Personcentrerad vård i hemmet: att växla till effektivare preventiv vård vid långvarig sjukdom
Project number : 237711
Created by: Inger Ekman, 2017-12-09
Last revised by: Inger Ekman, 2018-11-25
Project created in: FoU i Västra Götalandsregionen

Not updatedNot updated

1. Översiktlig projektbeskrivning

Engelsk titel

Personcentred Care att Home: shifting towards high quality, affordable, preventive health care

Populärvetenskaplig sammanfattning av projektet

Att leva med långvarig eller kronisk sjukdom innebär att den egna upplevelsen av hälsotillståndet och möjligheter och hinder att må så bra som möjligt är av stor betydelse. Kronisk obstruktiv lungsjukdom (KOL) och kronisk hjärtsvikt innebär ofta svåra symtom som andfåddhet och trötthet vilket gör att många blir bundna till hemmet. Detta förenat med frekventa slutenvårdstillfällen vid försämring av tillståndet leder till osäkerhet och ångest

Vi har tidigare visat att personcentrerad vård (PCV) vid försämring av kronisk hjärtsvikt är förenat med lägre kostnader, minskad otrygghet samt kortare vårdtider på sjukhus. I en nyligen genomförd randomiserad, kontrollerad studie fann vi att PCV i hemmet (via telefon) efter slutenvård för kronisk obstruktiv lungsjukdom (KOL) och/eller kronisk hjärtsvikt leder till högre självtillit och minskat antal besök i primärvård eller sjukhusvård. Patienter kontaktades efter utskrivning från sjukhus av en specialistsjuksköterska via telefon och berättade hur de mådde och hur vardagslivet tedde sig, i berättelsen identifierades inte bara behov och besvär utan främst resurser och förmågor (tex, vilja, kunskap om sin sjukdom eller stödjande familj). Utifrån berättelsen gjordes tillsammans en hälsoplan där mål formuleras och en plan för att nå dessa. Mot bakgrund av dessa positiva fynd och det stora behov av kunskap om hur vi kan skapa en högre grad av tillit till sin egen förmåga för de som har kronisk eller långvarig sjukdom i hemmet vill vi nu testa en utveckling av PCV i hemmet via en eHälsa plattform.

Patienter som fått diagnosen KOL eller kronisk hjärtsvikt vid besök i primärvården kontaktas och slumpas till en grupp som får PCV eller till kontrollgrupp. För tillräcklig kraft i studien kommer 220 patienter att inkluderas. En specialistutbildad sjuksköterska kontaktar varje patient i PCV gruppen och tillsammans formulerar de patientens personliga hälsoplan, vilken göra via en eHälsa plattform som utvecklats av forskare vid Göteborgs universitet tillsammans med patient- och närståenderepresentanter och hälsoprofessionella och som huvudsakligen innebär följande möjligheter för patienten:

Effektmått i studien är en sammanvägning av förbättrad "self-efficacy", minskad sjukfrånvaro och/eller ökad aktivitet, död eller sjukhusvård jämfört med konventionell vård. Begreppet "self-efficacy" innebär personens möjligheter att själv initiera och upprätthålla egenvård och hälsobeteende. Ett ytterligare effektmått är den hälsoekonomiska utvärderingen, där vi undersöker kostnaderna och konsekvenserna för de två behandlingsalternativen (PCV och traditionell vård) på såväl sjukvårdsnivå som på samhällsnivå. Resultatet kommer att beskrivas i en så kallad beslutsanalys, som för beslutsfattarna kan påvisa om interventionen är billigare eller dyrare, bättre eller sämre än traditionell vård.

