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  • 151.
    Garpenby, Peter
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Bilaga 6. Mot bättre vetande: Statens roll vid kunskapsstyrning av hälso- och sjukvården1999In: God vård på lika villkor? : underlag till slutbetänkande: Ingår i: God vård på lika villkor? om statens styrning av hälso- och sjukvården : slutbetänkande från Kommittén om hälso- och sjukvårdens finansiering och organisation, Stockholm: Fakta info direkt , 1999, p. 217-337Chapter in book (Other academic)
    Abstract [sv]

    Syftet med denna rapport är att beskriva och analysera statens1 styrning av hälso- och sjukvården, särskilt sådana styrformer där sammanställning av information (t ex om aktuellt forskningsläge och om god klinisk praxis) och informationsspridning utgör centrala inslag. Sådana aktiviteter är inte nya i sjukvården, men betraktade som inslag i statens styrning av hälso- och sjukvårdssektorn är de under stark utveckling. Av allt att döma kommer intresset för att nyttja systematiskt sammanställd information som ett inslag i styrningen av hälso- och sjukvården att öka, vilket även medför behov av aktiviteter som stärker förutsättningarna att lokalt tillgodogöra sig information. Avsikten med rapporten är att tydliggöra statens roll vid ”kunskapsstyrning” av hälso- och sjukvården.2 Möjligheten att utveckla en nationell strategi för ett mer kunskapsbaserat beslutsfattande i hälso- och sjukvården diskuteras.

    Analysen har genomförts med hjälp av våra tidigare studier inom området, vilka har kompletterats med litteratur, utredningar m.m. som belyser olika aspekter i anslutning till kunskapsstyrning. Vår beskrivning av relevanta aktörer och pågående aktiviteter inom den svenska sjukvårdssektorn har varit föremål för kommentarer från berörda parter.

  • 152.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Faculty of Health Sciences.
    Nationella kvalitetsregister inom hälso- och sjukvården: en uppföljande studie1996Report (Other academic)
  • 153.
    Garpenby, Peter
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Nationella vårdregister har ej funnit sin form: Granskning visar värdet för kvalitetskontroll1994In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 91, no 25, p. 2509-2511Article in journal (Other academic)
  • 154.
    Garpenby, Peter
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Quality registers in the Swedish Health Service1998In: Outcome Measuring: outcome-measures make a sense, do they make a difference?, Stockholm: Spri , 1998Chapter in book (Other academic)
  • 155.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment.
    Carlsson, Per
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment.
    Utvärdering och förslag till organisation av nationella register för kvalitetskontroll inom hälso- och sjukvården1994Report (Other academic)
  • 156.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Götherström, Ulla-Christel
    Larsson, Sussanne
    Linköping University.
    Inställningen till vårdprogram bland personal inom barn- och ungdomspsykiatrin: en uppföljande studie2003Report (Other academic)
  • 157.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Faculty of Health Sciences.
    Hälsoinformation idag och i morgon: Östgötarnas användning av och förtroende för olika informationskällor2000Report (Other academic)
  • 158.
    Garpenby, Peter
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Johansson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Nationella riktlinjer för hjärtsjukvård. Implementeringen i fyra landsting och regioner: Andra delen av utvärderingen2007Report (Other academic)
    Abstract [sv]

    Denna rapport utgör andra delen i en undersökning av hur fyra landsting och regioner påverkas av Socialstyrelsens Nationella riktlinjer för hjärtsjukvård (NRH) i den version som publicerades 2004. De landsting och regioner som ingår i studien är Landstinget Sörmland, Landstinget Västernorrland, Region Skåne och Västra Götalandsregionen. Undersökningen är utförd av PrioriteringsCentrum på uppdrag av Socialstyrelsen.

    Syftet är inte att förstå tillämpningen av NRH i klinisk verksamhet (i patientärenden) utan inom organisationen, genom samspelet mellan politik, administration och profession. I rapporten redovisas situationen under första halvåret 2007 och en analys sker av hela implementeringsprocessen under perioden 2004-2007.

    Den information som ligger till grund för rapporten har främst inhämtats genom individuella intervjuer. Sammanlagt har under perioden december 2006 till och med juli 2007 genomförts 45 intervjuer.

    När Socialstyrelsens Nationella riktlinjer för hjärtsjukvård (NRH) publicerades första gången 2004 utgjorde de en helt ny typ av dokument med en ambition att påverka såväl klinisk som politisk beslutsnivå hos sjukvårdshuvudmännen. Avsikten är att Nationella riktlinjer ska föra samman beslutsfattare på olika nivåer i landsting/region och resultera i mer likformig praxis och systematiska och öppna prioriteringar och därigenom föra sjukvården närmare målet en likvärdig och effektiv vård för befolkningen. Socialstyrelsen anger – som vi uppfattar det – tre medel som är viktiga för att förverkliga avsikterna bakom Nationella riktlinjer. Dessa är: (a) lokala och regional vårdprogram, (b) dialog mellan olika aktörer och (c) systematiska och öppna prioriteringar.

    I rapporten analyseras implementeringsprocessen ur ett aktör-strukturperspektiv och fördelningen av ansvar utifrån en teori om aktörers uppfattningar av mål och medel. Hur förutsättningarna i den mottagande organisationen (landstingen/regionerna) har påverkat implementeringen av NRH diskuteras också, liksom vilka förändringar som anknyter till NRH som kan observeras.

    Aktör-Struktur

    • Strukturella förändringar har inverkat på implementeringen av NRH, såsom övergången från geografisk förvaltningsorganisation till landstingsövergripande divisioner i Landstinget Sörmland. Inom Region Skåne och Västra Götalandsregionen kom implementeringen tidsmässigt att sammanfalla med strukturförändringar som påverkat förutsättningarna inom de studerade sjukhusen. Under implementeringen har förekomsten av det norrländska regionförbundet som struktur påverkat hanteringen av NRH inom Landstinget Västernorrland.

