liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Diffusion, implementation and consequences of new health technology: The cases of biological drugs for rheumatoid arthritis and the Swedish national guidelines
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Improvements in health technology raise hopes for better patient outcomes and a more efficient delivery of health care. However, the processes of diffusion and implementation of new health technology have been shown to be complicated and to pose a number of challenges for the healthcare sector. Many at tempts have been made to influence and manage the introduction and diffusion of health technology. One prominent example is the Swedish nat ional guidelines that aim at influencing both clinical and political decision - making in the health sector.

The overall aim of this thesis is to describe and analyze the factors influencing the diffusion and economic consequences of the introduction of a new technology with large variations in use, and to explore the process of implementation of nationally produced guidelines as an instrument for improv ing effectiveness and equity. The empirical focus is kept on the biological drugs (bDMARDs) for rheumatoid arthritis (RA), since they implied a substantial treatment change when they were first int roduced and they are relatively costly; and on the national guidelines for cardiac care, since they were the first nat ional guidelines, hence allowing a long-term perspect ive in the exploration of their implementat ion.

Paper I presents a register study that uses data from national and regional registries on healt hcare use and work disability of patients with RA and shows that there was a 32 percent increase in the total fixed cost of RA during 1990-2010, mainly after the introduct ion of bDMARDs. Paper II shows that choosing to initiate treatment with bDMARDs varied substantially among 26 rheumatologists presented with hypothetical patient cases, and that there were also disparities between rheumatologists practicing in the same clinic. Paper III presents data from the Swedish Rheumatology Quality Register covering 4010 patients with RA, and shows that when using multivariate logistic regression to adjust for patient characterist ics, disease activity and t he physician’s local context, physician preference was an import ant predict or for prescription of bDMARDs. Paper IV is a qualitative study about prescribing decisions, showing that a constellat ion of various factors and their interact ion influenced the prescribing decisions according to the 26 interviewed rheumatologists. The factors included the individual rheumatologist ’s experiences and perceptions of t he evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participat ion in clinical trials. The patient as an actor emerged as an important factor. Paper V is a longitudinal qualitat ive study exploring the responses among four Swedish county councils to the national guidelines for cardiac care through 155 interviews with politicians, administ rators and clinical managers. The results show that unilateral responses to the national guidelines within the county councils have been rare, but there have been at tempts to compromise and to at tain a balance between multiple constituents. There are examples of local information meetings, the use of the national guidelines in local healthcare programs, and performing audits with the national guidelines as a base. However, performing explicit prioritizat ion as advised in the NGCC is rarely found. Over t ime, however, a more systematic use of the national guidelines has been noted.

In conclusion, the diffusion of new health technology is influenced by a wide array of factors both at individual and organizational levels, as well as their interact ion. The diffusion resulted in large economic consequences and unequal access due to variations also at clinical level. Moreover, given that healthcare decision-making is influenced by many different factors, the simple influx of evidence-based guidelines will unlikely result in automat ic implementat ion. At tempts to influence healthcare decisions need to have a systems perspect ive and to account for the interact ion of factors between different actors.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 104 including Appendix A and B p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1431
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-113306DOI: 10.3384/diss.diva-113306ISBN: 978-91-7519-177-5 (print)OAI: oai:DiVA.org:liu-113306DiVA: diva2:780989
Public defence
2015-02-06, Berzeliussalen, Ingång 65, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2015-01-15 Created: 2015-01-15 Last updated: 2016-03-02Bibliographically approved
List of papers
1. Costs of rheumatoid arthritis during the period 1990–2010: a register-based cost-of-illness study in Sweden
Open this publication in new window or tab >>Costs of rheumatoid arthritis during the period 1990–2010: a register-based cost-of-illness study in Sweden
Show others...
2014 (English)In: Rheumatology, ISSN 1462-0324, E-ISSN 1462-0332, Vol. 53, no 1, 153-160 p.Article in journal (Refereed) Published
Abstract [en]

Objectives. The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990–2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs.

Methods. A prevalence-based cost-of-illness study was conducted based on data from national and regional registries.

Results. There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990–2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010.

Conclusion. By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment.

