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  • 151.
    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 and Society. Linköping University, Faculty of Health Sciences.
    Ordnat införande av metoder i klinisk verksamhet: En studie av försök med dialogmöten inom Landstinget i Östergötland2013Report (Other academic)
    Abstract [en]

    During 2010 to 2012 Östergötland County Council together with the Department of Medical and Health Sciences at Linköping University developed and tested a programme, The Östergötland Model, where research-based knowledge were compiled and presented in dialogic meetings among clinical units within the county council. The intention was to adapt and adjust a Canadian model of dialogic intervention, “The Alberta Ambassador Program”, to a Swedish healthcare context. This was done in order to better understand how research-based knowledge and practise-based knowledge can be systematically integrated in a real-world health care context.

    The working group, which was commissioned by the Advisory Board on Medical Technology at Östergötland County Council to manage this programme, organised 14 dialogic meetings at clinical units and health centres during 2012.

    The aim of this report is to analyse and discuss the development and the implemention of the local programme, The Östergötland Model, based on an analytical framework for “knowledge brokering” – a form for knowledge transition in health care. The findings will also be compared with the Canadian model in order to identify differences and similarities between these two models.

    The main data source is observations of the meetings of the Advisory Board and its working group, supplemented with a web questionnaire and semi-structured interviews with key participants.

    The report shows that the programme in Östergötland had elements from the different forms of “knowledge brokering”. One was “linkage and exchange” that emphasises the meeting between research and practise. However, as the programme was carried out the element “knowledge management” became more pronounced since a lot of work was put into establishing and disseminating a certain kind of knowledge. A third element, “capacity building” which is supporting practising clinicians to formulate issues that can be answered by research-based knowledge, can be identified but was never particularly prominent in the programme.

    A marked difference between the two programmes was that in Alberta the aimed effects was in a sense indirect by giving participants the role as opinion leaders with the task to communicate information and knowledge in the health care system. As a contrast, in Östergötland the ambition was to directly influence the behaviours at specific clinical units.

    Even though a great part of the work in the initial phase of the programme concerned the development of a document presenting evidence on the medical effects, this was not the central aim of the programme in Östergötland. Moreover, to compile evidence is not anything unique but rather an ordinary process in the health-care context. Instead, the most important part of this programme is the dialogic meeting where the participants were given the opportunity to reflect over their own way of acting and possibly to change in direction of a more systematic integration of research-based knowledge and practice-based knowledge in their clinics and health centres. Among the participants this form of implementing knowledge proved to be of great interest. Therefore, as this report shows, there are good reasons to reflect over how new forms of dialogue can be incorporated into the health-care organisation and thus form a process where both research-based and practice-based knowledge are integrated. This report argues that mediating bodies have an important role in facilitating such a dialogic process.

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    Ordnat införande av metoder i klinisk verksamhet: En studie av försök med dialogmöten inom Landstinget i Östergötland
  • 152.
    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 and Society. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Organisering av prioriteringsprocessen2013In: Att välja rättvist: om prioriteringar i hälso- och sjukvården / [ed] Per Carlsson och Susanne Waldau, Lund: Studentlitteratur, 2013, 1, p. 119-135Chapter 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.

  • 153.
    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.
    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.
    Political strategies in difficult times - The "backstage" experience of Swedish politicians on formal priority setting in healthcare2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 163, p. 63-70Article in journal (Refereed)
    Abstract [en]

    This paper contributes to the knowledge on the governing of healthcare in a democratic context in times of austerity. Resource allocation in healthcare is a highly political issue but the political nature of healthcare is not always made clear and the role of politicians is often obscure. The absence of politicians in rationing/disinvestment arrangements is usually explained with blame-shifting arguments; they prefer to delegate "the burden of responsibility" to administrative agencies or professionals. Drawing on a case where Swedish regional politicians involved themselves in setting priorities at a more detailed level than previously, the findings suggest that the subject of "blame avoidance" is more complicated than usually assumed. A qualitative case study was designed, involving semi-structured interviews with 14 regionally elected politicians in one Swedish health authority, conducted in June 2011. The interviews were analysed through a thematic analysis in accordance with the "framework approach" by Ritchie and Lewis. Findings show that an overarching strategy among the politicians was to appear united and to suppress conflict, which served to underpin the vital strategy of bringing the medical profession into the process. A key finding is the importance that politicians, when appearing "backstage", attach to the prevention of blame from the medical profession. This case illustrates that one has to take into account that priority settings requires various types of skills and knowledges - not only technical but also political and social. Another important lesson points toward the need to broaden the political leadership repertoire, as leadership in the case of priority setting is not about politicians being all in or all out. The results suggest that in a priority-setting process it is of importance to have politics on-board at an early stage to secure loyalty to the process, although not necessarily being involved in all details.

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  • 154.
    Gauffin, Håkan
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    Tillander, Bo
    Linköping University, Department of Clinical and Experimental Medicine, 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 Orthopaedics in Linköping.
    Dahlström, Örjan
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Lyth, Johan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Operations management Region Östergötland, Research and Development Unit.
    Raysmith, Ben
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Jacobsson, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Timpka, Toomas
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development, Department of Health and Care Development.
    Maintaining motivation and health among recreational runners: Panel study of factors associated with self-rated performance outcomes at competitions2019In: Journal of Science and Medicine in Sport, ISSN 1440-2440, E-ISSN 1878-1861, Vol. 22, no 12, p. 1319-1323Article in journal (Refereed)
    Abstract [en]

    Objectives: To investigate health-related factors associated with self-rated race performance outcomes among recreational long-distance runners. Design: Panel study. Methods: Data were collected from runners one month before and after a community-level race event including distances from 8 to 42.2 km. The primary outcome measure was self-rated race performance outcome. The explanatory variables represented health complaints suffered during the build-up year, the pre-race month, and the race and among full marathon runners predicted objective performance outcome (mean pace equal to training pace or faster). Multiple logistic regression was used to determine factors associated with the self-rated performance outcome. Results: Two-hundred forty-five runners (29%) provided complete data sets. Seventy-four percent of the runners reached their desired race performance outcome. Achievement of the performance outcome was more likely when having avoided illness during the build-up and pre-race periods (OR = 3.8; 95% CI:1.8-8.0, p amp;lt; 0.001), having avoided per-race injury (OR=3.0; 95% CI:1.2-7.4, p = 0.02) and avoided perrace illness (OR= 4.1; 95% CI:1.3-15, p = 0.020). Having obtained the self-rated performance outcome was also associated with running a shorter distance (OR=3.6; 95% CI: 1.7-8.0,p = 0.001) and being younger than 50 years of age (OR= 2.4; 95% CI:1.1-5.3-8.3, p = 0.03). Having met the predicted objective performance outcome predisposed marathon runners to also obtain the self-rated performance outcome (OR= 4.7, 95% CI: 1.5-16, p amp;lt; 0.01). Conclusions: Having avoided illness during build-up and pre-race was positively associated with self-rated race performance outcome among recreational runners. Adjusting the desired performance outcomes with regard to recent illness and age may help recreational runners to more often achieve their goals and thereby prevent them from leaving the sport. (C) 2019 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

  • 155.
    Geale, K.
    et al.
    Umeå University, Sweden; PAREXEL Int, Sweden.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Schmitt-Egenolf, M.
    Umeå University, Sweden.
    Evaluating equality in psoriasis healthcare: a cohort study of the impact of age on prescription of biologics2016In: British Journal of Dermatology, ISSN 0007-0963, E-ISSN 1365-2133, Vol. 174, no 3, p. 579-587Article in journal (Refereed)
    Abstract [en]

    Background Inequality in healthcare has been identified in many contexts. To the best of our knowledge, this is the first study investigating age inequality in the form of prescription patterns of biologics in psoriasis care. Objectives To determine whether patients with psoriasis have equal opportunities to receive biological medications as they age. If patients did not receive equal treatment, a subsequent objective was to determine the magnitude of the disparity. Methods A cohort of biologic-naive patients with psoriasis was analysed using Cox proportional hazards models to measure the impact of each additional year of life on the likelihood of initiating biological treatment, after controlling for sex, body mass index, comorbidities, disease activity and educational level. A supporting analysis used a nonparametric graphical method to study the proportion of patients initiating biological treatment as age increased, after controlling for the same covariates. Results The Cox proportional hazards model resulted in hazard ratios of a 1-year increase in age of 0.96-0.97 depending on calendar-year stratification, which implies that an increase in age of 30 years corresponds to a reduced likelihood of initiating biological treatment by 61.3-67.6%. The estimated proportion of patients initiating biological medication always decreased as age increased, at a statistically significant level. Conclusions Patients with psoriasis have fewer opportunities to access biological medications as they age. This result was shown to be applicable at all stages in a patients life course and was not only restricted to the elderly, although it implies greater disparities as the age difference between patients increases. These results show that inequality in access to biological treatments due to age is prevalent in clinical practice today. Further research is needed to investigate the extent to which this result is influenced by patient preferences.

  • 156.
    Geale, Kirk
    et al.
    Umeå University, Sweden; PAREXEL Int, Sweden.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Schmitt-Egenolf, Marcus
    Umeå University, Sweden.
    How is disease severity associated with quality of life in psoriasis patients? Evidence from a longitudinal population-based study in Sweden2017In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 15, article id 151Article in journal (Refereed)
    Abstract [en]

    Background: Assessing the impact of disease severity on generic quality of life (QOL) is a critical step in outcomes research and in the development of decision-analytic models structured around health states defined by clinical measures. While data from routine clinical practice found in healthcare registers are increasingly used for research, more attention should be paid to understanding the relationship between clinical measures of disease severity and QOL. The purpose of this work was therefore to investigate this relationship in psoriasis using a population-based dataset. Methods: Severity was measured by the Psoriasis Area and Severity Index (PASI), which combines severity of erythema, induration, and desquamation into a single value ranging from 0 to 72. The generic EQ-5D-3L utility instrument, under the UK tariff, was used to measure QOL. The association between PASI and EQ-5D-3L was estimated using a population-based dataset of 2674 patients with moderate to severe psoriasis enrolled over ten years in the Swedish psoriasis register (PsoReg). Given the repeated measurement of patients in the register data, a longitudinal fixed-effects model was employed to control for unobserved patient-level heterogeneity. Results: Marginal changes in PASI are associated with a non-linear response in EQ-5D-3L: Moving from PASI 10 to 9 (1 to 0) is associated with an increase of 0.0135 (0.0174) in EQ-5D-3L. Furthermore, unobserved patient-level heterogeneity appears to be an important source of confounding when estimating the relationship between QOL and PASI. Conclusions: Using register data to estimate the impact of disease severity on QOL while controlling for unobserved patient-level heterogeneity shows that PASI appears to have a larger impact on QOL than previously estimated. Routine collection of generic QOL data in registers should be encouraged to enable similar applications in other disease areas.

