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  • 101.
    Eckard, Nathalie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Comment: Including Both Costs and Effects - The Challenge of Using Cost-Effectiveness Data in National-Level Policy-Making: A Response to Recent Commentaries2015In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 4, no 8, p. 565-566Article in journal (Other academic)
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  • 102.
    Eckard, Nathalie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden2014In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 3, no 6, p. 323-332Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The inclusion of cost-effectiveness data, as a basis for priority setting rankings, is a distinguishing feature in the formulation of the Swedish national guidelines. Guidelines are generated with the direct intent to influence health policy and support decisions about the efficient allocation of scarce healthcare resources. Certain medical conditions may be given higher priority rankings i.e. given more resources than others, depending on how serious the medical condition is. This study investigated how a decision-making group, the Priority Setting Group (PSG), used cost-effectiveness data in ranking priority setting decisions in the national guidelines for heart diseases.

    METHODS: A qualitative case study methodology was used to explore the use of such data in ranking priority setting healthcare decisions. The study addressed availability of cost-effectiveness data, evidence understanding, interpretation difficulties, and the reliance on evidence. We were also interested in the explicit use of data in ranking decisions, especially in situations where economic arguments impacted the reasoning behind the decisions.

    RESULTS: This study showed that cost-effectiveness data was an important and integrated part of the decision-making process. Involvement of a health economist and reliance on the data facilitated the use of cost-effectiveness data. Economic arguments were used both as a fine-tuning instrument and a counterweight for dichotomization. Cost-effectiveness data were used when the overall evidence base was weak and the decision-makers had trouble making decisions due to lack of clinical evidence and in times of uncertainty. Cost-effectiveness data were also used for decisions on the introduction of new expensive medical technologies.

    CONCLUSION: Cost-effectiveness data matters in decision-making processes and the results of this study could be applicable to other jurisdictions where health economics is implemented in decision-making. This study contributes to knowledge on how cost-effectiveness data is used in actual decision-making, to ensure that the decisions are offered on equal terms and that patients receive medical care according their needs in order achieve maximum benefit.

  • 103.
    Eckard, Nathalie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Reaching agreement in uncertain circumstances: the practice of evidence-based policy in the case of the Swedish National Guidelines for heart diseases2017In: Evidence and Policy: A Journal of Research, Debate and Practice, ISSN 1744-2648, no 4, p. 687-707Article in journal (Refereed)
    Abstract [en]

    This paper explores the practice of evidence-based policy in a Swedish healthcare context. The study focused on how policymakers in the specific working group, the Priority-Setting Group (PSG), handled the various forms of evidence and values and their competing rationalities, when producing the Swedish National Guidelines for heart diseases that are based on both clinical and economic evidence and are established to support explicit priority-setting in healthcare. The study contributes to the theoretical and practical debate on evidence-based policy (EBP) by illustrating how the practical tensions of coming to agreement were managed, to a large extent, through deliberation and by creativity.

  • 104.
    Eckerblad, Jeanette
    et al.
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences.
    Theander, Kersti
    Karlstad University, Sweden.
    Ekdahl, Anne
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Geriatric Medicine in Linköping. Karolinska Institute KI, Sweden.
    Unosson, Mitra
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences.
    Wiréhn, Ann-Britt
    Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Milberg, Anna
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Region Östergötland, Local Health Care Services in East Östergötland, Department of Advanced Home Care in Norrköping. Region Östergötland, Local Health Care Services in East Östergötland, Center of Palliative Care.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Jaarsma, Tiny
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences.
    Symptom burden in community-dwelling older people with multimorbidity: a cross-sectional study2015In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 15, no 1Article in journal (Refereed)
    Abstract [en]

    Background: Globally, the population is ageing and lives with several chronic diseases for decades. A high symptom burden is associated with a high use of healthcare, admissions to nursing homes, and reduced quality of life. The aims of this study were to describe the multidimensional symptom profile and symptom burden in community-dwelling older people with multimorbidity, and to describe factors related to symptom burden. Methods: A cross-sectional study including 378 community-dwelling people greater than= 75 years, who had been hospitalized greater than= 3 times during the previous year, had greater than= 3 diagnoses in their medical records. The Memorial Symptom Assessment Scale was used to assess the prevalence, frequency, severity, distress and symptom burden of 31 symptoms. A multiple linear regression was performed to identify factors related to total symptom burden. Results: The mean number of symptoms per participant was 8.5 (4.6), and the mean total symptom burden score was 0.62 (0.41). Pain was the symptom with the highest prevalence, frequency, severity and distress. Half of the study group reported the prevalence of lack of energy and a dry mouth. Poor vision, likelihood of depression, and diagnoses of the digestive system were independently related to the total symptom burden score. Conclusion: The older community-dwelling people with multimorbidity in this study suffered from a high symptom burden with a high prevalence of pain. Persons with poor vision, likelihood of depression, and diseases of the digestive system are at risk of a higher total symptom burden and might need age-specific standardized guidelines for appropriate management.

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  • 105.
    Edin, Ulrike
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Gunnarsdotter, Anette
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Tegnevik, Tomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Att prioritera i team i tvärprofessionell verksamhet: ett exempel från habiliteringen2011Report (Other academic)
    Abstract [sv]

    I denna rapport beskrivs erfarenheter från två prioriteringsarbeten, ett inom Habilitering i östra länsdelen i Östergötland och ett inom Barn- och ungdomshabiliteringen i Region Skåne. Prioriteringscentrums huvudsakliga intresse för dessa arbeten var att de representerar verksamheter med tvärprofessionella team som genomfört ett prioriteringsarbete med den nationella modellen för öppna prioriteringar som verktyg. Tillämpbarheten av modellen i tvärprofessionella sammanhang har tidigare varit föremål för tveksamheter om huruvida modellen skulle passa för prioriteringar i team.

    De båda verksamheterna har haft olika förutsättningar vilket bidragit till att de genomfört sina arbeten på olika sätt; i Skåne har prioriteringar gjorts i tillfälligt sammansatta tvärprofessionella arbetsgrupper och i Östergötland i de ordinarie teamen. För de tillfälliga arbetsgrupperna har urvalet av deltagare varit viktigt för att säkerställa teamperspektivet och samtidigt vara Skåneövergripande.

    Den nationella modellen för öppna prioriteringar har upplevts fungera väl för att ta fram prioriteringar i teamverksamhet. Det har funnits svårigheter på vägen men dessa har varit av samma typ som finns beskrivna i professionsvis genomförda prioriteringsarbeten eller i arbeten som inte bedrivits i utpräglade teamverksamheter. Vad det gäller kravet på hur ett professionsvis och en tvärprofessionell prioriteringsprocess ska organiseras har det framkommit mer likheter än skillnader i detta projekt.

    Få nackdelar med det tvärprofessionella arbetssättet har framkommit. Möjligen kan det som vinns i tvärprofessionell säkerhet gå förlorat i yrkesspecifik trygghet om ledningen inte säkerställer att det finns gott metodstöd. Flera fördelar har däremot lyfts fram. Skapandet av helhetssyn och samsyn samt mindre revirtänkande är några av dem. Eftersom tvärprofessionella verksamheter ofta grundas på hög grad av samarbete mellan olika professioner, gemensamma målsättningar och samordning av insatser är det en rimlig slutsats att det i sådana verksamheter finns övervägande fördelar med att bedriva prioriteringsarbetet tvärprofessionellt. Ett sådant arbete bör innebära en så heltäckande representation av professioner som möjligt i processen samt att majoriteten av möjliga insatser ingår i den framtagna prioriteringsordningen för olika tillstånd. Varje enskilt prioriteringsobjekt behöver dock inte omfatta en aktiv insats från alla professioner i teamet. Det är den sammantagna helhetsbilden av tillstånd-åtgärdspar och den gemensamma diskussionen som skapar den tvärprofessionella dimensionen.

     

    Projektet kommer att följas upp med en enkätundersökning som genomförts före och efter avslutat prioriteringsarbete i de båda verksamheterna och som fokuserar på i vilken grad kännedom och samsyn om teamets prioriteringar påverkats av de prioriteringsarbeten som genomförts.

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    Att prioritera i team itvärprofessionell verksamhet: Ett exempel från habiliteringen
  • 106.
    Ekberg, Kerstin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Karlsson, Nadine
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Linderoth, Catharina
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Arbetsgivares kostnader, åtgärder och anpassningar för sjuknärvarande och sjukfrånvarande medarbetare: samband med återgång i arbete och produktion2017Report (Other academic)
    Abstract [sv]

    Studien syftade till att undersöka vilka åtgärder arbetsgivare gör för sjukskrivna medarbetare och vilka kostnader arbetsgivare och samhället har i samband med sjuknärvaro och sjukfrånvaro.

    Totalt 3000 sjukskrivna personer i AFA Försäkrings register med diagnoserna psykiska besvär eller besvär i rörelseorganen fick ett informationsbrev och förfrågan om samtycke till att forskarna skulle få skicka en enkät till deras arbetsledare; 393 sjukskrivna gav samtycke. En  webbenkät skickades till dessa arbetsledare. Totalt 198 arbetsledare (50 %) till sjukskrivna personer besvarade enkäten.

    Resultaten visar att arbetsgivare genomför en rad olika åtgärder och anpassningar när en medarbetare blir sjukskriven. Analyserna visade att dessa åtgärder och anpassningar i viss mån beror på vem den sjukskrivne medarbetaren är. Åtgärder och anpassningar var vanligare för sjukskrivna med psykiska diagnoser, för högutbildade och för sjukskrivna i högkvalificerade yrken. Kvinnor fick i högre grad anpassningar och åtgärder såsom ändrade arbetsuppgifter och psykosocialt stöd jämfört med män.

    Demografiska faktorer visade sig ha mindre betydelse för om den sjukskrivne återgick i arbete eller ej. Multipla logistiska regressionsanalyser visade att åtgärder och anpassningar på arbetsplatsen hade signifikanta samband med en ökad chans för återgång i arbete. Resultaten visade också att för sjukskrivna medarbetare vars arbetsledare hade tagit många kontakter med andra aktörer, som HR-avdelningen, företagshälsan och/eller Försäkringskassan var sannolikheten lägre att den sjukskrivne medarbetaren återgick i arbete. Arbetsledare tog fler kontakter, om den sjukskrivne medarbetaren hade en psykisk diagnos.

    Sjuknärvaro och produktionsförlust före, under och efter sjukskrivningen skattades av arbetsledarna. Sammanlagt beräknades produktionsförlusterna till cirka SEK 100 000 per sjukskrivningsfall. Härutöver lägger arbetsgivare tid på att ta kontakter, genomföra åtgärder och anpassningar och organisera om arbetet. Arbetsledare hade mycket oklar eller saknade helt uppfattning om vad tid, åtgärder och anpassningar kostar, varför detta inte har kunnat analyseras närmare. De beräknade genomsnittliga kostnaderna till följd av produktivitetsförluster är således en underskattning av de faktiska kostnaderna för arbetsgivare.

    Studien visar att arbetsledares kunskap om vad sjuknärvaro och sjukfrånvaro kostar för verksamheten och för samhället är begränsad. En ökad kostnadsmedvetenhet skulle kunna stimulera till att större resurser läggs på att implementera policys för hälsofrämjande åtgärder och att utbilda arbetsledare i att hantera frågor om hälsa och arbetsförmåga på arbetsplatsen.

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    Arbetsgivares kostnader, åtgärder och anpassningar för sjuknärvarande och sjukfrånvarande medarbetare: samband med återgång i arbete och produktion
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  • 107.
    Ekberg, Kerstin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, HELIX Vinn Excellence Centre.
    Wåhlin, Charlotte
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Occupational and Environmental Medicine Center. Karolinska Institutet, Stockholm, Sweden.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Region Östergötland, Heart and Medicine Center, Allergy Center.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Early and Late Return to Work After Sick Leave: Predictors in a Cohort of Sick-Listed Individuals with Common Mental Disorders2015In: Journal of occupational rehabilitation, ISSN 1053-0487, E-ISSN 1573-3688, Vol. 25, no 3, p. 627-637Article in journal (Refereed)
    Abstract [en]

    Objectives The study aims to identify individual and workplace factors associated with early return to work (RTW)-defined as within 3 months-and factors associated with later RTW-between 3 and 12 months after being sick-listed-in a cohort of newly sick-listed individuals with common mental disorders. Methods In a prospective cohort study, a cross-sectional analysis was performed on baseline measures of patients granted sick leave due to common mental disorders. A total of 533 newly sick-listed individuals fulfilled the inclusion criteria and agreed to participate. A baseline questionnaire was sent by post within 3 weeks of their first day of certified medical sickness; 354 (66 %) responded. Those who were unemployed were excluded, resulting in a study population of 319 individuals. Sick leave was recorded for each individual from the Social Insurance Office during 1 year. Analyses were made with multiple Cox regression analyses. Results Early RTW was associated with lower education, better work ability at baseline, positive expectations of treatment and low perceived interactional justice with the supervisor. RTW after 3 months was associated with a need to reduce demands at work, and turnover intentions. Conclusions Early RTW among sick-listed individuals with common mental disorders seems to be associated with the individuals need to secure her/his employment situation, whereas later RTW is associated with variables reflecting dissatisfaction with work conditions. No health measures were associated with RTW. The study highlights the importance of considering not only health and functioning, but also workplace conditions and relations at the workplace in implementing RTW interventions.

