OBJECTIVE: The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward.

METHODS: Narrative literature review.

RESULTS: Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety.

CONCLUSIONS: There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.

HIGHLIGHTS

• There are weaknesses in the current approaches to investigations of suicide.
• A paradigm shift in investigations is needed to contribute to a better understanding of suicide.
• New knowledge of suicidal behavior, prevention, and patient safety must be applied.

Ständiga förbättringar är det utvecklingsarbete där alla kan bidra. Allasdelaktighet i det systematiska förbättringsarbetet är både den storamöjligheten och den stora utmaningen. Att i liten skala systematiskt pröva,göra och utvärdera är den bärande idén i allt förbättringsarbete. Dettakapitel belyser olika exempel på hur ett systematiskt förbättringsarbetebrutits ned till ”ständiga förbättringar” genom att bli en del av det dagligaarbetet i vård, omsorg och behandling i socialtjänsten.

Patienter och professionella vårdaktörer är i en gemensam förändrings- och lärandeprocess, där vården parallellt med medborgarna och samhället lär sig hantera digitalisering. Under senare år, bl.a. pådrivet av covid-pandemin, har digitaliseringen och införande av nya arbetssätt gått så fort att utvärdering och forskning inte hunnit med i samma takt. Syftet med rapporten ”Hur klickar vi med vården?” är att bidra med aktuell kunskap om patienters användarmönster och erfarenheter av digitala och fysiska kontakter med primärvården. Resultaten är tänkt att användas som faktaunderlag och stöd för vårdens utvecklingsarbete.

Sveriges Kommuner och Regioner (SKR) tog hösten 2022 initiativet till forskningsprojektet ”Hur klickar vi med vården?”. Uppdraget genomfördes under 2023 av en oberoende forskargrupp på Hälsohögskolan vid Jönköping University. Resultaten är presenterade i två delstudier baserade på registerdata från primärvården och intervjuer med patienter. All registrerad data från den regionala primärvården i Region Jönköpings län och Region Sörmland under perioden januari 2020 – december 2022 har ingått i undersökningen. Data från Region Jönköpings län omfattar ca 352.000 personer vilka sammanlagt hade haft kontakt med primärvården ca 4,2 miljoner gånger, motsvarande för Region Sörmland var ca 245.000 personer som hade haft ca 3,2 miljoner kontakter. I dessa data ingår kontakter med privata helt digitala vårdgivare och för Region Jönköpings län data från 1177 Sjukvårdsrådgivning. I rapporten ingår även 35 kvalitativa intervjuer med ett nationellt urval av patienter. Resultatet av den kvalitativa studien är presenterat som sex teman som beskriver patienters erfarenheter av kontakt med vården.

Objectives: To explore the association between prestroke mobility dependency and dementia on functioning and mortality outcomes after stroke in patients>65 years of age.

Design: Longitudinal cohort study based on SveDem, the Swedish Dementia Registry and Riksstroke, the Swedish Stroke Registry.

Participants: A total of 1689 patients with dementia >65 years of age registered in SveDem and suffering a first stroke between 2007 and 2014 were matched with 7973 controls without dementia with stroke.

Measurements: Odds ratios (ORs) and 95% confidence intervals (CIs) for intrahospital mortality, and functioning and mortality outcomes at 3 months were calculated. Functioning included level of residential assistance (living at home without help, at home with help, or nursing home) and mobility dependency (independent, needing help to move outdoors, or needing help indoors and outdoors).

Results: Prestroke dependency in activities of daily living and mobility were worse in patients with dementia than controls without dementia. In unadjusted analyses, patients with dementia were more often discharged to nursing homes (51% vs 20%; P < .001). Mortality at 3 months was higher in patients with dementia (31% vs 23% P < .001) and fewer were living at home without help (21% vs 55%; P < .001). In adjusted analyses, prestroke dementia was associated with higher risk of 3-month mortality (OR 1.34; 95% CI 1.18-1.52), requiring a higher level of residential assistance (OR 4.07; 3.49-.75) and suffering from more dependency in relation to mobility (OR 2.57; 2.20-3.02). Patients with dementia who were independent for mobility prestroke were more likely to be discharged to a nursing home compared with patients without dementia with the same prestroke mobility (37% vs 16%; P < .001), but there were no differences in discharge to geriatric rehabilitation (19% for both; P = .976). Patients, who moved independently before stroke, were more often discharged home (60% vs 28%) and had lower mortality. In adjusted analyses, prestroke mobility limitations were associated with higher odds for poorer mobility, needing more residential assistance, and death.

Conclusions: Patients with mobility impairments and/or dementia present a high burden of disability after a stroke. There is a need for research on stroke interventions among these populations.

OBJECTIVES: The causes of death in dementia are not established, particularly in rarer dementias. The aim of this study is to calculate risk of death from specific causes for a broader spectrum of dementia diagnoses.

DESIGN: Cohort study.

SETTING: Swedish Dementia Registry (SveDem), 2007-2012.

PARTICIPANTS: Individuals with incident dementia registered in SveDem (N = 28,609); median follow-up 741 days. Observed deaths were 5,368 (19%).

MEASUREMENTS: Information on number of deaths and causes of mortality was obtained from death certificates. Odds ratios for the presence of dementia on death certificates were calculated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox hazards regression for cause-specific mortality, using Alzheimer's dementia (AD) as reference. Hazard ratios for death for each specific cause of death were compared with hazard ratios of death from all causes (P-values from t-tests).

RESULTS: The most frequent underlying cause of death in this cohort was cardiovascular (37%), followed by dementia (30%). Dementia and cardiovascular causes appeared as main or contributory causes on 63% of certificates, followed by respiratory (26%). Dementia was mentioned less in vascular dementia (VaD; 57%). Compared to AD, cardiovascular mortality was higher in individuals with VaD than in those with AD (HR = 1.82, 95% CI = 1.64-2.02). Respiratory death was higher in individuals with Lewy body dementia (LBD, including Parkinson's disease dementia and dementia with Lewy bodies, HR = 2.16, 95% CI = 1.71-2.71), and the risk of respiratory death was higher than expected from the risk for all-cause mortality. Participants with frontotemporal dementia were more likely to die from external causes of death than those with AD (HR = 2.86, 95% CI = 1.53-5.32).

CONCLUSION: Dementia is underreported on death certificates as main and contributory causes. Individuals with LBD had a higher risk of respiratory death than those with AD.

BACKGROUND: the increasing prevalence of Alzheimer's dementia (AD) has shifted the burden of management towards primary care (PC). Our aim is to compare diagnostic process and management of AD in PC and specialist care (SC).

