Family medicine knowledge center, AKC 62 News in brief 64 Research 77 Doctoral students 82 PhD Thesis Defences 85 Research in Focus 88 Resident Physician (ST) work 96 Collaborations 98 New staff members 102 Database group 104 Analysis group 105 Molecular biology laboratory 106 Financial perspective 108 Published scientific articles 110

The year that was!

n your hand is the 2019 yearbook for the Center for Primary Healthcare Research (CPF) and Competence Center for Primary Care in Skåne (KCP). At the time of writing of this introduction, the whole world, Europe, Sweden and Skåne is suffering a difficult pandemic; something the majority of us who are now healthcare professionals have not experienced before. Our healthcare and our entire society is being challenged now in an incalculable way and we are helping to cope with this difficult time. My hope is that by reading this yearbook you can disperse thoughts for a while and be inspired by the fantastic work being done in Skåne within family medicine, research, education and development, women's and children's health and migration and health. This is my first introduction as the new director at CPF and KCP.

rations and a strengthened AVC adminstration. Two new professors in general medicine are now in place, Bengt Zöller and Anders Halling. They will strengthen the research and teaching within family medicine, both with a foundation in primary care through their clinical work. We also have two new lecturers in cancer epidemiology with a focus on primary care, Xinjun Li and Jianguang Ji, who both have worked at CPF ever since its inception in 2008. In addition, research at CPF was strengthened further through employment of several new doctoral students and postdocs from Skåne primary care and the rest of the world - of which several are involved in our big project on migration and health funded by the European Research Council. We also have hired a new expert within geographical information systems (GIS) and a course administrator that holds the threads on both CPF's and primary care’s education unit courses. In 2019, CPF published 146 scientific articles in international journals focused on heart disease, psychiatry and drug abuse, health economics, gastroenterology, thrombotic diseases, diabetes and other common diseases in primary care. Among the journals we published in were several very highly

”Disperse thoughts and be inspired."

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An eventful and productive year We had an eventful 2019 at CPF with success in attracting large research grants, establishment of new collaborations, deepening of previous collabo-

ranked periodicals such as JAMA, JAMA Psychiatry, BMJ and American Journal of Psychiatry. Since its inception, CPF has published approximately 1300 scientific articles in international scientific journals with so-called peer review system.

April 4 2019, CPF arranged a conference ‘Roads to the future of primary care’ where, among other things, Anna Nergårdh was invited. This however, is just a selection; more about CPF can be read about in this book!

Research at CPF is constituted of clinical, experimental and epidemiological studies. We collaborate with eminent universities in USA, Germany, Japan, Spain, China and others. In 2019 we had our first article published about Skåne's new diagnostic center (DC), which is for patients with nonspecific symptoms and suspected cancer in primary care. The assessment is done in collaboration with Regional Cancer Center South. An important research collaboration took shape during the year between CPF, the cardiology clinic at Skåne University Hospital and LIF: Heart failure in southern Sweden (HISS). This implementation project will involve about 20 healthcare centers and the goal is to improve diagnosis and treatment of heart failure in primary care. The work of creating an educational platform for evidencebased medicine began to speed up with seminars for doctors. In 2020 we want to extend the concept to other occupational groups in primary care. On

KCP is bubbling with life within knowledge development, education and in-service training within family medicine, paediatric and maternal health care and migration and health. KCP is responsible for 426 incoming specialists in family medicine and together with CPF is an important part of the University Clinic Primary care in Skåne. KCP is one of many large administrations within the primary care educational unit, Family Medicine Consultancy, AKO, Knowledge Center migration and health, Knowledge Center child health care and Knowledge center women's health. Their mission is therefore extensive and their contribution to resident and trainee physicians is valued. Culture by prescription is one new administrative venture within KCP that I believe will improve mental health for many. AKO guidelines at Care Provider Skåne had an impressive 404,028 visits in 2019. I also want to highlight the work that

Committed employees I would like to emphasise that without CPF's and KCP's extremely committed and competent staff within each area that it would not have been possible to run the department on this high level and within the framework of the thriving platform that Region Skåne and Lund University has enabled.

Enjoy the yearbook! Kristina Sundquist, Professor, Family medicine Director, CPF and KCP

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Strong collaborations

Praised and significant efforts

Migration and health are doing on several projects, including about torture victims and correct language interpretation as well as the comprehensive work being done by the Knowledge Center for Child Health Care and Knowledge Center for women’s health, including about children and sexual abuse and reproductive health to name just some of their significant work tasks.

ORGANISATION All research, competence development, education and ST/AT coordination in Region Skåne’s primary healthcare are merged in two producing and competitively operational divisions, the Center for Primary Healthcare Research (CPF) and the Competence Center for Primary Healthcare in Skåne (KCP), which serve as a cohesive knowledge platform for both the private and public sectors.

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Vision

CENTER FOR PRIMARY HEALTHCARE RESEARCH (CPF) To counduct groundbreaking clinical research for primary care of highest quality and help benefit a healthier population as a result.

Vision

COMPETENCE CENTER FOR PRIMARY CARE IN SKÃ&#x2026;NE (KCP) Equal health, equal treatment and highly competent staff.

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Management and Mission

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The Center for Primary Healthcare Research (CPF) and the Competence Center for Primary Healthcare in Skåne are important resources for knowledge development and clinical processes in both public and private primary healthcare. Therefore, competition neutrality is of the highest importance. CPF and KCP have a joint management team to create an environment with an emphasis on collaboration and synergies that make for an optimal use of resources. The joint management group for CPF and KCP creates valuable synergies for research and knowledge development.

CPF’S AND KCP’S MANAGEMENT TEAM w

w w

w w w

Kristina Sundquist, director from 190501, professor and research leader Jan Sundquist, director until 190430, professor Helene Rosenqvist, head secretary CPF/admin support to other unit managers Patrik Midlöv, professor & research leader until 191115 Eva Pulverer Marat, unit head (PUE) Marie Köhler, unit head (KC child healthcare & KC women’s health) Jenny Malmsten, unit head (KC Migration & health) parental leave until 190901 Maria Sandor, temporary unit head (KC Migration & health) until 190830 Sten Tyrberg, team leader (AKO) Emelie Stenman, team leader (AVC) Anna Kjellbom, team leader (KC women’s health) until 190730 Rafael Caballero, team leader (KC women’s health) from 190801 Kathy Falkenstein-Hagander, team leader (KC child healthcare)

The role of the board CPF is based on a collaboration between Region Skåne and Lund University. The board members lead the work regarding strategic and comprehensive planning. This means that it makes decisions about the direction of the research that CPF intends to conduct and the board also draws up an operational plan and is responsible for the required follow-up of CPF’s operations and management of financial resources.

CPF’S BOARD From left in the picture: w Dean and professor Kristina Åkesson, Lund University* w Senior Professor Lars H Lindholm, Umeå University (Chairman)* w Professor Kristina Sundquist, director (Rapporteur, not included on board) w Professor Bodil Ohlsson, Lund University* Missing from picture: w Professor Jerzy Leppert, Uppsala University** w Professor Birgit Rasmussen, Lund University** * Representative of Lund University ** Representative of Region Skåne

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COMPETENCE CENTER FOR PRIMARY HEALTH CARE IN SKÅNE The Competence Center for Primary Healthcare in Skåne (KCP) provides in-service training, AT (trainee physician) and ST (resident physician) training, family medicine consultancy activities, further education, the Knowledge Center for Child Healthcare, Women’s Healthcare Services and Migration and Health Services. The common platform entails great advantages of coordination at KCP, as well as between KCP and CPF. Kristina Sundquist is the general director for CPF and KCP. THE COMPETENCE CENTER’S UNITS AND TEAMS: PRIMARY HEALTHCARE TRAINING UNIT SKÅNE FAMILY MEDICINE CONSULTANCY, REGION SKÅNE (AKO) KNOWLEDGE CENTER, MIGRATION AND HEALTH SERVICES KNOWLEDGE CENTER FOR CHILD HEALTHCARE SERVICES ANNUALREPORT2019

KNOWLEDGE CENTER FOR WOMEN’S HEALTHCARE SERVICES

KCP

Financial perspective

OPERATIONS

REVENUE COSTS

PROFIT/DEFICIT

w Primary Care Training Unit

22 542 134 20 596 624

1 945 510

7 487 918

- 53 739

12 806 200 11 655 523

1 150 677

7 434 179

w AKO w Knowledge Center for Child Healthcare Services

w Knowledge Center for Women’s Healthcare Services 4 799 716

4 147 891

651 825

8 082 360

6 413 339

1 669 021

w Knowledge Center for Migration and Health

Internships within administrative centered education

1 912

Internships within administrative centered education

404 028

Visits to AKO guidelines, Caregiver Skåne

2 450

Participants in Knowledge Center Migration And health’s various education initiatives

3000+

Participants in Knowledge Center for Child Healthcare’s various in-service training

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200

Employees at the midwife unit that participated in education about women's health and socioeconomic vulnerability

THE YEAR IN NUMBERS

1 700

KCP

PRIMARY CARE EDUCATION UNIT

PRIMARY CARE EDUCATION UNIT The Primary Care Education Unit (PUE) is co-located within the Center for Primary Healthcare Research. PUE's responsibilities include AT/ST issues, in-service training, diabetes coordinators, administrative workplace training within culture and health. Eva Pulverer-Marat is the unit head for PUE, as well as for AKO (Family medicine consultants), as described on page 28.

Vision

"We want to achieve equal health and equal care as well high competence of the employeeâ&#x20AC;?

GOALS 2019

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w Increase the quality of the supervision and knowledge of skills assessment methods in ST education. w Improve information to administration managers and raise awareness of the ST service. w That the AT physician is better prepared for and receives optimal learning during their primary care work placement. w Improve diabetes care in SkĂĽne and increase the number of certified units. w Good student satisfaction and well-educated future employees, which increases recruitment opportunities for primary care. w Support the development of methods that improves the educational meeting between supervisor and student (Peer learning). w Production of four video films and eight webinars. w Develop our digital services further. w To integrate, inform and research art and cultural activities as health promotion within primary care.

PRIMARY CARE EDUCATION UNIT

PUE IN NUMBERS

PRIMARY CARE EDUCATION UNIT:

KCP

2019

ANUMBER OF EMPLOYEES 2.5 education administrators 2.0 VFU officers 0.80 unit managers 12 ST study directors corresponding to 4.0 full-time positions 5 AT study directors corresponding to 1.1 full-time positions 3 diabetes coordinators corresponding to 1.5 full- time jobs 1 culture and health strategist 1 study director and in-service training manager for nurses equivalent to 0.6 full-time positions NUMBER OF ST ACTIVITIES 13 programs/courses with 690 participants 34 full-day ST meetings with 1,912 participants NUMBER OF AT ACTIVITIES 87 seminars AT brunches with 109 participants Several full days of practical skills (Practicum) IN-SERVICE TRAINING OTHER EMPLOYEES 37 courses with 1,257 participants Average evaluations - VT 2019 4.4 and HT 4.2; scale 1-5 ADMINISTRATIVE TRAINING (VFU) 1,700 student placements 2 Peer learning courses 7 PTP services (Practical service for psychologists)

STUDY DIRECTOR FOR SPECIALIST NURSES 8 training positions 25 education supervisors 2 specialist nurses in palliative care

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DIABETES COORDINATORS 4 training days 62 diabetes certified units

KCP

PRIMARY CARE EDUCATION UNIT

IN-SERVICE TRAINING The unit has arranged, administered and evaluated in-service training for employees in public and private primary care. The need for continuous professional competence development is great within primary care. The disease landscape is wide and there are many occupational categories. Our in-service training programs are adapted to the needs of the units and were planned in collaboration with profession-specific reference groups. These had meetings 2-3 times during the year. Reference groups are available for counsellors, psychologists, physiotherapists and occupational therapists, medical secretaries and dieticians, as well as nurses and district nurses. A total of 37 courses were arranged for other employees during 2019 with 1257 participants. Average educational value - VT 2019 4.4 and HT 4.2; scale 1 - 5. Examples of training courses that were organized were ACT (acceptance & commitment therapy) training for counsellors. Other training for psychologists and counsellors were PTSD and PE treatment (prolonged exposure), Generalised anxiety disorder (GAD), Stress-related ill-health - what do we know today and Suicide assessment. Cervical and Thoracic pain states, torticollis in children, OMT follow-up course elbow and hand were other valued full-day training days for physiotherapists and occupational therapists. Some of the in-service training courses that were arranged for district nurses/nurses were triage, skin and wounds, topical medicines in primary care, ear/nose health allergy and the nurse's role in health care selection. Medical secretaries had two full days in 2019 concerning varying subjects. In addition, a half-day training was organised during the spring term for dieticians concerning eating disorders and two blood pressure training courses in the spring of 2019 for assistant nurses. Recurring for all employees is motivational speaking education. ANNUALREPORT2019

PRIMARY CARE EDUCATION UNIT

KCP

WORKPLACE TRAINING (VFU) All student categories except medical students are covered in this unit. The workplace training coordinators are the link between primary care administrations and Skåne's three centers of education. The coordinators work for quality development and act as support for managers and staff on issues related to workplace training. Great demands are placed on our administrations to offer high quality workplace training as this covers 30-50% of the time in most healthcare education programs. During 2019, workplace training places were coordinated for a total of approximately 1,700 students in all primary care administrations, both public and private. During the year, the three centers of education in Skåne decided to divide the admission of new nursing students into local admissions, e.g. the University of Kristianstad has an admission to Kristianstad-Hässleholm and an admission to Ängelholm-Helsingborg. The design of the new division is based on Region Skåne's sub-regional collaboration groups. Training in the pedagogical supervisor model, Peer Learning for supervisors in primary care in Skåne, continued during 2019 with two training opportunities. Seven practical service for psychologists places were also provided during the year.

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KCP

PRIMARY CARE EDUCATION UNIT

TRAINEE PHYSICIAN TRAINING (AT) In 2019, some 235 trainee doctors (AT) had six month placements within primary care in Skåne. Five AT study directors worked on continuous quality assurance of the training places. There were 87 in service training programs arranged for AT doctors. Some examples of programs were skin diseases, dizziness, gynaecology and long-term pain. In-service training was carried out regarding practical skills for AT physicians who are at the beginning of their primary care placement in collaboration with Practicum Clinical Skills Centers Region Skåne. The training courses were held over 1-2 days and consisted of practical elements in minor surgery, spirometry/ allergy test, orthopaedic status, eye and ear microscopy. The programs received good evaluations and the plan is that these will continue. In addition to this, focus days have been arranged for AT doctors, regional AT days, AT matters and AT brunches. At the AT brunches, 109 AT physicians participated in lectures and discussions concerning primary care in Skåne. These meetings aim to increase interest and facilitate the recruitment to resident physician services in family medicine. The number of AT services has increased significantly in the Skåne region during the past year, which is evident in primary care. More and new healthcare centers had to receive AT doctors to manage the placements and this worked well. The AT study directors regularly visit the AT doctors in the workplace to make sure that the educational environment and the quality of the education are optimal. AT SUS has undergone SPUR with good results for family medicine. Primary care in Skåne received a very good rating overall in SYLF's AT ranking, but excels in Kristianstad, which became Sweden's best AT family medicine placement followed by Ängelholm in second place.

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KCP

RESIDENT PHYSICIAN TRAINING (ST) The number of resident physicians (ST) in family medicine continues to increase, at present there are 426 ST doctors in private and public units. When granting ST education grants, the study director performs a quality control of the healthcare center; the purpose is to promote a good educational environment and therefore an ST agreement is also signed between the study director, the head of operations and the ST doctor. A total of 12 study directors work in four different areas in Skåne. Each study director's area has monthly ST meetings with lectures and ST doctors have meetings in collegiate groups, FQ groups. These groups are designed to provide structured quality development and in-service training. Other activities for ST doctors and supervisors that took place during 2019 were regional ST days, supervisor meetings, diplomacy meetings, start-up meetings for new ST doctors and their supervisors, operations director meetings and regional supervisor days. The study director unit also arranged several courses such as a consultation course, supervisor course, pain course, family medicine work procedures, insurance medicine and an updated course for supervisors. In November there was an estimated supervisor day with over 160 supervisors from all over Skåne, part of the day was about competence assessment During 2019, there was a drive to increase the number of dual specialists in family medicine. Two films have been recorded for marketing purposes and the administrations have been given better financial conditions to be able to offer ST services in family medicine for dual specialists. During the year, nine services as dual specialists were added for doctors with previous specialist degrees from pulmonary medicine, internal medicine, cardiology and anaesthesiology.

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The major challenge during 2019 has been the additional training places for ST doctors, especially in Malmö. As a result, tandem placements have been started as a trial venture and this is described more in a separate report in the yearbook.

KCP

PRIMARY CARE EDUCATION UNIT

Highest grade for trainee and resident education in Skåne Skåne’s trainee physician education topped the nationwide rankings in 2019. And locally in Skåne, the success continued with high grades for both the trainee (AT) and resident physician (ST) education programs.

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n 2019, Sweden's junior doctors' association (SYLF) conducted an AT ranking for the entire country. In the ranking, Kristianstad central hospital was the best family medicine location with Ängelholm hospital in second place, says Eva Pulverer Marat. The ranking takes into account multiple items like introduction, supervision and training. But it’s not only on a national basis does Skåne impress: In the SPUR 2019 survey for ST doctors’ in the SUS admission area, the healthcare center and head of unit, Eva Pulverer

Marat, as well as the study director colleagues in the primary care unit's educational unit were given an excellent grade. ST education in family medicine is considerably higher than the average for all specialty education. SPUR stands for the Specialist Education Council and is an audit activity under the auspices of LIPUS (The Medical Institute for Professional Development of Healthcare). Previously, both KRYH and SUND have been given high ratings in SPUR reports for the AT programs in primary care. Skåne University Hospital in Lund and Malmö submitted its report for

AT from 2019 and the grades continue to be high for the AT programs within primary care. The SUS report for AT can actually be most easily summarised with the conclusion: No obvious weaknesses were noted. In all areas, from internal competences and the organisation of the service to the educational climate, only the highest grades were allocated for both the AT and ST education. It is the comprehensive review work that is behind the SYLF but above all - the SPUR reports. These impressive results create a good basis for the ongoing education work.

PRIMARY CARE EDUCATION UNIT

KCP

Tandem placements fulfilling a great need

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KCP

PRIMARY CARE EDUCATION UNIT

Fredrik Modig (left) and David Götestrand.

“Our goal is for as many resident physicians as possible to get an additional training place,” says David Götestrand, resident physician studies director in northwest Skåne.

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He, together with his colleague Fredrik Modig, resident physician studies director in Lund, carried out pilot projects in 2019 with tandem placements of resident physicians. In addition to being study directors, both are specialists in family medicine and work both clinically and within education.

n Helsingborg, we had a pilot project at the ear unit during the autumn, with close follow-ups both with the clinic and the students. The evaluations have gone well and at the same time we can increase the training time from six to eight weeks, says David Götestrand. The need for additional training places has grown massively in recent years. In

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work to take care of ill children. One concern on the part of the resident physician students is that personal chemistry can be a gamble; they work closely together during the placements. Regarding the education, one must keep an eye on, for example, the instrument training being shared equally and that the discussion with the specialist after the patient meeting is done thoroughly. Tandem placements fulfil a great need. Although Skåne currently has 420 resident physicians, there will still be a shortage according to the forecast in 2025. More clinics must increase the capacity for additional training placements. “For example, the children's clinic in Malmö has a very long queue. This will lead to an extension of the training period for several resident physicians,” says Fredrik. Both study directors agree that regional politicians must get hospitals and private clinics to adapt to the educational pressures that exist and help resolve the situation. Another major challenge is being able to maintain the good quality of education despite a large influx of resident physicians. “Tandem placements are a solution to optimise education,” emphasises David. The tandem placements was started with inspiration from the nursing school, which has long used the concept of peerlearning, which in turn was taken from England.

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approximately seven years, the number of resident physicians in Skåne has grown from just over 100 to 420. Further pressure concerning training places is created by the fact that more and more people want to become dual specialists, e.g. specialists from in-patient care who want to be trained as specialists in family medicine. Something needs to be done and taking on two resident

physicians at the same time is part of the answer. “In Lund we had a pilot trial in the spring at the dermatology clinic. And the result was good!” says Fredrik Modig. The same will be done from autumn 2020 in northwest Skåne, with an intake of eight resident physicians annually. The advantage of the tandem placements is that the students alternate between taking the main responsibility for the patient. They do the examination together and then consult both specialist physicians, from the respective training units, before returning to the patient. “We get more through education with improved quality. At the same time, we must of course adapt to the conditions and opportunities of the various clinics,” says David Götestrand. Fredrik Modig also sees benefits: “The medical students can talk together during the training and learn from each other. If one manages the instrument during an examination, the other can at the same time assist with a helping hand - this is also learned a lot.” One benefit for the clinics is that scheduling becomes easier than if they only took on one resident physician at a time. Since it is not uncommon for this part of the education to be done after some of the students have children, with tandem placements it is avoided that there will be gaps in the schedule due to staff working part-time or missing

KCP

PRIMARY CARE EDUCATION UNIT

Warding off mental ill health with ANNUALREPORT2019

KCP

PRIMARY CARE EDUCATION UNIT

Shared reading, city walks, exhibitions at museums, ceramics, choir singing and activities in the forest. Now people with mental ill health can receive a prescription for culture at their healthcare center. The initiative is one of several within the framework of the new mission at Health and Culture.

“To participate in or experience cultural activities can stimulate the senses and can contribute to a sense of context and meaningfulness. The purpose is to increase well-being, as well as physically as psychologically and should be seen as a complement to traditional care treatments.” The service as a cultural and health strategist is a general initiative and financed by both Region Skåne’s cultural committee and the board of health. Culture on prescription is a new initiative within primary care. “Region Skåne is leading the way in work on how culture in different ways can work preventively, health promotion and rehabilitative. My mission is primarily to be a link between research, cultural life, health and health care and society in Region Skåne.

Anita Jensen.

Accept and create yourself Culture on prescription is a 10-week program where people with stress, anxiety, mild to moderate depression or risk of social isolation/loneliness are offered to participate in various cultural activities twice a week, about two hours at a time. Healthcare personnel at the clinic identifies people they think may benefit from the initiative and ask if they want to participate.