Place, publisher, year, edition, pages
Oxford University Press, 2014
National Category
Medical and Health Sciences Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-100004 (URN)10.1093/rheumatology/ket290 (DOI)000329041900022 ()24136064 (PubMedID)
Available from: 2013-10-24 Created: 2013-10-24 Last updated: 2017-12-06Bibliographically approved
2. Individual variations in treatment decisions by Swedish rheumatologists regarding biological drugs for rheumatoid arthritis
Open this publication in new window or tab >>Individual variations in treatment decisions by Swedish rheumatologists regarding biological drugs for rheumatoid arthritis
Show others...
2015 (English)In: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 44, no 4, 265-270 p.Article in journal (Refereed) Published
Abstract [en]

Objective: In Sweden, reports indicate surprisingly large regional variation in prescription of biological drugs, despite a growing number of clinical studies describing their beneficial effects and guidelines by professional organizations and agencies. Our objective was to ascertain whether there is also variation between individual rheumatologists in prescribing biologics to patients with rheumatoid arthritis (RA) and to evaluate reasons for treatment choices.

Methods: Ten hypothetical patient cases were constructed and presented to 26 rheumatologists in five regions in Sweden. The cases were based on actual cases and were thoroughly elaborated by a senior rheumatologist and pre-tested in a pilot study. The respondents were asked whether they would treat the patients with a biological agent (YES/NO) and to explain their decisions.

Results: The response rate was 26/105; 25%. Treatment choices varied considerably between the rheumatologists, some prescribing biologics to 9/10 patients and others to 2/10. In five of the ten hypothetical cases, approximately half of the respondents would prescribe biologics. No regions with particularly high or low prescription were identified. Both the decision to prescribe biologics, as well as not to prescribe, were mainly motivated by medical reasons. Some rheumatologists also referred to lifestyle-related factors or social function of the patient.

Conclusion: The choice of initiation of biologics varied substantially among rheumatologists presented with hypothetical patient cases, and there were also disparities between rheumatologists practising at the same clinic. Treatment choices were primarily motivated by medical reasons. This situation raises concerns about a lack of consensus in RA treatment strategies.

Place, publisher, year, edition, pages
Informa Healthcare, 2015
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-113301 (URN)10.3109/03009742.2014.997286 (DOI)000359960100002 ()
Available from: 2015-01-15 Created: 2015-01-15 Last updated: 2017-12-05Bibliographically approved
3. Physician Preferences and Variations in Prescription of Biologic Drugs for Rheumatoid Arthritis: A Register-Based Study of 4,010 Patients in Sweden
Open this publication in new window or tab >>Physician Preferences and Variations in Prescription of Biologic Drugs for Rheumatoid Arthritis: A Register-Based Study of 4,010 Patients in Sweden
Show others...
2015 (English)In: Arthritis care & research, ISSN 2151-464X, E-ISSN 2151-4658, Vol. 67, no 12, 1679-1685 p.Article in journal (Refereed) Published
Abstract [en]

Objective. The prescription of biologic drugs for rheumatoid arthritis (RA) patients has varied considerably across different regions. Previous studies have shown physician preferences to be an important determinant in the decision to select biologic disease-modifying antirheumatic drugs (bDMARDs) rather than nonbiologic, synthetic DMARDs (sDMARDs) alone. The aim of this study was to test the hypothesis that physician preferences are an important determinant for prescribing bDMARDs for RA patients in Sweden. Methods. Using data from the Swedish Rheumatology Quality Register, we identified 4,010 RA patients who were not prescribed bDMARDs during the period 2008-2012, but who, on at least 1 occasion, had an sDMARD prescription and changed treatment for the first time to either a new sDMARD or a bDMARD. Physician preference for the use of bDMARDs was calculated using data on each physicians prescriptions during the study period. The relationship between prescription of a bDMARD and physician preference, controlling for patient characteristics, disease activity, and the physicians local context was evaluated using multivariate logistic regression. Results. When adjusting for patient characteristics, disease activity, and the physicians local context, physician preference was an important predictor for prescription of bDMARDs. Compared with patients of a physician in the lowest preference tertile, patients of physicians in the highest and middle tertiles had an odds ratio for receiving bDMARDs of 2.8 (95% confidence interval [95% CI] 2.13-3.68) and 1.28 (95% CI 1.05-1.57), respectively. Conclusion. Physician preference is an important determinant for prescribing bDMARDs.

