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  • 1.
    Abbott, Allan
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Schröder, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Effectiveness of implementing a best practice primary healthcare model for low back pain (BetterBack) compared with current routine care in the Swedish context: an internal pilot study informed protocol for an effectiveness-implementation hybrid type 2 trial2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 4, article id e019906Article in journal (Refereed)
    Abstract [en]

    Introduction Low back pain (LBP) is a major health problem commonly requiring healthcare. In Sweden, there is a call from healthcare practitioners (HCPs) for the development, implementation and evaluation of a best practice primary healthcare model for LBP.

    Aims (1) To improve and understand the mechanisms underlying changes in HCP confidence, attitudes and beliefs for providing best practice coherent primary healthcare for patients with LBP; (2) to improve and understand the mechanisms underlying illness beliefs, self-care enablement, pain, disability and quality of life in patients with LBP; and (3) to evaluate a multifaceted and sustained implementation strategy and the cost-effectiveness of the BetterBack☺ model of care (MOC) for LBP from the perspective of the Swedish primary healthcare context.

    Methods This study is an effectiveness-implementation hybrid type 2 trial testing the hypothesised superiority of the BetterBack☺ MOC compared with current routine care. The trial involves simultaneous testing of MOC effects at the HCP, patient and implementation process levels. This involves a prospective cohort study investigating implementation at the HCP level and a patient-blinded, pragmatic, cluster, randomised controlled trial with longitudinal follow-up at 3, 6 and 12 months post baseline for effectiveness at the patient level. A parallel process and economic analysis from a healthcare sector perspective will also be performed. Patients will be allocated to routine care (control group) or the BetterBack☺ MOC (intervention group) according to a stepped cluster dogleg structure with two assessments in routine care. Experimental conditions will be compared and causal mediation analysis investigated. Qualitative HCP and patient experiences of the BetterBack☺ MOC will also be investigated.

    Dissemination The findings will be published in peer-reviewed journals and presented at national and international conferences. Further national dissemination and implementation in Sweden and associated national quality register data collection are potential future developments of the project.

  • 2.
    Abdelrahman, Islam
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery. Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt.
    Elmasry, Moustafa
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery. Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt.
    Fredrikson, Mats
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences.
    Steinvall, Ingrid
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Validation of the burn intervention score in a National Burn Centre2018In: Burns, ISSN 0305-4179, E-ISSN 1879-1409, no 5, p. 1159-1166Article in journal (Refereed)
    Abstract [en]

    The Linköping burn score has been used for two decades to calculate the cost to the hospital of each burned patient. Our aim was to validate the Burn Score in a dedicated Burn Centre by analysing the associations with burn-specific factors: percentage of total body surface area burned (TBSA%), cause of injury, patients referred from other (non-specialist) centres, and survival, to find out which of these factors resulted in higher scores. Our second aim was to analyse the variation in scores of each category of care (surveillance, respiration, circulation, wound care, mobilisation, laboratory tests, infusions, and operation).

    We made a retrospective analysis of all burned patients admitted during the period 2000–15. Multivariable regression models were used to analyse predictive factors for an increased daily burn score, the cumulative burn score (the sum of the daily burn scores for each patient) and the total burn score (total sum of burn scores for the whole group throughout the study period) in addition to sub-analysis of the different categories of care that make up the burn score.

    We retrieved 22 301 daily recordings for inpatients. Mobilisation and care of the wound accounted for more than half of the total burn score during the study. Increased TBSA% and age over 45 years were associated with increased cumulative (model R2 0.43, p < 0.001) and daily (model R2 0.61, p < 0.001) burn scores. Patients who died had higher daily burn scores, while the cumulative burn score decreased with shorter duration of hospital stay (p < 0.001).

    To our knowledge this is the first long term analysis and validation of a system for scoring burn interventions in patients with burns that explores its association with the factors important for outcome. Calculations of costs are based on the score, and it provides an indicator of the nurses’ workload. It also gives important information about the different dimensions of the care provided from thorough investigation of the scores for each category.

  • 3.
    Ahlstrom, Gerd
    et al.
    Lund Univ, Sweden.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Benzein, Eva
    Linnaeus Univ, Sweden.
    Behm, Lina
    Lund Univ, Sweden.
    Wallerstedt, Birgitta
    Linnaeus Univ, Sweden.
    Persson, Magnus
    Lund Univ, Sweden.
    Sandgren, Anna
    Linnaeus Univ, Sweden.
    Implementation of knowledge-based palliative care in nursing homes and pre-post post evaluation by cross-over design: a study protocol2018In: BMC Palliative Care, ISSN 1472-684X, E-ISSN 1472-684X, Vol. 17, article id 52Article in journal (Refereed)
    Abstract [en]

    Background: The demography of the world is changing as the population is ageing. Because of this change to a higher proportion of older people, the WHO has called for improved palliative care for older persons. A large number of all deaths in the industrialised world occur while older people are living in nursing homes and therefore a key question becomes how the principles of palliative care can be implemented in that context. The aims of this study are: a) to describe a model of an educational intervention with the goal of implementing knowledge-based palliative care in nursing homes, and b) to describe the design of the evaluation of the effectiveness regarding the implementation of knowledge-based palliative care. Methods/design: A complex intervention is evaluated by means of a cross-over design. An educational intervention concerning palliative care consisting of five seminars during 6 months for staff and managers has been developed and conducted in 20 nursing homes in two counties. Before the intervention started, the feasibility was tested in a pilot study conducted in nursing homes not included in the main study. The intervention is evaluated through a non-randomized experimental design with intervention and control groups and pre- and post-assessments. The evaluation includes older persons living in nursing homes, next-of-kin, staff and managers. Data collection consists of quantitative methods such as questionnaires and register data and qualitative methods in the form of individual interviews, focus-group interviews and participant observations. Discussion: The research will contribute to new knowledge about how to implement knowledge-based palliative care in a nursing home setting. A strength of this project is that the Medical Research Council framework of complex intervention is applied. The four recommended stages, Development, Feasibility and piloting, Evaluation and Implementation, are combined for the educational intervention, which functions as a strategy to achieve knowledge-based palliative care in the nursing homes. Implementation is always a question of change and a good theoretical understanding is needed for drawing valid conclusions about the causal mechanisms of change. The topic is highly relevant considering the worlds ageing population. The data collection is completed and the analysis is ongoing.

  • 4.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundqvist, Martina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundqvist, Martina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Utvärdering av försöksverksamhet med service- och signalhundar2014Report (Other academic)
    Abstract [sv]

    Denna rapport redovisar utvärderingen av en försöksverksamhet med ser-vice- och signalhundar som bedrevs mellan år 2009 och 2014. Utvärderingen inkluderar servicehundar, signalhundar samt alarmerande servicehundar (epilepsihundar och diabeteshundar). Totalt 56 ekipage (förare samt hund) ingick i utvärderingsstudien. Data i studien samlades in före samt efter genomgången service- och signalhundsutbildning. Syftet med utvärderingen är att studera hur certifierade service- och signalhundar påverkar förarnas behov av offentliga stödinsatser och de totala samhällskostnaderna. Dessutom studerades hur service- och signalhundar påverkar förarna med avseende på hälsorelaterad livskvalitet, välbefinnande, självförtroende och fysisk aktivitet samt om användningen av service- och signalhundar är kostnadseffektiv ur ett samhällsperspektiv.

      Resultat och slutsatser

    • Service- och signalhundar minskar i genomsnitt förarnas behov av offentliga stödinsatser med 197 000 kronor (6 procent) under en tioårsperiod.
    • Livskvaliteten för personer med behov av service- och signalhundar är låg jämfört med den allmänna populationen i Sverige. Studien visar på en förbättring i livskvaliteten och välbefinnandet för förare med en certifierad hund.
    • Förarnas grad av fysisk aktivitet ökade med en certifierad hund och majoriteten av dem angav att de ökat sin tid utanför hemmet samt att de även ökat sin tid för att delta i sociala aktiviteter tack vare hunden.
    • Förarnas negativa emotionella upplevelser minskar med en certifierad hund.
    • Förarna beskriver själva den certifierade hunden som ett viktigt verktyg för ökad självständighet och trygghet.
    • Den hälsoekonomiska modellen som analyserar kostnadseffektiviteten visar att ett innehav av en certifierad hund är ett dominant alternativ jämfört med att inte ha en certifierad hund. Detta innebär att kostnaderna ur ett samhällsperspektiv under en tioårsperiod är lägre (-103 000 kronor) samtidigt som effekterna i form av vunna QALY (kvalitetsjusterade levnadsår) är högre (+0,15).
    • Finansieringsanalysen visar att förare som har certifierade hundar sparar resurser åt alla aktörer (stat, kommun och landsting) men får själva ökade utgifter på grund av hunden.
    • Studien baseras på ett lågt antal observationer (56 ekipage). Det i kombination med att det är en stor spridning i resursförbrukningen mellan ekipagen medför att det finns en statistisk osäkerhet i resultaten. Slutsatserna bedöms dock som rimliga eftersom de är samstämmiga.
  • 5.
    Amundstuen Reppe, Linda
    et al.
    Nordic University, Norway; Norwegian University of Science and Technology, Norway; St Olays Hospital, Norway.
    Lydersen, Stian
    Norwegian University of Science and Technology, Norway.
    Schjott, Jan
    Haukeland Hospital, Norway; University of Bergen, Norway; Haukeland Hospital, Norway.
    Damkier, Per
    Odense University Hospital, Denmark.
    Rolighed Christensen, Hanne
    Bispebjerg and Frederiksberg University Hospital, Denmark.
    Peter Kampmann, Jens
    Bispebjerg and Frederiksberg University Hospital, Denmark.
    Böttiger, Ylva
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pharmacology.
    Spigset, Olav
    Norwegian University of Science and Technology, Norway; St Olays Hospital, Norway.
    Relationship Between Time Consumption and Quality of Responses to Drug-related Queries: A Study From Seven Drug Information Centers in Scandinavia2016In: Clinical Therapeutics, ISSN 0149-2918, E-ISSN 1879-114X, Vol. 38, no 7, p. 1738-1749Article in journal (Refereed)
    Abstract [en]

    Purpose: The aims of this study were to assess the quality of responses produced by drug information centers (DICs) in Scandinavia, and to study the association between time consumption processing queries and the quality of the responses. Methods: We posed six identical drug-related queries to seven DICs in Scandinavia, and the time consumption required for processing them was estimated. Clinical pharmacologists (internal experts) and general practitioners (external experts) reviewed responses individually. We used mixed model linear regression analyses to study the associations between time consumption on one hand and the summarized quality scores and the overall impression of the responses on the other hand. Findings: Both expert groups generally assessed the quality of the responses as "satisfactory" to "good." A few responses were criticized for being poorly synthesized and less relevant, of which none were quality-assured using co-signatures. For external experts, an increase in time consumption was statistically significantly associated with a decrease in common quality score (change in score, -0.20 per hour of work; 95% CI, -0.33 to -0.06; P = 0.004), and overall impression (change in score, -0.05 per hour of work; 95% CI, -0.08 to -0.01; P = 0.005). No such associations were found for the internal experts assessment. Implications: To our knowledge, this is the first study of the association between time consumption and quality of responses to drug-related queries in DICs. The quality of responses were in general good, but time consumption and quality were only weakly associated in this setting. (C) 2016 The Authors. Published by Elsevier HS Journals, Inc.

  • 6.
    Anderson, Peter
    et al.
    Newcastle Univ, England; Maastricht Univ, Netherlands.
    Kloda, Karolina
    Pomeranian Med Univ, Poland.
    Kaner, Eileen
    Newcastle Univ, England.
    Reynolds, Jillian
    Hosp Clin Barcelona, Spain.
    Bendtsen, Preben
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Pelgrum-Keurhorst, Myrna N.
    Radboud Univ Nijmegen, Netherlands; Saxion Univ Appl Sci, Netherlands.
    Segura, Lidia
    Govt Catalonia, Spain.
    Wojnar, Marcin
    Med Univ Warsaw, Poland.
    Mierzecki, Artur
    Pomeranian Med Univ, Poland.
    Deluca, Paolo
    King’s College London, London, UK.
    Newbury-Birch, Dorothy
    Teesside Univ, England.
    Parkinson, Kathryn
    Newcastle Univ, England; State Agcy Prevent Alcohol Related Problems, Poland.
    Okulicz-Kozaryn, Katarzyna
    State Agency for Prevention of Alcohol-Related Problems, Warsaw, Poland.
    Drummond, Colin
    Kings Coll London, England; South London and Maudsley NHS Fdn Trust, England.
    Laurant, Miranda G. H.
    Radboud Univ Nijmegen, Netherlands; HAN Univ Appl Sci, Netherlands.
    Gual, Antoni
    Neurosciences Institute, Hospital Clinic, IDIBAPS, Barcelona, Spain.
    Impact of practice, provider and patient characteristics on delivering screening and brief advice for heavy drinking in primary healthcare: Secondary analyses of data from the ODHIN five-country cluster randomized factorial trial2017In: European Journal of General Practice, ISSN 1381-4788, E-ISSN 1751-1402, Vol. 23, no 1, p. 241-245Article in journal (Refereed)
    Abstract [en]

    Background: The implementation of primary healthcare-based screening and advice that is effective in reducing heavy drinking can be enhanced with training. Objectives: Undertaking secondary analysis of the five-country ODHIN study, we test: the extent to which practice, provider and patient characteristics affect the likelihood of patients being screened and advised; the extent to which such characteristics moderate the impact of training in increasing screening and advice; and the extent to which training mitigates any differences due to such characteristics found at baseline. Methods: A cluster randomized factorial trial involving 120 practices, 746 providers and 46 546 screened patients from Catalonia, England, the Netherlands, Poland, and Sweden. Practices were randomized to receive training or not to receive training. The primary outcome measures were the proportion of adult patients screened, and the proportion of screen-positive patients advised. Results: Nurses tended to screen more patients than doctors (OR = 3.1; 95% CI: 1.9, 4.9). Screenpositive patients were more likely to be advised by doctors than by nurses (OR = 2.3; 95% CI: 1.4, 4.1), and more liable to be advised the higher their risk status (OR = 1.9; 95% CI: 1.3, 2.7). Training increased screening and advice giving, with its impact largely unrelated to practice, provider or patient characteristics. Training diminished the differences between doctors and nurses and between patients with low or high-risk status. Conclusions: Training primary healthcare providers diminishes the negative impacts that some practice, provider and patient characteristics have on the likelihood of patients being screened and advised.

  • 7.
    Andersson, Agneta
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
    Health economic studies on advanced home care2002Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The aim of this thesis was to examine the cost-effectiveness of specific advanced home care and home rehabilitation interventions and to improve economic evaluation methods when applied to advanced home care. This included a comparison of two alternative ways of administering oxygen at home to patients with chronic hypoxaemia, as well as a review of scientific evidence on costs and effects of home rehabilitation after stroke. Also included were studies on prominent methodological issues in advanced home care - the redistribution of care efforts among caregivers and costing of informal care efforts.

    For patients with chronic hypoxaemia, a randomised, controlled trial showed that mobile liquid oxygen was considerably more costly compared to concentrator treatment. However, the treatment effects showed that liquid oxygen had a better impact on patient quality of life. The literature review revealed that the outcomes and costs of home rehabilitation after stroke are equal to those of alternative treatment strategies. Similar results were obtained in a study comparing hospital-based and home-based stroke rehabilitation, which also showed that there is a considerable redistribution of costs between health care providers and social welfare providers. Studies of patients in advanced home care in the county of Östergötland, Sweden, showed that the cost of informal care constitutes a considerable part of the care effort in all costing approaches used. Also, informal care costs were higher among patients who were men, who were younger, who had their own housing and had a cancer diagnosis.

    This thesis reveals that advanced home care interventions can differ regarding costs as well as effects, and thus comparisons between alternative home care interventions must also be performed. Further, redistribution effects are important to consider in evaluations. The cost of informal care is substantial in advanced home care. These costs must be included in evaluations with a societal perspective or else the comparisons will be biased.

    List of papers
    1. Domiciliary liquid oxygen versus concentrator treatment in chronic hypoxaemia: a cost-utility analysis
    Open this publication in new window or tab >>Domiciliary liquid oxygen versus concentrator treatment in chronic hypoxaemia: a cost-utility analysis
    Show others...
    1998 (English)In: European Respiratory Journal, ISSN 1399-3003, Vol. 12, no 6, p. 1284-1289Article in journal (Refereed) Published
    Abstract [en]

    Whether long-term oxygen therapy (LTOT) improves quality of life in chronic hypoxaemia has been questioned. LTOT with an oxygen concentrator (C/C) and gas cylinders for ambulation is considered cumbersome compared to mobile liquid oxygen equipment (L). The hypothesis for this study was that LTOT with liquid oxygen treatment (L) improves patients' health-related quality of life, but that it is also more expensive compared to concentrator (C/C) treatment. A prospective, randomized multicentre trial comparing C/C with L for LTOT was conducted during a six-month period. Fifty-one patients (29 on L and 22 on C/C) with chronic hypoxaemia, regularly active outside the home, participated in the study initially. Costs for oxygen were obtained from the pharmacies. Patient diaries and telephone contacts with members of the healthcare sector were used to estimate costs. Health-related quality of life was measured by the Sickness Impact Profile (SIP) and the EuroQol, instruments at the start and after 6 months. The average total cost per patient for group C/C for the six-month period was US$1,310, and for group L it was US$4,950. Health-related quality of life measured by the SIP instrument showed significant differences in favour of group L in the categories/dimensions of physical function, body care, ambulation, social interaction and total SIP score. In conclusion, liquid-oxygen treatment was more expensive compared to concentrator treatment. However, treatment effects showed that liquid oxygen had a better impact on quality of life.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13751 (URN)
    Available from: 2002-12-19 Created: 2002-12-19
    2. Home rehabilitation after stroke. Reviewing the scientific evidence on effects and costs
    Open this publication in new window or tab >>Home rehabilitation after stroke. Reviewing the scientific evidence on effects and costs
    2000 (English)In: International Journal of Technology Assessment in Health Care,, ISSN 0266-4623, Vol. 19, no 3, p. 842-848Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVES: The question addressed here is whether home rehabilitation after stroke is better and/or less expensive than the more conventional alternatives, i.e., rehabilitation during inpatient care, day care, and outpatient visits--alone or in combinations appropriate to disease stage and patient needs. Home rehabilitation is managed by teams of professionals who train patients at home. METHODS: The scientific literature was systematically searched for controlled studies comparing outcomes and costs of home rehabilitation with the more conventional strategies. RESULTS: The abstracts of 204 papers were evaluated, from which 89 were selected for greater scrutiny. From the 89 studies, we found 7 controlled studies involving 1,487 patients (6 of the 7 were randomized, 4 of the 6 assessed costs). No statistically significant differences, or tendencies toward differences, were revealed as regards the outcome of home rehabilitation versus hospital-based alternatives. Thus, home rehabilitation was neither better nor worse at improving patients' ability to manage on their own or resume social activities. Depression and reduced quality of life were common in all groups of patients and caregivers, irrespective of the rehabilitation strategy. In the four randomized studies that reported on costs, home rehabilitation was found to be less expensive than regular day care, but not less expensive than conventional strategies even though hospital stay was reduced. CONCLUSION: The outcomes and costs of home rehabilitation after stroke seem to be comparable to alternative treatment strategies.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13752 (URN)
    Available from: 2002-12-19 Created: 2002-12-19
    3. Health care and social welfare costs in home-based and hospital-based rehabilitation after stroke
    Open this publication in new window or tab >>Health care and social welfare costs in home-based and hospital-based rehabilitation after stroke
    2002 (English)In: Vol. 16, no 4, p. 386-392Article in journal (Refereed) Published
    Abstract [en]

    During the 1990s most western European and Organization of Economic Cooperation and Development (OECD) countries experienced financial difficulties and were forced to cut back on or restrain health care expenditures. Home rehabilitation has received attention in recent years because of its potential for cost containment. Often forgotten, however, is the redistribution of costs from one caregiver to another. The aim of this study was to analyse whether a redistribution of costs occurs between health care providers (the County councils) and social welfare providers (the municipalities) in a comparison of home-based rehabilitation and hospital-based rehabilitation after stroke. The study population included 123 patients, 53 in the home-based rehabilitation group and 68 in the hospital-based rehabilitation group. The patients were followed up at 6 and 12 months after onset of stroke. Resource use over a 12-month period included acute hospital care, in-hospital rehabilitation, home rehabilitation and use of home-help service as well as nursing home living. The hospital-based rehabilitation group had significantly fewer hospitalization days after a decision was made about rehabilitation at the acute care ward and consequently the cost for the acute care period was significantly lower. The cost for the rehabilitation period was significantly lower in the home-based rehabilitation group. However, the cost for home help service was significantly higher in the home-based rehabilitation group. The total costs for the care episode did not differ between the two groups. The main finding of this study is that there seems to occur a redistribution of costs between health care providers and social welfare providers in home rehabilitation after stroke in a group of patients with mixed degree of impairment.