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he librarian reads aloud. Today’s participants have the text in front of them and read and listen at the same time. The librarian stops several times and the conversation becomes a bit livelier. And personal. A short story by Swedish author Jonas Karlsson generates many thoughts and stories from the participants’ own life. It goes on at the so called ‘Shared reading’ at the city library in Malmö, one of several activities offered within the initiative culture by prescription. The intention is to investigate cultural activities that treatment can help individuals over the age of 25 who are or at risk of taking sick leave for stressrelated problems, light and moderate depression and anxiety. Patients participate from the healthcare centers Granen, Eden, Sorgenfri and Södervärn as well a unit for young adults in Region Skåne. “I'm happy that culture on prescription has gone from an idea to being practiced,” says Anita Jensen, researcher and a new cultural and health strategist at KCP with long experience of working in culture and health, including in the United Kingdom and Denmark. She adds:

KCP PRIMARY CARE EDUCATION UNIT

There is strong scientific evidence today that culture affects us both physically and mentally. A culture coordinator manages consent and handles the contact between healthcare and the different cultural institutions. A total of 20 activities in six locations around Malmö are led and arranged by professionals in the field of culture. “The initiative takes place in groups and which is both about embracing culture and creating oneself. The activity should be fun and without demands and where there is no preparation needed from the participants,” says Anita Jensen. Shared reading at the city library where participants read a poem or a short story aloud and pause for thoughts and discussion, city walks with the city archives, tour of exhibitions and workshops at museums, ceramics, choral singing and activities in the forest are just some of the activities. “The participants do all the activities together with a program coordinator that meets those taking part before each

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activity. When we meet for the last time we also inform them about other activities available in Malmö,” she says.

Scientifically proven At the beginning and end of the program, the participants can respond to questions about feeling and well-being, as well as their experience of cultural activities. Anita adds, “Evaluation is important so that we should know about this setup and implementation suits primary care. We will also evaluate the collaboration with the healthcare centers.” In her role as a researcher, Jensen is also working parallel developing an evaluation guide that can be used in all Nordic countries. She says that further evidence about the effect of culture on health is needed. “There is strong scientific evidence today that it affects us both physically and psychologically.” She mainly refers to the results from the WHO report "What is the evidence on the role of the arts in improving health and well-being? A scoping review” that was launched in November 2019 where international cultural and health interventions were reviewed,

based on over 900 scientific articles. The report "The All- Party Parliamentary Report on Arts, Health and Wellbeing (2017) Creative Health: The Arts for Health and Wellbeing” from the UK gives grounded answers according to Anita. The two reports appear to show the health effects such as: faster rehabilitation, reduced mental illness and loneliness, reduced drug consumption, increased cognitive function, better breathability, increased well-being and sense of context and meaningfulness.

Good complement Nowadays PAP (physical activity on prescription) is a well-known concept in primary care. Anita hopes that culture too will, in the long term, be possible to become a natural part of the treatment program. “The task ahead is to implement, improve awareness and evaluate. Many patients and staff in healthcare are seeking for other and more initiatives that patients can be referred to. It’s perhaps not a cure to everyone with culture, but it can become a meaningful complementary treatment,” concludes Anita Jensen.

PRIMARY CARE EDUCATION UNIT

KCP

NEW APPOINTMENTS AND EDUCATION BENEFITS FOR NURSES A director of studies has been hired to provide support and advice for specialist training courses with educational benefits and training for nurses, which were set up in primary care in 2019. These initiatives increase the ability of employees to study further within their specialist area with a partially retained salary. In the long term, this contributes to increased competence within the administration. In 2019, 25 people studied full-time with educational benefits, mainly in district nursing. Eight training positions were set up during the year and then the studies were part-time. Two of the educational positions have been in palliative care. In addition, two assistant nurses have been given the opportunity to study to become specialist nurses in palliative care. Another area that has been worked on is the clinical base year in the region. The clinical base year should provide knowledge and the opportunity for the employee to follow the patient throughout the entire course of care where primary care is usually the first way in. By including primary care, the employee is given the chance to take part in the entire course of care, to cooperate and have joint training. This entails increased knowledge, quality, cooperation and understanding between outpatient and in-patient care.

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KCP PRIMARY CARE EDUCATION UNIT

DIABETES COORDINATORS CERTIFICATION

In 2019, a total of 62 of Region Skåne's 162 health-care units met the requirements for certification. These units were awarded SEK 20,000/year and received a diploma to display in the waiting room. The purpose of the certification is to ensure quality care for people with diabetes. Skåne continues to lead the way in Sweden with this care. Information on certification can be found at Caregiver Skåne, Primary Care Education Unit. Enquiries are regularly sent to operations managers of non-certified units if they want support to get the unit certified. It is often found that there is insufficient time allocated for diabetes nursing centres. Some units lack a diabetes nurse or the diabetes nurse does not have sufficient time for the number of diabetes patients listed at the unit. During autumn 2019, the diabetes coordinators participated in a meeting together with leading healthcare politicians from Region Skåne. The purpose of the meeting was to highlight difficulties that exist in the diabetes care units. A followup meeting is planned for 2020. Elsewhere in the year, visits were made to the health-care units that wanted to review their results in the National Diabetes Register (NDR), as well as support regarding routines and structure within diabetes care.

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IMPROVEMENT PROJECTS

Several learning seminars were held during the year for diabetes nurses from various units around Skåne. One of the bases for the seminars has been "Success factors in diabetes care", (Sweden's Municipalities and County Council, SKL, 2013) a publication based on a national study on differences in the design of diabetes care in primary care. The data quality of the units has also been discussed on the basis of the National Diabetes Register, NDR. They have also shared their work experience and learnt from each other.

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IN-SERVICE TRAINING

Two half-day courses on Personcentered diabetes care were conducted in the spring and two halfday courses on Diabetes care in multicultural Sweden were held during the autumn. Both educational events were held in Malmö and Helsingborg. Education for diabetes nurses Diabetes care 7.5 credits at the advanced level and Pharmacology in diabetes 7.5 credits at the advanced level were completed at the University of Kristianstad in 2019 with the support of the diabetes coordinators. During the year, a collaboration was started with the Knowledge Center for Living Habits.

NETWORK

The diabetes coordinators participated and organised networking meetings for diabetes nurses in different parts of the region. The network meetings are greatly appreciated and there is a desire for more networks to start in Skåne. There are also requests from the municipality's nurses that they should be able to attend these network meetings.

The diabetes coordinators have participated in several workshops on a knowledge-based decision support and documentation template.

NDR - NATIONAL DIABETES REGISTER

During the year, the diabetes coordinators met with representatives of the region's patient associations. At this meeting, concerns arose from the patients about the quality of diabetes care within municipal home health care. This resulted in the diabetes coordinators inviting medically responsible nurses from municipalities in Skåne. Different needs emerged during the meeting such as the lack of diabetes in-service training. The diabetes coordinators were invited to a diabetes association to host a lecture on diabetes and what certification can mean for "me as a patient". In connection with the World Diabetes Day in Malmö, the coordinators were present with information and lectures on certified diabetes clinics in Skåne. An intensive collaboration with systems managers and administration specialists within IT and PMO took place continuously during the year for quality assurance of data transfer from PMO to NDR.

NEWSLETTER & WEBSITE

Newsletters have continued to be sent continuously to the units' diabetes nurses.The diabetes coordinators now also have a website under PUE where newsletters are added as well as Power Point presentations from education days as well as a slide show on certification of diabetes clinics. The presentation is also translated into English.

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SKÅNE'S DIGITAL HEALTH CARE SYSTEM, SDV

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AKO

AKO Skåne family medicine consultancy - AKO - is a resource for all the doctors in Hälsovalet. We work for safer, easier and more equal care. We work with the development of skills for primary care physicians and standardise care guidelines for primary care on the basis of a national clinical knowledge support. This is all done in order to facilitate the everyday work of general practitioners in a simple and easily accessible way.sätt.

Goals

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2019 – 2020 w COMPETENCE DEVELOPMENT To meet the GPs’ need for skills development in order to be able to offer the patient personcentered evidence-based safe care. w KNOWLEDGE SUPPORT To formulate Skåne’s own common evidence-based easily accessible care guidelines for specialists in family medicine. w COLLABORATION To contribute to creating routines so that Region Skåne's different administrations are used together in the best way. w AKO SKÅNE'S WEBSITE To create an easily accessible IT site with searchable, interesting and adequate infor mation for Hälsovalet’s doctors in knowledge management, collaboration and competence development.

FAST FACTS 10 people work within AKO Skåne's central administration. 50 family medicine consultants in 22 medical areas, distributed locally in collaboration with Skåne's various hospitals 86 local in-service training responsible doctors 41 in-service training courses, of which seven were regional further education courses – Family Medicine Plus 1,902 participants in further education. 270 published AKO guidelines, of which 120 were revised in 2019. 7 updated SVFs, standardised course of medical care for cancer, published in 2019, a total of 30. 404,028 visits to AKO guidelines at Caregiver Skåne. 18,656 views of 23 self-produced video films during 2019. 8 live webinars in 2019, which have been viewed 1,491 times. 77 medical questions and answers, of which 21 were new in 2019.

AKO

SKILLS DEVELOPMENT Local in-service training

Helsingborg: 8 occasions with a total of 485 participants Kristianstad: 8 occasions with a total of 201 participants Lund: 4 occasions with a total of 312 participants Malmö: 4 occasions with a total of 352 participants Examples of subjects at local further education: w Acute complications of cancer w Emergency medicine at a healthcare center w Organised PSA testing w Bleeding disorders w Liver Diseases w Gastro health (children) w Cardiology – investigation and follow-up of ischaemic heart disease w Sepsis – early signs, which efforts play a role and the latest news from the research w Gender dysphoria, investigation and treatment. w Opioids and medical cannabis in chronic pain conditions

Regional in-service training

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KNOWLEDGE MANAGEMENT Questions and answers

There are 77 medical questions and answers, of which 21 have been added in 2019.

AKO Care guidelines

Work on the health guidelines in Region Skåne has continued during 2019. 120 revised guidelines have been published, a total of 269 guidelines. Short versions are also made for SVF, the standardised cancer care course, where 7 SVFs were updated in 2019.

National knowledge support primary care

In total, there are now 64 recommendations published within the framework of national clinical knowledge support from the Southern healthcare region.

Regional further education gathered 220 participants on its seven occasions.The regional days have been about: w Heart and vascular w Chronic kidney disease w Primary Gynaecology w Evidence-based medicine in family medical practice w Headache and dizziness w Meeting patients with long-term pain w Complications with diabetes patients

AKO day

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The annual AKO Day also invited all the local continuing education physicians this time. The event was held in Helsingborg and there were 42 participants. The day dealt with, among other things, information about the new knowledge organization, in-service training report 2019, AKO guidelines and FQ groups – an important collegial network.

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AKO

Self-governing groups

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“The group can always do more than each of us,” says Ulf Eriksson with hearty enthusiasm. His mission with AKO is to monitor the FQ groups in Skåne and observe, among other things, what support they may need.

Ulf Eriksson.

organisation, i.e. the employer. “Since this autumn, all specialist doctors receive 5% in development time per week. If you work 40 hours a week, it will be two hours of development time. A digital platform to form new FQ groups may be possible in the future!” He quickly outlines some thoughts on what such a platform might look like: registering your interests, searching for others who appear to have similar interests, forming small or large groups and meeting. “Maybe there is a need for group leader training. Perhaps we can incorporate new GPs’ into FQ groups where there are also doctors with many years of experience,” says Ulf. The groups themselves con-

trol their learning needs; it is not about taking part in guidelines. The focus is on collegial learning. But in their education, the doctor at the health centre may need support. “Generally speaking, GPs’ take fewer training days than hospital specialists, at least nationally. The reason is usually the workload. In addition, when choosing courses, you often choose subjects you are already good at.” He adds, “With a competence development plan, you could gain increased motivation to attend courses that you prioritised yourself, in subjects that you would actually need to update in.” Theoretical knowledge can decrease during a long professional life in a rapidly changing profession, while at the same time other parts of professional knowledge can increase, e.g., the empathic approach towards patients. In group meetings, everyone could easily discover their underlying need for theoretical advancement. “The GP's work in primary care is often lonely, we only meet at fika and then you do not always want to talk about work. Scheduled FQ groups can also help us in recruiting. After all, medical students risk being scared off when they see what width we are going to cover. But when there is time for in-service training, the job can feel more reasonable!”

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he abbreviation FQ appeared in the 1990s and was launched by SFAM, the Swedish Association of General Practice. The F stands for in-service training and the Q is for quality. Ulf Eriksson is from Malmö but has been working for a long time in Blekinge where he is a GP at the Samariten educational center. “The intention is that in an FQ group, which has regular meetings, the doctors should come from several different health care centres and discuss work problems with colleagues that they do not meet every day,” he says. “You gather together over a coffee and talk about the job, but nothing about the administration! The professional development is at the centre (of the talk). You learn from each other – ‘how do you manage if a patient has such a disease?’ “By sitting down and discussing, we can give each other ‘AHA’ experiences when problems are illuminated from different angles.” His assignment for AKO Skåne has just begun. Among other things, he will find out how many FQ groups there are at the 160 healthcare centres. A survey is intended to find out what works well in the groups, as well as what does not work and what support may be needed from the

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AKO

The importance spoken word “The spoken word gets less space in today's society. We doctors talk increasingly about the patients and we don't have much time to talk to patients,” says Lena Bååth, specialist in family medicine for 20 years.

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Lena Bååth.

AKO

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of protecting the

esides being a district physician in Svedala, Loddekopinge and until recently in Lomma, Lena Bååth is active as a teacher at university as well as being a certified Balint group leader. “I've always enjoyed teaching,” says Lena, who considered becoming a school teacher before choosing the medical profession. “For me, the whole thinking concerning the patient is important and so I enjoy family medicine. The continuity, to follow one patient for an extended period of time, so that they

develop from being one diagnosis to a human being with all its contexts - that is how I want to work with patients. The same thing really applies to students and colleagues - and everything I want it to be connected with in the clinical everyday life. At the same time, Lena Bååth is well aware of the deplorable lack of continuity found in today's healthcare both in terms of patients and colleagues. “Already in 1998, when I started working as a GP, time constraints existed. However, there was more room for manoeuvre and means of self-control,” she says.

Pressure situation an issue For the past eight years, however, the administrative burden has increased for doctors. In 2015 came the new patient law, which meant that patients should be involved in care decisions according to ‘their faculties’. “But how to get it together when the time for the patient meeting itself decreases,” Lena wonders. Many of today's work tasks, you do not have to have medical training to perform them points out Lena. These kind of tasks utilise the power from the real medical work, i.e. talking to the

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AKO

patients but also interpreting and hearing what is not said. Some parts of the work tasks should be performed within a team of medical secretaries and trainee nurses surrounding the GP and the patient she suggests. This would liberate time for doctors and would lead to more patients being able to be seen, increase continuity and perhaps help the GPs remain at the same health care center. It would also free up more space than now for continuous professional development, in-service training, skills development, but also one’s learning in everyday life together with colleagues. “The job gets so boring though if one cannot make use of continuity and take a holistic view on patients, while at the same time you feel confident that you

have adequate and up-to-date knowledge. From the very beginning teaching came into the picture for Lena. Since 2007, she has been on the medical program with conversation methodology, but also, for example, ethics and research techniques. “Unfortunately, the spoken word gets less and less space, but discussions not so much with colleagues. To discuss and reflect is really the soul in being a GP,” emphasises Lena. From February 2020, Lena Bååth continues in her roles at AKO Skåne and the university at the department of clinical sciences, Malmö. “For AKO, I plan regional in-depth courses. The intention is to choose areas that the GP always must be updated within that are major public health concerns such as heart disease, COPD and diabetes etc. I also use the AKO guidelines for primary care in the courses.

To discuss and reflect is at the heart of being a GP. ANNUALREPORT2019

Stories & discussions The concept is about inviting specialists to give lectures concerning fall-related episodes, with interactivity and discussions together with the participants. It can, for example, be about thinking and application of guidelines for the treatment of patients with multiple simultaneous diseases. “Discussions and reasoning are then needed and it can happen in the same room - when both GPs’ and specialists are present. This type of discourse does not typically have a place in the clinical everyday life. For the university, Lena teaches ‘Individual and Society’ in semester 11 also in case seminars. It concerns patient cases with any of the usual public health diseases. Students discuss how the patient should be investigated and treated. In addition, she examines the students' reflections that are set out in a portfolio with several documents. Lena has taught conversation methodology for 20 years and, without doubt, it is the conversation, i.e. the spoken word, which is central to her, together with the meeting with the patient. How do students today look at conversation methodology compared with students 20 years ago? “Interest in conversation methodology is bigger today than it was twenty years ago. This is well connected with the patient at the center, which is gratifying!” she says.

Balint groups In a further area, Lena works

Aha

Green oasis The meetings are approximately 1.5 hours long where

you can participate in the whole meeting and during this period you often have time to discuss two cases and also some followups. Afterwards you often meet the patient again and many times use the suggestions that come up. The group often then gets to hear how it went and discuss further with the colleague that wants more help. The methodology was introduced in Sweden in the 70's and then in Skåne by then professor of psychiatry, Lennart Kaij. Here in Skåne today there are several active Balint groups.

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“In my group we have both younger and older doctors, both specialists and resident physicians in family medicine. It is optimal to have eight to nine participants in the group, but six is also sufficient,” she says. The description of such conversation groups feels like a green oasis in a society where there is becoming less space for the spoken word. What really does the spoken word mean in today’s society? “I think it depends on the development of society as a whole. We are encouraged rather to write SMS, email or be on social media. There is a fear of being misunderstood and that has become a trend towards to rather have control over exactly the words that you express. All this actually takes longer than talking directly with each other and really the risk of misinterpretation is greater, when writing, than when talking directly to each other,” concludes Lena. For the spoken word to get more space, the value on conversation needs to be higher. That work needs to be reinforced, which is what Lena Bååth is doing on a daily basis.

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with the spoken word, namely in Balint groups. A Balint group consists of approximately 6-9 doctors that meets regularly every other week under a structured format and with a group leader who is well acquainted with the participants’ working conditions. The name comes from the Hungarian psychoanalyst, Michael Balint, who along with English medics developed these kind of discussion groups. “We deal with difficult cases that are dealt with by the group along with a specialist doctor. This leads to an increased understanding of the patients. Often it is patient meetings that spark many feelings that can be difficult to understand yourself while sitting with the patient. This is shown in a dissertation by Dorte Kjeldmand that this leads to less occupational stress and more content patients,” says Lena.

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KKNOWLEDGE CENTER, MIGRATION & HEALTH

KNOWLEDGE CENTER FOR MIGRATION & HEALTH

ANNUALREPORT2019

The unit works with a long-term view regarding migration issues within healthcare in Region SkÃ¥ne. The mission includes asylum seekers, new arrivals, people without papers and those that live in hiding but also established migrant groups that have long been in Sweden. The goal of the department is equal and safe care for people from other countries, and to promote equal standards of care across the whole region.

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In-service Training The Knowledge Center for Migration & Health offers knowledge support with a focus on strengthening health and healthcare personnel’s knowledge about migration related queries within healthcare. In 2019, a total of 2450 people participated in the Knowledge Center for migration and health various educational initiatives.

Training effort for employees at Skåne's BB and neonatal departments In autumn 2019, the Knowledge Center for migration and health hosted targeted education for Region Skåne's BB and neonatal departments within SUS. The training was held as part of their own administrative days and all staff were invited. The purpose was to strengthen staff knowledge about the impact of migration on health, raise awareness of the norms that affect our meetings and show how the administrations can work to ensure equitable care from a migration perspective.

Introductory Education Each semester, the Knowledge Center for migration and health held an introductory courses for healthcare professionals in Region Skåne. In 2019, a total of 125 people received an introduction to the topic of migration and health that was held on five occasions

Newsletter

In 2019, the Knowledge Center for migration and health continued their education efforts around interpreted meetings from children's perspective. The initiative was made together with the Migration School and in collaboration with the head of the children’s rights ombudsman at the children's and youth hospitals in Region Skåne. All children’s rights representatives were invited to attend an educational event focusing on interpreted meetings from a child's perspective.

New project

New project will develop care for torture exposed patients

DIKT is the name of a new project that will develop care for torture exposed patients within healthcare in Region Skåne. The name DIKT stands for Documentation, identification and knowledge about torture and the project will improve the conditions for the identification and documentation of physical and mental torture injuries. The project is carried out in three stages surveying the state of knowledge, in-service training and developing a new healthcare program. The work began in the fall of 2019 and will continue until 2022. DIKT is run by the Knowledge Center migration and health with funds from the Ministry of Social Affairs.

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In their newsletter the Knowledge Center for migration and health shared information on ongoing work, current research and news. In 2019, four issues of the newsletter were published, of which there was a special issue with the theme of interpretation in health care on the occasion of the release of the report "Language interpretation in health care - a matter of human rights".

Interpreted meetings from a child’s perspective

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KNOWLEDGE CENTER, MIGRATION AND HEALTH

Digital knowledge push

Arranging education is not unusual for KC migration and health, but in 2020 it will be the premiere of a new concept, namely web education.

Mia Sandor.

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t’s enjoyable to develop new types of learning initiatives. We learn a lot on the way! We are working on developing web education on migration and health, says project manager Mia Sandor. She adds, “We have been offering introductory education in migration and health here in our premises for some time and the interest is great from the health service, so now we also do web education. Many people in healthcare have difficulty getting the time and opportunity participate in training, and it’s for them that the web investment is made. The web training will consist of different modules, which gives the user great flexibility to do the course at their own pace based on possible conditions in the workplace. “We receive many inquiries about education in the adminis-

tration and see a value in being able to offer a shorter introduction to the subject via this initiative with web education. It would be desirable if it is included as part of the introduction to all new employees in healthcare,” says Mia. Web education will be available during the year via Region Skåne's education portal, but will also be made available to external users. “We would like to see other regions and administrations have the opportunity to take part in the initiative as a way to share materials between different participants,” she says. At present, the set-up phase of web education based on "An important book on care" is also underway, the method handbook in supporting unaccompanied minors published by the KC migration and health in the autumn of 2018. Mia says, “The book contains a lot of material and the web education is a complement to the book.