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  • 157.
    Geale, Kirk
    et al.
    Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
    Saridogan, Ertan
    Womens Health Division, University College London Hospital, London, UK.
    Lehmann, Matthieu
    PregLem SA, Geneva, Switzerland.
    Arriagada, Pablo
    PregLem SA, Geneva, Switzerland.
    Hultberg, Marcus
    PAREXEL International, Stockholm, Sweden.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Repeated intermittent ulipristal acetate in the treatment of uterine fibroids: a cost-effectiveness analysis2017In: ClinicoEconomics and Outcomes Research, ISSN 1178-6981, E-ISSN 1178-6981, Vol. 9, p. 669-676Article in journal (Refereed)
    Abstract [en]

    There are limited treatment options available for women with moderate to severe symptoms of uterine fibroids (UFs) who wish to avoid surgery. For these women, treatment with standard pharmaceuticals such as contraceptives is often insufficient to relieve symptoms, and patients may require surgery despite their wish to avoid it. Clinical trials demonstrate that ulipristal acetate 5 mg (UPA) is an effective treatment for this patient group, but its cost-effectiveness has not been assessed in this population. A decision-analytic model was developed to simulate a cohort of patients in this population under treatment with UPA followed by surgery as needed compared to treatment with iron and non-steroidal anti-inflammatory drug (NSAID) followed by surgery as needed (best supportive care, BSC). The analysis took the perspective of the National Health Service (NHS) in England, UK, and was based on the published UPA clinical trials. Results were calculated for the long-term costs and quality-adjusted life years (QALYs) for each treatment arm and combined into an incremental cost-effectiveness ratio (ICER) as the primary outcome. The impact of parameter uncertainty on the results was assessed using scenario, deterministic, and probabilistic sensitivity analyses. The results show that treating patients with the UPA strategy, instead of the BSC strategy, results in an additional cost of £1,115 and a gain of 0.087 QALYs, resulting in an ICER of £12,850. Given commonly accepted cost-effectiveness thresholds in England, the use of UPA as a repeated, intermittent treatment for women with moderate to severe symptoms of UF wishing to avoid surgery is likely to be a cost-effective intervention when compared to BSC.

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  • 158.
    Gorenek, Bulent
    et al.
    Eskisehir Osmangazi University, Turkey.
    Bax, Jeroen
    Leiden University of Medical Centre, Netherlands.
    Boriani, Giuseppe
    University of Modena and Reggio Emilia, Italy.
    Chen, Shih-Ann
    National Yang Ming University, Taiwan.
    Dagres, Nikolaos
    University of Leipzig, Germany.
    Glotzer, Taya V.
    Hackensack University, NJ USA.
    Healey, Jeff S.
    McMaster University, Canada.
    Israel, Carsten W.
    Evangel Krankenhaus Bielefeld GmbH, Germany.
    Kudaiberdieva, Gulmira
    Adana, Turkey.
    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.
    Martin, David
    Lahey Hospital and Medical Centre, MA USA.
    Okumura, Ken
    Sasekai Kumamoto Hospital, Japan.
    Svendsen, Jesper H.
    Copenhagen University Hospital, Denmark.
    Tse, Hung-Fat
    University of Hong Kong, Peoples R China.
    Botto, Giovanni L.
    St Anna Hospital, Italy.
    Sticherling, Christian
    University of Spital Basel, Switzerland.
    Linde, Cecilia
    Karolinska University Hospital, Sweden.
    Kutyifa, Valentina
    University of Rochester, NY 14642 USA.
    Bernat, Robert
    Westfalz Klinikum, Germany.
    Scherr, Daniel
    Medical University of Graz, Austria.
    Lau, Chu-Pak
    University of Hong Kong, Peoples R China.
    Iturralde, Pedro
    Institute Nacl Cardiol, Mexico.
    Morin, Daniel P.
    University of Queensland, LA USA.
    Savelieva, Irina
    St Georges University of London, England.
    Device-detected subclinical atrial tachyarrhythmias: definition, implications and management-an European Heart Rhythm Association (EHRA) consensus document, endorsed by Heart RhythmSociety (HRS), Asia Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLEACE)2017In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 19, no 9, p. 1556-1578Article in journal (Refereed)
    Abstract [en]

    n/a

  • 159.
    Grossmann, Benjamin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping (ANOPIVA).
    Nilsson, Andreas
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping (ANOPIVA).
    Sjöberg, Folke
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Nilsson, Lena
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping (ANOPIVA).
    Patient-controlled sedation with propofol for endoscopic procedures: A cost analysis2020In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 64, no 1, p. 53-62Article in journal (Refereed)
    Abstract [en]

    Background

    Patient‐controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation.

    Methods

    Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine‐scopolamine or glycopyrronium.

    Results

    Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine‐scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups.

    Conclusion

    Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

  • 160.
    Gustavsson, Erik
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Patients with multiple needs for healthcare and priority to the worse off2019In: Bioethics, ISSN 0269-9702, E-ISSN 1467-8519, Vol. 33, no 2, p. 261-266Article in journal (Refereed)
    Abstract [en]

    There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition-specific severity). In this paper I argue that giving priority to the worse off in terms of condition-specific severity does not reflect the morally relevant sense of being worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity).

  • 161.
    Gustavsson, Erik
    et al.
    Linköping University, Department of Culture and Communication, Culture and Aesthetics. 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.
    Juth, Niklas
    LIME, Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden..
    Principles of Need and the Aggregation Thesis2019In: Health Care Analysis, ISSN 1065-3058, E-ISSN 1573-3394, Vol. 27, no 2, p. 77-92Article in journal (Refereed)
    Abstract [en]

    Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications.

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  • 162.
    Gustavsson, Erik
    et al.
    Linköping University, Department of Culture and Communication, Arts and Humanities. Linköping University, Faculty of Arts and Sciences.
    Juth, Niklas
    Centre for healthcare ethics, Karolinska institutet, Solna, Sverige.
    Munthe, Christian
    Institutionen för filosofi, lingvistik och vetenskapsteori, Göteborgs universitet, Sverige.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Institutionen för vårdvetenskap, Högskolan i Borås, Sverige.
    Etiska och praktiska utmaningar med ökat patientinflytande2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, article id DD3XArticle in journal (Other academic)
    Abstract [sv]

    Det finns ett ökat intresse för patientinflytande i vården. Ett sådant fokus kan dock komma i konflikt med ett antal värden/praktiker inom vården. I denna artikel identifierar vi att följande värden/praktiker kan påverkas: 

    Idén om patientens vårdbehov förefaller tappa sin moraliska och politiska ställning. 

    Prioriteringar på gruppnivå kan bli svårare att tillämpa på individnivå. 

    Det kan bli svårare att bedöma nyttan med behandlingar. 

    Det kan bli svårare att få fram evidens för behandlingar. 

    Det tycks komplicera idén om den följsamme patienten. 

    Det kan innebära vissa implikationer för resursanvändning. 

    Det kan ge ett nytt perspektiv på idén om att prioritera efter en ansvarsprincip.

  • 163.
    Gustavsson, Erik
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Etisk analys av pre-expositionsprofylax (PrEP) för hiv2018Report (Other academic)
    Abstract [sv]

    Föreliggande etiska analys rör pre- expositionsprofylax (PrEP) mot hiv som en hivnegativ person kan ta för att minska risken för att drabbas av en hivinfektion. Om PrEP tas som ordinerat ger det en ungefärlig skyddsgrad mot hiv på 85 % jämfört med en kontrollgrupp. Eftersom PrEP inte ger 100 % skydd och inte heller skyddar mot andra sexuellt överförbara sjukdomar så är rekommendationen att det tas i kombination med praktiserandet av säkert sex.

    Den här etiska analysen har gjorts på uppdrag av NT-rådet och behandlar följande två frågeställningar: 1) finns det etiska skäl som talar emot förskrivning av PrEP; (2) hur bör PrEP prioriteras i relation till den etiska plattformen med ett särskilt fokus på huruvida PrEP bör egenfinanseras. Det finns starka skäl att minska smittspridningen av hiv utifrån såväl ett individ- som ett samhällsperspektiv vilket talar för förskrivning av PrEP. I diskussionen kring PrEP har det dock framförts att PrEP skiljer sig från annan preventiv behandling för att minska smittspridning på ett sätt som talar emot att PrEP förskrivs. Den etiska analysen diskuterar ett antal sådana argument: att friska personer utan medicinskt behov behandlas, att det handlar om ett socialt riskbeteende, att individer själva bör ta ansvar för smittspridning genom att ändra sitt beteende, samt risken för resistensproblematik. Slutsatsen är att inte något av dessa motargument är tillräckligt starkt för att tala emot förskrivningen av PrEP.

    När det gäller prioritering av PrEP i relation till den etiska plattformen dras slutsatsen att PrEP hamnar i den lägre delen av prioriteringsskalan baserat på svårighetsgraden hos tillståndet som PrEP riktar sig emot. Det innebär att PrEP skulle kunna vara en kandidat för egenfinansiering.

    Eftersom den etiska plattformen säger mycket lite om vilka åtgärder som bör egenfinaiseras så har analysen utgått från två ramverk presenterade i den internationella literaturen. Trots att flera aspekter av dessa ramverk talar för att PrEP skulle vara passande för egenfinansiering så väger aspekten av minskad smittspridning tungt. Dessa positiva externa effekter tillsammans med svårigheten att bedöma huruvida patientpopulationen skulle kunna egenfinansiera PrEP bidrar till bedömningen att PrEP bör finansieras inom ramen för det offentliga åtagandet.

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    Etisk analys av pre-expositionsprofylax (PrEP) för hiv
  • 164.
    Gustavsson, Erik
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. University of Boras, Sweden.
    Health-care needs and shared decision-making in priority-setting2015In: Medicine, Health care and Philosophy, ISSN 1386-7423, E-ISSN 1572-8633, Vol. 18, no 1, p. 13-22Article in journal (Refereed)
    Abstract [en]

    In this paper we explore the relation between health-care needs and patients desires within shared decision-making (SDM) in a context of priority setting in health care. We begin by outlining some general characteristics of the concept of health-care need as well as the notions of SDM and desire. Secondly we will discuss how to distinguish between needs and desires for health care. Thirdly we present three cases which all aim to bring out and discuss a number of queries which seem to arise due to the double focus on a patients need and what that patient desires. These queries regard the following themes: the objectivity and moral force of needs, the prediction about what kind of patients which will appear on a micro level, implications for ranking in priority setting, difficulties regarding assessing and comparing benefits, and implications for evidence-based medicine.

  • 165.
    Gustavsson, Erik
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health and Society. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Högskolan i Borås, Institutionen för vårdvetenskap.
    Wiss, Johanna
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Rättviseteorier och prioriteringar2013In: Att välja rättvist: om prioriteringar i hälso- och sjukvården / [ed] Per Carlsson och Susanne Waldau, Lund: Studentlitteratur, 2013, 1, p. 49-64Chapter 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.

  • 166.
    Gustavsson, Erik
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health and Society. Linköping University, Faculty of Arts and Sciences.
    Wiss, Johanna
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Multikriterieanalyser vid prioriteringar inom hälso- och sjukvården: kriterier och analysmetoder2013Report (Other academic)
    Abstract [en]

    The first part of this report draws attention to the vast amount of different criteria for policymakers to consider in priority setting decisions. There are several similarities between criteria that have been used in decision making in different countries and regions. However, it is interesting to highlight an important difference between the Swedish ethical platform and other countries and regions. The difference lies in the lexical ordering between the principles in the Swedish platform. This implies that one should take into account the principle of human dignity before the principle of need and solidarity and that the same relation should apply between the principle of need and solidarity and the principle of cost effectiveness. This strict hierarchy does not exist between principles in other countries. Similarities between different ethical platforms are especially found in relation to the principle of need or severity of the disease of which both play an important role in all countries and regions. Cost- effectiveness is another criterion that appears in all platforms that we have included in this report. Furthermore, it should be mentioned that the effect of an intervention plays an important role in all of the studies and reports that we have included. In several cases, there is a special focus on the prioritization of interventions with a proven efficacy. The above mentioned criteria are the most commonly present in reports on priority setting in health care but there are many other criteria which may be relevant to consider. It should also be noted that there are great similarities between the various reports on what should not constitute a basis for prioritization. For example, many countries and regions are reluctant to include chronological age as one criterion in their official reports.

    The second part of the report presents the methods of multi-criteria analysis; an umbrella term for various methods that uses a formalized process and ranks different alternatives on how they perform on a number of selected criteria. The different steps of a general multi-criteria analysis are presented: (1) identification of the object (2) construction of the model (3) evaluation of results and (4) the development of an action plan. A performance matrix, which is a standard tool for multi-criteria, is illustrated. In the next step, a selection of a number of various methods is presented, namely: direct analysis of the performance matrix, ordinal methods, the even swap-method, multi-attribute utility theory (MAUT), and the analytic hierarchy process (AHP). A number of applications of multi-criteria analysis have been performed in the area of health care decision making and the advantages and disadvantages of applying these methods in this area are highlighted.

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    Multikriterieanalyser vid prioriteringar inom hälso- och sjukvården: kriterier och analysmetoder
  • 167.
    Gärtner, Manja
    et al.
    DIW Berlin.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    Västfjäll, Daniel
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Department of Management and Engineering, Economics. Decision Research .
    Decision-making traits and states as determinants of risky choicesManuscript (preprint) (Other academic)
    Abstract [en]

    We test the effects of dual processing differences in both individual traits and decision states on risk taking. In an experiment with a large representative sample (N = 1,832), we vary whether risky choices are induced to be based on either emotion or reason, while simultaneously measuring individual decision-making traits. Our results show that decision-making traits are strong and robust determinants of risk taking: a more intuitive trait is associated with more risk taking, while a more deliberative trait is associated with less risk taking. Experimentally induced states, on the other hand, have no effect on risk taking. A test of state-trait interactions shows that the association between an intuitive trait and risk taking becomes weaker in the emotion-inducing state and in the loss domain. In contrast, the association between a deliberative trait and risk taking is stable across states. These findings highlight the importance of considering state-trait interactions when using dual processing theories to predict individual differences in risk taking.

  • 168.
    Hager, Jakob
    et al.
    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 Thoracic and Vascular Surgery.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Center for Medical Image Science and Visualization (CMIV). 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.
    Länne, Toste
    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 Thoracic and Vascular Surgery.
    Lundgren, Fredrik
    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 Thoracic and Vascular Surgery.
    Changing Conditions - the same Conclusion: Cost-effective to Screen for Abdominal Aortic Aneurysm among 65-year-old Men, based on Data from an Implemented Screening Programme2014Manuscript (preprint) (Other academic)
    Abstract [en]

    Background: Health economic analyses based on randomized trials have shown that screening for abdominal aortic aneurysm (AAA) cost-effectively decreases AAA-related as well as allcause mortality. However, results from running screening programmes now reveal substantially changed conditions in terms of prevalence, attendance rate, costs and mortality after intervention. Our aim was to evaluate whether screening for AAA among 65-year-old men on a general basis is cost-effective under current clinical practice.

    Methods: A decision-analytic model, previously used to show the cost-effectiveness of an AAA-screening programme before decision to introduce screening in practice, was updated using results from implemented screening-programmes as well as data from contemporary published data and the Swedvasc registry.

    Results: The base-case analysis showed that the cost per life-year gained and quality-adjusted life year (QALY) gained were 3252 € and 4231 €, respectively. The probability of screening being cost-effective was high.

    Conclusion: Despite profound changes in disease pattern and AAA-management, the current results are similar to those reported almost 10 years ago, and thus screening 65-year-old men for AAA still appears to be cost-effective.

  • 169.
    Hager, Jakob
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping.
    Henriksson, Martin
    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.
    Länne, Toste
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Faculty of Medicine and Health Sciences.
    Lundgren, Fredrik
    Department of Surgery, Kalmar County Hospital, Kalmar, Sweden.
    Revisiting the cost-effectiveness of screening 65-year-old men for abdominal aortic aneurysm based on data from an implemented screening programme.2017In: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 36, no 6, p. 517-525Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health economic analyses based on randomized trials have shown that screening for abdominal aortic aneurysm (AAA) cost-effectively decreases AAA-related, as well as all- cause mortality. However, follow-up from implemented screening programmes now reveal substantially changed conditions in terms of prevalence, attendance rate, costs and mortality after intervention. Our aim was to evaluate whether screening for AAA among 65-year-old men is cost-effective based on contemporary data on prevalence and attendance rates from an ongoing AAA screening programme.

    METHODS: A decision-analytic model, previously used to analyse the cost-effectiveness of an AAA screening programme prior to implementation in clinical practice, was updated using data collected from an implemented screening programme as well as data from contemporary published data and the Swedish register for vascular surgery (Swedvasc).

    RESULTS: The base-case analysis showed that the cost per life-year gained and quality-adjusted life year (QALY) gained were €4832 and €6325, respectively. Based on conventional threshold values of cost-effectiveness, the probability of screening being cost-effective was high.

    CONCLUSION: Despite the reduction of AAA-prevalence and changes in AAA-management over time, screening 65-year-old men for AAA still appears to yield health outcomes at a cost below conventional thresholds of cost-effectiveness.

  • 170.
    Hager, Jakob
    et al.
    Linköping University, Department of Medical and Health Sciences, Physiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Länne, Toste
    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 Thoracic and Vascular Surgery.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundgren, Fredrik
    Linköping University, Department of Medical and Health Sciences, Physiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Lower Prevalence than Expected when Screening 70-year-old Men for Abdominal Aortic Aneurysm2013In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 46, no 4, p. 453-459Article in journal (Refereed)
    Abstract [en]

    Background

    Screening 65-year-old men for abdominal aortic aneurysms (AAA) is a cost-effective method to reduce the mortality from ruptured AAA. However, contemporary results show a lower than expected prevalence of AAA, thus questioning the benefit of screening. Since the prevalence increases with age, a possible way to enhance the benefit of screening might be to screen older men. Our aim was to determine the contemporary screening-detected prevalence among 70-year-old men.

    Methods

    A total of 5,623 unscreened 70-year-old men were invited to ultrasound screening. Uni- and multivariable analyses were used to assess the risk factors for AAA.

    Results

    The attendance rate was 84.0%. The prevalence of previously unknown AAAs was 2.3%. When adding the 64 men with an already known AAA to the screening-detected ones, the total prevalence in the population was at least 3.0%, and the previously discovered AAAs constituted 37.4% of the total prevalence. “Ex smoker” and “Current smoker” were the most important risk factors.

    Conclusions

    When screening 70-year-old men for AAA, the prevalence was less than half that expected, despite a high attendance rate. Smoking was the strongest risk factor. Almost 40% of the men with AAAs were already known from other means than screening.

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  • 171.
    Hager, Jakob
    et al.
    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 Thoracic and Vascular Surgery.
    Länne, Toste
    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 Thoracic and Vascular Surgery.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundgren, Fredrik
    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 Thoracic and Vascular Surgery.
    No benefit of screening for abdominal aortic aneurysm among 70- instead of 65-year-old men2014In: International Angiology, ISSN 0392-9590, Vol. 33, no 5, p. 474-479Article in journal (Refereed)
    Abstract [en]

    Objectives: Screening 65-year-old men for abdominal aortic aneurysm (AAA) reduces mortality from ruptured AAA (rAAA). Lower than expected prevalence of AAA is now found, why screening at a higher age and rescreening has been discussed. Our aim was to determine if screening at 70 years of age, instead of 65, increases clinical effectiveness.

    Methods: 7951 and 5623 previously un-screened 65- and 70-year old men were invited to ultrasound screening.

    Results: The attendance rate was 85.7% and 84.0%, p<0.01, for the 65- and 70-year old men respectively. The screening-detected prevalence did not differ, being 1.9% and 2.3%, p=0.15, respectively, probably due to the fact that 23.5% and 37.4% of all known AAA among 65- and 70-year-old men, were detected by other means prior to screening, p<0.01. However, the total known prevalence differed between the age-groups, being at least 2.1% and 3.0% respectively, p<0.001.

    Conclusion: The screening-detected AAA-prevalence did not differ between 65- and 70-yearold men, due to the greater number of AAA known prior to screening among 70- compared to 65-year-old men. Screening men at 70 instead of 65 years of age would not result in detection of substantially more previously unknown AAA, thus not preventing rAAA and consequently not more saved life-years. Further, data also indicates that it is questionable if re-screening the 65-year-old male population after five years would generate any important clinical effect.

  • 172.
    Hagman, William
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Västfjäll, Daniel
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Decision Research, Eugene, USA.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Arts and Sciences.
    Public Views on Policies Involving Nudges2015In: Review of Philosophy and Psychology, ISSN 1878-5158, E-ISSN 1878-5166, Vol. 6, no 3, p. 439-453Article in journal (Refereed)
    Abstract [en]

    When should nudging be deemed as permissible and when should it be deemed as intrusive to individuals’ freedom of choice? Should all types of nudges be judged the same? To date the debate concerning these issues has largely proceeded without much input from the general public. The main objective of this study is to elicit public views on the use of nudges in policy. In particular we investigate attitudes toward two broad categories of nudges that we label pro-self (i.e. focusing on private welfare) and pro-social (i.e. focusing on social welfare) nudges. In addition we explore how individual differences in thinking and feeling influence attitudes toward nudges. General population samples in Sweden and the United States (n=952) were presented with vignettes describing nudge-policies and rated acceptability and intrusiveness on freedom of choice. To test for individual differences, measures on cultural cognition and analytical thinking were included. Results show that the level of acceptance toward nudge-policies was generally high in both countries, but were slightly higher among Swedes than Americans. Somewhat paradoxically a majority of the respondents also perceived the presented nudge-policies as intrusive to freedom of choice. Nudge- polices classified as pro-social had a significantly lower acceptance rate compared to pro-self nudges (p<.0001). Individuals with a more individualistic worldview were less likely to perceive nudges as acceptable, while individuals more prone to analytical thinking were less likely to perceive nudges as intrusive to freedom of choice. To conclude, our findings suggest that the notion of “one-nudge- fits-all” is not tenable. Recognizing this is an important aspect both for successfully implementing nudges as well as nuancing nudge theory. 

