A platform for collaborations in respiratory research in Sweden
The PRAXIS study is a longitudinal study on patients with asthma and COPD recruited from both primary health care and hospitals. The PRAXIS study started in 2005 and includes data from patient questionnaires, questionnaires on structure for care units, medical record reviews and Swedish National registries.
The PRAXIS study began in 2005, following 1,089 patients with COPD and 1,100 patients with asthma in central Sweden. The majority of these patients were managed in primary care. Questionnaire sweeps were conducted in 2005, 2012, and 2022. Additionally, medical records (including both primary and secondary care) were reviewed for the periods immediately prior to the first sweep in 2005. Register linkage data for the COPD cohorts has also been added.
A new cohort in central Sweden was initiated in 2014/2015 with 1,800 COPD patients and 1,200 asthma patients, also followed with questionnaires to 2022. An application for register linkage data for the cohorts 2014/2015 have recently been submitted, as well as including a 10-1 reference population without asthma and COPD, matched by age/year of birth, sex and geographical area. Linkage includes the following registers: Patient register (secondary care diagnoses), Cause of Death, Prescription (all pharmacy-dispensed medication), LISA (Swedish acronym for a database of socioeconomic measures), Total Population (including vital status and migration for censoring).
Some main areas have been studied in the PRAXIS study. These are, on patient level: (1) predicting ability of different illness severity measures for morbidity and mortality (2) associations between patient characteristics and patient outcomes, and (3) phenotypes of the diagnoses. On organizational level the main areas that have been studied are (1) associations of management and treatment to patients’ or doctors’ outcomes, (2) associations of management and treatment to patient characteristics, and (3) description of management and treatment.
Anchor: Main sub-projectsThe knowledge about the prevalence and the consequences of continuity of care for patients with asthma or COPD in Sweden is insufficient. Demographic factors and the organization of health care differ between Sweden and countries of most of the previous research, which may make generalizations of previous research difficult in Sweden. For instance, there is low prevalence of tobacco smoking in Sweden, and asthma and COPD are to a large extent managed in primary care, which is not common in a global perspective. As far as we know, the association of continuity of care on healthcare outcomes for patients with asthma and COPD has not been studied in Sweden. For patients with asthma, we found no studies on the association of continuity of care on healthcare costs. In addition, no study has examined continuity of care for patients with asthma and COPD in a primary health care setting.
The aim of this study is to examine the association of relational continuity in primary care on morbidity, health related quality of life, health care costs and dispensed medications in patients with asthma and COPD.
Anna Nager (lead)
Lovisa Järnberg
Björn Ställberg
Hanna Sandelowsky
Maaike Giezeman
There are indications that asthma and COPD patients are more susceptible to COVID-19, although the results, particularly in asthma, have been contradictory. Even though the COVID-19 pandemic is officially over, a growing number of people have persistent symptoms following COVID-19, referred to as post COVID-19 condition. In Sweden, it is estimated that more than 2.5 million people have had COVID-19, but the prevalence of post COVID-19 condition is not well understood. Few previous studies from Sweden have explored whether asthma and COPD increase the risk of post COVID-19 condition. This knowledge is crucial for planning preventive and follow-up care in primary care centres, where asthma and COPD patients are primarily followed up in Sweden. Post COVID-19 condition often requires long-lasting rehabilitation, and identifying which subgroups of patients need follow-up is a research priority in the context of post COVID-19 condition. Furthermore, there has been a shortage of recent studies on sick leave among asthma and COPD patients, which is especially important in the case of asthma, as these patients are often younger and employed. Additionally, studies on how COVID-19 and post COVID-19 condition affect sick leave in asthma and COPD are notably lacking. Previous research has indicated that sick leave in asthma and COPD is not associated with objective measures, such as lung function, but rather with the degree of subjective symptoms. Thus, assessing the quality of life in these patients is crucial. However, there have been limited studies on the general health-related quality of life in asthma and COPD. The use of generic health-related quality-of-life measures, such as EQ5D5L, and disease-specific quality-of-life assessment allows for comparison between patients with different chronic conditions and healthy controls. The recent establishment of EQ5D5L reference scores for the general Swedish population has made using this measure for asthma and COPD easier. EQ5D5L can facilitate the determination of the impact of COVID-19 and post COVID-19 condition on the quality of life in asthma and COPD patients.
In this project, we aim to assess the impact of COVID-19 and post COVID-19 condition on primary care patients with asthma and COPD in terms of prevalence, disease control, sick leave and quality of life to address existing knowledge gaps.