Place, publisher, year, edition, pages
WILEY-BLACKWELL, 2015
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-124498 (URN)10.1002/acr.22640 (DOI)000367681900008 ()26097219 (PubMedID)
Note

Funding Agencies|Norrbacka-Eugenia Foundation; Swedish Rheumatism Association

Available from: 2016-02-02 Created: 2016-02-01 Last updated: 2017-11-30
4. Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study
Open this publication in new window or tab >>Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study
2014 (English)In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, no 153Article in journal (Refereed) Published
Abstract [en]

Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors.

Place, publisher, year, edition, pages
BioMed Central, 2014
Keyword
Prescription; Rheumatoid arthritis; Biological drugs; Implementation; Physicians; Clinical decision-making; Practice variations; Qualitative; CFIR
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-113028 (URN)10.1186/s13012-014-0153-5 (DOI)000345438200001 ()25304517 (PubMedID)
Available from: 2015-01-12 Created: 2015-01-08 Last updated: 2017-12-05
5. Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden
Open this publication in new window or tab >>Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden
2015 (English)In: Social Policy & Administration, ISSN 0144-5596, E-ISSN 1467-9515, Vol. 49, no 7, 911-927 p.Article in journal (Refereed) Published
Abstract [en]

In the last ten years, the concept of management by knowledge has gained growing attention inSwedish healthcare, as well as internationally. In Sweden, the most prominent example ofmanagement by knowledge is the National Guidelines, aimed at influencing both clinical andpolitical decision-making in the health sector. The objective of this article is to explore the response among four Swedish county councils to the National Guidelines for Cardiac Care (NGCC). Empirical material was collected through 155 expert interviews with the target groups of the NGCC, politicians, administrators and clinical managers. Analysis of the responses to this multifaceted policy instrument was addressed by drawing on implementation theory (Matland 1995) and institutional theory (Oliver 1991). The NGCC are primarily based on the voluntary diffusion of norms. The county councils are a long way from having adapted all the means suggested by the National Board of Health and Welfare (NBHW): explicit prioritization, healthcare programmes and dialogue between the various actor groups. The high degree of ambiguity in the content of the NGCC, the inherent conflict and the multiplicity and uncertainty in the context of the county councils, have often resulted in avoidance and compromise. The strategic responses we observe can be viewed as an attempt to balance multiple constituents and achieve the various internal organizational goals. The ambiguity and conflict inherent in the policy of the NGCC influence the strategic responses made by the organization. The question remains how far management by knowledge can be applied in a political context.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015
Keyword
Policy implementation; Institutional pressure; Strategic responses; Swedish National Guidelines
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-113304 (URN)10.1111/spol.12102 (DOI)000368267400006 ()
Available from: 2015-01-15 Created: 2015-01-15 Last updated: 2017-12-05Bibliographically approved

Open Access in DiVA

fulltext(1367 kB)362 downloads
File information
File name FULLTEXT01.pdfFile size 1367 kBChecksum SHA-512
99151b6d34ed022e3e11f46abbc00ccb0b283204a29dbcb34db3b6c983ce3132409f860b79161925dead42fd26c04ed9dfa94cea13fa2458088ccda01e7fe1ba
Type fulltextMimetype application/pdf
omslag(1547 kB)16 downloads
File information
File name COVER01.pdfFile size 1547 kBChecksum SHA-512
593d8be0b2cef4eaf06093eea5fc1b960f05fefc3a74dbbbd2bf4a3cf161f8819e6454e8b64b40888c01634113fd3c0448d7fe01763e7e16cb620f2d64607200
Type coverMimetype application/pdf

Other links

Publisher's full text

Authority records BETA

Kalkan, Almina

Search in DiVA

By author/editor
Kalkan, Almina
By organisation
Division of Health Care AnalysisFaculty of Health Sciences
Health Care Service and Management, Health Policy and Services and Health Economy

Search outside of DiVA

GoogleGoogle Scholar
Total: 362 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

doi
isbn
urn-nbn

Altmetric score

doi
isbn
urn-nbn
Total: 1762 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf