Karin Hellström Ängerud

Aim: To explore how cardiovascular risk communication is constructed, negotiated and enacted in practice to persons with type 2 diabetes. Design: Qualitative. Methods: Individual interviews were conducted with 14 HCPs in primary care. Data were analysed using the constructivist grounded theory method. Results: The core category, ‘Striving to enhance cardiovascular risk awareness in persons with type 2 diabetes while balancing responsibility and uncertainty’, captures the challenges in making CVD risk understandable and meaningful for patients. Four categories describe the HCPs' work: Navigating a complex assessment of cardiovascular risk, struggling to communicate cardiovascular risk in a pedagogical way, trying to build a trusting relationship and simultaneously highlighting the disease severity, and experiencing loneliness and requesting organisational changes. Conclusions: Healthcare professionals (HCPs) recognised their significant responsibility for cardiovascular risk communication, but simultaneously experienced uncertainty about how to assess patients' individual CVD risk. Diabetes specialist nurses described feelings of professional isolation, limited medical support from physicians and a lack of shared responsibility within the diabetes care team. HCPs also requested sufficient organisational resources. Implications for the Profession: Communicating cardiovascular risk remains difficult. Strengthening the role of HCPs in risk communication and ensuring they adopt a more person‐centred approach are essential to improving risk communication in primary healthcare. Impact: To assess cardiovascular risk and reveal patients' understanding, HCPs must go beyond education, build trust and understanding, and balance encouragement with demands. Reporting Method: COREQ checklist. Patient or Public Contribution: No patient or public contribution.

Background: Many persons with type 2 diabetes (T2D) lack risk awareness or underestimate their cardiovascular risk. Although health care professionals in primary health care strive to implement risk-awareness strategies for cardiovascular risk, persons with T2D report a lack of meaningful dialogue with health care professionals. Co-creation is grounded in participatory action research and involves participants as equal partners across all stages of a project. This study describes the development of an intervention to increase cardiovascular risk awareness in people with T2D. Objective: This study aims to describe the co-creation process of developing an intervention to increase awareness of cardiovascular risk in persons with T2D. Methods: A co-creative design was used to develop an intervention following a participatory action research framework. Four workshops with persons with T2D, diabetes specialist nurses, and physicians in primary health care explored communication about cardiovascular risk, co-identified needs, co-designed solutions, tested prototypes, and redefined and retested the content of the intervention. The data were analyzed using reflexive thematic analysis. Results: The analysis identified 4 themes: co-define: taking the person’s voice into account; co-design: problem-solving and generating ideas; prototype and test: drafting intervention proposals; and redefine and retest: reviewing suggested interventions. The workshop discussions highlighted the need for new interventions, including a risk assessment tool, a patient handbook, material to prompt reflection, and a web education for specialist diabetes nurses. Conclusions: This study demonstrates the value of co-creation, which was used to develop an intervention to enhance cardiovascular risk awareness in persons with T2D. Diabetes specialist nurses need to explore patients’ perceptions of risk and provide space for emotional responses. The web education is intended to strengthen the person-centered approach of diabetes specialist nurses, the patient handbook encourages reflection and dialogue on personal risk, and the risk assessment tool visualizes individual risk. These components may contribute to increased awareness of cardiovascular risk.

Aims: To evaluate the effects of a nurse-led, person-centred outpatient clinic on patient-reported outcomes in patients with atrial fibrillation (AF). Methods and results: In this open-label, parallel randomized controlled trial, 140 patients with AF were randomly assigned. The intervention group met experienced cardiac nurses, trained in person-centred care and AF. The control group met a physician in accordance with usual care. At baseline, and after 6 months, patients completed questionnaires: The EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the EuroQol Visual Analogue Scale, the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA), the Brief Illness Perception Questionnaire (B-IPQ), and the Hospital Anxiety and Depression Scale. Over time, health-related quality of life (HRQoL), as measured by the EQ-5D index and the ASTA mental subscale, improved in the intervention group (P = 0.035 and P = 0.014, respectively) and the control group (P = 0.031 and P = 0.026, respectively). Illness coherence (B-IPQ) also improved in both groups (P < 0.001 and P = 0.012, respectively). In the nurse-led group, HRQoL as measured by the ASTA total scale (P = 0.035) and personal control (B-IPQ) (P = 0.005) improved, while illness-related concerns (P = 0.008) and emotional representations (B-IPQ) (P = 0.001) decreased. There were no significant between-group differences on any of the analysed measurement instruments. Conclusion: No significant differences were observed between groups. However, improvements in HRQoL and illness coherence in both groups suggest that receiving support from nurses and physicians may improve these outcomes. Furthermore, the results suggest that a nurse-led, person-centred outpatient clinic may reduce patients’ emotional responses and concerns related to the illness, while strengthening their sense of personal control. Registration: ClinicalTrials.gov ID: NCT04609202.