Vetenskaplig sammanfattning av projektet

The Gothenburg Person Centred Care (gPCC) approach has proved effective in several conditions and care contexts. The aim of the present project is to test gPCC in patients´ homes using the example of patients with chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) or both. The design is a randomized, open-controlled, parallel, intervention study. Patients in the intervention group will be recruited from primary care by a specialised registered nurse (RN) after an invitation from the patient´s primary care physician. The RN will present an eHealth platform to patients. The platform can be accessed through their smartphone or I-pad. A personal health-plan is formulated together by the RN and the patient (often with relatives) and managed by the patient, who can invite people with the same diagnoses, care providers or whoever they want for support to manage the illness. The primary composite endpoint is changes in general self-efficacy, re-hospitalization or death. After one, two, three, six months and one year after discharge follow-up will be made. In addition health-economic analyses will be performed to estimate the difference in total societal costs. A minimum of 220 patients will be randomized to achieve 80% power. During 2017 and 2018 patients will be recruited, 2019 and 2020 analyses will be made and reports written. The results of this study, if proved effective, can be directly implemented in a number of long term illnesses. One way towards a future effective health care is to increase self-efficacy in patients by focusing prevention and support care at home

Typ av projekt

Forskningsprojekt

MeSH-termer för att beskriva typ av studier

checked Kvalitativ forskning (Qualitative Research)
checked Randomiserad klinisk prövning (Randomized Controlled Trial)


(Only selected options are displayed. Click here to display all options)

MeSH-termer för att beskriva ämnesområdet

information Added MeSH terms
Health Care Quality, Access, and Evaluation
The concept concerned with all aspects of the quality, accessibility, and appraisal of health care and health care delivery.

Projektets delaktighet i utbildning

checked Avhandling


(Only selected options are displayed. Click here to display all options)

2. Projektorganisation och finansiering

Arbetsplatser involverade i projektet

information Added workplaces
Regioner - Västra Götalandsregionen - Specialiserad vård - Sahlgrenska Universitetssjukhuset - Område 2 - Medicin, Geriatrik och Akutmottagning Östra workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Specialiserad vård - Sahlgrenska Universitetssjukhuset - Område 6 - Geriatrik, Lungmedicin och Allergologi workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - FoU primärvård - Närhälsan FoU-centrum Göteborg och Södra Bohuslän workplace verified by Västra Götalandsregionen on 2018-02-27

Coworker

Andreas Fors
Leg.Sjuksköterska, Sektion reproduktiv och perinatal hälsa, vårdpedagogik och radiografi, Närhälsan FoU-centrum Göteborg och Södra Bohuslän
Anders Ullman
Överläkare/sektionschef, Geriatrik, Lungmedicin och Allergologi
Karl Swedberg
Överläkare, Institutionen för medicin, Cardiovascular Science, Medicin, Geriatrik och Akutmottagning Östra
Michael Fu
Professor, Överläkare, Universitetssjukhusöverläkare, MD, PhD, FESC, Avdelningen för molekylär och klinisk medicin, Medicin, Geriatrik och Akutmottagning Östra

3. Processen och projektets redovisning

Detaljerad projektbeskrivning

Person-Centred Care at Home (gPCC at Home): Shifting towards high quality,

affordable preventive healthcare

1. Purpose and aims

The purpose of this project is to extend the Gothenburg Person Centred Care (gPCC) approach

to preventive care of chronically ill patients at risk of being hospitalised and to assess the

impact of gPCC at Home on quality and cost.

Specific aims are:

- To investigate the preventive effects of gPCC at Home on self-efficacy, symptom

distress/anxiety and hospitalisation of chronically ill patients, using the care of patients

with chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF)

as an example.

- To evaluate the efficacy of a customised web based gPCC platform in supporting

patients with chronic illnesses to manage their condition from their own homes.

- To perform a societal cost-utility analysis of gPCC at Home in comparison with the

traditional approach to health care.

2. Survey of the field

2.1 Current challenges in traditional health care

One of the major challenges in Sweden - and many other Western countries - is the rising

health care costs. Due to an ageing population the incidence of chronic illnesses is rapidly

increasing1 and in Sweden the national health expenditure rose from 8,5 % of the GDP in

2000 to over 12 % of the GDP in 2014 2. Without drastic changes, the quality and

accessibility of care might be in jeopardy.