DESIGN: cross-sectional study.

SUBJECTS: a total of, 9,625 patients diagnosed with AD registered 2011-14 in SveDem, the Swedish Dementia Registry.

METHODS: descriptive statistics are shown. Odds ratios are presented for test performance and treatment in PC compared to SC, adjusted for age, sex, Mini-Mental State Examination (MMSE) and number of medication.

RESULTS: a total of, 5,734 (60%) AD patients from SC and 3,891 (40%) from PC. In both, 64% of patients were women. PC patients were older (mean age 81 vs. 76; P < 0.001), had lower MMSE (median 21 vs. 22; P < 0.001) and more likely to receive home care (31% vs. 20%; P < 0.001) or day care (5% vs. 3%; P < 0.001). Fewer diagnostic tests were performed in PC and diagnostic time was shorter. Basic testing was less likely to be complete in PC. The greatest differences were found for neuroimaging (82% in PC vs. 98% in SC) and clock tests (84% vs. 93%). These differences remained statistically significant after adjusting for MMSE and demographic characteristics. PC patients received less antipsychotic medication and more anxiolytics and hypnotics, but there were no significant differences in use of cholinesterase inhibitors between PC and SC.

CONCLUSION: primary and specialist AD patients differ in background characteristics, and this can influence diagnostic work-up and treatment. PC excels in restriction of antipsychotic use. Use of head CT and clock test in PC are areas for improvement in Sweden.

This study investigated the systematic rise in cognitive ability scores over generations, known as the Flynn Effect, across middle childhood and early adolescence (7–15 years; 291 monozygotic pairs, 298 dizygotic pairs; 89% White). Leveraging the unique structure of the Louisville Twin Study (longitudinal data collected continuously from 1957 to 1999 using the Wechsler Intelligence Scale for Children [WISC], WISC–R, and WISC–III ed.), multilevel analyses revealed between-subjects Flynn Effects—as both decrease in mean scores upon test re-standardization and increase in mean scores across cohorts—as well as within-child Flynn Effects on cognitive growth across age. Overall gains equaled approximately three IQ points per decade. Novel genetically informed analyses suggested that individual sensitivity to the Flynn Effect was moderated by an interplay of genetic and environmental factors.

BACKGROUND: Health care is becoming more complex. For an increasing number of individuals, interacting with health care means addressing more than just one illness or disorder, engaging in more than one treatment, and interacting with more than one care provider. Individuals with severe mental illnesses such as schizophrenia are disproportionately affected by this complexity. Characteristic symptoms can make it harder to establish and maintain relationships. Treatment failure is common even where there is access to effective treatments, increasing suicide risk. Knowledge of complex adaptive systems has been increasingly recognized as useful in understanding and developing health care. A complex adaptive system is a collection of interconnected agents with the freedom to act based on their own internalized rules, affecting each other. In a complex health care system, relevant feedback is crucial in enabling continuous learning and improvement on all levels. New technology has potential, but the failure rate of technology projects in health care is high, arguably due to complexity. The Nonadoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability (NASSS) framework and complexity assessment tool (NASSS-CAT) have been developed specifically to help identify and manage complexity in technology-related development projects in health care.

OBJECTIVE: This study aimed to use a pilot version of the NASSS-CAT instrument to inform the development and deployment of a point-of-care dashboard supporting schizophrenia care in west Sweden. Specifically, we report on the complexity profile of the project, stakeholders' experiences with using NASSS-CAT, and practical implications.

METHODS: We used complexity assessment to structure data collection and feedback sessions with stakeholders, thereby informing an emergent approach to the development and deployment of the point-of-care dashboard. We also performed a thematic analysis, drawing on observations and documents related to stakeholders' use of the NASSS-CAT to describe their views on its usefulness.

RESULTS: Application of the NASSS framework revealed different types of complexity across multiple domains, including the condition, technology, value proposition, organizational tasks and pathways, and wider system. Stakeholders perceived the NASSS-CAT tool as useful in gaining perspective and new insights, covering areas that might otherwise have been neglected. Practical implications derived from feedback sessions with managers and developers are described.

CONCLUSIONS: This case study shows how stakeholders can identify and plan to address complexities during the introduction of a technological solution. Our findings suggest that NASSS-CAT can bring participants a greater understanding of complexities in digitalization projects in general.

BACKGROUND: Co-production of health is defined as 'the interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and actions that contribute to the health of individuals and populations'. It can assume many forms and include multiple stakeholders in pursuit of continuous improvement, as in Learning Health Systems (LHSs). There is increasing interest in how the LHS concept allows integration of different knowledge domains to support and achieve better health. Even if definitions of LHSs include engaging users and their family as active participants in aspects of enabling better health for individuals and populations, LHS descriptions emphasize technological solutions, such as the use of information systems. Fewer LHS texts address how interpersonal interactions contribute to the design and improvement of healthcare services.

OBJECTIVE: We examined the literature on LHS to clarify the role and contributions of co-production in LHS conceptualizations and applications.

METHOD: First, we undertook a scoping review of LHS conceptualizations. Second, we compared those conceptualizations to the characteristics of LHSs first described by the US Institute of Medicine. Third, we examined the LHS conceptualizations to assess how they bring four types of value co-creation in public services into play: co-production, co-design, co-construction and co-innovation. These were used to describe core ideas, as principles, to guide development.

RESULT: Among 17 identified LHS conceptualizations, 3 qualified as most comprehensive regarding fidelity to LHS characteristics and their use in multiple settings: (i) the Cincinnati Collaborative LHS Model, (ii) the Dartmouth Coproduction LHS Model and (iii) the Michigan Learning Cycle Model. These conceptualizations exhibit all four types of value co-creation, provide examples of how LHSs can harness co-production and are used to identify principles that can enhance value co-creation: (i) use a shared aim, (ii) navigate towards improved outcomes, (iii) tailor feedback with and for users, (iv) distribute leadership, (v) facilitate interactions, (vi) co-design services and (vii) support self-organization.

CONCLUSIONS: The LHS conceptualizations have common features and harness co-production to generate value for individual patients as well as for health systems. They facilitate learning and improvement by integrating supportive technologies into the sociotechnical systems that make up healthcare. Further research on LHS applications in real-world complex settings is needed to unpack how LHSs are grown through coproduction and other types of value co-creation.

Background

Individuals with psychotic disorders experience widespread treatment failures and risk early death. Sweden’s largest department specializing in psychotic disorders sought to improve patients’ health by developing a point-of-care dashboard to support joint planning and co-production of care. The dashboard was tested for 18 months and included more than 400 patients at two outpatient clinics.

