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  • 1.
    Aasa, Mikael
    et al.
    Karolinska Institute.
    Henriksson, Martin
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Dellborg, Mikael
    Gothenburg University.
    Grip, Lars
    Gothenburg University.
    Herlitz, Johan
    Gothenburg University.
    Levin, Lars-Åke
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Svensson, Leif
    Stockholm Prehospital Centre.
    Janzon, Magnus
    Linköping University, Department of Medicine and Health Sciences, Cardiology . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Cardiology.
    Cost and health outcome of primary percutaneous coronary intervention versus thrombolysis in acute ST-segment elevation myocardial infarction-Results of the Swedish Early Decision reperfusion Study (SWEDES) trial2010In: AMERICAN HEART JOURNAL, ISSN 0002-8703, Vol. 160, no 2, 322-328 p.Article in journal (Refereed)
    Abstract [en]

    Background In ST-elevation myocardial infarction, primary percutaneous coronary intervention (PCI) has a superior clinical outcome, but it may increase costs in comparison to thrombolysis. The aim of the study was to compare costs, clinical outcome, and quality-adjusted survival between primary PCI and thrombolysis. Methods Patients with ST-elevation myocardial infarction were randomized to primary PCI with adjunctive enoxaparin and abciximab (n = 101), or to enoxaparin followed by reteplase (n = 104). Data on the use of health care resources, work loss, and health-related quality of life were collected during a 1-year period. Cost-effectiveness was determined by comparing costs and quality-adjusted survival. The joint distribution of incremental costs and quality-adjusted survival was analyzed using a nonparametric bootstrap approach. Results Clinical outcome did not differ significantly between the groups. Compared with the group treated with thrombolysis, the cost of interventions was higher in the PCI-treated group ($4,602 vs $3,807; P = .047), as well as the cost of drugs ($1,309 vs $1,202; P = .001), whereas the cost of hospitalization was lower ($7,344 vs $9,278; P = .025). The cost of investigations, outpatient care, and loss of production did not differ significantly between the 2 treatment arms. Total cost and quality-adjusted survival were $25,315 and 0.759 vs $27,819 and 0.728 (both not significant) for the primary PCI and thrombolysis groups, respectively. Based on the 1-year follow-up, bootstrap analysis revealed that in 80%, 88%, and 89% of the replications, the cost per health outcome gained for PCI will be andlt;$0, $50,000, and $100,000 respectively. Conclusion In a 1-year perspective, there was a tendency toward lower costs and better health outcome after primary PCI, resulting in costs for PCI in comparison to thrombolysis that will be below the conventional threshold for cost-effectiveness in 88% of bootstrap replications.

  • 2.
    Alehagen, Urban
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Cardiology . Östergötlands Läns Landsting, Heart Centre, Department of Cardiology.
    Rahmqvist, Mikael
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics.
    Paulsson, Thomas
    AstraZeneca Sverige AB.
    Levin, Lars-Åke
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics.
    Quality-adjusted life year weights among elderly patients with heart failure2008In: European journal of heart failure, ISSN 1388-9842, Vol. 10, no 10, 1033-1039 p.Article in journal (Refereed)
    Abstract [en]

    Background

    When assessing health-related quality of life (HRQoL) in elderly patients with heart failure (HF), the process of obtaining quality-adjusted life year (QALY) weights is generally complicated and time-consuming.

    Aim

    To evaluate whether information regarding HRQoL and QALY weights can be derived directly from the established and widely used New York Heart Association (NYHA) functional classification system.

    Methods

    NYHA functional status was assessed independently both by the individual patients and by the examining cardiologist in 323 elderly patients with symptoms of HF recruited from primary care. HRQoL was evaluated using the SF-36 questionnaire and a time trade-off (TTO) scenario. The TTO technique generates direct QALY weights.

    Results

    Both the TTO technique and SF-36 values demonstrated a statistically significant correlation with NYHA functional status. The TTO values also correlated with all SF-36 dimensions. Increasing impairment was associated with statistically significant drops in both SF-36 values and TTO-based QALY weights. For patients in NYHA classes I–IV the QALY weights were 0.77, 0.68, 0.61, and 0.50, respectively. Thus in elderly patients, symptoms of HF have a major impact on perceived quality of life.

    Conclusion

    The results of the present study show that QALY weights, an important instrument in the health economic evaluation of treatment strategies, can be derived directly from NYHA classification in elderly HF patients.

  • 3.
    Alstrom, U
    et al.
    University of Uppsala Hospital.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Stahle, E
    University of Uppsala Hospital.
    Svedjeholm, Rolf
    Linköping University, Department of Medical and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Thoracic and Vascular Surgery in Östergötland.
    Friberg, O
    Örebro University Hospital.
    Cost analysis of re-exploration for bleeding after coronary artery bypass graft surgery2012In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 108, no 2, 216-222 p.Article in journal (Refereed)
    Abstract [en]

    Background. Re-exploration for bleeding after cardiac surgery is an indicator of substantial haemorrhage and is associated with increased hospital resource utilization. This study aimed to analyse the costs of re-exploration and estimate the costs of haemostatic prophylaxis. less thanbrgreater than less thanbrgreater thanMethods. A total of 4232 patients underwent isolated, first-time, coronary artery bypass graft (CABG) surgery during 2005-8. Each patient re-explored for bleeding (n = 127) was matched with two controls not requiring re-exploration (n = 254). Cost analysis was based on resource utilization from completion of CABG until discharge. A mean cost per patient for re-exploration was calculated. Based on this, the net cost of prophylactic treatment with haemostatic drugs for preventing re-exploration was calculated. less thanbrgreater than less thanbrgreater thanResults. Patients undergoing re-exploration had higher exposure to clopidogrel before operation, prolonged stays in the intensive care unit, and more blood transfusions than controls. The mean incremental cost for re-exploration was (sic)6290 [95% confidence interval (CI) (sic)3408-(sic)9173] per patient, of which 48% [(sic)3001 (95% CI (sic)249-(sic)2147)] was due to prolonged stay, 31% [(sic)1928 (95% CI (sic)1710-(sic)2147)] to the cost of surgery/anaesthesia, 20% [(sic)1261 (95% CI (sic)1145-(sic)1378)] to the increased number of blood transfusions, and andlt;2% [(sic)100 (95% CI (sic)39-(sic)161)] to the cost of haemostatic drugs. A cost model, at an estimated 50% efficacy for recombinant activated clotting factor VIIa and a 50% expected risk for re-exploration without prophylaxis, demonstrated that to be cost neutral, prophylaxis of four patients needed to result in one avoided re-exploration. less thanbrgreater than less thanbrgreater thanConclusions. The resource utilization costs were substantially higher in patients requiring re-exploration for bleeding. From a strict cost-effectiveness perspective, clinical interventions to prevent haemorrhage might be underutilized.

  • 4.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Eckard, Nathalie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Fixartjänster i Sveriges kommuner: Kartläggning och samhällsekonomisk analys. Regeringsuppdrag2013Report (Other academic)
    Abstract [en]

    This report deals with so called minor home help services. These services are primarily meant for older persons with the aim to prevent injuries caused by falling in domestic environments (ones home). The minor home help services are mostly provided by the municipalities in Sweden, although it is not mandatory to provide these services. The extent of the provision and use of minor home help services has previously not been studied on a national level. The aim of this study was to delineate the minor home help services run by the municipalities in Sweden and further to examine and estimate the societal costs and consequences of providing these services.

    Out of the 290 municipalities in Sweden, 191 (66 %) offer minor home help services to their citizens. The tasks carried out are primarily aimed at preventing falls from furniture such as step stools or ladders, removing items that may cause falls (cords, carpets etc.) and providing an overhaul of injury risks in the home. A few municipalities also offer outdoor services such as removing snow in wintertime. In the majority of the municipalities (58 %) the services are offered free of charge but the user has to pay for the materials, in 32 % the services are completely free of charge and in 9 % of the municipalities an amount is charged for the services. The minor home help services are organized in various ways in the municipalities: the services can be completely run by the municipality where the services are carried out by one or several employed persons, by persons with disabilities (involved in daily activity programmes in the municipality) or by persons involved in work programmes; or the minor home help services can be carried out by the community rescue service or companies paid by the municipality to offer these services to the citizens. There are also organizations with volunteers that carry out minor home help services, these are however not included in the main results since the focus in this report is on municipal minor home help services. Ninety nine municipalities do not offer minor home help services to their citizens. Reasons for this are e.g. economic restraints and low demand.