    Ansvar

    • Var i organisationen ansvaret för implementeringen placeras beror på hur olika aktörer uppfattar mål och medel. I inledningsskedet avgenomförandet 2004 såg vi tecken på en experimentell implementering av NRH. Ansvaret hamnade långt ner i organisationen – främst på verksamhetsnivå – och det fanns stora skillnader i landstingens/regionernas agerande. Jämför vi perioden 2004 till 2007 kan vi konstatera att det på tre år faktiskt skett en hel del förändringar i implementeringsprocessen i samtliga landsting/regioner. Vi bedömer dock att genomförandet av NRH under 2007 i huvudsak sker inom ramen för en experimentell implementering. Aktörsgrupperna i samtliga landsting/regioner sluter upp bakom mål och medel för NRH men uppfattar dem fortfarande som diffusa och vaga. Aktiviteterna utspelas alltjämt på en låg nivå inom respektive landsting/region.
    • Anledningen till att ansvaret för genomförandet av NRH inte flyttats till mer central nivå kan vara att tiden som förflutit har varit för kort. Det kan också bero på att medlet om öppna prioriteringar är konfliktfyllt ur politiskt hänseende.

    Passform

    • De styrsystem för resursfördelning som tillämpas inom de studerade landstingen/regionerna har enligt vår uppfattning svårt att hantera ändrade förutsättningar som kan uppstå genom innehållet i nationella riktlinjer. Det är inte självklart var i systemet prioriteringar ska ske – i regel sker de långt ner i organisationen – och nya ställningstaganden om resurstillskott eller omfördelningar av resurser mellan verksamheter är svåra att hantera med nuvarande styrsystem.
    • Vi har uppmärksammat att konferenser kring nationella riktlinjer förekommer i sjukvårdsregionernas regi där olika aktörer deltar och där Socialstyrelsen medverkar. Vi bedömer dock att 2004 års version av NRH inte blev föremål för den typen av konferenser som senare har utvecklats.
    • Det är förekomsten av samarbete inom den medicinska professionen som har varit mer avgörande än särskilda projekt för att arbeta med systematiska prioriteringar. Det går inte att påstå att Västra Götaland, som på papperet har hållit på längre än Region Skåne med systematiska vertikala prioriteringar, har varit mer framgångsrik i att genomförainnehållet i NRH.

    Förändringar

    • I ett första skede (2004) fann vi förändringar som påverkade sammansättningen av vården (på en klinik eller mellan sjukhus) eller att ändra i befintliga lokala vårdprogram. När läget 2007 undersöktes fann vi att landsting/regioner hade börjat tillämpa nya metoder eller var på gång att införa sådana. Det gällde då vårdprogram som avser hela landsting/regioner eller t o m hela sjukvårdsregioner där fleralandsting/regioner samverkar. På en del håll hade påbörjats  uppbyggnaden av mottagarorganisationer för nationella dokument som även omfattar utarbetandet av en standard för hur vårdprogram kan knytas till landstingens resursbeslut.
    • Om de observerade förändringarna relateras till de medel som Socialstyrelsen nämner i anslutning till Nationella riktlinjer, ser vi att lokala och regionala vårdprogram förefaller minst komplicerade att åstadkomma – de förutsätter dock samarbetsformer inom professionen. Dialog mellan aktörer förefaller vara ett större problem på grund av styrsystem som förekommer i landsting/regioner men håller i viss mån på att utvecklas genom arbete på sjukvårdsregionnivå (även om detta inte påverkat NRH av version 2004).
    • Öppna prioriteringar på landstingsnivån och särskilt horisontella sådana, som förutsätter politiska beslut, är betydligt svårare att åstadkomma. Det kräver att utvecklingsarbetet som förstärker dialogen blir framgångsrikt. Vi ser inte några inslag av större öppenhet i anslutning till NRH – att allmänheten får information om hur landsting/region avser att avväga sina resurser.

    Slutsatser

    • Efter intervjuerna 2004 kunde vi i den första rapporten konstatera att den professionella verksamheten och den politiskt-administrativa delen av landsting/region inte befann sig i fas med avseende på kunskap om och förståelse för vad NRH innebär för organisationen. Tre år senare är inte gapet i kunskap lika stort.
    • Vi har kunnat iaktta hur NRH främst har hanterats av den medicinska professionen, lokalt eller i olika sammanslutningar (expertgrupper, arbetsgrupper). När sådana grupperingar fungerar väl kan de utveckla avsevärd kraft för koordinering av sjukvårdens resurser. Det går att hantera delar av implementeringen av nationella riktlinjer inom professionella nätverk, men det kommer en punkt där prioriteringar i form av omfördelning och eventuella resurstillskott blir ofrånkomliga. Då måste också den politiska-administrativa ledningen ha tillräcklig kapacitet för att hantera situationen mer systematiskt.
  • 159.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Larsson, Sussanne
    Linköping University.
    Att genomföra psykiatrireformen i vardagen: en uppföljande studie1998Report (Other academic)
  • 160.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Larsson, Sussanne
    Linköping University.
    Hälsoinformation via Internet, bibliotek och patientinformationscentraler: en systematisk litteraturgranskning1999Report (Other academic)
  • 161.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Larsson, Sussanne
    Linköping University.
    Inställningen till vårdprogram bland personal inom barn- och ungdomspsykiatrin: en lägesrapport från Östergötland1999Report (Other academic)
  • 162.
    Garpenby, Peter
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Lawrence, Marie
    Socialstyrelsen, Stockholm.
    Kvalitetsregister bra verktyg för kliniker men av oklar nytta för beställare2003In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 100, no 9, p. 715-718Article in journal (Other academic)
    Abstract [sv]

    De nationella kvalitetsregistren är värdefulla för klinikerna, men fortfarande saknas en dialog med beställarna. Det visade en undersökning om hur registren används, som gjordes i maj 2001 bland ett urval av enheter(kliniker) och sjukvårdshuvudmän.

    En betydande majoritet av de enheter som deltog i undersökningen ansåg att registren tar fram värdefull information som är relevant för verksamheten.

    I första hand ansågs registren vara en hjälp i den löpande kvalitetsutvecklingen i hälso- och sjukvården.

    Representanter för sjukvårdshuvudmännen respektive den medicinska professionen hade markant olika syn på frågan om öppenhet med registerdata.

  • 163.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Lindvall, Paul
    Primärvård Under Kommunalt Huvudmannaskap: CMT:s analys av försöket i Katrineholm1997Report (Other academic)
  • 164.
    Garpenby, Peter
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Implementation as learning and balancing: the launching of a new program for dialogic intervention in Östergötland County Council2013Conference paper (Other academic)
  • 165.
    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.

  • 166.
    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.

  • 167.
    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. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    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.

  • 168.
    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.