    Keywords
    home-based rehabilitation, hospital-based rehabilitation, redistribution of cost, stroke, cost
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13753 (URN)10.1046/j.1471-6712.2002.00115.x (DOI)
    Available from: 2002-12-19 Created: 2002-12-19 Last updated: 2018-05-23
    4. The economic burden of informal care
    Open this publication in new window or tab >>The economic burden of informal care
    2002 (English)In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, Vol. 18, no 1, p. 46-54Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVES: The great interest focused on home care technologies during the last decade resulted from its potential to cut costs. However, the reallocation of costs between healthcare providers and social welfare providers, and the indirect costs of informal care, are not as frequent topics of discussion. The aim of this paper is to discuss different models for estimating the costs of informal care in the home care setting in economic appraisals. METHODS: The outcome of using different models for estimating indirect costs was illustrated using empirical data regarding the time spent by informal caregivers in providing care in a group of home care patients (n = 59). The models used comprise different interpretations of the traditional human capital approach and the friction cost model. RESULTS AND CONCLUSIONS: Informal care is an important component in home care. The inclusion of indirect costs of informal care in economic appraisals will have implications for the cost-effectiveness of home care, since it will raise costs depending on the model used for estimating indirect costs. In this study we have shown that indirect costs estimated by the friction cost model only amount to 18% to 44% of the cost when the human capital approach is used. The results indicate that, regardless of the method used to estimate indirect costs, the cost of informal care in evaluations of home care programs is often underestimated due to the exclusion of indirect costs.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13754 (URN)
    Available from: 2002-12-19 Created: 2002-12-19
    5. Costs of informal care for patients in advanced home care: a population based study
    Open this publication in new window or tab >>Costs of informal care for patients in advanced home care: a population based study
    2003 (English)In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 19, no 4, p. 656-663Article in journal (Refereed) Published
    Abstract [en]

    Objectives: Several studies have sought to analyze the cost-effectiveness of advanced home care andhome rehabilitation. However, the costs of informal care are rarely included in economic appraisals ofhome care. This study estimates the cost of informal care for patients treated in advanced home careand analyses some patient characteristics that influence informal care costs.Methods: During one week in October 1995, data were collected on all 451 patients in advanced homecare in the Swedish county of O¨ stergo¨ tland. Costs were calculated by using two models: one includingleisure time, and one excluding leisure time. Multiple regression analysis was used to analyze factorsassociated with costs of informal care.Results: Seventy percent of the patients in the study had informal care around the clock during theweek investigated. The patients had, on average, five formal care visits per week, each of which lastedfor almost half an hour. Thus, the cost of informal care constituted a considerable part of the costof advanced home care. When the cost of leisure time was included, the cost of informal care wasestimated at SEK 5,880 per week per patient, or twice as high as total formal caregiver costs. Whenleisure time was excluded, the cost of informal care was estimated at SEK 3,410 per week per patient,which is still 1.2 times higher than formal caregiver costs (estimated at SEK 2,810 per week per patient).Informal care costs were higher among patients who were men, who were younger, who had their ownhousing, and who were diagnosed with cancer.Conclusions: Studies of advanced home care that exclude the cost of informal care substantiallyunderestimate the costs to society, regardless of whether or not the leisure time of the caregiver isincluded in the calculations.

    Keywords
    Informal care, Advanced home care, Home rehabilitation, Cost
    National Category
    Public Administration Studies Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-13755 (URN)10.1017/S0266462303000618 (DOI)
    Available from: 2002-12-19 Created: 2002-12-19 Last updated: 2017-12-13Bibliographically approved
  • 8.
    Andersson, Agneta
    et al.
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
    Carstensen, John
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Arts and Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Emtinger, Bengt Göran
    The National Board of Health and Welfare.
    Costs of informal care for patients in advanced home care: a population based study2003In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 19, no 4, p. 656-663Article in journal (Refereed)
    Abstract [en]

    Objectives: Several studies have sought to analyze the cost-effectiveness of advanced home care andhome rehabilitation. However, the costs of informal care are rarely included in economic appraisals ofhome care. This study estimates the cost of informal care for patients treated in advanced home careand analyses some patient characteristics that influence informal care costs.Methods: During one week in October 1995, data were collected on all 451 patients in advanced homecare in the Swedish county of O¨ stergo¨ tland. Costs were calculated by using two models: one includingleisure time, and one excluding leisure time. Multiple regression analysis was used to analyze factorsassociated with costs of informal care.Results: Seventy percent of the patients in the study had informal care around the clock during theweek investigated. The patients had, on average, five formal care visits per week, each of which lastedfor almost half an hour. Thus, the cost of informal care constituted a considerable part of the costof advanced home care. When the cost of leisure time was included, the cost of informal care wasestimated at SEK 5,880 per week per patient, or twice as high as total formal caregiver costs. Whenleisure time was excluded, the cost of informal care was estimated at SEK 3,410 per week per patient,which is still 1.2 times higher than formal caregiver costs (estimated at SEK 2,810 per week per patient).Informal care costs were higher among patients who were men, who were younger, who had their ownhousing, and who were diagnosed with cancer.Conclusions: Studies of advanced home care that exclude the cost of informal care substantiallyunderestimate the costs to society, regardless of whether or not the leisure time of the caregiver isincluded in the calculations.

  • 9. Andersson, Anna
    et al.
    Garpenby, Peter
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Medical management in search for systematic and open priorities in Sweden2004Conference paper (Other academic)
  • 10.
    Andersson, David
    et al.
    Linköping University, Department of Medical and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Magnusson, Henrik
    Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Carstensen, John
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Arts and Sciences.
    Borgquist, Lars
    Linköping University, Department of Medical and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Co-morbidity and health care utilisation five years prior to diagnosis for depression: A register-based study in a Swedish population2011In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 11, p. 552-Article in journal (Refereed)
    Abstract [en]

    Background

    Depressive disorders have been associated with a number of co-morbidities, and we   hypothesized that patients with a depression diagnosis would be heavy users of health   care services, not only when first evaluated for depression, but also for preceding   years. The aim of this study was to investigate whether increased health care utilisation   and co-morbidity could be seen during five years prior to an initial diagnosis of   depression.

    Methods

    We used a longitudinal register-based study design. The setting comprised the general   population in the county of Östergötland, south-east Sweden. All 2470 patients who   were 20 years or older in 2006 and who received a new diagnosis of depression (F32   according to ICD-10) in 2006, were selected and followed back to the year 2001, five   years before their depression diagnosis. A control group was randomly selected among   those who were aged 20 years or over in 2006 and who had received no depression diagnosis   during the period 2001-2006.

    Results

    Predictors of a depression diagnosis were a high number of physician visits, female   gender, age below 60, age above 80 and a low socioeconomic status.

    Patients who received a diagnosis of depression used twice the amount of health care   (e.g. physician visits and hospital days) during the five year period prior to diagnosis   compared to the control group. A particularly strong increase in health care utilisation   was seen the last year before diagnosis. These findings were supported with a high   level of co-morbidity as for example musculoskeletal disorders during the whole five-year   period for patients with a depression diagnosis.

    Conclusions

    Predictors of a depression diagnosis were a high number of physician visits, female   gender, age below 60, age above 80 and a low socioeconomic status. To find early signs   of depression in the clinical setting and to use a preventive strategy to handle these   patients is important.

  • 11.
    Andersson, Fredrik
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Ferring Pharmaceut AS, Denmark.
    Anderson, Peter
    Adelphi Real World, England.
    Holm-Larsen, Tove
    Pharma Evidence, Denmark.
    Piercy, James
    Adelphi Real World, England.
    Everaert, Karel
    Ghent University Hospital, Belgium.
    Holbrook, Tim
    Adelphi Real World, England.
    Assessing the impact of nocturia on health-related quality-of-life and utility: results of an observational survey in adults2016In: JOURNAL OF MEDICAL ECONOMICS, ISSN 1369-6998, Vol. 19, no 12, p. 1200-1206Article in journal (Refereed)
    Abstract [en]

    Background and aim: The impact of nocturia (getting up at night to void) on health-related quality-of-life (HRQoL) is often under-estimated. This study investigated the relative burden in terms of HRQoL and utilities of nocturia in a real-world setting. Methods: Patient data were collected from two surveys: a nocturia-specific, cross-sectional survey of physicians and their patients (DSP), and a general UK population health survey (HSFE). Utilities (EQ-5D-5L), productivity (Work Productivity and Activity Index), and the impact of nocturia symptoms (Nocturia Impact Diary and Overactive Bladder Questionnaires) were assessed against the number of voids. A robust linear regression model with propensity score weights was used to control for confounding factors in estimating utilities. Results: Physician-recorded data were available from 8,738 patients across the US, Germany, Spain, France, and the UK; of these, 5,335 (61%) included patient-reported outcomes. In total, 6,302 controls were drawn from the two surveys and compared to 1,104 nocturia patients. Deterioration of HRQoL was associated with increasing number of night-time voids (pamp;lt;0.0001). In particular, significant differences were observed between 0-1 and 2 voids (pamp;lt;0.001). The regression model demonstrated that nocturia (amp;gt;= 2 per night) is associated with a modest but significant deterioration in utility of 0.0134 (pamp;lt;0.05). Limitations: The cause of nocturia is multifactorial and the mostly elderly patients may have several concomitant diseases. The authors tried to adjust for the most common ones, but there may be diseases or unknown relationships not included. Conclusions: Nocturia negatively affected HRQoL and patient utility. A clear effect is seen already at two voids per night. Every effort should, therefore, be made to reduce nocturia below the bother threshold of two voids per night.

  • 12.
    Andersson, Réka
    Linköping University, Department of Thematic Studies, Technology and Social Change. Linköping University, Faculty of Arts and Sciences.
    Gränsdragningar i Vårdens Vardag: Hanteringen av arbetsrelaterad psykisk ohälsa i det svenska välfärdssystemet2017Doctoral thesis, monograph (Other academic)
    Abstract [en]

    Mental ill health in working life is a major and growing problem in the welfare society. The problem is multifaceted and raises many questions about who is responsible, what kind of phenomenon it is and how it should be managed. This study examines how care professionals manage work-related mental ill health. Focusing on occupational healthcare and primary care, interest is directed towards how care professionals argue about workrelated mental illness, what dilemmas they face and the strategies they rely on in managing them. It also seeks to answer the question of responsibility regarding this complex problem, not least in the light of the privatization of occupational healthcare.

    The study uses a multidisciplinary perspective, combining concepts from technology and science studies (STS), sociology of professions and organizational theory in order to analyze various aspects of care management of work-related mental ill health. The empirical material is mainly based on interviews with physicians, psychotherapists, counsellors, occupational therapists, psychologists, rehabilitation coordinators and behavioral scientists, but also includes observations in primary care and occupational health care. The management of work-related mental ill health in everyday healthcare practice is characterized by the fact that the cause of the problem is complex, the division of responsibility unclear and that psychosocial causes of disease are controversial. The study discusses the challenges and possibilities of managing this complex problem in a broad sense. The analysis pays attention to the drawing of boundaries by the care professionals regarding both responsibility and the phenomenon of work-related mental illness. The concept of knowledge infrastructure is used to explain and understand the knowledge and material structures that the care professionals work within. The analysis shows that the care professionals have a pragmatic approach and use different strategies to create scope for dealing with work-related mental health.

  • 13.
    Andrén, Eva
    et al.
    Landstinget Sörmland.
    Andrén, Mats
    Norrbottens läns landsting.
    Bragsjö, Stefan
    Landstinget i Kalmar län.
    Björkryd, Karin
    Landstinget Sörmland.
    Johansson, Åsa
    Norrbottens läns landsting.
    Nilsson, Anna-Karin
    Landstinget i Kalmar län.
    Tjernberg Nordlund, Annette
    Landstinget Gävleborg.
    Rosberg, Birgitta
    Uppsala läns landsting.
    Ahlström, Monica
    Landstinget i Kalmar län.
    Pettersson, Ulla
    Landstinget i Kalmar län.
    Broqvist, Mari
    Prioriteringscentrum.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Öppna prioriteringar inom nya områden: logopedi, nutritionsbedömning, habilitering och arbetsterapi2011Report (Other academic)
    Abstract [sv]

    Det finns fortfarande ett behov av att öka kunskapen om och stödja den praktiska tillämpningen av riksdagens riktlinjer för öppna prioriteringar inom svensk hälso- och sjukvård. Flera förslag på hur ett sådant stöd kan se ut har tagits fram de senaste åren. Spridning av goda exempel är ett sådant förslag, metodstöd ett annat (PrioriteringsCentrum 2007). En mer påtaglig form av metodstöd är den nationella modell som vuxit fram för att konkretisera innebörden i riktlinjerna (Carlsson m fl 2007). Den får idag anses som välbeprövad inom ett flertal områden och har bidragit till att samsynen och kommunicerbarheten kring prioriteringar har ökat i landet. Erfarenheter visar dock att det behövs pedagogisk vägledning i hur modellen kan tillämpas. För att möta upp efterfrågan på sådant metodstöd erbjuder Prioriteringscentrum handledning i grupp. Den första handledningsgruppen är nu avslutad och det är deltagarnas prioriteringsarbeten som presenteras i denna rapport i syfte att sprida konkreta exempel på försök att tillämpa prioriteringsriktlinjerna.

    I rapporten presenteras fyra prioriteringsarbeten med fokus på:

    •    Regionsamverkan inom arbetsterapi
    •    Logopedi
    •    Yrkesspecifika prioriteringar på väg till teamet
    •    Från projekt till integrerat redskap

    Exemplet med prioriteringar i regionsamverkan utgörs av det prioriteringsarbete som genomförts i det s k femklövernätverket bestående av en samverkansgrupp för arbetsterapeuter i ledningsposition på sjukhusen i Uppland, Västmanland, Södermanland, Gävleborg och Dalarna. Arbetet var ett försök att skapa gemensamma prioriteringar i regionen för ett sjukdomsområde som kändes relevant. Valet kom att falla på arbetsterapi inom reumatologi. Arbetet har sedan huvudsakligen bedrivits i en projektgrupp, bestående av en representant från varje sjukhus där arbetet växlat mellan arbete på hemmaplan och avstämningsträffar i projektgruppen.

    Försöket har visat att det finns en samsyn inom regionen kring prioriteringar inom arbetsterapi och reumatologi. Säkerheten i prioriteringarna har ökat i och med att fem arbetsterapiorganisationer tillsammans bidragit med ett stort underlagsmaterial bl a genom att delge varandra sina kliniska erfarenheter. Förutsättningarna för en mer likartad vård i regionen har ökat. Arbetet har också gett upphov till frågor om i vilka situationer det är att föredra att prioriteringsarbete bedrivs lokalt, regionvis och/eller nationellt.

  • 14.
    Anell, Anders
    Institutet för hälso- och sjukvårdsekonomi (IHE), Lund.
    Subventionering av läkemedel i andra länder: Beslutsprocesser och användning av hälsoekonomiska utvärderingar2002Report (Other academic)
    Abstract [sv]

    Beslut om subventionering påverkar spridningen av läkemedel och utgör därmed ett instrument för prioritering av hälso- och sjukvårdens resurser. Liksom vid andra former av prioriteringar i hälso- och sjukvården är det relevant att ställa krav på rättvisa och legitimitet. Grundläggande för att uppnå legitimitet är att det finns en insyn i beslutsprocessen och att de kriterier som utgör utgångspunkt för besluten är kända.

    I denna rapport redovisas utformning av procedurer för beslut om subventionering i åtta länder. En specifik fråga som studeras är vilka beslutskriterier som används och betydelsen av hälsoekonomiska utvärderingar och kriteriet om kostnadseffektivitet. De länder som behandlas är Australien, Belgien, England, Finland, Frankrike, Kanada (provinserna Ontario och British Columbia), Nederländerna och Norge. Av dessa behandlas Belgien, Nederländerna och Norge översiktligt. I England studeras erfarenheter av National Institute for Clinical Excellence (NICE). NICE har som uppgift att rekommendera hur National Health Service (NHS) ska använda olika hälsoteknologier och är inte inblandad i beslut om subvention. Erfarenheterna från England kring uppbyggnaden av en transparent beslutsprocess och användningen av hälsoekonomiska utvärderingar har ändå bedömts som relevant för rapporten.

    Baserat på internationella erfarenheter kan konstateras att hälsoekonomiska utvärderingar kan ge stöd vid beslut om subvention och framför allt hur användningen av innovativa och dyra läkemedel kan avgränsas till patientgrupper som har störst nytta av en behandling. Samtidigt kan konstateras att kostnadseffektiva läkemedel inte alltid subventioneras och att läkemedel som har en låg kostnadseffektivitet ibland subventioneras ändå. Kostnadseffektivitet är alltså inte det enda och inte heller det viktigaste kriteriet som påverkar besluten. Andra viktiga kriterier är klinisk effektivitet, sjukdomens svårighetsgrad och behov av sjukvård, förekomst av alternativa terapier, budgetpåverkan och om en subvention är nödvändig med hänsyn till terapikostnaderna.

    Insynen i de kriterier som subventionskommittéer använder sig av vid bedömning av läkemedel varierar. Ingen av de studerade kommittéerna ger någon explicit information om den relativa betydelsen mellan olika kriterier eller i vilka beslutssituationer som information om kostnadseffektivitet spelar roll. En ökad tydlighet förefaller möjlig och skulle bidra till att förbättra insynen i de beslut och prioriteringar som görs. Samtidigt motverkas i så fall att hälsoekonomiska utvärderingar görs i onödan eller att de används som argument mot subventionering trots att andra kriterier är avgörande för besluten.

    Trots att uppdraget för NICE skiljer sig från subventionskommittéernas används hälsoekonomiska utvärderingar på likartat sätt i beslutsprocessen, i synnerhet vid bedömning av innovativa läkemedel. Det är svårt för subventionskommittéer att helt neka subvention av innovativa och dyra läkemedel, även i de fall kostnadseffektiviteten kan ifrågasättas. Beslutet har i många fall istället blivit att begränsa subventioneringen till de mest betydelsefulla indikationerna och/eller patientgrupperna. Det innebär också att subventionsbeslut inte kan isoleras från de rekommendationer som utformas av t.ex. läkemedelskommittéer. För svenskt vidkommande har läkemedelsreformens decentralisering av kostnadsansvar till sjukvårdshuvudmännen och det ökade ansvaret för läkemedelskommittéer en stor betydelse. Lokala läkemedelskommittéer som ansvariga för att främja en rationell läkemedelsanvändning ger bättre förutsättningar för att undvika detaljerade anvisningar om när läkemedel subventioneras från nationell nivå.

  • 15.
    Anskär, Eva
    et al.
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Primary Care Center, Primary Health Care Center Mantorp.
    Lindberg, Malou
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. 1177 Med Advisory Serv, Linkoping, Sweden.
    Falk, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Andersson, Agneta
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Time utilization and perceived psychosocial work environment among staff in Swedish primary care settings2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 166Article in journal (Refereed)
    Abstract [en]

    Background: Over the past decades, reorganizations and structural changes in Swedish primary care have affected time utilization among health care professionals. Consequently, increases in administrative tasks have substantially reduced the time available for face-to-face consultations. This study examined how work-time was utilized and the association between work time utilization and the perceived psychosocial work environment in Swedish primary care settings. Methods: This descriptive, multicentre, cross-sectional study was performed in 2014-2015. Data collection began with questionnaire. In the first section, respondents were asked to estimate how their workload was distributed between patients (direct and indirect patient work) and other work tasks. The questionnaire also comprised the Copenhagen Psychosocial Questionnaire, which assessed the psychosocial work environment. Next a time study was conducted where the participants reported their work-time based on three main categories: direct patient-related work, indirect patient-related work, and other work tasks. Each main category had a number of subcategories. The participants recorded the time spent (minutes) on each work task per hour, every day, for two separate weeks. Eleven primary care centres located in southeast Sweden participated. All professionals were asked to participate (n = 441), including registered nurses, primary care physicians, care administrators, nurse assistants, and allied professionals. Response rates were 75% and 79% for the questionnaires and the time study, respectively. Results: All health professionals allocated between 30.9% - 37.2% of their work-time to each main category: direct patient work, indirect patient work, and other work. All professionals estimated a higher proportion of time spent in direct patient work than they reported in the time study. Physicians scored highest on the psychosocial scales of quantitative demands, stress, and role conflicts. Among allied professionals, the proportion of work-time spent on administrative tasks was associated with more role conflicts. Younger staff perceived more adverse working conditions than older staff. Conclusions: This study indicated that Swedish primary care staff spent a limited proportion of their work time directly with patients. PCPs seemed to perceive their work environment in negative terms to a greater extent than other staff members. This study showed that work task allocations influenced the perceived psychosocial work environment.