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  • 173.
    Hallberg, S.
    et al.
    Quantify Research, Sweden.
    Banefelt, J.
    Quantify Research, Sweden.
    Fox, K. M.
    Strateg Healthcare Solut LLC, MD USA.
    Mesterton, J.
    Quantify Research, Sweden; Karolinska Institute, Sweden.
    Johansson, G.
    Uppsala University, Sweden.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sobocki, P.
    Karolinska Institute, Sweden; IMS Heatlh, Sweden.
    Gandra, S. R.
    Amgen Inc, CA 91320 USA.
    Lipid-lowering treatment patterns in patients with new cardiovascular events - estimates from population-based register data in Sweden2016In: International journal of clinical practice (Esher), ISSN 1368-5031, E-ISSN 1742-1241, Vol. 70, no 3, p. 222-228Article in journal (Refereed)
    Abstract [en]

    Objectives. The aim of this study was to assess treatment patterns of lipid-lowering therapy (LLT) in patients with hyperlipidaemia or prior cardiovascular (CV) events who experience new CV events. Methods. A retrospective population-based cohort study was conducted using Swedish medical records and registers. Patients were included in the study based on a prescription of LLT or CV event history and followed up for up to 7 years for identification of new CV events and assessment of LLT treatment patterns. Patients were stratified into three cohorts based on CV risk level. All outcomes were assessed during the year following index (the date of first new CV event). Adherence was defined as medication possession ratio (MPR) &gt; 0.80. Persistence was defined as no gaps &gt; 60 days in supply of drug used at index. ResultsOf patients with major cardiovascular disease (CVD) history (n = 6881), 49% were not on LLT at index. Corresponding data for CV risk equivalent and low/unknown CV risk patients were 37% (n = 3226) and 38% (n = 2497) respectively. MPR for patients on LLT at index was similar across cohorts (0.74-0.75). The proportions of adherent (60-63%) and persistent patients (56-57%) were also similar across cohorts. Dose escalation from dose at index was seen within all cohorts and 2-3% of patients switched to a different LLT after index while 5-6% of patients augmented treatment by adding another LLT. ConclusionsAlmost 50% of patients with major CVD history were not on any LLT, indicating a potential therapeutic gap. Medication adherence and persistence among patients on LLT were suboptimal.

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  • 174.
    Hallberg, S.
    et al.
    Quantify Research, Sweden.
    Gandra, S. R.
    Amgen Inc, CA 91320 USA.
    Fox, K. M.
    Strateg Healthcare Solut LLC, MD USA.
    Mesterton, J.
    Quantify Research, Sweden; Karolinska Institute, Sweden.
    Banefelt, J.
    Quantify Research, Sweden.
    Johansson, G.
    Uppsala University, Sweden.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sobocki, P.
    Karolinska Institute, Sweden; IMS Heatlh, Sweden.
    Healthcare costs associated with cardiovascular events in patients with hyperlipidemia or prior cardiovascular events: estimates from Swedish population-based register data2016In: European Journal of Health Economics, ISSN 1618-7598, E-ISSN 1618-7601, Vol. 17, no 5, p. 591-601Article in journal (Refereed)
    Abstract [en]

    To estimate healthcare costs of new cardiovascular (CV) events (myocardial infarction, unstable angina, revascularization, ischemic stroke, transient ischemic attack, heart failure) in patients with hyperlipidemia or prior CV events. A retrospective population-based cohort study was conducted using Swedish national registers and electronic medical records. Patients with hyperlipidemia or prior CV events were stratified into three cohorts based on CV risk level: history of major cardiovascular disease (CVD), coronary heart disease (CHD) risk-equivalent, and low/unknown risk. Propensity score matching was applied to compare patients with new events to patients without new events for estimation of incremental costs of any event and by event type. A CV event resulted in increased costs over 3 years of follow-up, with the majority of costs occurring in the 1st year following the event. The mean incremental cost of patients with a history of major CVD (n = 6881) was a,not sign8588 during the 1st year following the event. This was similar to that of CHD risk-equivalent patients (n = 3226; a,not sign6663) and patients at low/unknown risk (n = 2497; a,not sign8346). Ischemic stroke resulted in the highest 1st-year cost for patients with a history of major CVD and CHD risk-equivalent patients (a,not sign10,194 and a,not sign9823, respectively); transient ischemic attack in the lowest (a,not sign3917 and a,not sign4140). Incremental costs remained elevated in all cohorts during all three follow-up years, with costs being highest in the major CVD history cohort. Healthcare costs of CV events are substantial and vary considerably by event type. Incremental costs remain elevated for several years after an event.

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  • 175.
    Hallert, Eva
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. 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.
    Kalkan, Almina
    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 Medicine and Health Sciences.
    Reumatoid artrit är fortfarande en kostsam sjukdom – jämförelse mellan två kohorter2016In: BestPractice Reumatologi, ISSN 1903-6590, no 27, p. 14-17Article in journal (Other academic)
    Abstract [sv]

    Sjukdomsaktivitet, funktionsförmåga samt direkta och indirekta kostnader har analyserats i två kohorter av patienter med nydebuterad (≤ 1 år) reumatoid artrit (RA).

    Den första kohorten med 320 patienter (T1) rekryterades 1996–1998 och den andra med 463 patienter (T2) rekryterades 2006–2009. Patienterna har följts regelbundet avseende kliniska och laboratoriemedicinska variabler och har fortlöpande i hälsoekonomienkäter registrerat all sjukvårdskonsumtion och antal dagar med sjukskrivning/sjukersättning samt rapporterat livskvalitet med EQ-5D och EQ-VAS.

  • 176.
    Hallert, Eva
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. 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.
    Kalkan, Almina
    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 Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Allergy Center.
    Rheumatoid arthritis is still expensive in the new decade: a comparison between two early RA cohorts, diagnosed 1996-98 and 2006-092016In: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 45, no 5, p. 371-378Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES:

    To calculate total costs during the first year after diagnosis in 463 patients with early rheumatoid arthritis (RA) included during 2006-09 (T2) and compare the results with a similar cohort included in 1996-98 (T1).

    METHOD:

    Clinical and laboratory data were collected regularly in both cohorts, and patients completed biannual questionnaires reporting health care utilization and number of days lost from work.

    RESULTS:

    Disease activity was similar in both cohorts T1 and T2 at inclusion. Significant improvements were seen during the first year in both cohorts but were more pronounced in T2. Outpatient care increased and hospitalization decreased in T2 compared with T1. Almost 3% of patients had surgery in both cohorts, but in T2, only women had surgery. Drug costs were higher in T2 than in T1 (EUR 689 vs. EUR 435). In T2, 12% of drug costs were direct costs and 4% were total costs. The corresponding values for T1 were 9% and 3%. In T1, 50% were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion, compared to T2, where prescription was > 90%. Direct costs were EUR 5716 in T2 and EUR 4674 in T1. Costs for sick leave were lower in T2 than in T1 (EUR 5490 vs. EUR 9055) but disability pensions were higher (EUR 4152 vs. EUR 2139), resulting in unchanged total costs. In T1, direct costs comprised 29% and indirect costs 71% of the total costs. The corresponding values for T2 were 37% and 63%.

    CONCLUSIONS:

    The earlier and more aggressive treatment of RA with traditional DMARDs in T2 resulted in better outcomes compared to T1. Direct costs were higher in T2, partly offset by decreased sick leave, but total costs remained unchanged.

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  • 177.
    Hallert, Eva
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Kalkan, Almina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Rahmqvist, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Skogh, Thomas
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Rheumatology.
    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.
    Changes in sociodemographic characteristics at baseline in two Swedish cohorts of patients with early rheumatoid arthritis diagnosed 1996-98 and 2006-092015In: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 44, no 2, p. 100-105Article in journal (Refereed)
    Abstract [en]

    Objectives: To compare baseline sociodemographic characteristics in two rheumatoid arthritis (RA) cohorts enrolled 10 years apart, and to examine differences with respect to the general population. Method: Clinical and sociodemographic data were collected in 320 early RA patients during 1996-98 (TIRA-1) and 467 patients in 2006-09 (TIRA-2). Multivariate logistic regression tests were performed and intercohort comparisons were related to general population data, obtained from official databases. Results: TIRA-2 patients were older than TIRA-1 (58 vs. 56 years). Women (both cohorts, 67%) were younger than men in TIRA-1 (55 vs. 59 years) and in TIRA-2 (57 vs. 61 years). Disease activity was similar but TIRA-2 women scored worse pain and worse on the HAQ. Approximately 73% were cohabiting, in both cohorts and in the general population. Education was higher in TIRA-2 than in TIRA-2 but still lower than in the general population. Women had consistently higher education than men. Education was associated with age, younger patients having higher education. In both cohorts, lower education was associated with increased disability pension and increased sick leave. Sick leave was lower in TIRA-2 than in TIRA-1 (37% vs. 50%) but disability pension was higher (16% vs. 10%). In TIRA-1, 9% of women had disability pension compared with 17% in TIRA-2. A similar decrease in sick leave and an increase in disability pension were also seen in the general population. Older age and a higher HAQ score were associated with increased sick leave and being in the TIRA-2 cohort was associated with decreased sick leave. Conclusions: TIRA-2 patients were slightly older, better educated, had lower sick leave and higher disability pension than those in TIRA-1. Similar changes were seen simultaneously in the general population. Belonging to the TIRA-2 cohort was associated with decreased sick leave, indicating that societal changes are of importance.

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  • 178.
    Hallert, Eva
    et al.
    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 Rheumatology.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Kalkan, Almina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Skogh, Thomas
    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 Rheumatology.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Early rheumatoid arthritis 6 years after diagnosis is still associated with high direct costs and increasing loss of productivity: the Swedish TIRA project2014In: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 43, no 3, p. 177-183Article in journal (Refereed)
    Abstract [en]

    Objectives: To calculate total costs over 6 years after diagnosis of early rheumatoid arthritis (RA).