  • 169.
    Gesicho, Milka B.
    et al.
    Department of Information Science and Media Studies, University of Bergen, Norway.
    Babic, Ankica
    Linköping University, Department of Biomedical Engineering, Division of Biomedical Engineering. Linköping University, Faculty of Science & Engineering.
    Were, Martin C.
    Institute of Biomedical Informatics, Moi University, Kenya.
    Critical Issues in Evaluating National-Level Health Data Warehouses in LMICs: Kenya Case Study2017In: Informatics Empowers Healthcare Transformation / [ed] Househ M.S.,Mantas J.,Hasman A.,Gallos P., 2017, Vol. 238, p. 201-204Conference paper (Refereed)
    Abstract [en]

    Low-Middle-Income-Countries (LMICs) are beginning to adopt national health data warehousing (NHDWs) for making strategic decisions and for improving health outcomes. Given the numerous challenges likely to be faced in establishment of NHDWs by LMICs, it is prudent that evaluations are done in relation to the data warehouses (DWs), in order to identify and mitigate critical issues that arise. When critic issues are not identified, DWs are prone to suboptimal implementation with compromised outcomes. Despite the fact that several publications exist on evaluating DWs, evaluations specific to health data warehouses are scanty, with almost none evaluating NHDWs more so in LMICs. This paper uses a systematic approach guided by an evaluation framework to identify critical issues to be considered in evaluating Kenyas NHDW.

  • 170.
    Gremyr, Ida
    et al.
    Chalmers Univ Technol, Sweden.
    Elg, Mattias
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering. Linköping University, HELIX Vinn Excellence Centre.
    Smith, Frida
    Chalmers Univ Technol, Sweden; Reg Canc Ctr West, Sweden.
    Gustavsson, Susanne
    Skaraborgs Hosp, Sweden.
    Exploring the phase for highest impact on radicality: a cross-sectional study of patient involvement in quality improvement in Swedish healthcare2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 11, article id e021958Article in journal (Refereed)
    Abstract [en]

    Objectives Involving patients in quality improvement is often suggested as a critical step for improving healthcare processes. However, this comes with challenges related to resources, tokenism, validity and competence. Therefore, to optimise the use of available resources, there is a need to understand at what stage in the improvement cycle patient involvement is most beneficial. Thus, the purpose of this study was to identify the phase of an improvement cycle in which patient involvement had the highest impact on radicality of improvement. Design An exploratory cross-sectional survey was used. Setting and methods A questionnaire was completed by 155 Swedish healthcare professionals (response rate 34%) who had trained and had experience in patient involvement in quality improvement. Based on their replies, the impact of patient involvement on radicality in various phases of the improvement cycle was modelled using the partial least squares method. Results Patient involvement in quality improvement might help to identify and realise innovative solutions; however, there is variation in the impact of patient involvement on perceived radicality depending on the phase in which patients become involved. The highest impact on radicality was observed in the phases of capture experiences and taking action, while a moderate impact was observed in the evaluate phase. The lowest impact was observed in the identify and prioritise phase. Conclusions Involving patients in improvement projects can enhance the quality of care and help to identify radically new ways of delivering care. This study shows that it is possible to suggest at what point in an improvement cycle patient involvement has the highest impact, which will enable more efficient use of the resources available for patient involvement.

  • 171.
    Gustavsson, Erik
    Linköping University, Department of Culture and Communication, Culture and Aesthetics. Linköping University, Faculty of Arts and Sciences.
    Characterising Needs in Health Care Priority Setting2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The focus of this thesis is needs in the context of health care priority setting. The notion of needs has a strong standing in health care policy; however, how the idea should be understood more specifically and how it should guide decisions about priority setting remain contentious issues. The aim of this thesis is to explore how needs should be characterised in health care priority setting. This matter is approached by, first, exploring and developing the conceptual structure of health care needs, and second, discussing and suggesting solutions to normative questions that arise when needs are characterised as a distributive principle.

    In the first article, the conceptual structure of needs in general and health care needs in particular is explored, and it is argued that a specific characterisation of health care needs is required.

    In the second article, the notion of health care needs is explored in relation to preferences for health care within the context of shared decision-making. The paper further discusses a number of queries that arise in the intersection between what the patient needs and what the patient wants.

    The third article discusses how a principle of need should handle questions about interpersonal aggregation. The paper characterises a principle of need which strikes a reasonable balance between giving priority to the worst off and the distribution of benefits with regard to interpersonal aggregation.

    The fourth article discusses how a principle of need should account for the fact that patients often are badly off due to several conditions rather than one single condition. It is argued that how badly off patients are should be understood as a function of how badly off these patients are when all of their conditions (for which they need health care) are considered.

    The frame story provides the terminological, theoretical, contextual, and methodological background for the discussion undertaken in this thesis. The conclusions of the articles are brought together and the discussion extended in the concluding discussion by sketching a number of conditions of adequacy for the concept and principle of need relevant for health care priority setting.  

    List of papers
    1. From Needs to Health Care Needs
    Open this publication in new window or tab >>From Needs to Health Care Needs
    2014 (English)In: Health Care Analysis, ISSN 1065-3058, E-ISSN 1573-3394, Vol. 22, no 1, p. 22-35Article in journal (Refereed) Published
    Abstract [en]

    One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of health care need with a starting point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything.

    Place, publisher, year, edition, pages
    Springer, 2014
    Keywords
    Harm; Health; Health care; Health care need; Need; Priority-setting; Rationing; Well-being
    National Category
    Philosophy, Ethics and Religion Other Medical Sciences
    Identifiers
    urn:nbn:se:liu:diva-106476 (URN)10.1007/s10728-013-0241-8 (DOI)000331640900003 ()
    Available from: 2014-05-08 Created: 2014-05-08 Last updated: 2018-01-10Bibliographically approved
    2. Health-care needs and shared decision-making in priority-setting
    Open this publication in new window or tab >>Health-care needs and shared decision-making in priority-setting
    2015 (English)In: Medicine, Health care and Philosophy, ISSN 1386-7423, E-ISSN 1572-8633, Vol. 18, no 1, p. 13-22Article in journal (Refereed) Published
    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.

    Place, publisher, year, edition, pages
    Springer Verlag (Germany), 2015
    Keywords
    Needs; Health-care needs; Shared decision-making; Desires; Priority setting; Rationing
    National Category
    Clinical Medicine
    Identifiers
    urn:nbn:se:liu:diva-114234 (URN)10.1007/s11019-014-9568-7 (DOI)000347699000003 ()24807745 (PubMedID)
    Available from: 2015-02-16 Created: 2015-02-16 Last updated: 2019-06-27Bibliographically approved
    3. Principles of Need and the Aggregation Thesis
    Open this publication in new window or tab >>Principles of Need and the Aggregation Thesis
    2019 (English)In: Health Care Analysis, ISSN 1065-3058, E-ISSN 1573-3394, Vol. 27, no 2, p. 77-92Article in journal (Refereed) Published
    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.

