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André, Malin
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Publications (10 of 26) Show all publications
Strandberg, E. L., Brorsson, A., André, M., Gröndal, H., Molstad, S. & Hedin, K. (2016). Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden. BMC Family Practice, 17(78)
Open this publication in new window or tab >>Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden
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2016 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, no 78Article in journal (Refereed) Published
Abstract [en]

Background: Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care. Methods: Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners audit registrations. Qualitative data were collected through observations and semi-structured interviews. Results: From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioners diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual. Conclusions: Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2016
Keywords
Mixed methods design; Antibiotic prescribing; Guidelines; Implementation; Primary care
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-130376 (URN)10.1186/s12875-016-0494-z (DOI)000379800700003 ()27430895 (PubMedID)
Note

Funding Agencies|Public Health Agency of Sweden

Available from: 2016-08-15 Created: 2016-08-05 Last updated: 2017-11-28Bibliographically approved
André, M., Grondal, H., Strandberg, E.-L., Brorsson, A. & Hedin, K. (2016). Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat. BMC Family Practice, 17(56)
Open this publication in new window or tab >>Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat
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2016 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, no 56Article in journal (Refereed) Published
Abstract [en]

Background: Uncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines. Methods: An interview study was conducted among a strategic sample of 25 general practitioners (GPs). Results: All GPs mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, "Adherence to guidelines", and three were idiosyncratic: "Clinical picture and C-reactive protein (CRP)", "Expanded control", and "Unstructured". The residual uncertainty differed for the different strategies: in the strategy "Adherence to guidelines" and " Clinical picture and CRP" uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy " Expanded control" uncertainty was balanced based on expanded control; and in the strategy "Unstructured" uncertainty prevailed in spite of redundant examination and anamnesis. Conclusion: The majority of the GPs avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPs did not manage to cope with uncertainty or had to put in excessive work to control uncertainty.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2016
Keywords
Uncertainty; General practitioners; Sore throat; Guideline; C-reactive protein; Qualitative research
National Category
Social and Clinical Pharmacy
Identifiers
urn:nbn:se:liu:diva-129157 (URN)10.1186/s12875-016-0452-9 (DOI)000375989200001 ()27188438 (PubMedID)
Note

Funding Agencies|Kronoberg County Council; South Swedish Regional Council; University of Uppsala, Sweden

Available from: 2016-06-13 Created: 2016-06-13 Last updated: 2018-01-10
Grondal, H., Hedin, K., Lena Strandberg, E., André, M. & Brorsson, A. (2015). Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study. BMC Family Practice, 16(81)
Open this publication in new window or tab >>Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study
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2015 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 16, no 81Article in journal (Refereed) Published
Abstract [en]

Background: Excessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2-4 Centor criteria present and antibiotics were recommended if the test was positive. C-reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies. Methods: From a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used. Results: The use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection. Conclusions: Inappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.

Place, publisher, year, edition, pages
BioMed Central, 2015
Keywords
Near-patient tests; Sore throat; Guidelines; Decision-making; Qualitative interview study
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-120273 (URN)10.1186/s12875-015-0285-y (DOI)000357305200001 ()26141740 (PubMedID)
Available from: 2015-07-24 Created: 2015-07-24 Last updated: 2017-12-04
Hedin, K., Lena Strandberg, E., Grondal, H., Brorsson, A., Thulesius, H. & André, M. (2014). Management of patients with sore throats in relation to guidelines: An interview study in Sweden. Scandinavian Journal of Primary Health Care, 32(4), 193-199
Open this publication in new window or tab >>Management of patients with sore throats in relation to guidelines: An interview study in Sweden
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2014 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 32, no 4, p. 193-199Article in journal (Refereed) Published
Abstract [en]

Objective. To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews. Design. Qualitative content analysis was used to analyse semi-structured interviews. Setting. Swedish primary care. Subjects. A strategic sample of 25 GPs. Main outcome measures. Perceived management of sore throat patients. Results. It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs. Conclusion. This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.

Place, publisher, year, edition, pages
Informa Healthcare, 2014
Keywords
General practice; general practitioners; guidelines; qualitative research; sore throat; Sweden
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-113176 (URN)10.3109/02813432.2014.972046 (DOI)000346108700008 ()25363143 (PubMedID)
Note

Funding Agencies|Kronoberg County Council; South Swedish Regional Council; University of Uppsala, Sweden