    Method: In the longitudinal prospective multicentre TIRA study, 239 patients from seven units, diagnosed in 1996–98, reported regularly on health-care utilization and the number of days lost from work. Costs were obtained from official databases and calculated using unit costs (Swedish kronor, SEK) from 2001. Indirect costs were calculated using the human capital approach (HCA). Costs were inflation adjusted to Euro June 2012, using the Swedish Consumer Price Index and the exchange rate of June 2012. Statistical analyses were based on linear mixed models (LMMs) for changes over time.

    Results: The mean total cost per patient was EUR 14 768 in year 1, increasing to EUR 18 438 in year 6. Outpatient visits and hospitalization decreased but costs for surgery increased from EUR 92/patient in year 1 to EUR 444/patient in year 6. Drug costs increased from EUR 429/patient to EUR 2214/patient, mainly because of the introduction of biologics. In year 1, drugs made up for 10% of direct costs, and increased to 49% in year 6. Sick leave decreased during the first years but disability pensions increased, resulting in unchanged indirect costs. Over the following years, disability pensions increased further and indirect costs increased from EUR 10 284 in year 1 to EUR 13 874 in year 6. LMM analyses showed that indirect costs were unchanged whereas direct costs, after an initial fall, increased over the following years, leading to increasing total costs.

    Conclusions: In the 6 years after diagnosis of early RA, drug costs were partially offset by decreasing outpatient visits but indirect costs remained unchanged and total costs increased.

     

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  • 179.
    Hansson, Emma
    et al.
    Gothenburg Univ, Sweden; Lund Univ, Sweden.
    Elander, Anna
    Gothenburg Univ, Sweden.
    Hallberg, Hakan
    Gothenburg Univ, Sweden.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Vastra Gotaland Reg, Sweden; Boras Univ, Sweden.
    Should immediate breast reconstruction be performed in the setting of radiotherapy? An ethical analysis2020In: Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, ISSN 2000-656X, E-ISSN 2000-6764, Vol. 54, no 2, p. 83-88Article in journal (Refereed)
    Abstract [en]

    Immediate breast reconstruction (IBR) combined with post-mastectomy radiotherapy (PMRT) is associated with an increased risk for complications. Here, we analyse whether IBR combined with PMRT is ethically acceptable. We employ normative analysis following reflective equilibrium and the principles of Beauchamp and Childress: non-maleficence, beneficence, autonomy, and justice. From the perspective of beneficence and non-maleficence, we can choose either IBR or PMRT according to documented risks and complications, delayed autologous breast reconstruction with corresponding benefits but less risk for complications, or even no reconstruction, which for some women, might be equally beneficial. In such a situation, given the level of severity associated with lacking a breast after mastectomy, IBR violates the principles of beneficence and non-maleficence. To deny an IBR in the context of PMRT does not violate the principle of autonomy as it is normally interpreted in the healthcare system, not even when patient-centred care is taken into consideration. Moreover, there is a risk that the decision of the patient will be affected by heuristics, optimism bias, and surgeon bias. IBR in the context of PMRT could be in conflict with the principle of justice, as it could lead to displacement of care for other patient groups. Furthermore, an acceptable level of cost effectiveness should be low, given that living without a breast is a condition of moderate severity. In conclusion, given the current knowledgebase and established ethical norms within the healthcare system, we find strong ethical reasons not to offer IBR when PMRT is expected.

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  • 180.
    Hass, Ursula
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Andersson, Agneta
    Linköping University, Department of Medical and Health Sciences, Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Brodin, Håkan
    Linköping University, Department of Management and Engineering, Engineering Materials. Linköping University, The Institute of Technology.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Assessment of computer-aided assistive technology: analysis of outcomes and costs1997In: Augmentative and Alternative Communication: AAC, ISSN 0743-4618, E-ISSN 1477-3848, Vol. 3, no 2, p. 125-135Article in journal (Refereed)
    Abstract [en]

    The objectives of this study were to identify and quantify outcomes related to implementation of computer-aided assistive technologies (CAAT) for individuals with communication disabilities and to analyze CAAT costs comprising the selected devices as well as the selection process. The study was designed as a pre/post, longitudinal study. Intermediate and global measures were used as outcome measures. Costs reflecting the resource consumption for the selected devices as well as the selection process were estimated. Individuals with communication disabilities who were referred to the regional CAAT centers were asked to participate in the study. Eighty-seven individuals were recruited. The study shows that usage of CAAT involves reasonable marginal costs for the selection process and equipment (on average SEK 14,800). Usage of CAAT diminishes disability and increases skills in handling computers. However, the outcomes are not entirely positive regarding handicap, health-related quality of life, and utility.

    Read More: http://informahealthcare.com/doi/abs/10.1080/07434619712331277928

  • 181.
    Hedbrant, Johan
    et al.
    Linköping University, Department of Management and Engineering, Applied Thermodynamics and Fluid Mechanics. Linköping University, The Institute of Technology.
    Nordfeldt, Sam
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Nordfeldt, Sam
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Molecular and Clinical Medicine, Pediatrics.
    Ludvigsson, Johnny
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Molecular and Clinical Medicine, Pediatrics. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping.
    Ludvigsson, Johnny
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Molecular and Clinical Medicine, Pediatrics. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping.
    The Särimner Diabetes Simulator - A Look in the Rear View Mirror2007In: Diabetes Technology & Therapeutics, ISSN 1520-9156, E-ISSN 1557-8593, Vol. 9, no 1, p. 10-16Article in journal (Refereed)
    Abstract [en]

      

  • 182.
    Hedin, Christina
    et al.
    Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Sjödahl, Rune
    Linköping University, Department of Clinical and Experimental Medicine, 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 Surgery in Linköping.
    Aldman, Åke
    Västerviks sjukhus, Västervik, Sweden.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Kammerlind, Ann-Sofie
    Region Jönköpings län, Jönköping, Sweden.
    Nodbrant, Per
    Onkologiska kliniken, Länssjukhuset Ryhov, Jönköping, Sweden.
    Agrup, Måns
    Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Oncology. Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences.
    Theodorsson, Elvar
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Chemistry.
    Intraoperativ strålbehandling vid primar operation for bröstcancer: TARGIT-A-studien ej konklusiv2018In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 115, article id EWFFArticle, review/survey (Refereed)
    Abstract [sv]

    The TARGIT-A (TARGeted Intraoperative radioTherapy) multicentre study of early breast cancer compared intraoperative radiotherapy with external radiotherapy. While the intraoperative radiotherapy was standardised, the external postoperative comparison treatment followed established routines in the participating treatment centres resulting in substantial variations in dosages and treatment durations. The uncertainties in the interpretation of the study results created by the design of the TARGIT-A study constitute substantial obstacles to the possible introduction of intraoperative radiotherapy for early breast cancer.

  • 183.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Swedish Council on Health Technology Assessment (SBU), Stockholm.
    Arnberg, Karl
    The Dental and Pharmaceutical Benefits Agency (TLV) Stockholm.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Liliemark, Jan
    Swedish Council on Health Technology Assessment (SBU), Stockholm and The county councils' group on new drug therapies (NLT), The Swedish Association of Local Authorities and Regions (SALAR), Stockholm.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Swedish Council on Health Technology Assessment (SBU), Stockholm.
    The impact of health economic evaluations in Sweden.2014In: Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, ISSN 2212-0289, Vol. 108, no 7, p. 375-82Article in journal (Refereed)
    Abstract [en]

    The responsibility for healthcare in Sweden is shared by the central government, county councils and municipalities. The counties and municipalities are free to make their own prioritizations within the framework of the state healthcare laws. To guide prioritization of healthcare resources in Sweden, there is consensus that cost-effectiveness constitutes one of the three principles. The objective of this paper is to describe how cost-effectiveness, and hence health economic evaluations (HEE), have a role in pricing decisions, reimbursement of pharmaceuticals as well as the overall prioritization and allocation of resources in the Swedish healthcare system. There are various organizations involved in the processes of implementing health technologies in the Swedish healthcare system, several of which consider or produce HEEs when assessing different technologies: the Dental and Pharmaceutical Benefits Agency (TLV), the county councils' group on new drug therapies (NLT), the National Board of Health and Welfare, the Swedish Council on Health Technology Assessment (SBU), regional HTA agencies and the Public Health Agency of Sweden. The only governmental agency that has official and mandatory guidelines for how to perform HEE is TLV (LFNAR 2003:2). Even though HEEs may seem to have a clear and explicit role in the decision-making processes in the Swedish healthcare system, there are various obstacles and challenges in the use and dissemination of the results.

  • 184.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Gerber-Grote, Andreas
    Institut für Qualität und Wirtschaftlichkeit Gesundheitswes, Germany.
    Ghabri, Salah
    Department of Economic and Public Health Evaluation, Haute Autorite Sante, France.
    Hamers, Francoise F.
    Department of Economic and Public Health Evaluation, Haute Autorite de Sante, France.
    Prevolnik Rupel, Valentina
    Institute for Economic Research, Slovenia.
    Slabe-Erker, Renata
    Institute for Econ Research, Slovenia.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Is There a European View on Health Economic Evaluations? Results from a Synopsis of Methodological Guidelines Used in the EUnetHTA Partner Countries2016In: PharmacoEconomics (Auckland), ISSN 1170-7690, E-ISSN 1179-2027, Vol. 34, no 1, p. 59-76Article in journal (Refereed)
    Abstract [en]

    The objectives of this study were to review current methodological guidelines for economic evaluations of all types of technologies in the 33 countries with organizations involved in the European Network for Health Technology Assessment (EUnetHTA), and to provide a general framework for economic evaluation at a European level. Methodological guidelines for health economic evaluations used by EUnetHTA partners were collected through a survey. Information from each guideline was extracted using a pre-tested extraction template. On the basis of the extracted information, a summary describing the methods used by the EUnetHTA countries was written for each methodological item. General recommendations were formulated for methodological issues where the guidelines of the EUnetHTA partners were in agreement or where the usefulness of economic evaluations may be increased by presenting the results in a specific way. At least one contact person from all 33 EUnetHTA countries (100 %) responded to the survey. In total, the review included 51 guidelines, representing 25 countries (eight countries had no methodological guideline for health economic evaluations). On the basis of the results of the extracted information from all 51 guidelines, EUnetHTA issued ten main recommendations for health economic evaluations. The presented review of methodological guidelines for health economic evaluations and the consequent recommendations will hopefully improve the comparability, transferability and overall usefulness of economic evaluations performed within EUnetHTA. Nevertheless, there are still methodological issues that need to be investigated further.

