Integrated, Multidisciplinary, Person-centered Care for Patients With Complex Comorbidities: Heart, Kidney and Diabetes - a Randomized Trial
Phase: NA
Conditions: Diabetes Mellitus, Chronic Kidney Diseases, Cardiovascular Diseases, Chronic Disease, Multimorbidity
Sponsor: Danderyd Hospital

 
1 

  
Research plan 
 
Integrated, multidisciplinary, person-centered care for patients  
with complex comorbidities:  
heart, kidney and diabetes - a randomized trial 
- 
Integrerad, multidisciplinär personcentrerad vård för patienter  
med komplex multisjuklighet:  
hjärta, njure, diabetes - en randomiserad prövning 
- 
CareHND 
 
 
Clinical steering group, Danderyd University Hospital: 
Jonas Spaak, Head Physician, HND 
Karin Malmqvist, Head, Dept. Cardiology 
Joakim Bragd, Head, Dept. Internal Medicine 
Björn Samnegård, Head, Dept. Nephrology 
 
 
 
 
Research group: 
Jonas Spaak, Docent1 
Mats Brommels, Professor2 
Thomas Kahan, Professor1 
Stefan Jacobson, CEO, Professor1 
 
 
 
Carl Savage, PhD2 
Pamela Mazzocato, MSc, PhD2 
Terese Stenfors Hayes, PhD2 
 
1.  Department of Clinical Sciences, Danderyds Hospital (KIDS), Karolinska Institutet 
2.  Medical Management Centre, Department of Learning, Informatics, Management and Ethics 
(LIME), Karolinska Institutet 
 
Contact information: 
Jonas Spaak 
Hjärtkliniken, Danderyds sjukhus 
182 88 Stockholm 
SWEDEN 
 
Email: jonas.spaak@ki.se 
Cell/text: +46 (0)76 - 201 4178 
Version 2015:05 - HLF. Ethics Approval Dnr 2014/1:3 
 
 

 
2 
SWEDISH ABSTRACT 
 
Patienter med samtidig hjärt- och kärlsjukdom, njursvikt och diabetes representerar nästan hälften av 
alla patienter som vårdas vid hjärt-, njur- och diabeteskliniker, och cirka 15% lider av alla tre. Andelen 
patienter med flera samtidiga kroniska tillstånd ökar markant med åldern. Dessa komplicerade 
sjukdomar interagerar, och behandling av en påverkar de andra. Trots detta har en ökande 
subspecialisering medfört att kardiologen "bara" behandlar hjärtat, nefrologen "bara" njurarna och 
endokrinologen "bara" diabetes. Studier och riktlinjer följer samma mönster. I bästa fall leder detta till 
att patienterna får besöka flera specialister inom varje fält. I värsta fall till onödigt upprepade 
undersökningar, underdiagnostik och underbehandling. Ur patientperspektivet finns ett stort behov av 
samordning och förbättring av vården, inte bara för att minska sjukdomsprogression utan även för att 
optimera livskvalitet. 
Vi avser att studera om behandling och utfall för patienter med samtidig hjärtkärlsjukdom, njursvikt 
och diabetes kan förbättras genom en ny vårdmodell. Vi har utformat en integrerad klinik som hanterar 
alla tre förhållandena vid samma besök, med ett personcentrerat teambaserat tillvägagångssätt mellan 
patienter, sjuksköterskor och läkare, med två terapikonferenser per vecka med dedikerade och 
utbildade kardiologer, nefrologer och endokrinologer. Vid dessa utvecklas optimerade vårdplaner, och 
vid återbesök och telefonkontakter implementeras dessa tillsammans med patienten. 
Interventionen studeras i en randomiserad kontrollerad studie (CareHND; n = 131) vid HND-centrum, 
en unik integrerad öppenvårdsklinik i Stockholm och i en matchad långtidskohortuppföljning vid ”The 
Integrated Care Clinic”, i Vancouver, den första integrerade hjärt-njur-diabetes- kliniken i världen. 62 
patienter har randomiserats i pilotstudien. 
Vår huvudhypotes är att HND-centra resulterar i bättre vård, från flera aspekter, med ett ur ett 
helhetsperspektiv lägre resursutnyttjande. 
 