  • 16.
    Arneson, Hanna
    Linköping University, Department of Department of Health and Society, National Centre for Work and Rehabilitation. Linköping University, Faculty of Health Sciences.
    Empowerment and health promotion in working life2006Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: In ‘workplace health promotion’, empowerment is assumed to promote health. Nevertheless, few studies have examined the relationship between empowerment in working life, and health.

    Aim: To study the impact of empowerment in working life on health, with special focus on gender differences.

    Material and methods: Paper I is a review of the scientific literature, examining instruments intended to measure empowerment in working life. The second study (paper II) was a cross-sectional survey, assessing the relationship between psychological empowerment, and self-rated health and burnout among employees. Papers III and IV encompass a two-year longitudinal survey study of the gender-specific relationships between baseline levels of psychological empowerment, and the combination of psychological support and social support, and self-rated health and burnout two years later among employees. Study five (paper V) is a qualitative study, using focus-group interviews and phenomenography to evaluate a theory-based intervention method, problem-based learning, for workplace health promotion with regard to possible facilitation of empowerment processes.

    Results: In paper I, nine questionnaires were found and analysed. Most of the questionnaires focused on intra-individual issues, while a smaller number dealt with the interaction between individual and organisation. Control and competence were frequently used dimensions. The Psychological Empowerment Instrument had undergone the most comprehensive investigation, showing satisfactory validity and reliability. In paper II, men reported a greater degree of psychological empowerment than women in terms of self-determination and impact. Associations were found between psychological empowerment, and self-rated health and burnout (p<0.05). Men and women with higher levels of empowerment reported significantly better health, compared with those who had lower levels of empowerment. Papers III and IV show that for women, increasing levels of psychological empowerment at work at baseline were associated with better self-rated health as measured by the SF-36 scales physical role function, bodily pain, and mental health at the 2-year follow-up (p<0.05). Also for women, a combination of high psychological empowerment and high social support at the workplace was associated (p<0.05) with better self-rated health (bodily pain, general health, vitality, social functioning, emotional role, mental health, EQ-5D VAS, and EQ-5D index) and lower levels of work-related burnout at the 2-year follow-up. For men, psychological empowerment at baseline, and a combination of psychological empowerment and social support at the workplace, were associated with self-rated health at follow-up as measured by the EQ-5D VAS (p<0.05). Combinations of psychological empowerment and social support were associated with work-related burnout at the two-year follow-up for women only (p=0.002). The differences between men and women were confirmed in the gender×empowerment and social support interaction analysis for the measures bodily pain, social function, and work-related burnout (p<0.05). The phenomenographic analysis in paper V resulted in six descriptive categories: reflection, awareness and insight, self-direction and self-management, group coherence, social support and action. The results correspond to established theories on components of empowerment processes. The method “problem-based learning” initiated processes of change at organisational, workplace and individual levels. Social support and group coherence were expressed as essential in order to transform challenging strategies into action and goal realisation.

    Conclusions: This thesis demonstrates that psychological empowerment is associated with self-rated health and burnout. Psychological empowerment also impacts mental and somatic health after two years. The impact on health becomes more extensive when psychological empowerment is combined with social support at the workplace. Empowerment and social support are crucial core characteristics in ‘workplace health promotion’, but effects may differ for men and women. Empowerment processes can be facilitated by implementation of the participative intervention method known as “problem-based learning”. Practitioners and researchers who are active in health enhancement in working life should gain from implementing these findings, whether the focus is on health promotion, disease prevention, or rehabilitation back to work.

    List of papers
    1. Measuring empowerment in working life: a review
    Open this publication in new window or tab >>Measuring empowerment in working life: a review
    2006 (English)In: Work: A journal of Prevention, Assesment and rehabilitation, ISSN 1051-9815, E-ISSN 1875-9270, Vol. 26, no 1, p. 37-46Article in journal (Refereed) Published
    Abstract [en]

    This study identifies and describes questionnaires that measure empowerment in working life. Theoretical bases and empirical examination of the questionnaires are also reported. Nine questionnaires emerged from a database search including AMED, CINAHL, ERIC, MEDLINE and PSYCINFO. The main target groups were employees in general. Most authors share the same theoretical basis. Most of the questionnaires focus on intra- individual issues, while a smaller number deal with the interaction between individual and organization. Control and competence are frequently used dimensions. Cronbach's alpha for complete questionnaires ranged between 0.62 and 0.96. No comparisons with outcome of health were reported. Spreitzer's questionnaire [54] has undergone the most comprehensive investigation. Research is required to achieve better understanding of the interplay between conditions at work and empowerment and health.

    Keywords
    Empowerment; Health promotion; Measurement; Working life; Workplace health promotion
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-21811 (URN)16373978 (PubMedID)
    Available from: 2009-10-05 Created: 2009-10-05 Last updated: 2017-12-13Bibliographically approved
    2. Psychological empowerment and self-rated health and burnout in a sample of Swedish employees
    Open this publication in new window or tab >>Psychological empowerment and self-rated health and burnout in a sample of Swedish employees
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    PURPOSE: To explore the gender-specific association between psychological empowerment and self-rated health and burnout in a working population.

    MATERIAL AND METHOD: A cross-sectional survey was carried out among 1,243 employees (response rate 81% (n=1007), 65 % females). Psychological empowerment was measured by the Spreitzer questionnaire, developed for a working life context. The questionnaire includes the subscales: meaning, competence, self-determination and impact. Self-rated health was evaluated with EQ-5D and SF-36 and the Copenhagen Burnout Inventory was used to measure burnout.

    RESULTS: Men reported a greater degree of empowerment than women in terms of self-determination and impact. Significant associations (p<0.05) were found between psychological empowerment and self-rated health and burnout. Men and women with higher levels of empowerment reported significantly better health compared to those with lower levels of empowerment. In multivitriate analyses, all four subscales of empowerment were associated with burnout among both men and women. The most pronounced association with self-rated health was seen for the subscale impact. These associations were particularly strong among women.

    CONCLUSION: Psychological empowerment in working life is associated with self-rated health and burnout. Interventions aiming to promote health at work or aiming to prevent burnout may therefore benefit if they comprise empowerment in terms of impact, self-determination, meaning and competence. Also, workplace health promotion that includes empowerment processes should be gender conscious.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-84813 (URN)
    Available from: 2012-10-23 Created: 2012-10-23 Last updated: 2013-09-03Bibliographically approved
    3. Psychological empowerment, social support at the workplace and self-rated health and burnout: a 2-year longitudinal analysis in a sample of Swedish employees
    Open this publication in new window or tab >>Psychological empowerment, social support at the workplace and self-rated health and burnout: a 2-year longitudinal analysis in a sample of Swedish employees
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    PURPOSE: To explore the gender-specific longitudinal association between a combination of psychological empowerment and social support at the workplace and self-rated health and burnout in a working population.

    MATERIAL AND METHOD: The participants were employees working in the public service sector in central Sweden. The baseline survey in two cohorts was carried out in 2001 and the follow-up in 2003. The questionnaire was answered by 715 respondents at both points in time (overall response rate 67%). Measures used were the Psychological Empowerment Instrument by Spreitzer, the social support dimension in the Demand-Control-Support Questionnaire, the SF-36, the EQ-5D, and the Copenhagen Burnout Inventory. Based on empirical medians, psychological empowerment and social support at baseline were combined into four categories. Mlltivariate comparisons adjusted for age, education, study cohort and SRH and burnout at baseline were performed using multiple linear regression analysis. The genderxempowerment and social support interaction effect was assessed in the multiple linear regression analysis. All analyses were performed for men and women separately.

    RESULTS: For women, a combination of high psychological empowerment and high social support at the workplace, in comparison with a combination of low psychological empowerment and low social support, is strongly associated with better SRH (bodily pain, general health, vitality, social functioning, emotional role, mental health, the EQ-5D VAS, and EQ-5D index) and lower levels of work-related burnout at the 2-year follow-up after adjusting for demographics and baseline SRH and burnout. For men, there are univariate associations with burnout and some associations with SRH. After adjustments for demographics and baseline SRH and burnout, psychological empowerment and social support is associated with SRH as measured by the EQ-5D VAS for men. The gender x empowerment and social support interaction analyses confirm gender differences regarding bodily pain, social function, and work-related burnout.

    CONCLUSION: A combination of psychological empowerment and social support in working life strongly affects SRH and work-related burnout two years later for women, but only in part for men.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-84817 (URN)
    Available from: 2012-10-23 Created: 2012-10-23 Last updated: 2013-09-03Bibliographically approved
    4. Psychiological empowerment at the workplace and self-rated health and burnout: a 2-yeah longitudinal analysis in a sample of Swedish employees
    Open this publication in new window or tab >>Psychiological empowerment at the workplace and self-rated health and burnout: a 2-yeah longitudinal analysis in a sample of Swedish employees
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    PURPOSE: To explore the gender-specific longitudinal association between psychological empowerment at the workplace and self-rated health and burnout in a working population.

    MATERIAL AND METHOD: The participants were employees working in the public service sector in central Sweden. The baseline survey was carried out in 2001 and the follow-up in 2003. The questionnaire was answered by 715 respondents at both points in time (overall response rate 67%). Measures used were Psychological Empowerment Instrument by Spreitzer, the SF-36, the EQ-5D, and the Copenhagen Burnout Inventory. Gender specific differences in average score for self-rated health and burnout at follow-up were assessed using multiple linear regression adjusted for age, education, study cohort and self-rated health and burnout at baseline. An analysis on interactional effects due to gender was also performed.

    RESULTS: For women, increasing levels of psychological empowerment at work at baseline are associated with less bodily pain, better physical role function and mental health in the multivariate analysis at follow-up two years later. For men, increased psychological empowerment at baseline is significantly associated with better self-rated health as measured by the EQ-5D VAS at follow-up in the multivariatc analysis. Higher levels of psychological empowerment at baseline show a statistically significant association with a lower degree of burnout at follow-up in the univariate analysis for men and women. However, the associations diminished after adjustments in the multivariate analyses. No significant gender x empowerment interaction appeared.

    CONCLUSION: Psychological empowerment in working life was associated with somatic and mental aspects of SRH two years later for women. Men seem to be less affected by psychological empowerment, yet an association with the EQ-5D V AS appeared. Psychological empowerment did not predict burnout two years later for either men or women.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-84815 (URN)
    Available from: 2012-10-23 Created: 2012-10-23 Last updated: 2013-09-03Bibliographically approved
    5. Evaluation of empowerment processes in a workplace health promotion intervention based on learning in Sweden
    Open this publication in new window or tab >>Evaluation of empowerment processes in a workplace health promotion intervention based on learning in Sweden
    2005 (English)In: Health Promotion International, ISSN 0957-4824, E-ISSN 1460-2245, Vol. 20, no 4, p. 351-359Article in journal (Refereed) Published
    Abstract [en]

    The aim of this study was to evaluate a theory-based method for workplace health promotion (WHP) with regard to possible facilitation of empowerment processes. The intervention tool was the pedagogic method known as problem-based learning (PBL). The aim of the intervention was to promote empowerment and health among the employees. The intervention was implemented in three organizations within the public sector in Sweden, in a bottom-up approach. All employees, including management, in each organization, were offered the opportunity to participate (n = 113) and 87% (n = 97) participated. The intervention was implemented in 13 groups of six to eight participants who met once a week over a period of 4 months. The predetermined overall goal of the intervention was to promote employee health within the organizational setting. A facilitator in each group and a group-specific mutual agreement guided the intervention, as did the problem solving process. The participants set goals and developed strategies to reach their goals between the meetings. Thirty informants were interviewed in seven focus groups after the intervention about the intervention method and the process, following a semi-structured theme guide. The phenomenographic analysis resulted in six descriptive categories: reflection, awareness and insight, self-direction and self-management, group coherence, social support and actions. The results correspond to established theories of components of empowerment processes. The method initiated processes of change at organizational, workplace and individual levels as the participants examined their work situation, determined problems and initiated solutions. Social support and group coherence were expressed as essential in order to transform challenging strategies into action and goal realization. The findings indicate that systematic improvements of social support and group coherence among employees ought to be facilitated by the organization as a health-promoting arena. PBL appears to be a profitable and powerful instrument with the potential to enable empowerment.

    Keywords
    Empowerment, Problem-based learning, Workplace health promotion
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-50354 (URN)10.1093/heapro/dai023 (DOI)
    Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-12Bibliographically approved
  • 17.
    Aronsson, Håkan
    et al.
    Linköping University, Department of Management and Engineering, Logistics Management. Linköping University, The Institute of Technology.
    Hvitfeldt Forsberg, Helena
    Karolinskan Institutet, Stockholm.
    Lindblad, Staffan
    Karolinska institutet, Stockholm.
    Keller, Christina
    Högskolan i Jönköping.
    Managing health care decisions and improvement through simulation modeling2011In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 20, no 1, p. 15-29Article in journal (Refereed)
    Abstract [en]

    Simulation modeling is a way to test changes in a computerized environment to give ideas for improvements before implementation. This article reviews research literature on simulation modeling as support for health care decision making. The aim is to investigate the experience and potential value of such decision support and quality of articles retrieved. A literature search was conducted, and the selection criteria yielded 59 articles derived from diverse applications and methods. Most met the stated research-quality criteria. This review identified how simulation can facilitate decision making and that it may induce learning. Furthermore, simulation offers immediate feedback about proposed changes, allows analysis of scenarios, and promotes communication on building a shared system view and understanding of how a complex system works. However, only 14 of the 59 articles reported on implementation experiences, including how decision making was supported. On the basis of these articles, we proposed steps essential for the success of simulation projects, not just in the computer, but also in clinical reality. We also presented a novel concept combining simulation modeling with the established plan-do-study-act cycle for improvement. Future scientific inquiries concerning implementation, impact, and the value for health care management are needed to realize the full potential of simulation modeling.

  • 18.
    Aronsson, Mattias
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Health Economic Evaluations of Screening Programs - Applications and Method Improvements2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Screening to detect diseases early is attractive as it can improve the prognosis and decrease costs, but it is often a problematic concept and there are several pitfalls. Many healthy individuals have to be investigated to avoid a disease in a few, which results in a dilemma because to save a few, many are exposed to a procedure that could potentially harm them. Other examples of problems associated with screening are latent diseases and over-treating. The question of optimal design of a screening program is another source of uncertainty for decision-makers, as a screening program may potentially be implemented in very different ways. This highlights the need for structured analyses that weigh benefits against the harms and costs that occur as consequences of the screening.

    The aim of this thesis is, therefore, to explore, develop and implement methods for health economic evaluations of screening programs. This is done to identify problems and suggest solutions to improve future evaluations and in extension policy making.

    This aim was analysed using decision analytic cost-effectiveness analyses constructed as Markov models. These are well-suited for this task given the sequential management approach where all relevant data are unlikely to come from a single source of evidence. The input data were in this thesis obtained from the published literature and were complemented with data from Swedish registries and the included case studies. The case studies were two different types of screening programs; a program of screening for unknown atrial fibrillation and a program to detect colorectal cancer early. Further, the implementation of treatment with thrombectomy and novel oral anticoagulants were used to illustrate how factors outside the screening program itself have an impact on the evaluations.

    As shown by the result of the performed analyses, the major contribution of this thesis was that it provided a simple and systematic approach for the economic evaluation of multiple screening designs to identify an optimal design.

    In both the included case studies, the screening was considered costeffective in detecting the disease; unknown atrial fibrillation and colorectal cancer, respectively. Further, the optimal way to implement these screening programs is dependent on the threshold value for cost-effectiveness in the health care sector and the characteristics of the investigated cohort. This is because it is possible to gain increasingly more health benefits by changing the design of the screening program, but that the change in design also results in higher marginal costs. Additionally, changes in the screening setting were shown to be important as they affect the cost-effectiveness of the screening. This implies that flexible modelling with continuously updated models are necessary for an optimal resource allocation.

    List of papers
    1. Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer
    Open this publication in new window or tab >>Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer
    Show others...
    2017 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 8, p. 1078-1086Article in journal (Refereed) Published
    Abstract [en]

    Background: Colorectal cancer screening can decrease morbidity and mortality. However, there are widespread differences in the implementation of programmes and choice of strategy. The primary objective of this study was to estimate lifelong costs and health outcomes of two of the currently most preferred methods of screening for colorectal cancer: colonoscopy and sensitive faecal immunochemical test (FIT). Methods: A cost-effectiveness analysis of colorectal cancer screening in a Swedish population was performed using a decision analysis model, based on the design of the Screening of Swedish Colons (SCREESCO) study, and data from the published literature and registries. Lifelong cost and effects of colonoscopy once, colonoscopy every 10 years, FIT twice, FIT biennially and no screening were estimated using simulations. Results: For 1000 individuals invited to screening, it was estimated that screening once with colonoscopy yielded 49 more quality-adjusted life-years (QALYs) and a cost saving of (sic)64 800 compared with no screening. Similarly, screening twice with FIT gave 26 more QALYs and a cost saving of (sic)17 600. When the colonoscopic screening was repeated every tenth year, 7 additional QALYs were gained at a cost of (sic)189 400 compared with a single colonoscopy. The additional gain with biennial FIT screening was 25 QALYs at a cost of (sic)154 300 compared with two FITs. Conclusion: All screening strategies were cost-effective compared with no screening. Repeated and single screening strategies with colonoscopy were more cost-effective than FIT when lifelong effects and costs were considered. However, other factors such as patient acceptability of the test and availability of human resources also have to be taken into account.

    Place, publisher, year, edition, pages
    WILEY, 2017
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-139394 (URN)10.1002/bjs.10536 (DOI)000403158800015 ()28561259 (PubMedID)
    Note

    Funding Agencies|SCREESCO; Regionala Cancer-centrum i samverkan; Swedish Cancer Foundation; Karolinska Institute

    Available from: 2017-08-24 Created: 2017-08-24 Last updated: 2018-04-16
    2. Cost-effectiveness of mass screening for untreated atrial fibrillation using intermittent ECG recording
    Open this publication in new window or tab >>Cost-effectiveness of mass screening for untreated atrial fibrillation using intermittent ECG recording
    Show others...
    2015 (English)In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 17, no 7, p. 1023-1029Article in journal (Refereed) Published
    Abstract [en]

    Aims The aim of this study was to estimate the cost-effectiveness of 2 weeks of intermittent screening for asymptomatic atrial fibrillation (AF) in 75/76-year-old individuals. Methods and results The cost-effectiveness analysis of screening in 75-year-old individuals was based on a lifelong decision analytic Markov model. In this model, 1000 hypothetical individuals, who matched the population of the STROKESTOP study, were simulated. The population was analysed for different parameters such as prevalence, AF status, treatment with oral anticoagulation, stroke risk, utility, and costs. In the base-case scenario, screening of 1000 individuals resulted in 263 fewer patient-years with undetected AF. This implies eight fewer strokes, 11 more life-years, and 12 more quality-adjusted life years (QALYs) per 1000 screened individuals. The screening implies an incremental cost of (sic)50 012, resulting in a cost of (sic)4313 per gained QALY and (sic)6583 per avoided stroke. Conclusions With the use of a decision analytic simulation model, it has been shown that screening for asymptomatic AF in 75/76-year-old individuals is cost-effective.

    Place, publisher, year, edition, pages
    Oxford University Press (OUP): Policy B - Oxford Open Option B - CC-BY, 2015
    Keywords
    Atrial fibrillation; Screening; Hand-held ECG; Quality-adjusted life year ( QALY); Cost-effectiveness
    National Category
    Clinical Medicine
    Identifiers
    urn:nbn:se:liu:diva-120879 (URN)10.1093/europace/euv083 (DOI)000359153000006 ()25868469 (PubMedID)
    Note

    Funding Agencies|Swedish Heart and Lung Foundation; Board of Benevolence of the Swedish Order of Freemasons; Tornspiran

    Available from: 2015-08-28 Created: 2015-08-28 Last updated: 2017-12-04
    3. Cost-effectiveness of endovascular thrombectomy in patients with acute ischemic stroke
    Open this publication in new window or tab >>Cost-effectiveness of endovascular thrombectomy in patients with acute ischemic stroke
    Show others...
    2016 (English)In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 86, no 11, p. 1053-1059Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVE: To evaluate the cost-effectiveness of adding endovascular thrombectomy to standard care in patients with acute ischemic stroke.

    METHODS: The cost-effectiveness analysis of endovascular thrombectomy in patients with acute ischemic stroke was based on a decision-analytic Markov model. Primary outcomes from ESCAPE, Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA), Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT), and Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) along with data from published studies and registries were used in this analysis. We used a health care payer perspective and a lifelong time horizon to estimate costs and effects.