Current practice

Currently, organisation of healthcare is focused on 1) curing patients and 2) optimising the

efficiency of the care process. Although this is a valid approach, the patient’s own capabilities

and resources are not sufficiently taken into account. Moreover, the patient is not stimulated

to optimise his/her own resources and take more responsibility for self-management and

prevention.

Gothenburg Person Centred Care

Partly funded by the Swedish Research Council, the University of Gothenburg and Centre for

Person-centred Care have developed and tested a novel approach to care, the Gothenburg

Person Centred Care (gPCC) approach, which has been shown to facilitate the transition to

a more patient-inclusive approach to care. The gPCC approach (gPCC) has been evaluated in

several medical contexts and conditions, and shown to result in positive effects 3-12. For

instance, it shortens hospital stay, improves self-efficacy, reduces health care costs and

maintains functional performance 4 8-12. The Swedish Association of Local Authorities and

Regions (SKL), has embraced the PCC approach in their strategic ambitions 13.

Gothenburg Person Centred Care (gPCC)

The core component in gPCC is acknowledging the patient as a person in order to engage that

person as an active partner in her/his own care and treatment 14 15. Patients (often with the

help of relatives) present themselves as persons by their patient narratives which includes how

their daily life is being affected by the condition and treatment. A person-centred approach

not only means identifying health barriers, but also recognising a patient’s capabilities and

resources in their home and local environment.

At the basis of PCC is the Capability Approach, which has been used as a theoretical frame

of reference in several research disciplines, for example in economics by the Nobel laureate

Amartya Sen 16. A central component of gPCC is that the professional and patient jointly

develop a person-centred health plan based on their capabilities and health barriers. In gPCC

the role of health professionals changes from taking the lead and being dominant in care, to

supporting the patient to take as much responsibility as possible for his/her own condition.

To facilitate a transition to gPCC, the Centre for Person-centred Care has described an

approach, comprising three main components:

1. Initiating the narrative to get to know the patient and to identify the patient’s

experiences, present situation, needs, capabilities and resources.

2. Co-creating a health plan in line with identified resources and barriers combined with

medical and health research evidence.

3. Documenting and monitoring the health plan, adapting it to changes in the patient’s

goals and/or other circumstances.

Present state of research and development

Previous trials have all focused on the implementation of gPCC in hospitals and primary care

(Figure 1). A recently concluded study made the first step to explore the feasibility of

extending gPCC to patients’ homes, “gPCC at distance”. The study has shown that worsening

events were significantly reduced by 20% in patients with CHF and COPD following

delivery of care over the phone (unpublished data; n= 240; randomized into two groups). On

top of this, the gPCC group reported decreased anxiety levels and increased self-efficacy.

Where the previous study focused on preventing re-hospitalization of previously admitted

patients, this project proposal takes gPCC one step further and aims at preventing

hospitalization: gPCC at Home. The key to accomplish this goal is supporting patients to trust

themselves to, in collaboration with professionals, take more responsibility for their condition

and improve self-management.

To facilitate gPCC at Home, we developed - together with patients, relatives and health

professionals - a web based platform to provide patients with a possibility for improved

communication with health professionals and a way to keep track of their health plan. For the

development and validation of the platform we chose to focus on patients with COPD and/or

CHF recruited from primary care.

Patients, relatives and health professionals who have initially tested the web based platform

have reported it as user friendly, technically stable and leading to increased co-creation of

care.

3. Project description

3.1 Aims of the project

- To investigate the preventive effects of gPCC at Home on self-efficacy, symptom

distress/anxiety and hospitalisation of chronically ill patients, using the care of patients

with COPD and/or CHF as an example.

- To evaluate the efficacy of a customised web based gPCC platform supporting patients

with chronic illnesses to manage their condition from their own homes.

- To perform a societal cost-utility analysis of gPCC at Home in comparison with the

traditional approach to health care.

3.2 Hypothesis

We hypothesise that gPCC at Home will increase self-efficacy and reduce symptom burden,

and consequently the need for hospitalisation of people with chronic conditions, reducing the

cost of health care.