  • 185.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Council Health Technology Assessment SBU, Sweden.
    Lintamo, Laura
    Swedish Council Health Technology Assessment SBU, Sweden.
    Hultcrantz, Monica
    Swedish Council Health Technology Assessment SBU, Sweden; Karolinska Institute, Sweden.
    Jacobson, Stella
    Swedish Council Health Technology Assessment SBU, Sweden; Karolinska Institute, Sweden.
    Levi, Ragnar
    Swedish Council Health Technology Assessment SBU, Sweden.
    Munthe, Christian
    University of Gothenburg, Sweden.
    Tranaeus, Sofia
    Swedish Council Health Technology Assessment SBU, Sweden; Malmö University, Sweden; Karolinska Institute, Sweden.
    Ostlund, Pernilla
    Swedish Council Health Technology Assessment SBU, Sweden; Malmö University, Sweden.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. University of Boras, Sweden.
    FRAMEWORK FOR SYSTEMATIC IDENTIFICATION OF ETHICAL ASPECTS OF HEALTHCARE TECHNOLOGIES: THE SBU APPROACH2015In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 31, no 3, p. 124-130Article in journal (Refereed)
    Abstract [en]

    Objectives: Assessment of ethical aspects of a technology is an important component of health technology assessment (HTA). Nevertheless, how the implementation of ethical assessment in HTA is to be organized and adapted to specific regulatory and organizational settings remains unclear. The objective of this study is to present a framework for systematic identification of ethical aspects of health technologies. Furthermore, the process of developing and adapting the framework to a specific setting is described. Methods: The framework was developed based on an inventory of existing approaches to identification and assessment of ethical aspects in HTA. In addition, the framework was adapted to the Swedish legal and organizational healthcare context, to the role of the HTA agency and to the use of non-ethicists. The framework was reviewed by a group of ethicists working in the field as well as by a wider set of interested parties including industry, interest groups, and other potential users. Results: The framework consists of twelve items with sub-questions, short explanations, and a concluding overall summary. The items are organized into four different themes: the effects of the intervention on health, its compatibility with ethical norms, structural factors with ethical implications, and long term ethical consequences of using the intervention. Conclusions: In this study, a framework for identifying ethical aspects of health technologies is proposed. The general considerations and methodological approach to this venture will hopefully inspire and present important insights to organizations in other national contexts interested in making similar adaptations.

  • 186.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Hälsoekonomiska utvärderingar och beslutsfattande2016In: Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson / [ed] Martin Henriksson, Linköping: Linköping University Electronic Press, 2016, p. 38-50Chapter in book (Other academic)
  • 187.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson2016Collection (editor) (Other academic)
    Abstract [sv]

    Under alla år som jag arbetat med hälsoekonomi har Per Carlsson funnits närvarande. Mest intensivt som handledare under mina år som doktorand. När jag lärde känna Per år 2000 kom jag som nybakad nationalekonom till dåvarande CMT med en ganska snävt definierad nyttofunktion där fotboll var ett av de absolut dominerande attributen. Det har egentligen inte ändrats radikalt, men definitivt nyanserats en del under åren och det är delvis tack vare Per. Idol kan låta lite drastiskt, jag sprang inte omkring och bad om autografer eller att få fotas tillsammans med Per, men det är helt klart så att Per blev den första personen i min yrkeskarriär som jag med stor beundran såg upp till på ungefär samma sätt som man tidigare enbart gjort med sina idoler på fotbollsplanen. Med klokskap, sunt förnuft och en otrolig förmåga att hela tiden se de lite bredare sammanhangen blev han inte bara ett ovärderligt stöd i mitt eget arbete utan också en stor förebild mer generellt.

    När det nu är dags för Per att trappa ner efter en lång och framgångsrik yrkeskarriär i akademins och hälso- och sjukvårdspolicyns tjänst kändes det både självklart och naturligt att försöka bidra med en bestående hyllning. Glädjande nog var vi många som delade den tanken och resultatet blev den antologi med samlade reflektioner som du nu håller i din hand. Bidragen spänner över ett brett fält från teorier om livskvalitet till praktiskt prioriteringsarbete och är talande för den bredd som genomsyrat Pers karriär. Vidare kan man säga att bidragen också kronologiskt inkluderar hela Pers era inom området då vi inleder med Bengt Jönsson som var handledare till Per och avslutar med Johanna Wiss som snart disputerar med Per som handledare.

    Jag vill självklart också rikta ett stort tack till alla författare som bidragit till skriften. Den ger förhoppningsvis Per en möjlighet att reflektera över en livslång gärning inom akademi och hälso- och sjukvårdspolicy när det blir lite tid över i hängmattan framöver. Skriften ger också en bred populärvetenskaplig introduktion till aspekter som berör prioriteringar, utvärderingar, implementering och hälsoekonomi och det är min förhoppning att den kan uppskattas av alla som har intresse av dessa frågor.

    Martin Henriksson

    Maj 2016

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  • 188.
    Henriksson, Martin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. PAREXEL Int, Sweden.
    Jindal, Ramandeep
    PAREXEL Int, India.
    Sternhufvud, Catarina
    AstraZeneca, Sweden.
    Bergenheim, Klas
    AstraZeneca, Sweden.
    Sorstadius, Elisabeth
    AstraZeneca, Sweden.
    Willis, Michael
    Swedish Institute Health Econ, Sweden.
    A Systematic Review of Cost-Effectiveness Models in Type 1 Diabetes Mellitus2016In: PharmacoEconomics (Auckland), ISSN 1170-7690, E-ISSN 1179-2027, Vol. 34, no 6, p. 569-585Article, review/survey (Refereed)
    Abstract [en]

    Critiques of cost-effectiveness modelling in type 1 diabetes mellitus (T1DM) are scarce and are often undertaken in combination with type 2 diabetes mellitus (T2DM) models. However, T1DM is a separate disease, and it is therefore important to appraise modelling methods in T1DM. This review identified published economic models in T1DM and provided an overview of the characteristics and capabilities of available models, thus enabling a discussion of best-practice modelling approaches in T1DM. A systematic review of Embase(A (R)), MEDLINEA (R), MEDLINEA (R) In-Process, and NHS EED was conducted to identify available models in T1DM. Key conferences and health technology assessment (HTA) websites were also reviewed. The characteristics of each model (e.g. model structure, simulation method, handling of uncertainty, incorporation of treatment effect, data for risk equations, and validation procedures, based on information in the primary publication) were extracted, with a focus on model capabilities. We identified 13 unique models. Overall, the included studies varied greatly in scope as well as in the quality and quantity of information reported, but six of the models (Archimedes, CDM [Core Diabetes Model], CRC DES [Cardiff Research Consortium Discrete Event Simulation], DCCT [Diabetes Control and Complications Trial], Sheffield, and EAGLE [Economic Assessment of Glycaemic control and Long-term Effects of diabetes]) were the most rigorous and thoroughly reported. Most models were Markov based, and cohort and microsimulation methods were equally common. All of the more comprehensive models employed microsimulation methods. Model structure varied widely, with the more holistic models providing a comprehensive approach to microvascular and macrovascular events, as well as including adverse events. The majority of studies reported a lifetime horizon, used a payer perspective, and had the capability for sensitivity analysis. Several models have been developed that provide useful insight into T1DM modelling. Based on a review of the models identified in this study, we identified a set of best in class methods for the different technical aspects of T1DM modelling.

  • 189.
    Henriksson, Martin
    et al.
    Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Astra Zeneca Nordic-Baltic, Södertälje, Sweden.
    Nikolic, Elisabet
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Ohna, Audun
    Astra Zeneca Nordic-Baltic, Södertälje, Sweden.
    Wallentin, Lars
    Uppsala University, Sweden.
    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.
    Ticagrelor treatment in patients with acute coronary syndrome is cost-effective in Sweden and Denmark2014In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 48, no 3, p. 138-147Article in journal (Refereed)
    Abstract [en]

    Objectives. To evaluate the cost-effectiveness of treating patients with acute coronary syndromes (ACS) for 12 months with ticagrelor compared with generic clopidogrel in Sweden and Denmark. Design. Decision-analytic model to estimate lifetime costs, life-expectancy, and quality-adjusted life years (QALYs) with ticagrelor and clopidogrel. Event rates, healthcare resource use, and health-related quality of life during 12 months of therapy were estimated from the PLATelet inhibition and patient Outcomes (PLATO) trial. Beyond 12 months, quality-adjusted survival and costs were estimated conditional on events occurring during the 12 months of therapy. When available, country-specific data were employed in the analysis. Incremental cost-effectiveness ratios are presented from a healthcare perspective and a broader societal perspective including costs falling outside the healthcare sector in 2010 local currency. Results. The cost per QALY with ticagrelor compared with generic clopidogrel was SEK 25 022 and DKK 26 892 for Sweden and Denmark, respectively, from a healthcare perspective. The cost per QALY from a broader societal perspective was SEK 24 290 and DKK 25 051 for Sweden and Denmark, respectively. Conclusion. The cost per QALY of treating ACS-patients with ticagrelor compared with generic clopidogrel is below the conventional thresholds of cost-effectiveness in Sweden and Denmark.

  • 190.
    Henriksson, Martin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Siverskog, Jonathan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Johannesen, Kasper
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Eriksson, Thérèse
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Tröskelvärden och kostnadseffektivitet: innebörd och implikationer för ekonomiska utvärderingar och beslutsfattande i hälso- och sjukvården2018Report (Other academic)
    Abstract [en]

    The results of health economic evaluations are often reported as an incremental cost-effectiveness ratio (ICER) indicating the additional cost in relation to the additional benefit of providing the health care technology under evaluation compared with a relevant alternative. The health care technology may be a prevention program, a diagnostic method, a surgical procedure or a pharmaceutical treatment (henceforth we refer to interventions as a general term for all health care technologies). Commonly, benefits are measured in health-related outcomes such as the quality-adjusted life year (QALY). To interpret and operationalize ICERs in health care decision making, they have to be compared with some benchmark value. This value of a QALY when an intervention can be interpreted as being cost-effective is often referred to as the cost-effectiveness threshold in the literature. Ambitious attempts to estimate this threshold value have recently been reported, contributing with new knowledge in the field. In light of this research it is also evident that there are different interpretations of the threshold and different views regarding what the threshold should represent. Different interpretations may lead to different policy conclusions as well as diverging interpretations of cost-effectiveness. The aim of this report is to describe different interpretations of the cost-effectiveness threshold, summarize the empirical evidence, and discuss the threshold and further research in a Swedish context. In the report, the two main definitions of cost-effectiveness thresholds appearing in the literature are covered. One definition of the threshold is the consumption value of health, or the willingness to pay for health, and may represent what individuals on the margin are willing to forego in consumption in order to obtain an additional QALY. This definition is sometimes referred to as a demand side threshold, and has been dubbed v in the literature. Another definition of the threshold is based on the productivity of the health care sector and is some-times referred to as the supply side threshold, dubbed k in the literature. With this approach, estimates of the marginal productivity of the health care sector can indicate if a new intervention generates more health than is expected to be forgone when displacing other health care (to fund the new intervention). In principle, the cost-effectiveness threshold with this definition should be the cost per QALY gained of the least cost-effective intervention still funded within the health care system. The implications of a wider societal perspective (including non-health care sectors) for the two definitions of the cost-effectiveness threshold are discussed in the report. It is argued that the marginal productivity of the health care sector always has to be considered if some opportunity costs of a new intervention fall on the health care sector. When opportunity costs of a new intervention in the health care sector fall on private consumption, the consumption value of health may also have to be considered. The answer to the question of which definition of the cost-effectiveness threshold is more appropriate or relevant is therefore that it depends on the perspective deemed relevant as well as where the opportunity costs are expected to fall. Empirical studies have to a larger extent focussed on estimating the consumption value of health (v) compared with the marginal productivity of the health care sector (k). Regarding estimates of both v and k, the empirical evidence regarding a Swedish context is limited. An English study is, as far as we are aware, the first attempt to explicitly estimate k based on large scale data. In this study, the cost-effectiveness threshold was estimated at a cost per QALY of £13,000. In an attempt to translate this estimate to a Swedish setting, a cost per QALY in the interval $21,000 to $27,000 has been presented. Studies attempting to estimate v report estimates of 30,000 to several million Swedish kronor.