    RESULTS: The model showed that adding thrombectomy with stent retrievers to guideline-based care (including IV thrombolysis) resulted in a gain of 0.40 life-years and 0.99 quality-adjusted life-years along with a cost savings of approximately $221 per patient. The sensitivity analysis showed that the results were not sensitive to changes in uncertain parameters or assumptions.

    CONCLUSIONS: Adding endovascular treatment to standard care resulted in substantial clinical benefits at low costs. The results were consistent throughout irrespective of whether data from ESCAPE, EXTEND-IA, MR CLEAN, REVASCAT, or SWIFT PRIME were used in this model.

    Place, publisher, year, edition, pages
    Lippincott Williams & Wilkins, 2016
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-126429 (URN)10.1212/WNL.0000000000002439 (DOI)000371887200012 ()26873954 (PubMedID)
    Note

    Funding agencies: Dental and Pharmaceutical Benefits Agency

    Available from: 2016-03-24 Created: 2016-03-24 Last updated: 2017-11-30
    4. Designing an optimal screening program for unknown atrial fibrillation: a cost-effectiveness analysis.
    Open this publication in new window or tab >>Designing an optimal screening program for unknown atrial fibrillation: a cost-effectiveness analysis.
    Show others...
    2017 (English)In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 19, no 10, p. 1650-1656Article in journal (Refereed) Published
    Abstract [en]

    Aims: The primary objective of this study was to use computer simulations to suggest an optimal age for initiation of screening for unknown atrial fibrillation and to evaluate if repeated screening will add value.

    Methods and results: In the absence of relevant clinical studies, this analysis was based on a simulation model. More than two billion different designs of screening programs for unknown atrial fibrillation were simulated and analysed. Data from the published scientific literature and registries were used to construct the model and estimate lifelong effects and costs. Costs and effects generated by 2 147 483 648 different screening designs were calculated and compared. Program designs that implied worse clinical outcome and were less cost-effective compared to other programs were excluded from the analysis. Seven program designs were identified, and considered to be cost effective depending on what the health-care decision makers are ready to pay for gaining a quality-adjusted life-year (QALY). Screening at the age of 75 implied the lowest cost per gained QALY (€4 800/QALY).

    Conclusion: In conclusion, examining the results of more than two billion simulated screening program designs for unknown atrial fibrillation, seven designs were deemed cost-effective depending on how much we are prepared to pay for gaining QALYs. Our results showed that repeated screening for atrial fibrillation implied additional health benefits to a reasonable cost compared to one-off screening.

    Place, publisher, year, edition, pages
    Oxford: Oxford University Press, 2017
    Keywords
    Atrial fibrillation, Cost-utility analysis, Optimization analysis, Screening
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-141557 (URN)10.1093/europace/eux002 (DOI)000412840300006 ()28340009 (PubMedID)
    Note

    Funding agencies: Dental and Pharmaceutical Benefits Agency

    Available from: 2017-09-29 Created: 2017-09-29 Last updated: 2017-10-31
  • 19.
    Aronsson, Mattias
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hälsoekonomisk förstudie av digital patologi: Var finns de potentiella vinsterna?2015Report (Other academic)
    Abstract [en]

    Background

    There is an ongoing development in pathology laboratories towards increased digital storage and analysis of images from tissue samples through computer screens instead of conventional microscopes. The digital storage of information has a number of potential advantages. The information can be used by several individuals simultaneously, even remotely, which facilitates the use of expert knowledge and provide opportunities for increased capacity utilization.

    An expected increase in costs resulting from the implementation of digital pathology combined with uncertainty about the positive effects makes health economic analyses requested. Lack of data regarding the effects of digitalization has not yet allowed any adequate evaluations of the health economic aspects. Despite the practical difficulties that exist today, there are reasons to start thinking about what we want to investigate, how to do it and the possibility to fill current knowledge gaps.

    Purpose

    The purpose of this study is to investigate how a health economic evaluation of digital pathology can be designed, the possibility to make such an evaluation based on available data and identify the need for additional research.

    Method

    Digitalization of a pathology laboratory includes and affects many of the current activities at the unit in a complex manner. Therefore, the total economic effect of time savings, increased costs due to added operations, storage, and new equipment need to be studied.

    To make an early attempt to identify the costs and benefits of digital pathology in the present analysis we used three models with different perspectives. Shortterm and long-term potential effects of a full-scale implementation were analyzed with the use of the three analytical models.

    Results

    Important information is missing regarding the situation today, but above all,about the effects of a digitalization. This means that it is currently impossible tomake calculations or well-informed conclusions regarding the health economicimpact of a digitalization. However, using the three models we could make someconclusions. We have speculated on the potential benefits of a full-scale digitalization in two of the three models. Model 1 can be used to analyze an improved work flow within the pathology unit, above all, it is interesting to try to measure the average processing time per slide for the pathologist. Model 2 can be used to study how a reduction in waiting times for PAD-results affects the patient in terms of reduced anxiety. Based on Model 3, we conclude that it is unlikely that any shortened waiting times as a result of a digitalization means measurable medical benefit. However, it is important to point out that we only studied one example where a medical benefit could be expected.

    Conclusions

    • No scientific evaluation of the effects and costs regarding the diglization ofpathology laboratories in a Swedish setting were identified.
    • In the current situation it is not possible to make exact calculations or wellinformedconclusions regarding the health economic impact of a digitalizationas basic performance data and reliable cost data are not available.
    • With the help of the three models developed in this analysis it is possible todraw some conclusions about what types of data that are relevant to study.Model 1 can be used to analyze an improved work flow within the pathologyunit. Model 2 can be used to study how a reduction in waiting times for PADresultsaffect the patient in terms of reduced anxiety. Model 3 can be used as abasis for identification and analyze of situations in the health care where ashorter response time can influence clinical decisions.

    Studies of patient´s quality of life while waiting for test results is an exampleof data that need to be investigated for future health economic analyses. Suchanalyses would also benefit from an improved reporting of cost data. A thirdarea concerns studies of unnecessary or inaccurate health care due to false testresults.

  • 20.
    Aronsson, Mattias
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Hager, Jakob
    Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping. Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Hultcrantz, R.
    Karolinska Institute, Sweden.
    Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer2017In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 8, p. 1078-1086Article in journal (Refereed)
    Abstract [en]

    Background: Colorectal cancer screening can decrease morbidity and mortality. However, there are widespread differences in the implementation of programmes and choice of strategy. The primary objective of this study was to estimate lifelong costs and health outcomes of two of the currently most preferred methods of screening for colorectal cancer: colonoscopy and sensitive faecal immunochemical test (FIT). Methods: A cost-effectiveness analysis of colorectal cancer screening in a Swedish population was performed using a decision analysis model, based on the design of the Screening of Swedish Colons (SCREESCO) study, and data from the published literature and registries. Lifelong cost and effects of colonoscopy once, colonoscopy every 10 years, FIT twice, FIT biennially and no screening were estimated using simulations. Results: For 1000 individuals invited to screening, it was estimated that screening once with colonoscopy yielded 49 more quality-adjusted life-years (QALYs) and a cost saving of (sic)64 800 compared with no screening. Similarly, screening twice with FIT gave 26 more QALYs and a cost saving of (sic)17 600. When the colonoscopic screening was repeated every tenth year, 7 additional QALYs were gained at a cost of (sic)189 400 compared with a single colonoscopy. The additional gain with biennial FIT screening was 25 QALYs at a cost of (sic)154 300 compared with two FITs. Conclusion: All screening strategies were cost-effective compared with no screening. Repeated and single screening strategies with colonoscopy were more cost-effective than FIT when lifelong effects and costs were considered. However, other factors such as patient acceptability of the test and availability of human resources also have to be taken into account.

  • 21.
    Aronsson, Mattias
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Persson, Josefine
    Sahlgrenska Academy, University of Gothenburg.
    Blomstrand, Christian
    Sahlgrenska Academy, University of Gothenburg.
    Wester, Per
    University of Umeå, Sweden; Danderyd Hospital Karolinska Institutet, Sweden, Sweden.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Cost-effectiveness of endovascular thrombectomy in patients with acute ischemic stroke2016In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 86, no 11, p. 1053-1059Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate the cost-effectiveness of adding endovascular thrombectomy to standard care in patients with acute ischemic stroke.

    METHODS: The cost-effectiveness analysis of endovascular thrombectomy in patients with acute ischemic stroke was based on a decision-analytic Markov model. Primary outcomes from ESCAPE, Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA), Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT), and Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) along with data from published studies and registries were used in this analysis. We used a health care payer perspective and a lifelong time horizon to estimate costs and effects.

    RESULTS: The model showed that adding thrombectomy with stent retrievers to guideline-based care (including IV thrombolysis) resulted in a gain of 0.40 life-years and 0.99 quality-adjusted life-years along with a cost savings of approximately $221 per patient. The sensitivity analysis showed that the results were not sensitive to changes in uncertain parameters or assumptions.

    CONCLUSIONS: Adding endovascular treatment to standard care resulted in substantial clinical benefits at low costs. The results were consistent throughout irrespective of whether data from ESCAPE, EXTEND-IA, MR CLEAN, REVASCAT, or SWIFT PRIME were used in this model.

  • 22.
    Aronsson, Mattias
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Svennberg, Emma
    Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
    Rosenqvist, Mårten
    Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
    Engdahl, Johan
    Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
    Al-Khalili, Faris
    Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
    Friberg, Leif
    Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
    Frykman, Viveka
    Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Designing an optimal screening program for unknown atrial fibrillation: a cost-effectiveness analysis.2017In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 19, no 10, p. 1650-1656Article in journal (Refereed)
    Abstract [en]

    Aims: The primary objective of this study was to use computer simulations to suggest an optimal age for initiation of screening for unknown atrial fibrillation and to evaluate if repeated screening will add value.

    Methods and results: In the absence of relevant clinical studies, this analysis was based on a simulation model. More than two billion different designs of screening programs for unknown atrial fibrillation were simulated and analysed. Data from the published scientific literature and registries were used to construct the model and estimate lifelong effects and costs. Costs and effects generated by 2 147 483 648 different screening designs were calculated and compared. Program designs that implied worse clinical outcome and were less cost-effective compared to other programs were excluded from the analysis. Seven program designs were identified, and considered to be cost effective depending on what the health-care decision makers are ready to pay for gaining a quality-adjusted life-year (QALY). Screening at the age of 75 implied the lowest cost per gained QALY (€4 800/QALY).

    Conclusion: In conclusion, examining the results of more than two billion simulated screening program designs for unknown atrial fibrillation, seven designs were deemed cost-effective depending on how much we are prepared to pay for gaining QALYs. Our results showed that repeated screening for atrial fibrillation implied additional health benefits to a reasonable cost compared to one-off screening.

  • 23.
    Atwine, Fortunate
    et al.
    Linnaeus University, Växjö, Sweden; Mbarara University of Science and Technology (MUST). Mbarara, Uganda.
    Hjelm, Katarina
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Healthcare-seeking behaviour and management of type 2 diabetes: from Ugandan traditional healers’ perspective2016In: International Journal of Africa Nursing Sciences, E-ISSN 2214-1391, Vol. 5, p. 17-23Article in journal (Refereed)
    Abstract [en]

    [Background] Healthcare-seeking behaviour has been investigated to a limited extent in persons with diabetes, and the way traditional healers manage diabetes still needs exploration. [Aim] To explore healthcare-seeking behaviour and management of type 2 diabetes from the perspective of traditional healers in the folk sector to understand how traditional medicine is integrated into the professional health sector. [Design] A qualitative descriptive study. [Method] A purposeful sample of 16 traditional healers known in the area. Data were collected by individual semi-structured interviews. [Findings] Healthcare was sought from the professional health sector, mainly from the public hospitals, before the patients switched to the traditional healers. Reasons for seeking help from traditional healers were mainly chronic conditions such as diabetes, high blood pressure and the perceived failure of western medicine to manage diabetes. The cost at the healers’ facilities also influenced healthcare seeking because it was perceived to be affordable as it was negotiable and accessible because it was always available. Traditional medicine therapies of patients with diabetes were herbal medicine, nutritional products and counselling, but many patients whose conditions were difficult to manage were told to return to the public hospitals in the professional health sector. [Conclusion] Healthcare seeking was inconsistent in character, with a switch between different healthcare providers. Living conditions including treatment costs, healthcare organization, patients’ health beliefs and general condition seemed to influence healthcare seeking practice.

  • 24.
    Atwine, Fortunate
    et al.
    School of Health and Caring Sciences, Linnaeus University, Växjö, Sweden; Department of Nursing, Mbarara University of Science and Technology (MUST), Mbarara, Uganda.
    Hultsjö, Sally
    School of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
    Albin, Björn
    School of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
    Hjelm, Katarina
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Medicine and Health Sciences.
    Health-care seeking behaviour and the use of traditional medicine among persons with type 2 diabetes in south-western Uganda: a study of focus group interviews2015In: Pan African Medical Journal, ISSN 1937-8688, E-ISSN 1937-8688, Vol. 20, no 76Article in journal (Refereed)
    Abstract [en]

    Introduction: health-care seeking behaviour is important as it determines acceptance of health care and outcomes of chronic conditions but it has been investigated to a limited extent among persons with diabetes in developing countries. The purpose of the study was to describe health-care seeking behaviour and understand reasons for using therapies offered by traditional healers.

    Methods: descriptive study using focus-group interviews. Three purposive focus-groups were conducted in 2011 of 10 women and 7 men aged 39–72 years in Uganda. Data were collected through semi-structured interviews and qualitatively analysed according to a method described for focus-groups.

    Results: reasons for seeking help from traditional healers were symptoms related to diabetes such as polydipsia, fatigue and decreased sensitivity in lower limbs. Failure of effect from western medicine was also reported. Treatment was described to be unknown extracts, of locally made products taken as herbs or food, and participants had sought help from different health facilities with the help of relatives and friends.

    Conclusion: the pattern of seeking care was inconsistent, with a switch between different health care providers under the influence of the popular and folk sectors. Despite beliefs in using different healthcare providers seeking complementary and alternative medicine, participants still experienced many physical health problems related to diabetes complications. Health professionals need to be aware of the risk of switches between different health care providers, and develop strategies to initiate health promotion interventions to include in the care actors of significance to the patient from the popular, folk and professional sectors, to maintain continuity of effective diabetes care.

  • 25.
    Axelsson, Karin
    et al.
    Linköping University, Department of Management and Engineering, Information Systems. Linköping University, The Institute of Technology.
    Melin, Ulf
    Linköping University, Department of Management and Engineering, Information Systems. Linköping University, The Institute of Technology.
    Contextual Factors Influencing Health Information Systems Implementation in Public Sector: Investigating the Explanatory Power of Critical Success Factors2014In: Electronic Government: 13th IFIP WG 8.5 International Conference, EGOV 2014, Dublin, Ireland, September 1-3, 2014, Proceedings / [ed] Marijn Janssen, Hans Jochen Scholl, Maria A. Wimmer, Frank Bannister, Springer, 2014, p. 59-71Conference paper (Refereed)
    Abstract [en]

    In this paper, we approach the field of critical success factors (CSF) by analyzing a successful case of IT implementation within the public health sector. The purpose of the paper is to gain further understanding of if and how well CSFs can explain a successful case. The main conclusion drawn is that even though the studied organization shows signs of common CSFs, this alone cannot explain the success. An important contribution from this study is thus the focus on contextual factors when trying to understand what makes an implementation project successful.

  • 26.
    Bennich-Björkman, Li
    Statsvetenskapliga institutionen, Institutionen för folkhälsooch vårdvetenskap, Uppsala universitet.
    Förutsättningar för politiska prioriteringar i offentlig sjukvård: en jämförelse mellan landstingen i Östergötland och Uppsala2004Report (Other academic)
    Abstract [sv]

    Behovet av beslutssystem inom den offentligt finansierade sjukvården där politiker kan ta risken att fatta obehagliga, svåra och till och med impopulära beslut framstår som allt större i takt med att resurserna krymper, den medicinska tekniken förbättras och människor lever allt längre. Utgångspunkten i denna studie är att sådana beslut – beslut om horisontella prioriteringar – emellertid kräver särskilda förutsättningar inom landstingsorganisationen för att kunna förverkligas och bli varaktiga, eftersom det svenska politiska systemet som det konstruerats byggt in starka hinder mot beslutsfattande i avsikt att spara, omfördela eller försämra. De politiska kostnaderna för sådana – ibland tyvärr nödvändiga – beslut är höga. Landstingens kultur och organisation kan skapa förutsättningar för att dessa ”kostnader” kan bli mindre.

    Utvecklade förtroenderelationer, vad som här kallas ett högt ”inomorganisatoriskt” förtroende, inom och mellan sjukvårdens nyckelgrupper den medicinska professionen, de förtroendevalda, sjukvårdsadministratörerna och patientgrupper, är en avgörande sådan förutsättning. Först när politiker kan lita på att svåra beslut inte kommer att utnyttjas av andra politiker, av läkare, tjänstemän eller genom allianser mellan någon av dessa grupper och patientföreningar, finns förutsättningar för att fatta politiska beslut om horisontella prioriteringar och stå fast vid dem. Att bygga förtroende är emellertid ingen lätt uppgift. Många studier har till exempel pekat på att spänningen mellan politiker och den medicinska professionen har varit stor i det svenska sjukvårdssystemet.

    I denna studie görs en jämförelse mellan två landsting, Östergötlands och Uppsalas, för att undersöka hur relationerna inom landstingsorganisationerna gestaltar sig och vad detta kan bero på. Studien genomfördes 2002-2003 och grundmaterialet är intervjuer med ledande politiska företrädare, företrädare för den medicinska professionen samt chefstjänstemän i de båda landstingen. Huvudresultaten av jämförelsen visar att relationerna - landstingskulturen - skiljer sig starkt åt. Den i Östergötland kännetecknas av en hög grad av förtroende mellan politiker, läkare och sjukvårdsadministratörer, medan distans och på sina håll en misstro är vanligt förekommande i Uppsala. En förståelse för varandras skilda roller i systemet, respekt samt tydliga roller som medger ett definierat utrymme för varje grupp är beskrivningar som återkommer i de intervjuer som gjorts med ledande politiker, centrumchefer och chefstjänstemän i Östergötland, liksom ömsesidig lojalitet mellan profession och politiker. Landstinget i Östergötland har lyckats mejsla fram en känsla av landstinget som en gemensam organisation, vilket är ovanligt. I studien söks förklaringen till skillnaden i landstingskultur framförallt i att det sätt på vilket den konsekvent genomförda decentraliserade organisationen i Östergötland ”tvingat fram” en hög grad av personliga möten och personlig interaktion som saknas i Uppsala. Det i sin tur har bidragit till att bygga upp förtroendefulla relationer mellan de olika grupperna som annars, vilket är fallet i Uppsala, tenderar att leva långt från varandras verklighet.

  • 27.
    Bergthorsdottir, R
    et al.
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Nilsson, A G
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Gillberg, P
    Shire, Danderyd, Sweden.
    Ekman, Bertil
    Östergötlands Läns Landsting, Heart and Medicine Center, Department of Endocrinology. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Wahlberg, Jeanette
    Östergötlands Läns Landsting, Heart and Medicine Center, Department of Endocrinology. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Health-Related Quality of Life In Patients With Adrenal Insufficiency Receiving Plenadren Compared With Immediate-Release Hydrocortisone.2015In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 18, no 7, p. A616-Article in journal (Refereed)
    Abstract [en]

    Background

    Previous studies in patients with primary adrenal insufficiency (PAI) on conventional replacement therapy suggest decreased health-related quality of life (HRQoL), and that patients report more frequently fatigue, increased anxiety and inability to work compared to background population.

    Objectives

    To study self-reported health status with EQ-5D in patients with PAI. Patients treated with Plenadren (modified-release hydrocortisone) were compared with patients treated with immediate release hydrocortisone (IRHC) replacement therapy.

    Methods

    This was a cross-sectional, multi-centre, non-interventional survey of patients with PAI receiving Plenadren or immediate release hydrocortisone (IRHC) replacement.

    Subjects

    One hundred thirty-four adult patients with PAI of whom 36 (19 females [53%]) were treated with Plenadren and 98 (77 females [79%]) were treated with IRHC, were included.

    MAIN OUTCOME MEASURE

    HRQoL described by the EQ-5D, a generic preference-based measure of health.