KNOWLEDGE CENTER, MIGRATION AND HEALTH

The content of the web training will be based on the book but with additional exercises and interactive elements.” Interest in the book has been substantial, both locally and nationally, and the authors Johan Andersson, Ida Gunge and Sabina Gušić, have received great lecture interest. “But then we discussed what more we can do, in addition to the lectures”, Mia continues. “We want to spread the book's content and make the material easy to access and available to anyone who is in any way working with or coming into contact with unaccompanied young minors.” The work is carried out by a working group on KC migration and health consisting of the authors of the book and Mia as project manager. As with the

other web training, this will be published during the year and will be available both internally and externally. The course takes about two hours, but it is built up in modules, which you can pause and return to later. “The courses provide a good basis for discussions at, for example, workplace meetings - there is much that can be reflected on in groups and in relation to one's own administration, even if the courses are intended to be conducted individually,” concludes Mia Sandor.

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(fr v) Mia Sandor, Micaela Nilsson, Jenny Malmsten

It would be desirable if the education was included as part of the introduction to all new staff”

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KNOWLEDGE CENTER, MIGRATION AND HEALTH

With the report “Language interpretation in health care – A question of human rights”, the Knowledge Center (KC) for Migration and Health presented a multifaceted and comprehensive factual report regarding language interpretation. The report is unique in its kind in Sweden.

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Interpreted conversations

KNOWLEDGE CENTER, MIGRATION AND HEALTH

Ida Gunge and Johan Andersson.

shortage of medical interpreters who have a specific authorization,” says Ida Gunge. In Skåne in November 2019, there were only 15 medical interpreters. There are a total of 190 medical interpreters throughout the country. The interpreter profession is defined by the financial vulnerability of freelance work and the occupation has a transitory element. "Unfortunately, the job of an interpreter is a transitional

profession," comments Johan. But what worked well is the fixed interpreting times Region Skåne used at, for example, some midwife units and healthcare centers.

Difficult situations Along with the report, the KC for migration and health has also published ‘A pocket guide

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he entire team at our knowledge center has worked on the report and myself along with psychologist Johan Andersson have served as project managers, says Ida Gunge, human rights expert. Both are also developers at KC migration and health. The preparatory work for the report began in 2018 and in the spring of 2019 a data collection was carried out, partly in the form of surveys for the health care personnel in Region Skåne, interpreters (hired by Region Skåne) and patients, as well as interviews and focus groups. “But we also worked with knowledge collection regarding research on interpreted conversations in health care to illustrate the advantages and disadvantages when not using an interpreter. We also looked closer at what can be difficult in interpreted conversations and what legislation applies in this area,” says Johan Andersson. The detailed report, which was presented in December 2019, demonstrates everyone's right to health and access to information in health care. “Put simply, the right to understand and be able to express themselves in the care meeting,” explains Ida Gunge. Nowadays, it is relatively easy to find interpreters in Skåne compared to recent years after the increase in asylum seekers in 2015 when new language needs emerged. “However, there is still a large

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KNOWLEDGE CENTER, MIGRATION AND HEALTH

to good interpreting’ where the focus is on what the health care staff can practically do to contribute to a well-interpreted conversation. In addition, two training courses will be held during the spring for further staff support. More information about these can be found in the education catalogue on the website Vårdgivare Skåne. One difficulty is with interpretation done over the telephone. The survey results showed that both staff, interpreters and patients prefer interpreters to be in the room. “In some situations, however, it is good with telephone interpreters. For example, it may be about sensitive topics of conversation or when the language group is small - then there is a risk for confusion. But for telephone interpretation to work well, technology is a very important factor,” says Ida Gunge. In the process of producing the report, Ida and Johan, together with their colleagues,

used focus groups and interviews, both for interpreters and the healthcare staff. In the focus groups, various questions from the questionnaires were elaborated and improvement suggestions were discussed. At a national level, an interpreting study was recently presented. It proposed a ban on the use of children as an interpreter in Sweden. “Unfortunately, it happens too often that children are allowed to act as interpreters in health care meetings,” Ida Gunge points out. In the survey, about one-fifth of health care professionals responded that at some point during the past six months they used a child under 18 as an interpreter. The fact that children are allowed to act as interpreters is problematic from both a patient safety perspective and from a children’s rights perspective. In Region Skåne, since 2006, there has been a guideline that health care should not use child-

KNOWLEDGE CENTER, MIGRATION AND HEALTH

Better conditions need to be created for staff to follow the guideline.

More improvement suggestions For better health care for everyone in Skåne - no matter what language they speak in the region - Ida Gunge and Johan Andersson emphasise three important improvement suggestions: “Update the 2006 guidelines so that no relatives may be used as an interpreter,” says Johan. And Ida adds: “Better conditions need to be created for healthcare professionals to follow the guideline, e.g. through training in interpreted conversations directed to healthcare professionals. Another important proposal is to clarify the right to an interpreter. And more pilot projects with an interpreter in place in healthcare! The report and the pocket guide present more improvement proposals but much would be gained if these three suggestions were to be implemented.

Right to understand!

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ren and relatives as an interpreter. However, the guideline seems to be largely unknown. Johan Andersson points out another problem: “It is also not good if you use another relative as an interpreter instead of a professional interpreter. Sometimes, however, there are multilingual healthcare professionals and they can often use their multilingualism in the care meeting and that can be an advantage, but these assignments are not formalised. Nor does the multilingual staff receive any compensation for the skills used.” For the interpreters, the situation is not easy either. Half of the interpreters surveyed in the report stated that they were given other information during the care meeting than to just interpret: “It can be about practical things, such as holding test tubes, or following the patient to another examination room,” Ida Gunge says.

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KNOWLEDGE CENTER FOR CHILD HEALTHCARE SERVICES

KNOWLEDGE CENTER FOR CHILD HEALTH CARE The mission for the KC child health care involves support for the of whole child health care (BHV) in Skåne, primarily in the form of in-service training for employees, work on strengthening care links and counselling in child health issues. In three comprehensive regional missions related to vulnerable children (children as next of kin, children who are ill and health surveys at the request of the social services) the unit provides support for development within the entire health care system in Skåne.

In-service training In 2019, more than 3000 people participated in the KC for Child Health Care different in-service training programs. A major initiative that returns every year is Introduction to Children’s Health Care. In 2019, a total of 83 people participated in this further education targeted at all new employees in child health care. NEW GROUP MANAGER TRAINING SHOULD HAVE MORE INCLUSIVE PARENTAL SUPPORT The KC for Women's Health and the KC for Child Health Care introduced in 2019 a new course for group leaders with the aim of contributing to a more equal and inclusive parenting support for prospective and new parents. Through the course, nurses and midwives receive methods and support for becoming safer as a group leader, and a goal is to increase the number of participants for new and expectant parents in group meetings. In autumn 2019, the first two in-service education terms for employees were held at midwife units and paediatric care in Skåne and the response has been very positive.

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VACCINATION IN CHILD HEALTH CARE In 2019, the KC for Child Health Care offered several different training opportunities on vaccine issues. Among other things, this was due to the introduction of rotavirus vaccination in the national vaccination program for children. Employees in child health care have also been able to boost their knowledge of tuberculosis and BCG vaccination as well as participating in two vaccine workshops with the opportunity to go more in-depth on vaccination issues. EDUCATION OF CHILDREN AND SEXUAL ABUSE In November, the KC organised an additional mission support for children in vulnerable life situations with half-day education about children and sexual abuse. All contact persons for ‘Children in distress in Skåne’ were invited and a total of 253 people participated. The Convention on the Rights of the Child was emphasised throughout the day and how it can be of help and support in working with and detecting children who are at risk of being in distress.

KNOWLEDGE CENTER FOR CHILD HEALTHCARE SERVICES

Goal

The goal is to create equal high quality care throughout the region in order to increase the conditions for equal health for children.

Continued cooperation with library

Newsletters w Four editions of the news

letter for child health care were published in 2019. The newsletter summa rises ongoing work, current research and news about children's health and is targeted towards employees at all of Skåne’s child health care centers.

w Children as next of kin,

children that are ill and health screening at the request of social servi ces have a common newsletter that was also published four times in 2019.

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KC child health care and Region Skåne’s cultural administration continues its collaboration within ‘Book Start’ with funding from the council of culture. ‘Book Start’ is a national initiative to stimulate early language development in children and is based on the interaction between the public library, child health care and preschool. In 2020 ‘Book Start’ will focus on developing parent group meetings at the library.

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KNOWLEDGE CENTER FOR WOMEN’S HEALTHCARE SERVICES

KNOWLEDGE CENTER FOR WOMEN’S HEALTH Its’ mission involves support for midwife units in issues such as sexual and reproductive health, maternity care, contraception, cervical cancer prevention and sexually transmitted diseases. The support involves education, work with care networks and regional guidelines as well as collaborative work and counselling.

Newsletter

Regional guidelines ANNUALREPORT2019

The KC for Women's Health works continuously with updating and developing new regional guidelines for the work at the midwife units in Skåne. During 2019 there was also a comprehensive review of the base program for pregnancy and post-care in Skåne, which will be ready for publication 2020.

The KC women's health newsletter was published four times in 2019. In the newsletter, the KC summarises ongoing work, current research and news concerning sexual and and reproductive health. The newsletter is aimed at employees at all of Skåne’s midwife units.

KNOWLEDGE CENTER FOR WOMEN’S HEALTHCARE SERVICES

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In-service training Introductory training for new staff at midwife units Since 2018, the KC for Women's Health has offered introductory education to new staff members at Skåne’s midwife units. In 2019, the training was offered on two occasions and for the first time as a two-day internship.

New group leader training to provide more inclusive parent support The KC for Women's Health and the KC for Paediatric Care introduced in 2019 a new course for group leaders in order to contribute to a more equal and inclusive parental support for new and expectant parents. Through the course, nurses and midwives are given methods and support to become more confident as a group leader and a goal is to increase the participation of new parents in parent group meetings. In autumn 2019, the first two education sessions for employees were held at midwife units and paediatric care centers in Skåne and the response has been very positive.

The KC for women's health arranged training initiatives for 593 participants during 2019. Each semester was comprised of regional education days for all staff at the midwife units in Skåne. During the spring education days, the participants had to take part in current lectures on changed working methods at regarding decreased foetal movements, preeclampsia and hypertension as well as how climate change can affect your health during pregnancy. Autumn’s education days offered a recess in intrauterine foetal death and infections during pregnancy. The participants were also introduced to the method of mindfetalness.

Further initiatives and depth in women's health and socioeconomic vulnerability

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In 2019, the KC for Women's Health continued its education focus on women's health and socioeconomic vulnerability. The initiative began in 2018 (which you can read in last year's yearbook) and in 2019, employees at the midwife units in Skåne, and others interested, were able to immerse themselves in additional areas linked to the theme: w Pregnancy and parenting with experience of escape and trauma w Assessing and talking about mental health with foreign-born pregnant women w Person-centered discussion methodology w Norm critical pedagogy - a tool for person-centered care The initiative is now complete and a total of about 200 people participated in the various educational efforts during 2018–2019.

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PAEDIATRIC CARE & MATERNAL CARE

In 2019 the KC for Women’s Health and the KC for Child Health Care jointly produced the report "For equal maternal and child healthcare in Skåne: a current report and basis for action". The report is addressed to many, including prospective and new parents, staff, students, service workers and politicians within the healthcare sector and administrations that healthcare collaborates with. In the report, Rafael Caballero Caballero, coordinating midwife, processed regional data from the pregnancy register and Lars Olsson, psychologist and developer, processed data from child healthcare surveys. In the process, both teams from the KC for Women's Health and the Knowledge Center for Child Healthcare participated together with unit head Marie Köhler, paediatric consultant and medical doctor. On the following pages we present the report and some of the report’s authors.

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PAEDIATRIC CARE & MATERNAL CARE

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“I get sad when I see how bad lifestyle habits are in Skåne. What’s especially sad is that smoking among pregnant women is the second highest in Sweden,” says Rafael Caballero Caballero who together with Mariette Derwig wrote the interim report on lifestyle habits, which is included in the large report for equal maternal and child healthcare in Skåne.

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Proper public health initiatives needed!

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PAEDIATRIC CARE & MATERNAL CARE

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afael, who holds a MSc in International Public Health from Lund, is a midwife coordinator and developer at the KC for Women's Health. Mariette is a paediatric healthcare consultant and developer at the KC for Child Healthcare and is also a PhD student at Lund. “We had hoped for a change. Each year we have seen that smoking decreases during pregnancy but after birth the proportion of mothers who smoke again increases. And it is those who smoke the most that also breastfeed the least,” says Mariette. In Skåne (2018), 13.9% of women who became pregnant smoked daily three months before the start of pregnancy, compared with 11.3% for the whole country. During pregnancy, the number of smokers declines, but the figure is still higher in Skåne than the rest of Sweden. The report shows that prepregnancy smoking is more common among pregnant women with higher BMI. The epidemiological analysis shows that the lowest proportion of smokers is among pregnant women with normal BMI. “Changing the trend does not need one-off measures, but a regional public health department in Skåne. From the knowledge center, we can support such work to advocate the people of Skåne to take responsibility for their lifestyle habits,” says Rafael.

Understand and interpret He believes that health literacy needs to be increased, i.e. the

ability absorb such

information plus make your own choices and use healthrelated information to promote health. Equally, health information must be disseminated through targeted suitable channels. Low levels of education equate to a high risk of poor lifestyle habits. The report's analysis showed that smoking before pregnancy is more common among pregnant women who have an education level of primary or secondary schooling. The proportion of non-smoking pregnant women with none, or education shorter than nine years is high, while the proportion of pregnant women that smoked is lowest among those with university or college education and highest among those with primary school education level. “We need more cooperation between maternal and child health care to be able to support the whole family more,” emphasises Mariette. The connections around living habits are straightforward. Those who are more educated have better health, better finances and a better understanding

of the importance of lifestyle habits. “If people have healthy lifestyle habits, we prevent illness and people are as healthy as possible,” says Rafael. But healthy living habits do not come naturally. There is a need for constant, repeated awareness-raising measures. What one generation has learned is quickly forgotten by another.

Health promotion to breastfeed The good results of breastfeeding during the 90s have since diminished. Back then a joint campaign was made with great efforts all over Sweden. The health-promoting effects of breastfeeding are extensive. It contributes to good mental and

PAEDIATRIC CARE & MATERNAL CARE

physical health of the mother, while breastfeeding stimulates the child's immune system, reduces the risk of acute infections and sudden infant death. But the impact of campaigns done by baby formula producers' is strong. With social media, it is also easy to spread claims that breastfeeding is not so important or that bottle-feeding can increase the father's closeness to the infant. Sweden adheres to the WHO's recommendations regarding breastfeeding exclusively during the child's first six months. Thereafter, continued breastfeeding applies during the first year of life or longer, combined with a slow introduction to another diet “Compared to the rest of Sweden, the proportion of breast-

fed children was lower in Skåne during 2018,” says Rafael. The exclusive breastfeeding rate when the infant was four weeks old was 66.3% in Skåne, compared with the nation's 68.3%; the partial breastfeeding rate is also lower in Skåne than the rest of the country. The same applies to the proportion who do not breastfeed at all (16.6% compared to 15.8%). Most worrying is that the numbers are deteriorating annually.

Negative trend

Mariette Derwig and Rafael Caballero Caballero.

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The trend curve for lifestyle habits is predominantly negative. Almost half of the pregnant women in Skåne 2018 were of normal weight. The proportion of those registered at a midwife centre with increased BMI has gone from 38% in 2014 to 40% in 2018. Of these, 26.3% were overweight and 13.7% were obese. The proportion of pregnant women with normal weight registered at the midwife units in Skåne is declining year by year and is almost 1% below the national

average. Mothers with normal weight are those that breastfeed the most. The risk of the baby not being breastfed is three times greater if the mother has a BMI over 40. Hence, this group needs extra support. “30% of obese women do not breastfeed after four weeks,” says Rafael. Colleague Mariette adds, “If the mother has obesity, the risk of obesity also increases in the child. We work in the headwind!” However, there are some bright spots. Post childbirth, the motivation level is high in mothers to regain normal weight. Evidence-based dietary treatment after pregnancy in the Västra Götaland region has shown a good effect. By means of a single visit to a dietician and then only support via sms, the mothers obtained a healthy weight result after some time. The KC for lifestyle habits and disease prevention in collaboration with primary care dieticians in Region Skåne are working on a similar project. Rafael and Mariette welcome such a venture. Support and knowledge enhancement are paramount to their work: “Those who need the most support rarely come to the clinics; those who understand least, have least knowledge and don’t know where to seek help. We need to support these the most. If you have a bad habit, you often have more (bad habits). You don't take care of yourself and end up in a negative spiral,” Rafael concludes.

KCP

PAEDIATRIC CARE & MATERNAL CARE

Socioeconomy affects access to supply

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KCP

Socioeconomic factors play a role in the number of midwife visits that are done during pregnancy and almost every seventh children in vulnerable areas missed the four-year visit at paediatric care in 2019. The consequences are likely to be lifelong and are serious for public health, warns the paediatric doctor and head of unit, Marie Köhler.

kåne's child and maternal health care are held in high esteem. At the same time, there is much to suggest that their important health promotion initiatives don’t reach everyone and participation is vital in order to measure several important areas.

Missing important health promotion support In the KC report “For equal maternal and child health care in Skåne” it is noted, among other things, that expectant mothers in socioeconomic vulnerable areas make fewer visits during pregnancy and that also applies to participation in the aftercare visit. A similar picture emerges regarding participation in parental groups in child health care. Just over 13% of

the children in nerability in report. socioeconomic Anna Kjellbom with vulnerable areas the KC women's health, in Skåne did not public health researtake part in the cher and specialist in four-year visit at family medicine gives paediatric care some examples of compared to what the consequences 2% within more can be: socioeconomic “Fewer visits to the favourable areas. midwife during and “It's serious after pregnancy can, that some childfor example, mean Marie Köhler (left) and ren and families that important health Anna Kjellbom. still have poorer information gets lost access to both or be discovered via child health care and maternal complications that are delayed health care and are thus missing and aggravated, which can have important health promotion consequences for both mother and disease prevention efforts,” and child,” says Anna Kjellbom. notes Marie Köhler, head of unit A lower participation in and paediatric consultant for parental support administration the KC women’s health and child at paediatric care can also mean health, and one of the initiators worse conditions to promote behind the section on social vulchildren's health or a missed

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It is serious that some children and families have less access to both child healthcare and maternal healthcare.

KCP

PAEDIATRIC CARE & MATERNAL CARE

opportunity for families to become a part of a stronger social network. “If we can turn the numbers around we have so much to gain and it does not only apply solely to the child and the family but also in the longer term for the development of society at large. The opportunity to offer support and initiatives to parents at an early stage has been shown be very effective when you looking at health promotion efforts for public health from a life perspective,” says Anna Kjellbom.

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Ask about domestic violence Another important area is violence in close relationships. Enquiring about violence is now included in the base program for pregnancy monitoring. During 2018, some 96.6% of those pregnant in Skåne were asked, which means that for the first time the national goal of 95% was reached. “Being asked about violence is something that all pregnant women should get and it is gratifying that maternal care in

Skåne is now a forerunner. Now we need to know more about how the answers are followed up and we will continue to work with that,” says Marie. Research shows that pregnant women who have been subjected to violence by their partner are at even greater risk of being affected during pregnancy. The approach of asking about violence at the midwife unit shows that it is possible to change working methods and this must also start to apply to children,” points out Marie.

Asking the question about violence is important and it’s great to see that maternal care in Skåne is a forerunner.

PAEDIATRIC CARE & MATERNAL CARE

Figures remain the same The report also states that child health care made 502 reports regarding children in distress to social services, which corresponds to just under half a percent of all children. The proportion of reports remains unchanged compared to the previous year. Most reports were made in areas with a high Care Need Index, CNI (see fact box). “The reports are at the same level. There is a lot of talk because the number of reports is too low in relation to children's real vulnerability. Continue raise awareness of children in distress is therefore urgent,” says Anna Kjellbom.

Common knowledge boost

Fact

CARE NEED INDEX, CNI The socioeconomically vulnerable areas are calculated based on a measure called CNI [Care Need Index]. For families with children, five variables as measures of increased risk of ill health are applied. 1) Parent born outside Europe. 2) Unemployed parent. 3) Single parent. 4) New immigrant family. 5) Parent with low education. “It can be difficult to catch this number in an index, but it is a help when care resources will be distributed. It is also a support in seeing living conditions as underlying factors affecting children's health. An index can point to where there are differences in health,” says Marie Köhler.

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Just as important as mapping the state of work for equal maternal and child health care is to provide the profession with knowledge and tools. KC for women's health and paediatric care are working continuously with these issues. In 2019, the in-service training initiatives continued with "Women's health and socioeconomic vulnerability” which aims to raise awareness around socioeconomic factors that are important for women’s health. The initiative is aimed at midwives and other staff in the field of healthcare. Another initiative is education in “Parent group leadership” with the goal of increasing the number of participants in parental groups within maternal and

paediatric care. In December 2019 a shared education day was held about parents and children in vulnerable life situations and what social vulnerability can mean for health. Courses were also offered on “Children as next of kin” and “Children in distress" as well as "Children who are exposed to sexual abuse”. In autumn, new work material was connected to the care program regarding violence in close relationships. The work continues unabated during 2020. “These are very important issues from a public health perspective,” says Marie Köhler. An adjacent ongoing topic at the KC is the declining breastfeeding rates in Skåne. Here too, the external differences based on the mother's socioeconomic position and children from socio economically disadvantaged groups are reflected in the lower rates. In 2020, work will continue to strengthen breastfeeding promotion and investigate how the support can be more equal,” says Anna.

KCP

PAEDIATRIC CARE & MATERNAL CARE

Parental mental health in focus ANNUALREPORT2019

Although a lot of health promotion and prevention efforts are made, we see that some background factors such as, for example, country of birth and education level can determine what you give and take,â&#x20AC;? says Ida Ivarsson, psychologist and developer at KC child health care.

PAEDIATRIC CARE & MATERNAL CARE

Origin influence The report showed that 6.7% of pregnant women in Skåne who were enrolled at a midwife unit were treated for mental illness with both psychological and/or medical treatment. “The midwives do a fantastic job to create good relationships and discover ill-health, but still exists no systematic routine to screen for mental illness in pregnant women in a similar way at paediatric care. Here it can go unrecorded,” says Ida Ivarsson. The KC also revealed that country of birth influenced to

Similar conditions does not always mean the same as equal care.