    Place, publisher, year, edition, pages
    Springer, 2019
    Keywords
    Aggregation, Needs, Principles of need, Prioritarianism, Priority setting, Sufficiency
    National Category
    Ethics
    Identifiers
    urn:nbn:se:liu:diva-144208 (URN)10.1007/s10728-017-0346-6 (DOI)000466950700002 ()28866792 (PubMedID)2-s2.0-85028766963 (Scopus ID)
    Available from: 2018-01-10 Created: 2018-01-10 Last updated: 2019-06-23Bibliographically approved
  • 172.
    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.

  • 173.
    Gyllensten, Hanna
    et al.
    Nordic School Public Health NHV, Sweden; University of Gothenburg, Sweden; Karolinska Institute, Sweden.
    Jönsson, Anna K
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pharmacology.
    Hakkarainen, Katja M.
    Nordic School Public Health NHV, Sweden; EPID Research, Finland.
    Svensson, Staffan
    Narhalsan Hjallbo Medical Centre, Finland.
    Hägg, Staffan
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pharmacology. Jonköping County Council, Sweden.
    Rehnberg, Clas
    Karolinska Institute, Sweden.
    Comparing Methods for Estimating Direct Costs of Adverse Drug Events2017In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 20, no 10, p. 1299-1310Article in journal (Refereed)
    Abstract [en]

    Objectives: To estimate how direct health care costs resulting from adverse drug events (ADEs) and cost distribution are affected by methodological decisions regarding identification of ADEs, assigning relevant resource use to ADEs, and estimating costs for the assigned resources. Methods: ADEs were identified from medical records and diagnostic codes for a random sample of 4970 Swedish adults during a 3-month study period in 2008 and were assessed for causality. Results were compared for five cost evaluation methods, including different methods for identifying ADEs, assigning resource use to ADEs, and for estimating costs for the assigned resources (resource use method, proportion of registered cost method, unit cost method, diagnostic code method, and main diagnosis method). Different levels of causality for ADEs and ADEs contribution to health care resource use were considered. Results: Using the five methods, the maximum estimated overall direct health care costs resulting from ADEs ranged from Sk10,000 (Sk = Swedish krona; similar to(sic)1,500 in 2016 values) using the diagnostic code method to more than Sk3,000,000 (similar to(sic)414,000) using the unit cost method in our study population. The most conservative definitions for ADEs contribution to health care resource use and the causality of ADEs resulted in average costs per patient ranging from Sk0 using the diagnostic code method to Sk4066 (similar to(sic)500) using the unit cost method. Conclusions: The estimated costs resulting from ADEs varied considerably depending on the methodological choices. The results indicate that costs for ADEs need to be identified through medical record review and by using detailed unit cost data. Copyright (C) 2017, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc.

  • 174.
    Hallberg, Inger
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Univ Gothenburg, Sweden.
    Ranerup, Agneta
    Univ Gothenburg, Sweden.
    Bengtsson, Ulrika
    Univ Gothenburg, Sweden; Univ Gothenburg, Sweden.
    Kjellgren, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Univ Gothenburg, Sweden; Univ Gothenburg, Sweden.
    Experiences, expectations and challenges of an interactive mobile phone-based system to support self-management of hypertension: patients and professionals perspectives2018In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 12, p. 467-476Article in journal (Refereed)
    Abstract [en]

    Background: A well-controlled blood pressure (BP) reduces cardiovascular complications. Patient participation in care using technology may improve the current situation of only 13.8% of adults diagnosed with hypertension worldwide having their BP under control. Objective: The objective of this study was to explore patients and professionals experiences of and expectations for an interactive mobile phone-based system to support self-management of hypertension. Methods: The self-management system consists of: 1) a mobile phone platform for self-reports, motivational messages and reminders; 2) a device for measuring BP and 3) graphical feedback of self-reports. Patients diagnosed with high BP (n=20) and their treating professionals (n=7) participated in semi-structured interviews, after 8 weeks use of the system in clinical practice. Data were analyzed thematically. Results: The self-reporting of BP, symptoms, medication use, medication side effects, lifestyle and well-being was perceived to offer insight into how daily life activities influenced BP and helped motivate a healthy lifestyle. Taking increased responsibility as a patient, by understanding factors affecting ones well-being, was reported as an enabling factor for a more effective care. Based on the experiences, some challenges were mentioned: for adoption of the system into clinical practice, professionals educational role should be extended and there should be a reorganization of care to fully benefit from technology. The patients and professionals gave examples of further improvements to the system, for example, related to the visualization of graphs from self-reports and an integration of the system into the general technical infrastructure. These challenges are important on the path to accomplishing adoption. Conclusion: The potential of a more autonomous, knowledgeable and active patient, through use of the interactive mobile system would improve outcomes of hypertension treatment, which has been desired for decades. Documentation and visualization of patients self-reports and the possibilities to communicate these with professionals may be a significant resource for person-centered care.

  • 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.
    Hallgren Elfgren, Ing-Marie
    et al.
    Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Grodzinsky, Ewa
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Törnvall, Eva
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Swedish Diabetes Register, a tool for quality development in primary health care2013In: Primary Health Care Research and Development, ISSN 1463-4236, E-ISSN 1477-1128, Vol. 14, no 3, p. 250-257Article in journal (Refereed)
    Abstract [en]

    Introduction In Sweden, quality indicators in health care have been the basis for developing National Quality Registers. The Swedish National Diabetes Register (NDR) – one of the largest diabetes registers globally – was introduced in primary health care (PHC) in the county of Östergötland by an implementation project, 2002–2005.

    Aim The aim of the present paper was to investigate, by using the results of the NDR, whether the registration led to sustained outcomes of medical results of diabetes care in PHC in the county during the period 2005–2009.

    Method HbA1c, blood pressure (BP), albuminuria and low-density lipoprotein-cholesterol were registered online in the NDR. In 2005 and 2006, goal achievement for HbA1c was measured and compared between PHC centres (PHCC) within the county. In 2007, achievements to national goals were compared between the PHCCs within the county and with those Swedish counties that had attained a sufficiently high registration rate. In 2008 and 2009, the average county results were compared with the corresponding national average measurements for all 21 Swedish counties combined.