    RESULTS

    Patients on Plenadren and on IRHC had a mean ± SD age of 53.1 ± 12.7 years and 48.0 ± 13.1 years, respectively (P=0.043). The majority of the patients were diagnosed more than 5 years ago (69%). The mean ± SD daily Plenadren and IRHC doses were 27.0 ± 6.8 mg and 26.6 ± 10.9 mg, respectively (P=0.807). 47% of the Plenadren patients had been receiving Plenadren and 82% of the IRHC patients had been receiving IRHC for more than 3 years. Patients receiving Plenadren had better HRQoL measured by the EQ-5D questionnaire compared to patients replaced with IRHC (0.76 ± 0.18 vs 0.68 ± 0.18, respectively [P=0.040]).

    CONCLUSIONS

    Replacement therapy with Plenadren in patients with PAI confers measurable benefit on HRQoL relative to IRHC as estimated by the EQ-5D questionnaire, and may therefore be advantageous when compared to IRHC substitution.

  • 28.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, The Institute of Technology.
    Behov eller konstnadseffektivitet: vad ska avgöra prioriteringar inom hälso- och sjukvården?2003Report (Other academic)
    Abstract [sv]

    Gapet mellan behov och resurser inom hälso- och sjukvården gör tillsammans med det faktum att marknaden inte fungerar för att fördela vårdens tjänster att beslut om prioriteringar måste fattas genom planering. Sådana beslut bör för att vinna acceptans och legitimitet vara genomtänkta och baserade på värdegrunder med bred förankring i befolkningen. De värdegrunder som i detta sammanhang främst bör beaktas är de som kommer till uttryck i medicin- och vårdetik, prioriteringsutredningens riktlinjer samt hälso- och sjukvårdslagen. Resonemang om prioriteringsgrunder leder oftast fram till principerna rättvisa eller effektivitet. Rättvisa i prioriteringen av hälso- och sjukvård avser rimligast en fördelning efter behov medan effektivitet bör tolkas i termer av kostnadseffektivitet. De båda prioriteringskriterierna behovsrättvisa och kostnadseffektivitet anses ofta som oförenliga, något som inte minst visas av prioriteringsutredningens strikta rangordning i vilken behovsprincipen ges absolut företräde framför kostnadseffektivitetsprincipen.

    I denna rapport utmanas uppfattningen om en absolut konflikt mellan dessa begrepp, och därmed det nödvändiga i en strikt rangordning, mellan behov och kostnadseffektivitet. För att skapa en förståelse för de båda prioriteringskriterierna redogörs i rapporten för dess bakomliggande teorier samt för rimliga innebörder av olika centrala begrepp.

    När det gäller rättvisa tas utgångspunkten i Rawls teori om rättvisa som närmast är att betrakta som inriktad på jämlikhet. Den rimligaste tolkningen av Rawls teori tillämpad på den svenska sjukvården är att vårdens resurser skulle fördelas efter behov så att den person som har störst behov kommer i första hand. Behovsbegreppet relateras i prioriteringsutredningen till hälsa och livskvalitet där graden av inskränkning i dessa variabler styr behovets storlek. Behov kan dock definieras på olika sätt och i denna rapport har en teleologisk tolkning ansetts som rimligast. Enligt en sådan tolkning anses behov existera av något om detta är nödvändigt för ett visst ändamål. Inom hälso- och sjukvården är det rimligt att tolka behov som ett gap mellan det tillstånd som råder och ett mål som satts upp. Behovet avser rimligen vård(resurser) och målet borde vara att uppnå en förbättrad hälsa eller ett ökat välbefinnande. Gapet skulle alltså kunna utgöras av skillnaden mellan det rådande hälsotillståndet och ett hälsotillstånd som satts upp som mål. För att kunna tillämpa en sådan behovsprincip är det nödvändigt att på en och samma hälsoskala kunna mäta och fastställa såväl det rådande tillståndet som målet. För att behov av en vårdinsats ska existera krävs dessutom att insatsen är verksam, d.v.s. har en gynnsam effekt på hälsan.

    Kostnadseffektivitet har sin grund i välfärdsekonomisk teori, för vilken utilitaristisk moralteori utgör en viktig värdegrund. Den välfärdsekonomiska teorin och utilitarismen är viktiga influenser för den hälsoekonomiska disciplinen och dess utvärderingar. Syftet med sådana utvärderingar är att finna den lösning som maximerar den hälsorelaterade nyttan.

    Rättvisa och kostnadseffektivitet som begrepp tycks alltså fokusera på olika saker, hälsa respektive nytta, vilket gör det i högsta grad relevant att närmare studera olika begrepp som är kopplade till sjukvårdens resultat. Det finns två huvudinriktningar när det gäller hälsobegreppet, dels en biologisk/biostatistisk och dels en holistisk. Ett biologiskt synsätt har traditionellt dominerat inom den medicinska professionen. Boorses biostatistiska hälsobegrepp där hälsa jämställs med statistisk normalitet i biologiska funktioner har erhållit mycket uppmärksamhet och ligger ganska nära den traditionella medicinska uppfattningen. På senare år har dock en mer omfattande syn på hälsa blivit allt mer framträdande. Denna holistiska syn på hälsa inkluderar mer än bara biologiska funktioner då även människors förmåga att fungera i olika avseenden, socialt, fysiskt, psykiskt, arbetsmässigt etc, vägs in. Nyttobegreppet betraktas i termer av subjektiva autonoma preferenser, d.v.s. att det är människors egna önskemål och värderingar som avgör värdet av t.ex. en vårdinsats.

    Hälsa och nytta ses ibland som väldigt likartade, nästan som olika benämningar på samma sak. Av denna rapport framgår att man inte bör blanda samman dessa båda begrepp då de inte kan anses spegla samma aspekter av sjukvårdens resultat. Det finns också ett antal olika sätt att mäta resultaten – kliniska riskindikatorer för biologiskt orienterad hälsa, psykometriska instrument som kan anses indikera holistisk hälsa, metoder för fastställande av QALY-vikter som motsvarar hälsorelaterade preferenser.

    Ovanstående metoder har i annat sammanhang jämförts för att få åtminstone en preliminär bild av relationen mellan de båda begreppen hälsa och nytta. Resultatet av denna analys visade att marginalnyttan av hälsa är avtagande, d.v.s. att ju bättre hälsa desto mindre blir nyttotillskottet av en given hälsoförbättring. Detta innebär i sin tur att den antagna konflikten mellan rättvisa (hälsorelaterat behov) och kostnadseffektivitet (nyttomaximering) mildras. Slutsatsen i denna rapport är att de etiska principerna rättvisa uttryckt som behov och kostnadseffektivitet inte står i direkt motsatsställning till varandra så att rangordning krävs. Då båda principerna är både viktiga och önskvärda att inkludera i prioriteringsarbetet är det förmodligen bättre att söka en rimlig avvägning mellan dem än att välja att helt följa en princip på bekostnad av den andra.

  • 29.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Region Östergötland, Heart and Medicine Center, Allergy Center.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Rahmqvist, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Chronic pain in an elderly population in Sweden: Impact on costs and quality of life2015Report (Other academic)
    Abstract [en]

    Chronic pain among elderly people has long been a well-known problem, in terms of both societal costs and the quality of life of affected individuals. To estimate the magnitude of the problems associated with chronic pain in an elderly population, data on both costs and quality of life were gathered. A postal questionnaire was sent out to a stratified sample of 10 000 inhabitants 65 years and older in Linköping and Norrköping. The survey included questions on demographics, habits, and life situation, and different kinds of questions and instruments related to well-being (e.g., quality-of-life and pain-specific questions). In the questionnaire respondents were asked whether they were receiving any help—informal care—from a relative. If they answered yes, they were asked for permission to contact the informal caregiver and to provide contact details. The amount of informal care provided by relatives to persons with chronic pain was investigated by use of a questionnaire directed to the caregiving relatives, containing questions about time spent providing informal care.

    Data on costs were collected from registers of consumption of health care, drugs, and municipal services.

    The results of the study showed a very clear association between existence and severity of chronic pain and societal costs. The study population was subdivided into three groups with respect to having chronic pain or not, and a pain intensity during the last week of 0–4 (mild), 5–7 (moderate), or 8–10 (severe) on a scale of 0–10. Taking all costs (health care, drugs, municipal services, and informal care) into account, persons in the severe chronic pain group consumed on average 72% more resources than persons in the moderate chronic pain group and 143% more than those in the no or mild chronic pain group. Differences were most pronounced concerning municipal services and informal care costs.

    Even more alarming are the results on the quality of life of persons in the different groups. On the EQ-5D index, the average value for persons in the no or mild chronic pain group was 0.82. For those in the moderate chronic pain group the average value was 0.64, and for those in the severe chronic pain group the average value was only 0.38. EQ-VAS resulted in less pronounced but still clearly significant differences.

    It is concluded that this study, reaching a rather large part of the target population, shows that existence and severity of chronic pain among people 65 years and older affects costs to society and the quality of life of affected individuals in a massive way.

  • 30.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Allergy Center.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Chronic pain in a population 65 years and older: correlation with age of health care costs and quality of life2015Conference paper (Refereed)
  • 31.
    Bernhardsson, Susanne
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Närhälsan Rehabilitation, Region Västra Götaland, Hönö, Sweden.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Johansson, Kajsa
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Larsson, Maria E. H.
    Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden; The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    Clinical practice in line with evidence?: A survey among primary care physiotherapists in western Sweden2015In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 21, no 6, p. 1169-1177Article in journal (Refereed)
    Abstract [en]

    Rationale, aims and objectives

    Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables.

    Methods

    419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire.

    Results

    The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1–16). The most common treatment interventions across the three conditions were advice on posture (reported by 82–94%), advice to stay active (86–92%), and different types of exercise (65–92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29–96%. Modalities such as laser therapy and ultrasound were sparingly used (<5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience.

    Conclusions

    Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent.

  • 32.
    Beukes, Eldre W.
    et al.
    Anglia Ruskin University, England.
    Baguley, David M.
    Anglia Ruskin University, England; Nottingham Biomed Research Centre, England; University of Nottingham, England.
    Allen, Peter M.
    Anglia Ruskin University, England; Anglia Ruskin University, England.
    Manchaiah, Vinaya
    Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences. Linköping University, The Swedish Institute for Disability Research. Lamar University, TX 77710 USA; Audiol India, India; Manipal University, India.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Guided Internet-based versus face-to-face clinical care in the management of tinnitus: study protocol for a multi-centre randomised controlled trial2017In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 18, article id 186Article in journal (Refereed)
    Abstract [en]

    Background: Innovative strategies are required to improve access to evidence-based tinnitus interventions. A guided Internet-based cognitive behavioural therapy (iCBT) intervention for tinnitus was therefore developed for a U.K. population. Initial clinical trials indicated efficacy of iCBT at reducing tinnitus severity and associated comorbidities such as insomnia and depression. The aim of this phase III randomised controlled trial is to compare this new iCBT intervention with an established intervention, namely face-to-face clinical care for tinnitus. Methods/design: This will be a multi-centre study undertaken across three hospitals in the East of England. The design is a randomised, two-arm, parallel-group, non-inferiority trial with a 2-month follow-up. The experimental group will receive the guided iCBT intervention, whereas the active control group will receive the usual face-to-face clinical care. An independent researcher will randomly assign participants, using a computer-generated randomisation schedule, after stratification for tinnitus severity. There will be 46 participants in each group. The primary assessment measure will be the Tinnitus Functional Index. Data analysis will establish whether non-inferiority is achieved using a pre-defined non-inferiority margin. Discussion: This protocol outlines phase III of a clinical trial comparing a new iCBT with established face-to-face care for tinnitus. If guided iCBT for tinnitus proves to be as effective as the usual tinnitus care, it may be a viable additional management route for individuals with tinnitus. This could increase access to evidence-based effective tinnitus care and reduce the pressures on existing health care systems.

  • 33.
    Biermann, Olivia
    et al.
    Karolinska Institute, Sweden.
    Eckhardt, Martin
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Emergency Medicine. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine.
    Carlfjord, Siw
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Falk, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Forsberg, Birger C.
    Karolinska Institute, Sweden.
    Collaboration between non-governmental organizations and public services in health - a qualitative case study from rural Ecuador2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 32237Article in journal (Refereed)
    Abstract [en]

    Background: Non-governmental organizations (NGOs) have a key role in improving health in low-and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. Design: A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. Results: Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the providers structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. Conclusions: To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the populations trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the providers structure, and regarding partners roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations.

  • 34.
    Blomqvist, Kerstin
    Fokus Regionförbund, Kalmar läns landsting.
    Prioriteringar i vårdflöden för äldre: en förstudie2004Report (Other academic)
    Abstract [sv]

    Denna rapport är resultatet av ett avgränsat projekt som syftade till att undersöka prioriteringar i vård av äldre där flera vårdgivare är involverade. De huvudsakliga frågeställningarna handlade om vilka vardagliga prioriteringar som görs samt vilka motiv eller överväganden som dessa baseras på.

    Vilka hälso- och sjukvårdsinsatser som skall ges till äldre personer grundas i organisationens eller samhällets motiv och värderingar men också i personalens egna uppfattningar. Innan relevansen av valda insatser kan bedömas krävs insikt i hur prioriteringar görs och på vilka värderingar de baseras - prioriteringsprocessen behöver med andra ord göras transparent. Denna förstudie är ett försök att i någon mån genomlysa prioriteringsprocessen och därmed fungera som ett avstamp inför fortsatta studier för att förstå hur vård till äldre personer kan ges - utifrån deras egna upplevelser och önskemål.

    Ett strategiskt urval av elva personer, anställda inom kommunal och landstingsdriven vård och omsorg intervjuades med hjälp av hypotetiska fallbeskrivningar.

    Studien visade att de prioriteringar som beskrevs sällan handlade om val mellan patientgrupper. I stället beskrevs val mellan olika vård- och omsorgsformer och val mellan olika rehabiliteringsinsatser. De val som oftast beskrevs var om patienten skulle erbjudas vård vid sjukhuset eller vård och omsorg i hemmet och om patienten skulle erbjudas rehabiliteringsinsatser i form av träning eller rehabiliteringsinsats främst i form av hjälpmedel. Analysen visade att beslutet baserades på överväganden relaterade till patienten, personalen och/eller organisationen. I normalfallet grundades beslutet på en kombination av dessa överväganden.

    Förstudien ger en komplex bild av de överväganden personal grundar sina prioriteringar på. Ett fynd är att beslut om vård/omsorgs- och rehabiliteringsinsatser inte enbart baserades på faktorer hos den individuella patienten utan även på faktorer relaterade till personalen och den organisation där beslutet fattats.

    Rapporten uppmanar till en allmän prioriteringsdiskussion bland personal som arbetar med äldre personer genom att problematisera människovärdesprincipens tillämpning när exempelvis äldres sociala nätverk vägs in som en prioriteringsgrund för om träning skall erbjudas eller ej. Rapporten uppmanar också till diskussion kring val av måttstock för utvärdering av effekt av olika behandlingar.

    Med ett kostnadseffektivitetsperspektiv kan prioriteringar av sjukvård och rehabilitering till äldre bli olika beroende på om minimerat funktionsbortfall eller återgång till friskt tillstånd är effektmått. Rapporten uppmanar också till en diskussion om rädslan hos personal att värderas som någon som ”skickar in i onödan” kan påverka prioriteringar av sjukvård till äldre.

    Slutligen är det viktigt att påpeka att studien inte kan ge något svar på frågan om hur patienten/brukaren uppfattar och värderar kvaliteten i vård eller rehabilitering på olika vårdnivåer. För att få svar på en sådan fråga krävs fördjupade studier som innefattar äldre patienter och deras närstående.

  • 35.
    Brodtkorb, Thor-Henrik
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment. Linköping University, The Institute of Technology.
    Cost-effectiveness analysis of health technologies when evidence is scarce2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Given the increasing pressures on health care budgets, economic evaluation is used in many countries to assist decision-making regarding the optimal use of competing health care technologies. Although the standard methods of estimating cost-effectiveness underpinning these decisions have gained widespread acceptance, concerns have been raised that many technologies would not be considered for funding, due to scarcity of evidence. However, as long as the amount and quality of evidence used for the analysis are properly characterized, scarce evidence per se should not be seen as a hindrance to perform cost-effectiveness analyses. Characterizing uncertainty appropriately, though, may pose a challenge even when there is a large body of evidence available, and even more so when evidence is scarce. The aims of this thesis are to apply a methodological framework of cost-effectiveness analysis and explore methods for characterising uncertainty when evidence is scarce. Three case studies associated with limited evidence provide economic evaluations on current decision problems, investigate the feasibility of using the framework, and explore methods for characterizing uncertainty when evidence is scarce.

    The results of the case studies showed that, given current information, providing transfemoral amputees with C-Leg and Airsonett Airshower to patients with perennial allergic asthma could be considered cost-effective whereas screening for hyperthrophic cardiomyopathy among young athletes is unlikely to be cost-effective. In the cases of C-Leg and Airsonett Airshower conducting further research is likely to be cost-effective. The case studies indicate that it is feasible to apply methods of cost-effectiveness in health care for technologies not commonly evaluated due to lack of evidence. The analysis showed that failing to account for individual experts’ might have a substantial effect on the interpretation of the results of cost-effectiveness analysis. Formal expert elicitation is a promising method of characterizing uncertainty when evidence is missing, and thus enable cost-effectiveness and value of further research to be appropriately estimated in such situations.

    In conclusion, this thesis shows that scarcity of evidence should not preclude the use of cost-effectiveness analysis. On the contrary, in such cases it is probably more important than ever to use a framework that enable us to define key parameters for a decision problem and identify available evidence in order to determine cost-effectiveness given current information and provide guidance on further data collection.

    List of papers
    1. Cost-effectiveness of clean air administered to the breathing zone in allergic asthma
    Open this publication in new window or tab >>Cost-effectiveness of clean air administered to the breathing zone in allergic asthma
    2010 (English)In: CLINICAL RESPIRATORY JOURNAL, ISSN 1752-6981, Vol. 4, no 2, p. 104-110Article in journal (Refereed) Published
    Abstract [en]

    Introduction: Airsonett Airshower (AA) is a novel non-pharmaceutical treatment for patients with perennial allergic asthma that uses a laminar airflow directed to the breathing zone of patients during sleep. It has been shown that AA treatment in addition to optimized standard therapy significantly increases asthma-related quality of life among adolescent asthmatics. However, the cost-effectiveness of AA treatment has not yet been assessed. As reimbursement decisions are increasingly guided by results from the cost-effectiveness analysis, such information is valuable for health-care policy-makers. Objective: The objective of this study was to estimate the cost-effectiveness of adding AA treatment with allergen-free air during night sleep to optimized standard therapy for adolescents with perennial allergic asthma compared with placebo. Materials and Methods: A probabilistic Markov model was developed to estimate costs and health outcomes over a 5-year period. Costs and effects are presented from a Swedish health-care perspective (QALYs). The main outcome of interest was cost per QALY gained. Results: The Airshower strategy resulted in a mean gain of 0.25 QALYs per patient, thus yielding a cost per QALY gained of under 35 000 as long as the cost of Airshower is below 8200. Conclusions: Adding AA treatment to optimized standard therapy for adolescents with perennial allergic asthma compared with placebo is generating additional QALYs at a reasonable cost. However, further studies taking more detailed resource use and events such as exacerbations into account would be needed to fully evaluate the cost-effectiveness of AA treatment. Please cite this paper as: Brodtkorb T-H, Zetterstrom O and Tinghog G. Cost-effectiveness of clean air administered to the breathing zone in allergic asthma.

    Keywords
    asthma, cost-effectiveness, decision modeling, quality of life
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-54712 (URN)10.1111/j.1752-699X.2009.00156.x (DOI)000275766600007 ()
    Available from: 2010-04-06 Created: 2010-04-06 Last updated: 2015-09-22
    2. Cost-effectiveness of C-Leg compared to non microprocessor controlled knees: a modeling approach
    Open this publication in new window or tab >>Cost-effectiveness of C-Leg compared to non microprocessor controlled knees: a modeling approach
    2008 (English)In: Archives of Physical Medicine and Rehabilitation, ISSN 0003-9993, E-ISSN 1532-821X, Vol. 89, no 1, p. 24-30Article in journal (Refereed) Published
    Abstract [en]

    Objective: To estimate the costs and health outcomes of C-Leg and non–microprocessor-controlled (NMC) knees using a decision-analytic model.

    Design: Data on costs, rates and duration of problems, knee survival, and health-related quality of life were obtained from interviews with patients and prosthetists with experience of both C-Leg and NMC knees. Interview data were assessed in a decision-analytic Markov model to estimate cost-effectiveness from a health care perspective.

    Setting: Outpatient.

    Participants: A population sample of 20 patients currently using the C-Leg and prior experience of nonmicroprocessor knees, and 5 prosthetists.

    Interventions: Not applicable.

    Main Outcome Measure: Incremental cost per quality-adjusted life year (QALY).