Methods

This study evaluates the dashboard by addressing two questions:

1. Can differences in health-related outcome measures be attributed to the use of the dashboard?
2. How did the case managers experience the accessibility, use, and usefulness of the dashboard for co-producing care with individuals with psychotic disorders? 

This mixed-method case study used both Patient-Reported Outcome Measures (PROM) and data from a focus group interview with case managers. Data collection and analysis were framed by the Clinical Adoption Meta Model (CAMM) phases: i) accessibility, ii) system use, iii) behavior, and iv) clinical outcomes. The PROM used was the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0), which assesses functional impairment and disability. Patients at clinics using the dashboard were matched with patients at clinics not using the dashboard. PROM data were compared using non-parametric statistics due to skewness in distribution. The focus group included five case managers who had experience using the dashboard with patients.

Results

Compared to patients from clinics that did not use the dashboard, patients from clinics that did use the dashboard improved significantly overall (p = 0.045) and in the domain self-care (p = 0.041). Focus group participants reported that the dashboard supported data feedback-informed care and a proactive stance related to changes in patients’ health. The dashboard helped users identify critical changes and enabled joint planning and evaluation.

Conclusion

Dashboard use was related to better patient health (WHODAS scores) when compared with matched patients from clinics that did not use the dashboard. In addition, case managers had a positive experience using the dashboard. Dashboard use might have lowered the risk for missing critical changes in patients’ health while increasing the ability to proactively address needs. Future studies should investigate how to enhance patient co-production through use of supportive technologies.

Background Patients diagnosed with cancer who are due to commence radiotherapy, often, despite the provision of a considerable amount of information, report a range of unmet information needs about the treatment process. Factors such as inadequate provision of information, or the stressful situation of having to deal with information about unfamiliar things, may influence the patient’s ability to comprehend the information. There is a need to further advance the format in which such information is presented. The composition of information should be tailored according to the patient’s individual needs and style of learning. Method and findings The PD methodology is frequently used when a technology designed artefact is the desired result of the process. This research is descriptive of its kind and provides a transparent description of the co-design process used to develop an innovative digital information tool employing PD methodology where several stakeholders participated as co-designers. Involving different stakeholders in the process in line with recommended PD activities enabled us to develop a digital information tool that has the potential to be relevant and user-friendly for the ultimate consumer. Conclusions Facilitating collaboration, structured PD activities can help researchers, healthcare professionals and patients to co-design patient information that meets the end users’ needs. Furthermore, it can enhance the rigor of the process, ensure the relevance of the information, and finally have a potential to employ a positive effect on the reach of the related digital information tool.

BACKGROUND: Individuals undergoing radiation therapy for breast cancer frequently request information before, throughout and after the treatment as a means to reduce distress. Nevertheless, the provision of information to meet individuals needs from their level of health literacy is often overlooked. Thus, individuals information needs are often unmet, leading to reports of discontent. Internet and digital information technology has significantly augmented the available information and changed the way in which persons accesses and comprehends information. As health information is no longer explicitly obtained from healthcare professionals, it is essential to examine the sequences of the health information process in general, and in relation to health literacy. This paper reports on qualitative interviews, targeting women diagnosed with breast cancer who were given access to a health information technology tool, Digi-Do, before commencing radiation therapy, during, and after treatment. METHODS: A qualitative research design, inspired by the integrated health literacy model, was chosen to enable critical reflection by the participating women. Semi-structured interviews were conducted with 15 women with access to a digital information tool, named Digi-Do, in addition to receiving standard information (oral and written) before commencing radiation therapy, during, and after treatment. A deductive thematic analysis process was conducted. RESULTS: The results demonstrate how knowledge, competence, and motivation influence women's experience of the health information process. Three main themes were found: Meeting interactive and personal needs by engaging with health information; Critical recognition of sources of information; and Capability to communicate comprehended health information. The findings reflect the women's experience of the four competencies: to access, understand, appraise, and apply, essential elements of the health information process. CONCLUSIONS: We can conclude that there is a need for tailored digital information tools, such as the Digi-Do, to enable iterative access and use of reliable health information before, during and after the radiation therapy process. The Digi-Do can be seen as a valuable complement to the interpersonal communication with health care professionals, facilitating a better understanding, and enabling iterative access and use of reliable health information before, during and after the radiotherapy treatment. This enhances a sense of preparedness before treatment starts.

Healthcare is in constant change with fast development in knowledge, new technology and varying needs and expectations from patients, citizens, management, and politicians. There is a challenge in balancing the involved actors´ focus, needs, preferences, and resources for healthcare improvement. Improvement of healthcare is an ongoing activity, sometimes managed and controlled, often not. A key ingredient for success is competence where the need for competence varies with perspectives of the improving actors. Actors in healthcare improvement are professionals, patients, politicians, management, citizens, researchers, research foundations and others. In this report a review of frameworks in healthcare improvement are presented together with management myths and questions around needs for healthcare improvement competence and capabilities currently on the agenda.

Most improvement initiatives of some size have substantial parts of IT and have had so for a considerable time. This rather long experience of more and less successful IT implementation and use is transparent and useful in all kinds of healthcare improvement. One important issue in this report is what has real impact is the actual understanding and use of innovations and artefacts by healthcare actors in a broad sense for healthcare improvement (e.g., new clinical evidence, clinical guidelines, process changes, information systems and more). The aim in this report is to review frameworks which can be useful in healthcare improvement as well as in the study of healthcare improvement.

Conclusions concern what is found to be important to study and understand healthcare improvement, considering the presented frameworks. Improvement of healthcare is present in all the frameworks but in different ways and what is emphasized concerning scope and focus. Improving healthcare take place in the interaction of at least two parts, one of which is healthcare professionals, and another is the patient/next-of-kin. Professionals and patient populations interact in processes of social networks and structures. Actors and context are useful concepts for understanding action (use) and its social contexts. The actual use of innovations is best understood in terms of integration into clinical activities and processes – actors’ interaction, coordination and communication activities and processes.

Theoretical implications are that there is a need for more research concerning meso and macro perspectives on methods for healthcare improvement, and the interplay of perspectives regarding the understanding of improvement in healthcare. Of course, a challenge is that the objects of improvement are complex adaptive systems of healthcare is not easily to catch in simple rules. They are genuinely difficult both to change and evaluate changes. Practical implications of the report support design and contents of education programs in improvement of healthcare, in better understanding usefulness, practice, use, and experience base. To help the understanding of the need and usefulness of integrating different perspectives for successful healthcare improvement, e.g., micro, meso, and macro perspectives, use of mixed methods and more. 