    Experienced gains with minor home help services from the perspectives of the municipalities are prevention of falls, facilitation of the possibility to remain living in one’s own home, contribution to social wellbeing and being able to offer meaningful work tasks for persons in work programmes or persons with disabilities. Problems that have been brought forward are low demand of the services, problems with providing the target group with information and difficulties to measure the effect on fall injuries.

    A socioeconomic model was constructed for the analysis of costs and consequences of fall injuries. The model includes the large cost items as well as outcomes such as mortality and loss of quality of life when affected by a fall injury. The total direct costs in Sweden for fall injuries has previously been calculated to approximately 5 billion SEK, which includes only the direct costs during the first year of the injury. A calculation exercise was performed and applied to a hypothetical municipality with 50 000 inhabitants. This calculation exercise shows that if only a small amount of falls that lead to serious injuries (fractures) can be prevented by minor home help services, then the costs saved are approximately equivalent to the mean budget of minor home help services with one employed person. Calculations using real data including both costs and effects need to be performed.

  • 5.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Eckard, Nathalie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Sammanfattning. Fixartjänster i Sveriges kommuner: Kartläggning2013Report (Other academic)
    Abstract [sv]

    I föreliggande rapport redovisas ett delresultat från regeringsuppdraget ”Social innovation i vården och omsorgen om de mest sjuka äldre” som VINNOVA fick i mars 2012.

    Under 2012 fick VINNOVA ett regeringsuppdrag ”Social innovation i vården och omsorgen om de mest sjuka äldre”. Regeringen uppdrog åt VINNOVA att i samarbete med universitet och högskolor och i samråd med andra relevanta aktörer vidareutveckla goda exempel kring sociala innovationer. Mer specifikt innebar uppdraget att genomföra ett fördjupat utvecklingsarbete kring sociala innovationer inom boende, lättare servicetjänster, trygghetsskapande insatser och social samvaro. Social innovation är en viktig del av VINNOVAs nya fokus på att stärka innovationskraften i offentlig verksamhet för att underlätta spridning och användning av innovationer inom kommuner, landsting och statliga myndigheter.Social innovation är en åtgärd som syftar till att öka människors välbefinnande genom att identifiera och möta upp sociala behov.

  • 6.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Brodtkorb, Thor-Henrik
    ResearchTriangle Institute (RTI) Health Solutions, Lund.
    Could the choice of patient versus proxy ratings for assessing quality of life in dementia affect resource allocation in health care?2012In: Farmeconomia: Health economics and therapeutic pathways, ISSN 1721-6915, Vol. 13, no 1, 25-31 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The aim of this paper is to demonstrate how the choice of patient versus proxy ratings of patient health-related quality of life (HRQoL) in dementia, for use in cost-effectiveness analyses (CEAs), could potentially affect resource allocation in health care.

    METHODS:A model of Alzheimer’s disease (AD) based on cognitive ability was used to assess the consequences of using HRQoL ratings from either patients themselves or proxies if a new treatment was to be introduced. The model was based on previously published data on costs related to AD stages as well as HRQoL ratings from AD patients and from their caregivers as proxy raters.

    RESULTS:The results show that there can be large differences in the results of the CEAs depending on whether the ratings of patients’ HRQoL were made by the patients themselves or by the proxy. When patient self-ratings of HRQoL were used, the cost/quality-adjusted life year (QALY) gained was much higher as compared to the scenario when proxy ratings were used for the same analysis.

    CONCLUSIONS: The choice of patient self-ratings compared to proxy ratings of patients’ HRQoL can have a substantial effect on the results of CEAs. These differences in results may have an important impact on decision making and, ultimately, on resource allocation. In order to critically appraise the results of CEA studies in dementia we advise that both patient and proxy ratings are used in the CEA. To decide on methodology it is of great importance that focus is directed towards determining the most valid way to measure HRQoL in AD.

  • 7.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kalkan, Almina
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Preferenser och perspektiv vid beräkning av QALY2012In: QALY som effektmått inom vården: möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, 15-29 p.Chapter in book (Other academic)
  • 8.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, The Institute of Technology.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Teknik för personer med demens: En utvärderingsstudie av teknikintervention för personer med demenssjukdom och deras närstående2008Report (Other academic)
    Abstract [en]

    The overall aim of this study was to study costs and effects of an assistive technology intervention that included assistive technology, support and strategies for persons with dementia and their relatives. Further, the aim was to study the quality of the intervention process and how it was perceived by the participants in the project.

    This assessment study was performed within a project called “Technology and Dementia – development work, create methods and increase competence”. This project was coordinated by the Swedish Institute of Assistive Technology in collaboration with the Alzheimer Society in Sweden and the Dementia Association and was funded by the Swedish Inheritance Fund, Linköping University and the County Council of Östergötland. Two national resource centres were appointed within the project. These developed the assistive technology intervention.

    The study was designed as a pre/post study. Data was collected at three different occasions of measurement: baseline, first follow-up (four weeks after the intervention) and second follow-up (twelve weeks after the intervention). Different outcome measures were used to study the effect of the intervention: health related quality of life (HRQoL), support/caregiving situation, quality of sleep, perception of time and ability to perform everyday life activities. The costs in the study had a societal perspective. A process oriented instrument was used to study the quality of the intervention process. Persons with dementia as well as their relatives answered questionnaires and interviews in the study.

    Data was collected via interviews at the resource centres, via self ratings and through telephone interviews from the research team. The total population included in the analyses was 48 persons with dementia and 47 relatives.

    The results showed that there were no significant differences in effects between baseline and the two follow-ups, except for ability to perform everyday activities where data indicated deterioration during the study period. In one dimension of HRQoL for the relatives there was also a significant difference; the relatives rated greater difficulties at the second follow-up. Cognitive ability was used as a measure for disease stability during the study, and showed no significant differences. There was, however, a rather large drop-out at the second follow-up (15 %) in data on cognitive ability, therefore this result should be interpreted with caution; the persons with dementia may have deteriorated during the study period. This could be reflected in the deterioration in the ability to perform everyday life activities measure.

    The persons with dementia rated their HRQoL higher than the relatives’ proxy ratings (i.e. relatives’ ratings of the HRQoL of the persons with dementia), the differences between the proxy ratings and the persons’ own ratings were significant at all three occasions of measurement. The relatives rated their own HRQoL somewhat higher than the persons with dementia rated their own HRQoL. There were no significant differences between baseline and the followups.

    The intervention included many different types of assistive technologies. The cost of the intervention was 16 000 SEK/person with dementia and relative. There were no significant differences in costs of formal care during the study period. Many relatives performed informal care many hours of the day. Even though the differences in informal caregiving between baseline and the second follow-up were not significant there was a tendency of a slight increase in informal care time of everyday life activities and there was also a decrease in time spent supervising, a little less than one hour per day.

    An evaluation of the quality of the intervention process and how it was perceived was performed. Most relatives perceived that their needs were well fulfilled during the intervention process. Some aspects were brought forward where the intervention process could be improved. Seventy-two percent of the relatives rated the intervention as of great importance, 28 percent rated the intervention as of some importance or of no importance. The persons with dementia had higher expectations on the intervention than the relatives and most persons with dementia perceived the intervention as of great importance.

    Technology and Dementia was a trial project where potential effects and costs were studied. The study was explorative and contributes to increasing the knowledge on use of assistive technology in dementia and also on assessment methodology within this field. There were limitations in the study regarding size of the study population and lack of a comparison group.