    Result In 2005, a clear improvement trend for HbA1c and BP was shown within the county. In 2007–2009, goal achievements in the county studied were slightly better than the other counties measured and the country as a whole in almost every comparison.

    Discussion The present study has shown association between medical results and registration in the NDR. As the project was primarily a quality improvement work, the results have continuously influenced the development of diabetes care. Both the health professions and the county council now have – in the NDR – an effective and rapid method for evaluation and follow-up of diabetes care. The systematic documentation, followed by comparisons and analyses, create ideas for care improvements.

  • 177.
    Hallgren Elfgren, Ing-Marie
    et al.
    Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Grodzinsky, Ewa
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Törnvall, Eva
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    The Swedish National Diabetes Register in clinical practice and evaluation in primary health care2016In: Primary Health Care Research and Development, ISSN 1463-4236, E-ISSN 1477-1128, Vol. 17, no 6, p. 549-558Article in journal (Refereed)
    Abstract [en]

    The purpose of this project is to describe the use of the Swedish National Diabetes Register (NDR) in clinical practice in a Swedish county and to specifically monitor the diabetes care routines at two separate primary health-care centres (PHCC) with a special focus on older patients. Background: According to Swedish law, all health-care units have to maintain a system for quality evaluation and improvement. As the NDR holds the most important quality indicators, implementation of the NDR in primary care was carried out by an implementation project in 2002-2005. Methods: Initially, a digital questionnaire about NDR routines was sent to all PHCC. Statistics about hemoglobin adult 1c (HbA1c) and blood pressure (BP) was presented for the diabetes teams at two centres who were also interviewed. The responses became the basis for a focus group interview with both teams together, with data subject to content analysis. Findings: The study showed that reporting to the NDR has become a compulsory routine in primary care. The diabetes nurse specialist was responsible for the practical management of the register and used the NDR for continuous monitoring of the patients. Most centres used the NDRs statistics for evaluation and analyses annually. The diabetes nurse adapted the visits to the patients wishes and general condition. Only in terms of target values for HbA1c and BP did they accept slightly higher values for the older patients. Since the NDR was implemented, the registration rate has remained at 75% and has not increased. The reason given was that patients with diabetes living in nursing homes are checked up by the municipal nurse who does not use the NDR. However, the risk of omitting older patients in the NDR could be considerably decreased if data could be transferred from the electronic patient record.

  • 178.
    Hallgren, Ing-Marie
    et al.
    Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
    Grodzinsky, Ewa
    Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland. Linköping University, Department of Medical and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Törnvall, Eva
    Linköping University, Department of Social and Welfare Studies, Health, Activity, Care. Linköping University, Faculty of Health Sciences.
    “Measuring makes aware” Implementation of the Diabetes Registry for Quality Improvement in Primary Health 2013In: Abstracts, Linköping, 2013, p. 26-27Conference paper (Refereed)
  • 179.
    Hammarström, Gunhild
    Prioriteringscentrum.
    Ekonomi och etik: Argumentering vid besparingar inom sjukvården i ljuset av Prioriteringsutredningen2003Report (Other academic)
    Abstract [sv]

    Syftet med föreliggande studie har varit att studera om, och i så fall på vilket sätt Prioriteringsutredningens etiska riktlinjer har tillämpats i praktiken vid besparingar inom ett sjukhus. Studien utgörs av en fallstudie av en beslutsprocess år 1996 vid Akademiska sjukhuset i Uppsala läns landsting, där sjukhuset var ålagt ett besparingskrav från landstingets sida. Det empiriska material, som studien baseras på, består av den skriftliga dokumentation som föreligger från beslutsprocessens olika aktörer. De aktörer som deltagit i beslutsprocessen är sjukhusdirektören samt representanter för den medicinska professionen och landstingspolitiker på olika nivåer. De som jag ser som huvudaktörerna är, förutom sjukhusdirektören, en medicinskt-etiska arbetsgrupp tillsatt av sjukhusdirektören samt landstingets tre hälso- och sjukvårdsnämnder bestående av politiker.

    I samband med studien har jag kunnat konstatera att även om de olika aktörskategoriernas argumentering kan karakteriseras om rationell utifrån deras respektive mål och intentioner, har inte själva beslutsprocessen skett i enlighet ned den normativt rationalistiska beslutsmodell, som förutsätts inom traditionell organisationsteori.

    När det gäller frågan om i vilken mån Prioriteringsutredningens etiska riktlinjer har beaktats under själva beslutsprocessen, föreligger en viss skillnad mellan den argumentering, som förts i fråga om förslag till besparingar, och själva beslutet. Vid en jämförelse av politikerna i hälso- och sjukvårdsnämnderna och ledamöterna i den medicinskt-etiska arbetsgruppen framkommer, att i de besparingsförslag, som härrör från den medicinska professionen, har de etiska riktlinjerna beaktats. Jag har dock tolkat den medicinska professionens argumentation som relativt schablonmässig. Hälso- och sjukvårdsnämnderna har däremot i sitt gemensamma yttrande över huvudtaget inte nämnt Prioriteringsutredningen och dess riktlinjer.

    Hälso- och sjukvårdsnämnderna har främst argumenterat utifrån målet att uppnå en ”ekonomi i balans”, medan den medicinskt-etiska arbetsgruppen har utgått från ”patientens behov” och ”de medicinskt-etiska konsekvenserna” för patienterna. Min tolkning är att de båda aktörskategorierna har argumenterat utifrån olika normativa rationaliteter, genom att de har utgått från olika kulturella och normativa föreställningar och värderingar. De har därvid använt den argumentering som är accepterad inom respektive kultur, vilket ger ökad legitimitet till de föreslagna besparingarna inom den egna gruppen. Även om deras respektive argumentering kan fungera inkluderande i förhållande till den egna gruppen, kan den samtidigt fungera avskiljande och gränssättande gentemot den andra.

    Det slutliga beslutet om de faktiska besparingarna utgör i huvudsak en kompromiss mellan hälso- och sjukvårdsnämndernas kraftigare besparingskrav med sänkt omvårdnad och den medicinskt-etiska arbetsgruppens beaktande av konsekvenserna för patienterna. Eftersom beslutsprocessen varit interaktiv till sin karaktär, har jag tolkat kompromissen och överbryggandet av den gränssättande retoriken som ett resultat av både strategiskt och kommunikativt handlande från sjukhusdirektörens sida, d.v.s. ett handlande som är både framgångsorienterat och inriktat på inbördes förståelse.