    Results: The mean incremental cost (in 2006 Euros) and QALYs for the C-Leg was €7657 and 2.38, respectively, yielding a cost per QALY gained of €3218.

    Conclusions: It is important to provide decision-makers with relevant information on costs and health outcomes of different treatment strategies on actual decision problems despite limited evidence. The results of the study, taking into account both costs and a broadly defined health outcome in terms of QALY, show that given existing albeit limited evidence the C-Leg appears to yield positive health outcomes at an acceptable cost.

    Place, publisher, year, edition, pages
    Institutionen för medicin och hälsa, 2008
    Keywords
    Artificial limbs, Costs and cost analysis, Decision support techniques, Quality of life, Rehabilitation
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-11142 (URN)10.1016/j.apmr.2007.07.049 (DOI)
    Note
    Original publication: Thor-Henrik Brodtkorb, Martin Henriksson, Kasper Johannesen-Munk, Fredrik Thidell, Cost-effectiveness of C-Leg compared to non microprocessor controlled knees: a modelling approach, 2008, Archives of Physical Medicine and Rehabilitation, (89), 1, 24-30. http://dx.doi.org/10.1016/j.apmr.2007.07.049. Copyright: Elsevier B.V., http://www.elsevier.com/Available from: 2008-02-27 Created: 2008-02-27 Last updated: 2017-12-13
    3. Eliciting priors to characterize uncertainties in decision analytic models
    Open this publication in new window or tab >>Eliciting priors to characterize uncertainties in decision analytic models
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Background: Expert opinions are often used in decision models when evidence is scarce. This study describes the details of a formal elicitation exercise to estimate parameter values and their associated uncertainty and compares the results in term of cost-effectiveness and value of information with results from only eliciting mean values from experts.

    Methods: Elicited distributions for 11 unknown parameters where incorporated into a previously developed cost-effectiveness model for prosthetic knees for amputees. The original model included elicited mean values for the missing values, thus ignoring any uncertainty across experts’ beliefs.

    Results: The incremental cost-effective ratio (ICER) for the analysis based on the current elicited distributions was substantially higher (€13 625) than the ICER in the original analysis (€3 258). Even decision uncertainty, at a €35 000 threshold, increased significantly, increasing the value of further research from €355 100 in the original analysis, to €5 987 444 for the current elicited values.

    Conclusions: Failing to account for the individual expert’s uncertainty might have a considerable impact on the result of cost-effectiveness analyses. Formal expert elicitation offers a plausible method to generate prior distributions representing the experts’ uncertainty and thereby more appropriately account for the true uncertainty of the decision.

    National Category
    Economics and Business
    Identifiers
    urn:nbn:se:liu:diva-56593 (URN)
    Available from: 2010-05-26 Created: 2010-05-26 Last updated: 2010-05-26
    4. Screening for hypertrophic cardiomyopathy in young athletes: A cost-effectiveness analysis
    Open this publication in new window or tab >>Screening for hypertrophic cardiomyopathy in young athletes: A cost-effectiveness analysis
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Background: Screening to prevent sudden cardiac death among young athletes has been debated for some time and several countries have already introduced pre-participation cardiovascular screening to identify sports active individuals at risk. Although, hypertrophic cardiomyopathy (HCM) is the most common underlying disease that is documented to be detectable by screening the cost-effectiveness of such a screening strategy is still unclear.

    Methods: A screening program to detect HCM in young athletes was compared to a non screening strategy. Prevalence of HCM, mortality risks and test characteristics were estimated from published sources and formal expert elicitation. These estimates were incorporated in a decision analytic model to estimate costs and health outcomes, expressed in life years and quality adjusted life years (QALYs), over a lifetime perspective.

    Results: The screening strategy was associated with a mean incremental cost of €93 and a mean incremental gain of 0.0005 life years, yielding a cost per life year gained of €196 205. Taking quality of life into account, the screening strategy was associated with a loss of 0.034 QALY.

    Conclusions: The study shows that screening young athletes for hypertrophic cardiomyopathy is not likely to yield survival benefits at a cost normally considered to be cost-effective and if quality of life is considered in the analysis screening is associated with higher costs and a loss of QALYs. Thus, based on the present findings a strategy of screening young athletes for hypertrophic cardiomyopathy is unlikely to be cost effective.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-56594 (URN)
    Available from: 2010-05-26 Created: 2010-05-26 Last updated: 2010-05-26Bibliographically approved
  • 36.
    Brohede, Sabina
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping.
    Body Dysmorphic Disorder: Capturing a prevalent but under-recognized disorder2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background

    Individuals with body dysmorphic disorder (BDD) are highly distressed due to defects they perceive in their physical appearance that are not noticeable to others. The condition often leads to impaired functioning in relationships, socialization, and intimacy and a decreased ability to function in work, school, or other daily activities. Although BDD seems to be relatively prevalent, it is under-recognized by people in general and by health care professionals. Individuals with BDD are secretive about their symptoms, and they usually do not recognize that they are suffering from a psychiatric disorder. Instead, in an attempt to relieve their symptoms by correcting their perceived defects, they commonly seek dermatological treatment or cosmetic surgery. However, such interventions usually do not result in any decrease in BDD symptom severity, but can rather aggravate the symptoms. Therefore, it is crucial that health care professionals recognize BDD in order to offer adequate care. Prior to the studies conducted for this thesis, there were no known data regarding the prevalence of BDD in Sweden.

    Main aims

    (i) To translate a screening questionnaire for BDD (the Body Dysmorphic Disorder Questionnaire, BDDQ) into Swedish and validate the questionnaire in a community sample. (ii) To estimate the prevalence of BDD in the general population of Swedish women and in female dermatology patients. (iii) To explore BDD patients’ experiences of living with the disorder, including their experiences of the health care system.

    Methods

    The BDDQ was validated using the Structured Clinical Interview for DSM-IV (SCID) as the gold standard for diagnosing BDD (Study I). The validated BDDQ was used to estimate the prevalence of BDD in a randomly selected population-based sample of Swedish women (n=2 885) (Study II) and in a consecutive sample of female dermatology patients (n=425) (Study III). In Studies II and III, the Hospital Anxiety and Depression Scale was used to assess symptoms of depression and anxiety. In Study III, quality of life was evaluated by the Dermatology Life Quality Index. BDD patients’ lived experiences were explored using a qualitative research design (Study IV). Fifteen individuals with BDD were interviewed, and the interviews were analysed using Interpretive Description.

    Results

    The Swedish translation of the BDDQ displayed a sensitivity of 94%, a specidicity of 90% and a (positive) likelihood ratio of 9.4. The prevalence of women screening positive for BDD was 2.1% (95% CI 1.7–2.7) in the population-based sample of women and 4.9% (95% CI 3.2–7.4) in the dermatology patients’ sample. The positive predictive value of the BDDQ (71%) gave an estimated BDD prevalence of 1.5% (95% CI 1.1–2.0) in the female Swedish population. Women screening positive for BDD had signidicantly more symptoms of anxiety and depression compared to those screening negative for BDD in both samples. In the dermatology patients, quality of life was severely impaired in patients with positive BDD screening. The overarching concept found in Study IV was that patients with BDD felt imprisoned and were struggling to become free and to no longer feel abnormal. The participants had encountered difdiculties in accessing health care and had disappointing experiences of the health care system.

    Conclusion

    The findings of this thesis indicate that BDD is a relatively common disorder in the Swedish female population, and that it is more prevalent in dermatology patients. BDD patients struggle to be free from a feeling of imprisonment, and in this struggle they encounter difficulties in accessing health care. Therefore, it is important to increase awareness and recognition of BDD among health care professionals to ensure that patients with BDD receive the appropriate care.

    List of papers
    1. Validation of the Body Dysmorphic Disorder Questionnaire in a community sample of Swedish women
    Open this publication in new window or tab >>Validation of the Body Dysmorphic Disorder Questionnaire in a community sample of Swedish women
    2013 (English)In: Psychiatry Research, ISSN 0165-1781, E-ISSN 1872-7123, Vol. 210, no 2, p. 647-652Article in journal (Refereed) Published
    Abstract [en]

    Body Dysmorphic Disorder (BDD) is characterized by a distressing and impairing preoccupation with a nonexistent or slight defect in appearance. Patients with the disorder present to both psychiatric and non-psychiatric physicians. A few studies have assessed BDD prevalence in the general population and have shown that the disorder is relatively common. To date, no BDD assessment instruments have been validated in the general population. Our aim was to validate a brief self-screening instrument, the Body Dysmorphic Disorder Questionnaire (BDDQ), in a female community sample. The BDDQ was translated into Swedish and filled out by 2891 women from a randomly selected community sample. The questionnaire was validated in a subsample of 88 women, using the Structured Clinical Interview for DSM-IV (SCID) together with clinical assessment as the gold standard. In the validation subsample, the BDDQ showed good concurrent validity, with a sensitivity of 94%, a specificity of 90% and a likelihood ratio of 9.4. The questionnaire can therefore be of value when screening for BDD in female populations.

    Place, publisher, year, edition, pages
    Elsevier, 2013
    Keywords
    Self-report instrument; Measurement; Somatoform disorders; Appearance concerns; Body image
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-103301 (URN)10.1016/j.psychres.2013.07.019 (DOI)000328518600044 ()
    Available from: 2014-01-17 Created: 2014-01-16 Last updated: 2017-12-06
    2. Prevalence of body dysmorphic disorder among Swedish women: A population-based study
    Open this publication in new window or tab >>Prevalence of body dysmorphic disorder among Swedish women: A population-based study
    2015 (English)In: Comprehensive Psychiatry, ISSN 0010-440X, E-ISSN 1532-8384, Vol. 58, p. 108-115Article in journal (Refereed) Published
    Abstract [en]

    Background: Body dysmorphic disorder (BDD) is characterized by a highly distressing and impairing preoccupation with nonexistent or slight defects in appearance. Patients with BDD present to both psychiatric and non-psychiatric physicians. A few studies have assessed BDD prevalence in representative samples of the general population and have demonstrated that this disorder is relatively common. Our primary objective was to assess the prevalence of BDD in the Swedish population because no data are currently available. Methods: In the current cross-sectional study, 2891 randomly selected Swedish women aged 18-60 years participated. The occurrence of BDD was assessed using the Body Dysmorphic Disorder Questionnaire (BDDQ), which is a validated self-report measure derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria for BDD. In addition, symptoms of depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS). Results: The prevalence of BDD among Swedish women was 2.1%. The women with BDD had significantly more symptoms of depression and anxiety than the women without BDD. Depression (HADS depression score greater than= 8) and anxiety (HADS anxiety score greater than= 8) were reported by 42% and 72% of the women with BDD, respectively. Conclusions: The results of the present study indicate that BDD is relatively common among Swedish women (2.1%) and that it is associated with significant morbidity.

    Place, publisher, year, edition, pages
    WB Saunders, 2015
    National Category
    Clinical Medicine
    Identifiers
    urn:nbn:se:liu:diva-117368 (URN)10.1016/j.comppsych.2014.12.014 (DOI)000351807800015 ()25617963 (PubMedID)
    Note

    Funding Agencies|Linkoping University; Ostergotland County Council

    Available from: 2015-04-24 Created: 2015-04-24 Last updated: 2017-12-04
    3. I will be at deaths door and realize that Ive wasted maybe half of my life on one body part: the experience of living with body dysmorphic disorder
    Open this publication in new window or tab >>I will be at deaths door and realize that Ive wasted maybe half of my life on one body part: the experience of living with body dysmorphic disorder
    2016 (English)In: International journal of psychiatry in clinical practice (Print), ISSN 1365-1501, E-ISSN 1471-1788, Vol. 20, no 3, p. 191-198Article in journal (Refereed) Published
    Abstract [en]

    Objectives: The purpose of this study was to explore the experiences of patients living with body dysmorphic disorder (BDD), including their experiences with the health care system. Methods: Fifteen individuals with BDD were interviewed, and interpretive description was used to analyse the interviews. Results: The following six themes were identified: being absorbed in time-consuming procedures, facing tension between ones own ideal and the perceived reality, becoming the disorder, being restricted in life, attempting to reduce ones problems and striving to receive care. The overarching concept derived from the themes was feeling imprisoned - struggling to become free and to no longer feel abnormal. Conclusions: Ideas of imprisonment and abnormality compose the entire experience of living with this disorder. Although the participants suffered greatly from their BDD, these patients encountered difficulties in accessing health care and had disappointing experiences during their encounters with the health care system. Therefore, it is important to increase awareness and knowledge of BDD among health care professionals to ensure that patients with BDD receive the appropriate care.

    Place, publisher, year, edition, pages
    TAYLOR & FRANCIS LTD, 2016
    Keywords
    Body dysmorphic disorder; body image; interview; qualitative research
    National Category
    Psychiatry
    Identifiers
    urn:nbn:se:liu:diva-131206 (URN)10.1080/13651501.2016.1197273 (DOI)000380144000013 ()27314665 (PubMedID)
    Available from: 2016-09-16 Created: 2016-09-12 Last updated: 2017-11-21
  • 37.
    Broqvist, Mari
    PrioriteringsCentrum.
    Arbetsterapeuter och sjukgymnaster prövar metod för prioriteringar: ett samarbetsprojekt med FSA och LSR2006Report (Other academic)
    Abstract [sv]

    Många sjukgymnaster och arbetsterapeuter påtalar behov av mer stöd för att kunna diskutera och genomföra prioriteringar i sina verksamheter. Användbara metoder efterfrågas. PrioriteringsCentrum har därför under 2005 drivit samarbetsprojekt med Förbundet för Sveriges Arbetsterapeuter och Legitimerade Sjukgymnasters Riksförbund. Projektet har utgått från den arbetsmodell för vertikala prioriteringar som föreslås av Svenska Läkaresällskapet och som i huvudsak tillämpas i Socialstyrelsens prioriteringsarbete. Modellen har sin utgångspunkt i den etiska plattformen i Hälso- och sjukvårdslagen som ska ligga till grund för alla prioriteringar inom hälso- och sjukvård.

    Frågan är om den modell som vuxit fram är tillämpbar också för sjukgymnaster och arbetsterapeuter? Det är den fråga som vi i detta projekt försökt besvara. Arbetsmodellens användbarhet har granskats och möjliga anpassningar diskuterats. I huvudsak har vi funnit den användbar och viktig som vägledning i hur riksdagens riktlinjer för prioriteringar kan omsättas i praktiken. Följande slutsatser har dragits vad det gäller metod för vertikala prioriteringar inom arbetsterapi och sjukgymnastik:

    • Indelning och avgränsning av ett prioriteringsarbete (t ex i verksamhetsområden eller sjukdomsgrupper) måste avgöras utifrån syftet med arbetet.
    • Det är rimligt att prioriteringar görs mellan patientgrupper med olika ohälsotillstånd kombinerat med de arbetsterapeutiska eller sjukgymnastiska insatser som kan vara aktuella. Utöver sjukdom och/eller funktionsnedsättning utgörs ohälsotillstånd inom sjukgymnastik och arbetsterapi också av de konsekvenser som sjukdom/skada ger upphov till (d v s problem att klara olika aktiviteter och kunna vara delaktig). Antalet prioriteringsobjekt måste vara rimligt att hantera vilket påverkar hur noga dessa ska definieras.
    • För att bedöma vilka behov av arbetsterapi och sjukgymnastik som är störst är det rimligt att väga in svårighetsgraden för olika tillstånd samt patientnyttan och kostnadseffektiviteten med olika insatser. Hänsyn måste också tas till i vilken sjukdomsfas tillståndet bedöms, om det finns flera komplicerande tillstånd, konsekvenser vid utebliven insats samt vilka fakta eller vilken beprövad erfarenhet som ligger till grund för de bedömningar som görs. Det som var nytt i diskussionerna var att också de drabbades livssituation och sociala nätverk spelar roll i bedömningen av ett tillstånds svårighetsgrad.
    • För att komma fram till en viss prioriteringsnivå måste en kvalitativ sammanvägning göras av svårighetsgrad, patientnytta med insats och stöd för detta samt kostnadseffektivitet.
    • Projektgrupperna ansåg det rimligt att en prioriteringsordning tydliggörs i en rangordningslista. Denna ska dock ses som ett underlag för interna diskussioner och behöver omarbetas eller kompletteras om den ska kommuniceras till andra. Projektdeltagarna har också identifierat viktiga utvecklingsområden för tvärprofessionella diskussioner med målsättningen att försöka skapa en gemensam arbetsmodell som kan omfatta alla vårdprofessioner och gynna gränsöverskridande prioriteringsarbete;
    • De begrepp som används i ett prioriteringsarbete behöver spegla en bred hälsosyn, allt ifrån organ-, funktions- till aktivitets- och delaktighetsnivå. En mer enhetlig och distinkt begreppsapparat som kan förstås av alla yrkeskategorier behöver prövas.
    • Diskussioner behöver föras om vilka risker för försämring av ett tillstånd vid utebliven insats som är rimliga att beakta i ett prioriteringsarbete.
    • Diskussioner behöver också föras om hur målet med vårdens insatser påverkar hur man ska se på nyttan med olika insatser och vilka prioriteringar som bör göras. Förutsättningarna för att utveckla mer s k målrelaterade behovsbedömningar behöver undersökas.
    • Vidare behövs ett förtydligande om vad som ska ingå i bedömningen av kostnadseffektivitet då många yrkeskategorier i stor utsträckning är beroende av egna skattade kostnadsberäkningar.
    • Andra grunder än vetenskaplig evidens för bedömning av patientnytta behöver tydliggöras, t ex innebörden av ”beprövad erfarenhet”.
    • Patienters egna upplevelser av hur svårt deras tillstånd är och vilken nytta de ser med olika insatser måste också fångas i ett prioriteringsarbete.
    • Behov av förtydliganden eller förändringar av den etiska plattformen för prioriteringar i Hälso- och sjukvårdslagen finns fortfarande kvar. Det gäller t ex vilken hänsyn som kan tas till patienters funktion i samhället och sociala nätverk när det gäller bedömningar av hur svåra tillstånd är och vilken nytta sjukgymnastens och arbetsterapeutens insatser gör.

    Samtalet om prioriteringar måste gå vidare såväl inom dessa yrkesgrupper som tillsammans med andra professioner och politiker. Att följa och dokumentera prioriteringsarbete i praktiken är sannolikt ett viktigt nästa steg att ta för att sprida erfarenheter och gemensamt öka kunskapen om vad som gynnar tillväxten av öppna prioriteringar inom sjukgymnastik och arbetsterapi.

  • 38.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Asking the public: Citizens´ views on priority setting and resource allocation in democratically governed healthcare2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Resource allocation in publicly funded healthcare systems is inevitably linked with priority setting between different patient groups and between different service areas, so-called meso level priorities. Behind every priority-setting decision (investments, reallocating or rationing), are values affecting both the content of the decisions and how the decisions are made. The importance for priority-setting to reflect social values, has been emphasised for the legitimacy of the healthcare systems and the decision makers. Also important, if supposed to provide enough guidance in practice, is that content values, expressed in ethical principles and criteria, are further operationalised. Few studies exist where Swedish citizens have been asked about priority setting and rationing at meso level, and findings from other countries cannot automatically be transferred to the Swedish context.

    The overall aim of this thesis is to extend and deepen the knowledge of the Swedish citizens´ views on acceptance of rationing in healthcare, on appropriate decision makers for rationing, and on the severity criterion for priority setting. Two qualitative and one mixmethod study were conducted, where citizens were interviewed. Citizens´ views on severity were also compared, both with a Severity Framework, derived from parliamentary-decided ethical principles and used for resource allocation, and with health professionals´ and politicians´ ranking of different aspects of severity in a quantitative, survey study.

    Study I shows that citizen participants perceived that acceptance of rationing at meso level is built on the awareness of priority-setting dilemmas between patient groups. No such spontaneous awareness was found. Depending on reactions of self-interest or solidarity, acceptance was also perceived to be built on acceptable principles for rationing and/or access to alternatives to public care. Study II shows that awareness of the meso level forms the basis for awareness of different risks of unfairness, linked with potential decision makers (even health professionals). Collaborative arrangements were promoted in order to control for such risks, especially the risk of self-interest. Politicians, in contrast to previous studies, were favoured as final decision makers for rationing healthcare. In study III, citizen participants identified the same severity aspects as health professionals and experts had done in the Severity Framework. They contributed with some possible refinements, but also promoted aspects not in line with established ethical criteria for priority setting in Sweden. Study IV shows that citizen respondents differ to a larger proportion compared to politicians´ ranking of severity aspects, than with that of health professionals´. The greatest number of significant differences was found between politicians and health professionals.