 
 
 

 
3 
ENGLISH ABSTRACT 
 
Patients with concomitant cardiovascular disease, renal dysfunction and diabetes represent almost half 
of all patients attending cardiac, kidney and diabetes clinics, and about 15 % suffer all three. This 
proportion of patients with multiple chronic conditions increase markedly by age. These complicated 
diseases interact, and treatment of one affect the others. Despite this have a progressive 
subspecialisation caused cardiologist to treat “only” the heart, nephrologists “only” the kidneys and 
endocrinologists’ “only” diabetes. Studies and guidelines follow the same pattern. At best this require 
patients to visit specialists in each field; at worst result in redundant examinations, under-diagnosis 
and under-treatment of comorbidities. From the patient perspective, there is a great need for 
coordination and improvement of the care, not only to reduce disease progression but also to optimise 
quality of life. 
We aim to study if the treatment and outcome for patients with concomitant cardiovascular disease, 
renal dysfunction and diabetes can be improved through a new model to deliver healthcare. We have 
designed an integrated clinic to handle all three conditions at the same visit, with a person-centered 
team-based approach between patients, nurses and physicians, with bi-weekly therapy conferences by 
dedicated and educated cardiologists, nephrologists and endocrinologists. At these, optimised care-
plans are developed, and at following team-visits and phone contacts, these are implemented. 
The intervention will be studied in a randomised controlled trial (CareHND; n=260) at HND-centrum, 
a novel integrated outpatient clinic in Stockholm, and a matched long-term cohort follow-up at the 
Integrated Clinic in Vancouver, the first integrated heart-kidney-diabetes clinic in the world. 62 
patients have been randomized in the pilot study. 
Our main hypothesis is that HND-centra results in better care, from several aspects, at lower overall 
burden on the health care system.  
 
 

 
4 
Background – co morbidities more common than not 
Cardiovascular diseases (CVD) are the leading cause of death both in Sweden and globally, 
and if not prevented and treated optimally causing increased morbidity, impaired quality of 
life and premature death [2]. Hyperlipidemia, smoking, hypertension and diabetes are well 
established as the most powerful modifiable risk factors for CVD. CKD and diabetes share 
many of the mechanisms causing accelerated vascular aging [3], and in recent years chronic 
kidney disease (CKD) has emerged as a factor of equal importance [4]. About 20% of the 
population in developed countries have hypertension, while the prevalence exceeds 50% in 
those above age 60 years [2]. The prevalence of chronic kidney disease (CKD), defined by 
reduced glomerular filtration rate (GFR) or albuminuria, is in the range of 10–13% in the 
general population and about 30% in those above 65 years of age [5]. The prevalence of 
diagnosed diabetes mellitus in adults ≥65 years is 10-20% in Sweden, compared to 27% in 
North America, and an additional 50% have pre-diabetes [6]. In addition, data from NHANES 
2005–2006 show that 46% of diabetes cases may remain undiagnosed [7]. Thus, with this 
high prevalence numbers, the risk of having several of these diseases is high. In fact, in 
patients 65 years or older, it is more common to have two or more chronic conditions, than 
just one [8]. Patients with multiple chronic conditions receive a remarkable amount of health-
care recourses (Fig. 1.). However, in the Swedish health-care system, no one is coordinating 
these interventions. Least of all, the patient, whom often feel out of control, their daily lives 
filled with taking pills, injections, checking blood-glucose levels, seeing doctors and nurses, 
and doing blood works [1]. 
 
 
 
 
Background – co morbidities and compound risk 
The reasons why kidney failure causes heart disease, and vice versa (the cardiorenal 
syndrome) is still incompletely understood [9]. Patients with concomitant cardiovascular 
disease, renal dysfunction and diabetes are despite their high risk and high health care 
consumption often inadequately treated, since an increasingly specialised medical care too 
often focus on only one part of the disease panorama. Current studies and guidelines follow 
the same pattern. 
In acute coronary syndromes, the single most common cause of death worldwide [2], 
approximately 40% of the patients have at least moderate kidney dysfunction with an eGFR 
below 60 mL/min/m2 [10]. The 1-year-mortality among these is about 25%, compared to 5% 
in patients with normal renal function [10]. The increased mortality in CKD patients after an 
acute coronary event is directly related to decreasing kidney function [4]. This may in part be 
due to the fact that patients with kidney dysfunction are receiving less active treatment, such 
Fig 1. Overview of healthcare 
consumption during 18 months 
for a 75 years old man with 
concomitant cardiovascular 
disease, CKD and diabetes; a 
typical “HND-patient”. Adapted 
from “Team for the elderly, 
vision and reality” [1].  
Review shows medical notes on 
the medical centre taken by 6 
different doctors, 20 nurse 
practitioners, two RN, and 
regular notes from many more 
during 149 days of 
hospitalisation. OC: occupational 
therapist. 