Ida Ivarsson and Lars Olsson.

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lthough a lot of health promotion and prevention efforts are made, we see that some background factors such as, for example, country of birth and education level can determine what you give and take,” says Ida Ivarsson, psychologist and developer at KC child health care. It is important to time the discovery of mental ill-health among pregnant women, new mums and dads because it can affect the whole family negatively and can change a child's life. But meeting maternal and child health care initiatives to prevent and detect psychological ill health for everyone? To get answers the KC for paediatric care and women's health, with the help of a wealth of data from the national pregnancy register and paediatric care’s own reported data, they have mapped out initiatives based on four indicators: Mental ill health during pregnancy, childbirth fears, depression among new mothers and mental illness among the non-birth parent. “Maternal and child health care, which reaches almost all families until the child is six years old, are important areas for health promotion and prevention efforts and identification of mental illness. But similar conditions does not always mean the same as equal care, says Ida Ivarsson.

KCP

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PAEDIATRIC CARE & MATERNAL CARE

what extent pregnant women were treated for mental illness. In the report it was shown that 8.3% of Swedish-born pregnant women received treatment for mental illness during pregnancy compared to 3.8% of the group born in other European countries and 3.3% in the group born outside Europe. Similar patterns are shown for support measures in the case of childbirth fears, such as conversations with midwives or obstetrician, or initiatives from a counsellor or psychologist. A total of 8.8% percent of Swedishborn mothers got support while for non-European mothers the figure was 5.4%. “That’s despite previous studies showing that twice as many foreign-born women feel anxious or afraid of the birth compared to Swedish born. Some foreign-born women have no family here and may have been involved in a trauma due to migration. We need to do more to be able to meet these women in a better way,” says Ida. Education level is also an influencing factor where support for childbirth fears is given to a larger extent pregnant women with longer education than those with less education.

Routine screening When newborns of 6 - 8 weeks are examined at paediatric care, a routine screening of depressive symptoms of the mother is also done. “The paediatric nurse talks with the mother and based on the answers and, if needed, the mother is offered further means that may be a support call from a nurse or a referral for further information assessment and support,” says Ida Ivarsson. In 2018, some 86.8 of registered mothers participated in depression screening. Of those that participated, 11.7% received a support call or referral to psychologist/counsellor, adult psychiatry or the social services family support and family counselling. Even here the differences from the external socioeconomics become apparent. The percentage of mothers offered depression screening is lower within paediatric care in socioeconomically vulnerable areas (with a high Care Need Index,

CNI) than within paediatric care with low CNI. In which municipality in Skåne that you lived also had a great span for both if you participated in screening or received further support.

Support for partners How parents’ feel is an extremely important factor for the child’s health and development. And from a child’s perspective, it is important to find out if both parents could do with some support. Offering the parent, which has not given birth to the child, a greater opportunity to talk about their first time as a parent, have individual parental talks, regardless of gender, introduced as part of the general child health care is offered and implemented in Skåne via a large educational initiative. “It is good that we are now starting to see the father/partner in another way and care

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KCP

Study

Conversation with partner provides broader understanding of the child's situation in the family In a study by Malin Ståhl, Inger Kristensson Hallström, Malin Skoog and Andreas Vilhelmsson, they interviewed 11 paediatric nurses in Region Skåne who have been trained in holding conversations with the partner to the one who has given birth to children, about their experiences.

The paediatric nurses described that this group, who were all fathers, were positive to the conversation and felt important as parents and more included in child health care. The nurses valued the increased contact with fathers highly and felt that the conversation was necessary to gain a broader understanding of the child’ situation in the family. It could be at the same time a challenge to manage information that has emerged, especially if it was perceived as sensitive to it other parent.

New model for feedback and discuss data quality In their aspiration to provide good support for new approaches and action plans,

the KC for child health care are planning to develop a new model to feedback the results it acquires from its’ annual statistics collection directly to each child health care unit. All paediatric care units should have the opportunity to get direct feedback on their administration. A collaboration has started to develop an application for child health care’s administration results. “We hope that the arrangement with peer discussions, reflection, knowledge transfer and evidence-based material will be appreciated. It can also be a great way to capture areas of improvement that could result in joint projects,” Lars hopes.

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becomes more equal when we ask if both parents are feeling well. Part of the conversation is focused on the parent's own health, and for signs when mental ill-health emerges there are specific means that the paediatric nurse can use as support,” says Lars Olsson, psychologist and healthcare developer at KC Child Health Care. Preliminary information from 2019 showed that about 6-7 percent of fathers are offered extra support after the talk.

We hope that the setup with feedback, statistics, peer dialogue and reflection will be appreciated.

CPF OVERVIEW

CENTER FOR PRIMARY HEALTHCARE RESEARCH The Center for Primary Healthcare Research carries out, with primary care as its base, world leading research through an active exchange of knowledge that is comprised of basic research, epidemiology and patient-oriented research. The administration also includes the Academic Knowledge Center, in-service training, supervision, seminars and the Nordic regionâ&#x20AC;&#x2122;s first experimental laboratory based on primary health care. Units of the Center for Primary Healthcare Research: w Central Operations and Supporting Functions w Academic Care Center (AVC) w Experimental laboratory ANNUALREPORT2019

OVERVIEW

13 4 14 4

Newly enrolled PhD students

Resident physician courses in research methods

AVC coordinators

PhD thesis defences

Million kronor in external grants

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22,6

Published scientific articles

THE YEAR IN NUMBERS

146

CPF

CPF ACADEMIC CARE CENTERS

Academic Care Center The Center for Primary Healthcare Research has established a network of Academic Care Centers (AVC) with the mission via clinically active AVC coordinators to supervise research and development projects and increase scientific competence within primary care.

Coordinator

Until May 2019. Afterwards at CPF

AVC coordinator at Healthcare Center Bokskogen from 2020 c

Healthcare Center will cease as an AVC in 2020 ANNUALREPORT2019

New AVC coordinator 2020

New AVC 2020

Until 31 December 2019

AVC

w Louise Bennet

w Healthcare Center Sorgenfrimottagningen, Malmöa

w Beata Borgström Bolmsjöb

w Healthcare Center Sorgenfrimottagningen, Malmöc

w Stefan Brembergf

w Capio Citykliniken Helsingborg Söderc

w Annika Brorsson

w CPF, Malmö

w Susanna Calling

w Healthcare Center Bokskogen, Bara

w Disa Dahlmand

w Healthcare Center Granen, Malmöe

w Rickard Ekesbof

w Healthcare Center Näsby, Kristianstad

w Anders Halling

w Healthcare Center Tåbelund, Eslöv

w Ulf Jakobsson

w Healthcare Center Norra Fäladen, Lund

w Tommy Jönsson

w Healthcare Center Måsen, Lund

w Sara Modig

w Healthcare Center Tåbelund, Eslöv

w Veronica Milos Nymberg

w Healthcare Center Laröd, Helsingborg

w Miriam Pikkemaat

w Healthcare Center Husensjö, Helsingborg

w Nabi Pirouzifardd

w CPF, Malmö d

w Henning Stenberg

w Healthcare Center Fosietorpe

w Emelie Stenman

w CPF, Malmö

w Moa Wolff

w Healthcare Center Nöbbelöv

w Bengt Zöller

w CPF, Malmö

ACADEMIC CARE CENTERS

At each AKC there is one or several AKC coordinators with a PhD that those who work in primary care can turn to you if you need scientific guidance or are just in need of a sounding board regarding research questions.

family medicine is great. During the year we supervised 59 such projects. Other important activities are Professor Ulf Jakobsson's research school for nursing, physiotherapists and occupational therapists, our new educational investment in evidence-based medicine and "order a seminar" where you can order seminars with different themes, such as workplace meetings or FQ groups. In addition to the AVC mission, the coordinators are involved in various research projects such as studies on e-health, the Care Express, cardiovascular diseases, diabetes, elderly people's health and medications, firearm accidents, difficult-toheal wounds, medical history, antibiotic prescriptions and cancer diagnostics. This research, which is next to the AVC mission, has resulted in 39 scientific articles during the year. Some readers may wonder what happened to the former Academic Knowledge Center (AKC); they have now changed their name to Academic Care Centers because we think the new name better reflects the administration and sounds more inclusive, just as we want to be!

Fast Facts AVC2019 w 10 Academic Care Centers w 14 AVC coordinators with a PhD w 31 scientific group supervisors w 39 scientific articles w Supervision of 59 resident physician projects

CONTACT Look out for activities on the website and in the education catalogue. You are welcome to contact an AVC coordinator or AVC team leader Emelie Stenman (below), e-mail: emelie.stenman@med.lu.se

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n 2019, we had nine AVCs with 14 AVC coordinators, including 13 district physicians and one district nurse. All of the coordinators have a PhD, four of them are associate professors and three are professors, thus a collection of relatively experienced researchers who supervise resident physician projects, projects in other professional groups (for example nurses) and hold seminars and courses. During 2019, the AVC coordinators hosted 31 group supervision scientific seminars around SkĂĽne. It is often resident physicians who attend to discuss their scientific papers, but everyone in primary care who plans to or is doing research projects is warmly welcomed! The seminars are free of charge and usually last about two hours with a maximum of six participants. The 2020 seminars can be found on the AVC website and in the healthcare provider web directory. Supervision of scientific articles is one of the most important tasks of the AVC coordinators as the number of resident physicians is now higher than ever and the need for specialists in

CPF

CPF NEWS IN BRIEF

Kristina Sundquist is the most cited medical researcher at Lund University In autumn 2019 CPFâ&#x20AC;&#x2122;s director, Professor Kristina Sundquist, topped the ranking list of most cited researchers at Lund University in the Swedish magazine Fokus. She had the most citations in the field of medicine and life sciences and was the seventh most cited overall in the top 100 list of Sweden's most cited medical researchers. Jan Sundquist, professor at CPF, was ranked in fifteenth place on the same list of medical researchers in the country. Fokus ranked the researchers in Sweden who are most frequently cited in international journals.

ANNUALREPORT20189

Ulf Jakobsson honoured as ETP In 2019, Professor Ulf Jakobsson was named Excellent Teacher, ETP (Excellent Teaching Practitioner) and thus also became a member of the faculty of medicine's pedagogical academy. The ETP title is a mark of quality regarding one's competence as a teacher and that one contributes to the educational development within the faculty. It was in 2008 that the faculty of medicine decided to establish an educational academy. The academy members help teachers with support and career advice. The general purpose of the pedagogical academy is to increase the quality of the medical faculty's education and to develop the assessment of pedagogical skills at the faculty.

NEWS IN BRIEF

CPF

Major interest in courses in research methods CPF offers various course options in research methodology: an eight-day intensive course for resident physicians and a try-out-research course for nurses, occupational therapists and physiotherapists. We also participate in the course in basic research methodology (30 credits), which has been taught since 1989 in the southern healthcare region (the course is led by the department of clinical sciences in MalmĂś). The intensive course for resident physicians is given four times a year with 25 participants per course and during 2019 was fully booked with long waiting lists. In order to respond to the large number of resident physicians, we will provide another course in 2020, i.e. five courses in total. The try-out-research course, which includes six participants, also filled the places on both the first and second rounds directly. The 30-point course has 16 participants working on their projects over three semesters. The interest in research thus seems to be great within primary care in SkĂĽne, which bodes well for future evidence-based practice! Read more about our courses on CPF's website.

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CPF NEWS IN BRIEF

Was the first year in the role as CPFâ&#x20AC;&#x2122;s director quite as Professor Kristina Sundquist imagined? No, not really! It went even better! She says and emphasises that it is with a light touch and a smile on her face that she goes to work each day.

Ă&#x2026;RSBOK2019

CPF Foto: Johan BÃ¤vman

NEWS IN BRIEF

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CPF NEWS IN BRIEF

he key is to have clever, hard-working and creative employees who collaborate fantastically well in the many research projects that CPF leads. It is a privilege to be surrounded by these staff every day, employees who I myself have, in most cases, recruited, says CPF’s director Kristina Sundquist. She adds, “CPF was established in 2008 and I have had the privilege of being involved from the start in building up the administration’s success, which according to The National Board of Health and Welfare's evaluation is without parallel in Sweden.” The success also includes the Competence Center for Primary Care (KCP) which Kristina is also the director. KCP was linked to CPF in 2015 as an important part of being a cohesive platform for training and skills development for most occupational categories in primary care. Kristina is content in the role of leader and says that most things are about common sense. “The employees know me from before and they would quickly see if I am trying to play some kind of role. I'm myself at work and have

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an open dialogue with my employees where I have emphasized that I want their critical views in order for CPF to be able to continue to develop.”

Unique platform Strong research, development work and education must be conducted in an ongoing dialogue with the employees, according to Kristina. That academic and clinical work together develops various administrations is nothing new. But the way that it is being done in Skåne is unique says Kristina. From the shared connection to the clinic via the Academic Care Centers (AVC) and the link between KCP and CPF, and not least the joint board for CPF with representatives from Region Skåne and Lund University that provides backup when needed. During 2019, the AVC operation and research areas expanded; a total of 13 new doctoral students of whom many are financed with external research funding tied to the platform. The researchers at CPF has been good at landing large external grants. An example is a major grant from the European

I have had the privilege of being involved from the start in building up the unit’s success

Research Council that is worth €2.5 million to study, among other things, the mental health of immigrants. In addition, CPF has had long-term support from the National Institutes of Health (NIH), USA, for many years. “The support from NIH is to a large extent the harvest of our many collaborations with prominent researchers at the likes of Stanford University, Mt Sinai in New York and Virginia Commonwealth University. These collaborations at the university part of CPF leads to increased competence, which in turn spills over to the regional part of CPF, and also ours clinical supervision, courses and education in primary care,” says Kristina Sundquist.

Heart disease project At both CPF and KCP a large number of projects are ongoing. During the year, the HISS project which means “Congestive heart failure in southern Sweden” was established. It's a collaboration between primary care and cardiac care to improve treatment for primary care patients with congestive heart failure. “Heart failure is a common and

CPF

NEWS IN BRIEF

serious illness where just over half receive adequate treatment. We want to change this,” says Kristina. The plan is to identify the patients with heart failure and then provide the support of heart specialists that come out directly to the healthcare centers at the same time as important research is done. Another venture that Kristina wants to mention is Culture on Prescription that recently started at a number of healthcare centers in cooperation with the department of culture. “Mental ill health is increasing in our society. This is often about stress-related problems that do not necessarily require individual psychotherapy. With this project, the hope is to be able to help more patients lead a better life with less mental illness, even those patients who do not need to go to a psychotherapist.”

Clinical work continues In autumn 2019 Focus published an article about the researchers in Sweden cited most frequently in international journals. Kristina Sundquist was the researcher at Lund University who had

the most citations in the area of medicine and life sciences. How did it feel? “The truth is that I have no control at all on my citations. It was my sister who saw the article in the newspaper. I have been too busy with our projects and supervising doctoral students over the years but I was obviously very happy! Both for my own sake though also because this strengthens the whole of primary healthcare!” Kristina works clinically one day per week at Granen's health center, which she enjoys. “My professional identity always has first and foremost being a doctor. As a doctor in primary care I can make an immediate difference for the individual patients,” says Kristina. It is also in the meetings with the individual patients that queries are made and ideas are born that can be studied scientifically to increase knowledge and improve care. “This is a perfect combination that both improves both the research and the clinical work,” she concludes.

It’s in the meetings with patients that ideas and plans are hatched!

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CPF NEWS IN BRIEF

Two new lecturers in 2019 Long-term CPF staff, Xinjun Li and Jianguang Ji, were both appointed as senior lecturers in 2019.

Xinjun Li was one of the first appointments made by CPFâ&#x20AC;&#x2122;s former director, Jan Sundquist, when the organisation was founded in 2008. Li has enjoyed a long career in research since graduating from medical school in his native China in 1991. He got his PhD at Stockholmâ&#x20AC;&#x2122;s Karolinska Institutet in 2004. Since joining CPF his work has mostly focused on numerous projects of great variety and research training, independent investigations, support, database management support on a high level, including both supervision of doctoral students enrolled in the faculty, tutoring and teaching at the undergraduate level, as well as in research. Li has published 250 peer-reviewed international original works and is a collaborator on several international projects including those with Stanford and Berkeley universities.

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NEWS IN BRIEF

CPF

Jianguang Ji who got his PhD at Heidelberg University in Germany, subsequently joined CPF where he leads a research group that conducts large-scale epidemiological studies in an attempt to identify new ways to predict and treat patients with various diseases and disorders. An important part of Ji’s research is understanding the cause of some cancers and the keys to new methods to detect and treat the disease. Ji has published almost 150 scientific articles and continues to teach as well as being a supervisor to several PhD students. Commenting on his new appointment, Ji said: “I am excited to be appointed as senior lecturer at Lund University, which means that I will have more responsibility and duties. I will continue my previous research work on cancer epidemiology, and find new evidence to prevent and treat patients with cancer.“ “At the same time, I will be involved even more for the further development of CPF, such as our collaborations with outstanding scientists worldwide, being an external reviewer for doctoral dissertations, joining the editorial board of scientific journals etc. These challenges will be an excellent opportunity for my career.”

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CPF NEWS IN BRIEF

Road to the future of primary care On April 4th 2019, the lecture hall at CRC house in Malmö hosted a series of fascinating debates and lectures about healthcare. Key speakers were: Anna Nergårdh, national special commissioner on coordinated development for good and close care.

From Gothenburg came Christer Andersson, director and administration manager at Bergsjön Medical Center and BVC AB, Gothenburg. He told about his experiences in developing a healthcare center in a vulnerable area.

Åke Åkesson, director at Borgholm Health Center, Öland, explained the Borgholm approach.

Heidi Stensmyren, Chairperson of the Swedish Medical Association stressed that a national primary care reform requires doctor listings.

In addition, the audience was invited to research presentations, poster exhibitions and try out activities as well as speeches and lectures by Erik Renström, dean and professor of medicine and health sciences, Birte Sandberg, Chairperson of the Primary Care Committee, Jan Sundquist, professor and CPF's then director and Professor Kristina Sundquist, CPF's director, who talked about family medicine research: a concept in change. The day ended with an appreciated panel debate moderated by Lisa Kirsebom. ANNUALREPORT2019

NEWS IN BRIEF

CPF

NIH grants for research on the relationship of suicide, alcohol and drugs Professor Kristina Sundquist, CPF’s director, was awarded in 2019 together with researcher Alexis Edwards at Virginia Commonwealth University, a new grant from the National Institutes of Health – worth nearly SEK 20 million – to study suicide in relation to alcohol and drug abuse.

The project aims to clarify the mechanisms behind the links between alcohol and drug abuse and suicidal acts, including completed suicide. National registers that include medical data, as well as family and socioeconomic data for more than 10 million individuals will be used to create detailed datasets covering a wide range of individual, family and environmental factors. "Using innovative study methods, we will highlight the causal link between addiction and both suicide attempts and completed suicide," says Kristina Sundquist. She adds, “We will also study the utilisation of care among those with addictions where

we intend to create risk models for suicidal acts that will enable healthcare to identify processes that lead to both suicide attempts and completed suicides and thus create better opportunities in the healthcare system to prevent suicidal actions.”

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CPF NEWS IN BRIEF

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EU funding for interdisciplinary project

Lecture on primary care challenges

Professor Juan Merlo, research team leader for social epidemiology, is a member of the External Advisory Board for the multinational research and education program CLARIFY (CLoud Artificial Intelligence For PathologY). CLARIFY has received support from the EU research and innovation framework program, Horizon 2020, with the goal of developing a digital diagnostic infrastructure based on artificial intelligence and cloud technology. This is to improve the use of digital virtual images (Whole Slide Imaging, WSI) and thus increase knowledge exchange and facilitate decision making for pathologists. The project is multidisciplinary and is comprised of European researchers from academia, industry and healthcare in a joint approach to improve workflow, stimulate collaboration and increase diagnostic safety within pathology. Read more about the project here: http:// www.clarify-project.eu/

On April 11th, the physician and professor Richard Young, director of the Research and Recruiting and Family Medicine Residency Program at Research and Recruiting JPS Hospital in Texas, gave a talk on the challenges of measuring, improving and reporting quality factors in primary care. Initially, he explained how the operations at his department at the Texas hospital worked and compared with the impressions and statistics from Swedish primary care. One of his conclusions was: â&#x20AC;&#x153;Complex systems cannot be controlled by top-down managementâ&#x20AC;?.

NEWS IN BRIEF

CPF

Epidemiological and statistical issues discussed CPF's episeminars have been running since spring 2019 and are seminars focusing on epidemiological and statistical issues. About once a month, doctoral students meet statisticians and others interested in discussing and learn more about these often complex topics. The seminars are interactive and are very much based on discussions where it is suggested that the participants will read about the current theme. In addition to deepening their knowledge, these seminars also contribute greater insight into the work of colleagues since we always have a participant's project as a starting point for discussions. From right in picture: Nabi Pirouzifard, statistician, Wuqing Huang, PhD student, Cecilia SjĂśstedt, PhDstudent, Ming Sun (Shadow), Master's student, Kristina Sundquist, professor.

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CPF NEWS IN BRIEF

Uppsala APC visit During the last days of the 2019 semester, CPF was visited by Magnus Pettersson, Academic primary care center Uppsala (APC), to initiate a long-term collaboration. It is exciting and important for general practitioners in Sweden to cooperate. The picture shows from the left district physician and APC coordinator, Magnus Pettersson, APC Uppsala, Professor Kristina Sundquist, CPF, and Professor Jan Sundquist, CPF.

Collaboration agreement with University of Granada During 2019 Professor Jan Sundquist visited the University of Granada at the invitation of the medical faculty. A collaboration agreement was signed between the deans of Granada and Lund University. Jan has given lectures there on family medicine research and initiated two lines of collaboration concerning mental illness in primary care and cardiovascular diseases. From left: Professor Blanca Gutiérrez, Vice Dean and Professor in psychiatry, Professor Jan Sundquist, CPF, Eladio Jiménez Mejías, professor in family medicine medicine and professor Aurora Valenzuela Garach, dean of the medical faculty in Granada.

