2012

Annual ReportCenter for Primary Health Care Research

CPF

AKC Academic Knowledge Center (pri-mary health care centre with a research coach)

ALF Agreement for Medical Education and Research

CPF Center for Primary Health Care Research

CRC Clinical Research CentreFAS Swedish Council for Working Life

and Social ResearchNIH National Institutes of HealthPartners Region Skåne and Lund UniversityWHO World Health OrganizationVårdcentral Primary health care center

Abbreviations and Definitions

World Class Primary Care Research

CPFContents

Scientific Output

Story of the Year

Message from the Director 4

PageAbbreviations and Definitions 2

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Interview 18

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Message from the Director

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What you are now holding in your hand is the 2012 annual report on the Center for Primary Health Care Research (CPF). The establishment of the CPF in Oc-tober 2008 is consistent with the fact that primary care today takes care of most

development in medical research, in which the mechanisms and disease processes of our most common diseases are being mapped. We are only seeing the beginning of more personalised medicine, where molecular diagnostics allows detection and treatment of disease much earlier than before. At the CPF, we work with world-leading researchers in areas such as cardiovascular diseases, psychiatry, and cancer in order that primary care patients will benefit from this new knowledge.

Knowledge about human molecular biology needs to be integrated with clini-cal research and applied in order for patients to benefit. An example of this is an innovative study into how mindfulness training can help patients with depression and anxiety in primary care, and how it can affect biomarkers in the blood, which the CPF ran at 16 health care units. The new challenges in primary care require successful research environments such as the CPF. Its strategic location at the CRC in Malmö stimulates collaboration between the CPF and colleagues in other special-ties.

An example of this is our unique research laboratory at the Wallenberg Labora-tory - the first in Scandinavia with primary care as its focus. There we study the molecular mechanisms of chronic diseases by analysing samples from primary care patients. The work our talented employees have been engaged in resulted in 143 sci-entific articles during 2012 in international scientific journals Including The Lancet Oncology, American Journal of Epidemiology, Archives of General Psychiatry, and Journal of the National Cancer Institute.

patients with chronic diseases. In the mid-1990s, the treatment of the vast majority of patients with heart disease, diabetes, mental disorders, and inflamma-tory diseases was transferred to public and private primary health care units. As there is a great need for continued research on these diseases, it is in patients’ best interests to bring together research and primary care. For development to occur, patient consultations and research need to be close to one another.

The setting up of the CPF and its local nodes - Academic Knowledge Centers (AKCs) - created a modern, cohesive patient-focused environment for knowledge development and implementation in public and private primary health care in Skåne. This is especially important in this time of rapid

Jan Sundquist Professor and family physician

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World Class Primary Care Research

Why do we need a centre devoted to primary health care research?The decision to establish a research centre for primary care in Skåne was taken in 2007 on the recommendation of an international investigation led by Professor Karen Luker of the University of Manchester, UK. The overall objective of the investigation was to:

”serve as the basis for the partners’ future strategic undertakings and actions to create a competitive research environment in primary care” (from the Partners’ cooperation agreement)

Based on these recommendations, Region Skåne and Lund University decided to establish the Center for Primary Health Care Research (CPF) in Skåne. Its operations are producer-neutral, that is to say it works with both the public and private health care sectors.

The DirectorJan Sundquist, a professor of family medicine, had been working as the Director of the Centre for Family Medicine (CeFAM) at Karolinska Institutet since 2000 when he was appointed director of the CPF in 2008. He began work at the CPF on October 15, 2008 having previously worked in Skåne, both as a family physician/Director at Norra Fäladen Primary Health Care Centre in Lund and as a researcher at Lund University. Jan continues to work clinically as a family physician at Sorgenfri Primary Health Care Centre in Malmö. He has a large international research network covering areas such as family medicine, psychiatry, addiction, disease prevention, and cancer. Since his appointment, Jan has recruited all current employees at the CPF and with the help of these employees has created a number of networks in public and private primary health care, such as the AKC network and a network of 16 health care units mainly employing psychologists and counsellors (see below).

Jan’s duty as Director is to lead the CPF in its efforts to conduct world-lead-ing research based on issues that are relevant to primary care, with a focus on the most common public health problems. For this to be possible requires strong clinical links, with good primary care networks on the ground, and balanced finances.

The BoardThe CPF is managed by a board of six members. Region Skåne and Lund University each appoint three members, each of whom serves on the Board for three years (with the possibility of re-election). One of each partner’s appointed board members should operate outside Region Skåne and Lund

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University. The Partners’ cooperation agreement stipulates that the majority of the Board’s members must be scientifically trained and clinically active in primary care. Professor Kristian Riesbeck resigned as Assistant Dean in Sep-tember 2012 and at the same time ended his membership of the CPF’s Board. On January 1, 2013, he was succeeded by Professor Lars B. Dahlin, the new Assistant Dean of the Faculty of Medicine, Lund University.

The CPF’s Board during the first year of its 2012–2014 term comprised the following individuals:

• KristinaÅkesson, Professor, Head of Department, Department of Clini-cal Sciences in Malmö, Lund University

• LarsHjalmarLindholm, Senior Professor, Umeå University• KristianRiesbeck, Professor and Assistant Dean, Lund University (not in

photo)• UlfStrömberg, Professor, Region Halland• BennyStåhlberg, Head of Primary Health Care, Primärvården Skåne• PatrikMidlöv, (Chairman of the Board in 2012), Lecturer at Lund Uni-

versity, AKC Coordinator, EslövAffiliated member• StefanBremberg, MD, medical expert at CapioFöredragande• JanSundquist, Professor, Director of the CPF

The Board 2012–14. From left to right: Stefan Bremberg, Benny Ståhlberg, Ulf Strömberg, Kristina Åkesson, Patrik Midlöv, Jan Sundquist and Lars Hjalmar Lindholm. Photo: Kennet Ruona

World Class Primary Care Research

The Board has, among other things, decided that research at the CPF shall focus on two long-term programme areas: cardiovascular diseases and psychiatric disorders. In 2012, the Board discussed, among other things, the Family Medicine Quality Register (AKR), international collaboration, and the training of resident physicians.

EmployeesEmployees of different professions, employed by either or both of the organi-sation’s two partners, work at the CPF. Most of the researchers working at the CPF are clinically active in primary care.

We also have biomedical researchers at the CPF. In 2011, we established the first experimental family medicine laboratory in Scandinavia, to which we recruited talented young researchers from Aarhus University and Karolin-ska Institutet, as well as a biomedical scientist. In 2012, several experimental analyses were conducted in the lab, and the first results of these analyses will soon be published. The setting up of the lab means that researchers at the CPF now drive translational research, i.e. research that bridges basic and clinical research. Our experimental lab addresses questions arising in clin-ics and studies molecular mechanisms behind common diseases, including cardiovascular diseases and psychiatric disorders (the two-long programme areas at the CPF). Learn more about this on page 10.

In addition to the employees who are based at the CPF, the CPF also bears responsibility for a network of 9 AKC coordinators, who work clinically at AKCs and simultaneously support and promote research at the local level in primary care. All AKC coordinators have PhDs and receive 15 percent of their salaries from the CPF to perform their role.

The CPF has also, since 2010, been responsible for the family physician consulting organisation Allmänläkarkonsultorganisationen (AKO) in Skåne, which offers primary care a means of collaborating in an organised way with hospitals and private specialists. The AKO network consists of four district medical officers, who are responsible for around fifty GP consultants.

The CPF is affiliated to the Learning Centre for Child Health Care (Barn-hälsovård, BHV), where paediatric consultant Marie Kohler is the director. BHV employs health care developers in the form of paediatricians, child psychiatrists, district nurses, paediatric nurses, and psychologists, as well as an administrator. It has been commissioned by Region Skåne to be a produc-er-neutral resource for paediatric health care in Skåne. Its mandate includes, among other things, shaping Skåne’s quality focus for child care, having a general role in quality development, providing advice, developing and ana-lysing methods for health monitoring, offering continuing training, being a consultative body, and, in collaboration with the “health choices” office, working to develop and maintain high-quality paediatric care and to thereby promote good and equitable health in all children in Skåne.

Overall, the CPF is a transnational team composed of employees with many different skills that complement each other. Their interaction cre-ates a breeding ground for ground-breaking research that links clinics and academia.

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World Class Primary Care Research

MissionOur mission is to conduct family medicine research that is broad but at the same time examines in depth key strategic research areas relevant to major diseases. Ultimately, it’s about providing a scientific basis for better health and well-being among primary care patients. The CPF uses primary care as a foundation to perform family medicine research on the international front-line. We place great value in the active exchange of knowledge between basic research, epidemiology, and patient-oriented research.

Our research involves important interactions with primary care staff to take advantage of their experience, ideas, and knowledge. This strategy creates a breadth of research that stimulates staff to carry out large or small projects in their workplaces. Our major international partnerships with world-leading researchers generate new knowledge that will benefit the CPF, Lund University, and Region Skåne, thereby creating favourable conditions for cooperation with other disciplines and the development of research ac-tivities in Skåne.

Our research thus has a large breadth (see page 20) that reflects family medicine’s areas of responsibility. While we work broadly, we place a strong focus on specific research areas of special importance to primary care’s pa-tients and activities:

• Cardiovascular diseases: heritability, lifestyle, migration, and the envi-ronment

• Mental health: socioeconomics, migration, family environment, and residential area

• Cancer: biomarkers, epidemiology, and prediction models in primary care

• Molecular biological mechanisms and new potentially useful biomarkers for the diagnosis and treatment of chronic diseases

Aims for 2010–2012 Below is a summary of the vision, objectives and plans for clinical research presented in the business plan for 2010-2012.

• Establishment of a new Family Medicine Quality Register (AKR), which will contain anonymised patient data from health centres in southern Sweden. Pilot study completed. Implementation study starting now will be ready to be reported in June 2013.

• Creation of a website with links from the Region Skåne and Lund Uni-versity websites. The website www.cpf.se will serve as an interactive fo-rum for researchers, health care providers, and the public. Largely imple-mented. Work on the interactive platform remains to be completed.

• Recruitment of another professor and two lecturers in family medicine. Achieved.

• Establishment of an AKC in northwest Skåne. Achieved and AKC coordi-nator appointed.

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• To support, in collaboration with the AKC coordinators, the initiation of clinical studies in primary care in Skåne. Several clinical studies have been initiated or completed. This work continues as a permanent goal (see below).

• To make the CPF known on the ground with the goal that all clinics be aware of our existence. This work continues as a permanent goal (see below).

• To build a web-based communication platform (“Learning Lab”). In progress.

• The CPF shall have an ongoing seminar series covering topics such as research and research methods, statistics, and scientific writing for all

Introduction to research seminar for primary health care personnel. Photo: Bertil Kjellberg

CPF employees and primary care personnel with an interest in research. The CPF holds weekly seminars in hands-on research that are open to all staff in primary care. At these seminars, Jan Sundquist, Bengt Zöller, and Kristina Sundquist act as a sounding board for novice researchers who wish to ask questions and discuss project ideas. Statisticians offer advice. AKC coordinators run monthly seminars in clinics with a similar approach. We also have internal seminars every week to develop our employees’ skills in basic research and statistics/epidemiology. Family medicine seminars, where employees/PhD students present their research, are held on a regular basis.

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• To publish scientific articles relating to our research areas. In 2012, 143 articles were published or accepted for publication by international scien-tific journals.

• To apply for and obtain external research funding. Four researchers at the CPF bring in about 10 million SEK per year in external funding, and six CPF researchers bring in 6.5 million SEK in ALF funding. More and more research leaders at the CPF now receive funds in the form of research coun-cil grants and/or ALF funding.

• To present results at national and international conferences. Ongoing. Please see below for examples.

• The CPF’s employees shall jointly develop a balanced scorecard. Partially implemented, but the scorecard undergoes continual development in order to achieve excellence.

The molecular laboratory in family medicineIn 2011, the CPF started a research laboratory to study the molecular and physiological mechanisms by which genetic, epigenetic, and environmental factors influence diseases treated in primary care.

The laboratory is equipped with modern technology, including a Bio-Rad CFX384 real-time PCR machine, a Bio-Plex Suspension Array System, and an epMotion 5070 pipetting robot.

In January 2012, work started at 16 primary health care centres to recruit patients to a study on mindfulness. Some of the samples taken from the pa-tients in this study have already been analysed, while others are stored in the laboratory in our biobank (BD51) pending analysis. An important aspect of sample handling was to divide each sample into smaller aliquots so that the samples do not need to be thawed and refrozen as many times in the future. The need for samples to be frozen within 8 hours of their collection necessi-tated good logistics of transport, which covered a large part of Skåne. Sam-ples were collected throughout the spring, and a total of approximately 200 patients were included in the study, in which treatment with mindfulness was evaluated in patients with depression and anxiety.

Louise Bennett, PhD, a GP at Fågelbacken Primary Care Centre and a researcher at the CPF, is running a project studying the associations between diabetes, lifestyle, and ethnicity. In a pilot study, inflammatory marker and growth factor levels in 172 samples were analysed using the Bio-Plex tech-nique. Furthermore, we extracted miRNA from the same 172 samples and analysed different miRNAs by qPCR. We also used existing DNA samples from the study and analysed telomere length by PCR. Before analysis of patient samples could begin, optimisation of our various techniques and instruments was required.

Tommy Jönsson, PhD, a GP at Måsen Primary Care Centre, has studied how the Stone Age diet, compared with a regular diet, affects diabetes and diabetes-related diseases. He has complemented his earlier results with Western blot analyses. He has also examined patient samples for a variety of diabetes markers using the Bio-Plex technique.

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In collaboration with Professor Peter Svensson, we examined samples from the Malmö Thrombosis Study (MATS). We analysed various growth factors in 172 samples, and our hope is to use biomarkers to predict recurrence of venous thromboembolism (VTE).

Professor Björn Dahlbäck, with whose research group we share a floor in the Wallenberg Laboratory, has been very positive about working with us. In a first step in the spring, he gave us unique antibodies that are needed for the analysis of apolipoprotein M (apoM), as well ELISA protocols. ApoM plays significant roles in cholesterol transport in the human body and in the onset of various diseases.

In the autumn of 2012, we began the process of extracting miRNA from the 400 samples from the mindfulness study. During 2013, we will gener-ate cDNA and select various interesting miRNAs for analysis. In November 2012, we conducted an initial pilot study to analyse inflammatory mark-ers and growth factors in the samples. We subsequently selected additional markers and, just before Christmas, completed the first round of analysis of this exciting material.

Data management as a resource for researchers and cliniciansData management is important for the clinical and medical epidemiological research conducted by the CPF. In 2012, two data managers, two part-time SAS programmers, and a GIS engineer at the CPF managed the maintenance of researchers’ data and were responsible for the CPF’s researchers having access to accurate data for their analyses.

The databases are located on servers to which only database specialists and statisticians have access. Database specialists extract completely anonymised datasets for researchers and deposit them on a special server which the re-searchers must log on to. The server has all the necessary statistical programs and all the analyses are conducted on it. In 2012, a consultant from Pointer, Björn Ugglin, transformed registry data from the current SAS format to a format that allows storage on a Microsoft SQL Server. This simplifies the management of data.

The workflow for epidemiological register-based research usually starts with a working hypothesis being assessed by the Regional Ethical Review Board. When the Board reaches its decision, the researcher requests a quote for new data or orders data from a data manager. When the data is stored on the server (according to Data Inspection Board rules), it is subjected to quality review prior to subsequent hypothesis testing. Biostatisticians too analyse data. Researchers at the CPF subsequently meet to discuss the results and then write articles, which go on to be reviewed by scientific journals and eventually published.Clinical data from different studies in primary care are also stored. Since 2011, the CPF has had an online survey tool that uses the SQL Server to store the results of digital questionnaires. At the CPF there is also a web server, which, through secure transmission, allows survey responses to be collected

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via the Internet and from iPads. The data management group also has the task of taking care of data from completed projects, as well as the storage of additional new data records. There are a total of five servers at the CPF: three SAS servers (BIKT-JS, CPF-TS2, and CPF-TS3) and two SQL servers (CPF-MSSQL2 and Inquisite-SQL). Inquisite-SQL has two components: a database server and a web server.

Performance managementDuring 2012, CPF employees continued to work together on a balanced scorecard with a focus on developing the five perspectives for the perform-ance management of activities that were drawn up in 2010 and 2011. The purpose of the balanced scorecard is that all employees work towards a common vision based on our strategic objectives, which can be achieved via defined success factors. In 2012 we will continue to define success factors and measures for each perspective.

• Thevisiondescribes what we want to achieve: To perform ground-breaking clinical research to provide primary care of the highest quality and thus achieve a healthier population

• Thestrategicobjectivesdescribe where we want to be with respect to each perspective, assuming we achieve our vision.

• Thesuccessfactorsare what it takes to achieve the strategic objectives and what conditions must be met in order to achieve these objectives.

Thefiveperspectivesreflect our different areas of interest:

• Customer perspective

• Learning and growth perspective

• Employee perspective

• Process perspective

• Financial perspective

Story of the Year

Customer Processes

Fi

nanc

ial CPF

Employee Learning and growthOur vision:

To perform groundbreaking clinical research to provide pri-mary care of the highest quality

and thus achieve a healthier population.

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The customer perspective describes the customer interests to be met and how they will be met. It is therefore towards the customer perspective that the CPF’s internal processes, learning/growth, and development are directed. The CPF’s customer perspective describes a research centre for primary health care based on the interests of Region Skåne, Lund University, and external funding bodies.

Customer perspective: Region SkåneStrategic objective: The CPF stimulates primary care in Skåne to conduct clini-cally relevant primary care research.

The CPF supports both public and private primary health care units in Skåne, thereby helping to increase scientific expertise in primary care.

Academic Knowledge Centers – AKCsIn 2012, the CPF continued its efforts to encourage greater dialogue between primary care and academia. In this work, the regional network of Academic Knowledge Centers (AKCs) represents a very important link that helps to create new and creative connections between primary care and academia.

The AKCs are health care units engaged in research in partnership with the CPF. At each AKC, an AKC coordinator (research coach with a PhD) serves as a mentor and sounding board for scientific matters. During the year, 11 AKCs across Skåne were linked to us.

The AKC network works to engage primary care personnel across Skåne who are interested in research. All primary health care centres in Skåne are linked

Academic Knowledge Centers and primary health care centers in Skåne. Map: Klas Cederin

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to a specific AKC, where the AKC coordinator holds group meetings or open days a few times per semester. Research and development should be a natu-ral and integral part of primary care – it is there the ideas are!

AKCcoordinatorsin2012

• Louise Bennet (until June) Fågelbacken Primary Health Care Centre, Malmö

• Stefan Bremberg Capio Citykliniken, Helsingborg

• Annika Brorsson Sorgenfri Primary Health Care Centre, Malmö

• Susanna Calling Bokskogen Primary Health Care Centre, Bara

• Rickard Ekesbo Näsby Primary Health Care Centre, Kristianstad

• Ann-Christine Hallberg Fosietorp Primary Health Care Centre, Malmö

• Åsa Lilja Centrum Primary Health Care Centre, Landskrona

• Staffan Lindeberg Sankt Lars Primary Health Care Centre, Lund

• Patrik Midlöv Tåbelund Primary Health Care Centre, Eslöv

• Emelie Stenman CPF-based AKC Coordinator

• Ole Torffvit (t.o.m. juni) Capio Citykliniken, Kristianstad

• Bengt Zöller Ystad Primary Health Care Centre, Ystad

Activities in 2012, Region SkåneAKC: changes during the yearThe AKC coordinators’ main task is to be the CPF’s research coaches/sound-ing boards in primary care. All of the coordinators devote 15% of their working time to AKC-related activities, above all group meetings/open days, the CPF’s course in research methods for resident physicians, and individual supervision of resident physicians (in their obligatory scientific projects) and other health care personnel with an interest in research. Their own research is, to a large extent, funded externally, for example by regional research fund-ing, and in some cases by the CPF.

AKC meetingsAKC coordinators took part in nine AKC meetings in 2012. These meet-ings combined discussions of operational matters with seminars on writing grant applications, statistical methods, and current research, among other things. In addition to the regular AKC meetings, the CPF’s statisticians held a half-day seminar for AKC coordinators on hypothesis testing and statisti-cal power. The main aim of educational activities within the AKC network is that we become even better at guiding employees in primary care who are interested in research.

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Supervision and research in the AKC networkThe CPF and the AKC network offer all resident physicians in Skåne (~200) a five-day course in research methods (which is held 3-4 times per year) and group supervision in the form of special seminars for novice research-ers. They also have the option of taking a longer course in research methods (1 day a week for three semesters). Furthermore, AKC coordinators super-vised ~35 resident physicians individually during 2012. In addition, 22 PhD students, other employees in primary care, and students received individual supervision from the AKC coordinators.

The AKC coordinators conduct research projects in different areas of family medicine, e.g. cardiovascular diseases, mental illness, medicines and the elderly, and lifestyle habits. Results from these studies were presented in around 40 scientific articles and other publications in 2012.

Research coordinators: a tighter network – more effective communicationDuring the autumn of 2012, the CPF introduced a new concept in primary care: the ‘research coordinator’. A research coordinator is a member of staff at a primary health care centre who assists the centre’s head with research and development questions and has knowledge about planned and ongoing projects at the health care centre. The coordinator does not necessarily have formal academic qualifications (unlike AKC coordinators), but serves as a channel for communication between the CPF/AKCs and his/her own clinic and knows where to turn to for help with matters such as R&D, resident physicians’ scientific projects, and research funding. The CPF trains coordi-nators once a semester through half-day seminars that generate goal-related compensation.

In 2012, 11 interested research coordinators enrolled and participated in the first training day in October. The hope is that every primary health care centre will eventually have a research coordinator.

Resident physicians: Foundation course in research methods and introduction to research seminarsThe scientific component of resident physicians’ education gives us the op-portunity to engage and support doctors with an interest in research at the beginning of their careers and to spread an interest in research among the family physicians of the future.

Foundation course in research methodsFTo help resident physicians in their obligatory scientific project, the CPF runs a very popular introductory course in medical science and quality man-agement. The course comprises five days of education that caters for resident physicians from all specialties and the whole of Sweden. Participants receive introductions to, among other things, the philosophy of science, epidemiolo-gy, statistics, ethics, evidence-based medicine, and oral communication. The course comprises lectures, seminars, and group discussions, and culminates

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in examination of the participants’ own project plans. The course has been run in collaboration with Region Skåne and Institutet för professionell utveck-ling av läkare i Sverige (IPULS). It was held four times in 2012, with a total of 66 participants.

Introduction to research seminarsDuring 2012, the CPF offered resident physicians and other health profes-sionals in primary care the opportunity to try their hand at research on a part-time basis. They received support in planning and starting their own projects and were able to participate in special weekly introduction to re-search seminars with Professor Jan Sundquist, Docent Bengt Zöller, Profes-sor Kristina Sundquist, and statisticians. Several of the participants became so interested after this introduction to research that they chose to embark on a PhD. Introduction to research seminars will continue to be held in 2013.