 
5 
as early revascularisation [11], but may also be caused by a range of disturbances in for 
instance haemostasis and vascular function [3]. The lack of guidelines, which can be 
attributed to limited clinical data, as the majority of randomised trials in acute coronary 
syndromes so far have often excluded CKD patients [12]. 
More than 80% of all cardiovascular deaths can be delayed using changes in life-style and 
commonly prescribed drugs [13]. Despite this, many patients never receive the full benefits 
from these interventions because of frequent under-diagnosis, late presentation and 
consequent under-treatment [14,15]. This is particularly an issue for subjects with complex 
diseases such as concomitant cardiovascular disease, kidney dysfunction and diabetes. 
Background – Multidisciplinary secondary preventive interventions 
There exists good evidence for a range of measures that reduce the risk of relapse in patients 
with established cardiovascular disease [16]. The consensus is that all these interventions 
should take place simultaneously [16]. An excellent example of how efficient this approach 
can be when implemented rigorously is the STENO-2 study, where a multifactorial 
intervention in type 2 diabetes halved the absolute risk of death over 13 years [17]. However 
the STENO-2 study excluded patients with concomitant heart disease or kidney failure, 
notwithstanding their higher risk. Despite the high indication for optimal treatment, we have 
shown that only one in four patients with hypertension reach target blood pressure [14], and 
that few patients reach a good secondary prevention after myocardial infarction [15]. 
Traditional health-care models ascribe this to lack of patient compliance; a term implying that 
the patient and not the physician is at fault. 
 
Background – Person‐centered care in chronic disease management 
Chronic diseases require a different way of providing care than acute, since almost all the 
actual care is done by the patient him/herself through changes in lifestyle and actively taking 
medications. This requires a well-informed and involved patient; informed at a level which 
the patient can take in. A model that in recent years been shown to produce very positive 
results also in chronic cardiovascular diseases is person centered care [18-20]. Person-
centered care can be described as a partnership between patients and professional caregivers, 
where the patient is seen as a person with resources and abilities to participate in their own 
care [18]. The prerequisite for being able to provide person-centered care is that health 
professionals thoroughly understand not only the patient’s illness but also the patient’s 
situation in life. After establishing this relationship, a plan with goals and strategies for 
implementation and short - and long-term follow-up can be made. Realistic short-term 
successive goals on life-style improvements are usually an important part. 
Background – Integrated care units 
HND-centrum is a new way of conducting health care in the form of an integrated care unit 
[21]. Pilot studies using this approach have shown promising results, for instance the North 
West London Integrated Care Pilot for elderly patients with diabetes [22]. It is yet not clear 
how to efficiently design and develop integrated care units [21]. HND-centrum enables 
studies on how to design these to maximise patient value, in terms of health outcomes, and 
efficiency. The research aims to increase our knowledge on how health processes are formed 
within the HND-centrum; how staff integrates their knowledge and develops health care, and 
how the value of this can be measured by the ratio of outcomes and cost. 
Purpose and aims 
Patients with concomitant cardiovascular disease, renal dysfunction and diabetes represent a 
large proportion of all patients in cardiology, nephrology and diabetology. The progressively 
increased subspecialisation has caused the cardiologist to treat “only” the heart, nephrologists 
“only” the kidneys and endocrinologists’ “only” diabetes. Current studies and guidelines 

 
6 
follow the same pattern. At best, this requires the patient to visit multiple specialists in each 
field; while at worst, may result in serious under-diagnosis and under-treatment of co-
morbidities. From the patient's perspective, there is a great need for coordination and 
improvement of the care, not only to reduce the rate of disease progression but also to 
optimise quality of life. 
We will use HND-centrum, a new integrated outpatient clinic, which opened in Nov. 2013 as 
Sweden's first, and the second in the world after Vancouver, Canada. HND-centrum is staffed 
by experienced specialists from the three specialties, by nurses and paramedics. Already from 
the start the HND-centrum implements a person-centred healthcare. The clinical part of the 
project is supported by Danderyd Hospital.  
Our main hypothesis is that HND-centrum results in better care, from many aspects, at a 
lower overall cost to society. This is an application for a grant to show this through a 
randomised trial (Care-HND). 
Project plan 
HND-centrum is an outpatient clinic that will replace visits to several doctors and nurses, 
where instead competence and care are organised and integrated around the patient.  
The recently initiated study Care-HND (Fig. 2) will randomise 260 patients to HND-centrum 
or standard care.  
The sample size is based on a power calculation for the combined outcome: death, 
readmission for heart failure, myocardial infarction, PCI/CABG, end stage renal failure or 
TIA / stroke with two years follow up.  
The same power for quality of care and health care consumption require fewer patients, 131, 
to be randomized, and followed for 1 year. 
 