Available from: 2015-01-14 Created: 2015-01-12 Last updated: 2017-12-05
André, M., Billstedt, E., Bengtsson, C., Hallstrom, T., Lissner, L., Skoog, I., . . . Bjorkelund, C. (2014). Personality in women and associations with mortality: a 40-year follow-up in the Population Study of Women in Gothenburg. BMC Women's Health, 14(61)
Open this publication in new window or tab >>Personality in women and associations with mortality: a 40-year follow-up in the Population Study of Women in Gothenburg
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2014 (English)In: BMC Women's Health, ISSN 1472-6874, E-ISSN 1472-6874, Vol. 14, no 61Article in journal (Refereed) Published
Abstract [en]

Background: The question of whether personality traits influence health has long been a focus for research and discussion. Therefore, this study was undertaken to examine possible associations between personality traits and mortality in women. Methods: A population-based sample of women aged 38, 46, 50 and 54 years at initial examination in 1968-69 was followed over the course of 40 years. At baseline, 589 women completed the Cesarec-Marke Personality Schedule (the Swedish version of the Edwards Personal Preference Schedule) and the Eysenck Personality Inventory. Associations between personality traits and mortality were tested using Cox proportional hazards models. Results: No linear associations between personality traits or factor indices and mortality were found. When comparing the lowest (Q1) and highest quartile (Q4) against the two middle quartiles (Q2 + Q3), the personality trait Succorance Q1 versus Q2 + Q3 showed hazard ratio (HR) = 1.37 (confidence interval (CI) = 1.08-1.74), and for the factor index Aggressive non-conformance, both the lowest and highest quartiles had a significantly higher risk of death compared to Q2 + Q3: for Q1 HR = 1.32 (CI = 1.03-1.68) and for Q4 HR = 1.36 (CI = 1.06-1.77). Neither Neuroticism nor Extraversion predicted total mortality. Conclusions: Personality traits did not influence long term mortality in this population sample of women followed for 40 years from mid- to late life. One explanation may be that personality in women becomes more circumscribed due to the social constraints generated by the role of women in society.

Place, publisher, year, edition, pages
BioMed Central, 2014
Keywords
Personality traits; Secular trends; Population-based cohort; Women; Longevity
National Category
Health Sciences Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-107853 (URN)10.1186/1472-6874-14-61 (DOI)000336183700001 ()
Available from: 2014-06-23 Created: 2014-06-23 Last updated: 2017-12-05
Andre, M. & Lofvander, M. (2013). A study of primary care physicians rating their immigrant patients pain intensity. European Journal of Pain, 17(1), 132-139
Open this publication in new window or tab >>A study of primary care physicians rating their immigrant patients pain intensity
2013 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 17, no 1, p. 132-139Article in journal (Refereed) Published
Abstract [en]

Background Few studies focus on how physicians evaluate pain in foreign-born patients with varying cultural backgrounds. This study aimed to compare pain ratings [visual analogue scale (VAS) 0100] done by Swedish primary care physicians and their patients, and to analyse which factors predicted physicians higher ratings of pain in patients aged 1845 years with long-standing disabling back pain. Methods The two physicians jointly carried out the somatic and psychiatric diagnostic evaluations and alternated as consulting doctor or observer. One-third of the consultations were interpreted. Towards the end of the consultations, the patients rated their pain intensity right now (patients VAS). After the patient had left, the two physicians independently rated how much pain they thought the patient had, without looking at the patients VAS score. The mean of the two doctors VAS values (physicians VAS) for each patient was used in the logistic regression calculations of odds ratios (OR) in main effect models for physicians VAS above median (md) with patients sex, education, origin, depression, psychosocial stress and pain sites as explanatory variables. Results Physicians VAS values were significantly lower (md 15) than patients VAS (md 66; women md 73, men md 52). The ratings showed no significant association with whether the physician was acting as consultant or observer. The higher physician VAS was only predicted by findings of multiple pain sites. Conclusions Physicians appear to overlook psychological and emotional aspects when rating the pain of patients from other cultural backgrounds. This finding highlights a potential problem in multicultural care settings.

Place, publisher, year, edition, pages
Elsevier, 2013
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-90767 (URN)10.1002/j.1532-2149.2012.00162.x (DOI)000312300800016 ()
Note

Funding Agencies|Center for Clinical Research Dalarna - Uppsala University, Sweden||Center for Clincial Research Vastmanland - Uppsala University, Sweden||

Available from: 2013-04-05 Created: 2013-04-05 Last updated: 2017-12-06
Arvidsson, E., André, M., Borgquist, L., Mårtensson, J. & Carlsson, P. (2013). Day-to-day Rationing of Limited Resources in Swedish routine Primary Care: an interview study.
Open this publication in new window or tab >>Day-to-day Rationing of Limited Resources in Swedish routine Primary Care: an interview study
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2013 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Rationing is a reality in all health care, but little is known about day-to-day rationing in routine primary health care (PHC). This study aims to explore strategies to handle limited of resources in Swedish routine primary care.