    Frågan om i vilken mån Prioriteringsutredningens riktlinjer har inverkat på det faktiska beslutet är dock inte så lätt att besvara, eftersom även generella medicinskt-etiska principer har inverkat, och genom att det inte är möjligt att särskilja betydelsen av dessa generellt formulerade medicinskt-etiska principer i relation till Prioriteringsutredningens riktlinjer. En förklaring till detta kan också vara att de fastställda prioriteringsgrupperna kanske inte är helt praktiskt ”översättbara” till olika verksamheter inom ett sjukhus på den politiskt-administrativa nivån på det sätt som var tänkt.

  • 180.
    Hammarström, Gunhild
    Sociologiska institutionen, Uppsala universitet.
    Trygghet och omvårdnadsbehov: Förhållningssätt och föreställningar om prioriteringar och kriterier för beslut om särskiltboende2004Report (Other academic)
    Abstract [sv]

    Prioriteringar har blivit alltmer aktuella inom äldreomsorgen, eftersom vi har en åldrande befolkning, samtidigt som de ekonomiska resurserna inte är tillräckliga för att tillgodose allas önskemål och behov av hjälp med service, vård och omsorg. Genom denna studie har jag bl a sökt belysa hur personal inom den kommunala äldreomsorgen förhåller sig till kriterier för att bevilja s k särskilt boende och hur de ser på prioriteringar i samband med dessa beslut. Studien utgör en fallstudie och baseras på intervjuer med ett mindre antal biståndshandläggare och distriktssköterskor samt ett ”aktmaterial” bestående av beviljade beslut om särskilt boende för äldre.

    En bakgrund till studien är dels att kommunerna sedan Ädelreformens genomförande 1992 har fått ansvaret för vården och omsorgen av äldre, dels riksdagens beslut från 1997 om etiska riktlinjer för prioriteringar inom sjukvården. Socialtjänstlagen, som utgör den centrala rättsliga grunden för kommunernas äldreomsorg, innehåller emellertid inte några prioriteringsgrunder och det finns inte heller några nationella riktlinjer för prioriteringar inom äldreomsorgen. Prioriteringar torde ändå ha ägt rum mer eller mindre medvetet och mer eller mindre öppet.

    I analysen av de intervjuade biståndshandläggarna och distriktssköterskorna har flera olika dilemman identifierats i deras arbetssituation som utgör det sociala sammanhang utifrån vilket deras förhållningssätt på kriterier för beslut och prioriteringar kan förstås. De beskriver sin arbetssituation som präglad av brist på tid, personal och ekonomiska resurser och motstridiga krav från olika håll, såsom landstinget, den egna ledningen, anhöriga och de äldre själva. Den positiva sidan är relationen till de äldre, som utmärks av närhet. I fråga om vilka kriterier som berättigar till särskilt boende föreligger ett spänningsförhållande mellan betoningen på trygghet, som biståndshandläggarna ser som viktigt, och ledningens krav på stort omvårdnadsbehov.

    De intervjuade biståndshandläggarna och distriktssköterskorna såg i huvudsak begreppet prioritering som ett negativt värdeladdat begrepp, som främst används i samband med brist på resurser och ekonomiska nedskärningar. På grund av den rådande arbetssituationen ansåg de sig emellertid nödsakade att prioritera mellan de egna arbetsuppgifterna. Samtidigt hade de uppfattningen att dessa prioriteringar går ut över de gamla de ansvarar för och därför står i motsättning till verksamhetsmålen avseende äldres trygghet. Även om deras prioriteringar kan ha skett utifrån en ”intuitiv” rangordning inlärd genom deras professionella erfarenhet, kan den knappast sägas ha utgått från en medveten och öppen rangordning.

    Biståndshandläggarna såg inte sitt beslutsfattande om särskilt boende som en prioritering utan som ett beslut utifrån en individuell behovsprövning i enlighet med Socialtjänstlagens anda. Samtidigt framkom att de gjorde vissa gränsdragningar för att bevilja särskilt boende, t ex genom att inte beakta sociala behov. Eftersom de sinsemellan lade något olika vikt vid trygghet och omvårdnadsbehov torde de ha gjort olika prioriteringsliknande gränsdragningar, om än inte utifrån en öppen och känd rangordning av de sökandes behov.

    Genom att biståndshandläggarna har en beställarroll i den kommunala organisationen var de inte ansvariga för fördelningen av särskilda boenden vid verkställigheten av besluten. Deras uppfattning, liksom distriktssköterskornas, var emellertid att denna fördelning främst skedde utifrån ekonomiska överväganden och gynnade de personer som låg på sjukhus och som kommunen hade ett betalningsansvar för. Dessutom tycktes personer med demenssjukdom prioriteras. Såsom dessa beslut framställdes, torde de inte uppfylla kriterierna för att karakteriseras som prioriteringar utifrån en öppen rangordning av behov.

    De studerade biståndshandläggarna och distriktssköterskorna visade sig ha ringa kännedom om innehållet i Prioriteringsutredningen och riksdagens beslut om etiska riktlinjer för prioritering, liksom om kommunens riktlinjer för prioritering. Vid tiden för den genomförda studien kan vare sig de nationella eller lokala riktlinjerna sägas ha fått genomslag i den praktiska verksamheten. Det tycks ha saknats kommunikationsvägar och en dialog mellan politiker och tjänstemän på de olika nivåerna i kommunen, vilket medfört att biståndshandläggarna och distriktssköterskorna uppfattat sig stå helt ensamma med sina prioriteringsbeslut.

    Sedan denna studie genomfördes har det skett en omorganisation inom kommunen och både biståndshandläggarfunktionen och fördelningen av särskilda boenden har centraliserats, bl a för att åstadkomma en större rättvisa. Den nya organisationen ger förutsättningar för institutionaliserade möten mellan politikerna och tjänstemännen i syfte att åstadkomma en dialog mellan dem för att mejsla fram övergripande och gemensamma kriterier för öppna prioriteringar. Detta blir särskilt viktigt då en större nedskärning av platser i sådana boenden har aviserats, vilket kommer att ställa hårdare krav på medvetna och öppna prioriteringar än vad som skett ditintills.

  • 181.
    Hammarström, Sofia
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Narhalsan Knowledge Ctr Sexual Hlth, Sweden.
    Stenqvist, Karin
    Narhalsan Knowledge Ctr Sexual Hlth, Sweden; Univ Gothenburg, Sweden.
    Lindroth, Malin
    Jonkoping Univ, Sweden.
    Sexual health interventions for young people in state care: a systematic review2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 46, no 8, p. 817-834Article, review/survey (Refereed)
    Abstract [en]

    Objectives: To describe evaluated sexual health interventions for young people in state care and provide an assessment of the quality of and evidence for these interventions. Methods: A systematic review of sexual health interventions for young people in state care was conducted. Randomised controlled trials and quasi-experimental designs were eligible, 2051 records were screened, 412 full-text studies retrieved, and 12 publications with low-to-moderate risk of bias included. Results: Due to substantial heterogeneity in study populations, settings, intervention approaches, outcomes and measures, standard summary measures for intervention outcomes was not used. Instead, data were synthesised across studies and presented narratively. Conclusion: Without making recommendations, the result suggests that group-based educational interventions in general increase knowledge, attitudes and behaviour compared with standard care. However, these findings need to be further investigated, with a special emphasis on cultural context and the involvement of young people.

  • 182.
    Hansen, Emily
    Linköping University, Department of Computer and Information Science. Linköping University, The Institute of Technology.
    Implementing Lean healthcare: Things to consider when making the change2012Independent thesis Basic level (degree of Bachelor), 12 credits / 18 HE creditsStudent thesis
    Abstract [en]

    The pressure on the healthcare sector is increasing all over the world. The amount of treatable diseases increases and the time spent with each patient decreases. As a reaction towards the way the healthcare works today, patient-centred healthcare has become increasingly popular. Bringing the patient into the centre also needs changes in the staffs’ way of working. One way of making these changes is by implementing Lean healthcare.

    This thesis uses a systematic review approach to find out what organisational changes have been made at hospitals where they have implemented Lean healthcare and how the implementations were done.

    The results showed that the most important thing was to engage the staff at an early point. Those hospitals that had representatives from all the different categories of the staff were the ones who managed to make the modifications with less effort and they also had an easier way of maintaining them.

    The most obvious similarities in the organisational changes the hospitals had made were that they clearly defined who were supposed to do what and that they changed the work into multi-disciplinary teams. By that the hospitals saved a lot of time both for the staff and for the patients.

    Lean thinking has similarities theories of cognitive science, like distributed cognition and safety barriers and it could get inspiration from these areas to enhance the implementations.

    There are few articles concerning the organisational changes that have been made at hospitals when implementing Lean healthcare. However the results of this thesis was that the most important thing when implementing Lean healthcare is to involve everyone at an early stage and the only way to get Lean healthcare to really work is by changing the attitude and making people realise that improvement is a never ending process. The changes that were most common among the hospitals were to clearly define and document who was supposed to do what and to change the structure to multi-disciplinary teams working together.

  • 183.
    Harder, Thomas
    et al.
    RKI, Germany.
    Takla, Anja
    RKI, Germany.
    Eckmanns, Tim
    RKI, Germany.
    Ellis, Simon
    National Institute Health and Care Excellence NICE, England.
    Forland, Frode
    Norwegian Institute Public Heatlh, Norway.
    James, Roberta
    SIGN, Scotland.
    Meerpohl, Joerg J.
    University of Freiburg, Germany.
    Morgan, Antony
    Glasgow Caledonian University, Scotland.
    Rehfuess, Eva
    University of Munich, Germany.
    Schuenemann, Holger
    McMaster University, Canada.
    Zuiderent-Jerak, Teun
    Linköping University, Department of Thematic Studies, Technology and Social Change. Linköping University, Faculty of Arts and Sciences.
    de Carvalho Gomes, Helena
    European Centre Disease Prevent and Control ECDC, Sweden.
    Wichmann, Ole
    RKI, Germany.
    PRECEPT: an evidence assessment framework for infectious disease epidemiology, prevention and control2017In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 22, no 40Article in journal (Refereed)
    Abstract [en]

    Decisions in public health should be based on the best available evidence, reviewed and appraised using a rigorous and transparent methodology. The Project on a Framework for Rating Evidence in Public Health (PRECEPT) defined a methodology for evaluating and grading evidence in infectious disease epidemiology, prevention and control that takes different domains and question types into consideration. The methodology rates evidence in four domains: disease burden, risk factors, diagnostics and intervention. The framework guiding it has four steps going from overarching questions to an evidence statement. In step 1, approaches for identifying relevant key areas and developing specific questions to guide systematic evidence searches are described. In step 2, methodological guidance for conducting systematic reviews is provided; 15 study quality appraisal tools are proposed and an algorithm is given for matching a given study design with a tool. In step 3, a standardised evidence-grading scheme using the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) methodology is provided, whereby findings are documented in evidence profiles. Step 4 consists of preparing a narrative evidence summary. Users of this framework should be able to evaluate and grade scientific evidence from the four domains in a transparent and reproducible way.

  • 184.
    Harding, Andrew J. E.
    et al.
    Univ Lancaster, England.
    Morbey, Hazel
    Univ Lancaster, England.
    Ahmed, Faraz
    Univ Lancaster, England.
    Opdebeeck, Carol
    Manchester Metropolitan Univ, England.
    Wang, Ying-Ying
    Univ Lancaster, England.
    Williamson, Paula
    Univ Liverpool, England.
    Swarbrick, Caroline
    Univ Manchester, England.
    Leroi, Iracema
    Univ Manchester, England.
    Challis, David
    Univ Manchester, England.
    Davies, Linda
    Univ Manchester, England.
    Reeves, David
    Univ Manchester, England.
    Holland, Fiona
    Univ Manchester, England.
    Hann, Mark
    Univ Manchester, England.
    Hellström, Ingrid
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in East Östergötland.
    Hydén, Lars-Christer
    Linköping University, Department of Social and Welfare Studies, Division Ageing and Social Change. Linköping University, Faculty of Arts and Sciences.
    Burns, Alistair
    Univ Manchester, England.
    Keady, John
    Univ Manchester, England; Greater Manchester Mental Hlth NHS Fdn Trust, England.
    Reilly, Siobhan
    Univ Lancaster, England.
    Developing a core outcome set for people living with dementia at home in their neighbourhoods and communities: study protocol for use in the evaluation of non-pharmacological community-based health and social care interventions2018In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 19, article id 247Article in journal (Refereed)
    Abstract [en]