    Assessing assistive technology for persons with dementia and their relatives from a socioeconomic perspective entails certain methodological challenges. A model for assessment of assistive technology interventions was developed and tried in this study. Results and methodology are discussed in relation to the assessment model. From this assessment study, areas have been identified for future studies. Future studies will be performed through subgroup analyses to identify groups where the intervention was successful and groups where the intervention was not successful.

     

  • 9.
    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, 656-663 p.Article 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.

  • 10.
    Andersson, Agneta
    et al.
    Linköping University, Department of Medicine and Health Sciences. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Emtinger, Bengt Göran
    The economic burden of informal care2002In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, Vol. 18, no 1, 46-54 p.Article in journal (Refereed)
    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.

  • 11.
    Andersson, Agneta
    et al.
    Linköping University, Department of Medicine and Health Sciences. Linköping University, Faculty of Health Sciences.
    Ström, K.
    Brodin, H.
    Alton, M.
    Boman, G.
    Jakobsson, P.
    Lindberg, A.
    Uddenfeldt, M.
    Walter, H.
    Levin, Lars-Åke
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Domiciliary liquid oxygen versus concentrator treatment in chronic hypoxaemia: a cost-utility analysis1998In: European Respiratory Journal, ISSN 1399-3003, Vol. 12, no 6, 1284-1289 p.Article in journal (Refereed)
    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.

  • 12.
    Andersson, David
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Brodtkorb, Thor-Henrik
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Tinghög, Gustav
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    DESCRIBING AND COMPARING HEALTH-RELATED QUALITY OF LIFE DERIVED FROM EQ-5D AND SF-6D IN A SWEDISH GENERAL POPULATION in VALUE IN HEALTH, vol 13, issue 7, pp A240-A2402010In: VALUE IN HEALTH, Blackwell Publishing Ltd , 2010, Vol. 13, no 7, A240-A240 p.Conference paper (Refereed)
    Abstract [en]

    n/a

  • 13.
    Andersson, Swen-Olof
    et al.
    Orebro University Hospital.
    Andren, Ove
    Orebro University Hospital.
    Lyth, Johan
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Stark, Jennifer R
    Brigham and Womens Hospital.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Adami, Hans-Olov
    Harvard University.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Johansson, Jan-Erik
    Orebro University Hospital.
    Managing localized prostate cancer by radical prostatectomy or watchful waiting: Cost analysis of a randomized trial (SPCG-4)2011In: SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY, ISSN 0036-5599, Vol. 45, no 3, 177-183 p.Article in journal (Refereed)
    Abstract [en]

    Objective. The cost of radical prostatectomy (RP) compared to watchful waiting (WW) has never been estimated in a randomized trial. The goal of this study was to estimate long-term total costs per patient associated with RP and WW arising from inpatient and outpatient hospital care. Material and methods. This investigation used the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) trial, comparing RP to WW, and included data from 212 participants living in two counties in Sweden from 1989 to 1999 (105 randomized to WW and 107 to RP). All costs were included from randomization date until death or end of follow-up in July 2007. Resource use arising from inpatient and outpatient hospital costs was measured in physical units and multiplied by a unit cost to come up with a total cost per patient. Results. During a median follow-up of 12 years, the overall cost in the RP group was 34% higher (p andlt; 0.01) than in the WW group, corresponding to euroa,not sign6123 in Sweden. The difference was driven almost exclusively by the cost of the surgical procedure. The cost difference between RP and WW was two times higher among men with low (2--6) than among those with high (7--10) Gleason score. Conclusion. In this economic evaluation of RP versus WW of localized prostate cancer in a randomized study, RP was associated with 34% higher costs. This difference, attributed exclusively to the cost of the RP procedure, was not overcome during extended follow-up.

  • 14.
    Andrews, Johanna Y.
    et al.
    Karolinska Institute.
    Dalal, Koustuv
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences.
    Umbilical cord-cutting practices and place of delivery in Bangladesh2011In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 114, no 1, 43-46 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate place of delivery, umbilical cord-cutting instruments used, and substances applied to the cord stump in Bangladesh. Methods: A cross-sectional data analysis was performed on a nationally representative sample of 4925 women of reproductive age (15-49 years) with at least 1 child. Results: More than 80% of women delivered at home. In 6% of cases, blades from a clean-delivery kit (CDK) were used to cut the cord; in 90% of cases, the blades used were from another source; in 4% of cases, other instruments such as bamboo strips and scissors were used to cut the cord. In 51% of cases, a substance (e.g. antibiotic powder/ointment, alcohol/spirit, mustard oil with garlic, boric powder, turmeric, and chewed rice) was applied to the stump after the cord was cut. Conclusion: The present findings underscore the need for further advocacy, availability, and use of cord-cutting instruments from CDKs, especially for deliveries that occur outside healthcare facilities.

  • 15.
    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.

  • 16.
    Aremu, Olatunde
    et al.
    Karolinska Institutet.
    Lawoko, Stephen
    Karolinska Institutet.
    Dalal, Koustuv
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Department of Medical and Health Sciences, Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences.
    Neighborhood socioeconomic disadvantage, individual wealth status and patterns of delivery care utilization in Nigeria: a multilevel discrete choice analysis2011In: International Journal of Women's Health, ISSN 1179-1411, Vol. 3, 167-174 p.Article in journal (Refereed)
    Abstract [en]

    Background: High maternal mortality continues to be a major public health problem in most part of the developing world, including Nigeria. Understanding the utilization pattern of maternal healthcare services has been accepted as an important factor for reducing maternal deaths. This study investigates the effect of neighborhood and individual socieconomic position on the utilization of different forms of place of delivery among women of reproductive age in Nigeria.

    Methods: A population-based multilevel discrete choice analysis was performed using the most recent populationbased 2008 Nigerian Demographic and Health Surveys data of women aged between 15 and 49 years. The analysis was restriced to 15,162 ever-married women from 888 communities across the 36 states of the federation including the Federal Capital Territory of Abuja.

    Results: The choice of place to deliver varies across the socioeconomic strata. The results of the multilevel discrete choice models indicate that with every other factor controlled for, the household wealth status, women's occupation, women's and partner's high level of education attainment, and possession of health insurance were associated with use of private and government health facilities for child birth relative to home delivery. The results also show that higher birth order and young material age were associated with use of home delivery. Living in a highly socioeconomic disadvantaged neighborhood is associated with home birth compared with the patronage of government health facilities. More specifically, the result revealed that choice of facility-based delivery is clustered around the neighborhoods.

    Conclusion: Home delivery, which cuts across all socioeconomic strata, is a common practice among women in Nigeria. Initatives that would encourage the appropriate use of healthcare facilities at little or no cost to the most disadvantaged should be accorded the utmost priority.

     

  • 17.
    Aremu, Olatunde
    et al.
    Karolinska Institute.
    Lawoko, Stephen
    Karolinska Institute.
    Moradi, Tahereh
    Karolinska Institute.
    Dalal, Koustuv
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Socio-economic determinants in selecting childhood diarrhoea treatment options in Sub-Saharan Africa: A multilevel model2011In: ITALIAN JOURNAL OF PEDIATRICS, ISSN 1720-8424, Vol. 37, no 13Article in journal (Refereed)
    Abstract [en]

    ackground: Diarrhoea disease which has been attributed to poverty constitutes a major cause of morbidity and mortality in children aged five and below in most low-and-middle income countries. This study sought to examine the contribution of individual and neighbourhood socio-economic characteristics to caregivers treatment choices for managing childhood diarrhoea at household level in sub-Saharan Africa. less thanbrgreater than less thanbrgreater thanMethods: Multilevel multinomial logistic regression analysis was applied to Demographic and Health Survey data conducted in 11 countries in sub-Saharan Africa. The unit of analysis were the 12,988 caregivers of children who were reported to have had diarrhoea two weeks prior to the survey period. less thanbrgreater than less thanbrgreater thanResults: There were variability in selecting treatment options based on several socioeconomic characteristics. Multilevel-multinomial regression analysis indicated that higher level of education of both the caregiver and that of the partner, as well as caregivers occupation were associated with selection of medical centre, pharmacies and home care as compared to no treatment. In contrast, caregivers partners occupation was negatively associated with selection medical centre and home care for managing diarrhoea. In addition, a low-level of neighbourhood socio-economic disadvantage was significantly associated with selection of both medical centre and pharmacy stores and medicine vendors. less thanbrgreater than less thanbrgreater thanConclusion: In the light of the findings from this study, intervention aimed at improving on care seeking for managing diarrhoea episode and other childhood infectious disease should jointly consider the influence of both individual SEP and the level of economic development of the communities in which caregivers of these children resides.

  • 18.
    Arvidsson, Eva
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Patients' attitudes to priority setting in Primary Health Care: Can patients accept scarce resources?: Who should make prioritizations?2006In: 6th International Conference on Priorities in Health Care, Toronto, 2006Conference paper (Other academic)
  • 19.
    Arvidsson, Eva
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics.
    Three concepts Swedish GPs and district nurses find useful and a good base for prioritising2008In: 7th International Conference on Priorities in Health Care,2008, 2008Conference paper (Other academic)
  • 20.
    Arvidsson, Eva
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics.
    Ett dilemma vid prioritering i primärvården: Hur ska man prioritera något som inte inträffat?2008In: Läkarstämman,2008, 2008Conference paper (Other academic)
  • 21.
    Arvidsson, Eva
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Hur tänker patienter och personal vid prioriteringar i primärvården? (föredrag)2010Conference paper (Refereed)
  • 22.
    Arvidsson, Eva
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Priority Setting and Rationing in Primary Health Care2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

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

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

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

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

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

    List of papers
    1. Day-to-day Rationing of Limited Resources in Swedish routine Primary Care: an interview study
    Open this publication in new window or tab >>Day-to-day Rationing of Limited Resources in Swedish routine Primary Care: an interview study
    Show others...
    2013 (English)Manuscript (preprint) (Other academic)
    Abstract [en]

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

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

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

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

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

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

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

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

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

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

    Available from: 2013-01-28 Created: 2013-01-28 Last updated: 2013-03-22
    4. Priority setting in primary health care - dilemmas and opportunities: a focus group study
    Open this publication in new window or tab >>Priority setting in primary health care - dilemmas and opportunities: a focus group study
    2010 (English)In: BMC FAMILY PRACTICE, ISSN 1471-2296, Vol. 11, no 71Article in journal (Refereed) Published
    Abstract [en]

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

    Place, publisher, year, edition, pages
    BioMed Central, 2010
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-61207 (URN)10.1186/1471-2296-11-71 (DOI)000283116400001 ()
    Note
    Original Publication: Eva Arvidsson, Malin André, Lars Borgquist and Per Carlsson, Priority setting in primary health care - dilemmas and opportunities: a focus group study, 2010, BMC FAMILY PRACTICE, (11), 71. http://dx.doi.org/10.1186/1471-2296-11-71 Licensee: BioMed Central http://www.biomedcentral.com/ Available from: 2010-11-05 Created: 2010-11-05 Last updated: 2013-01-29
  • 23.
    Arvidsson, Eva
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Andre, Malin
    Uppsala University, Sweden .
    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 the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland.
    Andersson, David
    Linköping University, Department of Management and Engineering, Business Administration. Linköping University, The Institute of Technology.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Setting priorities in primary health care - on whose conditions? A questionnaire study2012In: BMC Family Practice, ISSN 1471-2296, Vol. 13, no 114Article in journal (Refereed)
    Abstract [en]

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

  • 24.
    Arvidsson, Eva
    et al.
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    André, Malin
    Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Borgquist, Lars
    Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland.
    Carlsson, Per
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Priority setting in primary health care - dilemmas and opportunities: a focus group study2010In: BMC FAMILY PRACTICE, ISSN 1471-2296, Vol. 11, no 71Article in journal (Refereed)
    Abstract [en]

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

  • 25.
    Arvidsson, Eva
    et al.
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    André, Malin
    Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Borgquist, Lars
    Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland.
    Lindström, Kjell
    Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Primary care patients' attitudes to priority setting in Sweden.2009In: Scandinavian journal of primary health care, ISSN 1502-7724, Vol. 27, no 2, 123-8 p.Article in journal (Refereed)
    Abstract [en]

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

  • 26.
    Arvidsson, Eva
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    André, Malin
    Linköping University, Department of Medical and Health Sciences, General Practice. Linköping University, Faculty of Health 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 the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland.
    Mårtensson, Jan
    Department of Nursing, School of Health and Sciences, Jönköping, Sweden.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Day-to-day Rationing of Limited Resources in Swedish routine Primary Care: an interview study2013Manuscript (preprint) (Other academic)
    Abstract [en]

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

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

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

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

  • 27.
    Bartha, Erzsebet
    et al.
    Karolinska Institute, CLINTEC, Div of Anaesthesiology.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Brodtkorb, Thor-Henrik
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kalman, Sigridur
    Karolinska Institute, CLINTEC, Div of Anasthesiology.
    Optimization of circulation by fluid treatment of elderly patients with hip fracture (oral presentation): Cost-effectiveness and value of information analysis2011Conference paper (Refereed)
  • 28.
    Bartha, Erzsebet
    et al.
    Karolinska Institute, CLINTEC, Div of Anesthesiology.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Hommel, Ami
    Lund University, Dept of Health Sciences.
    Thorngren, Karl-Göran
    Lund University Hospital, Dept of Orthopedics.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kalman, Sigridur
    Karolinska Institute, CLINTEC, Div of Anestesiology.
    Cost-effectiveness Analysis of Goal-directed Hemodynamic Treatment of Elderly Hip Fracture Patients: Before Clinical Research Starts2012In: Anesthesiology, ISSN 0003-3022, E-ISSN 1528-1175, Vol. 117, no 3, 519-530 p.Article in journal (Refereed)
    Abstract [en]

    Background: Health economic evaluations are increasingly used to make the decision to adopt new medical interventions. Before such decisions, various stakeholders have invested in clinical research. But health economic factors are seldom considered in research funding decisions. Cost-effectiveness analysis could be informative before the launch of clinical research projects, particularly when a targeted intervention is resource-intensive, total cost for the trial is very high, and expected gain of health benefits is uncertain. This study analyzed cost-effectiveness using a decision analytic model before initiating a large clinical research project on goal-directed hemodynamic treatment of elderly patients with hip fracture.

    Methods: A probabilistic decision analytic cost-effectiveness model was developed; the model contains a decision tree for the postoperative short-term outcome and a Markov structure for long-term outcome. Clinical effect estimates, costs, health-related quality-of-life measures, and long-term survival constituted model input that was extracted from clinical trials, national databases, and surveys. Model output consisted of estimated medical care costs related to quality-adjusted life-years.

    Results: In the base care analysis, goal-directed hemodynamic treatment reduced average medical care costs by €1,882 and gained 0.344 qualilty-adjusted life-years. In 96.5% of the simulations, goal-directed hemodynamic treatment is less costly and provides more quality-adjusted life-years. The results are sensitive to clinical effect size variations, although goal-directed hemodynamic treatment seems to be cost-effective even with moderate clinical effect.

    Conclusion: This study demonstrates that cost-effectiveness analysis is feasible, meaningful, and recommendable before launch of costly clinical research projects.

  • 29.
    Bendtsen, Preben
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Acute Health Care. Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Department of Medical Specialist.
    Karlsson, Nadine
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Department of Medical and Health Sciences, Work and Rehabilitation. Linköping University, Faculty of Health Sciences.
    Dalal, Koustuv
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences.
    Hazardous Drinking Concepts, Limits and Methods: Low Levels of Awareness, Knowledge and Use in the Swedish Population.2011In: Alcohol and Alcoholism, ISSN 0735-0414, E-ISSN 1464-3502, Vol. 46, no 5, 638-645 p.Article in journal (Refereed)
    Abstract [en]

    Aims: To investigate the awareness and knowledge of hazardous drinking limits among the general population in Sweden and the extent to which people estimate their alcohol consumption in standard drinks to assess their level of drinking.