Evaluation by the CPF of a newly opened diagnostics centre (Diagnostiskt Centrum) in KristianstadOn the initiative of Region Skåne and Regionalt Cancercentrum Syd, a di-agnostics centre (Diagnostiskt Centrum, DC) was established at Kristians-tad Hospital in the autumn of 2012. The aim is to detect cancer earlier, i.e. to shorten the time from initial symptoms to diagnosis of cancer, thereby improving the prognosis. The DC receives, from primary care, patients aged 18+ years who present with diffuse symptoms of serious illness which the doctor suspects may be cancer. Patients are referred to the DC, which initi-ates an investigation within three days. Besides cancer, a large proportion of referred patients are expected, after the investigation, to be diagnosed with other serious diseases, such as rheumatic or other autoimmune diseases. The CPF has been asked to evaluate the DC’s activities, work which began in the summer in the form of an application to the Regional Ethical Review Board. The first milestone will be a report in September 2013 that will form the basis for discussions on the shaping of the DC’s continuing operations.

We will also analyse the levels of new combinations of biomarkers – mo-lecular profiles – to bring new knowledge to primary care with the goal of primary care being able to identify cancer or autoimmune diseases at an early stage using a blood test. The experimental part of the evaluation fo-cuses on inflammatory markers (cytokines), epidermal growth factor (EGF) receptors, telomere length, and miRNA in patients diagnosed with cancer at the DC compared with patients who were not diagnosed with cancer. Results from the study will be disseminated through scientific publications.

Clinical projects in primary careMindfulness studyDuring 2012, and with the help of skilled employees at the CPF and staff on the ground, Jan Sundquist ran the project “Study of Mindfulness-based Group Treatment in Patients with Depression and Anxiety”.

The overall aim was to analyse whether simplified mindfulness-based stress reduction in groups is as effective as “standard treatment” at improving func-

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tioning and quality of life, preventing relapse, and reducing stress, psychiat-ric symptoms, and sick leave in patients with depression and anxiety.

The study placed great demands on coordination, e.g. logistics (blood collection/transportation, training of instructors, monitoring/support at the health care units, and data entry/quality control). In autumn 2011, we trained 31 members of staff from 16 health care units as mindfulness in-structors. The intervention began in January 2012 and ended in June. Collec-tion of data from the health care units was completed in the autumn. A total of 10-20 patients per health care unit took part in the study (223 patients in total). The project provided important knowledge and experience to the participating health care units.

Mindfulness instructors, who are psychologists, counsellors, and physi-cians, appreciated the skills they developed through this project. The project has created networks of health care units and different skills in primary health care in Skåne. The patients themselves expressed positive opinions on the mindfulness study:

For me it is important to exchange opinions and thoughts with others. I would not have gained the same understanding on my own.

It’s been good. Feels like I’ve learned to accept certain things that have hap-pened. I feel happier, have learned to accept myself.

The group treatment is very rewarding. You learn new things from each other every time.

Everyone has similar experiences and it’s nice not to feel alone and confused.

Network of health care units that participated in the mindfulness study. Map: Klas Cederin

Story of the Year

Interview

Yoga as a treatment in primary careMoa Wolff is a GP at Löddeköpinge Primary Health Care Centre. For over a year now she has been a PhD student at Lund University with the CPF’s Patrik Midlöv and Kris-tina Sundquist as her supervisors.

Moa studied medicine at Karolinska Institutet in Stock-holm, but then moved down to Skåne, where she did her junior doctor training in Ystad and her specialist training in Svedala and Malmö.

“My research concerns yoga as a form of treatment in primary care. My studies, both com-pleted and planned, focus on patients with high blood pressure and how they are affected by yoga, in terms of both blood pressure and quality of life.”

During the spring of 2011, just over 80 patients in Svedala were studied. As well as undergo-ing blood pressure measurements, they filled in a questionnaire on quality of life and lifestyle (WHO Quality of Life-BREF). After 12 weeks, the same procedure was repeated. Everything was compared with a control group.

“We compared two different yoga-based interventions”, says Moa. “Once a week during the entire intervention period, one group met a yoga instructor, who taught them an established method. The patients in this group also received CDs to enable them to practice at home for 30 minutes a day. Everything the participants did was recorded in a diary.”

Patients in the other group were taught, during a single 20 minute visit to the doctor, two yoga exercises to be performed for 15 minutes a day. This group too received CDs with instruc-tions and diaries. In addition, there was a control group that received standard treatment. The question was whether yoga could affect blood pressure and quality of life and, if so, which program was more effective: the one with an instructor or the one involving a single visit to the doctor?

“The results surprised us! Those who performed 15 minutes of yoga per day after visiting the doctor had a significant reduction in diastolic blood pressure compared to the control group. Quality of life was also improved in this intervention group.”

The results can perhaps be explained by the fact that the group that learned yoga from an in-structor performed exercises at home less frequently, possibly because the exercises were more physically demanding and time consuming. Blood pressure and quality of life were not altered in this group.

Moa has finished writing her first article and has started work on her second one. In addition,

Moa Wolff, GP, PhD student

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she is working on plans for studies three and four.“There have been a number of studies on yoga and blood pressure, but what we lack today are

primary care-based yoga studies and yoga-based treatment”, stresses Moa.Her interest in yoga began in 2009 when she attended a lecture by the founder of MediYoga

Sweden (the Swedish Institute for Medical Yoga).“He said that deep breathing through the left nostril lowers blood pressure! Is that really true? I

thought. As I was at that point looking for ideas for my final project, I ran a small pilot study and wrote about it and was pleasantly surprised.”

The patients who took part in the study were positive. There appears to be a demand for this type of treatment.

“In addition, it is fun to run one’s own projects”, says Moa. “With support and advice, of course, but one can plan the work oneself.”

Docent Patrik Midlöv is Moa’s main supervisor and Professor Kristina Sundquist her co-su-pervisor. Moa finances her research using funding from Södra Sjukvårdsregionen and from her supervisors.

“It is fun to do research in primary care”, emphasises Moa. “I have presented my research at a staff meeting and that was important!”

“Obstacles appear all the time: dealing with forms of different kinds, registers, ethical review board applications … messed up schedules! But that’s just the way it is!”

Moa expects to defend her thesis in 2015 or 2016. Then what?“Patient-centred research and intervention studies are what excite me most. But there is a great

deal of other exciting research at the CPF. Kristina Sundquist’s work on neighborhood environ-ments and health, for example.”

Is it your experience that the research environment in primary care has changed since the CPF was established?

“I believe that the CPF has influenced the research environment in primary care. When Jan Sundquist held an engaging lecture in Malmö during a resident physician day, he made research seem cool. I barely knew it existed before that! The CPF has given research in primary care a lift.”

Attending introduction to research seminars at the CPF and working on a resident physician project are, according to Moa, good ways of determining whether or not research is something for you.

“If you are a resident physician, you must take the opportunity to attend the CPF’s introduction to research seminars! If you are not a resident physician, you should get in touch with the CPF anyway!”

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Text: Bertil Kjellberg and Emelie Stenman Translation: Stephen Gilliver

Photo: Bertil KjellbergVideo: You can watch an interview with Moa on YouTube • http://youtu.be/tjUXcVLoH60

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Customerperspective:LundUniversityStrategicobjective:The CPF delivers world-leading research and research training.

The research at the CPF is innovative and at the absolute international forefront. Below we refer to some of the 143 articles that were published/ac-cepted for publication in highly ranked scientific journals.

Docent Bengt Zöller’s research on venous thromboembolic diseases, related diseases such as atherosclerosis and atrial fibrillation, and other diseases such as inflammatory diseases and cancer has yielded several new publications. In 2012 he was awarded new funding by the Swedish Heart-Lung Foundation. He combines his acclaimed ongoing research on venous thromboembolic diseases with clinical work at Limhamn Primary Health Care Centre. A unique project initiated in 2011 aims to characterise heredi-tary and acquired risk factors for VTE. The project aims to identify new mechanisms and new potentially useful biomarkers, and may thus have great instant clinical importance for primary care. An innovative study showed that individuals with an autoimmune disease (e.g. rheumatoid arthritis) have a greatly increased risk of coronary heart disease (e.g. myocardial infarction). The risk was particularly high among women (reference 106 in Scientific productions, below). Another study, of particular relevance to primary care patients, showed that familial factors influence the recurrence of atrial fibril-lation, which is usually diagnosed and treated in primary care (110).

Dr. Jianguang Ji, a successful young researcher in medical epidemiology at the CPF, analysed the cardiovascular health of cancer patients’ spouses and found that this vulnerable group, which often has great responsibility for the care of their cancer-afflicted partners, is at increased risk of coronary heart disease and stroke. This article, published in the very highly ranked journal Circulation, attracted much national and international attention (44).

Professor Jan Sundquist is principal investigator for an NIH-funded study in which he and Dr. Kenneth Kendler, one of the most cited and celebrated researchers in the fields of psychiatry and drug abuse, together with other prominent researchers at Virginia Commonwealth University in the USA, demonstrated that drug abuse has a strong familial basis. One study, con-ducted in 2012, was published in one of the highest ranked psychiatry journals in the world, Archives of General Psychiatry. The study utilised an adoption model to determine the relationship between genes and environ-mental factors and showed that both are important in the development of drug abuse. The key finding of this new study of 18,115 children born in 1950-1993 is that the influence of genes on the risk of developing drug abuse is much stronger if you grow up in a high-risk environment. A deprived environment increases the genetic risk of substance abuse (49).

During 2012, Professor Kristina Sundquist broadened her research group’s research by studying how residential areas affect our health and lifestyles. New findings show that men who live in deprived neighbourhoods have increased mortality from prostate cancer, and that women who live in such neighbourhoods have higher morbidity and mortality from cervical can-

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cer. In a further study, men and women in a primary care population were studied and the researchers found that diabetes patients living in deprived areas have increased coronary heart disease morbidity compared to diabetes patients living in affluent areas. These three innovative studies identified new groups at risk of chronic disease in the most vulnerable neighbourhoods. This is of great importance for all personnel who are clinically active in pri-mary care (13, 56, 59).

It is well known that physical activity can prevent many serious chronic diseases and improve well-being. In 2012, Dr. Kristina Sundquist’s research team showed that neighborhood access to exercise facilities leads to an ob-jective increase in physical activity (21).

Susanna Calling, PhD, a resident physician in family medicine, conducted an interesting study in collaboration with, among others, Marilyn Winkleby (visiting professor at the CPF and award-winning researcher at Stanford Uni-versity). The study followed prematurely born individuals during childhood, adolescence, and young adulthood, and found that, contrary to the research-ers’ expectations, those born prematurely fared just as well in terms of risk of

Casey Crump, Kristina Sundquist and Jan Sundquist, November 2012, Stanford University Photo: Marilyn Winkleby

accidents as those born at full term. The study was published online in Acta Paediatrica on November 26.

International collaborations are a key success factor at Lund University. The CPF has many such collaborations. In April 2012, Professors Kristina Sundquist and Jan Sundquist travelled to Virginia Commonwealth Univer-sity to visit Kenneth Kendler and Hermine Maes, partners in an NIH-funded project on mental illness and substance abuse. This collaboration resulted in

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a number of innovative publications in 2012 (see above).The CPF has ongoing collaborations with two other researchers at Vir-

ginia Commonwealth University: Dr. Sam Chen (studies of schizophrenia and cancer) and Dr. Briana Mezuk (studies of depression and diabetes). In November 2012, CPF researchers also visited Stanford University, where Marilyn Winkleby operates. The long-standing collaboration with Stanford University has resulted in three NIH grants with Jan Sundquist as principal investigator. Also based at Stanford University is another of the CPF’s re-search partners, Dr. Casey Crump, who is a clinically active family physician. During the visit to Stanford in November 2012, we also started a new col-laboration with Professor John Ioannidis and Dr. Chiraq Patel.