 
 
 
 
Figure 2. Flowchart for the  
Care-HND study where 260 
patients are randomised to HND-
centrum or standard care. After 
one year's time crossover to the 
intervention arm is permitted. 
Intention-to-treat anaysis. 

 
7 
Inclusion criteria – Care-HND: 
1 - Established cardiovascular disease (history of myocardial infarction, angina, or heart 
failure requiring hospitalization. Previous stroke or TIA with certain diagnosis), as well as: 
2 - Diabetes mellitus type 1 or 2 (treated diabetes, or new onset diabetes according to WHO 
criteria or HbA1C > 48, and symptoms, as well as: 
3 - Established kidney disease (eGFR <60 mL/min/m2 calculated with the CKD-EPI formula, 
or an average of the CKD -EPI and Cystatin-C eGFR, or borderline GFR but concomitant 
microalbuminuria, or macroalbuminuria, or kidney transplant). 
Integration with quality registries 
The majority of HND patients will continuously be registered in the national quality registries 
SWEDEHEART, National Diabetes Register and the Swedish Renal Registry. These in 
combination with National Welfare records on morbidity and mortality, and the Prescription 
Registry will be used for analysis of outcomes. Registry data will be used to characterize 
patients that meet the criteria HND but that are not randomised, in order to understand 
potential selection bias. 
Value‐based health care 
Value-based health care analyse outcome measures in relation to expenses over the whole 
course of the disease [23]. The outcome measures are described at three levels: immediate 
effects, time to recovery, and long-term consequences. Data from hospital management, 
process mapping and quality registry data will be used to monitor the randomised trial. From 
cost per patient (CPP), the estimated value for patients and society will be determined. 
Interprofessional teams, clinical microsystems and inter‐professional learning 
HND causes changed work routines for all involved professions, specialties including 
patients. This can be seen as a clinical microsystem around the patient. Today there are no 
studies that illustrate how members of such microsystem work together in this type of clinic. 
We aim to describe and understand this using observations, interviews, and surveys of the 
personnel. 
Sample Collection for bio banking and biochemical analyses 
Patients will be tested regularly for clinical routine tests such as electrolytes, CRP, urinary 
albumin/creatinine ratio, cystatin-C, and PTH. Patients will also give blood / plasma / serum / 
urine for a biobank for later analysis within:  
Transcriptomics: genetics and RNA including mRNA, SNPs and CNVs.  
Proteomics: fibrosis markers PICP, C1TP, TIMP1. Inflammatory markers as IL6, IL8, MCP1, 
CXCL16.  
Renal function markers: as NGAL KIM1, NHE3, IL18.  
Hemodynamic markers: MR- proADM, copeptin, titin.  
Markers of haemostasis: PAI-1 AG, D- dimer, VWF, E- selectin, and OHI. Free RNA and 
DNA. Microparticles.  
Metabolomics: insulin, leptin, GLP-1, PPY, GIP.  
A number of patients will give leukocytes. 
(Re‐)defining health related outcome 
From a patients’ perspective many more things matter than mortality, and we will develop a 
combined outcome-model based on the collaborative effort between Karolinska Institutet, 
Harward Business School, and Boston Consulting; ICHOM (ichom.org).  
In 2006, Professor Michael E. Porter wrote the well-known book, Redefining Health Care 
leading to the work redefining health related outcome. This concept has clear advantages by 
not selecting a single outcome measure as the only one to focus on, but takes into account all 
issues that may impact on the patient’s life and quality of life. A model has been developed 

 
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for a few common diseases, such as Myocardial Infarction (Fig. 3). However, myocardial 
infarction is a disease with a clear event in time; while HND are chronic conditions. Thus, the 
model will need some re-development for HND, in collaboration with LIME and ICHOM.  
 
 
 
Primary outcome measures 
Disease progression (n=260) 
Combined death or readmission due to heart failure, myocardial infarction, PCI/CABG, end 
stage renal failure, acute renal failure or TIA / stroke. 
 
Patient centered outcome measures (n=131) 
Perceived quality of care and patient empowerment 
Form based on PROMs (Patient Reported Outcome Measure) and PREMs (Patient Reported 
Experience Measure). 
 