Introduction 

Hospital readmissions of older persons are common and often associated with complex health problems. The objectives were to analyze risk factors for readmission within 30 days from hospital discharge.

Methods

A prospective study with a multifactorial approach based on the population-based longitudinal Swedish Adoption/ Twin Study of Aging (SATSA) was conducted. During 9 years of follow-up, information on hospitalizations, readmissions and associated diagnoses were obtained from national registers. Logistic regression models controlling for age and sex were conducted to analyze risk factors for readmissions.

Results

Of the 772 participants, [mean age 69.7 (±11.1), 84 (63%)] were hospitalized and among these 208 (43%) had one or several readmissions within 30 days during the follow-up period. Most of the readmissions (57%) occurred within the frst week; mean days from hospital discharge to readmission was 7.9 (±6.2). The most common causes of admission and readmission were cardiovascular diseases and tumors. Only 8% of the readmissions were regarded as avoidable admissions. In a multivariate logistic regression, falling within the last 12 months (OR 0.57, p=0.039) and being a male (OR 1.84, p=0.006) increased the risk of readmission.

Conclusions

Most older persons that are readmitted return to hospital within the frst week after discharge. Experiencing a fall was a particular risk factor of readmission. Preventive actions should preferably take place already at the hospital to reduce the numbers of readmission. Still, it should be remembered that most readmissions were considered to be necessary.

Background: Hospitalization among older persons is not unusual and can lead to serious consequences such as iatrogenic conditions. Although the majority of the hospitalizations are necessary, there are probably a substantial number of hospitalizations that could be avoided. Many of those persons that are hospitalized are living at home, and are entitled for home health care, meaning that they can receive basic as well as advanced medical care in their own home. Little is known about older persons’ perceptions about seeking hospital care despite having home health care.

Aim: To explore older persons’ reasoning for seeking hospital care.

Method: Twenty-two older persons (age 66-93, 73 % females) living in southern Sweden, receiving home health care and having experiences of hospitalization, were interviewed about their health care experiences. The data was analyzed using qualitative content analysis.

Results: Preliminary results indicate that the older persons’ emotions, past experiences and perceptions of health care resources influenced transitions to hospital. The results are illustrated by three categories: Home health care design; Specific medical condition; and Superior care at hospital. Conclusion: Understanding about older persons’ arguments for seeking care at hospital may have implication for how the homecare staff encounters individual’s perceived needs. Further, fulfillment of perceived health needs may reduce avoidable hospitalization and consequently improve quality of life.

INTRODUCTION:

Research indicate that cognitive impairment might be related to hospitalization, but little is known about these effects over time.

OBJECTIVE:

To assess cognitive change before and after hospitalization among older adults in a population-based longitudinal study with up to 25 years of follow-up.

METHOD:

A longitudinal study on 828 community living men and women aged 50-86 from the Swedish Adoption/Twin Study of Ageing (SATSA) were linked to The Swedish National Inpatient Register. Up to 8 assessments of cognitive performance (general cognitive ability, verbal, spatial/fluid, memory, and processing speed) from 1986 to 2010 were available. Latent growth curve modelling was used to assess the association between cognitive performance and hospitalization including spline models to analyse cognitive trajectories pre- and post-hospitalization.

RESULTS:

A total of 735 persons (89%) had at least one hospital admission during the follow-up. Mean age at first hospitalization was 70.2 (±9.3)years. Persons who were hospitalized exhibited a lower mean level of cognitive performance in general ability, processing speed and spatial/fluid ability compared with those who were not hospitalized. The two-slope models revealed steeper cognitive decline before hospitalization than after among those with at least one hospitalization event, as compared to non-hospitalized persons who showed steeper cognitive decline after the centering age of 70 years.

CONCLUSIONS:

Persons being hospitalized in late life have lower cognitive performance across all assessed domains. The results indicate that the main decline occurs before the hospitalization, and not after. This might indicate that when you get treatment you also benefit cognitively.

Background: Hospitalization among older people is common and associated with adverse outcomes. However, knowledge about long-term effects on motor functions and cognitive abilities in relation to hospitalization is scarce. In order to explore development of motor functions and cognition after hospitalization, a longitudinal study among middle-aged and older adults with up to 25 years of follow-up was conducted.

Methods: Overall, 828 participants from the Swedish Adoption/Twin Study of Ageing (SATSA) were linked to the Swedish National Inpatient Register, which contains information on participants’ hospital admissions. Up to 8 assessments of cognitive performance and 7 assessments of motor functions i.e. fine motor, balance/upper strength, and flexibility, from 1986 to 2010 were available. Latent growth curve modelling was used to assess the association between hospitalization and subsequent motor function and cognitive performance.

Results: A total of 735 (89 %) persons had at least one hospital admission during the follow-up. The mean age at first hospitalization was 70.2 (± 9.3) years. Persons who were hospitalized exhibited a lower mean level of cognitive performance in all domains and in motor functions compared with those who were not hospitalized. A significantly steeper decline was observed in motor function abilities as well as in processing speed, spatial/fluid, and general cognitive ability performance of hospitalized participants. These patterns remained even after comorbidities and dementia prevalence were controlled for.

Discussion: We are the first to show that hospitalization is associated with steeper decline in both motor function and cognitive abilities across more than two decades of post-hospitalization follow-up.

BACKGROUND: In the last years of life, burden of disease and disability and need of health- and social care often increase. Social, functional and psychological factors may be important in regard to social- and health care utilization. This study aims to describe use of health- and social care during the last year of life among persons living in ordinary housing or in assisted living facilities.

METHODS: A retrospective study examining health- and social care utilization during their last year of life, using a subsample from the Swedish twin registries individually linked to several Swedish national quality registries (NQR). Persons that died during 2008-2009 and 2011-2012 (n = 1518) were selected.

RESULTS: Mean age at death was 85.9 ± 7.3 (range 65.1-109.0). Among the 1518 participants (women n = 888, 58.5%), of which 741 (49%) were living in assisted living facilities and 1061 (69.9%) had at least one hospitalization during last year of life. The most common causes of death were cardiovascular disease (43.8%) and tumors (15.3%). A multivariable logistic regression revealed that living in ordinary housing, younger age and higher numbers of NQR's increased the likelihood of hospitalization.

CONCLUSIONS: Persons in their last year of life consumed high amount of health- and social care although 12% did not receive any home care. Married persons received less home care than never married. Persons living in ordinary housing had higher numbers of hospitalizations compared to participants in assisted living facilities. Older persons and persons registered in fewer NQR's were less hospitalized.