3.3 Research lines

1. Randomized controlled trial to test the feasibility of preventive gPCC at Home using a web

based platform

2. Health-economic evaluation of the intervention study

The main features of the web based platform, supporting gPCC at Home, are:

- Building a support network. The platform enables patients with long term illness to build

their own care network (comprising health professionals, relatives, friends and other

patients) so that they can easily reach out via the platform if needed, but also the other way

around. A link to other social platforms and their medical record (via www.1177.se) is

provided for. Internationally validated links are also presented, for example “heart failure

matters” (www.heartfailurematters.org), which provides practical information also in other

languages than Swedish, for example Arabic.

- Increasing self-management. The patients are encouraged to actively manage their

person-centred health plan, follow up on their goals and formulate new ones.

- Providing for a health monitor. The patients can visualize their progress in trend graphs

on specific parameters such as daily condition, burden of illness, sleep, breathlessness etc.

- Providing for professional support. Specially trained registered nurses (RNs) monitor the

process and are able to provide medical and health support by involving other

professionals such as physiotherapists, physicians, occupational therapists etc.

- Privacy-protected. All information (medical and non-medical) passes through the patient

and can be shared with others only with the patient’s consent.

- Data-protected. To guard patient privacy, the server of the platform will be run within the

IT-security of the University of Gothenburg.

3.4 Methods

3.4.1 Preparation phase

On an operational level: two dedicated full-time RNs will be trained:

- To manage the project on an operational level, to monitor the included patients and to offer

support at the patients’ request.

- To coach the participants on how to use the web based gPCC at Home support platform.

- To communicate with patients through gPCC at Home about their personal health plan on

for example goal achievement.

On an academic level: A PhD student will be supervised by the applicant and collaborators.

The preparatory process of this study included interview studies with patients and their families

as well as health professionals with experience in coaching patients at distance e.g. over the

phone 17. In terms of literature preparation, the capability approach 16 has been studied in depth

and discussed on an operational level.

3.4.2 Implementation of gPCC at Home for COPD and/or CHF

Study design

The study is a randomized, open, parallel group intervention study.

Patient selection:

- Inclusion criteria: Men and women listed at public primary care centres in Gothenburg and

registered with a diagnosis of COPD and/or CHF.

- Exclusion criteria: Not willing to participate, severe impairment that prevents the patient

from using the web based platform; no registered address, any severe disease with an

expected survival < 12 months; cognitive impairment (SPMSQ score > 6); ongoing

documented diagnosis of alcohol or drug abuse; other disease that can interfere with

follow-up (e.g. severe depression, other severe mental illness); participating in another

conflicting randomized intervention study.

Implementation steps of the gPCC approach

Patients with COPD and/or CHF and cared for in primary care will be invited by their primary

care physician and after written consent to participate will be randomized to usual care

(control) or gPCC at Home (intervention). Follow-up questionnaires on self-efficacy 18, health–

related quality of life 19 20, shortness of breath 21 22, anxiety and depression 23 will be distributed

to both groups after 3,6,12, and 24 months.

Intervention

- Usual care group:

Patients randomized to usual care will be managed by regular care as outlined in treatment

guidelines 24 25 and followed at their local primary care centre.

- Intervention group:

Patients randomized to the intervention group will be called by dedicated RNs. Based on the

patient narrative and the dialogue with the RN, the patient´s goals, resources and needs will

be identified. The patient (sometimes together with relatives) and the RN will formulate a

person-centred health plan. This plan is part of, and will be up-loaded to the gPCC at Home

platform, which also contains individual notes and information about CHF and COPD. The

plan will be the point of departure for the forthcoming dialogue at distance via gPCC at Home

that the patient and the RN (and relevant other professionals) will have during the study

period (six months).