Quality-of-care outcome measures (n=131) 
Achieved target blood pressure, lipids, HbA1c 
Secondary outcome measures 
 
Organ damage (n=131)  
Decline in eGFR. 
 
System biology (n=260) 
Changes in markers of disease progression in transcriptomics, proteomics and metabolomics. 
 
Health care structure and utilization (n=131) 
we will study the health care structure and function, involving cost effectiveness, both at 
HND-centrum and within usual care. Mixed model to describe health care utilization and 
explain changes in patterns. Number of outpatient and inpatient visits. 
 
Figure 3. International Consortium 
for Health Outcomes Measurement 
(ICHOM) is a non-profit 
organization founded by Harvard 
Business School, Karolinska 
Institutet and Boston Consulting 
Group with the purpose to improve 
health care studies worldwide by 
measuring and reporting patient 
outcomes in a standardized way. 

 
9 
Patient safety (n=131) 
Using logged patient safety reports. 
 
Interdisciplinary learning:  
Qualitative analysis of interdisciplinary learning between personnel. 
 
Methods: Cardiovascular structure and function 
Cardiac ultrasound, 24- hour blood pressure monitoring, sleep apnoea registration, thumb-
ECG (AF screening) performed in clinical routine with validated equipment and structured 
interpretation. Arterial Stiffness measured using applanation tonometry and pulse-wave 
velocity. Endothelial function evaluated by forearm flow -mediated vasodilatation (FMD). 
Methods: PROM and PREM 
PROM (patient reported outcome Measures) stands for health-related quality of life, patient 
experience of care outcomes, measured by questionnaires EQ5 -D and RAND-36. PREM 
(patient- reported experience Measures) means that patients describe their experiences of care 
and can include measures of quality of life, experience, self-awareness and control. For 
PREM there are currently no standardised instruments, and we have developed a number of 
questions about the patient's experience. 
Methods: Statistics and Data Management 
Data are analyzed with statistics. Differences between groups in the time to outcome analyzed 
by log-rank test. Survival using Kaplan-Mayer. Hazard ratios with Cox proportional hazard 
model. Primary outcomes analysed according to the intention-to-treat principle. 
Research project organisation 
Dr Spaak is medically responsible physician at HND-centrum and PI for the Care-HND study. 
Dr Spaak participates in and coordinates the following groups:  
PostDoc project 1: 
Piotr Sobocinski Doliwa, Jonas Spaak, Mårten Rosenqvist 
Study 1: Screening for atrial fibrillation in HND patients using thumb-ECG. How high is the 
prevalence of silent atrial fibrillation in patients with high CHA2DS2-VASc score without 
previous diagnosis? 
Project 1: Value‐based analysis of integrated clinic  
‐ traditional outcome measures 
Jonas Spaak, Thomas Kahan, Stefan Jacobson, Pia Lundman, Gun Jörneskog, Mårten 
Rosenqvist. Post-doc Peter Doliwa. 
Study 1: Improved prognosis.  
Study 2: Increased adherence to evidence- based therapy and secondary prevention goals.  
Study 3: Reduced progression of vascular dysfunction.  
Study 4-5: Difference in biomarkers in relationship to vascular structure and function. 
PhD Project 2: Value‐based analysis of integrated clinic  
‐ perceived quality of care and patient empowerment 
Åsa Franzén Dalin, Susanna Jäghult, Terese Stenfors-Hayes.  PhD student Gudrun Evén. 
Study 1: Can Care-HND improve the patient's health-related quality of life?  
Study 2: Can a multidisciplinary approach lead to a more involved patient?  
Study 3: Can Care-HND fewer health care contacts in a patient safely? 