Marta Kisiel (lead)
Agnes Andreason
Christer Janson
Björn Ställberg
Karin Lisspers
Patients with COPD often have other coexisting long-term disorders. A recent study found that 89% of COPD patients in primary health care had one other chronic condition and 23% had five or more. This multimorbidity has been shown to reduce COPD-related health status and increase the risk of exacerbations and mortality. Clinically important comorbid diseases are cardiovascular diseases, diabetes, depression, and osteoporosis.
The first part of the project described patient- and caregiver related factors associated with having routine check-ups for COPD in primary care, and assessed whether there was evidence of de-prioritisation of COPD in multimorbid patients compared to patients with no comorbidity. The final part of the project will examine the association of multimorbidity with subsequent exacerbation rate, severity, and outcomes in COPD patients during an eight-year follow-up, considering differences in healthcare settings.
The overall aim of this project is to explore aspects of importance for understanding and improving management of COPD patients with multimorbidity particularly in primary health care: this may also be of relevance for treatment of a broader patient group with multimorbidity, beyond those with COPD.
Scott Montgomery (lead)
Carolina Smith
Björn Ställberg
Mikael Hasselgren
Hanna Sandelowsky
Multimorbidity is a well-recognised problem in primary care and results in challenges for both physicians and patients. The difficulties include lack of organized care for all the conditions, and disease-specific guidelines can be inadequate: clinical trials typically exclude patients with multimorbidity. These problems are faced in primary care for patients with chronic obstructive lung disease: asthma and chronic obstructive pulmonary disease (COPD). Some disease combinations may result in disproportionately greater risks than would be expected from the sum of the two or more conditions. Interactions between diseases could be due to overlapping biological pathways, fragmented healthcare that does not consider all the conditions together, difficulty following treatment guidelines, or polypharmacy and related problems such as poor patient compliance or drug interactions.
PRAXIS and register data will be used to identify patterns of multimorbidity that represent important risks for future health and wellbeing. The project will then identify primary care characteristics that appear to ameliorate the associations of comorbidity combinations with the adverse outcomes, as well as considering the role of other personal characteristics and hospital healthcare in influencing the risk of adverse outcomes.
Scott Montgomery (PI)
Anna Nager
Hanna Sandelowsky
Maaike Giezeman
Mikael Hasselgren
Karin Lisspers
Björn Ställberg
Carolina Smith
Many patients with asthma have a poorly controlled disease and symptoms affecting their quality of life. Since asthma is an inflammatory disease, it is now recommended that anti-inflammatory treatment with inhaled corticosteroids should be the cornerstone for all asthma patients. Until recently, milder asthma was often treated with short-acting bronchodilators only, which gives a rapid release of symptoms but does not affect the underlying cause. The adherence to inhaled corticosteroids is generally low, possibly due to the fact that the patient does not get the fast release of symptoms and may thereby see the bronchodilator as the more appealing choice of treatment.
The overall aim of this PhD project is to follow how asthma symptom control and asthma treatment have changed over time. We will try to identify factors that affect the treatment and adherence to treatment, that we can hopefully use in a clinical context to improve asthma treatment and the patients’ quality of life.
Christer Janson (lead)
Caroline Ahlroth Pind
Björn Ställberg
COPD is a common and irreversible disease with increased mortality risk, where the greatest clinical problem are exacerbations. In primary care, mild COPD is special interest. To improve management and outcomes, correct diagnostics and staging according to the international Global initiative for Obstructive Lung Disease (GOLD) recommendations is important. The diagnosis of COPD should be confirmed using spirometry, which previously has been under-used. Staging is performed according to GOLD in stage 1-4 based on lung function and in group A to E based on health status and exacerbation frequency, but there are also several multi-dimensional instrument such as ADO (Age, Dyspnoea, Obstruction) and DOSE (Dyspnoea, Obstruction, Smoking, Exacerbations) which all can be used to predict mortality in COPD. Asthma is also one of the common comorbid conditions in patients, and differential diagnostics may be difficult.
The overall aim of the project is to investigate changes over time in diagnostics of COPD, to compare different prognostic staging instruments, to explore prevalence and associations with patient-related outcomes for COPD with and without comorbid asthma, and to study which factors that are most important predictors of mortality in mild COPD. The project includes all four papers in a planned doctoral thesis.
Josefin Sundh (lead)
Åsa Athlin
Mikael Hasselgren
Karin Lisspers
Patients with chronic obstructive pulmonary disease (COPD) have impaired lung function with dyspnea, cough, fatigue and impaired physical activity. Low physical activity level is one of the most important predictors of mortality and hospitalization in COPD, in all stages of the disease. According to national and international guidelines, increasing physical activity is of utter importance to prevent mortality, exacerbations and worsening of symptoms, and during the recent decade there has been a great focus on implementing non-pharmacological treatment in Sweden.
To investigate how physical activity level and interventions from physiotherapeuts and asthma/COPD nurses are associated with risk of excaberbations and poor health status in COPD, and to explore how the physical activity level and factors associated with more activity has changed over time in Swedish patients with COPD. The project includes two of four papers in a planned doctoral thesis.
Josefin Sundh (lead)
Jenny Höglund
Gabriella Eliason
Depression and anxiety are common comorbidities in patients with COPD, with profound effects on the individuals’ health, quality of life and prognosis. Patients with COPD and depression/anxiety have increased risk of exacerbations, morbidity, and mortality, compared to COPD patients without depression/anxiety. Previous work in the field is more comprehensive for patients bound to hospital clinics, where moderate-severe COPD is more common. However, the majority of patients in Sweden have mild-moderate COPD and are managed in primary care, and the relationship between depression/anxiety and COPD-related health has not been studied in primary health care in Sweden.
The aim of this project is to investigate the relationships between depression/anxiety and morbidity, mortality, and quality of life in patients with COPD in primary health care in Sweden, and how this is affected by patient-related and health care organizational factors.
We are going to conduct four studies to investigate the relationships between depression/anxiety in patients with COPD and (1) patient related factors, (2) COPD-related health status, exacerbations, and quality of life, (3) compliance to prescribed COPD-medication and (4) mortality over a period of 20 years.
Hanna Sandelowsky (lead)
Therese Öfverholm
Karin Lisspers
Mikael Hasselgren
Anna Nager
Uppsala University.
Anchor: CollaboratorsWe welcome potential collaborators to any of our sub-projects. Please contact the project lead for the sub-project you are interested in or write to any of the contact persons below.
Anchor: contactsBjörn Ställberg, email: b.stallberg@telia.com
Anna Nager, email: anna.nager@ki.se
Al-Hadrawi Z, Giezeman M, Hasselgren M, Janson C, Kisiel MA, Lisspers K, Montgomery S, Nager A, Sandelowsky H, Ställberg B, Sundh J. Comorbid allergy and rhinitis and patient-related outcomes in asthma and COPD: a cross-sectional study. Eur Clin Respir J. 2024 Aug 30;11(1):2397174.
Eriksson S, Giezeman M, Hasselgren M, Janson C, Kisiel MA, Montgomery S, Nager A, Sandelowsky H, Ställberg B, Sundh J, Lisspers K. Risk Factors Associated with Asthma Control and Quality of Life in Patients with Mild Asthma Without Preventer Treatment, a Cross-Sectional Study. J Asthma Allergy. 2024 Jul 9;17:621-632.
Ahlroth Pind C, Ställberg B, Lisspers K, Sundh J, Kisiel MA, Sandelowsky H, Nager A, Hasselgren M, Montgomery S, Janson C. Pharmacological treatment of asthma in Sweden from 2005 to 2015. J Asthma. 2023 Nov 1:1-9.
Athlin Å, Lisspers K, Hasselgren M, Ställberg B, Janson C, Montgomery S, Giezeman M, Kisiel M, Nager A, Sandelowsky H, Arne M, Sundh J. Diagnostic spirometry in COPD is increasing, a comparison of two Swedish cohorts. NPJ Prim Care Respir Med. 2023 Jun 2;33(1):23.
Bouhuis D, Giezeman M, Hasselgren M, Janson C, Kisiel MA, Lisspers K, Montgomery S, Nager A, Sandelowsky H, Ställberg B, Sundh J. Factors Associated with the Non-Exacerbator Phenotype of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis. 2023 Apr 6;18:483-492.
Giezeman M, Sundh J, Athlin Å, Lisspers K, Ställberg B, Janson C, Montgomery S, Kisiel MA, Nager A, Sandelowsky H, Hasselgren M. Comorbid Heart Disease in Patients with COPD is Associated with Increased Hospitalization and Mortality – A 15-Year Follow-Up. Int J Chron Obstruct Pulmon Dis. 2023 Jan 9;18:11-21.
Smith C, Hasselgren M, Janson C, Kisiel MA, Lisspers K, Nager A, Sandelowsky H, Ställberg B, Sundh J, Montgomery S. Does multimorbidity result in de-prioritisation of COPD in primary care? NPJ Prim Care Respir Med. 2023 Jan 14;33(1):2.
Kisiel MA, Berglund C, Janson C, Hasselgren M, Montgomery S, Nager A, Sandelowsky H, Ställberg B, Sundh J, Lisspers K. Quality of life and asthma control related to hormonal transitions in women’s lives. J Asthma. 2022 Sep;59(9):1869-1877.