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RESEARCH

CPF

Researchers

The research leaders at CPF during 2019. You can read more about their research and teaching at www.cpf.se NAME

WORK PLACE

RESEARCH AREA

w Anders Beckman, Associate Professor, Lecturer

w CPF, Lunden Healthcare Center

w Medical care research and pedagogic research

w Anders Halling, Professor

w CPF, Tåbelund Healthcare Center

w Epidemiology, COPD, multimorbidity

w Annika Brorsson, Associate Professor

w CPF

w Qualitative methods

w Ashfaque Memon, Associate Professor

w CPF

w Biomarkers, predictors for illness

w Bengt Zöller, Professor

w CPF, Södervärn healthcare center

w Cardiovascular disease

w Henrik Ohlsson, Associate Professor

w CPF

w Epidemiology, genetically and environmentally oriented application

w Jan Sundquist, Professor

w CPF

w Mental disease and substance abuse in primary healthcare

w Jianguang Ji, Associate Professor

w CPF

w Alcohol, family environment and cancer

w Juan Merlo, Professor

w Social epidemiology

w Social, healthcare and medication epidemiology, multi-level analyses

w Kristina Sundquist, Professor, Director

w CPF, Granen Healthcare Center

w Social and physical environment and cardiovascular disease

w Louise Bennet, Associate Professor,

w CPF, Capio City Clinic

w Diabetes and cardiovascular disease

w Margareta Troein, Professor Emeritus

w CPF

w Professional development

w Martin Lindström, Professor

w CPF

w Social capital and health

w Mirnabi Pirouzifard, Associate Professor

w CPF

w Cardiovascular diseases

w Patrik Midlöv, Professor, Prefect

w Tåbelund Healthcare Center

w Cardiology, geriatrics, pharmacology, e-Health

w Richard Ekesbo, Associate Professor

w CPF, Vårdhuset Malmö City

w Gastric/bowel diseases

w Susanna Calling, Associate Professor

w CPF, Bokskogen Healthcare Center

w Epidemiology, EBM, e-Health

w Ulf Gerdtham, Professor

w CPF

w Healthcare organisation, health politics and economics, national economics

w Ulf Jakobsson, Professor

w CPF, Norra Fäladen Healthcare Center

w Medicine and health sciences, gerontology, medical history

w Xinjun Li, Associate Professor

w CPF

w Cancer epidemiology in primary care

adjunct professor

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CPF RESEARCH

Born premature â&#x20AC;&#x201C; what happens in adulthood?

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ur discovery of increased risk of coronary heart disease, type 1 and type 2 diabetes, lipid disorders; respiratory disorders and sleep disorders and kidney problems for those born prematurely involves the need for preventive evaluation and long-term clinical followup to reduce the risk of serious complications for heart, kidneys and other organs. We also identified the underlying causes of these risks, including lipid disorders, which can guide prevention measures and thus be of clinical benefit to patients.

In October 2019 JAMA (impact factor 51.2) published our re-

sults based on a Swedish cohort of 2.5m persons born in Sweden from 1973 through 1997, who were followed up for survival and comorbidities through (see ref 25). Of all persons born preterm, 55% were alive without comorbidities at the end of follow-up. For those born fullterm and prematurely (weeks 22- 27) the corresponding figures were 63% and 22% respectively without comorbidities at the end of follow-up.

at the end of follow-up. Each additional five weeks of gestation were associated with a 14% reduction in risk of lipid disorders (adjusted hazard ratio [HR], 0.86; 95% CI, 0.83-0.89). The highest risk for lipid disorders was found for those born before week 28 (adjusted hazard ratio (HR) = 2.00 (1.41 â&#x20AC;&#x201C; 2.85) compared with those born full-term. There was a clear gradient with a risk that increased the earlier you were born.

In another study published in PloS Med, preterm birth was associated with an increased risk of lipid disorders in early to mid-adulthood (born between 1973 and 1995) (ref 20). A total of 25,050 (1.1%) persons were identified with lipid disorders

In another cohort study published in JAMA Pediatrics in June 2019, we found those born early-term (37-38 weeks) had a 1.53 times increased risk for ischaemic heart disease compared with those born full-term (39-41 weeks) (ref 19). Preterm-

RESEARCH

CPF

In 2019, Kristina Sundquist and collaborators at CPF and Mount Sinai in 2019 published several articles in high ranking journals, such as JAMA, BMJ, JAMA Pediatrics, Lancet Child and Adolescent Health and many others, that have increased the understanding of health and multimorbidity in the growing group of those born prematurely of different ages and that require improved and more active care in the clinic. Here we present seven of the scientific works with the support of the Heart Lung Foundation. On pages 80-81, some of the findings are presented in more detail.

born women had lower IHD incidence than preterm-born men. These associations did not appear to be explained by shared genetic or environmental factors in families.

Preterm birth (gestational age <37 weeks) has seldom been examined in relation to sleep disorders. We conducted the first population-based study of preterm birth in relation to sleep-disordered breathing (SDB) from childhood into mid-adulthood (ref 18). Published in Int J Epidemiol, we found that preterm birth was associated with increased risk of SDB from childhood into midadulthood, relative to full-term birth (39-41 weeks) (adjusted HR, ages 0-43 years: 1.43; 95% CI, 1.40-1.46; P<0.001). Persons born extremely preterm (<28 weeks) had more than 2-fold risk for SDB.

In a study published in Lancet Child Adolesc Health, 2019, we found that gestational age at birth was inversely associated with mortality from infancy to mid-adulthood. Preterm and early term birth should be recognised as chronic conditions that require long-term follow-up for adverse health sequelae into adulthood (ref 22).

In a study (ref 17), we showed that gestational age at birth was inversely associated with both type 1 and type 2 diabetes risk. The associations between preterm birth and type 2 (but not type 1) diabetes were stronger among women (e.g. at age 18-43 years), women: adjusted HR, 1.75 (1.47-2.09); men: 1.28 (1.08-1.53) (ref 17).

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In a study published in BMJ in May, we found that preterm and early term birth were strong risk factors for the development of chronic kidney disease (CKD) from childhood into mid-adulthood (ref 23). The association between preterm birth and CKD was strongest at ages 0-9 years (adjusted HR, 5.09; 95% CI, 4.116.31), then weakened but remained increased at ages 10-19 years (1.97; 1.57-2.49) and 20-43 years (1.34; 1.15-1.57). People born prematurely need long-term followup for monitoring and preven-

tive actions to preserve renal function across the lifecourse.

CPF

RESEARCH

Important findings Premature birth has been associated with cardiometabolic, respiratory and neuropsychiatric disorders in adulthood. The incidence of multimorbidity among adults born prematurely was, however, previously unknown. ANNUALREPORT2019

Results promote increased understanding of long-term health The results of our research will promote our understanding of the long term health of the growing population of survivors among those born prematurely and will improve counselling for these patients and their families.

RESEARCH

Lipid disorders and breathing problems

Increased risk for diabetes

As a result of improved early survival of premature babies, clinics to an increasing degree meet patients that were born premature and need to understand the long-term health risks for these patients.

In an article published in Diabetologia in December 2019 (Ref. 17), with results from a major national cohort, premature birth was associated with type 1 and type 2 diabetes risk from childhood to early, or mid-adult age. Premature babies and adults may need early prevention evaluation and long-term monitoring for diabetes risk.

We identified the long-term risks for several comorbidities in one of the largest and most comprehensive studies done so far. Our discovery of increased cardiovascular risks (CVD) indicate that adults born prematurely need early prevention evaluation and long-term clinical follow-up to reduce the risk of CVD (Ref. 19).

CPF

We also identified the underlying causes of these risks, including lipid disorders, which can help with screening and prevention. In addition, the breathing problems caused by sleep disorders an important cause of cardiometabolic diseases and mortality. Our results (Ref. 18) suggest that premature babies and adults need longterm follow-up to be able to quickly detect and treat respiratory problems caused by sleep disorders.

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The results of these studies will facilitate the development of more efficient clinical guidelines for long-term care for people born prematurely.

CPF

DOCTORAL STUDENTS

Newly enrolled PhD students 2019 ALEXANDER DOZET Health economics Health Care utilisation amongst elderly people Main supervisor: Ulf Gerdtham. AMELIE PERSSON Pharmacist Fake medicines as a threat to public health. A study of counselling in the first line of healthcare. Main supervisor: Patrik Midlöv. ANNA LINDER Mental health and its socioeconomic gradient, the role of demographic changes and school grading policies Main supervisor: Gerdtham.

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BJÖRN RYDHÖG Family medicine specialist The assessment of compliance with paleolithic diet and its clinical effects in dietary intervention studies. Main supervisor: Kristina Sundquist.

DEREK ASUMAN Health economic aspects of living with cerebral palsy in the Nordic countries Main supervisor: Johan Jarl. JUAN ANDRES VAZ LEONIDAS Resident physician Liver cirrhosis – epidemiology, prognosis and society costs. Main supervisor: Patrik Midlöv. KENTA OKUYAMA Epidemiology, neighborhood environments and cardiovascular-related outcomes in diverse populations. Main supervisor: Kristina Sundquist NAIQI ZHANG Systematic assessment of drug repurposing in oncology Main supervisor: Jianguang Ji.

OLOF CRONBERG Specialist physician Diagnosis related prescription of antibiotics for infections in primary care. Main supervisor: Katarina Hedin SANJAY THOMPSON Criminology The impact of neighbourhoods, peers and families on psychiatric disorders, substance use disorders and crime in first- and second-generation immigrants Main supervisor: Kristina Sundquist. SAKSHI VATS Identification of diagnostic and prognostic biomarkers for abdominal aortic aneurysm and their possible role in shared pathophysiology with other common cardiovascular diseases. Main supervisor: Ashfaque Memon.

WAZAH PELLO-ESSO Economic and socioeconomic influences on integration and first generation immigrants to Sweden Main supervisor: Kristina Sundquist. YANNI LI Circulating DNA as biomarker for diagnosis and prognosis of cancer. Main supervisor: Ashfaque Memon.

DOCTORAL STUDENTS

CPF

Earlier enrolled PhD students ARTIN ENTEZARJOU, Trainee Physician Digital triage and digital visits to the health care center. Supervisor: Patrik Midlöv CARIN TILLMAN, specialist physician Pharmaceutical continuity during treatment of diabetes. Main supervisor: Anders Beckman CECILIA SJÖSTEDT, specialist physician Individual, family and neighbourhood factors and mental illness Main supervisor: Xinjun Li

GABRIELLA CALERES, specialist physician. Elderly drug treatment – information transfer and follow-up in primary healthcare. Main supervisor: Patrik Midlöv HANNA WICKSTRÖM, specialist physician. TeleUlcer: Telemedicine and RiksSår (Swedish quality register for treatment resistant sores): Modern sore treatment for patients and staff. Main supervisor: Patrik Midlöv

HELENA ISBERG KORNFÄLT, specialist physician Urinary tract infections in primary healthcare. Main supervisor: Anders Beckman HENRIK GRELZ, district physician Long-term opioid treatment for prolonged non-malignant pain. Prevalence of opioid dependence and outcome of withdrawal. Main supervisor: Patrik Midlöv JAKOB AXELSSON, Administrator/Public Health Planner Social capital and sexual orientation. Main supervisor: Martin Lindström

JON PALLON, specialist physician Throat pain among children and young adults Main supervisor: Katarina Hedin LEILA WALEIJ, pharmaceutical chemist Drug treatment and drug related problems in frail, elderly patients. Main supervisor: Patrik Midlöv LINA EJLERTSSON, Recovery in work: An intervention project for better health among co-workers in primary healthcare. Main supervisor: Annika Brorsson

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CHRISTOPHER NILSSON, Trainee physician Aspects of ethnicity on blood pressure regulating mechanisms and kidney function. Supervisor: Louise Bennet

FRIDA THORSÉN, specialist physician Stress related poor health among young people Main supervisor: Kristina Sundquist

CPF

DOCTORAL STUDENTS

MAELÁN FONTES VILLALBA Food and metabolic syndrome in Western and non–Western populations. Focus on adipokines and glucagon. Main supervisor: Jan Sundquist MAGNUS LINDGREN, specialist physician Epidemiological studies on heart failure Main supervisor: Bengt Zöller MARIA GLANS, Pharmacist Risk factors for the readmittance of elderly hospital patients. Supervisor: Patrik Midlöv PEDRO CARRERA BASTOS The role of western diet on intestinal permeability measured by zonulin, including possible associations with the metabolic syndrome and autoimmune diseases. Main supervisor: Jan Sundquist ANNUALREPORT2019

PER ROSENGREN, trainee physician An epidemiological study of supraventricular tachycardia. Main supervisor: Bengt Zöller.

PER-OLA FORSBERG, specialist physician Neighbourhood influence on cardiovascular health. Main supervisor: Kristina Sundquist PETER NYMBERG, specialist nurse Opportunistic screening and intervention, cardiovascular disease. Main supervisor: Bengt Zöller SARA OLOFSSON, MSC Methodological studies on willingness to pay for risk reduction Main supervisor: Ulf Gerdtham SIXTEN BORG, statistician. Disaggregation and indirect estimation methods on data for health economic models and economic evaluation, with applications to inflammatory bowel disease and diabetes. Main supervisor: Ulf Gerdtham SOFIA ZETTERMARK, gender studies Use of hormonal anticonceptives and psychical health in young women: An intersectional approach. Main supervisor: Juan Merlo

STEN AXELSSON FISK, trainee physician Social theoretical and epidemiological perspectives on chronic obstructive pulmonary disease in Sweden. Main supervisor: Juan Merlo MIA SCHOLTEN, specialist physician Heart failure treatment within primary care Supervisor: Anders Halling ULRIKA ANDERSSON, Specialist physician E-health with treatment for high blood pressure in primary care. Supervisor: Patrik Midlöv. KRISTOFER SIGURDSSON, Specialist physician, How does primary care affect conditions of the inhabitants’ health and use of community resources? Supervisor: Patrik Midlöv HANNES KONHKE, Resident physician, Medical continuity in Swedish primary care Supervisor: Anders Beckman Wuqing Huang, Msc, Adverse health outcomes in offspring of cancer survivors. Supervisor: Jianguang Ji

DISSERTATIONS

CPF

PhD Thesis Defences 2019

CARL ANTONSON, resident physician. Mindfulness as a method for increasing mental well-being and cognitive performance and reducing stress among high school students: A prospective, controlled pilot study. Main supervisor: Kristina Sundquist

SOFIE SCHĂ&#x2013;N PERSSON, public health scientist Working relationships and interaction with the workplace Main supervisor: Ingemar Andersson

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FERDINDO PETRAZZUOLI Dementia management in European primary healthcare. Main supervisor: Hans Thulesius

KRISTINE THORELL Risk factors associated with use of medication in an elderly population. Main supervisor: Anders Halling.

CPF

DISSERTATION

Stress analysed from different perspectives On September 27th, Carl Antonson successfully defended his thesis Macro-social stressors, perceived stress, psychiatric symptoms, and self-esteem in adolescents and the feasibility of an internet-based mindfulness intervention Carl Antonson.

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DISSERTATION What do you consider to be the most important findings in your thesis? – The most important findings in the thesis is the importance are the following: that a dictatorship seems to foster adolescents that have a lower self-esteem than a democracy does; that the stress of Swedish adolescents doesn't seem to correlate with academic proficiency and urbanity of the school; and that adolescents need to have external incentives to follow the intervention if they are to benefit from the potential effects of internetbased mindfulness. What motivated you to choose this topic to study? – I have for a long time been very interested in how society impacts its compatriots and vice versa from a health, and more specifically, stress perspective. I worked in a privileged part of Malmö and still I witnessed a large degree of psychiatric burden. Most of this burden came from stress even though many of those patients came from well off positions in society and should have had a possibility to have a greater impact on their stress load if they chose to do so than if they were from less advantageous parts of society. When we, my co-researcher and wife Frida Thorsén and I, discussed what to do for those

patients we stumbled across mindfulness, educated ourselves on the subject, and thought that we had a potential solution to our clinical problem. The study on democracy and dictatorship was another question that probably has had a huge impact on my generation that were children when the Berlin Wall fell and grew up during the nineties when the world seemed to prosper and become more and more democratic. To then stumble upon a treasure of old data from both sides before the fall of the Berlin Wall, and to be able to repeat the data collection 25 years later, just seemed so important in a world that now seems to go the opposite direction towards a more autocratic society; something I strongly believe we must fight and one way is to try to illuminate the impact dictatorship has on individuals. How did you balance your PhD studies with your work and family commitments? – I didn't! I have worked a huge amount of non-paid hours in order to finish my PhD-project(s). That seems to be all too common for clinically working physicians as we rarely get enough research time. But on the other side is my family committed to my research as my wife Frida is also doing her PhD research together in the same

CPF

group, albeit with a different theme, and I have excellent kids and parents taking their responsibility and more. What advice would you have for prospective PhD students? – Find an issue that you really care about and a supervisor with enough competence to help you push through the hard stages and add an understanding and enthusiastic significant other. I believe that research issues primarily should come from topics that are a problem in your clinical work, if you do work clinically. Then you have enough understanding for complexities and motivation to help real persons, and the research and your clinical work will give positive spin-off effects to each other. What are your plans for the future now that you have your PhD? – I'm already planning a new interesting and important mindfulness based project that might be the answer to a clinical question causing a lot of pain and suffering to patients from my work as an occupational physician. Hopefully I can get funding to make it fly during the year. I will also try to return all the work my wife has done for me so that she can defend her thesis during 2020.

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I have for a long time been very interested in how society impacts its compatriots from a health perspective.

CPF

RESEARCH IN FOCUS

Newly discovered mechanisms behind blood clots For Bengt Zöller there is never a shortage of project ideas. And 2019 was another content-rich year for the professor at CPF and IKVM Malmö. “I collaborate in a project on the genetics of venous thromboembolism (VTE) with, among others, Professor Peter Svensson, head of clinical coagulation medicine in Malmö, and Christer Halldén, professor of biomedical genetics at the University of Kristianstad. We got astonishing results in our latest study,” enthuses Bengt Zöller.

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e adds, “First, we discovered that some VTE patients had genetic variants associated with mild bleeding tendencies, which was surprising. It was by analysing the sequencing data in a new way that we could discover that genetic variants, which alter amino acids (missense) in several different pro-coagulant genes, are protective against venous thromboembolism and therefore underrepresented in patients with VTE.”

New analysis method Thus, variants with mild

bleeding tendency may occur in thrombosis patients, but not to the same extent as in healthy individuals, as these variants are protective against thrombosis. This is thus a newly discovered mechanism that contributes to VTE. The results were published in the summer of 2019 in the journal Thrombosis and Haemostasis. “We will of course follow this up. The study gave results because we chose a different method to analyse than the usual method of analysing data on. It is important to think ahead in new ways,” says Professor Zöller.

This collaboration will also involve Olle Melander, professor of cardiovascular research and hypertension and Gunnar Engström, professor in cardiovascular research and epidemiology, regarding VTE risk factors including genetics in the Malmö Diet-Cancer Study. Together with Professor Kristina Sundquist, Bengt works on registry studies on the importance of inheritance and environment for venous thromboembolism, which is the third most common cardiovascular disease after coronary artery disease and stroke, and causes, for example, blood clots in the arms,

RESEARCH IN FOCUS

CPF

Bengt Zöller.

“Thanks to new technology and the good quality of our DNA samples, we are now hopefully on track to crack this riddle,” says Bengt, with enthusiastic energy.

Multi-tasking One day a week, Bengt Zöller works at Södervärn Health Care Center. The rest of his week is devoted to research, supervision and teaching of medical students at Lund University as well as doctoral students and resident physicians. Most notably, doctoral student and district physician Magnus Lindgren will hold his PhD defence regarding heredity in heart failure in March 2020. In addition, Bengt will supervise doctoral student and district nurse Peter Nymberg, who studies physical activity and self-assessed health including its relationship to venous thromboembolism, as well as doctoral student and resident physician, Per Rosengren, who is focused on cardiac arrhythmias. Zöller’s work as a professor and VTE expert also involves many international assignments as a member of the Editorial

Board of the Journal of Thrombosis and Haemostasis and Thrombosis Research, but also the invitation for membership in the Clinical Genome Resources Thrombosis Variant Curation Expert Panel (VCEP) that is sponsored by NIH. Most recently, he went to The Arctic University of Tromsö to be the first opponent for a dissertation on VTE and chronic obstructive pulmonary disease. Together with one of CPF's statisticians, Associate Professor Mirnabi PirouziFard, he also researches the heredity patterns that are behind various diseases. “We do a complex segregation analysis in which we determine the pattern of heredity patterns in Sweden,” remarks Bengt, who is also running a multimorbidity index together with research colleagues Anders Halling, Kristina Sundquist and Mirnabi PirouziFard. “It looks as if the environmental factors in this case are strong, but to some extent also heredity,” concludes Zöller and begins to study new results from colleagues in the ongoing project.

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legs and lungs. “I have always been very fond of chemistry and coagulation, which also sparked my research interest. I have been focusing on VTE ever since my dissertation in 1996,” says Bengt, who has a PhD at Lund University at the Department of Clinical Chemistry in Malmö about hereditary thrombosis propensity in the form of protein S deficiency and APC resistance (activated resistance to protein C). As far back as 1991 Zöller began his research career at Professor Björn Dahlbäck's laboratory, now senior professor at the Wallenberg laboratory, clinical chemistry. His interest in research has persisted since then. As has his collaboration with Professor Björn Dahlbäck. Together with Björn and Professor Christer Halldén and Professor Peter Svensson, they are investigating a large family history with hereditary thrombosis and protein S deficiency, which has a 10-fold higher risk of thrombosis compared to what one would expect from isolated protein S deficiency.

CPF

RESEARCH IN FOCUS

How should health care be managed to care for everyone living longer with chronic illnesses and comorbidities? Professor Anders Halling at IKVM Malmö and CPF works daily to tackle this issue – but 2019 has also contained something completely different: “I am an examiner at the doctor's program semester 11 so there has been a lot of pedagogy throughout the year. We are going to introduce a digital exam and it has involved a lot of work,” says Anders.

Focus on multimorbidity and pedagogy Anders Halling.

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RESEARCH IN FOCUS

n December 2019, the medical program's course ‘Individual and Society’ included a digital exam for the first time. “The students borrow iPads from the faculty and provide the answers to multiple-choice questions. The order is different on the questions for everyone and also on the response options,” he explains. The second part of Anders Halling's activities is about the research area concerning multimorbidity, heart failure and chronic illness, with a special interest in being able to follow patients for a long time.

