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Priority Setting and Rationing in Primary Health Care
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Studies on priority setting in primary health care are rare. Priority setting and rationing in primary health care is important because outcomes from primary health care have significant implications for health care costs and outcomes in the health system as a whole.

Aims: The general aim of this thesis has been to study and analyse the prerequisites for priority setting in primary health care in Sweden. This was done by exploring strategies to handle scarce resources in Swedish routine primary health care (Paper I); analysing patients’ attitudes towards priority setting and rationing and patients’ satisfaction with the outcome of their contact with primary health care (Paper II); describing and analysing how general practitioners, nurses, and patients prioritised individual patients in routine primary health care, studying the association between three key priority setting criteria (severity of the health condition, patient benefit, and cost-effectiveness of the medical intervention) and the overall priority assigned by the general practitioners and nurses to individual patients (Paper III); and analysing how the staff, in their clinical practise, perceived the application of the three key priority setting criteria (Paper IV).

Methods: Both qualitative (Paper I and IV) and quantitative (Paper II and III) methods were used. Paper I was an interview study with medical staff at 17 primary health care centres. The data for Paper II and Paper III were collected through questionnaires to patients and staff at four purposely selected health care centres during a 2-week period. Paper IV was a focus group study conducted with staff members who practiced priority setting in day-to-day care.

Results: The process of coping with scarce resources was categorised as efforts aimed to avoid rationing, ad hoc rationing, or planned rationing. Patients had little understanding of the need for priority setting. Most of them did not experience any kind of rationing and most of those who did were satisfied with the outcome of their contact with primary health care. Patients, compared to medical staff, gave relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions when prioritising individual patients in day-today primary health care. When applying the three priority setting criteria in day-to-day primary health care, the criteria largely influenced the overall prioritisation of each patient. General practitioners were most influenced by the expected cost-effectiveness of the intervention and nurses were most influenced by the severity of the condition. Staff perceived the criteria as relevant, but not sufficient. Three additional aspects to consider in priority setting in primary health care were identified, namely viewpoint (medical or patient’s), timeframe (now or later) and evidence level (group or individual).

Conclusion: There appears to be a need for, and the potential to, introduce more consistent priority setting in primary health care. The characteristics of primary health care, such as the vast array of health problems, the large number of patients with vague symptoms, early stages of diseases, and combinations of diseases, induce both special possibilities and challenges.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 118 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1342
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-88086ISBN: 978-91-7519-756-2 (print)OAI: oai:DiVA.org:liu-88086DiVA: diva2:601539
Public defence
2013-01-31, Eken, Universitetssjukhuset, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2013-01-29 Created: 2013-01-29 Last updated: 2013-01-29Bibliographically approved
List of papers
1. Day-to-day Rationing of Limited Resources in Swedish routine Primary Care: an interview study
Open this publication in new window or tab >>Day-to-day Rationing of Limited Resources in Swedish routine Primary Care: an interview study
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2013 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Rationing is a reality in all health care, but little is known about day-to-day rationing in routine primary health care (PHC). This study aims to explore strategies to handle limited of resources in Swedish routine primary care.

Methods: Data were compiled from 62 interviews with healthcare professionals (general practitioners, nurses, physiotherapists, and managers at primary care centres). A qualitative research method was applied in the analysis.

Results: The interviewed staff described perceptions of a general public with high expectations on PHC in combination with a lack of resources. Strategies to cope with scarce resources were avoiding rationing, ad hoc rationing, or planned rationing. Rationing was largely implicit and not based on ethical principles or other defined criteria. Trying to avoid rationing resulted in unintended rationing. Ad hoc rationing had undesired consequences, e.g. inadequate continuity of care and displacing certain patient groups, especially the chronically ill and the elderly. The staff expressed a need for support and for applicable guidelines, and called for policy statements based on priority decisions to help manage the situation.

