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Så resonerar läkare och sjuksköterskor vid prioriteringar av patienter i primärvård
Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
Falun.
Linköping University, Department of Department of Health and Society, General Practice. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
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2007 (Swedish)Report (Other academic)
Abstract [sv]

Studier av prioriteringar i primärvården är särskilt intressanta eftersom det är där de allra flesta av oss kommer i kontakt med hälso- och sjukvården. Det är också i primärvården prioriteringar och olika former av ransonering på grund av begränsade resurser är vanliga. De allra flesta av oss förstår och accepterar att vi inte omedelbart kan få träffa en läkare om det inte rör sig om akuta och allvarliga sjukdomstillstånd. Vi finner många gånger ett råd om egenvård som en tillfredställande lösning för tillfället. Hur olika prioriteringar görs ”bakom kulisserna” är dock många gånger oklart för oss. Vi kan ibland t.ex. undra varför vi får betala för vissa vårdtjänster medan andra är gratis. Osäkerhet om på vilka grunder prioriteringar sker gäller inte bara för patienter utan även sjukvårdspersonal. Erfarenheter från flera olika håll i Sverige pekar på att de etiska riktlinjer som utgör kärnan i riksdagens prioriteringsprinciper är svåra att använda i praktiken. Det är därför angeläget att få mer kunskap om hur prioriteringsprinciper och begrepp uppfattas av sjukvårdspersonalen för att utveckla arbetsformer som är begripliga och förenliga med rådande rutiner.

Distriktsläkare, mottagningssköterskor och distriktssköterskor vid fyra vårdcentraler som tidigare deltagit i en prioriteringsstudie har inbjudits att diskutera prioriteringar utifrån ett antal frågeställningar. Resultaten från dessa diskussioner visar bland att olika begrepp tolkas på många olika sätt. En framgångsrik implementering av den etiska plattformen kräver antagligen betydligt mer av öppna diskussioner om prioriteringar och principer i det dagliga vårdarbetet.

Två allmänläkare Eva Arvidsson från Kalmar och Malin André från Falun har bidragit med den största insatsen i projektet som för övrigt inbegriper Lars Borgquist från Avdelningen för allmänmedicin vid Linköpings universitet och Kjell Lindström från Primärvårdens utvecklingsenhet i Jönköping. Studien har finansierats av Forskningsrådet för sydöstra sjukvårdsregionen (FORSS).

Jag vill på projektgruppens vägnar tacka alla medverkande från vårdcentralerna Lindsdal och Borgholm i Kalmar läns landsting, Öxnehaga i Jönköpings läns landsting och Ryds vårdcentral i Landstinget i Östergötland.

Linköping 2007-07-24

Per Carlsson

Abstract [en]

 

Background

Experience from work with priority setting in health and medical care indicates that the ethical guidelines that are at the heart of Swedish Parliament’s principles for priority  setting  are difficult  to implement  into practical  clinical  decision- making. The same can be said of the model for priority setting drawn up by the Swedish National Board of Health and Welfare in the national guidelines  for care and treatment. For this reason, we need more knowledge on how principles for priority setting and related concepts are perceived by medical care personnel, the relevance of these concepts, and if there are other aspects that also impact the priority setting situation.  We also need to develop  new work methods  to meet Parliament’s intentions with priority setting in health and medical care.

To contribute  to the development  of new  work  methods,  we chose  to study priority setting in primary care practice. Our primary purpose was to describe the way in which general practitioners and district nurses perceive the concepts severity  of  illness,  benefit  and  cost-effectiveness  when  they  rank  priority  for individual patients. Our secondary purpose was to compare medical personnel’s perception of the concepts severity of illness, benefit and cost-effectiveness with the definitions  of these  concepts  in the model  for vertical  priority  setting  as established by the National Board of Health and Welfare.

Methods

Focus group interviews as a source of data collection was selected as the method since the study was explorative and the intention was to obtain as many aspects as possible pertaining  to priority setting concepts.  The method is suitable for collecting a large amount of information within a previously unexplored subject. Interviews were conducted with eight groups of physicians and nurses from four different primary care centers. The respondents  selected had participated  in a prospective  study  on  practical  priority  setting,  i.e.  they  had  experience  of implementing the concepts severity of illness, benefit, and cost-effectiveness in setting priorities in their daily work.

Results and Conclusions

Both  the  physicians  and  nurses  expressed  a  simplified  interpretation  of  the concepts severity of illness and benefit. One example of such simplification was that many nurses said that when ranking the severity of a condition, they based their decision on how imperative  it was for the patient to see a physician.  A

 

common response was that the concepts could be assessed from both patient and staff perspectives  but that these assessments  could differ. When asked to set priorities according to a specific template, respondents said that it was easier to rank patients with an acute condition that had a tangible effect on function and that could be immediately treated, than to rank patients according to factors that were a risk to their future health. This means that priority judgements based on knowledge of a patient category were perceived as uncertain and more difficult to use than direct personal experience of treating an individual patient. This was discussed, above all, by the physicians. Respondents gave several examples of actions taken despite that medical staff did not feel that there was any benefit to the patient.

In a comparison  of how these three concepts  are described  in the model for priority setting on the policy level drawn up by the National Board of Health and Welfare and how medical personnel implemented the concepts, we found both similarities and dissimilarities.

A model based on these concepts can be of use in priority setting in primary care, but it must be supplemented  and improved  to be applicable  to ranking patients  in day-to-day  medical  care. Supplements  that may be necessary  are; clarification that a combination of medical and patient perspectives is intended, clarification of how to use the concept cost-effectiveness, and the addition of a time factor and factors related to the individual patient. There is also a need for a more  structured  way  of working  with evidence-based  care.  We also  need  to clarify the differences between setting priorities for patient categories and for individual patients in day-to-day medical care.

In our opinion, the model for priority setting on the patient category level can be improved  to  be  more  applicable  as  a  template  for  decision-making  on  the individual patient level, however a supplementary  model may be necessary to support priority setting on the individual level.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2007. , 77 inkl bilagor 1-4 p.
Series
CMT Report, ISSN 0283-1228 (print), 1653-7556 (online) ; 2007:6
Keyword [en]
Primary health care
Keyword [sv]
Primärvård, prioritering inom sjukvården
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-40753ISRN: LIU CMT RA/0706Local ID: 54036OAI: oai:DiVA.org:liu-40753DiVA: diva2:261602
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2014-10-28Bibliographically approved

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Så resonerar läkare och sjuksköterskor vid prioriteringar av patienter i primärvård(379 kB)2448 downloads
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