Chronic diseases

the quality of treatment of these patient groups. “Such a national and holistic approach is lacking in Sweden. But it can of course be due to legal complications,” says Professor Halling. Since Halling has a background in cell biology - a doctoral thesis on cell biology and anatomy - he is particularly interested in being able to use biology in his research: “In the CHAPS project, which is about the prognosis of heart attacks, we study via blood tests which markers influence heart attacks. We have followed our cohort for 25 years and can now study the consequences that various factors have had ten years in the future,” concludes Anders. In both research and teaching, the future looks exciting for Anders Halling.

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Professor Halling has had a great influence in the development of an instrument for Region Skåne to measure co-morbidity with the so-called ACG system; this measures different degrees of morbidity and healthcare burden accordingly (ACG stands for Adjusted Clinical Groups). “In the GP’s everyday life, most of it is about emergency work; a very small part is about preventive work and so we have a large area where we do not know what the patient's situation is about. In addition to all this there are chronic diseases, and I focus on them.” In his research together with several doctoral students, Halling builds up more knowledge about the lives of those suffering from chronic illnesses. “Early in life, socioeconomically vulnerable people are more affected by chronic illnesses than those living in areas with high socioeconomic status. But

as we live longer, this group is affected as much as those that are socioeconomically vulnerable in the later years of life,” says Anders. This is something that will greatly impact healthcare in the near future and thus also an area where more knowledge is needed to shoulder the burden. In September, his doctoral student Kristine Thorell defended her thesis ‘Risk factors associated with the use of medication in an elderly population’, which among other things showed that drug use is affected by factors other than an individual's illness. Factors such as age, sex and socioeconomics affect the likelihood of drug use that is not fully explained by morbidity. But Anders Halling has more projects going on. “In 2019, together with my colleague, Professor Bengt Zöller, I started to look at the link between chronic diseases and genetic factors. A large number of other factors are of course also important for chronic diseases, such as the environment, sex and, for example, stress factors, but through it all genetics seems to have an influence,” he says. The more tools that research has to offer, the better health care can be given in knowledge support to help people with multi-morbidity and chronic illnesses. In Denmark, Halling worked on a computer program developed by a doctoral student, which then formed the basis for a national digital system that extracted data on chronic diseases from the patient records for better follow-up and overview of

CPF

CPF RESEARCH IN FOCUS

Cultural differences ANNUALREPORT2019

Interest in youth development in different cultures and her research data led Rada Berg to CPF.

ada Berg, retired paediatrician, child psychiatrist and school doctor, became very happy when she was asked about the possibility to use her data by two doctoral students at CPF, Carl Antonson and Frida Thorsén. The data she had collected in schools in Sweden and Bulgaria, at the time when the Iron Curtain collapsed, suited their PhD work focusing on the personal development of young people, stress and mental health. “In addition, Carl and Frida suggested that we would do the data collection 25 years later in both countries,” says Rada Berg. It was an inspired suggestion.

RESEARCH IN FOCUS

Rada Berg.

tunities today compared to the past report that things are getting worse for young people. Because our genetic heritage has not changed in such a short time you have to look for the answers in the environment,” says Rada. To study the interaction between individual, family and community is important. As well as comparing young people living in different environments and different cultures they also examined whether changes in society over time can affect youth/adolescents. Rada has prior interest in the work of researcher, Juri Bronfenbrenner, and his studies of American and Soviet children and adolescents along with Bruno Bettelheim, who studied children's development in Israel’s kibbutzs and Makarenko's educational methods for orphaned children and adolescents after WW1 in the USSR.

Rada contacted Milena Mutafchieva and Nadia Koltcheva at the New Bulgarian University in Sofia, Bulgaria and the new data collection was done quickly afterwards. In Sweden it was harder; she had to play tough with the school principals before it yielded results. “Once I sat outside the principal's office and announced that I can wait until he is free. The pensioner has time! We got the results,” Rada laughs. How is it then Rada has so much energy in spite of her advancing years? She believes it’s because when she was growing up that was taught to take nothing for granted and her mother always said to her that there is no benefit in saying I can’t, I don’t want to and I can’t be bothered. “Nowadays, however, the youth seem to have it harder. They have so many demands, especially the young girls. They have everything but are still unhappy. The stress in society makes up for it. Facebook and other social media create stress through their influences, messages, demands and unrealistic expectations,” says Rada. Rada concludes by saying how happy she is that her data was used and that she was very proud when Carl Antonson got his PhD in 2019. She looks forward to seeing Frida Thorsén's doing likewise in 2020! “Everything is possible! One should not let age get in the way of one's plans. Or let something else take that part either,” Rada concludes.

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Rada took on the task with enthusiasm. Already retired by this time, she was not dependent on income and forego a salary for the task. She wanted to allay any indication that she had got the ‘job’ via her daughter, Professor Kristina Sundquist, CPF’s director. Interest in youth development in different cultures is something Rada has had for many years. She came to Sweden in the 60's with her family, originally on a three-year contract that was renewed a few times, before the family decided to stay in Sweden. The inspiration for the data collection came after Rada had participated in a European Congress for child psychiatry in Bulgaria in 1987. It was there that Swedish and Bulgarian scientists decided to make a comparison study between Swedish and Bulgarian youths. Transcultural studies were interesting after World War II because two different ones had been created in post-war Europe. The first collection in Bulgaria took place during the end of the Soviet era while the new data collection was completed 25 years after democracy came in. “We thought it was interesting to compare how the changed political system had influenced the development of a new generation,” says Rada. Rada believes that youth research never ever been more important than now, when all reports are pointing in the same direction. “Despite all the improvements, young people's oppor-

CPF

CPF RESEARCH IN FOCUS

Perfect mix! “The combination; that's the best thing about my work. Being able to switch between education, research and pure patient work, and thereby benefit from what I learn in other areas,” says Anders Beckman, doctor, PhD and former teacher of semester 11 of medical education in Malmö.

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nders has been training medical students since 2000 at what was then semester 10, which subsequently became semester 11. During the 20 intervening years many changes have occurred: “Medical education has changed partly from being organfocused with courses in, for example, internal medicine and neurology, to dealing with general, comprehensive themes and partly to looking at the key competencies the students should have when they are finished. Anders Beckman's teaching field has been the ten-week course Individual and Society, a course that has in many ways been a forerunner in the new

way of teaching medical students. “We have integrated several different subjects into this area. The students learn that they are both the individual's doctor and society’s doctor. We mix teaching with an internship in family medicine,” he says. Several different aspects of the medical profession are addressed during the ten weeks: forensic medicine, work environment, leadership and patient safety. “We have been pioneers concerning student-centred teaching. From the traditional teach-

ing, built around a lecturer who is passionate about their subject, we have gone to putting the students’ questions at the centre, under the guidance of teachers. Teaching is grounded on student activity.” The changes continue. 20 years ago, 70 students were admitted to Malmö at the then semester 10, today they take in 120 per semester. “The students are divided into smaller groups of teachers and so they have a unique internship where they are alone and come into focus with individual feedback on what they do and with examinations out in the practice.”

RESEARCH IN FOCUS

CPF

Anders Beckman.

increase in the competence of nursing staff. His own research area is healthcare consumption. What factors influence people how, when and where to seek care? These may include factors such as education level, income and family circumstances. Above all, Anders Beckman has focused on healthcare selection reform and how it has impacted healthcare consumption. A long professional life provides many experiences. Compared to the students 20 years ago, today's more individual focus is "I before the team". Is

there anything he would like to change in medical education? “The students' education and internships are group-based until they come to us. Some believe it is easy to take it away. I would like to have more individual focus early in the education, for example through mentors who monitor students all the way,” says Anders, adding that the study results can be better influenced if the students were more mature when they started - that they saw something other than just education before they begin their medical training.

We have been pioneers concerning student-centred teaching.

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Before Anders started teaching, he worked as a district physician and operations manager at a healthcare centre in Malmö. He continues to practise medicine one day a week at a healthcare centre. But that's not all - Anders Beckman supervises students at different levels, both doctoral students and the scientific work done during semester 10. In addition, he is responsible for the one-and-a-half-year course in research methodology at the Department of Clinical Sciences. The course may form a part of a doctoral education or an

CPF RESIDENT PHYSICIAN WORK

Finger on the pulse “I wanted to do something handson and something that directly gives something back to the patient,” says Susanna Lundh, medical student, about her resident physician work on atrial fibrillation.

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wanted to do something hands-on and something that directly gives something back to the patient, says Susanna Lundh, medical student, about her resident physician work on atrial fibrillation. It was through CPF’s course for resident physicians (introductory course in medical science and quality work) that Susanna Lundh came into contact with Professor Kristina Sundquist, who had observed Susanna’s project and became her supervisor. Kristina Sundquist has run a Region Skåne study on atrial fibrillation known as FIRST. Susanna's project was equally brilliant and simple: patients over 65, which came to the Lunden healthcare centre, and who had never been diagnosed with atrial fibrillation, had their pulse checked by healthcare staff. If the pulse was irregular, the ECG was performed directly and, if necessary, further checks were done. With this method, atrial fibrillation was newly diagnosed in several patients who subse-

quently underwent investigation and then received treatment. During the four weeks duration of the project, 139 people were screened at the healthcare center. Of these, three were detected with atrial fibrillation. The practical and limited timescale project gave direct assistance to the patients. Prior to the project, Susanna held reviews with her colleagues; doctors and nurses at the healthcare centre. A simple formula was designed for the pilot study. “In general, the staff felt that the screening was neither burdensome nor time-consuming. This is an important factor if you want to introduce similar screenings on a larger scale in the future,” she says. But right now Susanna isn’t thinking that far ahead: She adds, “I am in my final year of my medical studies and I am fully booked with additional training placements, so the time at the healthcare center is limited at the moment. But then I would like to talk to the director at the healthcare center about

CPF

RESIDENT PHYSICIAN WORK

The staff felt that the screening was neither burdensome nor time-consuming. Susanna Lundh.

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how to proceed with the screening method.” The method is not expensive to implement. Nevertheless, the Swedish National Board of Health and Welfare does not recommend systematic screening for atrial fibrillation. But stroke can largely be prevented by the anticoagulants given with atrial fibrillation. Healthcare costs to treat stroke are so high that the European Society of Cardiology, among others, believes that the benefits of screening patients over 65 years outweighs the costs. Both the medication committees in Stockholm County and in the Västra Götaland region also recommend screening for the same age group. In Region Skåne there are so far no such recommendations, but several projects are ongoing. Susanna Lundh's study clearly shows how, with limited time and a relatively small work effort, new cases of atrial fibrillation can be found, so one can then offer treatment with anticoagulants and thus reduce the risk of stroke.

CPF COLLABORATIONS

Tough life issues For Alexis, the associations among suicidal behaviour, alcohol use disorders (AUDs), and depression is one that is close to her heart. “I am just innately interested in these big questions,” enthuses Alexis Edwards, Assistant Professor at the Virginia Institute for Psychiatric and Behavioural Genetics.

I ANNUALREPORT2019

think a lot of people that are working on psychiatric outcomes are working on 'mesearch' due to personal experience; I’ve always been interested in behaviour, she says. Edwards visited CPF in September 2019 as part of her ongoing collaboration with Professor Kristina Sundquist. Together, they are working on an NIH grant researching the etiology of risk: alcohol and drug use disor-

ders and suicidal behaviour. Her mentor is Professor Kenneth Kendler whom she is working in tandem with on several other research grants concerning AUDs. Kendler is also a long-term collaborator of CPF. Understanding the correlation between AUDs and suicidal behaviour is one that intrigues Edwards. She knows only too well the devastation of suicide having lost a friend who took his

own life some years back. “I could see on his Facebook that he had been on a road trip and had an amazing time. At the end of that road trip, he killed himself. Around the same time, Ken and I started talking about doing research into suicidal behaviour. It’s something that I have been interested in since grad school,” says Alexis. Just how clear the association is between AUDs and suicidal behaviour is what Alexis will be

COLLABORATIONS

effect on suicide rates. Having been a regular visitor “Sweden has a much healtto CPF in recent years, Edwards hier relationship with alcohol! says her time spent in Sweden There are public health benefits has changed her perception of to some aspects of the state-con- the country. trolled system here. To me, the “I thought it was less diverse trade-off is worth it.” though so it is great to see how Hailing from South Carodiverse it really is. Sweden is a lina, Edwards says she has been lovely country to visit and very fascinated with human behawell organised.” viour ever since childhood. Now And she is looking forward based in Richmond, Virginia, to a continued fruitful working the academic has authored or relationship with CPF long into co-authored almost 80 published the future. scientific articles. “I love working with the staShe says that her research tisticians here, in particular, as is far more than just analysing I work very closely with them. I data on a screen in a detached hope this collaboration continuway. For her, it’s imperative that es and I am excited to be leading her work is benefitting public the research on this project with health. Kristina.” “I was naturally curious growing up. It is Alexis Edwards. easy to get hopeless about things but I hope that what we are doing can help people out there and improve outcomes.” “In academia, success is measured in ways that are not always meaningful to me; that means getting papers published and obtaining grants. What I want to be doing is improving people's lives and hope that clinicians are reading our work that at least is informative to them that they can apply to clinical practice.”

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trying to unravel until the completion of the grant in March 2023. The project has attracted almost $400,000 per year in funding from the NIH. “There is a correlation between people who have AUD and those who attempt or die by suicide. The correlation could be due to shared genetic or environmental liability. There could also be a causal relationship.” Edwards notes, “If you are impaired because of the substance then your thinking isn't clear in that moment, which makes you more likely to do something impulsive.” She adds, “The specific aims [include] looking at individuallevel factors that may account for the relationship between substance use disorders and suicidal behaviour. We want to understand more about the genetic factors… then [we can] also look at how peer relationships and exposure to suicidal behaviour at the neighbourhood level might play a role.” While Sweden has a very different approach regarding the sale of alcohol compared with the United States, both countries have a similar rate of suicide says Edwards. She is curious to investigate to what extent Sweden’s state-controlled Systembolaget has an impact on neighbourhood mental health. “We will be looking at proximity to alcohol outlets. In some Swedish municipalities, they changed the opening hours; we can see whether that extended access to alcohol outlets had an

CPF

CPF COLLABORATIONS

Appreciated visit In September 2019, CPF welcomed a trio of visitors from Japan who enjoyed a fact-finding five-day trip to Malmรถ. Professor Minoru Isomura (Dept. of Pathology in Faculty of Medicine, Shimane University) was joined by two of his students: Manami Yamauchi and Kohei Ueda.

From right: Professor Minoru Isomura and psychology students Manami Yamauchi och Kohei Ueda.

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COLLABORATIONS

difference in culture," he said. However, as the psychosocial team at Granen explained, this is a relatively new phenomenon in Sweden and adolescent mental health remains an area of major concern for physicians and therapists. The group learnt about mental health in school in a subsequent meeting with school psychologist, Annika Dellholm. On the penultimate day of their visit, the trio spoke with Niklas Harris at the Malmรถ sports academy. "The sports academy was very impressive. Sports scholarships are provided to the top athletes. We have something similar in Japan but that is funded by the government; here it was funded by Malmรถ City, which was a big surprise," said Professor Minoru Isomura. Observing the differences in work structure between the two nations left a lasting impression

on the Japanese researchers. "There is a flat working environment here whereas in Japan it is more hierarchical. This is something that we would like to apply in Japan but of course it is not easy to change things. I intend to study more about the Swedish healthcare system and use that in my teaching going forward." added Professor Isomura. One custom of the Swedish workplace was also keenly observed and enjoyed by the visitors - fika. "It seems to have a positive effect on team spirit and helps a lot. There is so much dialogue here among everyone. It would be good to introduce fika to Japan!" said Kohei Ueda.

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he psychology students were eager to learn more about Swedish primary care while Professor Isomura was a welcome returnee having first visited CPF in 2018. As part of their trip, the trio went to the Dalby healthcare center to learn about the collaborative care model. They also paid a visit to the Abel rehab clinic and were briefed on how Swedish primary care functions by AKC team leader, Emelie Stenman. The group were welcomed by the psychosocial team at Granen health care center where a long discussion took place about the contrasts between Swedish and Japanese healthcare. Psychology student, Kohei Ueda, was struck about the difference in dealing with adolescent mental health in Sweden compared to his homeland. "In Japan, you are seen as weak if you admit that you need to speak to a counsellor. This is a

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CPF NEW STAFF MEMBERS New PhD students

In 2019, CPF welcomed several new recruits to the staff. A number of international doctoral students embarked on their PhD while there were also new faces in other departments.

SANJAY THOMPSON is working on the ERC funded grant on migration medicine and integration. The Jamaican native obtained his Master’s in criminology at Malmö University before joining CPF. In 2019 he was recognised by Sweden’s Ministry of Foreign Affairs with a Global Swede award for showing creativity within his academic area. Later in 2019, he was nominated by a government committee in Jamaica for the international achievement for outstanding youth under 30 award. WAZAH PELLO-ESSO is studying the economic and socioeconomic influences on integration and health in first-generation immigrants to Sweden. He has a Master’s in business and economics as well as a Bachelor’s degree in statistics and econometrics. Wazah works on an ERC funded project as does postdoc ARDAVAN KHOSHNOOD, who, in addition to a master's in criminology at Malmö University, also has a PhD in clinical medicine/emergency care at Lund University. Ardavan joined CPF in late 2018.

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New faces at work

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NEW STAFF MEMBERS Chinese native YANNI LI is researching circulating DNA as a biomarker in the diagnosis and prognosis of cancer for PhD. Li has a Master’s from Nankai University in stem cell and development biology. Joining her in the Wallenberg laboratory is SAKSHI VATS who is investigating abdominal aortic aneurysm (AAA) as part of her PhD studies. Originally from India, she joined CPF after getting her Master’s in molecular medicine at Imperial College in London KENTA OKUYAMA’S PhD is on the prevention of chronic diseases from neighbourhood built and social environment perspectives. A native of Japan, Kenta studied previously in the US where he got his Master’s in public health, epidemiology. NAIQI ZHANG is pursuing her PhD in cancer epidemiology. She has a Master’s in epidemiology at the School of Public Health, Sun Yat-Sen University from her native China.

Her compatriot WUQING HUANG, who joined CPF in late 2018, is also studying for her PhD in cancer epidemiology.

CPF

New Postdocs GUOQIAO ZHENG is working on the research project Systematic Assessment of Drug Repurposing in Oncology Using Nationwide Registers in Sweden for her postdoctoral studies. She got her PhD at the German Cancer Research Center in Heidelberg where her supervisor was long-time CPF collaborator, Kari Hemminki. Iranian native MEHDI OSOOLI is conducting research on how neighbourhoods, peers, and families impact migrants’ mental health in Sweden. The postdoc has a Master’s in public health from Lund University and also got his PhD in Sweden.

Others ANTON WESTHOLM is CPF’s new Geographic Information Systems (GIS) engineer succeeding Klas Cederin, who retired in 2019. Westholm previously worked for Region Skåne and for SWECO Position. FREDRIKA PERSSON is working in the administration department and joins CPF from Swedish healthcare company Capio.

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Meanwhile, Master’s student MING SUN ended her one-year stint at CPF in 2019 after spending 12 months studying the association between cancer and dementia and will continue her studies in China.

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CPF DATABASE GROUP

Our data security team The database group provides support to all statisticians, doctoral students, and other researchers at CPF on issues related to the analysis datasets, databases, data management, user permissions, data security, programming, IT purchases, software licenses, server installations, RedCAP and server administration. In addition, the group contributes to on applications for extracts from national and regional registers used in various research projects. The database group includes the database administrators, Helene Brandt and Mats-Åke Persson and Susanne Andrén, project assistant.

Server environment During the summer, a new server came into operation for all doctoral students and specialist researchers. This has meant faster analyses of large amounts of data, reduced risk of interruptions, higher security, and automatic logging permissions in accordance with GDPR requirements. ANNUALREPORT2019

The database group has also helped the lab at CPF with ordering and commissioning of a new LINUX server that includes will be used for DNA sequencing of fragments from the biobank.

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Data Collection Collection of data from the Mindfulness project “Mindfulness as a method to improve well-being, quality of life and the health of school students in grades 0-9” is ongoing with the support of web application RedCap. Helene Brandt creates the entry forms while the students themselves respond to the web surveys (anonymously). Susanne Andrén goes to the schools to give the students access to the questionnaire via the internet or, in case of emergency, as a paper survey. So far we have received responses from about 2 000 students.

GDPR During the year, the database group participated in a working group who have discussed the new data laws within the framework of GDPR. This work resulted in a CPF guideline for data processing of personal data in accordance with GDPR.

ANALYSIS GROUP

CPF

Broad collaborations The analysis group consisting of statisticians and database managers collaborate on study planning, database building and analysis. Regardless of small or large amounts of data, close collaboration between the analysis team and the clinical researchers is required. In most projects, an analyst is involved from beginning to end and contributes to study design, data management, statistical analysis, interpretation of results and writing of a scientific article. In other projects, the analyst is only involved in some parts of the process.

and about 1900 pupils have now agreed to be part of the study. In late autumn 2019, a pilot project was started at the Granen healthcare center as part of a larger planned study, HISS, Heart Failure in SkĂĽne, where data from heart failure patients are collected and blood samples are taken to improve diagnostics and treatment. The analysis team also works closely with the experimental primary care lab at CPF. Examples of new research projects in 2019 are studies on mitochondrial DNA and type 2 diabetes and macrophage migration inhibiting factors (MIF) on the effect of mindfulness treatment. In addition to supporting the scientific activities, the statisticians are also active in the teaching of resident physicians and research students, since knowledge of statistical methods is a necessary tool for planning, analysing and evaluating quantitative studies.