Ingress: Värnamo kommun har hamnat i en rävsax till följd av de krav Svenska Fotbollsförbundet (SvFF) ställer på arenor för föreningar som når svensk elitfotboll. Antingen beslutar man om att starta arenabygget eller väljer att skjuta upp detta byggande tre år.

Background The concept of occupational identity has become an important focus within occupational science and occupational therapy, drawing both recognition and inquiry. Even if the concept is highly relevant for understanding the occupational nature of human beings, ambiguity regarding the identification and application of occupational identity exists. Aim This analysis aimed to clarify the concept of occupational identity by examining its current use and application within occupational therapy. Materials and methods Walker and Avant's method for concept analysis was utilized to clarify the concept of occupational identity. Results Analysis resulted in three distinct categories of use: occupational identity construction, occupational identity discrepancy and occupational identity disruption, described contextually in terms of the self being, the self being and doing, and the self being and doing with others. Conclusions Findings validated the significant connection between occupation and identity through doing, being and future becoming. Also uncovered were considerable connections to belonging. Significance Occupational identity encompassed complex connections comprising both individual and collective components. Personally meaningful expression and connection were of particular significance to occupational identity as discrepancies or disruption of meaningful connections had negative implications for occupational engagement.

Robot use in older people’s medication ­management – an interview study with community nurses ­in Sweden

The aim of this study was to describe nurses’ experiences of using robots in medication management among older persons. Twelve nurses were interviewed by telephone, using an interview ­guide. Collected data were analysed using an inductive qualitative content analysis.

Three main categories were identified; Creating independence regards how the medicine dispensing robot contributes to the independence and autonomy of older people as well as increased responsibility, engagement, and feelings of security. Increased patient safety means that the right patient gets the right medicine at the right time, contributing to fewer adverse drug events. Saving resources highlights savings, both regarding the environment and human resources, as staff spend less time administering medication.

The use of medicine dispensing robots can generate profits on individual, group, and organizational levels. However, it is important that implementation and use are individually adjusted.

Supragingival dental plaque samples were collected from 40 Swedish adolescents, including 20 with caries lesions (CAR) and 20 caries-free (CF). Fresh plaque samples were subjected to an ex vivo acid tolerance (AT) test where the proportion of bacteria resistant to an acid shock was evaluated through confocal microscopy and live/dead staining, and the metabolites produced were quantified by H-1 Nuclear Magnetic Resonance (H-1 NMR). In addition, DNA was extracted and the 16S rRNA gene was sequenced by Illumina sequencing, in order to characterize bacterial composition in the same samples. There were no significant differences in AT scores between CAR and CF individuals. However, 7 out of the 10 individuals with highest AT scores belonged to the CAR group. Regarding bacterial composition, Abiotrophia, Prevotela and Veilonela were found at significantly higher levels in CAR individuals (p=0.0085, 0.026 and 0.04 respectively) and Rothia and Corynebacterium at significantly higher levels in CF individuals (p=0.026 and 0.003). The caries pathogen Streptococcus mutans was found at low frequencies and was absent in 60% of CAR individuals. Random-forest predictive models indicate that at least 4 bacterial species or 9 genera are needed to distinguish CAR from CF adolescents. The metabolomic profile obtained by NMR showed a significant clustering of organic acids with specific bacteria in CAR and/or high AT individuals, being Scardovia wiggsiae the species with strongest associations. A significant clustering of ethanol and isopropanol with health-associated bacteria such as Rothia or Corynebacterium was also found. Accordingly, several relationships involving these compounds like the Ethanol : Lactate or Succinate : Lactate ratios were significantly associated to acid tolerance and could be of predictive value for caries risk. We therefore propose that future caries risk studies would benefit from considering not only the use of multiple organisms as potential microbial biomarkers, but also their functional adaptation and metabolic output.

The value-based healthcare (VBHC) concept was first proposed as a solution to many of the ills of healthcare. Since then, we have seen the term “value” defined, used, confused, and interpreted in multiple ways. While we may disagree that competition based on value will solve healthcare’s complex challenges, value is a concept integral to the future of healthcare. Before VBHC becomes consigned to the long list of quality improvement trends and management fads that have passed through healthcare, we call for a dialogue around the term value and the implications of its different interpretations. The intention is not just to critique, but to facilitate ongoing efforts to substantially improve healthcare in ways that are relevant and sustainable for society at large.

In Sweden the health system is nationally regulated and locally provided by 21 regions and 290 municipalities. To meet the shifting paradigm, where the person is viewed as a co-producer of health and care, Sweden has laws, regulations and policies which support the patient as an active partner in the communication with professionals in the system. Coproduction, person-centred care and shared decision making contribute jointly to the paradigm shift. Principles of human dignity and equity must be supported nationally and enacted in the decentralized, regional provision of care. Infrastructures exist or are under development which can support and strengthen care that is co-produced and based in a person-centred philosophy and approach, where shared decision making becomes a reality in practice. A Knowledge management system together with National Quality registries have the potential to form a co-produced, person-centred learning health system, where patients, and next of kin and professionals are included as partners. The joint integration of Shared decision making, Person-centre care and Coproduction into the Swedish healthcare system now looks like a possible way to realize the emerging paradigm.

BACKGROUND: Masticatory parameters, such as reduced number of teeth and posterior contacts, have been shown to be associated with reduced cognitive status. The underlying mechanisms that affect these associations, are however, not well understood.

OBJECTIVES: The study aims to investigate the association between masticatory dysfunction and cognition and explore the mediating effect of brain structure.

METHODS: In this cross-sectional study, 45 older adults with subjective masticatory dysfunction (mean age 72.3 ± 4.0 years) were included. Mini-Mental State Examination score <25, brain trauma, neurological disease, neurodegenerative disorders, depression or poor Swedish language skills were criteria for exclusion. Cognitive functions (executive function and episodic memory) and masticatory dysfunction defined by functional occluding status (FOS; the number of occluding units and number of remaining teeth) were analysed with partial correlation models. Structural magnetic resonance imaging was performed on 28 feasible participants. Multiple regression analyses were performed to evaluate the predictive value of brain structure and white matter hypointensities (WM-hypo) on cognitive functions. A mediation analysis was applied to assess significant predictor/s of the association between FOS and cognition.

RESULTS: Both episodic memory and executive functions were positively correlated with FOS. WM-hypo predicted cognitive status (executive function, p ≤ .01). WM-hypo mediated 66.6% (p = 0.06) of the association between FOS and executive functions.