Patients will be inspired to make notes on “a good day” or “a bad day” respectively to

thoroughly consider how to reach the goals in their health plan, containing three parts; 1. “My

goal is to feel or be able to do”. 2. “To be able to reach my goal I will.” 3.”Support I need to

reach my goal”. gPCC at Home is designed to fit the patient record online (www.1177.se) and

to inspire usage as the patient can also keep a health diary (through text and video logs), view

trend graphs concerning their health and communicate with e.g. relatives and health

professionals by sending text or voice messages or by calling. The web based platform is

interactive and is based on the patient´s self-reported symptoms and daily condition. Thereby

the patient is made aware of both promoting and risk factors to maintain health, which results

in relevant and achievable goal setting.

In the communication between the RN and patient during the study period, the health plan is

regularly evaluated and any needs of reformulating the goals may be discussed. The overall

goal is to help patients identify and use their own capabilities/resources such as strong will,

social relations etc. and formulate goals that help them increase their self-efficacy and cope

with their condition in daily life.

The RN presents the gPCC at Home web based support for communication (I-pad,

smartphone, computer) and they agree on how they will be in contact thereafter. The RN

invites the patient and activates their account where he/she can login via an individual user

name and formulate, comment and evaluate the agreed health plan developed from the initial

phone conversation. Access to the diary will be password protected. Different forms of

symptom-ratings and comments can also be made. The RN can see the patient´s account and

make comments. The patient can add staff or private persons to have access to the account.

The patient can also limit access. This form of access makes it simple to connect the gPCC at

Home health plan to the health account for each patient (patient record through internet

(www.1177.se)). By this approach patients are “self-implementing” the gPCC at Home

approach into the existing health system.

3.4.3 Endpoints

The primary efficacy endpoint is a composite score of changes in general self-efficacy 18 based

on the General Self-Efficacy Scale (GSE), hospitalization and death. The rationale for such an

endpoint is the value of combining patient experience and clinical outcomes 26.

The General Self-Efficacy Scale (GSE) 18

GSE is a 10-item questionnaire concerning self-confidence in, e.g. dealing efficiently with

unexpected events, handling unforeseen situations, and finding solutions to problems. gPCC

addresses the patients’ confidence in their ability to perform specific activities rather than just

convincing them of the value of such activities 14 27.

A patient is classified as improved, deteriorated or unchanged:

- A patient is classified as deteriorated if any of the following occurred:

 at 6 months, self-efficacy has decreased by > 5 units (the minimal change of clinical

significance) or has been admitted to hospital for unscheduled reasons or died.

- A patient is classified as improved if:

 self-efficacy has increased by > 5 units and has not been hospitalized.

Those who have neither deteriorated nor improved are considered unchanged.

The secondary efficacy endpoints are:

- Health care utilization measured as the number of admissions and unscheduled outpatient

visits due to unplanned visits to hospital and/or primary care due to worsening symptoms

of COPD/CHF,

- Incremental cost-utility ratios,

- EuroQol Group´s five-dimension health state questionnaire (EQ-5D) 19 20,

- General Self- Efficacy scale (GSE-scale) 18,

- Shortness of breath in heart failure (SOB-HF) 21,

- COPD Assessment Test (CAT) 22,

- Hospital anxiety and depression scale (HADS) 23.

3.4.4 Power

To achieve 80% power based on an alfa-error of 0.05 for an increase of the proportion of

improved patients from 20% to 40%, the number of participants in each group (comparison and

intervention) needs to comprise 91 patients. We need to include 110 patients in each group to

have some margin for withdrawals. Thus a minimum of 220 patients has to be randomized.

3.4.5 Health-economic evaluation of the intervention study

The primary objective of the health-economic analyses is to estimate the difference in total

societal costs between the two approaches in relation to the difference in quality-adjusted lifeyears

gained (incremental cost-utility ratios) for the “average” patient, and analyse its

dependence on personal characteristics. The estimation includes two steps: a) to quantify all

resource use and quality of life related to illness and treatment in physical terms and b) to

evaluate uses of resources in monetary terms and calculate a utility measure between minus and

plus one from the quality-of-life instrument.