    This thesis has several implications. Politicians ought to strive for greater public awareness of the priority-setting dilemma at the meso level in healthcare, both according to the process and the content values behind the decisions. Social values not in accordance to the parliamentary decision indicate a need to facilitate an ongoing dialogue, reason-giving activities and promotion of content values of solidarity. To capture social values on priority setting and rationing, ambitious public deliberation is not the only way. Methodologically stringent research, with a variety of study designs, could contribute in many important ways.

    List of papers
    1. To accept, or not to accept, that is the question: citizen reactions to rationing
    Open this publication in new window or tab >>To accept, or not to accept, that is the question: citizen reactions to rationing
    2014 (English)In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 17, no 1, p. 82-92Article in journal (Refereed) Published
    Abstract [en]

    Background  The publicly financed health service in Sweden has come under increasing pressure, forcing policy makers to consider restrictions. Objective  To describe different perceptions of rationing, in particular, what citizens themselves believe influences their acceptance of having to stand aside for others in a public health service. Design  Qualitative interviews, analysed by phenomenography, describing perceptions by different categories. Setting and participants  Purposeful sample of 14 Swedish citizens, based on demographic criteria and attitudes towards allocation in health care. Results  Participants expressed high awareness of limitations in public resources and the necessity of rationing. Acceptance of rationing could increase or decrease, depending on one's (i) awareness that healthcare resources are limited, (ii) endorsement of universal health care, (iii) knowledge and acceptance of the principles guiding rationing and (iv) knowledge about alternatives to public health services. Conclusions  This study suggests that decision makers should be more explicit in describing the dilemma of resource limitations in a publicly funded healthcare system. Openness enables citizens to gain the insight to make informed decisions, i.e. to use public services or to 'opt out' of the public sector solution if they consider rationing decisions unacceptable.

    Place, publisher, year, edition, pages
    John Wiley & Sons, 2014
    Keywords
    citizen perspective, phenomenography, priority setting, rationing, Sweden
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-104308 (URN)10.1111/j.1369-7625.2011.00734.x (DOI)000330647300010 ()22032636 (PubMedID)
    Available from: 2014-02-14 Created: 2014-02-14 Last updated: 2018-04-03
    2. It takes a giraffe to see the big picture - Citizens' view on decision makers in health care rationing
    Open this publication in new window or tab >>It takes a giraffe to see the big picture - Citizens' view on decision makers in health care rationing
    2015 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 128, p. 301-308Article in journal (Refereed) Published
    Abstract [en]

    Previous studies show that citizens usually prefer physicians as decision makers for rationing in health care, while politicians are downgraded. The findings are far from clear-cut due to methodological differences, and as the results are context sensitive they cannot easily be transferred between countries. Drawing on methodological experiences from previous research, this paper aims to identify and describe different ways Swedish citizens understand and experience decision makers for rationing in health care, exclusively on the programme level. We intend to address several challenges that arise when studying citizens' views on rationing by (a) using a method that allows for reflection, (b) using the respondents' nomination of decision makers, and (c) clearly identifying the rationing level. We used phenomenography, a qualitative method for studying variations and changes in perceiving phenomena. Open-ended interviews were conducted with 14 Swedish citizens selected by standard criteria (e.g. age) and by their attitude towards rationing. The main finding was that respondents viewed politicians as more legitimate decision makers in contrast to the results in most other studies. Interestingly, physicians, politicians, and citizens were all associated with some kind of risk related to self-interest in relation to rationing. A collaborative solution for decision making was preferred where the views of different actors were considered important. The fact that politicians were seen as appropriate decision makers could be explained by several factors: the respondents' new insights about necessary trade-offs at the programme level, awareness of the importance of an overview of different health care needs, awareness about self-interest among different categories of decision-makers, including physicians, and the national context of long-term political accountability for health care in Sweden. This study points to the importance of being aware of contextual and methodological issues in relation to research on how citizens experience arrangements for rationing in health care.

    Place, publisher, year, edition, pages
    Elsevier, 2015
    Keywords
    Sweden Health care Rationing Programme level Decision maker Citizens' view Interview Phenomenography
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-115129 (URN)10.1016/j.socscimed.2015.01.043 (DOI)000351323500037 ()25638017 (PubMedID)
    Note

    The authors gratefully acknowledge the contribution made by the participants in this study. This study was supported by the Swedish Federation of County Councils Research Program on Change Processes in Health Care and the Swedish National Centre for Priority Setting in Health Care.

    Available from: 2015-03-09 Created: 2015-03-09 Last updated: 2018-04-03
    3. The meaning of severity - do citizenś views correspond to a severity framework based on ethical principles for priority setting?
    Open this publication in new window or tab >>The meaning of severity - do citizenś views correspond to a severity framework based on ethical principles for priority setting?
    2018 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 122, no 6, p. 630-637, article id S0168-8510(18)30081-2Article in journal (Refereed) Published
    Abstract [en]

    The importance for governments of establishing ethical principles and criteria for priority setting in line with social values, has been emphasised. The risk of such criteria not being operationalised and instead replaced by de-contextualised priority-setting tools, has been noted. The aim of this article was to compare whether citizenś views are in line with how a criterion derived from parliamentary-decided ethical principles have been interpreted into a framework for evaluating severity levels, in resource allocation situations in Sweden. Interviews were conducted with 15 citizens and analysed by directed content analysis. The results showed that the multi-factorial aspects that participants considered as relevant for evaluating severity, were similar to those used by professionals in the Severity Framework, but added some refinements on what to consider when taking these aspects into account. Findings of similarities, such as in our study, could have the potential to strengthen the internal legitimacy among professionals, to use such a priority-setting tool, and enable politicians to communicate the justifiability of how severity is decided. The study also disclosed new aspects regarding severity, of which some are ethically disputed, implying that our results also reveal the need for ongoing ethical discussions in publicly-funded healthcare systems.

    Place, publisher, year, edition, pages
    Elsevier, 2018
    Keywords
    Citizens views, Directed content analysis, Ethical principles, Priority setting, Severity of ill health, Sweden
    National Category
    Medical Ethics
    Identifiers
    urn:nbn:se:liu:diva-147772 (URN)10.1016/j.healthpol.2018.04.005 (DOI)000438479000010 ()29728287 (PubMedID)
    Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2018-08-02
  • 39.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Medborgardialogen i Östergötland: ett utvecklingsarbete i landstinget. Delrapport 12002Report (Other academic)
    Abstract [sv]

    En medborgardialog är under utvecklande i Landstinget i Östergötland. Senaste årens demokratiutveckling, en förändrad politisk organisation samt behovet av öppna prioriteringar anses vara några av orsaker till detta. Den enskilde landstingspolitikern har också genom medicinskt programarbete byggt upp en tillit till att dialogen med medborgaren fungerar. En politisk arbetsgrupp arbetar nu med ett flerårigt utvecklingsprojekt kring medborgardialog i Östergötland. Syftet med projektet är inte primärt att diskutera en särskild fråga med medborgarna utan att testa vilka arenor som politiker kan använda i en dialog med medborgaren.

    Arbetet har så här långt bestått av en planeringsfas där politikerna arbetat med målformuleringsarbete för arbetsgruppens arbete, kunskapsuppbyggnad samt framtagande av testarenor och den politiska frågan kring läkemedel som ska prövas på olika arenor.

    Mycken kunskap är vunnen i arbetsgruppen så här långt. Politikerna har bl.a. i mindre samtalsgrupper diskuterat med ett 60-tal östgötar om hur en medborgardialog skulle kunna utformas. Ur samtalen har framkommit att medborgarna anser det viktigt att känna sig berörd, insatt och kunnig i det som ska diskuteras samt att förstå dialogens syfte. Ämnet ska ta sin utgångspunkt i det konkreta och beröra sådant som har att göra med etiska frågor, prioriteringar och sjukvårdens förutsättningar. Formerna för ett samtal kan variera alltifrån det oplanerade, spontana samtalet till det möte där medborgarna bereds möjlighet att grundligt sätta sig in i en fråga. Önskemålen har också en spännvidd från det mer personliga mötet i en mindre grupp till en dialog via Internet i form av enkäter. Det som framkommit i samtalen med medborgarna har verifierats genom den enkätundersökning som genomfördes med 900 östgötar via Internet.

    PrioriteringsCentrum har i uppdrag att följa och dokumentera detta utvecklingsarbete. Syftet är att sprida erfarenheter om sådant som har att göra med praktiskt prioriteringsarbete där en dialog med medborgarna utgör en viktig del. Av de erfarenheter som hittills vunnits skulle jag vilja lyfta följande punkter som kan antas ha betydelse för landsting och kommuner med intresse för att utveckla en medborgardialog;

    • För att skapa bärkraft i ett utvecklingsarbete kring medborgardialog behöver det finnas en gemensam bild i hela den politiska organisationen av behovet av ett samtal med medborgarna. Det måste dessutom finnas ett stöd från tjänstemännen i organisationen, inte bara av eldsjälar utan genom att flera personer med intresse och kunskap om vad en medborgardialog kan innebära involveras i arbetet.
    • Den politiska viljan med medborgardialogen behöver tydliggöras för att syftet också ska bli tydligt för de medborgare som berörs. Gäller det att öka delaktigheten hos medborgarna, skapa bredare beslutsunderlag, skapa legitimitet för prioriteringsbeslut eller finns det andra syften? Frågor om politikerns roll och förhållningssätt i dialogen med medborgarna behöver också klargöras. Ska han eller hon inta en lyssnande, informerande och/eller argumenterande roll?
    • Resultatet av medborgardialogen dvs. de värderingar som medborgarna för fram i olika frågor måste finna sina vägar in i den politiska beslutsprocessen. Om inte detta sker finns en risk att legitimiteten för dialogen i medborgarnas ögon går förlorad. Implementeringsfrågor är därför viktiga att hantera i den politiska organisationen.
    • All utveckling kräver tid. Detta gäller också för nya arbetssätt för landstingspolitiker. Att avsätta tid för reflektion, att avgöra vilka skeden detta är av särskild vikt men också avgöra vad som är rimlig tid för den uppgift man har syns som viktiga delar för att utveckla den politiska prioriteringsprocessen på ett genomtänkt sätt.
    • Ett systematiskt arbetssätt men som också tillåter ett lärande under arbetets gång verkar vara ett framgångsrikt angreppssätt. Här ingår målformulering, analys och syntes av vunna erfarenheter samt utvärdering är viktiga utvecklingssteg.
    • En förändrad politikerroll skapar ett behov av ett förändrat stöd till politikerna. I och med att politikernas arbetssätt blir mer processinriktat ökar behovet av stöd kring sådana arbetsmetoder. Medborgardialogen kan också innebära ett behov av stöd och vägledning i hur samtal kring svåra frågor kan föras med medborgarna.
    • Att arbeta fram de frågor som ska diskuteras med medborgarna är en grannlaga uppgift. Det finns olika perspektiv på alla frågor. Om en organisation har modet att ta hjälp av många olika kunskapsföreträdare i ett sådant arbete ökar troligen möjligheten att skapa en bra utgångspunkt för samtalet med medborgarna, även om vägen dit blir lite längre.

    Utvärdering är som sagt en viktig del i ett utvecklingsarbete. I nästa rapport kommer de arenor som nu prövas i Östergötland att beskrivas och utvärderas.

  • 40.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Politiker möter medborgare i samtal om prioriteringar: ett praktiskt exempel2003Report (Other academic)
    Abstract [sv]

    Ett flerårigt utvecklingsarbete kring öppen dialog mellan politiker och medborgare om prioriteringar har genomförts i Östergötland. PrioriteringsCentrum har följt politikerna genom hela detta arbete. Landstinget i Östergötland önskade nämligen få sitt arbete dokumenterat och därmed mer systematiskt betraktat som ett led i sitt eget lärande om arbete med medborgardialog och öppna prioriteringar.

    Politikernas syfte med projektet har inte primärt varit att diskutera en särskild fråga med medborgarna utan att bygga upp erfarenheter kring hur en medborgardialog kan gå till. Det är dessa erfarenheter som denna rapport handlar om.

    Sammanlagt 2 300 östgötar har deltagit i försöket med medborgardialog. Politikerna har valt tre olika kontaktsätt; medborgarråd, samtalsgrupper och samtal kring en minienkät. I samtliga möten har frågorna varit kopplade till läkemedel och prioriteringar. Av alla de erfarenheter som dessa möten gett upphov till redovisas följande i rapporten;

    Medborgare kan mycket väl acceptera att diskutera prioriteringar med politiker men det finns mycket som kan påverka hur väl detta accepteras. Valet av ämne är en sådan viktig del. Att frågorna är aktuella, relativt kända och berör många anses positivt liksom att de är partipolitiskt neutrala, kan påverkas av de lokala politikerna, innehåller ett konkret prioriteringsdilemma och så långt möjligt speglar den typ av beslut politiker har att fatta. Information om behovet av prioriteringar och politikernas roll i prioriteringsarbetet är också viktigt. Avgörande för att dialogen ska accepteras är kanske ändå kvalitén i samtalet där lyssnandet har ett stort värde.

    Tillgång på information gynnar dialogen mellan medborgare och politiker eftersom prioriteringar i vården är komplexa. För mycket information kan dock föra diskussionen för långt från hur ”vanligt” folk kan tänka samtidigt som information kan bidra positivt till ändrade attityder i befolkningen kring prioriteringar. Politikernas behov av kunskap inför en medborgardialog är inte ätt att ta ställning till. I första hand är de intresserade av att diskutera värderingar och inte fakta samtidigt som en viss kunskap krävs för att förstå det som kommer upp i diskussionen.

    Prioriteringsdiskussioner med medborgarna kan ha ett värde för politikerna på flera olika sätt. Det kan handla om förslag till olika lösningar vid resursbrist och visa på vilken acceptans som finns i befolkningen kring olika resonemang kring prioriteringar. Diskussionerna ger också politikerna en bild av dagsläget kring patientnära prioriteringar i vården samt behovet av information i befolkningen kring redan fattade beslut.

    Medborgare som i ibland anses som särskilt svåra att nå av politiker har visat stort intresse av att diskutera prioriteringar när politikerna väl sökt sig ut till platser där dessa medborgare finns i sin vardag.

    • Erfarenheterna från detta försök visar att det finns samtalsämnen som återkommer trots att deltagarna sinsemellan upplevs olika t.ex. vad det gäller politisk aktivitet, olika etnisk bakgrund, olika åldrar och vårderfarenhet. I samtliga samtal kommer man in på frågor om människovärde, behov och hälsa. Å andra sidan i grupper där deltagarna förefaller tämligen lika kan olika perspektiv komma upp på prioriteringar som t.ex. har med ekonomi eller samhällsperspektiv att göra. Behovet av representativitet beror på vilket syfte politikerna önskar uppnå med medborgardialogen. I det långa loppet anses ändå representativitet viktigt för att få legitimitet för dialogen.
    • Medborgardialogen behövs för att skapa ökad delaktighet, ökad legitimitet för prioriteringar, skapa nyanserade beslutsunderlag men också för att utveckla politikernas eget prioriteringsarbete. Dialogen med medborgaren har både en plats inom partierna och som en parlamentarisk uppgift. Den behöver dock få en tydlig koppling till landstingens styrprocess för att behålla sin legitimitet.
    • Slutligen diskuteras i denna rapport vad som skulle kunna gynna respektive hindra att politiker väljer att utveckla en medborgardialog. Här handlar det bl.a. om vilken demokratisyn som är förhärskande, vilka politiker som är bärare av medborgardialogen, medvetenheten om prioriteringsbehovet, politikernas roll vad det gäller prioriteringar och hur de värderar process eller resultat samt medborgardialogens status som politiskt arbetssätt.

    För de politiker som är intresserade av att arbeta vidare med medborgardialog finns alltså många viktiga frågor att ställa sig men också en hel del kunskap och erfarenhet att ta tillvara. PrioriteringsCentrum hoppas med denna rapport ytterligare kunna bidra till att inspirera till praktiskt utvecklingsarbete kring öppna prioriteringar.

  • 41.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences. PrioriteringsCentrum.
    Öppna prioriteringar inom arbetsterapi och sjukgymnastik2004Report (Other academic)
    Abstract [sv]

    Ett av de viktigaste verktygen för ett framgångsrikt prioriteringsarbete i vården är samtal. Samtal kollegor emellan, med andra yrkesgrupper, med politiker och med allmänheten. Att vara medveten om sina egna prioriteringar i patientarbetet är en viktig utgångspunkt för ett sådant samtal. Idag finns lite kunskap om hur vårdpersonal resonerar kring prioriteringar i vården. Vårdpersonal har också hittills spelat en undanskymd roll i diskussioner om hur vårdens resurser ska användas och fördelas (SOU 2001:8).

    Denna rapport syftar till att öka kunskapen om hur arbetsterapeuter och sjukgymnaster resonerar kring öppna prioriteringar och vad det är som styr de prioriteringar de gör i sitt patientnära arbete. Innehållet grundar sig på vad som framkommit i de 16 intervjuer som genomförts med representanter från dessa yrkeskategorier, verksamma på olika håll i Sverige. Både landstings- och kommunanställda har deltagit i intervjuerna.

    Intervjuerna visar att graden av medvetenhet om prioriteringar varierar kraftigt bland de intervjuade arbetsterapeuterna och sjukgymnasterna. Många beskriver att de hela tiden gör val mellan olika insatser i sitt arbete - de har bara inte tänkt på det som ”prioriteringar”. Å andra sidan finns det exempel på enheter inom sjukgymnastik och arbetsterapi som på ett medvetet sätt arbetat med att rangordna sina insatser. Som bilagor till rapporten finns exempel på detta från Karolinska sjukhuset i Stockholm och Akademiska sjukhuset i Uppsala. Fortfarande är det dock vanligast med ringa öppenhet i de prioriteringar som görs av dessa yrkesgrupper.

    Ett annat resultat av intervjuerna var de många faktorer som kunde påvisas som påverkar de prioriteringar arbetsterapeuter och sjukgymnaster gör i sin dagliga verksamhet. Omvärldsfaktorer som läkarens kompetens och intresse, lagar, politiska styrsystem och viljeyttringar samt yttre fysiska förutsättningar som t.ex. lokalernas utformning ligger ofta utanför vad dessa yrkesgrupper själva kan påverka men som de samtidigt måste förhålla sig till i sina val. Den egna kompetensen, intresseinriktningen, kultur och traditioner samt upplevelsen av prestige beskrivs mer som inre faktorer som är direkt påverkbara av den enskilde yrkesföreträdaren liksom yrkesgruppens syn på hälsa, kostnadseffektivitet hos åtgärden och patientens egen upplevelse av behov.

    Vad som framkommit i denna rapport styrker helt den bild som Prioriteringsutredningen (SOU 1995:5) gav, nämligen att arbetsterapeuter och sjukgymnaster inte deltar i organiserat prioriteringsarbete i särskilt hög grad. Beslutsunderlagen riskerar därmed att bli ensidiga och ge en bristfällig bild av vårdbehov.

    Det finns också andra starka drivkrafter än de politiska för en fortsatt utveckling av öppna prioriteringar inom dessa yrkeskårer. Arbetsmiljöfrågor och framtida krav från patienter och allmänhet är några sådana exempel. För att komma vidare i arbetet finns flera möjliga steg att ta, några av dessa kan vara att:

    1. Bygga upp kunskap om de prioriteringar som görs idag.
    2. Genomföra diskussioner om vårdbehov för de patientgrupper som arbetsterapeuter och sjukgymnaster arbetar med.
    3. Utveckla metoder för öppna prioriteringar inom arbetsterapi och sjukgymnastik.
    4. Bidra till ökad delaktighet i prioriteringsdiskussioner på alla nivåer.
    5. Utveckla strategier för offentliggörande av prioriteringar.

    Genom att arbeta vidare med dessa utvecklingsfrågor skulle mer medvetna och öppna prioriteringar kunna bli möjliga inom arbetsterapi och sjukgymnastik vilket i sin tur skulle möjliggöra en större insyn i hur behov kopplade till rehabiliteringsinsatser tillgodoses i vården idag. Syftet med öppna prioriteringar är att bidra både till en ökad rättvisa och till effektivitet i vården.

  • 42.
    Broqvist, Mari
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Prioriteringscentrum.
    Branting Elgstrand, Maria
    Socialstyrelsen.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Eklund, Kristina
    Socialstyrelsen.
    Jakobsson, Anders
    National Model for Transparent Prioritisation in Swedish Health Care: Reviderad version2011Report (Other academic)
    Abstract [en]

    The national model for transparent prioritisation concerns a systematic method of interpreting and implementing the Riksdag’s guidelines and ethical platforms in practice. The model may be used for prioritisation, primarily at group level, by all types of publicly funded health care providers, within county councils, municipalities and privately managed health care. The prioritisation model is applicable in both vertical and horizontal prioritisation.