Analysis group staff Xinjun Li (associate professor), Jianguang Ji (associate professor), Henrik Ohlsson (biostatistician, associate professor), Karolina PalmĂŠr (biostatistician, MSc), Sara Larsson LĂśnn (biostatistician, PhD), Mir Nabi Pirouzi Fard (biostatistician, associate professor) and Anton Westholm (GIS engineer) all work in registry-based research. ANNUALREPORT2019

uch of the research at CPF is register-based and over the years the group has built up a unique pool of expertise on how these registers can be used in the best way. Our Swedish registers are a gold mine for research, which has resulted in, in addition to local projects, CPF having several joint collaborations with international research groups. The analyses are then performed by the analysis group in Sweden, but always in close collaboration with the researcher. However, some scientific questions cannot be answered on the basis of registries and a significant part of medical research is based on analysis of collected data from clinical studies. One example is the ongoing mindfulness project where survey data is collected annually from school students in year F-9. In 2019, more schools were recruited for the mindfulness project

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CPF

MOLECULAR BIOLOGY LABORATORY

Own laboratory

During 2019 the staff at the lab worked on multiple projects as described here by researchers Xiao Wang, PhD and Ashfaque Memon, associate professor. Projects included: w Identification of novel diagnostic

CPF is the only family medicine institution in Sweden that has its own molecular medicine laboratory. We also have our own biobanks department. The lab is open to clinically effective researchers and molecular medicine/ translational researchers.

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106

and prognostic biomarkers for abdominal aortic aneurysm (AAA) in collaboration with the depart ment of vascular diseases, SkĂĽne University hospital with Prof Anders GottsĂ¤ter. w Role of circulating DNA (both mitochondria and nuclear DNA) in cancer in collaboration with associate professor Lao Saal (Medicon village, Lund University). w Mitochondrial dysfunction in chronic diseases. w Genetic, epigenetic and protein biomarkers of venous thrombo embolism (VTE). w Role of inflammatory biomarkers and microRNAs in response to mindfulness therapy given to patients with depression, anxiety, or stress and adjustment disorders.

In total four papers were published and four are under review in reputable journals such as European Journal of Preventive Cardiology, Clinical Epigenetics, Journal of Thrombosis and Thrombolysis etc. In addition, two new PhD students were recruited to work on AAA and cancer respectively.

MOLECULAR BIOLOGY LABORATORY

CPF

Notable findings We screened 92 protein biomarkers to identify diagnostic and predictive biomarkers for AAA, a localized enlargement of the abdominal aorta. We identified multiple novel biomarkers and showed that the combination of biomarkers identified in our study can be useful biomarkers for diagnosis and prediction of growth of AAA, Memon et al., Eur J Prev Cardiol. 2019. This study is a step forward in understanding the pathophysiology of AAA and provides a profile of protein biomarkers, which could help in the development of a powerful multi-marker test for diagnosis and prediction of AAA. Furthermore, based on the above results, a PhD project was designed to identify genetics and epigenetics in genes corresponding to newly identified proteins. In addition, the role of oxidative stress in pathophysiology of AAA is also being investigated. Furthermore, the first paper as part of the PhD study on epigenetic changes associated with pathophysiology of AAA has been submitted and is under review (Sakshi et al.) In the cancer project, we investigated the role of both circulating nuclear and mitochondrial DNA as universal diagnostic biomarkers for multiple cancer types. (Sundquist et al, manuscript is under review). In addition, a PhD project was designed to study the role of mitochondria and its dysfunction in cancer using next-generation sequencing, droplet digital PCR and cell culture for mechanistic studies. In the VTE project, for the first time we investigated microRNAs (miRNA) in VTE recurrence and identified a group of miRNAs as predictive biomarkers of VTE recurrence (Wang et al, Clin Epigenetics. 2019 Feb 13;11(1):28). Furthermore, we are also working on improving the diagnostic and predictive models we developed for VTE and its recurrence.

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In the mindfulness project, we screened 92 inflammatory proteins in plasma samples from 178 patients at baseline and after eight weeks of treatment. We identified a group of inflammatory biomarkers that respond to mindfulnessbased group therapy (MBGT) or cognitive-behavioral therapy. The changes in these protein levels were associated with the change in the circulating miRNA144-5p. Our preliminary results suggest that the identified inflammatory biomarkers were regulated by miR-144-5p. Together with our previous findings, we believe that miR-144-5p plays an important role in mental disorders. We now plan to design a cell culture study to understand the underlying mechanism.

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CPF

FINANCIAL PERSPECTIVE

THE FINANCIAL PERSPECTIVE EXTERNAL COUNCIL GRANTS FORTE

STATE BUDGET GRANT 2019

w Ulf Gerdtham

730 000

GRANT 2019

w Patrik Midlöv

1 433 000

w Kristina Sundquist

350 000

w Ulf Gerdtham

577 000

w Ulf Jakobsson

601 000

w Juan Merlo

2 400 000

w Juan Merlo

170 000

w Kristina Sundquist

1 200 000

w Bengt Zöller

396 000

w Jan Sundquist

1 000 000

TOTAL

w Jianguang Ji

700 000

w Patrik Midlöv

800 000

3 527 000

ALF HEART LUNG FOUNDATION

GRANT 2019

w Jan Sundquist

1 416 000 1 683 000

w Bengt Zöller

400 000

w Kristina Sundquist

844 143

w Ulf Gerdtham

779 000

w Bengt Zöller

718 000

w Martin Lindström

548 000

w Louise Bennet

307 000

w Patrik Midlöv

388 000

600 000

CANCER FOUNDATION w Jianguang Ji INTERNATIONAL GRANTS

TOTAL

NATIONAL INSTITUTES OF HEALTH

w Kristina Sundquist

6 500 000

w Jan Sundquist

2 200 000

EUROPEAN RESEARCH COUNCIL w Jan Sundquist

5 000 000

OTHER ANNUALREPORT2019

w Jan Sundquist

100 000

w Ulf Jakobsson

100 000

TOTAL EXTERNAL

108

22 574 143

5 839 000

FINANCIAL PERSPECTIVE

CPF

REGIONAL GRANTS (TKR) REVENUE Regional grant, CPF Funding for salaries Total revenues Region Skåne

BUDGET 2019

RESULT 2019

12 784 5 559 18 343

13 272 5 093 18 365

2 933 2 642

Other revenues – Compensation for temporary personne TOTAL REVENUE

21 276

2 735 1 477 21 100

EXPENSES PERSONNEL EXPENSES Combined services Cost for AVC private Cost for AVC public Research time public/private OPERATING COSTS IT costs, LU and RS & telephony Travel costs, costs and accommodation Postage, printing, office supplies, advertising Lab material TOTAL COSTS

19 505 3 381 536 2 047 680 784 575 51 119 39 20 289

18 630 3 404 373 1 935 1 111 1 352 585 46 234 488 19 982

369 618

714 367

21 276 0

21 063 37

Rent for premises Overheads costs TOTAL COSTS SURPLUS/DEFICIT

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109

CPF

PUBLISHED SCIENTIFIC ARTICLES 2019

FAMILY MEDICINE 1.

Ahmad A, Sundquist K, Palmér K, Svensson PJ, Sundquist J, Memon AA. Risk prediction of recurrent venous

thromboembolism: a multiple genetic risk model. J Thromb Thrombolysis. 2019 Feb;47(2):216-226.

Akrawi DS, Zöller B, Fjellstedt E, Sundquist J, Sundquist K, PirouziFard M. Heritability of glomerulonephritis:

A Swedish adoption study. Eur J Clin Invest. 2019 Jun 6:e13148.

Al-Majdoub M, Spégel P, Bennet L. Metabolite profiling paradoxically reveals favorable levels of lipids, markers of

oxidative stress and unsaturated fatty acids in a diabetes susceptible group of Middle Eastern immigrants. Acta

Diabetol. 2019 Dec 20.

Alexandridis V, Rudnicki M, Jakobsson U, Teleman P. Adjustable mini-sling compared with conventional mid-urethral

slings in women with urinary incontinence: a 3-year follow-up of a randomized controlled trial. Int Urogynecol J. 2019

Sep;30(9):1465-1473.

Caleres G, Modig S, Midlöv P, Chalmers J, Bondesson Å. Medication Discrepancies in Discharge Summaries and As

sociated Risk Factors for Elderly Patients with Many Drugs. Drugs Real World Outcomes. 2019 Dec 13.

Calling S, Johansson SE, Wolff M, Sundquist J, Sundquist K. The ratio of total cholesterol to high density lipoprotein

cholesterol and myocardial infarction in Women's health in the Lund area (WHILA): a 17-year follow-up cohort study.

BMC Cardiovasc Disord. 2019 Oct 29;19(1):239.

Calling S, Ohlsson H, Sundquist J, Sundquist K, Kendler KS. Socioeconomic status and alcohol use disorders across

the lifespan: A co-relative control study. PLoS One. 2019 Oct 17;14(10):e0224127.

Catalano C, da Silva Filho MI, Frank C, Lu S, Jiraskova K, Vymetalkova V, Levy M, Liska V, Vycital O, Naccarati A,

Vodickova L, Hemminki K, Vodicka P, Weber ANR, Försti A. Epistatic effect of TLR3 and cGAS-STING-IKKε-TBK1-IFN

signaling variants on colorectal cancer risk. Cancer Med. 2019 Dec 23.

Cederroth CR, PirouziFard M, Trpchevska N, Idrizbegovic E, Canlon B, Sundquist J, Sundquist K, Zöller B.

Association of Genetic vs Environmental Factors in Swedish Adoptees With Clinically Significant Tinnitus.

JAMA Otolaryngol Head Neck Surg. 2019 Jan 17.

10. Chattopadhyay S, Thomsen H, Yadav P, da Silva Filho MI, Weinhold N, Nöthen MM, Hoffman P, Bertsch U, Huhn S,

Morgan GJ, Goldschmidt H, Houlston R, Hemminki K, Försti A. Genome-wide interaction and pathway-based identifi

cation of key regulators in multiple myeloma. Commun Biol. 2019 Mar 4;2:89.

11. Chattopadhyay S, Zheng G, Hemminki A, Försti A, Sundquist K, Sundquist J, Hemminki K. Influence of family history

on risk of second primary cancers and survival in squamous cell skin cancer patients. Br J Dermatol. 2019 Dec 19

12. Chattopadhyay S, Hemminki A, Försti A, Sundquist K, Sundquist J, Hemminki K. Familial Risks and Mortality in Se

cond Primary Cancers in Melanoma. JNCI Cancer Spectr. 2019 Jan 9;2(4):pky068.

13. Chattopadhyay S, Hemminki A, Försti A, Sundquist K, Sundquist J, Hemminki K. Second primary cancers in patients

with invasive and in situ squamous cell skin carcinoma, Kaposi sarcoma and Merkel cell carcinoma: role for immune

mechanisms? J Invest Dermatol. 2019 Jul 6. pii: S0022-202X(19)31854-8.

14. Chattopadhyay S, Hemminki O, Försti A, Sundquist K, Sundquist J, Hemminki K. Impact of family history of

cancer on risk and mortality of second cancers in patients with prostate cancer. Prostate Cancer Prostatic Dis. 2019

Mar;22(1):143-149.

15. Chattopadhyay S, Zheng G, Sud A, Sundquist K, Sundquist J, Försti A, Houlston R, Hemminki A, Hemminki K. Second

primary cancers in non-Hodgkin lymphoma: family history and survival. Int J Cancer. 2019 May 4.

16. Crump C, Sundquist J, Sundquist K. Risk of hypertension into adulthood in persons born prematurely: a national ANNUALREPORT2019

cohort study. Eur Heart J. 2019 Dec 23.

17. Crump C, Sundquist J, Sundquist K. Preterm birth and risk of type 1 and type 2 diabetes: a national cohort study.

Diabetologia. 2019 Dec 3.

18. Crump C, Friberg D, Li X, Sundquist J, Sundquist K. Preterm birth and risk of sleep-disordered breathing from child

hood into mid-adulthood. Int J Epidemiol. 2019 Apr 21. pii: dyz075.

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PUBLISHED SCIENTIFIC ARTICLES 2019

CPF

19. Crump C, Howell EA, Stroustrup A, McLaughlin MA, Sundquist J, Sundquist K. Association of Preterm Birth With Risk

of Ischemic Heart Disease in Adulthood. JAMA Pediatr. 2019 Jun 3.

20. Crump C, Sundquist J, Sundquist K. Association of preterm birth with lipid disorders in early adulthood: A Swedish

cohort study. PLoS Med. 2019 Oct 18;16(10):e1002947.

21. Crump C, Sundquist J, Winkleby MA, Sundquist K. Cardiorespiratory fitness and long-term risk of sleep apnea: A

national cohort study. J Sleep Res. 2019 Apr 7:e12851.

22. Crump C, Sundquist J, Winkleby MA, Sundquist K. Gestational age at birth and mortality from infancy into mid-adult

hood: a national cohort study. Lancet Child Adolesc Health. 2019 Apr 4. pii: S2352-4642(19)30108-7.

23. Crump C, Sundquist J, Winkleby MA, Sundquist K. Preterm birth and risk of chronic kidney disease from childhood

into mid-adulthood: national cohort study. BMJ. 2019 May 1;365:l1346.

24. Crump C, Sundquist K, Sundquist J, Winkleby MA. Exercise Is Medicine: Primary Care Counseling on Aerobic Fitness

and Muscle Strengthening. J Am Board Fam Med. 2019 Jan-Feb;32(1):103-107.

25. Crump C, Winkleby MA, Sundquist J, Sundquist K. Prevalence of Survival Without Major Comorbidities Among Adults

Born Prematurely. JAMA. 2019 Oct 22;322(16):1580-1588.

26. Dahlbäck B, Guo LJ, Zöller B, Tran S. New functional test for the TFPIα cofactor activity of Protein S working in

synergy with FV-Short. J Thromb Haemost. 2019 Apr;17(4):585-595.

27. Edwards AC, Ohlsson H, Mościcki EK, Sundquist J, Sundquist K, Kendler KS. Geographic proximity is associated with

transmission of suicidal behavior among siblings. Acta Psychiatr Scand. 2019 May 18.

28. Edwards AC, Ohlsson H, Svikis DS, Sundquist J, Sundquist K, Kendler KS. Protective Effects of Pregnancy on Risk of

Alcohol Use Disorder. Am J Psychiatry. 2019 Feb 1;176(2):138-145.

29. Fawad A, Nilsson PM, Struck J, Bergmann A, Melander O, Bennet L. The association between plasma proneurotensin

and glucose regulation is modified by country of birth. Sci Rep. 2019 Sep 20;9(1):13640.

30. Garmy P, Clausson EK, Berg A, Steen Carlsson K, Jakobsson U. Evaluation of a school-based cognitive-behavioral

depression prevention program. Scand J Public Health. 2019 Mar;47(2):182-189.

31. Gregson J, Kaptoge S, Bolton T, Pennells L, Willeit P, Burgess S, Bell S, Sweeting M, Rimm EB, Kabrhel C, Zöller B, et

al. Cardiovascular Risk Factors Associated With Venous Thromboembolism. JAMA Cardiol. 2019 Feb 1;4(2):163-173.

32. Hamano T, Li X, Sundquist J, Sundquist K. Neighborhood linking social capital as a predictor of lung cancer:

A Swedish national cohort study. Cancer Epidemiol. 2019 May 21;61:23-29.

33. Hemminki K, Huang W, Sundquist J, Sundquist K, Ji J. Autoimmune diseases and hematological malignancies:

Exploring the underlying mechanisms from epidemiological evidence. Semin Cancer Biol. 2019 Jun 7. pii: S1044-

579X(18)30181-0.

34. Högström G, Ohlsson H, Crump C, Sundquist J, Sundquist K. Aerobic fitness in late adolescence and the risk of

cancer and cancer-associated mortality in adulthood: A prospective nationwide study of 1.2 million Swedish men.

Cancer Epidemiol. 2019 Jan 25;59:58-63.

35. Huang W, Sundquist J, Sundquist K, Ji J. Mortality patterns in long-term survivors of childhood or adolescent central

nervous system tumour in Sweden. J Neurooncol. 2019 Nov 1.

36. Huang W, Sundquist J, Sundquist K, Ji J. Use of Phosphodiesterase 5 Inhibitors Associates With Risk of Colorectal

Cancer in Men With Benign Colorectal Neoplasms. Gastroenterology. 2019 May 16. pii: S0016-5085(19)40892-5.

37. Huang W, Sundquist K, Sundquist J, Crump C, Ji J. Risk of being born preterm in offspring of survivors with childhood or adolescent central nervous system tumour in Sweden. Int J Cancer. 2019 Oct 8.

38. Ji J, Huang W, Sundquist J, Sundquist K. Hospitalization rate in offspring of cancer survivors: a national cohort study.

J Cancer Surviv. 2019 Feb 18.

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39. Ji J, Sundquist J, Sundquist K. Use of terbinafine and risk of death in patients with prostate cancer: A population-

based cohort study. Int J Cancer. 2019 Apr 15;144(8):1888-1895.

40. Junuzovic M, Rietz A, Jakobsson U, Midlöv P, Eriksson A. Firearm deaths in Sweden. Eur J Public Health. 2019 Apr

1;29(2):351-358.

41. Kendler KS, Larsson Lönn S, Salvatore JE, Sundquist J, Sundquist K. The impact of parenthood on risk of

registration for alcohol use disorder in married individuals: a Swedish population-based analysis. Psychol Med. 2019

Oct;49(13):2141-2148.

42. Kendler KS, Ohlsson H, Edwards AC, Sundquist J, Sundquist K. Geographical proximity and the transmission of drug

abuse among siblings: evaluating a contagion model in a Swedish National Sample. Epidemiol Psychiatr Sci. 2019

Aug 23:1-9.

43. Kendler KS, Ohlsson H, Lichtenstein P, Sundquist J, Sundquist K. The Nature of the Shared Environment. Behav

Genet. 2019 Jan;49(1):1-10.

44. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. A Contagion Model for Within-Family Transmission of Drug Abuse.

Am J Psychiatry. 2019 Mar 1;176(3):239-248.

45. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Contagion models for the transmission of drug abuse among

propinquity-of-rearing defined acquaintances: A Swedish national study. Drug Alcohol Depend. 2019 Aug 1;201:94-100.

46. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Maternal half-sibling families with discordant fathers: a contrastive

design assessing cross-generational paternal genetic transmission of alcohol use disorder, drug abuse and major

depression. Psychol Med. 2019 Apr 17:1-8.

47. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Parent-offspring transmission of drug abuse and alcohol use

disorder: Application of the multiple parenting relationships design. Am J Med Genet B Neuropsychiatr Genet. 2019

Mar 1.

48. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Prediction of Onset of Substance-Induced Psychotic Disorder and

Its Progression to Schizophrenia in a Swedish National Sample. Am J Psychiatry. 2019 May 6:appiajp201918101217.

49. Kohno K, Niihara H, Hamano T, Takeda M, Nakagawa Y, Shiwaku K, Nabika T, Zöller B, Li X, Sundquist K, Sundquist J,

Morita E. J-curve association between alcohol intake and varicose veins in Japan: The Shimane CoHRE Study. J

Dermatol. 2019 Jul 29.

50. Kornfält Isberg H, Hedin K, Melander E, Mölstad S, Beckman A. Increased adherence to treatment guidelines in pa

tients with urinary tract infection in primary care: A retrospective study. PLoS One. 2019 Mar 28;14(3):e0214572.

51. Kornfält Isberg H, Melander E, Hedin K, Mölstad S, Beckman A. Uncomplicated urinary tract infections in Swedish

primary care; etiology, resistance and treatment. BMC Infect Dis. 2019 Feb 13;19(1):155.

52. Larsen LB, Sondergaard J, Thomsen JL, Halling A, Sønderlund AL, Christensen JR, Thilsing T. Digital Recruitment

and Acceptance of a Stepwise Model to Prevent Chronic Disease in the Danish Primary Care Sector: Cross-Sectional

Study. J Med Internet Res. 2019 Jan 21;21(1):e11658.

53. Larsen LB, Sondergaard J, Thomsen JL, Halling A, Sønderlund AL, Christensen JR, Thilsing T. Step-wise approach to

prevention of chronic diseases in the Danish primary care sector with the use of a personal digital health profile and

targeted follow-up - an assessment of attendance. BMC Public Health. 2019 Aug 13;19(1):1092.

54. Li X, Sjöstedt C, Sundquist J, Zöller B, Sundquist K. Familial association of attention-deficit hyperactivity disorder with ANNUALREPORT2019

autoimmune diseases in the population of Sweden. Psychiatr Genet. 2019 Apr;29(2):37-43.

55. Li X, Sundquist J, Forsberg PO, Sundquist K. Association between neighbourhood deprivation and heart failure

among patients with diabetes mellitus: A 10-year follow-up study in Sweden. J Card Fail. 2019 Apr 30. pii: S1071-

9164(18)31236-3.

56. Li X, Sundquist J, Hamano T, Sundquist K. Family and neighborhood socioeconomic inequality in cryptorchidism and

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hypospadias: A nationwide study from Sweden. Birth Defects Res. 2019 Jan 15;111(2):78-87.

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57. Li X, Sundquist J, Hamano T, Sundquist K. Neighborhood Deprivation and Risks of Autoimmune Disorders: A National

Cohort Study in Sweden. Int J Environ Res Public Health. 2019 Oct 9;16(20).

58. Lindgren MP, Ji J, Smith JG, Sundquist J, Sundquist K, Zöller B. Mortality risks associated with sibling heart failure. Int

J Cardiol. 2019 Oct 12. pii: S0167-5273(19)30895-2.

59. Long EC, Ohlsson H, Sundquist J, Sundquist K, Kendler KS. Different Characteristics and Heritabilities of Alcohol Use

Disorder Classes: A Population-Based Swedish Study. Alcohol Alcohol. 2019 Sep 26.

60. Lu S, Catalano C, Huhn S, Pardini B, Partu L, Vymetalkova V, Vodickova L, Levy M, Buchler T, Hemminki K, Vodicka P,

Försti A. Single nucleotide polymorphisms within MUC4 are associated with colorectal cancer survival. PLoS One.

2019 May 15;14(5):e0216666.

61. Lönn SL, Melander O, Crump C, Sundquist K. Accumulated neighbourhood deprivation and coronary heart disease: a

nationwide cohort study from Sweden. BMJ Open. 2019 Sep 17;9(9):e029248.

62. Manderstedt E, Lind-Halldén C, Svensson P, Zöller B, Halldén C. Next-Generation Sequencing of 17 Genes Associated

with Venous Thromboembolism Reveals a Deficit of Non-Synonymous Variants in Procoagulant Genes. Thromb

Haemost. 2019 Sep;119(9):1441-1450.