    Methods: A population-based study involving 6000 individuals selected from the total Swedish population was performed. Data were collected by means of a postal questionnaire. The mail survey response rate was 54.3% (n = 3200) of the net sample of 5891 persons.

    Results: With regard to drinking patterns, 10% of the respondents were abstainers, 59% were sensible drinkers and 31% were classified as hazardous drinkers. Most of the abstainers (80%), sensible drinkers (64%) and hazardous drinkers (56%) stated that they had never heard about the standard drink method. Familiarity with the hazardous drinking concept also differed between the three categories although ∼61% of sensible and hazardous drinkers expressed awareness of the concept (46% of the abstainers). Knowledge about the limits for sensible drinking was very poor. Between 94 and 97% in the three categories did not know the limit. There was a statistically significant association between having visited health care within the last 12 months and being aware of the standard drink method and the hazardous drinking concept, but not with knowing the hazardous drinking limits. Similarly, there was a significant association between having had at least one alcohol conversation in health care within the last 12 months and being aware of the standard drink method and the hazardous drinking concept, but not with knowing the hazardous drinking limits.

    Conclusion: The results can be seen as a major challenge for the health-care system and public health authorities because they imply that a large proportion of the Swedish population does not know when alcohol consumption becomes a threat to their health. The current strategy to disseminate knowledge about sensible drinking limits to the population through the health-care system seems to have failed and new means of informing the population are warranted.

  • 30.
    Bendtsen, Preben
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Acute Health Care. Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Department of Medical Specialist.
    McCambridge, Jim
    London School of Hygiene and Tropical Medicine, United Kingdom.
    Bendtsen, Marcus
    Linköping University, Department of Computer and Information Science, Human-Centered systems. Linköping University, The Institute of Technology.
    Karlsson, Nadine
    Linköping University, Department of Medical and Health Sciences, Work and Rehabilitation. Linköping University, Faculty of Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Effectiveness of a proactive mail-based alcohol Internet intervention for university students: dismantling the assessment and feedback components in a randomized controlled trial2012In: Journal of Medical Internet Research, ISSN 1438-8871, Vol. 14, no 5Article in journal (Refereed)
    Abstract [en]

    Background: University students in Sweden routinely receive proactive mail-based alcohol Internet interventions sent from student health services. This intervention provides personalized normative feedback on alcohol consumption with suggestions on how to decrease drinking. Earlier feasibility trials by our group and others have examined effectiveness in simple parallel-groups designs.Objective: To evaluate the effectiveness of electronic screening and brief intervention, using a randomized controlled trial design that takes account of baseline assessment reactivity (and other possible effects of the research process) due to the similarity between the intervention and assessment content. The design of the study allowed for exploration of the magnitude of the assessment effects per se.Methods: This trial used a dismantling design and randomly assigned 5227 students to 3 groups: (1) routine practice assessment and feedback, (2) assessment-only without feedback, and (3) neither assessment nor feedback. At baseline all participants were blinded to study participation, with no contact being made with group 3. We approached students 2 months later to participate in a cross-sectional alcohol survey. All interventions were fully automated and did not have any human involvement. All data used in the analysis were based on self-assessment using questionnaires. The participants were unaware that they were participating in a trial and thus were also blinded to which group they were randomly assigned.Results: Overall, 44.69% (n = 2336) of those targeted for study completed follow-up. Attrition was similar in groups 1 (697/1742, 40.01%) and 2 (737/1742, 42.31% retained) and lower in group 3 (902/1743, 51.75% retained). Intention-to-treat analyses among all participants regardless of their baseline drinking status revealed no differences between groups in all alcohol parameters at the 2-month follow-up. Per-protocol analyses of groups 1 and 2 among those who accepted the email intervention (36.2% of the students who were offered the intervention in group 1 and 37.3% of the students in group2 ) and who were risky drinkers at baseline (60.7% follow-up rate in group 1 and 63.5% in group 2) suggested possible small beneficial effects on weekly consumption attributable to feedback.Conclusions: This approach to outcome evaluation is highly conservative, and small benefits may follow the actual uptake of feedback intervention in students who are risky drinkers, the precise target group.Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 24735383; http://www.controlled-trials.com/ISRCTN24735383 (Archived by WebCite at http://www.webcitation.org/6Awq7gjXG)

  • 31.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Hälsoekonomiska utvärderingar: Vad menas och hur gör man?2009Report (Other academic)
    Abstract [en]

    Health economic assessment is a tool for estimating cost-effectiveness ofresource uses in health care. Information on cost-effectiveness constitutes onepart of the foundation on which priority setting decisions are made, in order tomake the best possible use of available resources.

    The aim of this report is to describe the methods, meaning, and implications ofhealth economic assessments. Methodological issues are discussed, and thereport is formulated to reflect the standpoints of health economists working at CMT.

    The theoretical foundation of health economic assessments is in welfare theory,prescribing a societal perspective of the analyses. A societal perspectiveprescribes that all relevant costs and effects are to be included in the analysis.Direct costs are dominated by the use of health care resources and indirect costsmainly consist of production losses, due to the fact that unhealthy people areunable to perform their work. The theory also prescribes that resourcesconsumed are to be valued according to the opportunity cost approach, i.e. thevalue of a resource in its best alternative use. In practice health economicassessments contain some deviations from what is prescribed by welfare theory,for instance when it comes to costing it is often necessary to settle with rougherestimates.

    Below are examples of questions that are dealt with in this report:

    • What theoretical foundation should form the basis of our analyses?
    • What perspective should be taken in the analysis, that of the society orthat of the health care sector?
    • Should costs associated with informal care be included in the analysis,and if so how should they be valued?
    • How should costs associated with production losses be valued?
    • Should costs of added life years be included in the analysis?
    • What alternative ways are there for measuring quality of life (QALYweights),and which of these is the most appropriate?
    • Which level of discount rate should be used in analyses stretching overlonger times than one year?

    Further questions related to the analysis are described, such as the appropriatetime-frame of the analysis, simulation of future costs and consequences, andsensitivity analyses.

  • 32.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    QALY som effektmått inom vården: Möjligheter och begränsningar2012Report (Other academic)
    Abstract [en]

    As health care resources are finite priorities are necessary in order to attain an optimal use of resources. To support priority setting an increasing number of health economic assessments are undertaken, in which costs for different treatment strategies are compared to the positive effects on health/quality of life that they result in. These positive effects are often expressed as quality adjusted life years (QALYs) and the result of a health economic assessment is expressed as a cost per QALY gained. However, it is not self-evident what a QALY stands for as it can be measured and calculated in different ways.

    This report is dedicated to QALY with respect to what it means, what it is meant to represent, how it is measured, theoretical and methodological problems, and possible alternative procedures. The purpose of the report is furthermore to identify interesting and relevant research questions regarding QALY and the measurement of health care effects.

    The report starts with an introductory chapter putting the QALY-approach into context through a background and theoretical basis. Then prospect theory is briefly outlined. Prospect theory was launched as a critique against the basis of the traditional QALY-approach (i.e. the expected utility theory) and might constitute a possible alternative approach for measuring effects in health care. Chapter 2 describes from which perspectives QALY-weights can be measured and the significance of choice of perspective to the result. By perspective is here mainly meant who should be asked for how good or bad a state of ill health is, affected patients or representatives of the public? In chapter 3 methods for measuring and valuing QALY-weights are described. Both direct and indirect methods are explained. Methodological problems are described and pros and cons of different methods are discussed together with expected differences in results. Chapter 4 is dedicated to the special issues of negative QALY-weights, i.e. health states worse than death, and valuation of temporary health states. Methods for measuring QALY-weights in these situations and its methodological problems are discussed. In chapter 5 the QALY-approach is put into context by relating it to the concept of fairness. Issues discussed are for instance whether the QALY-approach is compatible with a fair distribution of resources and if fairness should be taken into account or not in the QALYapproach. In chapter 6 the QALY-approach is linked to theories of happiness. Might theories of happiness enrich the traditional health economic approach? Can theories of happiness contribute to better methods for measuring health care outcomes, i.e. what we usually call QALY? The report is closed with a discussion leading to interesting and important research questions.