Resource use will include:

- healthcare use from the regional patient register VEGA (Region Västra Götaland),

- drug use prescription and causes of death (National Board of Health and Welfare)

- social care from the city of Gothenburg,

- lost productivity for the patient, from sickness absence registered in the MiDAS database

(Social insurance agency) and self-report in patient questionnaires (since the first 14 days

of each sick-leave are not covered by official statistics),

- lost productivity for next of kin as well as other costs to the individual and/or family and

friends related to the treatment collected from patient questionnaires and diaries.

There are a number of issues involved in valuing healthcare in monetary terms, related to the

basic economic-theoretical concept of “opportunity cost” true societal valuations and marginal

costs. We will follow state of the art and make alternative estimates of costs and present the

results as sensitivity analyses 28 which will be a test of the robustness of results. Health related

quality of life measured by EQ-5D is collected repeatedly in the patient questionnaires. As a

sensitivity analysis, we will use both a general population value set from UK 29, as there is no

such value set validated for Sweden, and a Swedish patient population set 30 for the translation

of EQ-5D results to utilities.

Difference in costs and difference in utilities will be compared (assuming that there will be no

difference in length of life between the two groups) and cost-utility ratios will be estimated.

The dependence of personal characteristics, e.g., education and income (collected from the

LISA database at Statistics Sweden and through patient questionnaires), will be tested using

multivariate statistical analyses. Furthermore, the distribution of costs will be analysed by

major stake-holders, i.e. county council/region, municipality, market sectors (productivity loss)

and individual/family/friends, respectively, to facilitate also more limited approaches to

economic evaluation.

1. WHO. The global burden of disease 2004 update. 2008

2. http://data.worldbank.org/

3. Feldthusen C, Dean E, Forsblad-d'Elia H, et al. Effects of Person-Centered Physical Therapy on

Fatigue-Related Variables in Persons With Rheumatoid Arthritis: A Randomized Controlled

Trial. Archives of physical medicine and rehabilitation 2016;97(1):26-36.

4. Fors A, Ekman I, Taft C, et al. Person-centred care after acute coronary syndrome, from hospital to

primary care - A randomised controlled trial. Int J Cardiol 2015;187:693-99.

5. Larsson A, Palstam A, Lofgren M, et al. Resistance exercise improves muscle strength, health status

and pain intensity in fibromyalgia-a randomized controlled trial. Arth res & ther 2015;17:161.

6. Olsson LE, Jakobsson Ung E, Swedberg K, et al. Efficacy of person-centred care as an intervention

in controlled trials - a systematic review. J Clin Nurs 2013;22(3-4):456-65.

7. Brännström M, Boman K. Effects of person‐centred and integrated chronic heart failure and

palliative home care. PREFER: a randomized controlled study. European journal of heart

failure 2014;16(10):1142-51.

8. Ekman I, Wolf A, Olsson L-E, et al. Effects of person-centred care in patients with chronic heart

failure: the PCC-HF study. European heart journal 2012;33(9):1112-19.

9. Olsson LE, Karlsson J, Ekman I. The integrated care pathway reduced the number of hospital days

by half: A prospective comparative study of patients with acute hip fracture. Journal of

orthopaedic surgery and research 2006;1(3)

10. Hansson E, Ekman I, Swedberg K, et al. Person-centred care for patients with chronic heart failure

- a cost-utility analysis. Eur J Cardiovasc Nurs 2016;15(4):276-84.

11. Olsson L-E, Karlsson J, Berg U, et al. Person-centred care compared with standardized care for

patients undergoing total hip arthroplasty—a quasi-experimental study. Journal of

orthopaedic surgery and research 2014;9(1)

12. Olsson LE, Hansson E, Ekman I, et al. A cost-effectiveness study of a patient-centred integrated

care pathway. J Adv Nurs 2009;65(8):1626-35.

13. Sveriges Kommuner och Landsting. Motion 61 - Personcentrerad vård. 2015 [Available from:

http://skl.se/download/18.85439e61506cc4d3a2765a5/1445863105802/Motion+61+Personcen

trerad+v%C3%A5rd.pdf.