    The national model for transparent prioritisation aims to increase the systematic application of the Riksdag’s guidelines in order to ensure that a greater proportion of resources are allocated appropriately and efficiently to the care of those in greatest need of it, enabling and facilitating transparent prioritisation. The model does not, however, stipulate how the actual work of priority setting shall be organised.

  • 43.
    Broqvist, Mari
    et al.
    PrioriteringsCentrum, Landstinget i Östergötland.
    Carlsson, Per
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment.
    Jacobsson, Catrine
    PrioriteringsCentrum, Landstinget i Östergötland.
    Karlsson, Erling
    PrioriteringsCentrum, Landstinget i Östergötland.
    Lund, Karin
    PrioriteringsCentrum, Landstinget i Östergötland.
    Öppna politiska prioriteringar av hälso- och sjukvård: rapportering från ett seminarium2005Report (Other academic)
    Abstract [sv]

    Det har snart gått ett år sedan seminariet om öppna horisontella prioriteringar, som finns dokumenterat i denna rapport, genomfördes. Syftet med seminariet, som arrangerades av PrioriteringsCentrum i samarbete med Socialstyrelsen och Sveriges Kommuner och Landsting, var att väcka intresse för frågan om öppna politiska prioriteringar och bidra till metodutveckling på området. Jag uppfattar att det första syftet uppnåddes medan diskussionerna om arbetsformer visar på mycket varierade uppfattningar. Det framgår tydligt att inställningen och erfarenheterna till mer öppna politiska prioriteringar inom vård och omsorg är olika bland sjukvårdspolitiker. På så sätt bidrog seminariet med intressanta frågeställningar snarare än att det gav entydiga svar.

    Under det senaste året har bland annat den tredje Nationella Prioriteringskonferensen genomförts i Göteborg med ett rekordstort deltagande - inte minst så var politikergruppen väl representerad. Den workshop om öppna politiska prioriteringar som arrangerades var den mest efterfrågade. Det finns ett stort intresse för frågan som förhoppningsvis denna rapport kan stimulera ytterligare. Den ger inga entydiga svar på frågan hur prioriteringsarbetet ska gå till. Detta svar måste antagligen tills vidare formuleras av var och en i sin miljö med hänsyn tagen till lokala förutsättningar. PrioriteringsCentrum kommer att fortsätta att följa utvecklingen och arbeta vidare med denna intressanta fråga.

    Tack till Socialstyrelsen och Sveriges Kommuner och Landsting för samarbetet, övriga författare och Katrin Lindroth som redigerat rapporten.

    Linköping november 2005

    Per Carlsson

    Professor, föreståndare för PrioriteringsCentrum

  • 44.
    Broqvist, Mari
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    It takes a giraffe to see the big picture - Citizens' view on decision makers in health care rationing2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 128, p. 301-308Article in journal (Refereed)
    Abstract [en]

    Previous studies show that citizens usually prefer physicians as decision makers for rationing in health care, while politicians are downgraded. The findings are far from clear-cut due to methodological differences, and as the results are context sensitive they cannot easily be transferred between countries. Drawing on methodological experiences from previous research, this paper aims to identify and describe different ways Swedish citizens understand and experience decision makers for rationing in health care, exclusively on the programme level. We intend to address several challenges that arise when studying citizens' views on rationing by (a) using a method that allows for reflection, (b) using the respondents' nomination of decision makers, and (c) clearly identifying the rationing level. We used phenomenography, a qualitative method for studying variations and changes in perceiving phenomena. Open-ended interviews were conducted with 14 Swedish citizens selected by standard criteria (e.g. age) and by their attitude towards rationing. The main finding was that respondents viewed politicians as more legitimate decision makers in contrast to the results in most other studies. Interestingly, physicians, politicians, and citizens were all associated with some kind of risk related to self-interest in relation to rationing. A collaborative solution for decision making was preferred where the views of different actors were considered important. The fact that politicians were seen as appropriate decision makers could be explained by several factors: the respondents' new insights about necessary trade-offs at the programme level, awareness of the importance of an overview of different health care needs, awareness about self-interest among different categories of decision-makers, including physicians, and the national context of long-term political accountability for health care in Sweden. This study points to the importance of being aware of contextual and methodological issues in relation to research on how citizens experience arrangements for rationing in health care.

  • 45.
    Brunner-La Rocca, H.P.
    et al.
    Heart Failure Clinic, Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202AZ Maastricht, The Netherlands.
    Fleischhacker, L.
    Fleischhacker GmbH, Schwerte, Germany.
    Golubnitschaja, O.
    EPMA, Brussels, Belgium.
    Heemskerk, F.
    RIMS bvba, Overijse, Belgium.
    Helms, T.
    German Foundation for the Chronically Ill, Fürth, Germany.
    Hoedemakers, T.
    Sananet Care BV, Sittard, Netherlands.
    Allianses, S.H.
    RIMS bvba, Overijse, Belgium.
    Jaarsma, Tiny
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Kinkorova, J.
    Medical Faculty Pilsen, Pilsen, Czech Republic.
    Ramaekers, J.
    Sananet Care BV, Sittard, Netherlands.
    Ruff, P.
    Exploris AG, Zürich, Switzerland.
    Schnur, I.
    sense.ly, San Francisco, USA.
    Vanoli, E.
    Mulimedica SPA, Milano, Italy.
    Verdu, J.
    Medtronic Iberica SA, Madrid, Spain.
    Zippel-Schultz, B.
    German Foundation for the Chronically Ill, Fürth, Germany.
    Challenges in personalised management of chronic diseases-heart failure as prominent example to advance the care process2016In: The EPMA Journal, ISSN 1878-5077, Vol. 7, article id 2Article, review/survey (Refereed)
    Abstract [en]

    Chronic diseases are the leading causes of morbidity and mortality in Europe, accounting for more than 2/3 of all death causes and 75 % of the healthcare costs. Heart failure is one of the most prominent, prevalent and complex chronic conditions and is accompanied with multiple other chronic diseases. The current approach to care has important shortcomings with respect to diagnosis, treatment and care processes. A critical aspect of this situation is that interaction between stakeholders is limited and chronic diseases are usually addressed in isolation. Health care in Western countries requires an innovative approach to address chronic diseases to provide sustainability of care and to limit the excessive costs that may threaten the current systems. The increasing prevalence of chronic diseases combined with their enormous economic impact and the increasing shortage of healthcare providers are among the most critical threats. Attempts to solve these problems have failed, and future limitations in financial resources will result in much lower quality of care. Thus, changing the approach to care for chronic diseases is of utmost social importance.

  • 46.
    Brüggemann, Jelmer
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Exploring patient strategies in response to untoward healthcare encounters2017In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 24, no 2, p. 190-197Article in journal (Refereed)
    Abstract [en]

    Background: Increasing attention to patients’ rights and their ability to choose their healthcare provider have changed the way patients can respond to untoward, disempowering and abusive healthcare encounters. These responses are often seen as crucial for quality improvement, yet they are little explored and conceptualized.

    Objective: To explore patients’ potential responses to untoward healthcare encounters and looking at their possible consequences for care quality improvement as well as for the individual patient.

    Research design: The article is structured looking at two primary strategies: patient exit (leaving a healthcare provider) and patient voice (expressing grievances), derived from Hirschman (1970). These strategies were explored by the use of theoretical and empirical literature and applied to an individual patient case. The case functions as a pedagogical tool to illustrate and problematize what exit and voice strategies can mean for a single patient.

    Ethical considerations: The patient case is my version of a generalized scenario that is described elsewhere. It does not represent an individual patient’s story, but aims to be realistic and recognizable.

    Findings and conclusion: Based on the existing literature, it is hypothesized that, in their current form, exit and voice strategies have a limited effect on care quality and can come at a price for patients. However, both strategies may be of value to patients and providers. Therefore, the healthcare system could empower patients to engage in action and could further develop ways for providers to effectively use patients’ responses to improve practice and find ways to prevent patients from untoward experiences in healthcare.

  • 47.
    Bucht, Helena
    et al.
    Sunderby sjukhus, Luleå.
    Hall, Birgitta
    Sunderby sjukhus, Luleå.
    Johansson, Ingrid
    Gällivare sjukhus.
    Erlandsson, Sofia
    Samrehab, Oskarshamns sjukhus.
    Tinnert, Agneta
    Habiliterings- och rehabiliteringskliniken (HRK), Länssjukhuset i Kalmar.
    Fränkel, Titti
    Akademikerförbundet SSR.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Kuratorer prioriterar: Tillämpning av den nationella modellen för öppna prioriteringar2013Report (Other academic)
    Abstract [en]

    Since 1997, an ethical platform has been available in Sweden describing the grounds for priority setting in health care. A systematic method, i.e. the National Model for Transparent Prioritisation in Swedish Health Care, is increasingly being used to facilitate implementation of the platform’s principles and intentions. Although many different types of services have tested this model, heretofore no social work services had used the model as grounds for a priority setting process. Hence, the model had been untested in services addressingsocial and psychosocial needs in health care.

    This report aims to inspire and guide mainly medical social workers by describing two concrete examples of how medical social workers have interpreted and applied the national model in their organisations. These examples have been taken from the Kalmar County Council and the Norrbotten County Council, each of which conducted their prioritisation process without being aware of each other. In both instances, the aim was to clarify the roles of medical social workers and ensure optimum utilisation of their expertise. Each process was countywide and included all medical social workers in tertiary care (approximately 20 individuals in each county council) for 1.5 years.

    Initially it was not clear how to describe and categorise the various conditions and interventions to be prioritised (ranked). What became important for the medical social workers ranking was not the illness or injury of the various patient groups, but the psychosocial consequences of illness and injury. In Kalmar County Council they used established classifications, such as the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) and the National Board of Health and Welfare’s Classification of Health Interventions (KVÅ). In Norrbotten County Council they used concepts normally applied in their daily work, which had been accepted by the social work group in an earlier review of social work services. In addition, they classified cases according to the expected duration of the contact.

    To determine the severity level of different conditions, the medical social workers in both county councils used a matrix that had been developed for rehabilitation services in Kalmar County Council, but tested in many different types of services. The matrix describes different aspects regarding severity levels, e.g. impairment of body functions, activity limitations, participation restriction, duration, and risk of not intervening. Moreover, the medical social workers in Kalmar County Council listed complicating factors (e.g. previous trauma) that could further increase the severity levels of different conditions. 

    The patient benefits of social work interventions have been appraised using the same parameters as those used for severity levels – e.g. to what degree does the intervention improve participation? In Kalmar County Council definition of the steps in the patient benefit scale (very high, high, moderate, and low) was worked out and unanimously used.

    Regarding cost effectiveness, medical social workers in both county councils reported that it was not traditional for the individual social worker to consider the cost effectiveness of different interventions in their daily work. During the prioritisation process they discussed the opportunity costs of excluding social work interventions and how the duration and type of social work interventions affect cost effectiveness. Experience in searching for scientific evidence concerning the interventions was also lacking. The medical social workers equipped themselves through various educational activities, but based their assessments mainly on experience-based knowledge and the laws that partially regulate their activities.

    Both services gave high priority to most of the conditions and interventions that medical social workers deal with. One possible reason for this was that low- priority interventions were already being rationed. Another reason could be that unfamiliarity with openly discussing priorities led to caution in differentiating severity levels and patient benefits. However, the priority processes to some degrade crystalised what should receive high and low priority respectively, and what should no longer be included in medical social workers’ tasks.

    In summary, the medical social workers reported that the prioritisation processes had been valuable since they contributed to verbalising and discussing experienced-based knowledge ("tacit knowledge"). They articulated the conditions and interventions they work with daily, which is expected to further improve communication about medical social workers’ tasks, both within health services and with patients and next of kin. Furthermore, the knowledge base for interventions has increased, as has the consensus concerning priorities. Future challenges for members that participated in these two projects include implementing and following up their priorities and patiently continuing to improve the process of priority setting over the long term.

  • 48.
    Buck, Harleah G.
    et al.
    Univ S Florida, FL 33612 USA.
    Strömberg, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Chung, Misook L.
    Univ Kentucky, KY USA.
    Donovan, Kristine A.
    Moffit Canc Ctr, FL USA.
    Harkness, Karen
    McMaster Univ, Canada.
    Howard, Allison M.
    Univ S Florida, FL USA.
    Perkiö Kato, Naoko
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Polo, Randall
    Univ S Florida, FL USA.
    Evangelista, Lorraine S.
    Univ Calif Irvine, CA 92697 USA.
    A systematic review of heart failure dyadic self-care interventions focusing on intervention components, contexts, and outcomes2018In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 77, p. 232-242Article, review/survey (Refereed)
    Abstract [en]

    Background: Having support from an informal carer is important for heart failure patients. Carers have the potential to improve patient self-care. At the same time, it should be acknowledged that caregiving could affect the carer negatively and cause emotional reactions of burden and stress. Dyadic (patient and informal carer) heart failure self-care interventions seek to improve patient self-care such as adherence to medical treatment, exercise training, symptom monitoring and symptom management when needed. Currently, no systematic assessment of dyadic interventions has been conducted with a focus on describing components, examining physical and delivery contexts, or determining the effect on patient and/or carer outcomes. Objective: To examine the components, context, and outcomes of dyadic self-care interventions. Design: A systematic review registered in PROSPERO, following PRISMA guidelines with a narrative analysis and realist synthesis. Data Sources: PubMed, EMBASE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials were searched using MeSH, EMTREE terms, keywords, and keyword phrases for the following concepts: dyadic, carers, heart failure and intervention. Eligible studies were original research, written in English, on dyadic self-care interventions in adult samples. Review methods: We used a two-tiered analytic approach including both completed studies with power to determine outcomes and ongoing studies including abstracts, small pilot studies and protocols to forecast future directions. Results: Eighteen papers - 12 unique, completed intervention studies (two quasi- and ten experimental trials) from 2000 to 2016 were reviewed. Intervention components fell into three groups education, support, and guidance. Interventions were implemented in 5 countries, across multiple settings of care, and involved 3 delivery modes face to face, telephone or technology based. Dyadic intervention effects on cognitive, behavioral, affective and health services utilization outcomes were found within studies. However, findings across studies were inconclusive as some studies reported positive and some non-sustaining outcomes on the same variables. All the included papers had methodological limitations including insufficient sample size, mixed intervention effects and counter-intuitive outcomes. Conclusions: We found that the evidence from dyadic interventions to promote heart failure self-care, while growing, is still very limited. Future research needs to involve advanced sample size justification, innovative solutions to increase and sustain behavior change, and use of mixed methods for capturing a more holistic picture of effects in clinical practice.

  • 49.
    Bukmann Larsen, Pia
    et al.
    Slagelse Hospital, Denmark.
    Storjord, Elin
    Nordland Hospital, Norway; UiT, Norway.
    Bakke, Asne
    Stavanger University Hospital, Norway.
    Bukve, Tone
    Akershus University Hospital, Norway.
    Christensen, Mikael
    Aarhus University Hospital, Denmark.
    Eikeland, Joakim
    Oslo University Hospital, Norway.
    Engeland Haugen, Vegar
    Haukeland Hospital, Norway.
    Husby, Kristin
    Akershus University Hospital, Norway.
    McGrail, Rie
    Aarhus University Hospital, Denmark.
    Meier Mikaelsen, Solveig
    Sykehuset Innlandet, Norway.
    Monsen, Grete
    Noklus, Norway.
    Fogh Moller, Mette
    Herning Hospital, Denmark.
    Nybo, Jan
    Aalborg University Hospital, Denmark.
    Revsholm, Jesper
    Randers Regional Hospital, Denmark.
    Johanne Risoy, Aslaug
    Noklus, Norway; University of Bergen, Norway.
    Skalsvik, Unni Marie
    Nordland Hospital, Norway.
    Strand, Heidi
    Akershus University Hospital, Norway.
    Serrano Teruel, Reyes
    Noklus, Norway.
    Theodorsson, Elvar
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Chemistry.
    The microINR portable coagulometer: analytical quality and user-friendliness of a PT (INR) point-of-care instrument2017In: Scandinavian Journal of Clinical and Laboratory Investigation, ISSN 0036-5513, E-ISSN 1502-7686, Vol. 77, no 2, p. 115-121Article in journal (Refereed)
    Abstract [en]

    Regular measurement of prothrombin time as an international normalized ratio PT (INR) is mandatory for optimal and safe use of warfarin. Scandinavian evaluation of laboratory equipment for primary health care (SKUP) evaluated the microINR portable coagulometer (microINR((R))) (iLine Microsystems S.L., Spain) for measurement of PT (INR). Analytical quality and user-friendliness were evaluated under optimal conditions at an accredited hospital laboratory and at two primary health care centres (PHCCs). Patients were recruited at the outpatient clinic of the Laboratory of Medical Biochemistry, St Olavs University Hospital, Trondheim, Norway (n=98) and from two PHCCs (n=88). Venous blood samples were analyzed under optimal conditions on the STA-R((R))Evolution with STA-SPA+reagent (Stago, France) (Owren method), and the results were compared to capillary measurements on the microINR((R)). The imprecision of the microINR((R)) was 6% (90% CI: 5.3-7.0%) and 6.3% (90% CI: 5.1-8.3) in the outpatient clinic and PHCC2, respectively for INR 2.5. The microINR((R)) did not meet the SKUP quality requirement for imprecision 5.0%. For INR amp;lt;2.5 at PHCC2 and at both levels in PHCC1, CV% was 5.0. The accuracy fulfilled the SKUP quality goal in both outpatient clinic and PHCCs. User-friendliness of the operation manual was rated as intermediate, defined by SKUP as neutral ratings assessed as neither good nor bad. Operation facilities was rated unsatisfactory, and time factors satisfactory. In conclusion, quality requirements for imprecision were not met. The SKUP criteria for accuracy was fulfilled both at the hospital and at the PHCCs. The user-friendliness was rated intermediate.

  • 50.
    Bäckman, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Ett decennium senare: Resursfördelningsprocessen i Landstinget i Östergötland 20122013Report (Other academic)
    Abstract [en]

    For nearly a decade, the Östergötland County Council has been working with prioritization as a basis for allocating resources. However, the process has changed over the years and has become known as the resource allocation process.

    In 2012, the county council’s resource allocation process started with team leaders collecting and ranking proposals from their centres based on what they found to be new needs and interventions requiring additional resources. These proposals were supposed to address interventions estimated to cost at least 2 million Swedish kronor (SEK), and each centre could submit no more than ten proposals. Then, representatives of the various centres were assembled in groups to discuss and arrive at an overall proposal for the county council. Administrators reviewed and processed the proposals, after which politicians on the board of health made decisions on the allocation of new resources. Based on these decisions, the results were incorporated into various agreements and contracts with the county council’s services.

    This is the fifth report on the Ötergöland County Council’s prioritization and resource allocation process. The report describes how the county council addressed resource allocation to meet new needs during 2012. Moreover, the report aims to capture and report on several participants’ experiences and viewpoints regarding the process. The information is based on: observations from county council conferences on resource allocation; interviews with politicians, administrators, and team leaders; and studies of various relevant documents published by the county council regarding the resource allocation process. In summary, the report addresses the following points:

    The motive for county council’s resource allocation process was perceived to be a practical issue, but also focused on creating unity, common understanding, and greater transparency.

    The preconditions affecting the work, i.e. uncertainty about the potential magnitude of supplementary resources and separation of the decisions into temporary one-time funding or fixed increases in framework funding, were seen as both advantages and disadvantages.

    The clarity of the process and its various steps was perceived to be good, but the openness and transparency of the separate components could be greater.

    The directives and instructions guiding the process were perceived as being lucid.

    The changes in the process were viewed to be positive compared to the situation in previous years, e.g. starting the work earlier in the year, adding a kick-off conference day, and including the private-sector providers. However, the separate processing of matters concerning pharmaceuticals during the year was viewed as being negative.

    The roles of the various participants were viewed to be clearly defined; they knew what they were expected to do. Politicians indicated that they should play a more prominent and active role in the process, while the team leaders seemed satisfied with their role.

    The decision-making information for the initial ranking by team leaders was viewed to have improved year after year as the process was repeated. However, variations remained in the quality of the information.

    Internal information and transparency has been a fundamental aim of the process and was viewed to be relatively good.

    External information and transparency, however, has been weak.

    The opportunity for dialogue amongst the various actors was reported to be satisfactory and viewed to function well.

    Continuation of the process was favoured by those interviewed. However, they gave examples of things that should be changed or improved, e.g. increased political transparency and participation, a greater sum to distribute, increased transparency and clarity regarding how the administrative staff process the proposals, and faster processing of certain issues throughout the year.

    The findings of this report will hopefully give readers some insight into the current prioritization and resource allocation process in Östergötland County Council – nearly a decade after the first major county-council-wide prioritization initiative in 2003. The interviewees felt that the county council had achieved its goals, as exemplified by the 2012 resource allocation process.

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