During the middle of the year, Kristina Sundquist received the honour of being appointed a visiting professor at Stanford University School of Medi-cine, Stanford Prevention Research Center.

“It is very valuable to us that we can in this way strengthen our collabora-tion with such a prestigious university as Stanford University. We can build a more creative research environment that focuses on health problems that are important to our patients, broader and better research, and increased expertise in how to design studies on various risk factors and how to prevent cardiovascular diseases”, says Kristina Sundquist.

We also have ongoing collaborative projects with universities in, among other countries, Japan, Spain, and Germany.

Communication activities in 2012During the year, research results from the CPF received national and inter-national media attention. Our research findings were also presented by our employees at several national and international conferences.

In spring 2012, the BBC reported Dr. Jianguang Ji’s study on cancer and Huntington’s disease, “Cancer incidence in patient with polyglutamine diseases: a population-based study in Sweden” (http://www.bbc.co.uk/news/health-17678587), which was published in The Lancet Oncology. The study showed that people with Huntington’s disease have a lower risk of developing cancer. Dr. Jianguang Ji told the BBC that:

“Clarification of the mechanism underlying the link between polyglutamine diseases and cancer in the future could lead to the development of new treat-ment options for cancer.”

The article was also featured in the very highly ranked scientific journal Nature Reviews Clinical Oncology.

Ji and his colleagues also examined the specific risk of coronary heart dis-ease and stroke in the spouses of individuals with cancer. The study, which attracted media attention, showed that the risk of coronary heart disease and stroke was increased by nearly thirty percent in the spouses of individu-als with cancer. The probable reason for this is stress the spouses of cancer patients are exposed to.

In August 2012, the journal Circulation presented the CPF’s activities in a freely available article, entitled “Establishing a Powerful Network of Academ-ic Knowledge Centres to Investigate Cardiac Risk Factors”. Circulation is the highest ranked journal in the world in the field of cardiovascular diseases. In

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the article, Professor Jan Sundquist discusses the AKCs and CPF: (http://goo.gl/VRLiW, p. 40-42).

Research teams at the CPF and Virginia Commonwealth University exam-ined how deprived home environments can influence the genetic risk of drug abuse. The article “Genetic and Familial Environmental Influences on the Risk for Drug Abuse: A National Swedish Adoption Study”, published in Archives of General Psychiatry, received a lot of media attention in both the U.S. and Sweden. For example, CNN reported the results of the study on March 5 (http://www.cnn.com/2012/03/05/health/adopted-biological-drug-abuse/index.html).

Xinjun Li, a researcher at the CPF, gave a much appreciated lecture, “Mal-mo studies on immigrants’ health”, at the EUNAM network meeting in Paris

Bengt Zöller, Kristina Sundquist, Jan Sundquist, Jianguang Ji and Xinjun Li Photo: Bertil Kjellberg

on September 20.AKC coordinator Patrick Midlöv and his colleagues published the arti-

cle “The effect of medication reconciliation in elderly patients at hospital discharge,” which was named article of the month for January 2012 by the Faculty of Medicine at Lund University.

Professor Kristina Sundquist was invited to lecture on Swedish primary care and AKCs at Shimane University, Matsue, Shimane, Japan in October 2012.

Professor Kristina Sundquist was also a member of the organising com-mittee of an international symposium held in Malmo on 29–30 March 2012: “Reproductive epidemiology in a life course perspective”. Kristina gave a lecture titled “SGA and PTB Consequences for health: findings based on national registers” and participated in the panel discussion “Future research directions”.

Ulf Eriksson was awarded the “Early Career Poster Award” for his presen-tation “Availability of exercise facilities and physical activity in 2,037 adults: cross-sectional results from the Swedish Neighborhood and Physical Activ-ity (SNAP) study” at the 2012 Annual Meeting of the International Society

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for Behavioral Nutrition and Physical Activity (ISBNPA) in Austin, Texas. Ulf is a nutritionist and a post-doc in public health at the CPF. The prize was awarded because of “the high caliber, conceptual quality and methodological rigor evident in your research, which the judges found very impressive.”

Research leaders and lecturers associated with the CPF in 2012

Family Medicine1. ProfessorJanSundquist,GPatSorgenfriPrimaryHealthCareCentre:

Family medicine, psychiatric epidemiology, and migration.Jan’s research has a clinical focus on common diseases, such as mental disorders, and the groups in society that are most vulnerable, e.g. foreign-born individ-uals. His research uses tools and methods that can be of clinical benefit in primary care and has a translational focus, with studies of biomarkers to better understand the biological effects of clinical interventions.

2. ProfessorKristinaSundquist,GPatGranenPrimaryHealthCareCentre:Family medicine, epidemiology, and lifestyle.Kristina’s research focuses on the roles of genes and the environment, and interactions between them, in common chronic diseases, e.g. cardiovascular disease. This is achieved by epidemiological register-based studies, clinical stud-ies in primary care, and advanced geographical analyses.

3. ProfessorSigvardMölstad,GPatHöörPrimaryHealthCareCentre:Family medicine and infectious diseases.Sigvard’s research focuses on the diagnosis and treatment of common infections in primary care, and the effects and side effects of antibiotics at the individual and societal level. His research is primarily conducted as clinical trials in everyday primary care, either locally or in collaboration with national or European primary care networks.

4. ProfessorMargaretaTroeinTöllborn,GPatSödervärnPrimaryHealthCareCentre:Family medicine and community medicine.Margareta’s research focuses on learning, particularly how doctors learn new things and apply them to their everyday practice, how patients learn new things and apply them to their daily lives, and how students reflect on their edu-cation, their future work, ethics, communication, and priorities.

5. DocentUlfJakobsson,lectureratLundUniversity,districtnurseatDalbyPrimaryHealthCareCentre:Gerontology, elderly care, and long-term illness.Primary Health Care Centre: Gerontology, elderly care, and long-term illness. Ulf ’s research mainly focuses on gerontology and eld-erly care, as well as chronic pain and pain management. Two population studies, focusing on the above areas, are underway.

6. DocentPatrikMidlöv,lectureratLundUniversity,GPatTåbelundPrimaryHealthCareCentre:Family medicine and the elderly.Patrik’s re-search is focused on two main areas: drug-related problems in the elderly and cardiovascular diseases in primary care. The latter covers adherence to guidelines for identification of peripheral vascular disease in diabetes patients and non-pharmacological treatment of hypertension and diabe-tes in primary care.

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7. AndersBeckman,MD,lectureratLundUniversity,GPatLundenPrimaryHealthCareCentre:Family medicine, health care utilisation, and pedagogy.Anders’s research has two main focuses: (1) how health care utilisation is influenced by various factors, overall and in relation to structural changes (health choices), and (2) educational research.

8. DocentBengtZöller,SwedishHeart-LungFoundation-fundedre-searcher,GPatLimhamnPrimaryHealthCareCentre:Venous throm-boembolism and cardiovascular disease.Bengt’s research focuses on cardiovascular epidemiology. Areas of particular interest are the con-tributions of hereditary and non-hereditary factors to risk of VTE and related diseases, such as atherosclerosis and atrial fibrillation. The rela-tionships between VTE and other diseases, such as inflammatory disease and cancer, are also being studied, as are new potentially useful biomark-ers for increased VTE risk.

9. DocentEvaEkvallHansson,physiotherapist: Physiotherapy research in primary care. The primary focus of Eva’s research is dizziness and balance disturbances, fall-related injuries, and rehabilitation. Arthritis and higher education are two other areas of interest.

10.DocentStaffanLindeberg,GPatSanktLarsPrimaryHealthCareCentreinLund: Family medicine and lifestyle. Staffan’s research primarily aims to determine how ordinary Swedish food can cause chronic diseases such as type 2 diabetes and cardiovascular disease. A primary care-based study in Skåne is comparing the effects of different lifestyle changes on abdominal obesity and related pathological changes. Collaboration with researchers in Lanzarote, Portugal, and San Francisco on a study of Paleolithic diets is ongoing. The research team includes, among others, Tommy Jönsson, MD, a GP at Måsen Primary Health Care Centre.

11.DocentRickardEkesbo,GPatCapioCitykliniken,VästraHamnen,Malmö: Family medicine, gastrointestinal problems in primary care, and lifestyle. Rickard is studying gastrointestinal problems in outpatients, primarily irritable bowel syndrome, and their relationships with various factors, e.g. diet, and health economics. In addition, he has planned a population-based study of chronic infections, inflammation, and sub-sequent morbidity and health care utilisation for the coming year. He is also studying lifestyle habits and their influence on morbidity.

12.LouiseBennet,MD,GPatFågelbackenPrimaryHealthCareCentre: Family medicine, the epidemiology of diabetes, lifestyle, and migration. Louise’s research is focused on how genes and lifestyle habits affect the development of type 2 diabetes in an immigrant population from the Middle East, in comparison with a non-immigrant population. Her stud-ies include a population study, which was completed in December 2012, and a primary care-based randomised lifestyle intervention study that will commence towards the end of 2013. In addition, she is, in collabora-tion with Jan and Kristina Sundquist, studying biomarkers in individuals at high risk of diabetes who were born in Iraq or Sweden in order to bet-ter understand the biological effects of clinical interventions.

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13.SusannaCalling,MD,residentphysicianatBaraPrimaryHealthCareCentre:Family medicine and epidemiology. Susanna’s research focuses on common diseases in two main areas: cardiovascular disease and child health. Her research into cardiovascular disease covers its relationship with obesity, the metabolic syndrome, and genetic factors, as well as the effects of sociodemographic and lifestyle factors. Her research on child health aims to determine how diseases among children and mothers are affected by neighborhood environments and individual-level sociodemo-graphic factors.

14.AshfaqueMemon,MD,researchfellowattheCPFandthemolecularlaboratoryinfamilymedicine. Ashfaque’s research is focused on iden-tifying markers for early detection of chronic diseases and prediction of treatment response. He is studying inflammatory markers and growth factors in diabetes, mental disorders, cardiovascular diseases, and can-cers. He and his colleagues are also interested in identifying and charac-terising candidate miRNAs involved in the pathogenesis of chronic dis-eases and mental disorders. The laboratory research team also includes Jan Sundquist, Kristina Sundquist, Bengt Zöller, Xiao Wang, and Anna Hedelius.

Social medicine and Health economics in 201215.ProfessorJuanMerlo: Social epidemiology. Research on the importance

of the social environment as a determinant of an individual’s health, and the interaction between the individual and the society in which the indi-vidual lives. Life-course and multilevel analyses are the most important epidemiological methods Juan’s group is developing. Juan’s research aims to identify factors that influence health and health care utilisation, and to generate knowledge that serves as a scientific basis to achieve a more eq-uitable distribution of health care resources and preventive public health measures (see also http://www.med.lu.se/social_epidemiology)

16.ProfessorMartinLindström:Social medicine and health policy. Research on social capital, lifestyle, and health. Social differences in lifestyle and health. Research on children’s and adolescents’ health and life-course epidemiology.

17.ProfessorUlfGerdtham:Health economics. Research on, among other things, the relationship between economics and health, and the causes of health’s socioeconomic distribution. Ulf ’s health economics research is conducted jointly at the Departments of Economics and Clinical Scienc-es at Lund University. Ulf is also research director of the program Health Economics & Management at the School of Economics and Manage-ment, Lund University.

Visiting professorsIn 2012, the CPF had two visiting professors: Professor Marilyn Winkleby of Stanford University in California and Professor Kari Hemminki of the Ger-man Cancer Research Center in Heidelberg, Germany. During 2012, Marilyn and Kari tutored several of the younger researchers at the CPF through visits, phone calls, and e-mails..

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Research educationDuring 2012, three PhD students successfully defended their theses:• DentistGiuseppeNicolaGiordanodefended his thesis “Social Capital

and Self-rated Health: testing association with longitudinal and mul-tilevel methodologies” on May 8. Main supervisor: Professor Martin Lindström.

• NurseBirgitModéndefended her thesis “Epidemiological studies of risk factors for injuries in an adult population” on September 21. Main super-visor: Docent Maria Rosvall

• GPSaraModigdefended her thesis “Managing drug use in the elderly: General practitioners’ adherence to guidelines and patients’ conceptions of medication” on November 16. Main supervisor: Docent Patrik Midlöv.

NewPhDstudentsregisteredin2012:• PharmacistTedlayehuWolde: – “Immigration and health”.

Main supervisor: Kari Hemminki• JuniordoctorJesperAlexPetersen:– “Social capital versus material fac-

tors as an explanation of health”. Main supervisor: Martin Lindström

PhDstudentsattheCPFin2012whowereregisteredwithLundUniversitypriorto2012: • Axelson,Henrik(MSc), registered in 2006 – “Essays on the impact of

targeted social health insurance: evidence from Vietnam”. Main supervisor: Ulf Gerdtham

• Axelsson,Jakob(publichealthplanner,MPhil), registered in 2010 – “Social circumstances and sexual health”. Main supervisor: Martin Lindström

• Axén,Elin(medicaldoctor), registered in 2004 – “Access to health care/patient satisfaction with care”. Main supervisor: Martin Lindström

• Bahrani,Leila(MasterofPharmacy), registered in 2011 – “Drug treat-ment and drug-related problems in frail elderly patients”. Main supervisor: Patrik Midlöv

• Borg,Sixten(BachelorofMathematics/Statistics),registered in 2011 – “Disaggregation and indirect estimation methods on data for health economic models and economic evaluation, with applications to inflam-matory bowel disease and diabetes”. Main supervisor: Ulf Gerdtham

• Chaikiat,Åsa(residentphysician), registered in 2011 – “Diabetes in primary care”. Main supervisor: Kristina Sundquist

• Eriksson,Ulf (nutritionist), registered in 2009 – “Neighborhood envi-ronment and physical activity”. Main supervisor: Kristina Sundquist

• Hansen,Kristina(medicaldoctor)registered in 2010 – “Importance of early factors for children’s and adults’ health”.Main supervisor: Maria Rosvall

• Heckley,Gawain(MSc), registered in 2011 – “Essays on the demand for and the effect of alcohol”. Main supervisor: Ulf Gerdtham

• Kiadaliri,AliasgharAhmad(MSc), registered in 2010 – “Developing a health economic model for patients with type 2 diabetes in Sweden”. Main supervisor: Ulf Gerdtham

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• Larsson,Caroline(certifiedphysiotherapist), registered in 2011 – “Pain in the elderly”. Main supervisor: Ulf Jakobsson

• Lindström,Christine(medicaldoctor), registered in 2004 – “Social capital and leisure time physical activity”. Main supervisor: Martin Lindström

• Milos,Veronica(residentphysicianinfamilymedicine), registered in 2011 – “Interventions to increase compliance in primary care”. Main supervisor: Patrik Midlöv

• Olsson-Möller,Ulrika(certified physiotherapist), registered in 2008 – “Falls and dizziness in frail older people”. Main supervisor: Ulf Jakobsson

• Persson,Sofie(MSc),registered in 2010– “Social and economic conse-quences of childhood onset of type 1 diabetes”. Main supervisor: Ulf Gerdtham

• Riihimäki,Matias(medicaldoctor), registered in 2011 – “Using death certificates in cancer epidemiology - Causes of death in cancer patients and epidemiology of metastases”. Main supervisor: Kristina Sundquist

• Saha,Sanjib(MPH,PgC), registered in 2010 – “Economic Evaluation of Public Health Programs Focusing on Lifestyle Interventions (Nutrition and/or Physical activity)”. Main supervisor: Ulf Gerdtham

• Sandberg,Magnus(certifiednurse), registered in 2009 – “Home based case management for older people (+65). Content, cost utility and effects on healthcare costs and healthcare utilization”. Main supervisor: Ulf Jakobsson

• Skoog,Jessica(medicaldoctor), registered in 2009 – “Analysis of factors of importance for drug prescription”. Main supervisor: Anders Halling

• Taube,Elin(nurse), registered in 2009 – “Loneliness among the elderly: experiences, causes, effects and prevention”. Main supervisor: Ulf Jakobsson

• Waehrens,Rasmus(GP), registered in 2011 – “Irritable bowel syn-drome”. Main supervisor: Bengt Zöller

• Wolff,Moa(GP), registered in 2011 – “Effect of yoga on hypertension”. Main supervisor: Patrik Midlöv

Customerperspective:ExternalfundingbodiesStrategicobjective:The CPF delivers relevant research.

Relevant research refers to research that addresses research questions in the projects that external funding bodies have financed. CPF projects have received funding from the Swedish Research Council, FAS, the Swedish Heart-Lung Foundation, the National Institutes of Health (USA), the Ellison Medical Foundation (USA), and the EU. During 2012, the CPF also received grants, scholarships, and travel scholarships from, among others, System-bolagets råd för alkoholforskning, King Gustaf V and Queen Victoria’s Foun-dation of Freemasons, the Crafoord Foundation, Per Håkanssons stiftelse, and Skåne University Hospital foundations and funds.

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LearningandgrowthperspectiveStrategicobjective:The CPF has an inquisitive and critical approach, with flexibility and innovation as its guiding principles

The learning and growth perspective describes the building blocks necessary for innovation and development in our efforts to stimulate world-leading research in primary care. This requires expansion into new areas of research and strengthening of our existing research areas.

For example, to analyse complex data and address advanced research ques-tions we need knowledge of data processing and statistical analysis. In 2012, our statisticians and researchers collaborated with world-renowned col-laborators at Virginia Commonwealth University and conducted innovative advanced analyses using individual, family, and environmental data. This generated new knowledge about how genetic and environmental factors in-teract in the development of, among other things, substance abuse. The new analytical skills we have acquired have benefited a number of researchers at the CPF.

Another important example of our innovation is the experimental research being conducted in our experimental laboratory (see page 10).

Continuous learning and growth is carrying us steadily forwards. Primary care and the specialty family medicine are facing a paradigm shift to improve the prevention, diagnosis, and treatment of the most common diseases. Gen-erally, personalised medicine attempts to determine an individual’s heredity and medical history, as well as environmental risk factors. GPs who work preventatively know how difficult it can be to influence a person’s lifestyle. Furthermore, not all patients respond to the same kind of treatment/medi-cation. This is because we are all different and have, for example, different genetic make-ups. It is, for instance, well known that physical activity low-ers blood pressure, but not in everyone, since the response of the individual depends on differences in so-called “genetic variants”. Differences in genetic variants also mean that the symptoms of diabetes are affected differently by physical activity and fibre intake. Therefore, we need to increase our knowl-edge of how primary care patients (a very large group) can be taken care of in the best way. The CPF’s research in life sciences will, in the next three years, advance translational research, where disease problems identified in primary care form the basis for laboratory-based investigations in genomics, proteomics, and metabolomics. The aim is to contribute to the central role primary care will have in the future in personalised medicine, i.e. using the patient’s unique characteristics to develop tools to prevent, diagnose, and treat chronic diseases in primary care.

Processperspective

Strategicobjective:The CPF has the right expertise and good cooperation and communication in its operations, which are characterised by knowledge, qual-ity, efficiency, and continual evaluation.

The process perspective answers the questions How do we go about achieving our vision? and What do we need to improve?

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The process perspective thus describes the conditions and methods the CPF requires to achieve its mission. It’s about good and effective practices and identify-ing the necessary success factors.

All employees at the CPF are involved in efforts to improve processes and participate in discussions about our goals and strategies for success. Through this work, we jointly concluded that trust, clear communication, and understanding are key success factors for creating effective teams. We understand that this is a dynamic process that is constantly evolving. We strive to learn from each other’s different backgrounds to achieve successful development. We trust each other’s abilities, that tasks will be completed on time, and that the results of our efforts will be good. We also try to give each other constructive criticism to become even better in the future. We challenge ideas and encourage a scientific debate, where we do not a priori strive for a consensus, but instead hope to achieve a consensus after everyone has had the chance to comment, in an environment of openness

This creates a platform for collaboration and interaction in which we constantly consider new perspectives and issues.

EmployeeperspectiveStrategicobjective: The CPF affords its employees good opportunities for develop-ment and the ability to exert influence in a professional climate characterised by trust, consideration, happiness, and solidarity.

During the year, employees at the CPF worked on the action plan that was devel-oped after the 2011 employee survey, Springlife, focusing on the areas of improve-ment that were deemed to be important. All members of staff had the opportunity to make suggestions as to how to improve things in these areas. The CPF has, dur-ing the year, enjoyed frequent workplace meetings, training days with workshops, and retreats. This work led to improved results in the most recent survey, con-ducted in autumn 2012. 20 employees were eligible to participate in the autumn 2012 survey and the response rate was 100 percent. The results are presented as 11 improvement areas with different benchmarks and show high scores for employee power, efficiency, social climate, learning at work, and feedback. The results also show a high value for a summary measure, indicating a positive forecast for the group’s health and productivity. An action plan based on the latest survey, with priority areas for further development, is being developed and further work to improve health, dedication, and job satisfaction at the CPF will continue during 2013.

At the end of 2012, the CPF had 30 employees: 15 employed by Region Skåne and 15 by Lund University. Other staff affiliated to the CPF include 10 individuals from primary care who spend 10-20% of their working time conducting research and the 10 people who work as AKC coordinators.

Most of the CPF’s employees received training during the year. Among other things, they received instruction in programming, scientific writing, epidemiol-ogy, and pedagogy.

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FinancialperspectiveStrategicobjective: The CPF has sustainable finances.

The financial perspective describes the conditions required for balanced finances in the short term and sustainable finances in the long term. The CPF strives to achieve a financial situation that is sustainable and that allows room for manoeu-vre. This will be achieved by continuing to collaborate externally and through successful efforts to obtain external research funding.

Other important success factors are dedicated and cost-conscious colleagues and good internal financial practices.

Through our hard work on grant applications in 2012, we acquired the follow-ing funding for 2013: 10.9 million SEK in external grants, 6.5 million SEK in ALF funding, and 3 million SEK in government grants.

Family medicine Social medicine / Health economics

Total amount of external funding

FAS 2 000 000 2 500 000 4 500 000

Swedish Research Council 1 500 000 800 000 2 300 000

Swedish Heart-Lung Foundation 400 000 400 000

NIH/Ellison Medical Foundation (USA) 3 200 000 3 200 000

EU 350 000

Other 1 235 000 100 000 1 335 000

Total external grants 7 450 000 3 400 000

Government grants 3 017 000

ALF funding 4 073 000 + 1 250 000

1 155 000 6 478 000

Lund University and ALF, 2013The table shows external grants (a total of 10.9 million SEK), government grants (3.0 million SEK), and ALF funding (6.5 million SEK) for 2013, divided into family medicine and social medicine/health economics. The values represent SEK.