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  • 108.
    Ekberg, Kerstin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Linköping University, HELIX Vinn Excellence Centre.
    Wåhlin, Charlotte
    Institute of Environmental Medicine, Karolinska Institutet.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. 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.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Predictive values for early and late return to work of the Work Ability Index (WAI), the single-item question (WAI-1), and EQ-5D among sick listed in musculoskeletal and mental disorders2013Conference paper (Refereed)
  • 109.
    Ekdahl, Anne W.
    et al.
    Karolinska Institute, Sweden; Helsingborg Hospital, Sweden.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Eckerblad, Jeanette
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Social and Welfare Studies, Division of Nursing Science.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Jaarsma, Tiny
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Lindh Mazya, Amelie
    Karolinska Institute, Sweden; Danderyd Hospital, Sweden.
    Milberg, Anna
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in East Östergötland, Center of Palliative Care. Region Östergötland, Local Health Care Services in East Östergötland, Department of Advanced Home Care in Norrköping.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Unosson, Mitra
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Social and Welfare Studies, Division of Nursing Science.
    Wiklund, Rolf
    Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Long-Term Evaluation of the Ambulatory Geriatric Assessment: A Frailty Intervention Trial (AGe-FIT): Clinical Outcomes and Total Costs After 36 Months2016In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 17, no 3, p. 263-268Article in journal (Refereed)
    Abstract [en]

    Objective: To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 months after study inclusion. Design: Randomized, controlled, assessor-blinded, single-center trial. Setting: A geriatric ambulatory unit in a municipality in the southeast of Sweden. Participants: Community-dwelling individuals aged >= 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG). Intervention: Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care. Outcome measures: Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months. Results: Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P =.026). The mean number of inpatient days was lower in the IG (15.1 [SD 18.4]) than in the CG (21.0 [SD 25.0], P =.01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 [SD 85,560] and USD 65,626 [SD 66,338], P =.43). Conclusions: CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGAs superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs. (c) 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

  • 110.
    Ekdahl, Anne W
    et al.
    Region Östergötland, Local Health Care Services in Central Östergötland, Department of Geriatric Medicine in Linköping. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm.
    Wirehn, Ann-Britt
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Jaarsma, Tiny
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Medicine and Health Sciences.
    Unosson, Mitra
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Medicine and Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Eckerblad, Jeanette
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Medicine and Health Sciences.
    Milberg, Anna
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Region Östergötland, Local Health Care Services in East Östergötland, Department of Advanced Home Care in Norrköping. Region Östergötland, Local Health Care Services in East Östergötland, Center of Palliative Care.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Costs and Effects of an Ambulatory Geriatric Unit (the AGe-FIT Study): A Randomized Controlled Trial2015In: Journal of the American Medical Directors Association, ISSN 1538-9375, Vol. 16, no 6, p. 497-503Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To examine costs and effects of care based on comprehensive geriatric assessment (CGA) provided by an ambulatory geriatric care unit (AGU) in addition to usual care.

    DESIGN: Assessor-blinded, single-center randomized controlled trial.

    SETTING: AGU in an acute hospital in southeastern Sweden.

    PARTICIPANTS: Community-dwelling individuals aged 75 years or older who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion and randomized to the intervention group (IG; n = 208) or control group (CG; n = 174). Mean age (SD) was 82.5 (4.9) years.

    INTERVENTION: Participants in the IG received CGA-based care at the AGU in addition to usual care.

    OUTCOME MEASURES: The primary outcome was number of hospitalizations. Secondary outcomes were days in hospital and nursing home, mortality, cost of public health and social care, participant' sense of security in care, and health-related quality of life (HRQoL).

    RESULTS: Baseline characteristics did not differ between groups. The number of hospitalizations did not differ between the IG (2.1) and CG (2.4), but the number of inpatient days was lower in the IG (11.1 vs 15.2; P = .035). The IG showed trends of reduced mortality (hazard ratio 1.51; 95% confidence interval [CI] 0.988-2.310; P = .057) and an increased sense of security in care interaction. No difference in HRQoL was observed. Costs for the IG and CG were 33,371£ (39,947£) and 30,490£ (31,568£; P = .432).

    CONCLUSIONS AND RELEVANCE: This study of CGA-based care was performed in an ambulatory care setting, in contrast to the greater part of studies of the effects of CGA, which have been conducted in hospital settings. This study confirms the superiority of this type of care to elderly people in terms of days in hospital and sense of security in care interaction and that a shift to more accessible care for older people with multimorbidity is possible without increasing costs. This study can aid the planning of future interventions for older people.

    TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01446757.

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  • 111.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan, Sweden.
    Bylin, Kristoffer
    Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan, Sweden.
    Karlson, Björn W.
    Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Early rehospitalizations of frail elderly patients - the role of medications: a clinical, prospective, observational trial2017In: Drug, Healthcare and Patient Safety, ISSN 1179-1365, E-ISSN 1179-1365, Vol. 9, p. 77-88Article in journal (Refereed)
    Abstract [en]

    Early readmissions of frail elderly patients after an episode of hospital care are common and constitute a crucial patient safety outcome. Our purpose was to study the impact of medications on such early rehospitalizations.

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  • 112.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hospital Grp, Sweden.
    Dahlin Ivanoff, Synneve
    University of Gothenburg, Sweden.
    Landahl, Sten
    University of Gothenburg, Sweden.
    Ostberg, Goran
    NU Hospital Grp, Sweden.
    Johansson, Maria
    NU Hospital Grp, Sweden.
    Andersson, David
    University of Gothenburg, Sweden.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Karlson, Bjorn W.
    University of Gothenburg, Sweden.
    Acute care of severely frail elderly patients in a CGA-unit is associated with less functional decline than conventional acute care2017In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 12, p. 1239-1248Article in journal (Refereed)
    Abstract [en]

    Background: A high percentage of individuals treated in specialized acute care wards are frail and elderly. Our aim was to study whether the acute care of such patients in a comprehensive geriatric assessment (CGA) unit is superior to care in a conventional acute medical care unit when it comes to activities of daily living (ADLs), frailty, and use of municipal help services. Patients and methods: A clinical, prospective, controlled trial with two parallel groups was conducted in a large county hospital in West Sweden and included 408 frail elderly patients, age 75 or older (mean age 85.7 years; 56% female). Patients were assigned to the intervention group (n=206) or control group (n=202). Primary outcome was decline in functional activity ADLs assessed by the ADL Staircase 3 months after discharge from hospital. Secondary outcomes were degree of frailty and use of municipal help services. Results: After adjustment by regression analyses, treatment in a CGA unit was independently associated with lower risk of decline in ADLs [odds ratio (OR) 0.093; 95% confidence interval (CI) 0.052-0.164; P amp;lt; 0.0001], and with a less prevalent increase in the degree of frailty (OR 0.229; 95% CI 0.131-0.400; P amp;lt; 0.0001). When ADLs were classified into three strata (independence, instrumental ADL-dependence, and personal ADL-dependence), changes to a more dependence-associated stratum were less prevalent in the intervention group (OR 0.194; 95% CI 0.085-0.444; P=0.0001). There was no significant difference between the groups in increased use of municipal help services (OR 0.682; 95% CI 0.395-1.178; P=0.170). Conclusion: Acute care of frail elderly patients in a CGA unit was independently associated with lesser loss of functional ability and lesser increase in frailty after 3 months.

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  • 113.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hospital Grp, Sweden.
    Karlson, Björn W.
    University of Gothenburg, Sweden.
    Dahlin Ivanoff, Synneve
    University of Gothenburg, Sweden.
    Landahl, Sten
    University of Gothenburg, Sweden.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Heintz, Emelie
    Karolinska Institute, Sweden.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?2017In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 12Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit. Design: This is a clinical, prospective, randomized, controlled, one-center intervention study. Setting: This study was conducted in a large county hospital in western Sweden. Participants: The study included 408 frail elderly patients, aged amp;gt;= 75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female. Intervention: This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit. Measurements: The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs. Results: After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.14-0.79), ambulation (OR =0.19, 95% CI = 0.1-0.37), dexterity (OR =0.38, 95% CI =0.19-0.75), emotion (OR =0.43, 95% CI =0.22-0.84), cognition (OR =0.076, 95% CI =0.033-0.18) and pain (OR =0.28, 95% CI =0.15-0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] = 0.55, 95% CI = 0.32-0.96), and the two groups did not differ significantly in terms of hospital care costs (Pamp;gt;0.05). Conclusion: Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost.

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  • 114.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg, Sweden.
    Karlsson, Björn
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Heintz, Emelie
    Department of Learning, Informatics, Management and Ethics (LIME), QRC Research Unit, Karolinska Institutet, Stockholm, Sweden.
    Alwin, Jenny
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients2018In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 19, no 10, p. 871-878.e2Article in journal (Refereed)
    Abstract [en]

    Objective

    The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective.

    Design

    Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups.

    Intervention

    Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit.

    Setting and Participants

    A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female.

    Measures

    The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up.

    Results

    We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was −3226 US dollars (95% CI: −6167 to −285).

    Conclusion

    The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months.

  • 115.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hosp Grp, Sweden.
    Karlsson, Thomas
    Univ Gothenburg, Sweden.
    Soderqvist, Sara
    NU NAL Uddevalla Hosp Grp, Sweden.
    Karlson, Bjorn W.
    NU NAL Uddevalla Hosp Grp, Sweden; Univ Gothenburg, Sweden.
    Hospitalized frail elderly patients - atrial fibrillation, anticoagulation and 12 months outcomes2018In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 13, p. 749-756Article in journal (Refereed)
    Abstract [en]

    Background and objective: Multiple chronic conditions and recurring acute illness are frequent among elderly people. One such condition is atrial fibrillation (AF), which increases the risk of stroke up to fivefold. The aim of this study was to investigate the prevalence of AF among hospitalized frail elderly patients, their use of anticoagulation and their 12-month outcomes. Patients and methods: This was a clinical observational study of acutely hospitalized frail patients over the age of 75 years. The CHA2DS2-VASc Score was used to evaluate ischemic stroke risk in patients with AF. Clinically relevant outcomes were the composite of ischemic stroke and/or bleeding within 12 months, which was considered as primary in the analysis, ischemic stroke/transient ischemic attack (TIA), mortality, bleeding and hospital care consumption. Students (test, Fishers exact test, Mann Whitney U test and a Cox proportional hazards model were used for the analyses. Results: The prevalence of AF was 47%, and 63% of them were prescribed an anticoagulant. AF patients without anticoagulation were older, more often females, more often in residential care, and they had worse Mini Nutritional Assessment and activities of daily living scores. Of the patients without anticoagulation, 56% had a documented contraindication. In univariate analysis, there were significantly more events among AF patients without anticoagulation regarding the composite outcome of ischemic stroke and/or bleeding (hazard ratio [1112] 3.65, 95% CI = 1.70-7.86; p amp;lt; 0.001). When adjusting for potential confounders in Cox regression analysis, the difference remained significant (HR 4.54, 95% CI = 1.83-11.25; p = 0.001). Conclusion: The prevalence of AF in a hospitalized frail elderly population was 47%. Of these, 63% were prescribed anticoagulation therapy. Almost half of the patients without stroke pro-phylaxis had no documented contraindication. At 1 year, there were significantly more events in terms of ischemic stroke and/or bleeding among AF patients without anticoagulation therapy than among those with.

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  • 116.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hosp Grp, Sweden.
    Pettersson, Staffan
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alexander, Karen
    Duke Clin Res Inst, NC USA.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Eriksson, Sofia
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Janzon, Magnus
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine.
    Lindenberger, Marcus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alfredsson, Joakim
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Frailty as an instrument for evaluation of elderly patients with non-ST-segment elevation myocardial infarction: A follow-up after more than 5 years2018In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 25, no 17, p. 1813-1821Article in journal (Refereed)
    Abstract [en]

    Background There is a growing body of evidence on the relevance of using frailty measures also in a cardiovascular context. The estimated time to death is crucial in clinical decision-making in cardiology. However, data on the importance of frailty in long-term mortality are very scarce. The aim of the study was to assess the prognostic value of frailty on mortality at long-term follow-up of more than 5 years in patients 75 years or older hospitalised for non-ST-segment elevation myocardial infarction. We hypothesised that frailty is independently associated with long-term mortality. Design This was a prospective, observational study conducted at three centres. Methods and results Frailty was assessed according to the Canadian Study of Health and Aging clinical frailty scale (CFS). Of 307 patients, 149 (48.5%) were considered frail according to the study instrument (degree 5-7 on the scale). The long-term all-cause mortality of more than 5 years (median 6.7 years) was significantly higher among frail patients (128, 85.9%) than non-frail patients (85, 53.8%), (P amp;lt; 0.001). In Cox regression analysis, frailty was independently associated with mortality from the index hospital admission to the end of follow-up (hazard ratio 2.06, 95% confidence interval 1.51-2.81; P amp;lt; 0.001) together with age (P amp;lt; 0.001), ejection fraction (P = 0.012) and Charlson comorbidity index (P = 0.018). Conclusions In elderly non-ST-segment elevation myocardial infarction patients, frailty was independently associated with all-cause mortality at long-term follow-up of more than 6 years. The combined use of frailty and comorbidity may be the ultimate risk prediction concept in the context of cardiovascular patients with complex needs.

  • 117.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alfredsson, Joakim
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Löfmark, Rurik
    Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, Sweden .
    Lindenberger, Marcus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping. Ryhov County Hospital, Jönköping, Sweden .
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction2014In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 21, no 10, p. 1216-1224Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: For the large population of elderly patients with cardiovascular disease, it is crucial to identify clinically relevant measures of biological age and their contribution to risk. Frailty is denoting decreased physiological reserves and increased vulnerability. We analysed the manner in which the variable frailty is associated with 1-year outcomes for elderly non-ST-segment elevation myocardial infarction (NSTEMI) patients. METHODS AND RESULTS: Patients aged 75 years or older, with diagnosed NSTEMI were included at three centres, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. Of 307 patients, 149 (48.5%) were considered frail. By Cox regression analyses, frailty was found to be independently associated with 1-year mortality after adjusting for cardiovascular risk and comorbid conditions (hazard ratio 4.3, 95% CI 2.4-7.8). The time to the first event was significantly shorter for frail patients than for nonfrail (34 days, 95% CI 10-58, p = 0.005). CONCLUSIONS: Frailty is strongly and independently associated with 1-year mortality. The combined use of frailty and comorbidity may constitute an important risk prediction concept in regard to cardiovascular patients with complex needs.

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  • 118.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hosp Grp, Sweden.
    Östberg, Göran
    NU Hosp Grp, Sweden.
    Johansson, Maria
    NU Hosp Grp, Sweden.
    Karlson, Björn W.
    NU Hosp Grp, Sweden; Univ Gothenburg, Sweden.
    Are frail elderly patients treated in a CGA unit more satisfied with their hospital care than those treated in conventional acute medical care?2018In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 12, p. 233-240Article in journal (Refereed)
    Abstract [en]

    Objectives: Our aim was to study whether the acute care of frail elderly patients directly admitted to a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit in terms of patient satisfaction. Design: TREEE (Is the TReatment of frail Elderly patients Effective in an Elderly care unit?) is a clinical, prospective, controlled, one-center intervention trial comparing acute treatment in CGA units and in conventional wards. Setting: This study was conducted in the NAL-Uddevalla county hospital in western Sweden. Participants: In this follow-up to the TREEE study, 229 frail patients, aged amp;gt;= 75 years, in need of acute in-hospital treatment, were eligible. Of these patients, 139 patients were included in the analysis, 72 allocated to the CGA unit group and 67 to the conventional care group. Mean age was 85 years and 65% were female. Intervention: Direct admittance to an acute elderly care unit with structured, systematic interdisciplinary CGA-based care, compared to conventional acute medical care via the emergency room. Measurements: The primary outcome was the satisfaction reported by the patients shortly after discharge from hospital. A four-item confidential questionnaire was used. Responses were given on a 4-graded scale. Results: The response rate was 61%. In unadjusted analyses, significantly more patients in the intervention group responded positively to the following three questions about the hospitalization: "Did you get the nursing from the ward staff that you needed?" (p=0.003), "Are you satisfied with the information you received on your diseases and medication?" (p=0.016), and "Are you satisfied with the planning before discharge from the hospital?" (p=0.032). After adjusted analyses by multiple regression, a significant difference in favor of the intervention remained for the first question (p=0.027). Conclusion: Acute care in a CGA unit with direct admission was associated with higher levels of patient satisfaction compared with conventional acute care via the emergency room.

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  • 119.
    Ekstrand, Jan
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Aspetar Orthopaed and Sports Med Hosp, Qatar.
    Spreco, Armin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development, Department of Health and Care Development.
    Davison, Michael
    FIFA Med Ctr Excellence, England.
    Elite football teams that do not have a winter break lose on average 303 player-days more per season to injuries than those teams that do: a comparison among 35 professional European teams2019In: British Journal of Sports Medicine, ISSN 0306-3674, E-ISSN 1473-0480, Vol. 53, no 19, p. 1231-1235Article in journal (Refereed)
    Abstract [en]

    Objective To compare injury rates among professional mens football teams that have a winter break in their league season schedule with corresponding rates in teams that do not. Methods 56 football teams from 15 European countries were prospectively followed for seven seasons (2010/2011-2016/2017)-a total of 155 team-seasons. Individual training, match exposure and time-loss injuries were registered. Four different injury rates were analysed over four periods within the season, and linear regression was performed on team-level data to analyse the effect of winter break on each of the injury rates. Crude analyses and analyses adjusted for climatic region were performed. Results 9660 injuries were reported during 1 447 011 exposure hours. English teams had no winter break scheduled in the season calendar: the other European teams had a mean winter break scheduled for 10.0 days. Teams without a winter break lost on average 303 days more per season due to injuries than teams with a winter break during the whole season (pamp;lt;0.001). The results were similar across the three periods August-December (p=0.013), January-March (pamp;lt;0.001) and April-May (p=0.050). Teams without a winter break also had a higher incidence of severe injuries than teams with a winter break during the whole season (2.1 severe injuries more per season for teams without a winter break, p=0.002), as well as during the period JanuaryMarch (p=0.003). A winter break was not associated with higher team training attendance or team match availability. Climatic region was also associated with injury rates. Conclusions The absence of a scheduled winter break was associated with a higher injury burden, both before and during the two periods following the time that many European teams take a winter break. Teams without a winter break (English clubs) had a higher incidence of severe injuries following the time of the year that other teams (other European clubs) had their scheduled break.

  • 120.
    El-Alti, Leila
    et al.
    Univ Gothenburg, Sweden.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Munthe, Christian
    Univ Gothenburg, Sweden.
    Person Centered Care and Personalized Medicine: Irreconcilable Opposites or Potential Companions?2019In: Health Care Analysis, ISSN 1065-3058, E-ISSN 1573-3394, Vol. 27, no 1, p. 45-59Article in journal (Refereed)
    Abstract [en]

    In contrast to standardized guidelines, personalized medicine and person centered care are two notions that have recently developed and are aspiring for more individualized health care for each single patient. While having a similar drive toward individualized care, their sources are markedly different. While personalized medicine stems from a biomedical framework, person centered care originates from a caring perspective, and a wish for a more holistic view of patients. It is unclear to what extent these two concepts can be combined or if they conflict at fundamental or pragmatic levels. This paper reviews existing literature in both medicine and related philosophy to analyze closer the meaning of the two notions, and to explore the extent to which they overlap or oppose each other, in theory or in practice, in particular regarding ethical assumptions and their respective practical implications.

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  • 121.
    Elf, Mikael
    et al.
    Department of Psychology, University of of Gothenburg, Sweden; Swedish Institute for Health Science, Lund, Sweden.
    Rystedt, Hans
    Department of Education, Communication and Learning, University of of Gothenburg, Sweden.
    Skärsäter, Ingela
    Institute of Health and Care Science, University of Gothenburg School of Social and Health Sciences, Halmstad University, Sweden.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    An investigation of intended and real use of a research web health portal and its implementation2014In: Electronic Journal of Health Informatics, ISSN 1446-4381, E-ISSN 1446-4381, Vol. 8, no 1, p. e8-Article in journal (Refereed)
    Abstract [en]

    Participatory design (PD) projects involve prospective users as co-designers in a process where the design object emerges through several iterations. However, the result of such a process can only partly anticipate how the future real users will use the designed object. For this reason, its actual use needs to be investigated. The present study investigated the relationship between intended use and real use in two web-based health support systems in order to explore the conditions for redesign. The dependency between intended use and real use was found to be weak. Rather, the real use was dependent on 1) the context of use and 2) the needs or interest of the users. We conclude that redesign should be based on continuous use of web metrics collected in natural settings and by involving users on a recurring basis. While a web health portal must have an agenda it is important to adapt thing design to use design, why redesign in essence will become an adaptation to user needs

  • 122.
    Ellström, Per-Erik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Work and Working Life. Linköping University, Department of Behavioural Sciences and Learning, Education and Sociology. Linköping University, Faculty of Arts and Sciences. Linköping University, HELIX Vinn Excellence Centre.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, HELIX Vinn Excellence Centre.
    Promoting Practice-Based Innovation Through Learning at Work2014In: International handbook of research in professional and practice-based / [ed] Stephen Billett, Christian Harteis, Hans Gruber, Dordrecht: Springer, 2014, p. 1161-1185Chapter in book (Refereed)
  • 123.
    Engstrand, Christina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Kvist, Joanna
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Factors affecting functional recovery after surgery and hand therapy in patients with Dupuytren's disease2015In: Journal of Hand Therapy, ISSN 0894-1130, E-ISSN 1545-004X, Vol. 28, no 3, p. 255-260Article in journal (Refereed)
    Abstract [en]

    Study design: Prospective cohort study. Introduction: The evidence of the relationship between functional recovery and impairment after surgery and hand therapy are inconsistent. Purpose of the study: To explore factors that were most related to functional recovery as measured by DASH in patients with Dupuytrens disease. Methods: Eighty-one patients undergoing surgery and hand therapy were consecutively recruited. Functional recovery was measured by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Explanatory variables: range of motion of the finger joints, five questions regarding safety and social issues of hand function, and health-related quality of life (Euroqol). Results: The three variables "need to take special precautions", "avoid using the hand in social context", and health-related quality of life (EQ-5D index) explained 62.1% of the variance in DASH, where the first variable had the greatest relative effect. Discussion: Safety and social issues of hand function and quality of life had an evident association with functional recovery. Level of evidence: IV.

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  • 124.
    Engstrand, Christina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Nylander, Göran
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Kvist, Joanna
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Hand function and quality of life before and after fasciectomy for Dupuytren contracture2014In: Journal of Hand Surgery-American Volume, ISSN 0363-5023, E-ISSN 1531-6564, Vol. 39, no 7, p. 1333-1343Article in journal (Refereed)
    Abstract [en]

    PURPOSE:

    To describe changes in joint motion, sensibility, and scar pliability and to investigate the patients' expectations, self-reported recovery, and satisfaction with hand function, disability, and quality of life after surgery and hand therapy for Dupuytren disease.

    METHODS:

    This prospective cohort study collected measurements before surgery and 3, 6, and 12 months after surgery and hand therapy. Ninety patients with total active extension deficits of 60° or more from Dupuytren contracture were included. Outcomes measures were range of motion; sensibility; scar pliability; self-reported outcomes on expectations, recovery, and satisfaction with hand function; Disabilities of the Arm, Shoulder, and Hand scores; safety and social issues of hand function; physical activity habits; and quality of life with the Euroqol.

    RESULTS:

    The extension deficit decreased, and there was a transient decrease in active finger flexion during the first year after surgery. Sensibility remained unaffected. Generally, patients with surgery on multiple fingers had worse scar pliability. The majority of the patients had their expectations met, and at 6 months, 32% considered hand function as fully recovered, and 73% were satisfied with their hand function. Fear of hurting the hand and worry about not trusting the hand function were of greatest concern among safety and social issues. The Disability of the Arm, Shoulder, and Hand score and the Euroqol improved over time.

    CONCLUSIONS:

    After surgery and hand therapy, disability decreased independent of single or multiple operated fingers. The total active finger extension improved enough for the patients to reach a functional range of motion despite an impairment of active finger flexion still present 12 months after treatment.

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  • 125.
    Engstrand, Christina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Kvist, Joanna
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Patients'€™ perspective on surgical intervention for Dupuytren'€™s disease€: experiences, expectations and appraisal of results2016In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 38, no 24-26, p. 2538-2549Article in journal (Refereed)
    Abstract [en]

    Purpose To explore patients’ perspectives on surgical intervention for Dupuytren’s disease (DD), focusing on patients’ appraisal of results, involving previous experiences, expectations and patient characters.

    Method The participants were 21 men, mean age 66 years, scheduled for DD surgery. Qualitative interviews were conducted 2–4 weeks before surgery and 6–8 months after surgery. The model of the Patient Evaluation Process was used as theoretical framework. Data were analyzed using problem-driven content analysis.

    Results Five categories are described: previous experiences, expectations before surgery, appraisal of results, expectations of the future and patient character. Previous experiences influenced participants’ expectations, and these were used along with other aspects as references for appraisal of results. Participants’ appraisal of results concerned perceived changes in hand function, care process, competency and organization, and could vary in relation to patient character. The appraisal of results influenced participants’ expectations of future hand function, health and care.

    Conclusions Patients’ appraisal of results involved multidimensional reasoning reflecting on hand function, interaction with staff and organizational matters. Thus, it is not enough to evaluate results after DD surgery only by health outcomes as this provides only a limited perspective. Rather, evaluation of results should also cover process and structure aspects of care.

    Implications for Rehabilitation

    • To improve health care services, it is important to be aware of the role played by patient’s previous experiences, expectations as well as staff and organizational aspects of care.
    • Knowledge about patients’ experience and view of the results from surgery and rehabilitation should be established by assessment of care effects on health as well as structure and process aspects of care.
    • Evaluation of structure and process aspects of care can be done by using questions about if the patient felt listened to, received clear information and explanations, was included in decision-making, and their view of waiting time or continuity of care.
    • Improving health care services means not only providing the best treatment method available but also developing individualized care by ensuring good interaction with the patient, providing accurate information, and working to improve the structure of the care process.
    • Before treatment, health care providers should have a dialogue with the patient and consider previous experiences and expectations in order to ensure the patient has balanced expectations of the outcome.
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  • 126.
    Eriksson, Therese
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Tinghög, Gustav
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Societal Cost of Skin Cancer in Sweden in 20112015In: Acta Dermato-Venereologica, ISSN 0001-5555, E-ISSN 1651-2057, Vol. 95, no 3, p. 347-348Article in journal (Other academic)
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  • 127.
    Eriksson, Thérèse
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Utvärdering av vårdval ryggkirurgi i Stockholms län2018Report (Other academic)
    Abstract [sv]

    Uppdrag och syfte

    Centrum för utvärdering av medicinsk teknologi vid Linköpings Universitet fick under 2014 i uppdrag av Stockholms Läns Landsting (SLL) att utvärdera vårdval ryggkirurgi (VVR). I VVR används ett värdebaserat ersättningssystem vilket gör att VVR skiljer sig från andra vårdval inom Stockholms län.

    Syftet med denna utvärdering är att 1) utifrån registerdata utvärdera VVR utifrån volym, kostnad samt hälsoutfall med Region Östergötland som kontroll, 2) redogöra för hur anställda inom SLL respektive de privata vårdgivarna har upplevt utformning, implementering, förvaltning av VVR och hur det har påverkat deras arbete samt hur de upplevde beslutsprocessen för införandet.

    Metod

    Att kombinera kvantitativa och kvalitativa metoder kan vara värdefullt vid utvärdering av en komplex intervention med många faktorer att ta hänsyn till. Kvantitativ och kvalitativ metod erbjuder olika sätt att beskriva ett fenomen, vilket innebär att metoderna kan generera olika resultat. Man bör inte utgå ifrån att resultaten ska replikera varandra utan snarare att man ska få en djupare förståelse för fenomenet. I denna utvärdering är utgångspunkten att metoderna kan och bör användas som komplement till varandra.

    Den kvalitativa delen i denna rapport bygger på intervjuer med anställda på Hälso- och sjukvårdsförvaltningen (HSF) vid SLL samt anställda hos de privata vårdgivarna1. Ändamålsenlig urvalsteknik har använts för att välja intervjupersoner och intervjuerna baseras på en explorativ ansats. Den kvantitativa delen baseras på registerdata från fem olika registerhållare, deskriptiva data presenteras och statistiska analysmetoder har använts för att jämföra grupper och utveckling över tid före och efter införandet av VVR. Utvärderingen grundar sig på Donabedians ramverk för utvärdering av kvalitet inom sjukvården (1).

    Resultat baserat på registerdata

    Volym

    Antalet indexoperationer har ökat med 17 procent efter införandet av VVR. Volymökningen kan förklaras med att det operationstak som fanns vid upphandling har tagits bort och att den nya ersättningsnivån kräver en högre produktion. Även tillgängligheten har ökat, dels på grund av det finns fler vårdgivare, dels på grund av utökade öppettider samt fler mer centralt belägna mottagnings- och rehabiliteringslokaler.

    Hälsoutfall

    Under de tre år som har gått sedan införandet av VVR har 1006 fler patienter opererats jämfört med motsvarande period före införandet. Detta motsvarar en vinst på 210 QALYs till följd av VVR. Livskvalitetsvinsten efter operation per patient har inte påverkats av VVR, men justerat för vårdtyngd och socioekonomiska faktorer har den postoperativa livskvaliteteten ökat med 0,04 i EQ-5D-index.

    Kostnader

    SLL:s kostnad för elektiv ryggkirurgi har i genomsnitt ökat med 20 miljoner kronor per år efter införandet av VVR. Den totala kostnaden för elektiv ryggkirurgi har ökat med 16 procent jämfört med motsvarande period före vårdvalet. Kostnadsökningen kan förklaras av volymökningen som uppgick till 17 procent. Kostnaden per operation har minskat med 7 procent. Även kostnaden per vårdepisod2 har minskat med 9 procent.

    Den inkrementella kostnadseffektkvoten för VVR estimerades till drygt 50 000 kronor per vunnet kvalitetsjusterat levnadsår (QALY). Om kostnaden för vård under hela vårdepisoden och indirekta kostnader kopplade till sjukfrånvaro inkluderades i analysen uppgick den inkrementella kostnadseffektkvoten till 230 000 kronor per vunnen QALY.

    Individ- och prestationsersättning

    Baserat på patientens svar på Global Assessment såg den prestationsbaserade ersättningen i genomsnitt ut enligt följande:

    • Helt försvunnen smärta: 3 651 kr
    • Mycket förbättrad smärta: 1 167 kr
    • Något förbättrad smärta: -1 746 kr
    • Oförändrad smärta: -4 453 kr
    • Försämrad smärta: -6 215 kr
    • Hade inte smärta: 529 kr

    Tanken var att prestationsersättningen skulle uppgå till ungefär 10 procent av bas- och garantiersättning, i realiteten blev andelen som högst knappt 7 procent. I de flesta fall uppgick prestationsersättningen till cirka ±2 procent av bas- och garantiersättningen. Den individbaserade justeringen låg i majoriteten av fallen på ca ±2 procent.

    I jämförelse med de kostnader som uppkommer på grund av kostnadsansvaret för postoperativ vård menade vårdpersonal att den värdebaserade ersättningen (baserat på GA) var för låg. De ansåg därför att det inte var värt att följa upp den värdebaserade ersättningen och därmed har incitamenten inte haft önskad effekt då fokus främst ligger på att hålla de postoperativa kostnaderna nere istället för på hur den värdebaserade ersättningen kan maximeras.

    Sjukskrivning

    Andelen sjukskrivna patienter minskar efter införandet av VVR. Antalet sjukskrivningsdagar har ökat, främst på grund av längre sjukskrivning före operation.

    Konsumtion av smärtstillande läkemedel

    Andelen patienter som använder opioidbaserade läkemedel postoperativt har minskat med VVR, även doseringen per patient har minskat. Andelen patienter som använder antiepileptika har preoperativt och i samband med operation ökat, men postoperativt minskat. Andelen patienter som använde antidepressiva postoperativt ökade efter införandet av VVR, likaså doseringen preoperativt och i samband med operation.

    Resultat baserat på intervjuer

    Utformning, implementering och förvaltning

    Hos vårdgivare var beslutet att införa VVR väl förankrat, mycket på grund av att professionen fick komma till tals under utformningen av vårdvalet. Hos Hälso- och sjukvårdsförvaltningen (HSF) hade beslutet inte samma stöd då man tidigare bedömt att elektiv ryggkirurgi inte lämpade sig som vårdval samt att landstingets system inte kunde stödja den typen av ersättningssystem som diskuterades.

    Generellt har kommunikationen upplevts som god mellan vårdgivare och HSF under utformningen av VVR. Personal hos vårdgivare upplevde kommunikationen som särskilt god i jämförelse med hur kommunikationen varit i utformningen av andra vårdval.

    Flera intervjupersoner menade att det saknades stöd för hur man praktiskt skulle arbeta med det nya systemet, vilket kan förklaras av att VVR var nytt även för personalen på HSF. Personal hos vårdgivarna upplevde att det tog för lång tid att få svar på frågor vilket i sin tur ledde till att ärenden samlades på hög och personal kände stress över att antalet olösta ärenden ökade. Vårdvalet upplevdes som personbundet, särskilt under de första åren efter införandet av VVR.

    På HSF fanns en medvetenhet om att de inte riktigt hade resurser till löpande uppföljning och revidering av avtalen med vårdgivare. Det gav upphov till viss frustration över att veta vad som bör förändras utan att ha de resurser som krävs för att genomföra det. För att ekonomiska incitament ska vara långsiktigt effektiva är det viktigt med kontinuerlig uppföljning och justering.

    Arbetsprocesser

    Vårdgivare

    VVR är utformat så att vårdgivarna är fria att utforma sina arbetsprocesser på det sätt som de själva anser är bäst. Den enda begränsningen är ersättningen som landstinget har bestämt baserat på kostnadsdata från en av vårdgivarna. Det tvärprofessionella arbetet var mer påtagligt hos två av de fyra intervjuade vårdgivarna.

    Efter införandet av VVR uppgav vårdpersonal att de blivit mer enhetliga i registreringsförfarandet och mer stringenta i sina bedömningar av operationsindikationer. En negativ sidoeffekt som framkommit är att särskilda ingrepp inte gått att utföra inom vårdvalets ramar. Därför anser vårdgivarna att en justering av tillåtna kombinationer vore lämpligt så att fler diagnoser och ingrepp inkluderas för att undvika att patienter hamnar utanför systemet.

    Vårdgivarna inom VVR har ett postoperativt kostnadsansvar för patienten vilket ger dem anledning att bygga upp ett förtroende hos patienterna för att öka chansen för att patienten kommer tillbaka vid komplikationer samt efterlever läkarens anvisningar. Då patienterna är fria att söka sig till en annan vårdgivare skulle det underlätta för vårdgivarna om de blev informerade när deras patient vårdades på annat håll för att på så vis ge dem en chans att själva åtgärda komplikationen. Det postoperativa kostnadsansvaret har dock upplevts som administrativt krävande då IT-systemet inte är tillräckligt förfinat för att urskilja vård kopplad till VVR från annan vård. Därutöver uppgav intervjupersoner en upplevd avsaknad av struktur och stöd för hur man praktiskt skulle inkludera sjukgymnastik. Samordningen av sjukgymnastik har varit komplicerat för alla vårdgivare och det är svårt att styra patienter som har ett fritt val. Detta ansvar har blivit en central del i vårdgivarnas arbete varför många tycker att större vikt borde

    ha lagts på utformningen av detta ansvar. Det kan därför uppfattas som att inkluderingen av sjukgymnastik var ett för stort steg att ta i samband med införandet av VVR men samtidigt ett steg i rätt riktning som egentligen skulle ha krävt både bättre utformade system och en bättre samverkan med sjukgymnastik som område.

    Hälso- och sjukvårdsförvaltningen (HSF)

    Generellt har HSF inte haft möjlighet att genomföra den kontinuerliga uppföljning och revidering som vårdvalet kräver på grund av relativt små personella resurser. Istället har arbetssättet gällande vårdval generellt kännetecknats av större revideringar med några års mellanrum. Detta arbetssätt påminner i stor utsträckning om det arbetssätt som råder under upphandlingsförfaranden inom SLL. En utav grundidéerna med vårdval går därför till viss del förlorad när avtalsrevideringarna är stora och sker sällan istället för att mindre justeringar görs fortlöpande för att anpassa systemet. Vidare skulle HSF:s arbete gynnas av att få in ökad kompetens som kan hantera och utveckla de typer av informationssystem som är en förutsättning för att upprätthålla ett komplext vårdval som VVR.

    Arbetsbelastning

    Den administrativa bördan upplevs ha ökat för personal både på HSF och hos vårdgivarna. Den största orsaken till den ökade administrativa bördan är det nya ersättningssystemet som krävt mycket manuellt arbete, främst på grund av hanteringen av det postoperativa kostnadsansvaret. För vårdgivare upplevs även den kliniska arbetsbelastningen ha ökat då de genomför fler operationer på grund av den lägre ersättningsnivån, ökad konkurrens och för att det inte finns något operationstak.

    Inställningen till VVR med ett värdebaserat ersättningssystem

    Införandet av VVR upplevs generellt som positivt eftersom det ger vårdgivarna större utrymme för långsiktighet. Det finns dock en oro för att fortsatt effektivisering ska leda till negativa effekter för patienter. Vårdgivare betonade därför vikten av indexuppräkning av ersättningsnivån. Generellt finns en positiv inställning till att ersättningen är kopplad till patientutfall, men med nuvarande utformning och ersättningsnivå ligger inte fokus på att maximera patientutfall utan på att minimera potentiellt undvikbara oönskade händelser (PUOH) och fysioterapi. Det nya ersättningssystemet kopplat till VRR uppfattas som komplext vilket till stor del kan bero på brist på transparens kring hur olika patientfaktorer påverkar ersättningen. Lämpligheten att basera ersättningsnivån på det patientrapporterade utfallsmåttet global assessment (GA) har också ifrågasatts. Dels för att GA baseras på en subjektiv värdering, dels för att en för stor vikt i ersättningen ligger på att patienten ska bli helt smärtfri, vilket inte är vanligt för patientgruppen inom VRR.

    Vilka faktorer upplevs ha störst betydelse för utfallet?

    Det postoperativa kostnadsansvaret menar vårdgivarna är den aspekt i VRR som har haft störst påverkan i det dagliga arbetet. Det har genererat en obruten vårdkedja som bidragit till att man som vårdgivare får en närmare relation till patienten. Med det postoperativa kostnadsansvaret kan vårdgivarna följa patienten hela vägen från bedömning till ettårsuppföljning. Därutöver framhävs också avtalsformen, att bedriva verksamhet enligt Lagen om valfrihetssystem (LOV) underlättar planering av verksamheten på lång sikt och ger utrymme för att arbeta mer mot kvalitet jämfört med avtalsformen under Lagen om offentlig upphandling (LOU). Under intervjuerna framförde många att även om VVR inte givit någon mätbar effekt ännu (2013-2016), så har kopplingen av ersättning till hälsoutfall varit viktig då det upplevts som en fingervisning om var fokus bör ligga på för att uppnå bättre kvalitet.

    Slutsatser

    • Antalet opererade patienter har ökat med 17 procent efter införandet av VVR.
    • Den totala kostnaden har ökat med 16 procent, däremot har medelkostnaden per operation minskat.
    • Vårdvalet har inte haft någon effekt på den individuella livskvalitetsvinsten, men då fler patienter opereras ökar den aggregerade livskvalitetsvinsten.
    • Den minskade genomsnittliga kostnaden per operation indikerar en effektivare vård då livskvalitetsvinsten inte har påverkats negativt.
    • Den prestationsbaserade ersättningens andel av den totala ersättningen behöver bli större för att generera effekt.
    • Individjusteringen upplevs inte vara tillräcklig för att motverka skillnader i ekonomisk risk mellan patienter.
    • Istället för fokus på postoperativ hälsomaximering ligger fokus på postoperativ kostnadsminimering.
    • Vårdvalet har inte haft någon större effekt på patientsammansättningen.
    • Andelen sjukskrivna patienter minskar efter införandet av VVR.
    • Den generella uppfattningen av vårdval ryggkirurgi var positiv bland personal hos de privata vårdgivarna och HSF.
    • Uppfattningen hos vårdpersonal var att det postoperativa kostnadsansvaret hade haft störst effekt på det dagliga arbetet och att det gav vårdgivarna en bättre helhetssyn av patientens behov.
    • Kopplingen av ersättning till patientrapporterat utfallsmått upplevdes också som viktigt, även om den i dagsläget var för låg för att generera effekt.
    • Vårdvalet har medfört en hög administrativ arbetsbörda på grund av det nya beskrivnings- och ersättningssystemet. Idag kvarstår relativt mycket manuellt arbete med den komplexa ersättningsmodellen.
    • Hur forskning och utveckling ska bedrivas och finansieras behöver lösas, särskilt eftersom de offentliga sjukhusen inte är inkluderade i VVR och de privata aktörerna opererar majoriteten av patienterna inom elektiv ryggkirurgi.
    • Resultaten tyder på en omställningsperiod de första åren efter införandet av VVR och därför är det viktigt att följa utvecklingen från år 2016 och framåt för mer långsiktiga effekter av VVR.
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  • 128.
    Eriksson, Thérèse
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundqvist, Martina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hälsoekonomisk effektanalys av forskning inom programmet Innovationer för framtidens hälsa2014Report (Other academic)
    Abstract [sv]

    Det övergripande syftet i denna rapport är att undersöka vad de forskningsprojekt som erhållit medel från VINNOVA har resulterat i och om resultaten har omsatts i praktiken inom hälsooch sjukvården eller kommersiellt, men också att beräkna hälsoekonomiska effekter när det är möjligt. När det gäller programmet Innovationer för framtidens hälsa inkluderades de projekt som erhållit medel från VINNOVA mellan åren 2009 och 2013 och som avslutats fram till augusti 2013. Dessa uppgick till 19 stycken och spänner över ett brett spektra av medicinska och hälsorelaterade tillämpningsområden och befinner sig i olika faser i forskningen. Projekten representerar en blandning av tillämpad forskning och forskning på en mer grundläggande nivå.

    Projektens utveckling har analyserats utifrån en innovations- och spridningsprocess, om det finns visade hälsoeffekter och hälsoekonomiska effekter analyseras även dessa. Alla projekt, med undantag från ett, har genererat minst en produkt. Fyra forskningsprojekt har genererat två produkter, därför har totalt 23 produkter klassificerats. Projektens innovationsprocess har analyserats utifrån en innovationstrappa bestående av sju steg. Typvärdet för projektens förflyttning uppgår till ett steg, totalt har nio projekt förflyttat sig ett steg. Det därefter mest frekventa värdet är två steg, totalt åtta projekt har förflyttat sig två steg. Den största förflyttningen var fem steg, från steg ett till steg sex. Utfallet för projektens spridningsprocess gällande hälsoekonomiska effekter beskrivs nedan:

    • Två projekt har resulterat i en etablerad produkt med avläsbara hälsoeffekter. (A)
    • Tre projekt har resulterat i en produkt som befinner sig i en tidig spridningsfas i hälso- och sjukvården. (C)
    • Tio projekt har resulterat i en produkt som hittills endast använts i forskningssyfte eller för forskningsändamål. (D)
    • Sex projekt har resulterat i kunskaper som med stor sannolikhet kan vidareförädlas till en produkt. (E)
    • Två projekt har resulterat i kunskaper som har öppnat upp för vidare/fördjupad forskning. (F)

    Inget av de studerade projekten har klassificerats i kategori B eller G, dvs. forskning som lett till en etablerad produkt men utan hälsoeffekter respektive forskning som inte bidragit till en produkt eller kunskaper som kommer att leda till en produkt. Majoriteten av projekten har resulterat i en produkt som hittills endast använts i forskningssyfte för forskningsändamål eller en färdig produkt avsedd att användas endast för forskningsändamål.

    Hälsoekonomiska analyser genomfördes på grundval av de två projekt som genererat hälsoeffekter. Uppskattningen av hälsoekonomisk effekt bör tolkas med försiktighet då beräkningarna är baserade på antaganden med många osäkerheter.

    • Screeningsinstrumentet WINROP är ett datorprogram som avgör vilka nyfödda barn som ligger i riskzonen för att utveckla ögonsjukdomen prematuritetsretinopati (ROP). En fördel med metoden är att, för barnen, besvärande ögonundersökningar kan undvikas. Baserat på antalet för tidigt födda barn år 2012, skulle även en kostnadsbesparing på cirka 2,6 miljoner kronor per år kunna åstadkommas.
    • Lungtransplantationssystemet Vivoline LS1 används för att utvärdera, rekonditionera och förvara lungor inför en transplantation. Systemet möjliggör att fler lungor kan bli tillgängliga för transplantation. Uträkningar pekar på att Vivoline LS1 skulle kunna generera en samhällsvinst på mellan 9 och 51 miljoner kronor per år. Osäkerheten i beräkningen beror på stora variationer i kostnader för en lungtransplantation vilken kan bero på komplexiteten i processen.

    Vidare gjordes en långtidsuppföljning av sju projekt som bedömdes lovande i en tidigare effektanalys från 2009. Ingen av de inkluderade teknologierna hade avvecklats och de flesta hade genomgått en teknisk och marknadsmässig utveckling. Ett projekt fick vid uppföljningen klass A istället för B.

    Analysen visar att det går att härleda forskningens effekter och att effekterna blir tydligare med tiden. Uppföljningen av de avslutade projekten inom programmet Innovationer för framtidens hälsa visar en viss måluppfyllelse av programmets kortsiktiga mål och det ser lovande ut även för de långsiktiga.

    Slutsatser

    • Sjutton av de nitton projekten i programmet Innovationer för framtidens hälsa har efter kort tid utvecklats positivt utifrån ett innovationsperspektiv.
    • Tio projekt har resulterat i en eller flera produkter som hittills använts i forskningssyfte dvs. produkterna är fortfarande föremål för kliniska prövningar eller är enbart avsedda att användas för forskningsändamål.
    • Två projekt har visat hälsoekonomiska effekter.
    • Finansieringen från VINNOVA upplevdes ha haft stor betydelse för projekten.
    • I långtidsuppföljningen av projekt som tidigare erhållit medel från VINNOVA och NUTEK har projekten utvecklats vidare sedan den tidigare uppföljningen och det finns exempel på hälsoekonomiska effekter.
    • Det är fördelaktigt att beskriva forskningsprojekten utifrån både ett effekt- och innovationsprocessperspektiv.
    • Ett bättre stöd för kommersialisering och implementering efterlyses.
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  • 129.
    Eriksson, Thérèse
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Samhällskostnader för hudcancer 20112014Report (Other academic)
    Abstract [sv]

    Bakgrund

    Under senare år har antalet nya fall av hudcancer kraftigt ökat. I Sverige har antalet dödsfall till följd av hudcancer ökat med 38 procent mellan åren 1997 och 2011. Denna utveckling leder inte enbart till ökat mänskligt lidande i samband med sjukdom utan också till en ökad ekonomisk börda för samhället. Det är därför av stor vikt att motverka denna oroande utveckling för att undvika en allt tyngre samhällsbörda till följd av hudcancer.

    Syfte

    I denna rapport presenteras förekomsten av olika hudcancerdiagnoser i Sverige 2011 samt samhällskostnaderna relaterat till dessa diagnoser. Dessutom redovisas en sammanställning av genomförda hälsoekonomiska utvärderingar av preventiva insatser mot hudcancer som finns publicerat internationellt.

    Resultatet från studien utgör även ett viktigt kunskapsunderlag i uppföljningen och vid måluppfyllelsebedömningen av miljökvalitetsmåletSäker strålmiljö.

    Resultat

    De totala kostnaderna för hudcancer i Sverige år 2011 beräknas till 1,58 miljarder kronor. Direkta kostnader (dvs. sjukvårdskostnader) uppgick till 909 miljoner kronor (58 procent), medan indirekta kostnader(dvs. produktionsbortfall) uppgick till 671 miljoner kronor (42 procent). Malignt melanom är den enskilda hudcancerdiagnos som står för de största samhällskostnaderna, 830 miljoner kronor. Det är framförallt kostnaderna kopplade till produktionsbortfall vid dödsfall som bidrar till att malignt melanom är den samhällsekonomiskt mest belastande hudcancerformen. Icke melanom hudcancer står dock för de största sjukvårdskostnaderna, 348 miljoner kronor. Detta beror främst på att dessa cancertyper sammantaget är betydligt vanligare förekommande än malignt melanom. Kostnaderna som presenteras i rapporten visar på en ökning med 331 miljoner kronor jämfört med de kostnader som presenterades år 2005 i en rapport av Tinghög et al på uppdrag av Statens strålskyddsinstitut (SSI).

    Konklusioner

    Den sammantagna slutsatsen baserad på litteraturöversikten av hälsoekonomiska utvärderingar av preventiva metoder mot hudcancer är att det idag saknas studier relevanta för den svenska kontexten där kostnadseffe - tiviteten bedömts. Svårigheten att kunna genomföra randomiserade kontrollerade studier är en bidragande orsak till detta. Framöver bör initiativ för att beräkna kostnadseffektivi eten av preventiva åtgärder efterlysas.

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  • 130.
    Erlandsson, Eva
    et al.
    Svensk Försäkring.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Prioriteringscentrum.
    Wallenskog, Annika
    Sveriges Kommuner och Landsting.
    Vården kräver tydligare prioriteringar och nya lösningar2014In: Dagens Samhälle, p. 20 februari-Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Hur mycket sjukvård har vi råd med i framtiden och hur ska vi prioritera för att möta behoven och patienternas krav på kvalitet och tillgänglighet? Forskare och experter från SKL, Prioriteringscentrum och Svensk Försäkring presenterar en rapport som lägger grunden för en diskussion om välfärdsutmaningarna och hur de ska finansieras utifrån principerna om vård på lika villkor och efter behov.

  • 131.
    Ernesäter, Annica
    et al.
    University of Gavle, Faculty of Health and Occupational Studies, Gävle and Uppsala University, Dept of Public Health and Caring Sciences, Sweden.
    Engström, Maria
    University of Gavle, Faculty of Health and Occupational Studies, Gävle and Uppsala University, Dept of Public Health and Caring Sciences, Sweden.
    Winblad, Ulrika
    Uppsala University, Department of Public Health and Caring Sciences, Health Services Research, Sweden.
    Rahmqvist, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Holmström, Inger K
    Uppsala University, Department of Public Health and Caring Sciences, Health Services Research and Mälardalen University School of Health, Care and Social Welfare, Sweden.
    Telephone nurses' communication and response to callers' concern-a mixed methods study.2016In: Applied Nursing Research, ISSN 0897-1897, E-ISSN 1532-8201, Vol. 29, p. 116-121Article in journal (Refereed)
    Abstract [en]

    AIMS: The aim of this study was to describe telephone nurses' and callers' communication, investigate relationships within the dyad and explore telephone nurses' direct response to callers' expressions of concern

    BACKGROUND: Telephone nurses assessing callers' need of care is a rapidly growing service. Callers with expectations regarding level of care are challenging.

    METHOD: RIAS and content analysis was performed on a criterion sampling of calls (N=25) made by callers who received a recommendation from telephone nurses of a lower level of care than expected.

    RESULTS: Telephone nurses mainly ask close-ended questions, while open-ended questions are sparsely used. Relationships between callers' expressions of Concern and telephone nurses responding with Disapproval were found. Telephone nurses mainly responded to concern with close-ended medical questions while exploration of callers' reason for concern was sparse.

    CONCLUSION: Telephone nurses' reluctance to use open-ended questions and to follow up on callers' understanding might be a threat to concordance, and a potential threat to patient safety.

  • 132.
    Ertzgaard, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Rehabilitation Medicine.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sorbo, Ann
    Sahlgrens Acad, Sweden; Sodra Alvsborg Hosp, Sweden.
    Lindgren, Marie
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Rehabilitation Medicine.
    Sandsjo, Leif
    Univ Boras, Sweden.
    Evaluation of a self-administered transcutaneous electrical stimulation concept for the treatment of spasticity: a randomized placebo-controlled trial2018In: European Journal of Physical and Rehabilitation Medicine, ISSN 1973-9087, E-ISSN 1973-9095, Vol. 54, no 4, p. 507-517Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Spasticity is a common consequence of injury to the central nervous system negatively affecting patients everyday activities. Treatment mainly consists of training and different drugs, often with side effects. There is a need for treatment options that can be performed by the patient in their home environment. AIM: The objective of this study was to assess the effectiveness of an assistive technology (AT), Mono, a garment with integrated electrodes for multifocal transcutaneous electrical stimulation intended for self-treatment of spasticity, in study participants with spasticity due to stroke or CP. DESIGN: The study was a randomized, controlled, double-blind study with a cross-over design. SETTING: Participants were recruited from two rehabilitation clinics. Treatments were performed in participants homes and all follow-ups were performed in the two rehabilitation clinics. POPULATION: Thirty-one participants were included in the study and 27 completed the study. Four participants discontinued the study. Two declined participation before baseline and two withdrew due to problems handling the garment. METHODS: Participants used the AT with and without electrical stimulation (active/non-active period) for six weeks each. followed by six weeks without treatment. Goal Attainment Scaling (GAS), change in mobility, arm-hand ability, spasticity and pain were measured at baseline and after 6, 12 and 18 weeks. RESULTS: Fifteen of the 27 participants fulfilled the treatment protocol in terms of recommended use. Deviations were frequent. No statistically significant differences in outcome were found between the active and the non-active treatment periods. During the active period, an improvement was seen in the 10-meter comfortable gait test, time and steps. An improvement was seen in both the active and non-active periods for the GAS. CONCLUSIONS: Compliance was low, partly due to deviations related to the garment, complicating the interpretation of the results. Further research should focus on identifying the target population and concomitant rehabilitation strategies. CLINICAL REHABILITATION IMPACT: The evaluated concept of multifocal transcutaneous electrical stimulation (TES) represents an interesting addition to the existing repertoire of treatments to alleviate muscle spasticity. The evaluated concept allows TES to be self-administered by the patient in the home environment. A more elaborate design of training activities directly related to patients own rehabilitation goals is recommended and may increase the value of the evaluated concept.

  • 133.
    Everaert, Karel
    et al.
    Ghent Univ Hosp, Belgium.
    Anderson, Peter
    Adelphi Real World, England.
    Wood, Robert
    Adelphi Real World, England.
    Andersson, Fredrik L.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Ferring Pharmaceut AS, Denmark.
    Holm-Larsen, Tove
    Ghent Univ Hosp, Belgium.
    Nocturia is more bothersome than daytime LUTS: Results from an Observational, Real-life Practice Database including 8659 European and American LUTS patients2018In: International journal of clinical practice (Esher), ISSN 1368-5031, E-ISSN 1742-1241, Vol. 72, no 6, article id e13091Article in journal (Refereed)
    Abstract [en]

    Purpose: Lower urinary tract symptoms (LUTS) encompass several diagnoses, including overactive bladder (OAB) and benign prostatic hyperplasia (BPH). Nocturia is a standalone symptom, but also included in OAB and BPH. Current discussion addresses whether the overlap of the diagnoses is too broad, leading to misdiagnosis. This study explored the differences in level, causes and consequences for patients with a diagnosis of daytime LUTS compared with a diagnosis of nocturia, and discussed whether people are being treated for the symptoms that truly bother them the most. Patients and methods: Data were drawn from a survey of physicians and patients in France, Germany, Spain, UK and USA. Physicians filled out patient record forms (PRFs) for patients with LUTS diagnosis. The patients completed the patient self-completion form (PSC). Three PRO questionnaires were included; the OAB-q SF, NI-Diary and WPAI. Patients were grouped based on the diagnoses assigned to them by their physicians in a real-life setting. Results: Eight thousand seven hundred and thirty eight patients had a LUTS diagnosis and 5335 completed a PSC. Patients diagnosed with night-time symptoms were significantly more bothered by their LUTS than only daytime LUTS patients (all questionnaires Pamp;lt;.0001). Patients with nocturia reported being tired "always" or "usually" more often than patients with daytime problems only (Pamp;lt;.0001). Only 13% of patients with nocturia had an initial sleep period of more than 2-3hours. Conclusion: In this population of real-life patients, those with a diagnosis of nocturia reported significantly higher impact on their quality of life than patients with a diagnosis of daytime LUTS only. The underlying causes of bother were related to sleep problems. It is essential that nocturia is understood, treated and monitored as a distinct problem from OAB and BPH, to ensure that patients are treated for their main symptom.

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  • 134.
    Falk, Barbro
    BF Information, Kalmar.
    Wirén, Kristina (Photographer)
    Fotograf Kristina Wirén, Kalmar.
    Nionde nationella prioriteringskonferensen 2017: En summering2017Report (Other academic)
    Abstract [sv]

    Engagerat, angeläget och inspirerade. Så kan man sammanfatta den nionde nationella priorite­ringskonferensen som arrangerades i Kalmar den 23-25 oktober. Första dagen var det förmöte med grundkurs i prioriteringskunskap och de två följande dagarna bjöds det på ett fullspäckat program med intressanta sessioner. Omkring 300 personer från hela landet hade tagit sig till konferensanläggningen Kalmarsalen för att uppdatera sig på området, träffa kollegor och utbyta erfarenheter.

    Den nationella prioriteringskonferensen är en mötesplats för personer som arbetar med prioritering inom vård och omsorg på olika sätt och fokuserar på metoder och arbetssätt, organisering av prioriteringsprocesser, rollfördelning mellan aktörer, lämpliga beslutsunderlag etc. Temat för årets konferens var: ”Vårdens prioriteringar – union eller konflikt?”.

    Konferensen äger rum vartannat år och nu var det den nionde gången som arrangemanget gick av stapeln. För värdskapet i år svarade Landstinget i Kalmar län i samarbete med Prioriterings-centrum vid Linköpings universitet. Moderator under konferensen var Christina Kennedy, chefredaktör på Dagens Medicin.

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  • 135.
    Falk, Lars
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Inflammation Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Dermatology and Venerology. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Hegic, Sabina
    Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Primary Health Care in Motala. Linköping University, Department of Clinical and Experimental Medicine, Dermatology and Venerology. Linköping University, Faculty of Health Sciences.
    Wilson, Daniel
    Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Wiréhn, Ann-Britt
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Home-sampling as a Tool in the Context of Chlamydia trachomatis Partner Notification: A Randomized Controlled Trial2014In: Acta Dermato-Venereologica, ISSN 0001-5555, E-ISSN 1651-2057, Vol. 94, no 1, p. 72-74Article in journal (Other academic)
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  • 136.
    Falk, Magnus
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Bradley, Thomas
    Östergötlands Läns Landsting, Centre for Laboratory Medicine, Department of Clinical Pharmacology.
    Edström, Morgan
    Östergötlands Läns Landsting, Center for Diagnostics, Department of Clinical Pharmacology.
    Johansson-Fredin, Solveig
    Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Tärning, Eva
    Östergötlands Läns Landsting, Centre for Laboratory Medicine, Department of Clinical Pharmacology.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Från evidens till praktik: utvärdering av ett nytt arbetssätt för att använda evidens i vårdens förbättringsarbete2014Report (Other academic)
    Abstract [sv]

    Att hälso- och sjukvården ska bedrivas utifrån vetenskap och beprövad erfarenhet är allmänt vedertaget. Ett snabbt ökande kunskapsflöde innebär dock höga krav på såväl behandlande enheter som på den enskilda läkaren, som i sitt vardagsarbete ska fatta medicinska beslut utifrån bästa möjliga kunskap. Att på ett strukturerat och effektivt sätt underlätta spridningen av, och tillgången till, evidensbaserad kunskap utgör en stor utmaning för hela samhället, inklusive forskarsamhället. För vården är det en utmaning att använda kunskapen.

    Syftet med projektet var att utveckla, pröva och utvärdera en lokalt anpassad modell för implementering av evidensbaserad kunskap i klinisk verksamhet, baserad på ett arbetssätt som tidigare prövats i Kanada (Alberta Ambassador Programme), och som modifierades för att passa de lokala förutsättningarna i Östergötland, där projektet genomfördes. Som kliniskt beslutsproblem att studera valdes förskrivning av läkemedlet pregabalin, som används vid epilepsi, generaliserat ångestsyndrom (GAD) och neuropatisk smärta. Valet grundades på att läkemedlet är dyrt i förhållande till alternativen, på en  ökande förskrivning med stor variationinom länet, samt på rapporter om  förskrivning utanför rekommenderadesjukdomstillstånd. Sammantaget pekade detta på osäkerhet i hur läkemedlet skulle användas och därmed utrymme för förbättring.

    Projektet genomfördes i fyra steg: 1) Framtagning av ett övergripande evidensdokument för pregabalin, 2) Expertgruppsmöten (uppdelade på psykiatri/smärta) där det utifrån evidensdokumentet arbetades fram ett sammanfattande evidensunderlag/expertrekommendation, 3) Dialogmöten på ett antal sjukhuskliniker/vårdcentraler, samt 4) Uppföljning och utvärdering. En webbenkät skickades till deltagarna direkt efter genomförda dialogmöten, samt efter tio veckor. Resultatet visade att deltagarna till övervägande del var nöjda med innehållet i och formerna för dialogen. En majoritet bedömde innehållet som värdefullt för kliniska ställningstaganden, och att det vid tioveckorsuppföljningen fått spridning på den egna enheten. Statistik över receptförskrivningen av pregabalin tio månader före och efter interventionen, visade för länets tre psykiatriska kliniker (vilka före interventionen skilt sig drastiskt åt i fråga om förskrivning per 1000 patienter) en tydlig utjämning i förskrivning mellan klinikerna. För övriga sjukhuskliniker och vårdcentraler gick det däremot inte att se någon tydlig förändring i detta avseende.

    Sammanfattningsvis bedöms den prövade modellen för implementering av evidensbaserad kunskap ha fungerat väl utifrån det praktiska genomförandet och baserat på deltagarnas omdömen, och bör därav kunna prövas även inom andra områden.

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  • 137.
    Falk, Magnus
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Sjödahl, Rune
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Region Östergötland, Center for Health and Developmental Care, Patient Safety.
    Wiréhn, Ann-Britt
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    Lagerfelt, Marie
    Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Woisetschläger, Mischa
    Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Radiology in Linköping.
    Ahlström, Ulla
    Vårdcentralen Kungsgatan Linköping, Sweden Region Östergötland, Sweden.
    Myrelid, Pär
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Modifierad brittisk modell kortade ledtid till datortomografi av kolon2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112Article in journal (Refereed)
    Abstract [en]

    The British national Institute for Health and Care Excellence (NICE) has presented guidelines based on signs and symptoms which should raise a suspicion of colorectal cancer. A slightly modified version of these guidelines, adapted to Swedish conditions, named Swedish NICE (sNICE) criteria, was implemented at eight primary care centres. By following the sNICE criteria, cases with higher degree of suspicion of colorectal cancer were advised for computer tomography (CT) of the colon, whereas cases of low degree of suspicion were advised for the considerably less time and patient demanding CT of the abdomen. For patients with isolated anal symptoms without presence of sNICE criteria, active expectancy for six weeks was recommended, followed by renewed consideration. Results showed that the ratio between CT colon and CT abdomen was reduced from 2.2 to 1.1 after introduction of the sNICE criteria. Also, the proportion of patients undergoing CT colon within two weeks from admittance was increased from 3 to 25 %. We conclude that the sNICE criteria may be a useful supportive tool for the primary care physician.

  • 138.
    Flume, Mathias
    et al.
    Kassenärztliche Vereinigung Westfalen-Lippe (KVWL), Dortmund, Germany.
    Bardou, Marc
    CIC INSERM 1432, CHU CHU Dijon-Bourgogne, Dijon Cedex, France.
    Capri, Stefano
    School of Economics and Management, Cattaneo-LIUC University, Castellanza (Varese), Italy.
    Sola-Morales, Oriol
    Health innovation technology Transfer, Barcelona, Spain.
    Cunningham, David
    Cunningham Healthcare Advisory, Croydon, Surrey, UK.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Postma, Maarten J.
    Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
    Touchot, Nicolas
    groupH, London, UK.
    Approaches to manage affordability of high budget impact medicines in key EU countries2018In: Journal of market access and health policy, ISSN 2001-6689, Vol. 6, no 1, article id 1478539.Article in journal (Refereed)
    Abstract [en]

    Background: The launch of hepatitis C (HCV) drugs such as sofosbuvir or ledipasvir has fostered the question of affordability of novel high budget impact therapies even in countries with high domestic product. European countries have developed a variety of mechanisms to improve affordability of such therapies, including affordability thresholds, price volume agreements or caps on individual product sales, and special budgets for innovative drugs. While some of these mechanisms may help limit budget impact, there are still significant progresses to be made in the definition and implementation of approaches to ensure affordability, especially in health systems where the growth potential in drug spending and/or in the patient contribution to health insurance are limited. Objectives: In this article, we will review how seven countries in western Europe are approaching the question of affordability of novel therapies and are developing approaches to continue to reward new sciences while limiting budget impact. We will also discuss the question of affordability of cost-effective but hugely expensive therapies and the implications for payers and for the pharmaceutical industry. Results: There is clearly not one solution that is used consistently across countries but rather a number of tools that are combined differently in each country. This illustrates the difficulty of managing affordability within different legal frameworks and within different health care system architectures.

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  • 139.
    Fohlin, Helena
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development, Regional Cancer Center.
    Bekkhus, Tove
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Oncology.
    Sandström, Josefine
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences.
    Fornander, Tommy
    Karolinska Inst, Sweden.
    Nordenskjöld, Bo
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Oncology.
    Carstensen, John
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Stål, Olle
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Oncology.
    RAB6C is an independent prognostic factor of estrogen receptor-positive/progesterone receptor-negative breast cancer2020In: Oncology Letters, ISSN 1792-1074, E-ISSN 1792-1082, Vol. 19, no 1, p. 52-60Article in journal (Refereed)
    Abstract [en]

    The majority of breast cancer tumors are estrogen receptor-positive (ER+) and can be treated with endocrine therapy. However, certain patients may exhibit a good prognosis without systemic treatment. The aim of the present study was to identify novel prognostic factors for patients with ER breast cancer tumors using gene copy data, and to investigate if these factors have prognostic value in subgroups categorized by progesterone receptor status (PR). Public data, including the whole genome gene copy data of 199 systemically untreated patients with ER+ tumors, were utilized in the present study. To assess prognostic value, patients were divided into two groups using the median gene copy number as a cut-off for the SNPs that were the most variable. One SNP was identified, which indicated that the Ras-related protein Rab-6C (RAB6C) gene may exhibit prognostic significance. Therefore, RAB6C protein expression was subsequently investigated in a second independent cohort, consisting of 469 systematically untreated patients (of which 310 were ER+) who received long term follow-up. In the public data set, a distant recurrence risk reduction of 55% was determined for copy numbers above the median value of RAB6C compared with numbers below [multivariable adjusted hazard ratio (HR), 0.45; 95% CI 0.28-0.72; P=0.001)]. It was also more pronounced in the ER+/PR- subgroup (HR, 0.15; 95% CI, 0.05-0.46; P=0.001). In the second cohort, patients of the ER+/PR- subgroup who exhibited high RAB6C expression had a reduced distant recurrence risk (HR, 0.17; 95% CI, 0.05-0.60; P=0.006). However, this was not identified among ER+/PR- tumors (HR, 1.31; 95% CI, 0.69-2.48; P=0.41). The results of the present study indicated that RAB6C serves as an independent prognostic factor of distant recurrence risk in systemically untreated patients with an ER+/PR- tumor.

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  • 140.
    Freedman, Ben
    et al.
    University of Sydney, Australia; University of Sydney, Australia.
    Camm, John
    St George Hospital, England.
    Calkins, Hugh
    Johns Hopkins University, MD USA.
    Healey, Jeffrey S.
    McMaster University, Canada.
    Rosenqvist, Marten
    Karolinska Institute, Sweden.
    Wang, Jiguang
    Jiaotong University, Peoples R China.
    Albert, Christine M.
    Harvard Medical Sch, MA USA.
    Anderson, Craig S.
    George Institute Global Heatlh, Australia.
    Antoniou, Sotiris
    Barts Health NHS Trust, England.
    Benjamin, Emelia J.
    NHLBI, MA USA; Boston University, MA 02215 USA.
    Boriani, Giuseppe
    University of Modena and Reggio Emilia, Italy.
    Brachmann, Johannes
    Klinikum Coburg, Germany.
    Brandes, Axel
    Odense University Hospital, Denmark.
    Chao, Tze-Fan
    National Yang Ming University, Taiwan.
    Conen, David
    McMaster University, Canada; University Hospital, Switzerland.
    Engdahl, Johan
    Karolinska Institute, Sweden.
    Fauchier, Laurent
    Karolinska Institute, Sweden; University of Tours, France.
    Fitzmaurice, David A.
    University of Birmingham, England.
    Friberg, Leif
    Karolinska Institute, Sweden.
    Gersh, Bernard J.
    Mayo Clin, MN USA.
    Gladstone, David J.
    University of Toronto, Canada.
    Glotzer, Taya V.
    Hackensack University, NJ USA.
    Gwynne, Kylie
    University of Sydney, Australia.
    Hankey, Graeme J.
    University of Western Australia, Australia.
    Harbison, Joseph
    Trinity Coll Dublin, Ireland.
    Hillis, Graham S.
    University of Western Australia, Australia.
    Hills, Mellanie T.
    StopAfib Org, TX USA.
    Kamel, Hooman
    Weill Cornell Medical Coll, NY USA.
    Kirchhof, Paulus
    University of Birmingham, England; SWBH and UHB NHS trusts, England; AFNET, Germany.
    Kowey, Peter R.
    Lankenau Institute Medical Research, OK USA.
    Krieger, Derk
    University Hospital Zurich, Switzerland.
    Lee, Vivian W. Y.
    Chinese University of Hong Kong, Peoples R China.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Lip, Gregory Y. H.
    University of Birmingham, England; Aalborg University, Denmark.
    Lobban, Trudie
    Arrhythmia Alliance, England.
    Lowres, Nicole
    University of Sydney, Australia.
    Mairesse, Georges H.
    Clin Sud Luxembourg, Belgium.
    Martinez, Carlos
    Institute Epidemiol Stat and Informat, Germany.
    Neubeck, Lis
    Edinburgh Napier University, Scotland.
    Orchard, Jessica
    University of Sydney, Australia.
    Piccini, Jonathan P.
    Duke University, NC USA.
    Poppe, Katrina
    University of Auckland, New Zealand.
    Potpara, Tatjana S.
    University of Belgrade, Serbia.
    Puererfellner, Helmut
    Ordensklinikum Linz, Austria.
    Rienstra, Michiel
    University of Groningen, Netherlands.
    Sandhu, Roopinder K.
    University of Alberta, Canada.
    Schnabel, Renate B.
    University of Heart Centre, Germany.
    Siu, Chung-Wah
    University of Hong Kong, Peoples R China.
    Steinhubl, Steven
    Scripps Translat Science Institute, CA USA.
    Svendsen, Jesper H.
    University of Copenhagen, Denmark.
    Svennberg, Emma
    Karolinska Institute, Sweden.
    Themistoclakis, Sakis
    Osped Angelo Venice Mestre, Italy.
    Tieleman, Robert G.
    Martini Hospital, Netherlands.
    Turakhia, Mintu P.
    Stanford University, CA 94305 USA; VA Palo Alto Health Care Syst, CA USA.
    Tveit, Arnljot
    Baerum Hospital, Norway.
    Uittenbogaart, Steven B.
    Academic Medical Centre, Netherlands.
    Van Gelder, Isabelle C.
    University of Groningen, Netherlands.
    Verma, Atul
    University of Toronto, Canada.
    Wachter, Rolf
    University of Gottingen, Germany.
    Yan, Bryan P.
    Chinese University of Hong Kong, Peoples R China.
    Screening for Atrial Fibrillation A Report of the AF-SCREEN International Collaboration2017In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 135, no 19, p. 1851-+Article in journal (Refereed)
    Abstract [en]

    Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country-and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

  • 141.
    Frisk, Fredrik
    et al.
    nstitute for Postgraduate Dental Education, Jönköping, Sweden.
    Kvist, Thomas
    University of Gothenburg, Sweden .
    Axelsson, Susanna
    SBU (Swedish Council on Health Technology Assessment), Stockholm, Sweden.
    Bergenholtz, Gunnar
    University of Gothenburg, Sweden .
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. SBU (Swedish Council on Health Technology Assessment), Stockholm, Sweden.
    Mejare, Ingegerd
    SBU (Swedish Council on Health Technology Assessment), Stockholm, Sweden.
    Norlund, Anders
    SBU (Swedish Council on Health Technology Assessment), Stockholm, Sweden.
    Petersson, Arne
    Malmö University, Sweden .
    Sandberg, Hans
    Karolinska Institutet, Stockholm, Sweden.
    Tranaeus, Sofia
    SBU (Swedish Council on Health Technology Assessment), Stockholm, Sweden.
    Hakeberg, Magnus
    University of Gothenburg, Sweden .
    Pulp exposures in adults - choice of treatment among Swedish dentists2013In: Swedish Dental Journal, ISSN 0347-9994, Vol. 37, no 3, p. 153-161Article in journal (Refereed)
    Abstract [en]

    This study comprises a survey of Swedish dentists treatment preferences in cases of carious exposure of the dental pulp in adults. The survey was conducted as part of a comprehensive report on methods of diagnosis and treatment in endodontics, published in 2010 by the Swedish Council on Health Technology Assessment. A questionnaire was mailed to a random subsample of 2012 dental offices where one dentist at each office was requested to answer all questions. Each questionnaire contained one of three sets of questions about endodontic practice routines. Thus around one-third of the subsample received case-specific questions about treating carious exposure. Only general practitioners aged below 70 years were included. The final study sample comprised 412 participants. The dentists were presented with two case scenarios. In Case a 22-year old patient had a deep carious lesion in tooth 36 and in Case 2 a 50-year old patient had a deep carious lesion in tooth 14. The participants were asked to nominate their treatment of choice: pulp capping, partial pulpotomy or pulpectomy. For Case 1, 17 per cent of the respondents selected pulpectomy; the corresponding rate for Case 2 was 47 per cent. Female gender and age group 25-49 years were predictive of selection of less invasive treatment options. However, according to recent guidelines (2011) from the National Board of Health and Wellfare, Swedish dentists are recommended to elect pulpectomy prior to pulp capping/partial pulpotomy when confronted with a tooth having a cariously exposed pulp in adults.