BACKGROUND Many persons with type 2 diabetes lack risk awareness or underestimate their cardiovascular risk. Although healthcare professionals in primary healthcare strive to implement risk-awareness strategies for cardiovascular risk, persons with type 2 diabetes report a lack of meaningful dialogue with the healthcare professionals. Co-creation is grounded in Participatory Action Research (PAR) and involves participants as equal partners across all stages of a project. This study describes the development of an intervention to increase cardiovascular risk awareness in people with type 2 diabetes. OBJECTIVE To describe the co-creation process of developing an intervention to increase awareness of cardiovascular risk in persons with type 2 diabetes (T2D). METHODS Design:A co-creative design was used to develop an intervention following a Participatory Action Research (PAR) framework. Methods: Four workshops with persons with T2D, diabetes specialist nurses, and physicians in primary healthcare explored communication about cardiovascular risk, co-identified needs, co-designed solutions, tested prototypes, and redefined and retested the content of the intervention. Data were analysed using reflexive thematic analysis. RESULTS The analysis identified four themes: Co-define: Taking the person’s voice into account; Co-design: problem-solving and generating ideas; Prototype and test: drafting intervention proposals; and Re-define and re-test: reviewing suggested interventions. The workshop discussions highlighted the need for new interventions, including a risk-assessment tool, a patient handbook, material to prompt reflection, and a webb education for specialist diabetes nurses. CONCLUSIONS This study demonstrates the value of co-creation, which was used to develop an intervention to enhance cardiovascular risk awareness in persons with T2D. Diabetes specialist nurses need to explore patients’ perceptions of risk and provide space for emotional responses. The Webb education is intended to strengthen the person-centred approach of diabetes specialist nurses, the patient handbook encourages reflection and dialogue on personal risk, and the risk-assessment tool visualises individual risk. These components may contribute to increased awareness of cardiovascular risk.

Objective: To assess a systematic implementation approach for introducing dapagliflozin to individuals with heart failure and reduced ejection fraction in an outpatient clinical setting. Methods: Retrospective medical record data were analysed. All individuals diagnosed with heart failure who resided within the hospital catchment area and had visited cardiology or internal medicine department between 2010 and 2019 were screened by using the main inclusion criteria from the DAPA-HF trial. The effectiveness of the previously described seven-step systematic implementation approach was assessed by the proportion receiving information letter, dapagliflozin treatment, follow-ups at 2–12 weeks and 12 months post-dapagliflozin initiation, persistence on dapagliflozin, adverse events, and reasons for discontinuation. Results: Of the 2433 individuals, 352 met the main DAPA-HF trial criteria in step 2. After exclusions in steps 3 and 4, 191 individuals remained. Of these, 158 were invited for eligibility discussion in step 5, with 107 having received an information letter beforehand. In step 6, dapagliflozin was prescribed to 69 individuals, and in step 7, follow-ups were conducted with 56 individuals at 2–12 weeks and 62 individuals at 12 months. Sixty out of 69 persisted on dapagliflozin after 12 months. Adverse events were reported by nine individuals. Discontinuation was attributed to reasons such as urinary tract infections, genital or abdominal discomfort, and hypotension. Conclusion: The systematic introduction of dapagliflozin to heart failure patients was effective. Despite this, challenges in uniformly implementing procedures across patients were evident, emphasizing the necessity for a systematic implementation approach.

To compare patient-reported outcomes (PROs) in patients newly (n = 53), compared with patients with a previous diagnosis (n = 76), reported AF as more temporary (P = 0.003) and had a higher belief in personal and treatment control (P = 0.004 and P = 0.041, respectively). At a 6-month follow-up, patients newly diagnosed reported a lower symptom burden (P = 0.004), better health-related quality of life (HRQoL); (P = 0.015), and a higher personal control (P < 0.001) than patients previously diagnosed. Over time, in patients newly diagnosed, symptom burden and the anxiety symptom score decreased (P = 0.001 and P = 0.014, respectively) and HRQoL improved (P = 0.002). Patients newly diagnosed with AF reported more positive PROs both at baseline and at a 6-month follow-up than patients with a previous diagnosis of AF. Therefore, it is important to quickly capture patients newly diagnosed to support their belief in their own abilities. Such support may, alongside medical treatments, help patients manage the disease, which may lead to reduced symptom burden and better HRQoL over time.