63. Martinsson A, Li X, Torp-Pedersen C, Zöller B, Andell P, Andreasen C, Gislason G, Køber L, Sundquist K, Smith JG,

Andersson C. Outcomes associated with dual antiplatelet therapy after myocardial infarction in patients with aortic

stenosis. Int J Cardiol. 2019 Jan 19. pii: S0167-5273(18)33784-7.

64. McGee EE, Castro FA, Engels EA, Freedman ND, Pfeiffer RM, Nogueira L, Stolzenberg-Solomon R, McGlynn KA,

Hemminki K, Koshiol J. Associations between autoimmune conditions and hepatobiliary cancer risk among elderly US

adults. Int J Cancer. 2019 Feb 15;144(4):707-717.

65. Memarian E, Sundquist K, Calling S, Sundquist J, Li X. Socioeconomic factors, body mass index and bariatric surgery:

a Swedish nationwide cohort study. BMC Public Health. 2019 Mar 4;19(1):258.

66. Memon AA, Zarrouk M, Ågren-Witteschus S, Sundquist J, Gottsäter A, Sundquist K. Identification of novel diagnostic

and prognostic biomarkers for abdominal aortic aneurysm. Eur J Prev Cardiol. 2019 Aug 29:2047487319873062.

67. Mezuk B, Ohlsson H, Cederin K, Sundquist J, Kendler KS, Sundquist K. Immigrant enclaves and risk of drug in

volvement among asylum-seeking immigrants in Sweden: A quasi-experimental study. Drug Alcohol Depend. 2019 Oct

25;205:107666.

68. 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 Dec 9:1-8.

69. Molvin J, Jujic A, Nilsson PM, Leosdottir M, Lindblad U, Daka B, Bennet L, Råstam L, Lyssenko V, Magnusson M. A

diabetes-associated genetic variant is associated with diastolic dysfunction and cardiovascular disease. ESC Heart

Fail. 2019 Dec 20.

70. Mukama T, Fallah M, Tian Y, Sundquist K, Sundquist J, Brenner H, Kharazmi E. Risk-tailored starting age of breast

cancer screening based on women's reproductive profile: A nationwide cohort study. Eur J Cancer. 2019 Nov 21. pii:

S0959-8049(19)30774-9.

71. Mukama T, Kharazmi E, Xing X, Sundquist K, Sundquist J, Brenner H, Fallah M. Risk-Adapted Starting Age of Screening for Relatives of Patients With Breast Cancer. JAMA Oncol. 2019 Nov 14.

72. Niazi Y, Thomsen H, Smolkova B, Vodickova L, Vodenkova S, Kroupa M, Vymetalkova V, Kazimirova A,

Barancokova M, Volkovova K, Staruchova M, Hoffmann P, Nöthen MM, Dušinská M, Musak L, Vodicka P, Hemminki

K, Försti A. Genetic variation associated with chromosomal aberration frequency: A genome-wide association study.

Environ Mol Mutagen. 2019 Jan;60(1):17-28.

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CPF PUBLISHED SCIENTIFIC ARTICLES 2019 73. Nymberg P, Stenman E, Calling S, Sundquist J, Sundquist K, Zöller B. Self-rated health and venous thromboembolism

among middle-aged women: a population-based cohort study. J Thromb Thrombolysis. 2019 Nov 19.

74. Nymberg VM, Bolmsjö BB, Wolff M, Calling S, Gerward S, Sandberg M. 'Having to learn this so late in our lives…'

Swedish elderly patients' beliefs, experiences, attitudes and expectations of e-health in primary health care. Scand J

Prim Health Care. 2019 Mar;37(1):41-52.

75. Ohlsson H, Kendler KS. Applying Causal Inference Methods in Psychiatric Epidemiology A Review JAMA Psychiatry.

December 11, 2019.

76. Okuyama K, Abe T, Hamano T, Takeda M, Sundquist K, Sundquist J, Nabika T. Hilly neighborhoods are associated with

increased risk of weight gain among older adults in rural Japan: a 3-years follow-up study. Int J Health Geogr. 2019

May 10;18(1):10.

77. Olaya-Contreras P, Balcker-Lundgren K, Siddiqui F, Bennet L. Perceptions, experiences and barriers to lifestyle

modifications in first-generation Middle Eastern immigrants to Sweden: a qualitative study. BMJ Open. 2019 Oct

19;9(10):e028076.

78. Packness A, Halling A, Simonsen E, Waldorff FB, Hastrup LH. Are perceived barriers to accessing mental healthcare

associated with socioeconomic position among individuals with symptoms of depression? Questionnaire-results from

the Lolland-Falster Health Study, a rural Danish population study. BMJ Open. 2019 Mar 15;9(3):e023844.

79. Pikkemaat M, Andersson T, Melander O, Chalmers J, Rådholm K, Bengtsson Boström K. C-peptide predicts all-cause

and cardiovascular death in a cohort of individuals with newly diagnosed type 2 diabetes. The Skaraborg diabetes

80. Pikkemaat M, Boström KB, Strandberg EL. "I have got diabetes!" - interviews of patients newly diagnosed with type 2

diabetes. BMC Endocr Disord. 2019 May 24;19(1):53.

81. Rudnicki M, Jakobsson U, Teleman P. Impact of per-operative antibiotics on the urinary tract infection rate following

mid-urethral sling surgery for urinary incontinence: a randomized controlled trial. Int Urogynecol J. 2019 Nov 27.

82. Rydhög B, Granfeldt Y, Frassetto L, Fontes-Villalba M, Carrera-Bastos P, Jönsson T. Assessing compliance with Pa

leolithic diet by calculating Paleolithic Diet Fraction as the fraction of intake from Paleolithic food groups. Clinical

Nutrition Experimental. 2019 Jun: 25:29-35.

83. Salvatore JE, Larsson Lönn S, Long EC, Sundquist J, Kendler KS, Sundquist K, Edwards AC. Parental alcohol use

disorder and offspring marital outcomes. Addiction. 2019 Jan;114(1):81-91.

84. Sharma S, Kohli C, Johnson L, Bennet L, Brusselaers N, Nilsson PM. Birth size and cancer prognosis: a systematic

review and meta-analysis. J Dev Orig Health Dis. 2019 Oct 24:1-8.

85. Siddiqui F, Lindblad U, Nilsson PM, Bennet L. Effects of a randomized, culturally adapted, lifestyle intervention on

mental health among Middle-Eastern immigrants. Eur J Public Health. 2019 Oct 1;29(5):888-894.

86. Skoog J, Lenander C, Modig S. An intervention model with self-assessment and subsequent multi-professional review

might be effective and feasible to improve drug safety in primary healthcare. A survey-based evaluation of SÄKLÄK2.

J Eval Clin Pract. 2019 Jun 14.

87. Skoog J, Modig S. Self-assessment and subsequent external review as an effective model for improving drug use for

elderly in primary care: A descriptive study of SÄKLÄK2. J Eval Clin Pract. 2019 Nov 7.

88. Skoog Ståhlgren G, Tyrstrup M, Edlund C, Giske CG, Mölstad S, Norman C, Rystedt K, Sundvall PD, Hedin K. Penicillin

V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group

A streptococci: randomised controlled, open label, non-inferiority study. BMJ. 2019 Oct 4;367:l5337.

89. Stenman E, Palmér K, Rydén S, Sävblom C, Svensson I, Rose C, Ji J, Nilbert M, Sundquist J. Diagnostic spectrum ANNUALREPORT2019

and time intervals in Sweden's first diagnostic center for patients with nonspecific symptoms of cancer. Acta Oncol.

2019 Mar;58(3):296-305.

90. Sud A, Chattopadhyay S, Thomsen H, Sundquist K, Sundquist J, Houlston RS, Hemminki K. Analysis of 153,115 pa

tients with hematological malignancies refines the spectrum of familial risk. Blood. 2019 Aug 8. pii: blood.2019001362.

91. Sundquist K. A Finding of Increased Risk of Nonaffective Psychosis in Refugees That Is Highly Relevant to the Current

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Worldwide Refugee Crisis. JAMA Psychiatry. 2019 Aug 14.

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92. Säfholm S, Bondesson Å, Modig S. Medication errors in primary health care records; a cross-sectional study in

Southern Sweden. BMC Fam Pract. 2019 Jul 31;20(1):110.

93. Thorell K, Midlöv P, Fastbom J, Halling A. Importance of potentially inappropriate medications, number of chronic

conditions and medications for the risk of hospitalisation in elderly in Sweden: a case-control study. BMJ Open. 2019

Sep 27;9(9):e029477

94. Tian Y, Kharazmi E, Sundquist K, Sundquist J, Brenner H, Fallah M. Familial colorectal cancer risk in half siblings and

siblings: nationwide cohort study. BMJ. 2019 Mar 14;364:l803.

95. Wemrell M, Bennet L, Merlo J. Understanding the complexity of socioeconomic disparities in type 2 diabetes risk: a

study of 4.3 million people in Sweden. BMJ Open Diabetes Res Care. 2019 Nov 7;7(1):e000749.

96. Westerlind B, Östgren CJ, Midlöv P, Marcusson J. Diagnostic Failure of Cognitive Impairment in Nursing Home

Residents May Lead to Impaired Medical Care. Dement Geriatr Cogn Disord. 2019;47(4-6):209-218.

97. Westerlind B, Östgren CJ, Mölstad S, Midlöv P, Hägg S. Use of non-benzodiazepine hypnotics is associated with falls

in nursing home residents: a longitudinal cohort study. Aging Clin Exp Res. 2019 Aug;31(8):1087-1095.

98. Wändell P, Carlsson AC, Li X, Gasevic D, Ärnlöv J, Holzmann MJ, Sundquist J, Sundquist K. Atrial fibrillation in im

migrants under the age of 45 y in Sweden. Int Health. 2019 May 1;11(3):193-202.

99. Wändell P, Carlsson AC, Li X, Gasevic D, Ärnlöv J, Sundquist J, Sundquist K. End-Stage Kidney Diseases in

Immigrant Groups: A Nationwide Cohort Study in Sweden. Am J Nephrol. 2019 Feb 1;49(3):186-192.

100. Wändell P, Carlsson AC, Li X, Gasevic D, Sundquist J, Sundquist K. Dementia in immigrant groups: A cohort study of

all adults 45 years of age and older in Sweden. Arch Gerontol Geriatr. 2019 Mar 6;82:251-258.

101. Wändell P, Carlsson AC, Li X, Gasevic D, Sundquist J, Sundquist K. Urolithiasis in immigrant groups: a nationwide

cohort study in Sweden. Scand J Urol. 2019 Apr 8:1-8.

102. Wändell P, Carlsson AC, Li X, Sundquist J, Sundquist K. Association Between Relevant Co-Morbidities and Dementia

With Atrial Fibrillation-A National Study. Arch Med Res. 2019 Feb;50(2):29-35.

103. Wändell P, Carlsson AC, Li X, Sundquist J, Sundquist K. Effects of cardiovascular pharmacotherapies on incident

dementia in patients with atrial fibrillation: A cohort study of all patients above 45 years diagnosed with AF in

hospitals in Sweden. Int J Cardiol. 2019 Oct 8. pii: S0167-5273(19)34104-X.

104. Wändell P, Carlsson AC, Li X, Sundquist J, Sundquist K. Levothyroxine treatment and incident dementia in adults with

atrial fibrillation. Aging Clin Exp Res. 2019 May 22.

105. Wändell P, Carlsson AC, Sundquist J, Sundquist K. Effect of Levothyroxine Treatment on Incident Dementia in Adults

with Atrial Fibrillation and Hypothyroidism. Clin Drug Investig. 2019 Feb;39(2):187-195.

106. Wändell P, Carlsson AC, Sundquist J, Sundquist K. The association between gout and cardiovascular disease in

patients with atrial fibrillation. SN Compr Clin Med. 2019 Apr;1(4):304-310.

107. Wändell P, Fredrikson S, Carlsson AC, Li X, Gasevic D, Sundquist J, Sundquist K. Epilepsy in second-generation im

migrants: a cohort study of all children up to 18 years of age in Sweden. Eur J Neurol. 2019 Jul 24.

108. Wang X, Sundquist K, Svensson PJ, Rastkhani H, Palmér K, Memon AA, Sundquist J, Zöller B. Association of

recurrent venous thromboembolism and circulating microRNAs. Clin Epigenetics. 2019 Feb 13;11(1):28.

109. Yu H, Hemminki A, Sundquist K, Hemminki K. Familial Associations of Colon and Rectal Cancers With Other Cancers.

Dis Colon Rectum. 2019 Feb;62(2):189-195.

110. Zhang L, Hemminki O, Chen T, Yu H, Zheng G, Chattopadhyay S, Försti A, Sundquist K, Sundquist J, Hemminki K.

Second cancers and causes of death in patients with testicular cancer in Sweden. PLoS One. 2019 Mar

28;14(3):e0214410.

111. Zhang L, Hemminki O, Chen T, Zheng G, Försti A, Sundquist K, Sundquist J, Hemminki K. Familial Clustering, Second Primary Cancers and Causes of Death in Penile, Vulvar and Vaginal Cancers. Sci Rep. 2019 Aug 14;9(1):11804.

112. Zhang L, Hemminki O, Zheng G, Försti A, Sundquist K, Sundquist J, Hemminki K. Comparison of Familial Clustering

of Anogenital and Skin Cancers Between In Situ and Invasive Types. Sci Rep. 2019 Nov 6;9(1):16151.

113. Zheng G, Chattopadhyay S, Sud A, Sundquist K, Sundquist J, Försti A, Houlston R, Hemminki A, Hemminki K. Se

cond primary cancers in patients with acute lymphoblastic, chronic lymphocytic and hairy cell leukaemia. Br J Hae

matol. 2019 Jan 31

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114. Zheng G, Chattopadhyay S, Sud A, Sundquist K, Sundquist J, Försti A, Houlston RS, Hemminki A, Hemminki K. Types of

second primary cancers influence survival in chronic lymphocytic and hairy cell leukemia patients. Blood Cancer J. 2019 Mar

26;9(4):40.

115. Zheng G, Hemminki A, Försti A, Sundquist J, Sundquist K, Hemminki K. Second primary cancer after female breast cancer:

Familial risks and cause of death. Cancer Med. 2019 Jan;8(1):400-407.

116. Zöller B, Pirouzifard M, Sundquist J, Sundquist K. Association of Short-Term Mortality of Venous Thromboembolism with

Family History of Venous Thromboembolism and Charlson Comorbidity Index. Thromb Haemost. 2019 Jan;119(1):48-55.

117. Zöller B. Genetics of venous thromboembolism revised. Blood. 2019 Nov 7;134:1568-1570.

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118. Afentou N, Jarl J, Gerdtham UG, Saha S. Economic Evaluation of Interventions in Parkinson's Disease: A Systematic Literature Review. Mov Disord Clin Pract. 2019 Apr 11;6(4):282-290. 119. Ayuso-Álvarez A, Simón L, Nuñez O, Rodríguez-Blázquez C, Martín-Méndez I, Bel-Lán A, López-Abente G, Merlo J, Fernandez-Navarro P, Galán I. Association between heavy metals and metalloids in topsoil and mental health in the adult population of Spain. Environ Res. 2019 Dec;179(Pt A):108784. 120. Borg S, Eeg-Olofsson K, Palaszewski B, Svedbo Engström M, Gerdtham UG, Gudbjörnsdottir S. Patient-reported outcome and experience measures for diabetes: development of scale models, differences between patient groups and relationships with cardiovascular and diabetes complication risk factors, in a combined registry and survey study in Sweden. BMJ Open. 2019 Jan 4;9(1):e025033. 121. Borg S, Gerdtham UG, Eeg-Olofsson K, Palaszewski B, Gudbjörnsdottir S. Quality of life in chronic conditions using patient- reported measures and biomarkers: a DEA analysis in type 1 diabetes. Health Econ Rev. 2019 Nov 7;9(1):31. 122. Burger R, Christian CS, Gerdtham UG, Haal K, Hompashe DM, Smith A, Schutte AE. Use of simulated patients to assess hypertension case management at public healthcare facilities in South Africa. J Hypertens. 2019 Oct 3. 123. Cirera L, Huerta JM, Chirlaque MD, Overvad K, Lindström M, Regnér S, Tjønneland A, Boutron-Ruault MC, Rebours V, Fag herazzi G, Katzke VA, Boeing H, Peppa E, Trichopoulou A, Valanou E, Palli D, Grioni S, Panico S, Tumino R, Ricceri F, van Gils C, Vermeulen RCH, Skeie G, Braaten T, Weiderpass E, Merino S, Sánchez MJ, Larrañaga N, Ardanaz E, Sund M, Khaw KT, Key TJ, Jenab M, Naudin S, Murphy N, Aune D, Ward H, Riboli E, Bueno-de-Mesquita B, Navarro C, Duell EJ. Socioeconomic Effect of Education on Pancreatic Cancer Risk in Western Europe: An Update on the EPIC Cohorts Study. Cancer Epidemiol Biomarkers Prev. 2019 Jun;28(6):1089-1092. 124. Dackehag M, Ellegård LM, Gerdtham UG, Nilsson T. Debt and mental health: new insights about the relationship and the im portance of the measure of mental health. Eur J Public Health. 2019 Jun 1;29(3):488-493. 125. Evans CR, Leckie G, Merlo J. Multilevel versus single-level regression for the analysis of multilevel information: The case of quantitative intersectional analysis. Soc Sci Med. 2019 Aug 24:112499. 126. Fridh M, Lindström M, Rosvall M. Associations between self-injury and involvement in cyberbullying among mentally distressed adolescents in Scania, Sweden. Scand J Public Health. 2019 Mar;47(2):190-198. 127. Gerdtham UG, Wengström E, Wickström Östervall L. Trait self-control, exercise and exercise ambition: Evidence from a healthy, adult population. Psychol Health Med. 2019 Aug 13:1-10. 128. Ghith N, Merlo J, Frølich A. Albuminuria measurement in diabetic care: a multilevel analysis measuring the influence of accredi tation on institutional performance. BMJ Open Qual. 2019 Jan 14;8(1):e000449. 129. Gracia E, Martín-Fernández M, Lila M, Merlo J, Ivert AK. Prevalence of intimate partner violence against women in Sweden and Spain: A psychometric study of the 'Nordic paradox'. PLoS One. 2019 May 16;14(5):e0217015.

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PUBLISHED SCIENTIFIC ARTICLES 2019

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130. Ivert AK, Gracia E, Lila M, Wemrell M, Merlo J. Does country-level gender equality explain individual risk of intimate partner violence against women? A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) in the European Union. Eur J Public Health. 2019 Sep 24. pii: ckz162. 131. Jakovljevic M, Jakab M, Gerdtham U, McDaid D, Ogura S, Varavikova E, Merrick J, Adany R, Okunade A, Getzen TE. Comparative financing analysis and political economy of noncommunicable diseases. J Med Econ. 2019 Aug;22(8):722-727. 132. Kristensen PK, Merlo J, Ghith N, Leckie G, Johnsen SP. Hospital differences in mortality rates after hip fracture surgery in Denmark. Clin Epidemiol. 2019 Jul 16;11:605-614. 133. Linder A, Gerdtham UG, Trygg N, Fritzell S, Saha S. Inequalities in the economic consequences of depression and anxiety in Europe: a systematic scoping review. Eur J Public Health. 2019 Jul 13. 134. Lindström C, Rosvall M, Lindström M. Unmet health-care needs and mortality: A prospective cohort study from southern Sweden. Scand J Public Health. 2019 Aug 13:1403494819863530. 135. Lindström M, Nystedt TA, Rosvall M, Fridh M. Sexual orientation and poor psychological health: a population-based study. Public Health. 2019 Oct 15;178:78-81. 136. Lindström M, Rosvall M. Marital status and 5-year mortality: A population-based prospective cohort study. Public Health. 2019 May;170:45-48. 137. Lindström M, Rosvall M. Parental separation/divorce in childhood and tobacco smoking in adulthood: A population-based study. Scand J Public Health. 2019 May 9:1403494819846724. 138. Merlo J, Wagner P, Leckie G. A simple multilevel approach for analysing geographical inequalities in public health reports: The case of municipality differences in obesity. Health Place. 2019 Jul;58:102145. 139. Nystedt T, Rosvall M, Lindström M. Sexual orientation, suicide ideation and suicide attempt: A population- based study. Psychiatry Res. 2019 May;275:359-365. 140. Nystedt TA, Rosvall M, Lindström M. The association of self-reported discrimination to all-cause mortality: A population-based prospective cohort study. SSM Popul Health. 2019 Jan 24;7:100360. 141. Olofsson S, Gerdtham UG, Hultkrantz L, Persson U. Dread and Risk Elimination Premium for the Value of a Statistical Life. Risk Anal. 2019 Nov;39(11):2391-2407. 142. Olofsson S, Gerdtham UG, Hultkrantz L, Persson U. Value of a QALY and VSI estimated with the chained ap proach. Eur J Health Econ. 2019 Sep;20(7):1063-1077. 143. Persmark A, Wemrell M, Zettermark S, Leckie G, Subramanian SV, Merlo J. Precision public health: Mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Indivi dual Heterogeneity and Discriminatory Accuracy (MAIHDA). PLoS One. 2019 Aug 27;14(8):e0220322. 144. Saha S, Grahn B, Gerdtham UG, Stigmar K, Holmberg S, Jarl J. Structured physiotherapy including a work place intervention for patients with neck and/or back pain in primary care: an economic evaluation. Eur J Health Econ. 2019 Mar;20(2):317-327. 145. Saha S, Nordstrom J, Gerdtham UG, Mattisson I, Nilsson PM, Scarborough P. Prevention of Cardiovascular Disease and Cancer Mortality by Achieving Healthy Dietary Goals for the Swedish Population: A Macro- Simulation Modelling Study. Int J Environ Res Public Health. 2019 Mar 12;16(5). 146. Saha S, Nordström J, Mattisson I, Nilsson PM, Gerdtham UG. Modelling the Effect of Compliance with Nordic Nutrition Recommendations on Cardiovascular Disease and Cancer Mortality in the Nordic Countries. Nutrients. 2019 Jun 25;11(6).

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ANNUAL REPORT 2019 CPF, Center for Primary Healthcare Research KCP, Competence Center for Primary Care in SkĂĽne Print: Media Tryck, 2020 www.cpf.se www.vardgivare.skane.se/kompetens-utveckling/ sakkunniggrupper/primarvard-i-skane/