2012 budget Results for 2012 2013 budget

Revenues Revenues from Region Skåne

Region Skåne funding for the CPF

11 800 000 11 800 000 11 800 000

Funding for salaries 6 600 000 6 002 100 5 400 000

Regional research funding 720 000 480 000 170 000

Other revenues 610 000 2 165 500 2 320 000

Outsourcing of personnel 600 000 2 152 500 2 320 000

Education 10 000 13 000

Total 19 730 000 20 447 600 19 690 000

Total revenues 19 730 000 20 447 600 19 690 000

Costs

Personnel 12 497 000 12 589 200 13 102 000

Investments 0 0 0

Operations 5 249 400 6 293 700 4 576 000

Total 17 746 400 18 882 900 17 678 000

Overheads 733 600 719 400 737 000

Offices 1 250 000 693 800 1 275 000

Total costs 19 730 000 20 296 100 19 690 000

Deficit/surplus 0 151 500 0

The table to the right shows funding from Region Skåne to finance the CPF during 2012 (2012 budget), the actual fi-nancial results for 2012, and the planned budget for 2013. The values represent SEK.

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Scientific Output

Vetenskapliga publikationer 2012143 artiklar

Allmänmedicin1. Andersen CD, Bennet L, Nyström L, Lindblad U,

Lindholm E, Groop L, Rolandsson O. Worse glycae-mic control in LADA patients than in those with type 2 diabetes, despite a longer time on insulin therapy. Diabetologia. 2013;56(2):252-8.

2. Andersson BT, Christensson L, Jakobsson U, Fridlund B, Broström A. Radiographers’ self-assessed level and use of competencies-a national survey. Insights Imag-ing. 2012;3(6):635-45.

3. Arvidsson D, Eriksson U, Lönn SL, Sundquist K. Neighborhood walkability, income, and hour-by-hour physical activity patterns. Med Sci Sports Exerc. (In press).

4. Arvidsson D, Kawakami N, Ohlsson H, Sundquist K. Physical activity and concordance between objec-tive and perceived walkability. Med Sci Sports Exerc. 2012;44(2):280-7.

5. Bevier M, Sundquist J, Hemminki K. Incidence of cancer of unknown primary in Sweden: analy-sis by location of metastasis. Eur J Cancer Prev. 2012;21(6):596-601.

6. Bevier M, Sundquist K, Hemminki K. Risk of breast cancer in families of multiple affected women and men. Breast Cancer Res Treat. 2012;132(2):723-8.

7. Bondesson A, Eriksson T, Kragh A, Holmdahl L, Midlöv P, Höglund P. In-hospital medication reviews reduce unidentified drug-related problems. Eur J Clin Pharmacol. 2013;69(3):647-55.

8. Bondesson A, Holmdahl L, Midlöv P, Höglund P, An-dersson E, Eriksson T. Acceptance and importance of clinical pharmacists’ LIMM-based recommendations. Int J Clin Pharm. 2012;34(2):272-6.

9. Brandt A, Sundquist J, Hemminki K. Risk for inci-dent and fatal prostate cancer in men with a family history of any incident and fatal cancer. Ann Oncol. 2012;23(1):251-6.

10. Bringsén A, Andersson HI, Ejlertsson G, Troein M. Exploring workplace related health resources from a salutogenic perspective. Results from a focus group study among healthcare workers in Sweden. Work. 2012;42(3):403-14.

11. Calling S, Palmér K, Jönsson L, Sundquist J, Winkleby M, Sundquist K. Preterm birth and unintentional injuries: risks to children, adolescents and young adults show no consistent pattern. Acta Paediatr. 2013;102(3):287-93.

12. Carlsson AC, Wändell P, Sundquist K, Johansson SE, Sundquist J. Differences and time trends in drug treatment of atrial fibrillation in men and women

and doctors’ adherence to warfarin therapy recom-mendations: a Swedish study of prescribed drugs in primary care in 2002 and 2007. Eur J Clin Pharmacol. 2013;69(2):245-53.

13. Chaikiat Å, Li X, Bennet L, Sundquist K. Neighbor-hood deprivation and inequities in coronary heart disease among patients with diabetes mellitus: a multilevel study of 334,000 patients. Health Place. 2012;18(4):877-82

14. Crump C, Sundquist K, Sieh W, Winkleby MA, Sun-dquist J. Perinatal and family risk factors for Hodgkin lymphoma in childhood through young adulthood. Am J Epidemiol. 2012;176(12):1147-58.

15. Crump C, Sundquist K, Sieh W, Winkleby MA, Sundquist J. Perinatal and family risk factors for non-Hodgkin lymphoma in early life: a Swedish national cohort study. J Natl Cancer Inst. 2012;104(12):923-30.

16. Crump C, Winkleby MA, Sundquist J, Sundquist K. Gestational age at birth and risk of gastric acid-related disorders in young adulthood. Ann Epidemiol. 2012;22(4):233-8.

17. Edvardsson I, Troein M, Ejlertsson G, Lendahls L. Snus user identity and addiction. A Swedish focus group study on adolescents. BMC Public Health. 2012;12(1):975.

18. Ekesbo R, Midlöv P, Gerward S, Persson K, Nerbrand C, Johansson L. Lack of adherence to hyperten-sion treatment guidelines among GPs in southern Sweden-a case report-based survey. BMC Fam Pract. 2012;13:34.

19. Eriksson T, Holmdahl L, Midlöv P, Höglund P, Bondesson Å. The hospital LIMM-based clinical pharmacy service improves the quality of the patient medication process and saves time. Eur J Hosp Pharm 2012;19(4):375-7.

20. Eriksson U, Arvidsson D, Gebel K, Ohlsson H, Sundquist K. Walkability parameters, active trans-portation and objective physical activity: moderating and mediating effects of motor vehicle ownership in a cross-sectional study. Int J Behav Nutr Phys Act. 2012;9:123.

21. Eriksson U, Arvidsson D, Sundquist K. Availability of exercise facilities and physical activity in 2,037 adults: cross-sectional results from the Swedish neighbor-hood and physical activity (SNAP) study. BMC Public Health. 2012;12:607.

22. Garmy P, Nyberg P, Jakobsson U. Sleep and television and computer habits of Swedish school-age children. J Sch Nurs. 2012;28(6):469-76.

23. Garmy P, Jakobsson U, Nyberg P. Development and psychometric evaluation of a new instrument for measuring sleep length and television and computer habits in school-age children. J Sch Nurs. 2012;28 (2):138-43.

33

Scientific Output

24. Gerward S, Persson K, Midlöv P, Ekesbo R, Gullberg B, Hedblad B. Trends in out-of-hospital ischaemic heart disease deaths 1992 to 2003 in southern Sweden. Scand J Public Health. 2012;40(4):340-7.

25. Hansson EE, Beckman A, Wihlborg A, Persson S, Troein M. Satisfaction with rehabilitation in relation to self-perceived quality of life and function among patients with stroke - a 12 month follow-up. Scand J Caring Sci. (In press).

26. Hemminki K, Riihimäki M, Sundquist K, Hemminki A. Site-specific survival rates for cancer of unknown primary (CUP) according to location of metastases. Int J Cancer. (In press).

27. Hemminki K, Bevier M, Sundquist J, Hemminki A. Site-specific cancer deaths in cancer of unknown pri-mary diagnosed with lymph node metastasis may re-veal hidden primaries. Int J Cancer. 2013;132(4):944-50.

28. Hemminki K, Bevier M, Sundquist J, Hemminki A. Cancer of unknown primary (CUP): does cause of death and family history implicate hid-den phenotypically changed primaries? Ann Oncol. 2012;23(10):2720-4.

29. Hemminki K, Houlston R, Sundquist J, Sundquist K, Shu X. Co-morbidity between early-onset leukemia and type 1 diabetes - suggestive of a shared viral etiol-ogy? PLoS One. 2012;7(6):e39523.

30. Hemminki K, Li X, Försti A, Sundquist J, Sundquist K. Incidence and survival in non-hereditary amy-loidosis in Sweden. BMC Public Health. 2012;12:974.

31. Hemminki K, Liu H, Heminki A, Sundquist J. Power and limits of modern cancer diagnostics: cancer of unknown primary. Ann Oncol. 2012;23(3):760-4.

32. Hemminki K, Liu X, Försti A, Ji J, Sundquist J, Sun-dquist K. Effect of autoimmune diseases on incidence and survival in subsequent multiple myeloma. J Hematol Oncol. 2012;5:59.

33. Hemminki K, Liu X, Ji J, Försti A, Sundquist J, Sundquist K. Effect of autoimmune diseases on risk and survival in female cancers. Gynecol Oncol. 2012;127(1):180-5.

34. Hemminki K, Liu X, Ji J, Sundquist J, Sundquist K. Autoimmune disease and subsequent digestive tract cancer by histology. Ann Oncol. 2012;23(4):927-33.

35. Hemminki K, Liu X, Ji J, Sundquist J, Sundquist K. Ef-fect of autoimmune diseases on mortality and survival in subsequent digestive tract cancers. Ann Oncol. 2012;23(8):2179-84.

36. Hemminki K, Liu X, Ji J, Sundquist J, Sundquist K. Effect of autoimmune diseases on risk and sur-vival in histology-specific lung cancer. Eur Respir J. 2012;40(6):1489-95.

37. Hemminki K, Sundquist J, Brandt A. Do discordant cancers share familial susceptibility? Eur J Cancer. 2012;48(8):1200-7.

38. Jakobsson U, Kristensson J. The Pain Impact Inventory - further validation in various subgroups. Pain Pract. 2012;12(5):350-6.

39. Jakobsson, U. Westergren, A. Lindskov, S. Hagell, P. (2012). Construct validity of the SF-12 in three differ-ent samples. J Eval Clin Pract. 2012;18(3):560-6.

40. Jendle J, Torffvit O, Ridderstråle M, Ericsson Å, Nilsen B, Bøgelund M. Willingness to pay for diabetes drug therapy in type 2 diabetes patients: based on LEAD clinical programme results. J Med Econ. 2012;15 Suppl 2:1-5.

41. Ji J, Sundquist K, Ning Y, Kendler KS, Sundquist J, Chen X. Incidence of cancer in patients with schizo-phrenia and their first-degree relatives: a population-based study in Sweden. Schizophr Bull. (In press).

42. Ji J, Sundquist K, Sundquist J, Hemminki K. Compa-rability of cancer identification among Death Registry, Cancer Registry and Hospital Discharge Registry. Int J Cancer. 20121;131(9):2085-93.

43. Ji J, Sundquist K, Sundquist J. Cancer incidence in pa-tients with polyglutamine diseases: a population-based study in Sweden. Lancet Oncol. 2012;13(6):642-8.

44. Ji J, Zöller B, Sundquist K, Sundquist J. Increased risks of coronary heart disease and stroke among spousal caregivers of cancer patients. Circulation. 2012;125(14):1742-7.

45. Ji J, Sundquist K, Sundquist J. A population-based study of hepatitis D virus as potential risk factor for hepatocellular carcinoma. J Natl Cancer Inst. 2012;104(10):790-2.

46. Ji J, Sundquist K, Sundquist J. Cancer risk after hos-pitalization for osteoporosis in Sweden. Eur J Cancer Prev. 2012;21(4):395-9.

47. Jönsson LS, Palmér K, Ohlsson H, Sundquist J, Sun-dquist K. Is acculturation associated with physical activity among female immigrants in Sweden? J Public Health (Oxf). (In press).

48. Kendler KS, Ohlsson H, Sundquist K, Sundquist J. Within-family environmental transmission of drug abuse: a Swedish national study. JAMA Psychiatry. 2013;70(2):235-42.

49. Kendler KS, Sundquist K, Ohlsson H, Palmér K, Maes H, Winkleby MA, Sundquist J. Genetic and familial environmental influences on the risk for drug abuse: a national Swedish adoption study. Arch Gen Psychiatry. 2012;69(7):690-7.

50. Kharazmi E, da Silva Filho MI, Pukkala E, Sundquist K, Thomsen H, Hemminki K. Familial risks for child-hood acute lymphocytic leukaemia in Sweden and Finland: far exceeding the effects of known germline variants. Br J Haematol. 2012;159(5):585-8.