Bouhuis D, Giezeman M, Janson C, Kisiel MA, Lisspers K, Montgomery S, Nager A, Sandelowsky H, Ställberg B, Sundh J. Factors associated with self-assessed asthma severity. J Asthma. 2022 Apr;59(4):691-696.
Kisiel MA, Zhou X, Sundh J, Ställberg B, Lisspers K, Malinovschi A, Sandelowsky H, Montgomery S, Nager A, Janson C. Data-driven questionnaire-based cluster analysis of asthma in Swedish adults. NPJ Prim Care Respir Med. 2020 Apr 6;30(1):14.
Athlin Å, Giezeman M, Hasselgren M, Montgomery S, Lisspers K, Ställberg B, Janson C, Sundh J. Prediction of Mortality Using Different COPD Risk Assessments – A 12-Year Follow-Up. Int J Chron Obstruct Pulmon Dis. 2021 Mar 16;16:665-675.
Bouhuis D, Giezeman M, Janson C, Kiesel M, Lisspers K, Montgomery S, Nager A, Sandelowsky H, Ställberg B, Sundh J. Factors associated with self-assessed asthma severity. J Asthma. 2021 Jan 27:1-10.
Wireklint P, Hasselgren M, Montgomery S, Lisspers K, Ställberg B, Janson C, Sundh J. Factors associated with knowledge in self-management of worsening in asthma in primary care – a cross-sectional study. J Asthma. 2020 Apr 14:1-11.
Kisiel M, Zhou X, Sundh J, Ställberg B, Lisspers K, Malinovschi A, Sandelowsky H, Montgomery S, Nager A, Janson C. Data-driven questionnaire based cluster analysis of asthma in Swedish adults. NPJ Prim Care Respir Med. 2020 Apr 6;30(1):14.
Lindgren H, Hasselgren M, Montgomery S, Lisspers K, Ställberg B, Janson C, Sundh J. Factors associated with well-controlled asthma – a cross-sectional study. Allergy – 2019 Jul 12.
Åberg J, Hasselgren M, Montgomery S, Lisspers K, Ställberg B, Janson C, Sundh J. Sex-related differences in management of Swedish patients with a clinical diagnosis of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2019 May 7;14:961-969.
Giezeman M, Hasselgren M, Lisspers K, Ställberg B, Montgomery S, Janson C, Sundh J. Influence of comorbid heart disease on dyspnea and health status in patients with COPD – a cohort study. Int J Chron Obstruct Pulmon Dis. 2018 Nov 28;13:3857-3865
Stegberg M, Hasselgren M, Montgomery S, Lisspers K, Ställberg B, Janson C, Sundh J. Changes in smoking prevalence and cessation support, and factors associated with successful smoking cessation in Swedish patients with asthma and COPD. Eur Clin Respir J. 2018 Jan 4;5(1):1421389
Sundh J, Åberg J, Hasselgren M, Montgomery S, Ställberg B, Lisspers K, Janson C. Factors influencing pharmacological treatment in COPD: a comparison of 2005 and 2014. Eur Clin Respir J. 2017 Dec 4;4(1):1409060.
Sundh J, Lindgren H, Hasselgren M, Montgomery S, Janson C, Ställberg B, Lisspers K. Pulmonary rehabilitation in COPD – available resources and utilization in Swedish primary and secondary care. Int J Chron Obstruct Pulmon Dis. 2017 Jun 8;12:1695-1704.
Sundh J, Janson C, Lisspers K, Montgomery S, Ställberg B. Clinical COPD Questionnaire score (CCQ) and mortality.
Int J COPD 2012; 7:833842
Sundh J, Janson C, Lisspers K, Ställberg B, Montgomery S. The Dyspnoea, Obstruction, Smoking, Exacerbation (DOSE)index is predictive of mortality in COPD. Prim Care Respir J 2012.
Sundh J, Ställberg B, Lisspers K, Montgomery S, Janson C. Comorbidity, Body Mass Index and Quality of life in COPD using the Clinical COPD Questionnaire. J COPD 2011; 8:173-181.
Arne M, Lisspers K, Ställberg B, Boman G, Hedenström H, Janson C, Emtner M. How often is diagnosis of COPD confirmed with spirometry? Respir Med 2010; 104:550-556.
Ställberg B, Lisspers K, Hasselgren M, Janson C, Johansson G, Svärdsudd K. Asthma control in primary care. A comparison between 2001 and 2005. Prim Care Respir J 2009 18: 279-286.
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