  • 33.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Fernell, Elisabeth
    Astrid Lindgrens barnsjukhus, Karolinska universitetssjukhuset.
    Hur påverkas vardagslivet av ADHD och närliggande funktionsnedsättningar?: Analys och sammanfattning av en enkätstudie riktad till Riksförbundet Attentions medlemmar2005Report (Other academic)
  • 34.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Bakgrund till QALY som effektmått2012In: QALY som effektmått inom vården: möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, 3-14 p.Chapter in book (Other academic)
  • 35.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Nordfeldt, Sam
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    ADHD from a socio-economic perspective2008In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 97, no 2, 239-245 p.Article, review/survey (Refereed)
    Abstract [en]

    Aim: Attention deficit hyperactivity disorder (ADHD) and related disorders affect children's ability to function in school and other environments. Awareness has increased in recent years that the same problems often persist in adulthood. Based on previous studies, we aimed to outline and discuss a descriptive model for calculation of the societal costs associated with ADHD and related disorders. Methods: Following a literature review including childhood and adult studies, long-term outcomes of ADHD and associated societal costs were outlined in a simple model. Results: The literature concerning long-term consequences of ADHD and related disorders is scarce. There is some evidence regarding educational level, psychosocial problems, substance abuse, psychiatric problems and risky behaviour. The problems are likely to affect employment status, healthcare consumption, traffic and other accidents and criminality. A proposed model structure includes persisting problems in adulthood, possible undesirable outcomes (and their probabilities) and (lifetime) costs associated with these outcomes. Conclusions: Existing literature supports the conclusion that ADHD and related disorders are associated with a considerable societal burden. To estimate that burden with any accuracy, more detailed long-term data are needed. © 2007 The Author(s).

  • 36.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Allergy Centre UHL.
    Nyström Kronander, Ulla
    Östergötlands Läns Landsting, Heart and Medicine Centre, Allergy Centre UHL.
    Allergenspecifik immunoterapi vid behandling av allergisk rinit: Behandlingseffekter, kostnader och kostnadseffektivitet2012Report (Other academic)
    Abstract [sv]

    Prevalensen av allergier har skattats till omkring 20 % i Sverige. Allergisk rinit är vanligast bland unga vuxna och prevalensen är högre i länder med hög levnadsstandard. På individnivå har miljön i tidig barndom stor betydelse för utveckling av allergier senare i livet. Symtomen förknippade med allergisk rinit ger upphov till nedsatt livskvalitet, vårdkostnader, och produktionsförluster till följd av sjukskrivningar.

    Tidigare fanns endast symtomlindrande behandlingar att tillgå, men på senare år har sjukdomsmodifierande behandlingar lanserats. Dessa består av allergenspecifika immunoterapier (ASIT) som bygger på en successivt ökad tillvänjning av allergenextrakt för att skapa immunitet. ASIT kan bestå av subkutan immunoterapi (SCIT) eller sublingual immunoterapi (SLIT). Det finns läkemedel av detta slag som ingår i den svenska läkemedelsförmånen, men med begränsningen att de får förskrivas endast när bästa möjliga symtomdämpande behandling inte ger ett tillfredsställande resultat. Syftet med denna rapport var att genom en litteraturgenomgång undersöka vilken evidens som finns för klinisk effekt, inverkan på kostnader, samt kostnadseffektivitet av ASIT jämfört med enbart symtomatisk behandling vid allergisk rinit. Litteraturgenomgången utgjorde sedan grund för en bedömning av behovet av att genomföra en svensk kostnadseffektstudie.

    Vad gäller klinisk effekt av ASIT jämfört med symtomatisk behandling hittades flera studier av såväl SCIT som SLIT. Studierna visade genomgående på signifikanta förbättringar jämfört med symtomatisk behandling med avseende på symtom, livskvalitet, och behov av symtomatisk medicinering. Även vårdkostnader andra än de för symtomatisk behandling är lägre med ASIT.

    Kostnadseffektiviteten av ASIT har analyserats i flera studier gällande europeiska förhållanden. I ett par av dessa studier har även svenska förhållanden studerats specifikt. Samtliga publicerade studier fann att kostnadseffektiviteten av ASIT var god, med kostnader per QALY under 200 000 kronor om bara direkta kostnader beaktas och betydligt lägre kostnader per QALY om även indirekta kostnader beaktas. Dessa resultat bekräftas i ett räkneexempel utifrån kända fakta som avslutar denna rapport.

    Sammantaget talar publicerade vetenskapliga studier enhälligt för att ASIT, jämfört med enbart symtomatisk behandling, är en kostnadseffektiv behandling. Det finns ingen anledning att tro att denna slutsats skulle förändras av att genomföra en kostnadseffektstudie under svenska förhållanden. Vid en sådan studie bör extra fokus ligga på att utreda effekter på livskvalitet (QALYs) och produktionsförluster.

  • 37.
    Berterö, Carina
    et al.
    Linköping University, Department of Medicine and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Lundgren, Fredrik
    Linköping University, Department of Medicine and Health Sciences, Physiology . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
    The Lived Experience of 65-year-old Men Being Screened for Abdominal Aortic aneurysm; a Short-Term Perspective2009In: PRO-Newsletter, no 41, 1-5 p.Article in journal (Refereed)
    Abstract [en]

    The purpose was to investigate whether screening for abdominal aortic aneurysm and the finding of an enlarged aorta in those men causes worries and affects the life-situation. Men at the age of 65 years were invited to ultrasound screening and they who had an enlarged aorta (≥30 mm), were invited for a qualitative interview analyzed by interpretive phenomenological method. Totally 11 men were interviewed. Three themes were identified: be under superintendence; affected, but live as usual; and hereditariness leading to fatalism. Although not unaffected by the screening result the men carry on with their life as usual. However, the need for a long term study to confirm the results is now in accomplishment.

  • 38.
    Berterö, Carina
    et al.
    Linköping University, Department of Medicine and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Lundgren, Fredrik
    Linköping University, Department of Medicine and Health Sciences, Physiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Cardiology.
    Screening for abdominal aortic aneurysm, a one-year follow up: An interview study2010In: Journal of Vascular Nursing, ISSN 1062-0303, E-ISSN 1532-6578, Vol. 28, no 3, 97-101 p.Article in journal (Refereed)
    Abstract [en]

    The purpose of the present study was to investigate whether screening for abdominal aortic aneurysm (AAA) and the finding of an enlarged aorta cause worries and affect the living situations of men with aneurysms or of their families within a 12-month follow-up period. Men invited to ultrasound screening and having an enlarged aorta (>/=30 mm) were invited for an interview. In total, 10 men were interviewed. The semi-structured interview was conducted by using an interview guide. Data was analyzed by using an interpretative phenomenological method. Three themes were identified: (i) feeling secure being under superintendence; (ii) living as usual, but repressing thoughts; and (iii) feeling disillusionment due to negative outcome. Being given the message that an enlarged aorta was discovered at the screening was manageable; hence, continuing growth of the aorta led to some unpleasant feelings. The men were living as usual; however, they all had some reflections about having an AAA and that something could happen when they least expected it. They reported thoughts about the consequences of the enlarged aorta itself and the surgery. In a one-year retrospective interview, men who have had an aneurysm detected in a screening program for AAA reported feeling secure being under superintendence. The one finding in our study concerning worries and effects on life situation could be interpreted as disillusionment due to negative outcomes. Decisions to introduce screening for AAA in Sweden and other countries with ongoing programs should be considered to include guidelines for how to handle disillusionment.