CONCLUSION: Associations between FOS and cognitive functions are reported, where FOS, a potential modifiable risk factor, was related to both episodic memory and executive functions. The mediating effect of WM-hypo on the association between FOS and executive functions highlights the impact of the vascularisation of the brain on the link between mastication and cognition. The present study provides increased knowledge that bridges the gap between masticatory dysfunction and cognition.

A better understanding of insecure living circumstances and the relational world of older people has the potential to contribute to the development of care planning and delivery. This chapter examines conditions of precarity and empowering social ties of older people in community sites. The study used ethnographic methods to understand the lived experiences of 20 older people that was predominantly female and African American in Baton Rouge in the U.S. State of Louisiana. The ethnographic fieldwork for this investigation was conducted from 2013 to 2018 through participant-observations and open-ended interviews in three community sites in Baton Rouge. The field data was analyzed using social network and empowerment frameworks. The social ties of older people in Louisiana were compared with a previous study on social ties of older people in two Swedish senior centers. The analysis focuses self-, peer- and community empowerment levels and how they protect against precarity of older people.

The findings from studying different community sites of older people in Louisiana demonstrate that the key social support ties that provided a buffer against precarity of older people were close friendships made in community sites and spiritual faith ties to God. Conditions of precarity and sources of stress of older people in Louisiana were constant threats of discontinuity of home-based health care services, prescription and medication access, not affording health care and other social problems of poverty, cognitive impairment and declining health.

In Louisiana, self- and peer empowerment of older people were strong, but community empowerment through home-based health care services were not enough to prevent and reduce precarity of older people. Toward the background that Sweden can be considered to have a comprehensive social welfare system it is easier to see examples of empowerment of older people on all three levels. Self- and community empowerment were the strongest when studying examples of community sites for older people. In the Swedish study, the social network of older people was dominated by thin ties between senior peers. Community sites are needed as completent to ageing at home. In Louisiana, strong (thick) ties of older people were dominant.

For the older people in Louisiana to receive consistent home-based health care services was not a given but required an ongoing active and joint effort by older people, family caregivers and friends. Policy implications of this study are that ongoing care support by family caregivers, friends and home-based health care services and medication access without gaps are needed to reduce and protect against precarity of older people. Self-empowerment should be supported by not only peer but also community empowerment.

While there is a growing body of research on the social aspects of older people's dance, studies focusing on emotions are rare. In this study, we use an interactionist sociological perspective to examine the role of emotions in older social dancers' experiences in Sweden. Through qualitative interviews with 29 active or previously active dancers, we found that their experiences of emotional energy and experiences of flow override concerns of age and aging. Age, however, did become significant as the age differences at dance events could bring forth feelings of alienation associated with feeling old. In addition, cultural and gendered norms of appropriate age differences between dancing partners produced shame and pride as well as feelings of being either old or young. Moreover, certain bodily experiences were interpreted in terms of age. Overall, the study contributes to the discussions of the complexity of subjective experiences of age by highlighting its emotional aspects through social partner dancing.

This secondary analysis of qualitative interviews describes how older Swedish men approach the caregiver role for a wife with dementia, over time. An increasing number of male caregivers will become primary caregivers for partners living with dementia at home, and they will likely be caregivers for an extended period of time. It has been stated that caregiving experiences influence how older men think of themselves. The theoretical starting point is a constructivist position, offering an understanding of older caregiving men's constructions and reconstructions of themselves and their caregiver roles. Seven men, who were cohabiting with their wives, were interviewed on up to five occasions at home during a 5- to 6-year period. The findings comprise three themes; me and it, me despite it, it is me, depict how these men gradually take on and normalise the caregiving tasks, and how they develop and internalise a language based on their caring activities. The results provide understanding about the relationship between men as caregivers and how this influences them as individuals. By careful attention to each caregiving man's individual needs rather than making gendered assumptions about men and caring, the aim of the caregiver support for men might best target men's own meaning to the caring in their the everyday practices.

Background

Health promotion services need to be developed to respond to the needs of an ageing population. Lifestyle Redesign(R) (LR(R)) is an occupational therapy intervention that has been addressed as cost-effective in the USA.

Aims/objectives

This scoping review aimed to identify how the LR(R) has been implemented and what the results have been with older adults living independently in countries other than the USA.

Material and methods

Sixteen studies were included. Quantitative results were interpreted through the numeric data and qualitative results through inductive thematic analysis.

Results

The delivery of the LR(R) shared both similarities and differences with the original LR(R), and the variations concerned interventions length, facilitators, and the outcome measures used. In the quantitative results, there was often a positive trend in intervention groups' health-related quality of life, mental health, and occupational performance; in qualitative results, there was improvement in self-esteem and possibilities in building new communities.

Conclusions and significance

The original LR(R) was often transferrable into cultural settings other than the USA and many positive outcomes in the health and well-being of older adults were addressed. However, to understand the feasibility and effectiveness of the LR(R), scientific research and publications need to be enhanced.

BACKGROUND:

Stroke and dementia are frequent comorbidities. Dementia possibly increases total costs of stroke care, especially cost of institutionalization and informal medical care. However, stroke rehabilitation costs in dementia patients are understudied.

OBJECTIVE:

To estimate inpatient stroke rehabilitation costs for Swedish dementia patients in comparison with non-dementia patients.

METHODS:

A longitudinal cohort study with linked data from the Swedish Dementia Register and the Swedish Stroke Register was conducted. Patients diagnosed with dementia who suffered a first ischemic stroke between 2010 and 2014 (n = 138) were compared with non-dementia patients (n = 935). Cost analyses were conducted from a Swedish health care perspective. The difference of rehabilitation costs between the two groups was examined via simple linear regression (before and after matching by propensity scores of dementia) and multiple linear regression.

RESULTS:

Mean inpatient rehabilitation costs for dementia and non-dementia patients were SEK 103,693/$11,932 and SEK 130,057/$14,966, respectively (median SEK 92,183/$10,607 and SEK 106,365/$12,239) (p = 0.001). Dementia patients suffered from more comorbidities and experienced lower functioning, compared to non-dementia patients. The inpatient rehabilitation cost for patients with known dementia was 0.84 times the cost in non-dementia individuals.

CONCLUSION:

Dementia diagnosis was significantly associated with lower inpatient stroke rehabilitation costs. This might be explained by physicians' beliefs on the limited effectiveness of rehabilitation in dementia patients. Further research on cost-effectiveness of stroke rehabilitation and patients' satisfaction with stroke rehabilitation is necessary.

Background: Patient dissatisfaction with stroke care is associated with poor self-rated health and unmet care needs. Dementia patients' satisfaction with stroke care is understudied.