51. Kharazmi E, Fallah M, Sundquist K, Hemminki K. Familial risk of early and late onset cancer: nationwide prospective cohort study. BMJ. 2012;345:e8076.

34

52. Larsson CA, Krøll L, Bennet L, Gullberg B, Råstam L, Lindblad U. Leisure time and occupational physical activity in relation to obesity and insulin resistance: a population-based study from the Skaraborg Project in Sweden. Metabolism. 2012;61(4):590-8.

53. Li X, Sundquist J, Sundquist K. Immigrants and preterm births: a nationwide epidemiological study in Sweden. Matern Child Health J. (In press).

54. Li X, Sundquist J, Zöller B, Louise B, Sundquist K. Risk of hospitalization for type 2 diabetes in first- and second-generation immigrants in Sweden: a nation-wide follow-up study. J Diabetes Complications. 2013;27(1):49-53.

55. Li X, Sundquist J, Sundquist K, Zöller B. Occupational risk factors for systemic lupus erythematosus: a na-tionwide study based on hospitalizations in Sweden. J Rheumatol. 2012;39(4):743-51.

56. Li X, Sundquist J, Zöller B, Calling S, Sundquist K. Neighborhood deprivation and risk of cervical cancer morbidity and mortality: a multilevel analysis from Sweden. Gynecol Oncol. 2012;127(2):283-9.

57. Li X, Sundquist K, Sundquist J. Risks of small-for-gestational-age births in immigrants: a nationwide epidemiological study in Sweden. Scand J Public Health. 2012;40(7):634-40.

58. Li X, Sundquist J, Sundquist K. Subsequent risks of Parkinson disease in patients with autoimmune and related disorders: a nationwide epidemiological study from Sweden. Neurodegener Dis. 2012;10(1-4):277-84.

59. Li X, Sundquist K, Sundquist J. Neighborhood dep-rivation and prostate cancer mortality: a multilevel analysis from Sweden. Prostate Cancer Prostatic Dis. 2012;15(2):128-34.

60. Lind M, Jendle J, Torffvit O, Lager I. Glucagon-like peptide 1 (GLP-1) analogue combined with insulin reduces HbA1c and weight with low risk of hypogly-cemia and high treatment satisfaction. Prim Care Diabetes. 2012;6(1):41-6.

61. Lindeberg S. Dietary shifts and human health: cancer and cardiovascular disease in a sustainable world. J Gastrointest Cancer. 2012;43(1):8-12.

62. Lindeberg S. Paleolithic diets as a model for preven-tion and treatment of Western disease. Am J Hum Biol. 2012;24(2):110-5.

63. Lithner M, Johansson J, Andersson E, Jakobsson U, Palmquist I, Klefsgard R. Perceived information after surgery for colorectal cancer - an explorative study. Colorectal Dis. 2012;14(11):1340-50.

64. Little P, Stuart B, Moore M, Coenen S, Butler CC, Godycki-Cwirko M, Mierzecki A, Chlabicz S, Torres A, Almirall J, Davies M, Schaberg T, Mölstad S, Blasi F, De Sutter A, Kersnik J, Hupkova H, Touboul P,

Hood K, Mullee M, O’Reilly G, Brugman C, Goossens H, Verheij T; on behalf of the GRACE consortium. Amoxicillin for acute lower-respiratory-tract infec-tion in primary care when pneumonia is not sus-pected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis. (In press).

65. Liu H, Hemminki K, Sundquist J, Holleczek B, Kata-linic A, Emrich K, Brenner H; GEKID Cancer Sur-vival Working Group. Second primary cancers after cancer of unknown primary in Sweden and Germany: efficacy of the modern work-up. Eur J Cancer Prev. (In press).

66. Liu X, Ji J, Forsti A, Sundquist K, Sundquist J, Hem-minki K. Autoimmune diseases and subsequent urological cancers. J Urol. (In press).

67. Liu X, Ji J, Sundquist K, Sundquist J, Hemminki K. Mortality causes in cancer patients with type 2 diabe-tes mellitus. Eur J Cancer Prev. 2012;21(3):300-6.

68. Liu X, Ji J, Sundquist K, Sundquist J, Hemminki K. The impact of type 2 diabetes mellitus on cancer-specific survival: a follow-up study in Sweden. Cancer. 2012;118(5):1353-61.

69. Lundkvist K, Sundquist K, Li X, Friberg D. Famil-ial risk of sleep-disordered breathing. Sleep Med. 2012;13(6):668-73.

70. Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. The effect of medication reconciliation in elderly patients at hospital discharge. Int J Clin Pharm. 2012;34(1):113-9.

71. Modig S, Höglund P, Troein M, Midlöv P. GP’s adher-ence to guidelines for cardiovascular disease among elderly: a quality development study. ScientificWorld-Journal. 2012;2012:767892.

72. Modig S, Kristensson J, Troein M, Brorsson A, Midlöv P. Frail elderly patients’ experiences of information on medication. A qualitative study. BMC Geriatr. 2012;12:46.

73. Mousavi SM, Sundquist J, Hemminki K. Cancer incidence among Turkish, Chilean, and North African first-generation immigrants in Sweden compared with residents in the countries of origin and native Swedes. Eur J Cancer Prev. 2013;22(1):1-7.

74. Mousavi SM, Sundquist K, Hemminki K. Does the risk of stomach cancer remain among second-generation immigrants in Sweden? Gastric Cancer. 2012;15(2):213-5.

75. Mousavi SM, Sundquist K, Hemminki K. Risk of lung cancer by histology among immigrants to Sweden. Lung Cancer. 2012;76(2):159-64.

76. Nager A, Szulkin R, Johansson SE, Johansson LM, Sundquist K. High lifelong relapse rate of psychiatric disorders among women with postpartum psychosis. Nord J Psychiatry. 2013;67(1):53-8.

Scientific Output

35

77. Olofsson M, Toepfer M, Ostgren CJ, Midlöv P, Matussek A, Lindgren PE, Mölstad S. Low level of antimicrobial resistance in Escherichia coli among Swedish nursing home residents. Scand J Infect Dis. 2013;45(2):117-23.

78. Olofsson M, Lindgren PE, Ostgren CJ, Midlöv P, Mölstad S. Colonization with Staphylococcus aureus in Swedish nursing homes: a cross-sectional study. Scand J Infect Dis. 2012;44(1):3-8.

79. Olsson Möller U, Midlöv P, Kristensson J, Ekdahl C, Berglund J, Jakobsson U. Prevalence and predictors of falls and dizziness in people younger and older than 80 years of age-A longitudinal cohort study. Arch Gerontol Geriatr. 2013;56(1):160-8.

80. Olsson Möller U, Kristensson J, Midlöv P, Ekdahl C, and Jakobsson U. Predictive validity and cut-off scores in four diagnostic tests for falls - A study in frail older people at home. Phys Occup Ther Geriatr. 2012;30(3)189-201.

81. Prendergast V, Jakobsson U, Renvert S, Hallberg IR. Effects of a standard versus comprehensive oral care protocol among intubated neuroscience ICU patients: results of a randomized controlled trial. J Neurosci Nurs. 2012;44(3):134-46; quiz 147-8.

82. Roudgari H, Hemminki K, Brandt A, Sundquist J, Fallah M. Prostate cancer risk assessment model: a scoring model based on the Swedish Family-Cancer Database. J Med Genet. 2012;49(5):345-52.

83. Sandberg M, Kristensson J, Midlöv P, Fagerström C, Jakobsson U. Prevalence and predictors of healthcare utilization among older people (60+): focusing on ADL dependency and risk of depression. Arch Geron-tol Geriatr. 2012;54(3):e349-63.

84. Shu X, Liu H, Ji J, Sundquist K, Försti A, Sundquist J, Hemminki K. Subsequent cancers in patients diagnosed with cancer of unknown primary (CUP): etiological insights? Ann Oncol. 2012;23(1):269-75.

85. Shu X, Sundquist K, Sundquist J, Hemminki K. Risk of cancer of unknown primary among immigrants to Sweden. Eur J Cancer Prev. 2012;21(1):10-4.

86. Shu X, Sundquist K, Sundquist J, Hemminki K. Time trends in incidence, causes of death, and survival of cancer of unknown primary in Sweden. Eur J Cancer Prev. 2012;21(3):281-8.

87. Stenman E, Leijon ME, Calling S, Bergmark C, Arvidsson D, Gerdtham UG, Sundquist K, Ekesbo R. Study protocol: a multi-professional team interven-tion on physical activity referrals in primary care patients with cardiovascular risk factors - the Dalby lifestyle intervention cohort (DALICO) study. BMC Health Serv Res. 2012;12(1):173.

88. Sundquist J, Li X, Sundquist K. Neighborhood dep-rivation and mortality in individuals with cancer: a

multilevel analysis from Sweden. Eur J Cancer Prev. 2012;21(4):387-94.

89. Taloyan M, Wajngot A, Johansson SE, Tovi J, Sundquist K. Sexual dysfunction in Assyrian/Syrian immigrants and Swedish-born persons with type 2 diabetes. BMC Res Notes. 2012;5:522.

90. Tofik R, Torffvit O, Rippe B, Bakoush O. Urine IgM-excretion as a prognostic marker for progression of type 2 diabetic nephropathy. Diabetes Res Clin Pract. 2012;95(1):139-44.

91. Torffvit O, Kalani M, Apelqvist J, Eliasson B, Eriks-son JW, Brismar K, Jörneskog G. Increased urine IgM and IgG(2) levels, indicating decreased glomerular size selectivity, are not affected by dalteparin therapy in patients with type 2 diabetes. Biochem Res Int. 2012;2012:480529.

92. Torffvit O. The effect of achieving a systolic blood pres-sure of 140mmHg. A prospective study of ambulatory measurements in type 2 diabetic patients with neph-ropathy. J Diabetes Complications. 2012;26(6):540-5.

93. Tovar J, Nilsson A, Johansson M, Ekesbo R, Aberg AM, Johansson U, Björck I. A diet based on multiple functional concepts improves cardiometabolic risk parameters in healthy subjects. Nutr Metab (Lond). 2012;9:29.

94. Wallin AO, Jakobsson U, Edberg AK. Job satisfac-tion and associated variables among nurse assist-ants working in residential care. Int Psychogeriatr. 2012;24(12):1904-18.

95. Widarsson M, Kerstis B, Sundquist K, Engström G, Sarkadi A. Support needs of expectant moth-ers and fathers: a qualitative study. J Perinat Educ. 2012;21(1):36-44.

96. Wändell P, Carlsson AC, Sundquist K, Johansson SE, Sundquist J. Effect of cardiovascular drug classes on all-cause mortality among atrial fibrillation patients treated in primary care in Sweden: a cohort study. Eur J Clin Pharmacol. 2013;69(2):279-87.

97. Zöller B, Ohlsson H, Sundquist J, Sundquist K. High familial risk of atrial fibrillation/atrial flutter in multi-plex families: a nationwide family study in Sweden. J Am Heart Assoc. (In press).

98. Zöller B, Ji J, Sundquist J, Sundquist K. Family history and risk of hospital treatment for varicose veins in Sweden. Br J Surg. 2012;99(7):948-53.

99. Zöller B, Ji J, Sundquist J, Sundquist K. Risk of coro-nary heart disease in patients with cancer: a nation-wide follow-up study from Sweden. Eur J Cancer. 2012;48(1):121-8.

100. Zöller B, Ji J, Sundquist J, Sundquist K. Risk of haem-orrhagic and ischaemic stroke in patients with cancer: a nationwide follow-up study from Sweden. Eur J Cancer. 2012;48(12):1875-83.