  • 39.
    Bistoletti, Peter
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Sennfält, Karin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    En hälsoekonomisk modellstudie av primärscreening mot livmoderhalscancer med cellprov- och HPV DNA-test2008Report (Other academic)
    Abstract [en]

    Title: A modelling study of the cost-effectiveness of primary cytology and HPV DNA cervical cancer screening (En hälsoekonomisk modellstudie av primärscreening mot livmoderhalscancer med cellprov och HPV DNA-test)

    Organisation: Center for Medical Technology Assessment, Department of Medical and Health Sciences, Linköping university, S- 581 83 Linköping, Sweden.

    Contact person: Peter Bistoletti, peterbistoletti@yahoo.com.

    Language: Swedish

    Publication type: Health Technology Assessment report

    Technology type: Screening

    Objectives: The general objective of this report was to assess the costeffectiveness of different cervical cytology screening strategies with and without HPV DNA-testing in primary cervical cancer screening. Four strategies were compared: 1) cervical cytology screening at age 32, 35, 38, 41, 44, 47, 50, 55 and 60, 2) same strategy with addition of testing for HPV DNA persistence at age 32, 3) screening with combined cytology and HPV DNA-testing at age 32, 41 and 50, 4) no screening

    Methods: Input data were derived from a population-based HPV screening trial, from population-based screening registries and health service costs. A probabilistic Markov model was used to estimate life expectancy and health-care costs per woman during the remaining lifetime.

    Results: Cytology screening between 32-60 years of age in 3-5 year intervals increased life expectancy and life time costs were reduced from 533 to 248 US Dollars per women compared with no screening. Addition of HPV DNA-testing at age 32 increased costs from 248 to 284 US Dollars without benefit on life expectancy. Screening with both cytology and HPV DNA testing at ages 32, 41 and 50 reduced costs from 248 to 210 US Dollars with slightly increased life expectancy.

    Recommendations: Population-based, organized cervical cytology screening between age 32 to 60 in this setting is an effective health care policy which both prevents cervical cancer and can produce overall health care cost savings. If screening intervals are increased to nine years, combined cytology and HPV DNA screening appeared to be at least equally effective and less costly.

  • 40.
    Boman, Kurt
    et al.
    Umeå University, Sweden .
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Gustavsson, Mats
    Primary Health Care Unit, Sweden .
    Olofsson, Mona
    Umeå University, Sweden .
    Renstrom, Gun-Britt
    Skelleftea County Hospital, Sweden .
    Johansson, Lars
    Umeå University, Sweden .
    Telemedicine improves the monitoring process in anticoagulant treatment2012In: Journal of Telemedicine and Telecare, ISSN 1357-633X, Vol. 18, no 6, 312-316 p.Article in journal (Refereed)
    Abstract [en]

    We compared the INR (International Normalized Ratio) monitoring process using a telemedicine device with the conventional approach in which blood samples were sent to the hospital for analysis. We conducted a randomized controlled trial. We enrolled 40 patients on chronic warfarin therapy from two primary healthcare centres (PHCs). Half were monitored using the telemedicine device and half were monitored conventionally. Each patient received three INR measurements. The total processing time was measured from blood sampling until warfarin dosing was performed in the anticoagulant clinic. The median total processing time was significantly shorter with telemedicine than usual care (34 vs. 260 min, P andlt; 0.001). This was mainly because sample transport was avoided using the point-of-care device and automatic data transmission. Telemedicine reduced the total processing time for INR monitoring and has the potential to improve the management of patients undergoing anticoagulant treatment at PHCs.

  • 41.
    Borendal Wodlin, Ninnie
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences.
    Nilsson, Lena
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kjølhede, Preben
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Cost-effectiveness of general anesthesia versus spinal anesthesia in fast track abdominal benign hysterectomy2011In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 205, no 4, 043- p.Article in journal (Refereed)
    Abstract [en]

    Objective: The study objective was to compare total costs for hospital stay and postoperative recovery for two groups of women who underwent fast track abdominal benign hysterectomy, one group under general anesthesia, the other under spinal anesthesia. Costs were evaluated in relation to health related quality of life.

    Study Design: Costs of treatment using data from a randomized multicenter study at five hospitals in Sweden were analyzed retrospectively. Of 180 women scheduled for benign abdominal hysterectomy; 162 were randomized for the study, 80 allocated to general anesthesia and 82 to spinal anesthesia.

    Results: Total costs (hospital costs plus costs reduced productivity costs) were lower for the spinal anesthesia group. Women who had spinal anesthesia had a faster recovery measured by health related quality of life and QALYs gained in postoperative month one.

    Conclusion: Use of spinal anesthesia for fast track benign abdominal hysterectomy was more cost-effective than general anesthesia.

  • 42.
    Brandt, Åse
    et al.
    Dept of Research and Development, Århus, Denmark.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Guest Editorial: Assistive Technology Outcomes Research: Contributions to Evidence-Based Assistive Technology Practice2012In: Technology and Disability, ISSN 1055-4181, Vol. 24, 5-7 p.Article in journal (Other academic)
  • 43.
    Brodtkorb, Thor-Henrik
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Förutsättningar för etablering av en nationell prioriteringskommitté i hälso- och sjukvården: Erfarenheter från andra länder2011Report (Other academic)
    Abstract [sv]

    Syftet med denna studie är att redovisa förutsättningar för en nationell kommitté eller motsvarande för utvärdering och prioritering vid beslut avseende införande av andra sjukvårdsteknologier än läkemedel i hälso- och sjukvården samt att presentera för- och nackdelar med olika lösningar.

    Huvuddelen av underlaget till studien kommer från intervjuer med ett flertal internationella aktörer - för att fånga ett brett faktaunderlag om hur andra länder har agerat i frågan. De länder som har ingått i studien är Australien, England, Kanada, Nederländerna, Norge, Nya Zeeland och Spanien. Utöver intervjuer med nyckelpersoner i respektive land har vi genomfört två workshops med representanter från Nationella samordningsgruppen för kunskapsstyrning. Statliga myndigheter och företrädare för medicintekniska företag har varit inbjudna att delta.

    Vi bedömer att det är realistiskt och motiverat att överväga införande av ett nationellt system för utvärdering och beslut om införande och utmönstring av icke-farmakologiska sjukvårdsteknologier. I ett sådant system förutsätts att beslut fattas av någon typ av nationell prioriteringskommitté eller nämnd, fortsättningsvis i rapporten förkortad NPK.

    Vårt uppdrag har varit att presentera och diskutera olika praktiska och principiella komponenter i ett sådant system. Hur organisationen bör utformas i detalj har vi inte tagit ställning till då frågan ligger utanför vårt uppdrag. I genomgången har vi pekat på fördelar och nackdelar med olika lösningar för de tio komponenter som vi menar utgör byggstenarna för en NPK. Baserat på dessa för- och nackdelar, men utan att ta ställning till organisatoriska eller tidsmässiga aspekter, eller omfattningen på verksamheten, så framträder för oss ett huvudalternativ. Detta huvudalternativ bör diskuteras i relation till alternativa lösningar och preciseras ytterligare.

    Med tanke på att utgångspunkten för denna rapport har varit att undersöka förutsättningar för etablering av en nationell prioriteringskommitté i hälso- och sjukvården, är det också naturligt att vi haft den nationella nivån som utgångspunkt. Varje land vi har undersökt har ett system som är utformat för att passa in i den sjukvårdsstruktur och finansiering som finns i det enskilda landet. Då ansvaret för Sveriges hälso- och sjukvård delas mellan stat och landsting, förefaller det mest adekvat att staten får ansvar för samordning, tillhandahållande av beslutsstöd och kompetens (via myndigheter och kommittéer) och att en NPK formas och drivs av staten tillsammans med sjukvårdshuvudmännen. De sistnämnda har ansvar för att producera och finansiera hälso- och sjukvården. En sådan organisation vore mest i linje med dagens sjukvårdssystem och hur finansieringsansvaret är uppdelat. Alternativet är att bilda ett nationellt organ med enbart företrädare från regioner och landsting. Mot detta talar att statens expertkompetens utnyttjas i lägre grad och att det finns en risk att regionalpolitiska hänsynstaganden kan spela en alltför stor roll.