    Much of the variation in results appears to be explained by methodological differences in the studies including: study design (online, interviews or surveys), response alternatives, statistical methods for analysing data, type of health evaluated (length of life, quality of life or both), certainty in evaluated health change, and whether the evaluated health change will be obtained by the respondent or someone else. Estimates of v in a Swedish setting are scarce when a general health change has been valued by a sample of the general public. The only identified study in the peer-reviewed literature with respondents from Sweden reports estimates in the interval 150,000 to 350,000 Swedish kronor. In a recent report available from the Swedish Institute for Health Economics (IHE) an estimated cost per QALY of 2.4 million is reported. It is concluded in the report that it is not possible to determine which definition of the cost-effective-ness threshold is most relevant or appropriate for health care decision making unless the purpose of the health care sector, and the relevant perspective are defined first. It is further concluded that regardless of the definition of the threshold, the empirical knowledge of marginal productivity of the health care sector (k) as well as the consumption value of health (v) is limited in a Swedish context. Further empirical studies are needed on both. Statistical modelling of available statistical resources may be a feasible approach for estimating the marginal productivity, while well conducted experiments, or methods to study revealed preferences by observing behaviour of individuals in real-life decision making may be feasible approaches for estimating the consumption value of health.

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    Tröskelvärden och kostnadseffektivitet: innebörd och implikationer för ekonomiska utvärderingar och beslutsfattande i hälso- och sjukvården
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  • 191.
    Hofmann, Bjorn
    et al.
    Norwegian Univ Sci and Technol NTNU, Norway; Univ Oslo, Norway.
    Bond, Ken
    CADTH, Canada.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Evaluating facts and facting evaluations: On the fact-value relationship in HTA2018In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 24, no 5, p. 957-965Article in journal (Refereed)
    Abstract [en]

    Health technology assessment (HTA) is an evaluation of health technologies in terms of facts and evidence. However, the relationship between facts and values is still not clear in HTA. This is problematic in an era of fake facts and truth production. Accordingly, the objective of this study is to clarify the relationship between facts and values in HTA. We start with the perspectives of the traditional positivist account of evaluating facts and the social-constructivist account of facting values. Our analysis reveals diverse relationships between facts and a spectrum of values, ranging from basic human values, to the values of health professionals, and values of and in HTA, as well as for decision making. We argue for sensitivity to the relationship between facts and values on all levels of HTA, for being open and transparent about the values guiding the production of facts, and for a primacy for the values close to the principal goals of health care, ie, relieving suffering. We maintain that philosophy (in particular ethics) may have an important role in addressing the relationship between facts and values in HTA. Philosophy may help us to avoid fallacies of inferring values from facts; to disentangle the normative assumptions in the production or presentation of facts and to tease out implicit value judgements in HTA; to analyse evaluative argumentation relating to facts about technologies; to address conceptual issues of normative importance; and to promote reflection on HTAs own value system. In this we argue for a(n Aristotelian) middle way between the traditional positivist account of evaluating facts and the social-constructivist account of facting values, which we call factuation. We conclude that HTA is unique in bringing together facts and values and that being conscious and explicit about this factuation is key to making HTA valuable to both individual decision makers and society as a whole.

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  • 192.
    Holmbom, Martin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Giske, Christian G.
    Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden.; Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden..
    Fredrikson, Mats
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences.
    Östholm Balkhed, Åse
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Infectious Diseases.
    Claesson, Carina
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Nilsson, Lennart E
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Hoffmann, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Hanberger, Håkan
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Infectious Diseases.
    14-Year Survey in a Swedish County Reveals a Pronounced Increase in Bloodstream Infections (BSI). Comorbidity: An Independent Risk Factor for Both BSI and Mortality2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 11Article in journal (Refereed)
    Abstract [en]

    Objectives: we assessed the incidence, risk factors and outcome of BSI over a 14-year period (2000-2013) in a Swedish county.

    Methods: retrospective cohort study on culture confirmed BSI among patients in the county of Östergötland, Sweden, with approximately 440,000 inhabitants. A BSI was defined as either community-onset BSI (CO-BSI) or hospital-acquired BSI (HA-BSI).

    Results: of a total of 11,480 BSIs, 67% were CO-BSI and 33% HA-BSI. The incidence of BSI increased by 64% from 945 to 1,546 per 100,000 hospital admissions per year during the study period. The most prominent increase, 83% was observed within the CO-BSI cohort whilst HA-BSI increased by 32%. Prescriptions of antibiotics in outpatient care decreased with 24% from 422 to 322 prescriptions dispensed/1,000 inhabitants/year, whereas antibiotics prescribed in hospital increased by 67% (from 424 to 709 DDD per 1,000 days of care). The overall 30-day mortality for HA-BSIs was 17.2%, compared to 10.6% for CO-BSIs, with an average yearly increase per 100,000 hospital admissions of 2 and 5% respectively. The proportion of patients with one or more comorbidities, increased from 20.8 to 55.3%. In multivariate analyses, risk factors for mortality within 30 days were: HA-BSI (2.22); two or more comorbidities (1.89); single comorbidity (1.56); CO-BSI (1.21); male (1.05); and high age (1.04).

    Conclusion: this survey revealed an alarming increase in the incidence of BSI over the 14-year study period. Interventions to decrease BSI in general should be considered together with robust antibiotic stewardship programmes to avoid both over- and underuse of antibiotics.

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  • 193.
    Holm-Larsen, Tove
    et al.
    Pharma Evidence, Denmark; University of Copenhagen, Denmark.
    Andersson, Fredrik
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    van der Meulen, Egbert
    Ferring Int PharmaScience Centre, Denmark.
    Yankov, Vladimir
    Ferring Pharmaceut Inc, NJ USA.
    Rosen, Raymond C.
    New England Research Institute, MA USA.
    Peter Norgaard, Jens
    Ferring Int PharmaScience Centre, Denmark.
    The Nocturia Impact Diary: A Self-Reported Impact Measure to Complement the Voiding Diary2014In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 17, no 6, p. 696-706Article in journal (Refereed)
    Abstract [en]

    Background: Nocturia is a chronic, fluctuating disease that disrupts sleep and has a wide-ranging impact on quality of life. Valid tools to measure the patient-reported impact of nocturia are essential for evaluating the value of treatment, but the available tools are suboptimal. Objectives: This study reports the development and validation of the Nocturia Impact Diary an augmented form of the Nocturia Quality of Life questionnaire designed to be completed in conjunction with the widely used 3-day voiding diary. Methods: The process comprised three steps: Step 1: Development of a concept pool using the Nocturia Quality of Life questionnaire and data from relevant studies; Step 2: Content validity study; Step 3: Psychometric testing of construct validity, reliability, and sensitivity of the diary in a randomized, placebo controlled study in patients with nocturia. Results: Step 1: Fourteen items and 4 domains were included in the first draft of the diary. Step 2: Twenty-three patients with nocturia participated in the cognitive debriefing study. Items were adjusted accordingly, and the content validity was high. Step 3: Fifty-six patients were randomized to desmopressin orally disintegrating tablet or placebo. The diary demonstrated high construct validity, with good sensitivity and a good fit to Rasch model, as well as high internal consistency, discriminatory ability, and acceptable sensitivity to change. Results indicated that the diary was unidimensional. Conclusions: The Nocturia Impact Diary is a convenient, validated patient-reported outcome measure it should be used in conjunction with a voiding diary to capture the real-life consequences of nocturia and its treatment.

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  • 194.
    Husberg, Magnus
    et al.
    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 Medicine and Health Sciences.
    Hallert, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Costs and disease activity in early rheumatoid arthritis in 1996-2000 and 2006-2011, improved outcome and shift in distribution of costs: a two-year follow-up2018In: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 47, no 5, p. 378-383Article in journal (Refereed)
    Abstract [en]

    Objective: To evaluate changes in healthcare utilization, costs, and disease activity from 1996 to 2011 for patients with early rheumatoid arthritis (RA).Method: Two cohorts of patients with early RA, included in 1996-1998 (T1) and 2006-2009 (T2), were followed regularly. Healthcare utilization, costs, and disease activity were compared between cohorts during 2years after diagnosis.Results: Disease activity was significantly improved in T2 vs T1. Drug costs increased in T2 vs T1 (EUR 911 vs EUR 535, respectively; p=0.017), and costs for RA-related hospitalization decreased. More than 90% in T2 were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion compared to 50% in T1. At 2year follow-up, levels were still amp;gt;90% in T2, while corresponding values in T1 were just above 70%. Comparing T2 to T1, total direct costs were slightly higher in T2 (EUR 3941 vs EUR 3364, respectively; ns), sick leave decreased (EUR 3511 vs EUR 5672; p=0.025), while disability pension increased slightly (EUR 4889 vs EUR 4244; ns), but total indirect costs remained unchanged (EUR 8400 vs EUR 9916; ns). Total direct and indirect costs did not differ between the cohorts (EUR 12342 in T2 vs EUR 13280 in T1; ns), and loss of productivity still represented the largest component of total costs.Conclusion: T2 patients were prescribed DMARDs earlier and more aggressively than T1 patients. Stable and better improvements in disease activity, function, and quality of life were achieved in T2 compared to T1. There was a shift within the components in direct costs and indirect costs, but total costs remained essentially unchanged.