Conclusions: The interviews suggested a need to improve the transparency of priority setting procedures in PHC, although the nature of the PHC setting presents special challenges. Improving transparency could, in turn, improve equity and the efficient use of resources in PHC.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-88085 (URN)
Available from: 2013-01-29 Created: 2013-01-29 Last updated: 2013-01-29Bibliographically approved
2. Primary care patients' attitudes to priority setting in Sweden.
Open this publication in new window or tab >>Primary care patients' attitudes to priority setting in Sweden.
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2009 (English)In: Scandinavian journal of primary health care, ISSN 1502-7724, Vol. 27, no 2, 123-8 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To analyse attitudes to priority setting among patients in Swedish primary healthcare. DESIGN: A questionnaire was given to patients comprising statements on attitudes towards prioritizing, on the role of politicians and healthcare staff in prioritizing, and on patient satisfaction with the outcome of their contact with primary healthcare (PHC). SETTINGS: Four healthcare centres in Sweden, chosen through purposive sampling. PARTICIPANTS: All the patients in contact with the health centres during a two-week period in 2004 (2517 questionnaires, 72% returned). MAIN OUTCOMES: Patient attitudes to priority setting and satisfaction with the outcome of their contact. RESULTS: More than 75% of the patients agreed with statements like "Public health services should always provide the best possible care, irrespective of cost". Almost three-quarters of the patients wanted healthcare staff rather than politicians to make decisions on priority setting. Younger patients and males were more positive towards priority setting and they also had a more positive view of the role of politicians. Less than 10% of the patients experienced some kind of economic rationing but the majority of these patients were satisfied with their contact with primary care. CONCLUSIONS: Primary care patient opinions concerning priority setting are a challenge for both politicians and GPs. The fact that males and younger patients are less negative to prioritizing may pave the way for a future dialogue between politicians and the general public.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-18972 (URN)10.1080/02813430902883901 (DOI)19466679 (PubMedID)
Available from: 2009-06-07 Created: 2009-06-07 Last updated: 2013-01-29
3. Setting priorities in primary health care - on whose conditions? A questionnaire study
Open this publication in new window or tab >>Setting priorities in primary health care - on whose conditions? A questionnaire study
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2012 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, no 114Article in journal (Refereed) Published
Abstract [en]

Background: In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs, nurses, and patients prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. less thanbrgreater than less thanbrgreater thanMethods: Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. less thanbrgreater than less thanbrgreater thanResults: Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. less thanbrgreater than less thanbrgreater thanConclusions: The challenge for primary care providers is to balance the patients demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.

Place, publisher, year, edition, pages
BioMed Central, 2012
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-87966 (URN)10.1186/1471-2296-13-114 (DOI)000312733800001 ()
Note

Funding Agencies|FORSS (Council for Research in Southeast Sweden)||county council of Jonkoping||county council of Kalmar||county council of Ostergotland||Faculty of Health Sciences, Linkoping University||

Available from: 2013-01-28 Created: 2013-01-28 Last updated: 2017-12-06
4. Priority setting in primary health care - dilemmas and opportunities: a focus group study
Open this publication in new window or tab >>Priority setting in primary health care - dilemmas and opportunities: a focus group study
2010 (English)In: BMC FAMILY PRACTICE, ISSN 1471-2296, Vol. 11, no 71Article in journal (Refereed) Published
Abstract [en]

Background: Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria. Methods: Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work. Results: The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patients), 2) timeframe (now or later), and 3) evidence level (group or individual). Conclusions: The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.

Place, publisher, year, edition, pages
BioMed Central, 2010
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-61207 (URN)10.1186/1471-2296-11-71 (DOI)000283116400001 ()
Note
Original Publication: Eva Arvidsson, Malin André, Lars Borgquist and Per Carlsson, Priority setting in primary health care - dilemmas and opportunities: a focus group study, 2010, BMC FAMILY PRACTICE, (11), 71. http://dx.doi.org/10.1186/1471-2296-11-71 Licensee: BioMed Central http://www.biomedcentral.com/ Available from: 2010-11-05 Created: 2010-11-05 Last updated: 2013-01-29

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