Objective: To compare satisfaction with stroke care in patients with and without dementia.

Methods: This longitudinal cohort study included 5,932 dementia patients (2007-2017) who suffered a first stroke after dementia diagnosis and 39,457 non-dementia stroke patients (2007-2017). Data were retrieved by linking the Swedish Stroke Register, the Swedish Dementia Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. The association between dementia and satisfaction was analyzed with ordinal logistic regression.

Results: When dementia patients answered themselves, they reported significantly lower odds of satisfaction with acute stroke care (OR: 0.71; 95% CI: 0.60-0.85), healthcare staff's attitude (OR: 0.79; 95% CI: 0.66-0.96), communication with doctors (OR: 0.78; 95% CI: 0.66-0.92), stroke information (OR: 0.62; 95% CI: 0.52-0.74); but not regarding inpatient rehabilitation (OR: 0.93; 95% CI: 0.75-1.16), or outpatient rehabilitation (OR: 0.93; 95% CI: 0.73-1.18). When patients answered with caregivers' help, the association between dementia status and satisfaction remained significant in all items. Subgroup analyses showed that patients with Alzheimer's disease and mixed dementia reported lower odds of satisfaction with acute care and healthcare staff's attitude when they answered themselves.

Conclusion: Patients with dementia reported lower satisfaction with stroke care, revealing unfulfilled care needs among dementia patients, which are possibly due to different (or less) care, or because dementia patients require adaptations to standard care.

Objective: To explore the dementia diagnostic process and drug prescription for persons with dementia (PWD) with different socioeconomic status (SES). Design: Register-based cohort study. Setting and Participants: This study included 74,414 PWD aged ≥65 years from the Swedish Dementia Register (2007–2018). Their data were linked with the Swedish Longitudinal Integrated Database for Health Insurance and Labor Market Studies (2006–2017) to acquire the SES information 1 year before dementia diagnosis. Methods: Education and income—2 traditional SES indicators—were divided into 5 levels. Outcomes comprised the dementia diagnostic examinations, types of dementia diagnosis, diagnostic unit, and prescription of antidementia drugs. Binary logistic regression was performed to evaluate socioeconomic inequalities. Results: Compared to PWD with the lowest educational level, PWD with the highest educational level had a higher probability of receiving the basic diagnostic workup [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.10-1.29], clock test (OR 1.12, 95% CI 1.02-1.24) and neuroimaging (OR 1.23, 95% CI 1.09-1.39). Compared with PWD in the lowest income quintile, PWD in the highest income quintile presented a higher chance of receiving the basic diagnostic workup (OR 1.35, 95% CI 1.26-1.46), clock test (OR 1.40, 95% CI 1.28-1.52), blood analysis (OR 1.21, 95% CI 1.06-1.39), Mini-Mental State Examination (OR 1.47, 95% CI 1.26-1.70), and neuroimaging (OR 1.30, 95% CI 1.18-1.44). PWD with higher education or income had a higher likelihood of obtaining a specified dementia diagnosis or being diagnosed at a memory clinic. SES presented no association with prescription of antidementia medication, except for the association between education and the use of memantine. Conclusions and Implications: Higher education or income was significantly associated with higher chance of receiving dementia diagnostic examinations, a specified dementia diagnosis, being diagnosed at a memory clinic, and using memantine. Socioeconomic inequalities in dementia diagnostic process and prescription of memantine occurred among PWD with different education or income levels.

Background: Long-term care improves independence and quality of life of persons with dementia (PWD). The influence of socioeconomic status on access to long-term care was understudied.

Objective: To explore the socioeconomic disparity in long-term care for PWD.

Methods: This registry-based study included 14,786 PWD, registered in the Swedish registry for cognitive and dementia disorders (2014-2016). Education and income, two traditional socioeconomic indicators, were the main exposure. Outcomes were any kind of long-term care, specific types of long-term care (home care, institutional care), and the monthly average hours of home care. The association between outcomes and socioeconomic status was examined with zero-inflated negative binomial regression and binary logistic regression.

Results: PWD with compulsory education had lower likelihood of receiving any kind of long-term care (OR 0.80, 95% CI 0.68-0.93), or home care (OR 0.83, 95% CI 0.70-0.97), compared to individuals with university degrees. Their monthly average hours of home care were 0.70 times (95% CI 0.59-0.82) lower than those of persons with university degrees. There was no significant association between education and the receipt of institutional care. Stratifying on persons with Alzheimer's disease showed significant association between lower education and any kind of long-term care, and between income and the hours of home care.

Conclusions: Socioeconomic inequalities in long-term care existed in this study population. Lower-educated PWD were less likely to acquire general long-term care, home care and had lower hours of home care, compared to their higher-educated counterparts. Income was not significantly associated with the receipt of long-term care.

BACKGROUND: Sick leave due to long-term stress is increasing in Finland and other Western countries. Occupational therapists might contribute to the prevention of and/or recovery from stress-related exhaustion.

AIMS/OBJECTIVES: To describe what is known about occupational therapy for stress-related exhaustion.

MATERIAL AND METHODS: A five-step scoping review included papers published in six databases from 2000 to 2022. Extracted data was summarized to show the occupational therapy contribution within the literature.

RESULTS: There were 29 papers meeting the inclusion criteria, of which a limited number described preventive interventions. Most articles described recovery-oriented occupational therapy with group interventions. The occupational therapists contributed with prevention measures, mostly targeting recovery in multi-professional interventions in terms of stress reduction or return-to-work.

CONCLUSIONS: Occupational therapy involving stress management both prevents stress and supports recovery from stress-related exhaustion. Occupational therapists internationally use craft, nature activities or gardening as stress management measures.

SIGNIFICANCE: Occupational therapy appears to be a potential treatment option for stress-related exhaustion internationally in conditions that could also work in Finland, for example in occupational healthcare.

Objective

This study aims to investigate the relationship between diurnal cortisol patterns, cognition and Alzheimer's disease (AD) biomarkers in memory clinic patients.

Method

Memory clinic patients were recruited from Karolinska University Hospital in Sweden (n=155). Diurnal cortisol patterns were assessed using five measures: awakening levels, cortisol awakening response, bedtime levels, the ratio of awakening to bedtime levels (AM/PM ratio) and total daily output. Cognition was measured in five domains: memory, working memory, processing speed, perceptual reasoning and overall cognition. AD biomarkers A beta(42), total tau and phosphorylated tau were assessed from cerebrospinal fluid (CSF). Cognition was measured at follow-up (average 32 months) in a subsample of participants (n=57).