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  • 195.
    Husberg, Magnus
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Hallert, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Non-medical costs during the first year after diagnosis in two cohorts of patients with early rheumatoid arthritis, enrolled 10 years apart2017In: Clinical Rheumatology, ISSN 0770-3198, E-ISSN 1434-9949, Vol. 36, no 3, p. 499-506Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to calculate non-medical costs during year 1 after diagnosis in two cohorts of patients with early rheumatoid arthritis enrolled 1996–1998 and 2006–2009. Clinical data were collected regularly in both cohorts. Besides information about healthcare utilization and days lost from work, patients reported non-medical costs for aids/devices, transportation, formal and informal care. Formal care was valued as full labour cost for official home help (€42.80/h) and informal care from relatives and friends as opportunity cost of leisure time, corresponding to 35% of labour cost (€15/h). In both cohorts, only 2% used formal care, while more than 50% used informal care. Prescription of aids/devices was more frequent in cohort 2 and more women than men needed aids/devices. Help with transportation was also more common in cohort 2. Women in both cohorts needed more informal care than men, especially with personal care and household issues. Adjusting for covariates in regression models, female sex remained associated with higher costs in both cohorts. Non-medical costs in cohort 2 were €1892, €1575 constituting informal care, corresponding to 83% of non-medical costs. Total non-medical costs constituted 25% of total direct costs and 11% of total direct and indirect costs. Informal care accounted for the largest part of non-medical costs and women had higher costs than men. Despite established social welfare system, it is obvious that family and friends, to a large extent, are involved in informal care of patients with early RA, and this may underestimate the total burden of the disease.

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  • 196.
    Häggman-Henrikson, B.
    et al.
    Malmö University, Sweden; Umeå University, Sweden; Malmö University, Sweden.
    Alstergren, P.
    Malmö University, Sweden; SCON, Sweden; Skåne University Hospital, Sweden.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Malmö University, Sweden.
    Hogestatt, E. D.
    Lund University, Sweden.
    Ostlund, P.
    Umeå University, Sweden; Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Tranaeus, S.
    Umeå University, Sweden; Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Vitols, S.
    Swedish Agency Health Technology Assessment and Assessment, Sweden; Karolinska Institute, Sweden.
    List, T.
    Malmö University, Sweden; SCON, Sweden; Skåne University Hospital, Sweden.
    Pharmacological treatment of oro-facial pain - health technology assessment including a systematic review with network meta-analysis2017In: Journal of Oral Rehabilitation, ISSN 0305-182X, E-ISSN 1365-2842, Vol. 44, no 10, p. 800-826Article, review/survey (Refereed)
    Abstract [en]

    This health technology assessment evaluated the efficacy of pharmacological treatment in patients with oro-facial pain. Randomised controlled trials were included if they reported pharmacological treatment in patients amp;gt;= 18 years with chronic (amp;gt;= 3 months) oro-facial pain. Patients were divided into subgroups: TMD-muscle [ temporomandibular disorders (TMD) mainly associated with myalgia]; TMD-joint (TMD mainly associated with temporomandibular joint pain); and burning mouth syndrome (BMS). The primary outcome was pain intensity reduction after pharmacological treatment. The scientific quality of the evidence was rated according to GRADE. An electronic search in PubMed, Cochrane Library, and EMBASE from database inception to 1 March 2017 combined with a handsearch identified 1552 articles. After screening of abstracts, 178 articles were reviewed in full text and 57 studies met the inclusion criteria. After risk of bias assessment, 41 articles remained: 15 studies on 790 patients classified as TMD-joint, nine on 375 patients classified as TMD-muscle and 17 on 868 patients with BMS. Of these, eight studies on TMD-muscle, and five on BMS were included in separate network meta-analysis. The narrative synthesis suggests that NSAIDs as well as corticosteroid and hyaluronate injections are effective treatments for TMD-joint pain. The network meta-analysis showed that clonazepam and capsaicin reduced pain intensity in BMS, and the muscle relaxant cyclobenzaprine, for the TMD-muscle group. In conclusion, based on a limited number of studies, evidence provided with network meta-analysis showed that clonazepam and capsaicin are effective in treatment of BMS and that the muscle relaxant cyclobenzaprine has a positive treatment effect for TMD-muscle pain.

  • 197.
    Iwarsson, Erik
    et al.
    Karolinska University Hospital, Sweden.
    Jacobsson, Bo
    Gothenburg University, Sweden; Institute Public Heatlh, Norway.
    Dagerhamn, Jessica
    Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Bernabe, Eduardo
    Kings Coll and St Thomas Hospital, England.
    Heibert Arnlind, Marianne
    Karolinska Institute, Sweden.
    Analysis of cell-free fetal DNA in maternal blood for detection of trisomy 21, 18 and 13 in a general pregnant population and in a high risk population - a systematic review and meta-analysis2017In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 96, no 1Article, review/survey (Refereed)
    Abstract [en]

    IntroductionThe aim of this study was to review the performance of non-invasive prenatal testing (NIPT) for detection of trisomy 21, 18 and 13 (T21, T18 and T13) in a general pregnant population as well as to update the data on high-risk pregnancies. Material and methodsSystematic review and meta-analysis. PubMed, Embase and the Cochrane Library were searched. Methodological quality was rated using QUADAS and scientific evidence using GRADE. Summary measures of diagnostic accuracy were calculated using a bivariate random-effects model. ResultsIn a general pregnant population, there is moderate evidence that the pooled sensitivity is 0.993 (95% CI 0.955-0.999) and specificity was 0.999 (95% CI 0.998-0.999) for the analysis of T21. Pooled sensitivity and specificity for T13 and T18 was not calculated in this population due to the low number of studies. In a high-risk pregnant population, there is moderate evidence that the pooled sensitivities for T21 and T18 are 0.998 (95% CI 0.981-0.999) and 0.977 (95% CI 0.958-0.987) respectively, and low evidence that the pooled sensitivity for T13 is 0.975 (95% CI 0.819-0.997). The pooled specificity for all three trisomies is 0.999 (95% CI 0.998-0.999). ConclusionsThis is the first meta-analysis using GRADE that shows that NIPT performs well as a screen for trisomy 21 in a general pregnant population. Although the false positive rate is low compared with first trimester combined screening, women should still be advised to confirm a positive result by invasive testing if termination of pregnancy is under consideration.

  • 198.
    Jaarsma, Pier
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Gelhaus, Petra
    Institute for Ethics, History and Philosophy of Medicine, University of Muenster, Muenster, Germany.
    Medium-Range Narratives as a Complementary Tool to Principle-Based Prioritization in Sweden: Test Case "ADHD"2019In: Journal of Bioethical Inquiry, ISSN 1176-7529, E-ISSN 1872-4353, Vol. 16, no 1, p. 113-125Article in journal (Refereed)
    Abstract [en]

    In this paper, for the benefit of reflection processes in clinical and in local, regional, and national priority-setting, we aim to develop an ethical theoretical framework that includes both ethical principles and medium-range narratives. We present our suggestion in the particular case of having to choose between treatment interventions for attention deficit hyperactivity disorder (ADHD) and treatment interventions for other conditions or diseases, under circumstances of scarcity. In order to arrive at our model, we compare two distinct ethical approaches: a generalist (principles) approach and a particularist (narratives) approach. Our focus is on Sweden, because in Sweden prioritization in healthcare is uniquely governmentally regulated by the “ethics platform.” We will present a (fictional) scenario to analyse the strengths and weaknesses of the generalist principled perspective of the ethics platform and the particularist perspective of narrative ethics. We will suggest an alternative (moderately particularist) approach to prioritization, which we dub a “principles plus medium-range narratives” approach. Notwithstanding the undeniably central role of principles in distributive justice, we claim that medium-range narratives concerning individuals or groups who stand to benefit or lose from ADHD prioritization practices should also be read or listened to and taken into account at all levels of priority-setting. These narratives are expected to ethically optimize clinical priority-setting, as well as that undertaken at local, regional, and national levels.

  • 199.
    Jaarsma, Pier
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Welin, Stellan
    Linköping University, Department of Culture and Communication, Arts and Humanities. Linköping University, Faculty of Arts and Sciences.
    Autism, Accommodation and Treatment: A Rejoinder to Chong-Ming Lims Critique2015In: Bioethics, ISSN 0269-9702, E-ISSN 1467-8519, Vol. 29, no 9, p. 684-685Article in journal (Other academic)
    Abstract [en]

    We are very grateful to Chong-Ming Lim for his thoughtful reply published in this journal on one of our articles, which motivated us to think more carefully about accommodating autistic individuals and treating autism. However we believe there are some confusions in Lims argument. Lim uses the accommodation thesis, according to which we should accommodate autistic individuals rather than treat autism, as the starting point for his reasoning. He claims that if the accommodation thesis is right, then we should not treat autistic individuals for their autism, not even low-functioning (i.e. intellectually disabled) ones, because this would be disrespectful to all autistic individuals. We should instead limit ourselves to accommodate all autistic individuals. However, the opposition between accommodation and treatment is not valid in the case of autism, because of ambiguity in the concepts of accommodation and treatment. Moreover there is confusion in Lims reasoning caused by omitting important facts about the practice of treating autism.

  • 200.
    Jacobs, Maartje S.
    et al.
    Univ Groningen, Netherlands; Martini Hosp, Netherlands.
    Schouten, Jeroen F.
    Univ Groningen, Netherlands.
    de Boer, Pieter T.
    Univ Groningen, Netherlands.
    Hoffmann, Mikael
    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.
    Postma, Maarten J.
    Univ Groningen, Netherlands; Univ Med Ctr Groningen, Netherlands; Univ Med Ctr Groningen, Netherlands.
    Secondary adherence to non-vitamin-K antagonist oral anticoagulants in patients with atrial fibrillation in Sweden and the Netherlands2018In: Current Medical Research and Opinion, ISSN 0300-7995, E-ISSN 1473-4877, Vol. 34, no 10, p. 1839-1847Article in journal (Refereed)
    Abstract [en]

    Objective: There is limited evidence on patients adherence and the impact of the prescribed dosing regimen in non-vitamin-K oral anticoagulants (NOACs). We aimed to assess secondary adherence to NOACs and to determine the impact of the dosing regimen in patients with atrial fibrillation. Methods: Patients using a NOAC between 2009 and 2013 were identified from the nation-wide Swedish Prescribed Drug Register and the Dutch regional IADB.nl database. Patients using a consistent dosage for at least 180 consecutive days were included. Adherence was calculated using the medication possession ratio (MPR) and adjusted for overlapping dates. Adherence was defined as a MPR amp;gt;= 0.8. Sensitivity analyses were performed using a MPR amp;gt;= 0.9. Logistic regression was performed to compare secondary adherence and to explore the influence of the dosing regimen. Results: A total of 5254 Swedish and 430 Dutch NOAC users were included. The mean MPR was 96.0% (SD 7.8%) in Sweden and 95.1% (SD 10.1%) in the Netherlands. Multivariable logistic regression analysis showed that a twice daily regimen had a lower likelihood of being secondary adherent compared to a once daily regimen in Sweden (odds ratio [OR] 0.21 [95% CI 0.12-0.35]). Limitations: The influence of selection bias introduced by the inclusion criterion of amp;gt;= 2 dispensations covering at least 180 days could not be excluded. Conclusions: This study demonstrated that secondary adherence was high in this specific setting among patients with at least two initial dispensations of a NOAC covering a minimum of 180 days. The use of NOACs in a once daily regimen showed higher adherence compared to a twice daily regimen.

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