14. Ekman I, Swedberg K, Taft C, et al. Person-centered care—Ready for prime time. European

journal of cardiovascular nursing 2011;10(4):248-51.

15. Ekman I, Hedman H, Swedberg K, et al. Commentary: Swedish initiative on person centred care.

BMJ (Clinical research ed) 2015;350:h160.

16. Sen A. Capability and Well-being. In: Nussbaum M, Sen A, eds. The Quality of Life. Oxford:

Clarendon Press 1993:30-53.

17. Heckemann B, Wolf A, Ali L, et al. Discovering untapped relationship potential with patients in

telehealth: a qualitative interview study. BMJ Open 2016;6(3):e009750.

18. Schwarzer R, Jerusalem M. Generalized Self-Efficacy scale. In: Weinman J, Wright S, & Johnston

M, eds. Measures in health psychology: A user’s portfolio Causal and control beliefs.

Windsor, England.: NFER-NELSON 1995:35-37.

19. Brooks R. EuroQol: the current state of play. Health policy (Amsterdam, Netherlands)

1996;37(1):53-72.

20. EuroQol--a new facility for the measurement of health-related quality of life. Health policy

(Amsterdam, Netherlands) 1990;16(3):199-208.

21. Ekman I, Granger B, Swedberg K, et al. Measuring shortness of breath in heart failure (SOB-HF):

development and validation of a new dyspnoea assessment tool. Eur J Heart Fail

2011;13(8):838-45.

22. Jones PW, Brusselle G, Dal Negro RW, et al. Properties of the COPD assessment test in a crosssectional

European study. The European respiratory journal 2011;38(1):29-35.

23. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta psychiatrica

Scandinavica 1983;67(6):361-70.

24.NationalMedicalGuidelines.https://alfresco.vgregion.se/alfresco/service/vgr/storage/node/content/3

349/KOL%2c%20diagnostik%20och%20behandling.pdf?a=false&guest=true.

25.NationalMedicalGuidelines.http://epi.vgregion.se/upload/L%c3%a4kemedel/hj%c3%a4rta%20k%c

3%a4rl/RMR_Hj%c3%a4rtsvikt_maj%202014_ny.pdf.

26. Packer M. Proposal for a new clinical end point to evaluate the efficacy of drugs and devices in the

treatment of chronic heart failure. Journal of cardiac failure 2001;7(2):176-82.

27. Bandura A. The anatomy of stages of change. American Journal of Health promotion : AJHP

1997;12(1):8-10.

28. Brouwer W, Rutten F, Koopmanschap M. Costing in economic evalutations. In: Drummond M,

McGuire A, eds. Economic Evaluation in Health Care – Merging Theory with Practice:

Oxford: Oxford University Press; 2001:68-93.

29. Dolan P, Gudex C, Kind P, et al. A social tariff for EuroQol: results from a UK general population

survey: Centre for Health Economics University of York, UK 1995.

30. Burstrom K, Sun S, Gerdtham UG, et al. Swedish experience-based value sets for EQ-5D health

states. Qual Life Res 2014;23(2):431-42.

31. Fors A, Taft C, Ulin K, et al. Person-centred care improves self-efficacy to control symptoms after

acute coronary syndrome: a randomized controlled trial. Eur J Cardiovasc Nurs

2016;15(2):186-94.

32. Fors A, Gyllensten H, Swedberg K, et al. Effectiveness of person-centred care after acute coronary

syndrome in relation to educational level: Subgroup analysis of a two-armed randomised

controlled trial. Int J Cardiol 2016;221:957-62.

33. Wolf A, Fors A, Ulin K, et al. An eHealth Diary and Symptom-Tracking Tool Combined With

Person-Centered Care for Improving Self-Efficacy After a Diagnosis of Acute Coronary

Syndrome: A Substudy of a Randomized Controlled Trial. Journal of medical Internet

research 2016;18(2):e40.


Personcentrerad vård i hemmet: att växla till effektivare preventiv vård vid långvarig sjukdom, from FoU i Västra Götalandsregionen
http://www.researchweb.org/is/html/vgr/project/237711