To describe the process of becoming aware of and acting on personal cardiovascular (CVD) risk in type 2 diabetes (T2D). A purposive sample of 14 persons living with T2D participated in semi-structured, open-ended, in-dept interviews. The interviews were analysed with grounded theory. The analysis identified the core category "Balancing emotions, integrating knowledge and understanding to achieve risk awareness and act on it." Five categories describe the movement from not being aware of the risk of cardiovascular disease (CVD) to becoming aware of this risk and taking action to reduce it. Persons with T2D need to transform their knowledge and experience of CVD risk and incorporate it in their individual situations. Emotional and existential experiences of CVD risk can lead to awareness about the severity of the condition and contribute to increased motivation for self-management. However, an overly high emotional response can be overwhelming and may result in insufficient self-management. Persons with T2D seemed not to fully grasp their increased risk of CVD or recognize that self-management activities were aimed at reducing this risk. However, their awareness of CVD risk gradually increased as they came to understand the severity of T2D and became more emotionally and existentially engaged.

Background: Health-related quality of life (HRQoL) is worse in patients with atrial fibrillation (AF) compared with other populations. Factors affecting HRQoL in patients with AF are not fully clarified. Illness perceptions are important determinants of disease management and may affect HRQoL. Objective: The aims of this study were to describe illness perceptions and HRQoL in women and men with AF and to explore the relationship between illness perceptions and HRQoL in patients with AF. Methods: This cross-sectional study included 167 patients with AF. Patients completed the Revised Illness Perception Questionnaire and HRQoL questionnaires: Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias, the three-level version of the EuroQol 5-dimensional questionnaire, and EuroQol visual analog scale. Subscales of the Revised Illness Perception Questionnaire significant in correlation analysis with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias HRQoL total scale were included in a multiple linear regression model. Results: Mean age was 68.7 ± 10.4 years, and 31.1% were women. Women reported lower personal control (P = .039) and worse HRQoL measured with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias physical subscale (P = .047) and the EuroQol visual analog scale (P = .044) compared with men. Illness identity (P < .001), consequences (P = .031), emotional representation (P = .014), and timeline cyclical (P = .022) were related to and adversely affected HRQoL. Conclusions: This study found a relationship between illness perceptions and HRQoL. Some subscales of illness perceptions negatively affected HRQoL in patients with AF, which indicates that efforts to change illness perceptions may be helpful in improving HRQoL. Patients should be given the opportunity to talk about the disease, their symptoms, their emotions, and the consequences of the disease to enable increased HRQoL. A challenge for healthcare will be to design support for each patient based on his/her illness perceptions.

Aim To explore the experiences of living with symptomatic atrial fibrillation. Design This study, with a descriptive qualitative design, was performed using semi-structured individual interviews. Method Six women and nine men with symptomatic atrial fibrillation were included. The transcribed interviews were analysed using qualitative content analysis. The COREQ checklist was followed. Results The analysis resulted in a main theme, namely balancing life and included the themes striving for illness control, becoming a receiver or an active partner in care and dealing with changed self-image. The participants strived to understand their illness, prevent attacks and manage anxiety. Some of the participants were not involved in decision-making, were uninformed about self-care measures, reported a lack of continuity in care and felt that the doctors focused on information about the medical part of care.

Background: Patient-reported symptoms of acute myocardial infarction (MI) may be affected by recall bias depending on when and where symptoms are assessed. Aim: The aim of this study was to gain an understanding of patients' symptom description in more detail before and within 24 hours after a confirmed MI diagnosis. Methods: A convergent parallel mixed-methods design was used to examine symptoms described in calls between the tele-nurse and the patient compared with symptoms selected by the patient from a questionnaire less than 24 hours after hospital admission. Quantitative and qualitative data were analyzed separately and then merged into a final interpretation. Results: Thirty patients (median age, 67.5 years; 20 men) were included. Chest pain was the most commonly reported symptom in questionnaires (24/30). Likewise, in 19 of 30 calls, chest pain was the first complaint mentioned, usually described together with the symptom onset. Expressions used to describe symptom quality were pain, pressure, discomfort, ache, cramp, tension, and soreness. Associated symptoms commonly described were pain or numbness in the arms, cold sweat, dyspnea, weakness, and nausea. Bodily sensations, such as feeling unwell or weak, were also described. Fear and tiredness were described in calls significantly less often than reported in questionnaires (P = .01 and P = .02), whereas “other” symptoms were more often mentioned in calls compared with answers given in the questionnaire (P = .02). Some symptoms expressed in the calls were not listed in the questionnaire, which expands the understanding of acute MI symptoms. The results showed no major inconsistencies between datasets. Conclusion: Patients' MI symptom descriptions in tele-calls and those reported in questionnaires after diagnosis are comparable and convergent.