Scientific Output

101. Zöller B, Li X, Sundquist J, Sundquist K. A nationwide family study of pulmonary embolism: identification of high risk families with increased risk of hospital-ized and fatal pulmonary embolism. Thromb Res. 2012;130(2):178-82.

102. Zöller B, Li X, Sundquist J, Sundquist K. Autoimmune diseases and venous thromboembolism: a review of the literature. Am J Cardiovasc Dis. 2012;2(3):171-83.

103. Zöller B, Li X, Sundquist J, Sundquist K. Multiplex sibling history of coronary heart disease is a strong risk factor for coronary heart disease. Eur Heart J. 2012;33(22):2849-55.

104. Zöller B, Li X, Sundquist J, Sundquist K. Neighbor-hood deprivation and hospitalization for venous thromboembolism in Sweden. J Thromb Thromboly-sis. 2012;34(3):374-82.

105. Zöller B, Li X, Sundquist J, Sundquist K. Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from Sweden. Lancet. 2012;379(9812):244-9.

106. Zöller B, Li X, Sundquist J, Sundquist K. Risk of subsequent coronary heart disease in patients hospitalized for immune-mediated diseases: a na-tionwide follow-up study from Sweden. PLoS One. 2012;7(3):e33442.

107. Zöller B, Li X, Sundquist J, Sundquist K. Risk of subsequent ischemic and hemorrhagic stroke in patients hospitalized for immune-mediated diseases: a nationwide follow-up study from Sweden. BMC Neurol. 2012;12:41.

108. Zöller B, Li X, Sundquist J, Sundquist K. Risk of venous thromboembolism in first- and second-generation immigrants in Sweden. Eur J Intern Med. 2012;23(1):40-7.

109. Zöller B, Li X, Sundquist J, Sundquist K. Socio-economic and occupational risk factors for venous thromboembolism in Sweden: a nationwide epide-miological study. Thromb Res. 2012;129(5):577-82.

110. Zöller B, Ohlsson H, Sundquist J, Sundquist K. Family history as a risk factor for recurrent hospitalization for lone atrial fibrillation: a nationwide family study in Sweden. BMC Cardiovasc Disord. 2012;12:121.

SocialmedicinochHälsoekonomi111. Ahnquist J, Wamala SP, Lindström M. Social deter-

minants of health - a matter of social or economic capital? Interaction effects of socioeconomic factors and social capital on mental health disorders. Soc Sci Med. 2012;74(6):930-9.

112. Amiri, A, Gerdtham, U-G, Ventelou, B. HIV/AIDS-GDP Nexus? Evidence from panel-data for African countries. Econom Bull. 2012;32(1):1060-7.

113. Chaix B, Bean K, Daniel M, Zenk SN, Kestens Y, Charreire H, Leal C, Thomas F, Karusisi N, Weber C, Oppert JM, Simon C, Merlo J, Pannier B. Asso-ciations of supermarket characteristics with weight status and body fat: a multilevel analysis of individu-als within supermarkets (RECORD study). PLoS One. 2012;7(4):e32908.

114. Chaix B, Kestens Y, Bean K, Leal C, Karusisi N, Meg-hiref K, Burban J, Fon Sing M, Perchoux C, Thomas F, Merlo J, Pannier B. Chaix B, Kestens Y, Bean K, Leal C, Karusisi N, Meghiref K, Burban J, Fon Sing M, Perchoux C, Thomas F, Merlo J, Pannier B. Cohort profile: residential and non-residential environments, individual activity spaces and cardiovascular risk fac-tors and diseases - the RECORD Cohort Study. Int J Epidemiol. 2012;41(5):1283-92.

115. Chaix B, Kestens Y, Perchoux C, Karusisi N, Merlo J, Labadi K. An interactive mapping tool to assess indi-vidual mobility patterns in neighborhood studies. Am J Prev Med. 2012;43(4):440-50.

116. Den Ruijter HM, Peters SA, Anderson TJ, Britton AR, Dekker JM, Eijkemans MJ, Engström G, Evans GW, de Graaf J, Grobbe DE, Hedblad B, Hofman A, Holewijn S, Ikeda A, Kitagawa K, Kitamura A, Koffijberg H, Lonn EM, Lorenz MW, Mathiesen EB, Nijpels G, Okazaki S, O’Leary DH, Polak JF, Price JF, Robertson C, Rembold CM, Rosvall M, Rundek T, Salonen JT, Sitzer M, Stehouwer CD, Witteman JC, Moons, Bots ML. Common carotid intima-media thickness measurements in cardiovascular risk pre-diction: a meta-analysis. JAMA. 2012;308(8):796-803.

117. Giordano G, Björk J, Lindström M. Social capital and self-rated health - a study of temporal (causal) rela-tionships. Soc Sci Med. 2012;75(2):340-8.

118. Giordano G, Lindström M. Socialt kapital och självrapporterad hälsa- en undersökning av samband med longitudinella analyser och flernivåanalyser. Soc Med Tidskr. 2012;89(4-5):367-77.

119. Hjalte, F, Brännström, J, Gerdtham, U-G. Societal costs of hearing disorders: a systematic and critical review of literature. Int J Audiol. 2012;51(9);655-62.

120. Hjerpe P, Boström KB, Lindblad U, Merlo J. Increased registration of hypertension and cancer diagnoses af-ter the introduction of a new reimbursement system. Scand J Prim Health Care. 2012;30(4):222-8.

121. Isma N, Merlo J, Ohlsson H, Svensson PJ, Lindblad B, Gottsäter A. Socioeconomic factors and concomitant diseases are related to the risk for venous thromboem-bolism during long time follow-up. J Thromb Throm-bolysis. (In press).

122. Ivert AK, Merlo J, Svensson R, Levander MT. How are immigrant background and gender associated with the utilisation of psychiatric care among adolescents? Soc Psychiatry Psychiatr Epidemiol. (In press).

36

Scientific Output

37

123. Jarl J, Gerdtham U-G. Does drinking affect job per-formance? A Heckman analysis of the effect of current and past alcohol consumption on sickness absentee-ism. Applied Econom. 2012;44(22):2811-25.

124. Librero J, Peiró S, Leutscher E, Merlo J, Bernal-Delga-do E, Ridao M, Martínez-Lizaga N, Sanfélix-Gimeno G. Timing of surgery for hip fracture and in-hospital mortality: a retrospective population-based cohort study in the Spanish National Health System. BMC Health Serv Res. 2012;12:15.

125. Lindeberg S, Rosvall M, Östergren PO. Exhaustion predicts coronary heart disease independently of symptoms of depression and anxiety in men but not in women. J Psychosom Res. 2012;72(1):17-21.

126. Lindström M, Ali SM, Rosvall M. Socioeconomic sta-tus, labour market connection, and self-rated psycho-logical health: the role of social capital and economic stress. Scand J Public Health. 2012;40(1):50-9.

127. Lindström M, Axelsson J, Rosvall M. Experience of violation during the past three months, social capital and self-rated health: a population-based study. Scand J Public Health. 2012;40(8):753-60.

128. Lindström M, Hansen K, Rosvall M. Economic stress in childhood and adulthood, and self-rated health: a population based study concerning risk accumula-tion, critical period and social mobility. BMC Public Health. 2012;12:761.

129. Lindström M, Rosvall M. Marital status, social capital, and health locus of control: a population-based study. Public Health. 2012;126(9):790-5.

130. Lindström M, Rosvall M. Marital status, social capital, economic stress, and mental health: a population-based study. Soc Sci J. 2012;49(3):339-42.

131. Lindström M. Marital status and generalized trust in other people: a population-based study. Soc Sci J. 2012;49(1):20-3.

132. Lindström M. Socialt kapital och hälsa. Socialt kapital i socialmedicinsk forskning i Sverige. Soc Med Tidskr. 2012; 89(4-5):307-12.

133. Merlo J, Ohlsson H, Chaix B, Lichtenstein P, Kawachi I, Subramanian SV. Revisiting causal neighborhood effects on individual ischemic heart disease risk: a quasi-experimental multilevel analysis among Swed-ish siblings. Soc Sci Med. 2013;76(1):39-46.

134. Merlo J, Viciana-Fernández FJ, Ramiro-Fariñas D; Research Group of Longitudinal Database of Andalu-sian Population (LDAP). Bringing the individual back to small-area variation studies: a multilevel analysis of all-cause mortality in Andalusia, Spain. Soc Sci Med. 2012;75(8):1477-87.

135. Modén B, Ohlsson H, Merlo J, Rosvall M. Psychotrop-ic drugs and accidents in Scania, Sweden. Eur J Public Health. 2012;22(5):726-32.

136. Ohrlander T, Merlo J, Ohlsson H, Sonesson B, Acosta S. Socioeconomic position, comorbidity, and mortal-ity in aortic aneurysms: a 13-year prospective cohort study. Ann Vasc Surg. 2012;26(3):312-21.

137. Rohrmann S, Steinbrecher A, Linseisen J, Hermann S, May A, Luan J, Ekelund U, Overvad K, Tönneland A, Halkjaer J, Fagheraazzi G, Boutron-Ruault MC, Clavel-Chapelon F, Agnoli C, Tumino R, Masala G, Mattiello A, Ricceri F, Travier N, Amiano P, Ardanaz E, Chirlaque MD, Sanchez MJ, Rodriguez L, Milsson LM, Johansson I, Hedblad B, Rosvall M, Lund E, Braaten T, Naska A, Ofranos P, Trichopoulou A, van den Berg S, Bueno-de-Mesquita HB, Bergmann MM, Steffen A, Kaaks R, Teucher B, Wareham NJ, Khaw KT, Crowe FL, Illner AK, Slimani N, Gallo V, Mouw T, Norat T, Peeters PH. The association of education with long-term weight change in the EPIC-PANACEA cohort. Eur J Clin Nutr. 2012;66(8):957-63.

138. Van Leeuwen W, Nilsson S, Merlo J. Mother’s country of birth and prescription of psychotropic medication in Swedish adolescents: a life course approach. BMJ Open. 2012;2(5): e001260.

139. Wingren CJ, Agardh D, Merlo J. Acculturation and celiac disease risk in second-generation immigrants: a nationwide cohort study in Sweden. Scand J Gastroen-terol. 2012;47(10):1174-80.

140. Wingren CJ, Agardh D, Merlo J. Congenital anoma-lies and childhood celiac disease in Sweden. J Pediatr Gastroenterol Nutr. 2012;55(6):736-9.

141. Wingren CJ, Agardh D, Merlo J. Revisiting the risk of celiac disease in children born small for gestational age: a sibling design perspective. Scand J Gastroen-terol. 2012;47(6):632-9.

142. Wingren CJ, Agardh D, Merlo J. Sex differences in coeliac disease risk: a Swedish sibling design study. Dig Liver Dis. 2012;44(11):909-13.

143. Wingren CJ, Björck S, Lynch KF, Ohlsson H, Agardh D, Merlo J. Coeliac disease in children: a social epidemiological study in Sweden. Acta Paediatr. 2012;101(2):185-91.

Scientific Output

Center for Primary Health Care Research

CRC, Building 28, Floor 11

Jan Waldenströms gata 35

Skåne University Hospital

Malmö

Contact details:

www.cpf.se

Editing:

Per Condelius, Stephen Gilliver, Anna Hedelius, Bertil Kjellberg, Helene Rosenqvist, Emelie Stenman

Responsibility for text: Jan Sundquist

Translation: Stephen Gilliver

Graphic design: Bertil Kjellberg

38

www.cpf.se

CPF

The CPF conducts epidemiological, qualitative, clinical, and experimen-tal research with primary care as its foundation, and with a focus on major diseases that can be prevented by improving lifestyle habits.

Our research should be world leading and our goal is to provide a solid scientific basis for well-functioning, attractive primary care and improved public health.

2012Annual Report