  • 142.
    Gardner, Benjamin
    et al.
    UCL, England.
    Broström, Anders
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Clinical Neurophysiology.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hrubos Strom, Harald
    Akershus University Hospital, Norway.
    Ulander, Martin
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuroscience. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Clinical Neurophysiology.
    Fridlund, Bengt
    Jonköping University, Sweden.
    Skagerström (Malmsten), Janna
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Johansson, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Editorial Material: From does it work? to what makes it work?: The importance of making assumptions explicit when designing and evaluating behavioural interventions in EUROPEAN JOURNAL OF CARDIOVASCULAR NURSING, vol 13, issue 4, pp 292-2942014In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953, Vol. 13, no 4, p. 292-294Article in journal (Other academic)
    Abstract [en]

    n/a

  • 143.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Evidensbaserade policybeslut i hälso- och sjukvård: Redovisning av nio strategier2015Report (Other academic)
    Abstract [en]

    In Sweden, the importance of a "knowledge-based health care" has been emphasized in official documents and agreements between the government and the regional health authorities, at least since the mid- 1990s. Within the concept of evidence-based policy (EBP), however there is a much broader ambition than merely to substantiate the clinical part of health service decision-making with evidence. The intention behind EBP is to increase the influence of “evidence” in both administrative and political decision-making.

    Available review articles indicate that the actual knowledge about how to promote EBP is very limited. The few articles that exist point in the same direction, namely that two areas essential: (a) personal relationships and contacts between producers of research and users of research and (b) measures to make research results clear and accessible so that their use will increase.

    This report presents nine different strategies to enhance EBP: those that focus on the evidence base, the interaction between producers and users of evidence, and increased understanding of the conditions prevailing in collective decision-making. A distinction should be made between approaches that have a limited view of what constitutes evidence – the focus is usually on research evidence - and those strategies that are based on assumptions that EBP is best promoted through a broader view of what constitutes evidence. Strategies that bring together producers and users of evidence, where for example "knowledge broker" is one form, constitutes a more interactive approach.

    A further expanded perspective on EBP is through strategies that focus on the development and use of evidence in relation to complex or "wicked" problems”. Here the decision maker is not only expected to use evidence but to apply a leadership to unconditionally identify evidence, using a multiplicity of actors. A broader view on the evidence base in collective decision-making need not entail that research-generated knowledge is given a limited role. It may instead be interpreted as a reason to advance the understanding of how different forms of knowledge can serve as complementary input in collective decisionmaking in a democratic society.

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  • 144.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Kunskapsstyrning: Mångtydig styrform som behöver studeras2016In: Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson / [ed] Martin Henriksson, Linköping: Linköping University Electronic Press, 2016, p. 30-37Chapter in book (Other academic)
  • 145.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Medborgaren i prioriteringsprocessen2001Report (Other academic)
    Abstract [sv]

    Del I: Medborgaren i prioriteringsprocessen – en översikt

    • Uppfattningen att allmänheten (eller befolkningen) bör konsulteras inför beslut som gäller prioritering av resurser i hälso- och sjukvården vinner ökad anslutning i framför allt länder där denna sektor finansieras med offentliga medel som kontrolleras av politiska församlingar. Oberoende av om vården finansieras genom skatter eller försäkringspremier är beslutsfattare i många länder medvetna om riskerna med att reservera ställningstaganden om resursfördelning enbart för en liten krets av ”experter”.
    • Motiven för att involvera allmänheten har både en moralisk och en demokratisk dimension. När beslutsfattare inom hälso- och sjukvården ställs inför frågor som inte låter sig besvaras med enbart ideologiska eller vetenskaplig argument ökar motivet för en folklig förankring. Om medborgarna upplever brist på inflytande i frågor som uppfattats som väsentliga kan förtroendet för en demokratisk ”kontroll” av hälso- och sjukvården undergrävas.
    • Det går att urskilja tre huvudsakliga syften med en utökad konsultation av allmänheten i anslutning till prioriteringsprocessen. I det första fallet är syftet med konsultationen att nå fram till ett konkret resultat som speglar befolkningens värderingar. I det andra fallet att ”rättfärdiga” prioriteringsprocessen, d.v.s. att flertalet medborgare ska uppfatta processen som ”rimlig” och ”rättvis”. I det tredje fallet att få till stånd en demokratisk process som engagerar medborgarna medan det är mindre viktigt att den leder till ett konkret resultat på kort sikt.
    • Det finns några viktiga principiella skillnader mellan de olika metoder som står till buds för att involvera allmänheten. För det första om allmänhetens medverkan sker avskilt från andra parters deltagande (t.ex. politiker, experter m.fl.) eller om man integrerar deltagandet, d.v.s. sammanför allmänheten med andra parter i gemensamma forum. För det andra om man eftersträvar en viss grad av representativitet (för befolkningen i stort) eller om det sker en medveten selektion (t.ex. enbart personer med vissa erfarenheter) eller om medborgarna deltar på eget initiativ oavsett bakgrund (självselektion). För det tredje om möjlighet till diskussion mellan deltagarna erbjuds i den aktuella konsultationen eller om de medverkande lämnar sina synpunkter (ställningstaganden) individuellt. För det fjärde om extern information presenteras för deltagarna som grund för antingen kollektiv diskussion eller individuellt ställningstagande.
    • Praktiska försök i Storbritannien med fördjupat deltagande för allmänheten i prioriteringsprocessen tyder på att deltagarnas attityder i sakfrågor liksom tilltron till den egna förmågan att komma fram till en ståndpunkt kan förändras över tiden. Vissa frågeställningar kräver mer tid för att deltagarna ska kunna ta ställning till olika alternativ (de är helt enkelt inte vana att tolka frågor om t.ex. hälso- och sjukvård i abstrakta termer). Det gäller särskilt i situationer där deltagarna uppmanades att ta ställning till val mellan kliniska metoder. I frågor som gäller övergripande principer för hälso- och sjukvården (t.ex. vad medborgarna förväntar sig av en offentligt finansierad sjukvård) tycks däremot deltagarna ha lättare att uttrycka sin uppfattning.
    • Utmaningen ligger i att hitta rätt kombinationer av metoder vid rätt tillfälle. Det är orimligt att föreställa sig att bara en metod för konsultation av allmänheten skulle vara tillfyllest i alla situationer. För att ta reda på vad som det rätta i olika miljöer måste vi genomföra väl planerade försök som dokumenteras systematiskt från början till slut. Endast under sådana omständigheter kan vi på ett meningsfullt sätt utvärdera försöken och lära oss något för framtiden.

    Del II: Medborgarjuryn vid prioritering – en fördjupning

    • Deltagarna i en medborgarjury representerar sig själva - inte något särskilt intresse eller någon bestämd kunskap eller erfarenhet. De utgör en delmängd av befolkningen som samlas för att gemensamt framlägga sin syn på ett samhällsproblem. I utgångsläget har juryn att besvara en i förväg formulerad fråga, men har möjlighet att inom rimliga gränser avvika från eller utveckla frågeställningen. Viktiga inslag i metoden är utfrågning av ”vittnen” som ska förse juryn med underlag, tid till diskussion mellan deltagarna, och slutligen utformningen av en rekommendation som offentliggörs.
    • Metoden bygger på antagandet att medborgarnas värderingar och preferenser formas genom ”lärande” i form av åsiktsutbyte och offentliga samtal. Målet är att hitta former för demokratiskt deltagande som inte bara uttrycker enskilda individers privata intressen utan uppmuntrar till breda lösningar på väsentliga samhällsproblem.
    • Följande rekommendationer avseende medborgarjuryns arbete lämnas av IPPR, som utvärderat en del av de brittiska försöken:
    1. Frågeställningen ska utgår från ett verkligt ”fall”, inte ett hypotetiskt.
    2. Den ansvariga organisationen (sponsorn) ska vara beredd på och kunna hantera detta ”fall” i beslutsprocessen.
    3. Den ansvariga organisationen ska vara beredd att ta till sig en rekommendation från juryn även om den inte överensstämmer med den egna ståndpunkten.
    4. Den ansvariga organisationen ska vara klar på vad den önskar ha ut av juryprocessen.
    • Medborgarjuryn är en av få tekniker för konsultation av allmänheten som resulterar i ett konkret material som direkt kan vägas in i en politisk beslutsprocess. Den frågeställning som juryn har att behandla är tydliggjord, förutsättningarna för arbetet är klargjort i förväg. Den rekommendation som juryn ska lämna ifrån sig är tänkt att uppfylla förhållandevis stora krav på motivering och klarhet. Därmed är medborgarjuryn i några viktiga avseenden vida överlägsen andra metoder för konsultation av allmänheten.
    • Medborgarjuryn som metod rymmer dock - jämfört med en del andra metoder för konsultation - några uppenbara problem. Den är inte bara tidskrävande och kostsam utan den engagerar direkt ett mycket begränsat antal medborgare, vars representativitet kan ifrågasättas. I det sistnämnda ligger den mest allvarliga svagheten. En annan kritisk punkt gäller processen varigenom juryn kommer fram till sitt ställningstagande. Det är helt klart att arrangören har ett intresse av att juryn formulerar en gemensam ståndpunkt. Det finns en risk att ”avvikare” påverkas inte bara av övriga deltagares argument (vilket är helt i linje med arbetsformen) men också av de underförstådda kraven från arrangören att komma fram till en gemensam uppfattning.
    • Sammanfattningsvis kan sägas att vi saknar en djupgående och systematisk kunskap om hur medborgarjuryn kan användas som metod för att konsultera allmänheten i anslutning till en prioriteringsprocess inom vård och omsorg. De försök som har genomförts har en alltför fragmentarisk karaktär för att uppfylla högt ställda krav på evidens.
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  • 146.
    Garpenby, Peter
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    Prioriteringsprocessen Del II: Det interna förtroendet2004Report (Other academic)
  • 147.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Reflections on a Swedish citizens' jury: the case of priority setting between patients with different needs.2002Conference paper (Other academic)
  • 148.
    Garpenby, Peter
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Bäckman, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Formal priority setting in health care: the Swedish experience2016In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 30, no 6, p. 891-907Article in journal (Refereed)
    Abstract [en]

    Purpose - From the late 1980s and onwards health care in Sweden has come under increasing financial pressure, forcing policy makers to consider restrictions. The purpose of this paper is to review experiences and to establish lessons of formal priority setting in four Swedish regional health authorities during the period 2003-2012.

    Design/methodology/approach - This paper draws on a variety of sources, and evidence is organised according to three broad aspects: design and implementation of models and processes, application of evidence and decision analysis tools and decision making and implementation of decisions.

    Findings - The processes accounted for here have resulted in useful experiences concerning technical arrangements as well as political and public strategies. All four sites used a particular model for priority setting that combined top-down- and bottom-up-driven elements. Although the process was authorised from the top it was clearly bottom-up driven and the template followed a professional rationale. New meeting grounds were introduced between politicians and clinical leaders. Overall a limited group of stakeholders were involved. By defusing political conflicts the likelihood that clinical leaders would regard this undertaking as important increased.

    Originality/value - One tendency today is to unburden regional authorities of the hard decisions by introducing arrangements at national level. This study suggests that regional health authorities, in spite of being politically governed organisations, have the potential to execute a formal priority-setting process. Still, to make priority-setting processes more robust to internal as well as external threat remains a challenge.

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  • 149.
    Garpenby, Peter
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Bäckman, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Samlade erfarenheter av öppna landstingsvisa prioriteringar2013In: Att välja rättvist: om prioriteringar i hälso- och sjukvården / [ed] Per Carlsson och Susanne Waldau, Lund: Studentlitteratur, 2013, 1:1, p. 149-168Chapter in book (Other academic)
    Abstract [sv]

    Hälso- och sjukvårdens resurser räcker inte till alla behov och önskemål från patienter och medborgare, vilket gör att personal och beslutsfattare hamnar i svåra situationer. Hur ska vi veta att det är rätt patienter som tvingas stå tillbaka? Att välja rättvist tar upp centrala begrepp och etiska principer kring prioriteringar. Boken beskriver även metoder för att göra prioriteringar på ett systematiskt sätt och erfarenheter av såväl nationella som internationella prioriteringar.

    Prioriteringsbeslut fattas på alla nivåer och kan gälla fördelning av resurser till olika verksamheter, behandlingsbeslut av enskilda patienter eller investeringar i nya medicinska metoder. Boken ger förslag på hur beslutsunderlagen kan förbättras. Här ges anvisningar om hur man mäter behov och nytta hos patientgrupper och i befolkningen, hur kostnadseffektivitet beräknas och hur man skapar ett kunskapsunderlag. På så sätt får läsaren inte bara ta del av prioriteringarnas teori utan även av deras praktik, inte minst genom konkreta exempel på hur öppna prioriteringar i dag tillämpas i svensk hälso- och sjukvård.

    Boken är avsedd för dig som arbetar kliniskt eller planerar att arbeta med prioriteringar – nationellt, i landsting eller i kommuner. Boken ger även en värdefull inblick för dig som vill lära mer om hur vårdens svåra val ska kunna hanteras i framtiden.

  • 150.
    Garpenby, Peter
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Implementation as learning and balancing: the launching of a new program for dialogic intervention in Östergötland County Council2013Conference paper (Other academic)
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