Methods: Data were compiled from 62 interviews with healthcare professionals (general practitioners, nurses, physiotherapists, and managers at primary care centres). A qualitative research method was applied in the analysis.

Results: The interviewed staff described perceptions of a general public with high expectations on PHC in combination with a lack of resources. Strategies to cope with scarce resources were avoiding rationing, ad hoc rationing, or planned rationing. Rationing was largely implicit and not based on ethical principles or other defined criteria. Trying to avoid rationing resulted in unintended rationing. Ad hoc rationing had undesired consequences, e.g. inadequate continuity of care and displacing certain patient groups, especially the chronically ill and the elderly. The staff expressed a need for support and for applicable guidelines, and called for policy statements based on priority decisions to help manage the situation.

Conclusions: The interviews suggested a need to improve the transparency of priority setting procedures in PHC, although the nature of the PHC setting presents special challenges. Improving transparency could, in turn, improve equity and the efficient use of resources in PHC.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-88085 (URN)
Available from: 2013-01-29 Created: 2013-01-29 Last updated: 2013-01-29Bibliographically approved
André, M., Andén, A., Borgquist, L. & Rudebeck, C. E. (2012). GPs decision-making - perceiving the patient as a person or a disease. BMC Family Practice, 13(38)
Open this publication in new window or tab >>GPs decision-making - perceiving the patient as a person or a disease
2012 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, no 38Article in journal (Refereed) Published
Abstract [en]

Background: The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work. less thanbrgreater than less thanbrgreater thanMethods: A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients. less thanbrgreater than less thanbrgreater thanResults: 68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person. less thanbrgreater than less thanbrgreater thanConclusions: The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.

Place, publisher, year, edition, pages
BioMed Central, 2012
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82080 (URN)10.1186/1471-2296-13-38 (DOI)000307939500001 ()
Note

Funding Agencies|Center for Clinical Research in Dalarna, Sweden||County Council of Norrbotten, Sweden||

Available from: 2012-09-28 Created: 2012-09-28 Last updated: 2017-12-07
Arvidsson, E., André, M., Borgquist, L. & Carlsson, P. (2010). Priority setting in primary health care - dilemmas and opportunities: a focus group study. BMC FAMILY PRACTICE, 11(71)
Open this publication in new window or tab >>Priority setting in primary health care - dilemmas and opportunities: a focus group study
2010 (English)In: BMC FAMILY PRACTICE, ISSN 1471-2296, Vol. 11, no 71Article in journal (Refereed) Published
Abstract [en]

Background: Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria. Methods: Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work. Results: The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patients), 2) timeframe (now or later), and 3) evidence level (group or individual). Conclusions: The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.

Place, publisher, year, edition, pages
BioMed Central, 2010
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-61207 (URN)10.1186/1471-2296-11-71 (DOI)000283116400001 ()
Note
Original Publication: Eva Arvidsson, Malin André, Lars Borgquist and Per Carlsson, Priority setting in primary health care - dilemmas and opportunities: a focus group study, 2010, BMC FAMILY PRACTICE, (11), 71. http://dx.doi.org/10.1186/1471-2296-11-71 Licensee: BioMed Central http://www.biomedcentral.com/ Available from: 2010-11-05 Created: 2010-11-05 Last updated: 2013-01-29
Andén, A., André, M. & Rudebeck, C.-E. (2010). What happened? GPs' perceptions of consultation outcomes and a comparison with the experiences of their patients. European Journal of General Practice, 16(2), 80-84
Open this publication in new window or tab >>What happened? GPs' perceptions of consultation outcomes and a comparison with the experiences of their patients
2010 (English)In: European Journal of General Practice, ISSN 1381-4788, E-ISSN 1751-1402, Vol. 16, no 2, p. 80-84Article in journal (Other academic) Published
Abstract [en]

Objective: To investigate GPs’ perceptions of consultation outcomes and to investigate the associations between these and outcomes perceived by the patients. Design: 25 GPs and 10 patients for each GP filled in a questionnaire about the outcome of the same consultation. The questions in the questionnaires were formulated from concepts found in preceding qualitative studies. Their answers were analysed and compared. Setting: GPs and patients from 16 group practices in Norrbotten, Sweden. Results: The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better. The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70%. Their affirmative concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief.

Conclusion: The GPs’ were lacking in their ability to assess the patients’ increased understanding and the concordance between their own and the patients’ expectation of cure/symptom relief was low.

Keywords
Family Practice, Outcome, Outcome Assessment, Consultation, General Practitioner
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-18480 (URN)10.3109/13814780903528587 (DOI)20100110 (PubMedID)
Available from: 2009-05-28 Created: 2009-05-28 Last updated: 2017-12-13Bibliographically approved
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