    Med tanke på att budgetansvaret för att bekosta nya teknologier i hälso- och sjukvården i Sverige i huvudsak ligger på landstingen så förfaller det ologiskt att förorda direkt budgetansvar för NPK. Därmed inte sagt att kostnadsmedvetenhet inte är mycket viktigt i en sådan kommitté. Det bör därför vara en kommitté som kan balansera budgethänsyn med kostnadseffektivitet och rättvis fördelning av resurser.

    De flesta länder strävar mot ett system som är inkluderande när det gäller vilka typer av teknologier som ska ingå i utvärderingarna. De flesta typer av teknologier, både gamla och nya, ter sig därför som aktuella även i Sverige. Samtidigt är det tydligt att det inte går att utvärdera alla teknologier med tanke på den stora arbetsmängd detta skulle leda till. Den svenska branschorganisationen Swedish Medtech uppskattar att det idag finns cirka en halv miljon unika medicintekniska produkter och utifrån detta så förstår vi att inflödet av enbart nya medicintekniska produkter är mycket stort. Dessutom innebär många av dessa endast marginella förändringar jämfört med tidigare teknologier. Vi förespråkar ett system som prioriterar vilka teknologier som ska utvärderas baserat på deras konsekvenser (hälsoeffekt, ekonomisk omfattning, etisk kontrovers etc.) snarare än typ av teknologi eller om den är gammal eller ny. På detta sätt undviks att vissa typer av teknologier får ”fribrev” in isystemet.

    Det finns tre huvudalternativ med tanke på vem som tar fram kunskapsunderlag till utvärderingarna: 1. Enbart företagen; 2. Enbart den beslutande kommittén eller motsvarande; 3. Dessa två kombinerat. Baserat på våra erfarenheter från andra länder och även de återkopplingar vi har fått från referensgruppen tror vi att det vore olyckligt att införa ett system som helt utesluter företagen som uppgiftslämnare. Framför allt kommer NPK i sådana fall att gå miste om dataunderlag som ännu inte är publicerat men som kan vara av stor vikt för besluten. Dock behöver företagsbaserade underlag givetvis granskas av någon oberoende instans innan beslutet fattas.

    Det finns behov av tydliga incitament för att lyfta frågor till utvärdering och beslut. Erfarenheter från Västra Götalandsregionen tyder på att den startfinansieringsmodell som tillämpas där har varit ett lyckat sätt för att få in förslag på teknologier som bör utvärderas. Incitament behöver dock inte alltid vara av ekonomisk art utan kan även vara av administrativ karaktär. Registrering av alla nya teknologier (produkter och procedurer) i ett register innan de får användas skulle kunna bidra till att identifiera kandidater för utvärdering.

    Samtliga länder vi har undersökt har valt att ha flera aktörer involverade i processerna för identifiering, utvärdering, prioritering och beslut angående införande. Flera informanter har även framhållit vikten av att separera den organisation som fattar beslutet från den eller de som tar fram beslutsunderlaget för att öka legitimiteten. Det kan vara administrativt mer komplicerat med två separata organisationer men våra intryck från denna studie tyder på att denna nackdel uppvägs av de fördelar som uppnås.

    Det är en fördel om processerna för identifiering, utvärdering och beslut är så öppna som möjligt. Stor öppenhet i alla steg medför dock en stor arbetsbörda och kostnader. Frågan om öppenhet och medverkan från allmänheten förefaller vara en avvägning mellan tillräcklig grad av sekretess och öppenhet rörande både process och beslut för att uppnå legitimitet. Att vid ett eventuellt införande av NPK starta med en relativt sluten process där enbart besluten redovisas men sedan ha en tydlig ambition och plan för att bli mer öppen i hela processen efter hand kan vara en framkomlig väg. Vi bedömer att den värdegrund och det utvecklingsarbete av öppna prioriteringar som redan pågår i Sverige är av hög relevans för NPK. Vi ser därför inget behov av en särskild värdegrund för NPK, utöver den som blir resultatet av de pågående  prioriteringsdiskussionerna. Det är dock angeläget att ett eventuellt bildande av NPK föregås av framtagning av tydliga direktiv till NPK om hur den ska förhålla sig till och tillämpa riksdagens riktlinjer för prioriteringar.

    Med avseende på politisk involvering eller inte i besluten har det i samtliga länder vi har undersökt varit en tydlig politisk koppling till själva beslutet om införande eller inte av teknologin. Detta står i kontrast till hur det för närvarande fungerar i Sverige med t.ex. TLV, där besluten inte involverar politiker. I denna fråga verkar det snarare handla om att skapa ett system som gör att den kommitté eller person som ska fatta införandebeslutet har tillräckligt förtroende och legitimitet att förvalta denna uppgift. Det kan betyda att politiker inkluderas i en kommitté som befolkningsföreträdare eller representanter för den part som ansvarar för finansieringen. Lika väl kan det fungera med personer i kommittén som medverkar på personliga mandat, som har en adekvat kompetens och erfarenhet men också ett förtroende från andra att lösa uppgiften.

    Formen för ”Omprövning” är starkt sammankopplad med valet av andra strukturella komponenter. Vår utgångspunkt är dock att det bör finnas någon typ av omprövningsmekanism under processen samt efter beslut. Skulle det bli en myndighet som fattar bindande beslut på liknande sätt som TLV gör i dag bör det vara möjligt för företag att överklaga beslutet till domstol. I andra fall är det NPK som bör utveckla egna rutiner för omprövning på eget eller andras initiativ.

    Vi har i denna studie undersökt förutsättningar för etablering av en nationell prioriteringskommitté i Sverige för icke-farmakologiska sjukvårdsteknologier i hälso- och sjukvården. Arbetet har baserats på erfarenheter från länder med existerande system för beslut om införande av sjukvårdsteknologier samt diskussioner i Sverige med en referensgrupp samt styrgrupp för projektet. Vi har i vårt arbete identifierat tio viktiga komponenter för uppbyggnaden av en sådan kommitté och fört en diskussion kring dessa. Vi ser möjligheter och fördelar med att etablera en nationell prioriteringskommitté i Sverige för identifiering, utvärdering och prioritering vid beslut avseende införande av andra sjukvårdsteknologier än läkemedel i hälso- och sjukvården. För- och nackdelar med olika tänkbara lösningar har diskuterats i rapporten, medan de mer exakta formerna för en nationell prioriteringskommitté är en fråga för fortsatt utredning.

  • 44.
    Brodtkorb, Thor-Henrik
    et al.
    RTI Health Solutions, Lund.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kalkan, Almina
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Metoder för värdering av QALYS2012In: QALY som effektmått inom vården: Möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, 30-53 p.Chapter in book (Other academic)
  • 45.
    Brodtkorb, Thor-Henrik
    et al.
    Linköping University, The Institute of Technology. Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment.
    Henriksson, Martin
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics.
    Johannesen-Munk, Kasper
    Dept of rehabilitation School of Health Sciences, Jönköping.
    Thidell, Fredrik
    Dept of rehabilitation School of Health Sciences, Jönköping.
    Cost-effectiveness of C-Leg compared to non microprocessor controlled knees: a modelling approach (oral presentation)2007Conference paper (Other academic)
  • 46.
    Brodtkorb, Thor-Henrik
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Allergy Center.
    Zetterström, Olle
    Linköping University, Department of Clinical and Experimental Medicine, Allergy Centre. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Allergy Center.
    Tinghög, Gustav
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Cost-effectiveness of clean air administered to the breathing zone in allergic asthma2010In: CLINICAL RESPIRATORY JOURNAL, ISSN 1752-6981, Vol. 4, no 2, 104-110 p.Article in journal (Refereed)
    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.

  • 47.
    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.

  • 48.
    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.

  • 49.
    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.

  • 50.
    Broqvist, Mari
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    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
    Nationell modell för öppna prioriteringar inom hälso- och sjukvård: 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.

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