Results

In assessing the associations between cortisol and cognition, higher awakening cortisol levels were associated with greater processing speed at baseline. No relationship was found between diurnal cortisol patterns and change in cognition over time or CSF AD biomarkers in the total sample. After stratification by CSF A beta(42) levels, higher awakening cortisol levels were associated with worse memory performance in amyloid-positive participants. In amyloid-negative participants, higher bedtime cortisol levels and a lower AM/PM ratio were associated with lower overall cognition, greater awakening cortisol levels were associated with better processing speed, and a higher AM/PM ratio was associated with better perceptual reasoning. Additionally, higher awakening cortisol levels were associated with lower CSF A beta(42) levels in amyloid-positive participants, while higher bedtime cortisol levels and a lower AM/PM ratio were associated with higher CSF total tau in amyloid-negative participants.

Conclusions

Our findings suggest that diurnal cortisol patterns are associated with cognitive function and provide new insights into the association between diurnal cortisol patterns and AD-related CSF biomarkers. Further research is needed to examine the complex relationship between cortisol, cognition and brain pathology.

BACKGROUND: Harm from medications is a major patient safety challenge among older persons. Adverse drug events tend to arise when prescribing or evaluating medications; therefore, interventions targeting these may promote patient safety. Guidelines highlight the value of a joint plan for continued treatment. If such a plan includes medications, a medication plan promoting patient safety is advised. There is growing evidence for the benefits of including patients and health care professionals in initiatives for improving health care products and services through co-design.

OBJECTIVE: This study aimed to identify participants' needs and requirements for a medication plan and explore their reasoning for different design choices.

METHODS: Using a case study design, we collected and analyzed qualitative and quantitative data and compared them side by side. We explored the needs and requirements for a medication plan expressed by 14 participants (older persons, nurses, and physicians) during a co-design initiative in a regional health system in Sweden. We performed a directed content analysis of qualitative data gathered from co-design sessions and interviews. Descriptive statistics were used to analyze the quantitative data from survey answers.

RESULTS: A medication plan must provide an added everyday value related to safety, effort, and engagement. The physicians addressed challenges in setting aside time to apply a medication plan, whereas the older persons raised the potential for increased patient involvement. According to the participants, a medication plan needs to support communication, continuity, and interaction. The nurses specifically addressed the need for a plan that was easy to gain an overview of. Important function requirements included providing instant access, automation, and attention. Content requirements included providing detailed information about the medication treatment. Having the plan linked to the medication list and instantly obtainable information was also requested.

CONCLUSIONS: After discussing the needs and requirements for a medication plan, the participants agreed on an iteratively developed medication plan prototype linked to the medication list within the existing electronic health record. According to the participants, the medication plan prototype may promote patient safety and enable patient engagement, but concerns were raised about its use in daily clinical practice. The last step in the co-design framework is testing the intervention to explore how it works and connects with users. Therefore, testing the medication plan prototype in clinical practice would be a future step.

BACKGROUND: Harm from medications is a major patient safety challenge. Most adverse drug events arise when a medication is prescribed or reevaluated. Therefore, interventions in this area may improve patient safety. A medication plan, that is, a plan for continued treatment with medications, may support patient safety. Participation of patients in the design of health care products or services may improve patient safety. Co-design, as in the Double Diamond framework from the Design Council, England, can emphasize patient involvement. As the COVID-19 pandemic brought restrictions to face-to-face co-design approaches, interest in remote approaches increased. However, it is uncertain how best to perform remote co-design. Therefore, we explored a remote approach, which brought together older persons and health care professionals to co-design a medication plan prototype in the electronic health record, aiming to support patient safety.

OBJECTIVE: This study aimed to describe how remote co-design was applied to create a medication plan prototype and to explore participants' experiences with this approach.

METHODS: Within a case study design, we explored the experiences of a remote co-design initiative with 14 participants in a regional health care system in southern Sweden. Using descriptive statistics, quantitative data from questionnaires and web-based workshop timestamps were analyzed. A thematic analysis of the qualitative data gathered from workshops, interviews, and free-text responses to the survey questions was performed. Qualitative and quantitative data were compared side by side in the discussion.

RESULTS: The analysis of the questionnaires revealed that the participants rated the experiences of the co-design initiative very high. In addition, the balance between how much involved persons expressed their wishes and were listened to was considered very good. Marked timestamps from audio recordings showed that the workshops proceeded according to the plan. The thematic analysis yielded the following main themes: Everyone's perspective matters, Learning by sharing, and Mastering a digital space. The themes encompassed what helped to establish a permissive environment that allowed the participants to be involved and share viewpoints. There was a dynamic process of learning and understanding, realizing that despite different backgrounds, there was consensus about the requirements for a medication plan. The remote co-design process seemed appealing, by balancing opportunities and challenges and building an inviting, creative, and tolerant environment.

CONCLUSIONS: Participants experienced that the remote co-design initiative was inclusive of their perspectives and facilitated learning by sharing experiences. The Double Diamond framework was applicable in a digital context and supported the co-design process of the medication plan prototype. Remote co-design is still novel, but with attentiveness to power relations between all involved, this approach may increase opportunities for older persons and health care professionals to collaboratively design products or services that can improve patient safety.

BACKGROUND: Older persons with polypharmacy are at increased risk of harm from medications. Therefore, it is important that physicians and nurses, together with the persons, evaluate medications to avoid hazardous polypharmacy. It remains unclear how healthcare professionals experience such evaluations. This study aimed to explore physicians' and nurses' experiences from evaluations of older persons' medications, and their related actions to manage concerns related to the evaluations.

METHOD: Individual interview data from 29 physicians and nurses were collected and analysed according to the critical incident technique.

RESULTS: The medication evaluation for older persons was influenced by the working conditions (e.g. healthcare professionals' clinical knowledge, experiences, and situational conditions) and working in partnership (e.g. cooperating around and with the older person). Actions taken to manage these evaluations were related to working with a plan (e.g. performing day-to-day work and planning for continued treatment) and collaborative problem-solving (e.g. finding a solution, involving the older person, and communicating with colleagues).

CONCLUSION: Working conditions and cooperation with colleagues, the older persons and their formal or informal caregivers, emerged as important factors related to the medication evaluation. By adjusting their performance to variations in these conditions, healthcare professionals contributed to the resilience of the healthcare system by its capacity to prevent, notice and mitigate medication problems. Based on these findings, we hypothesize that a joint plan for continued treatment could facilitate such resilience, if it articulates what to observe, when to act, who should act and what actions to take in case of deviations from what is expected.