 
10 
PhD Project 3: Value‐based analysis of integrated clinic 
‐ health management and economics 
Mats Brommels, Clas Rehnberg, Carl Savage, Pamela Mazzocato, Clas Rehnberg, Pär 
Höglund. PhD Student George Keel. 
Health economic analysis of outcomes from PhD project 1-2, and health management. 
Study 1: Can time- and activity -based measures be used to estimate health care costs in both 
cardiac, renal and diabetes care, and at HND-centrum?  
Study 2-3: Is Care-HND cost effective from a broader perspective? 
Study 4: Can Care-HND re-define chronic disease management? 
PhD Project 4: Clinical learning and improvement  
‐ guideline development and interdisciplinary learning 
Terese Stenfors Hayes, Susanna Jäghult, Åsa Franzén Dalin 
Study 1: How is interdisciplinary learning taking place at HND?  
Study 2: What learning processes occur at team conferences?  
Study 3: How to integrate this knowledge in health care?  
Study 4: How can these processes be standardised and developed to increase value to 
patients? 
Ethical Issues 
The study is approved by the Regional Ethics Committee (Dnr 2014/1:3). Possibly, those 
randomised to Care-HND obtain a clinical benefit, which is our purpose to show. Previous 
studies are lacking to substantiate this. However, we will offer all patients in the control arm 
an opportunity to cross-over at the return visit after one year.  
Description of the gender perspective 
The study includes both men and women and we aim to get an even distribution to get an 
indication of the possible existence of gender-related differences. We believe we will find 
differences in, for example, the presence of sleep apnoea, and in the experience / PREM of the 
received care. However, we believe that Care-HND will have a similar effect on both genders 
regarding the primary outcome measures. 
 
Preliminary results 
Initial descriptive data of the patients so far admitted to the HND-centrum show that they are 
older, on average 72 years. Of all, 25% are below 64 years of age, while 58% are between 65 
and 79 years, and 16% are over 80 years of age. Median age when they received their diabetes 
mellitus diagnosis is 60years. Of all, 85% have type 1 diabetes, and 15% type 2. Of all, 43% 
are on insulin only. 
We have previously not studied these three entities together, but have focused on the 
cardiorenal interactions showing underteratment despite net benefit. The published results 
have been presented in context in the background. One example is that we have shown that 
warfarin treatment is associated with significant reduced mortality also in CKD patients [24]. 
We are currently looking into similar treatments (fondaparinux, ARB, statins). We are also 
studying combined treatment adherence and outcome (PhD project for Masih Khedri, J Spaak 
main supervisor), renal dysfunction and calcium-phosphate disturbances and vascular 
dysfunction (Kristina Lundwall, J Spaak main supervisor), renal dysfunction and haemostasis 
(Josefin Mörtberg, J Spaak main supervisor), and vascular function in stress 
cardiomyopathy/Takotsubo syndrome (Christina Ekenbäck, J Spaak main supervisor). 
 
Research environment and Collaborators 

 
11 
Clinical integration at Danderyd University Hospital 
HND-centrum is staffed by specialist doctors and specialist nurses in cardiology, endocrinology and 
nephrology, with a profound interest in the field, and share a common vision that we can do this better. 
All are deeply involved in the new clinic and are very positive about the planned CareHND study. 
Clinical research expertise in the subject area 
We have accumulated extensive expertise with active clinical researcher in cardiovascular, renal and 
diabetes. Stefan Jacobson, Professor of Nephrology and while CEO of Danderyd Hospital is 
responsible for the field of nephrology in CareHND trial. Gun Jörneskog, Associate Professor, 
Department of Internal Medicine, is responsible for the field of microcirculation and diabetes. Thomas 
Kahan, Professor, Department of Cardiology, is responsible for the field of cardiovascular function. 
Mårten Rosenqvist. Professor, Department of Cardiology, is responsible for the area of clinical 
implementation. Jonas Spaak. PhD, MD, Cardiology clinic is medically responsible for HND-centrum. 
Jonas is main responsible for the area of cardiovascular risk and treatment, and links national registries 
and outcome. Pia Lundman, PhD, Consultant in Cardiology is responsible for the field dyslipidemia 
and metabolic risk. 
Research Expertise in qualitative research and empowerment: 
Susanna Jäghult, program director of the medical clinic, RN, PhD and Åsa Franzén - Dahlin, RN, 
PhD, quality developer of the medical clinic, Danderyd Hospital are both very familiar with qualitative 
research methods and studies. 
Research skills in the field of health economics and health care processes: 
Carl Savage, PhD, a researcher at the Medical Management Centre, Karolinska Institutet. Broad 
expertise in the field. Louise Hagander, MD, PhD, business developer at the hospital management 
section at Danderyd Hospital. Pamela Mazzocato, post-doctoral researcher at LIME / KI. 
Interprofessional teams, clinical microsystems and inter‐professional learning 
Terese Stenfors - Hayes, senior researcher, Department of Learning, Informatics, Management and 
Ethics (LIME), Center for Learning and Knowledge (CLK), did her Post-Doc fellowship at the world's 
first integrated HND clinic in Vancouver, Canada. Susanna Jäghult also contributes here in her role as 
an educational leader at the clinic. 
 
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