    Background: The key aim of the study is to establish an agreed standardised core outcome set (COS) for use when evaluating non-pharmacological health and social care interventions for people living at home with dementia. Methods/design: Drawing on the guidance and approaches of the Core Outcome Measures in Effectiveness Trials (COMET), this study uses a four-phase mixed-methods design: 1 Focus groups and interviews with key stakeholder groups (people living with dementia, care partners, relevant health and social care professionals, researchers and policymakers) and a review of the literature will be undertaken to build a long list of outcomes. 2 Two rounds of Delphi surveys will be used with key stakeholder groups. Statements for the Delphi surveys and participation processes will be developed and informed through substantial member involvement with people living with dementia and care partners. A consensus meeting will be convened with key participant groups to discuss the key findings and finalise the COS. 3 A systematic literature review will be undertaken to assess the properties of tools and instruments to assess components of the COS. Measurement properties, validity and reliability will be assessed using the Consensus-based Standards for the Selection of Health Measurement (COSMIN) and COMET guidance. 4 A stated preference survey will elicit the preferences of key stakeholders for the outcomes identified as important to measure in the COS. Discussion: To the best of our knowledge, this study is the first to use a modified Delphi process to involve people living with dementia as a participant group. Though the study is confined to collecting data in the United Kingdom, use of the COS by researchers will enhance the comparability of studies evaluating non-pharmacological and community-based interventions.

  • 185.
    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

  • 186. Hass, Ursula
    et al.
    Brodin, Håkan
    Andersson, Agneta
    Persson, Jan
    Assistive technology selection: a study of participation of users with rheumatoid arthritis1997In: IEEE transactions on rehabilitation engineering, ISSN 1063-6528, E-ISSN 1558-0024, Vol. 5, no 3, p. 263-275Article in journal (Refereed)
  • 187.
    Hasson, Henna
    et al.
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Augustsson, Hanna
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Schwarz, Ulrica von Thiele
    Karolinska Inst, Sweden; Malardalen Univ, Sweden.
    Empirical and conceptual investigation of de-implementation of low-value care from professional and health care system perspectives: a study protocol2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 67Article in journal (Refereed)
    Abstract [en]

    Background: A considerable proportion of interventions provided to patients lacks evidence of their effectiveness This implies that patients may receive ineffective, unnecessary, or even harmful care Thus, in addition to implementing evidence based practices, there is also a need to abandon interventions that are not based on best evidence, i e, low value care However, research on de implementation is limited, and there is a lack of knowledge about how effective de implementation processes should be earned out The aim of this project is to explore the phenomenon of the de implementation of low value health care practices from the perspective of professionals and the health care system. Methods: Theories of habits and developmental learning in combination with theories of organizational alignment will be used The projects work will be conducted in five steps Step 1 is a scoping review of the literature, and Step 2 has an explorative design involving interviews with health care stakeholders Step 3 has a prospective design in which workplaces and professionals are shadowed during an ongoing de implementation In Step 4, a conceptual framework for de implementation will be developed based on the previous steps In Step 5, strategies for de implementation are identified using a co design approach. Discussion: This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de implementation of low value care The professionals perspectives will be highlighted, including insights into how they make decisions, handle de implementation in daily practice, and what consequences it has on their work Furthermore, the health care system perspective will be considered and new knowledge on how de implementation can be understood across health care system levels will be obtained The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact The project employs a solution oriented perspective by developing a framework for de implementation of low value practices and suggesting practical strategies to improve de implementation processes at all levels of the health care system The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.

  • 188.
    Haverkamp, Frederike J. C.
    et al.
    Radboudumc, Netherlands.
    Veen, Harald
    WHO, Switzerland.
    Hoencamp, Rigo
    Alrijne Med Ctr Leiderdorp, Netherlands; Leiden Univ, Netherlands; Minist Def, Netherlands.
    Muhrbeck, Måns
    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 Norrköping.
    von Schreeb, Johan
    Karolinska Inst, Sweden.
    Wladis, Andreas
    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 Disaster Medicine and Traumatology. Int Comm Red Cross, Switzerland.
    Tan, Edward C. T. H.
    Radboudumc, Netherlands.
    Prepared for Mission? A Survey of Medical Personnel Training Needs Within the International Committee of the Red Cross2018In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 42, no 11, p. 3493-3500Article in journal (Refereed)
    Abstract [en]

    Background Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them. This is the first study of its kind to assess the self-perceived preparedness, deployment experiences, and learning needs concerning medical readiness for deployment of ICRC medical personnel. Methods All enlisted ICRC medical employees were invited to participate in a digital questionnaire conducted during March 2017. The survey contained questions about respondents personal background, pre-deployment training, deployment experiences, self-perceived preparedness, and the personal impact of deployment. Results The response rate (consisting of nurses, surgeons, and anesthesiologists) was 54% (153/284). Respondents rated their self-perceived preparedness for adult trauma with a median score of 4.0 on a scale of 1 (very unprepared) to 5 (more than sufficient); and for pediatric trauma with a median score of 3.0. Higher rates of self-perceived preparedness were found in respondents who had previously been deployed with other organizations, or who had attended at least one master class, e.g., the ICRC War Surgery Seminar (p amp;lt; 0.05). Additional training was requested most frequently for pediatrics (65/150), fracture surgery (46/150), and burns treatment (45/150). Conclusion ICRC medical personnel felt sufficiently prepared for deployment. Key points for future ICRC pre-deployment training are to focus on pediatrics, fracture surgery, and burns treatment, and to ensure greater participation in master classes.

  • 189.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Health economic aspects of diabetic retinopathy2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    To ensure that the resources of the health care sector are used effectively, new technologies need to be evaluated before implementation to examine if they generate health outcomes at an acceptable cost. This information can be collected by performing health economic evaluations in which the costs and health outcomes of different technologies are compared. To estimate the effect on health care budgets, there is also a need for information about the prevalence of the specific disease. Health outcomes in health economic evaluations are often measured in quality-adjusted life years (QALYs), which are calculated by multiplying the remaining life years after an intervention by a weight representing the health-related quality of life (HRQoL) during those years.

    This thesis aims to provide deeper knowledge of the health economic aspects of diabetic retinopathy (DR), an eye complication that affects patients with diabetes and may in the worst case lead to blindness. The focus is on three empirical and two methodological health economic research questions. The empirical research areas cover prevalence, costs, and HRQoL related to patients with DR. The methodological research questions explore the performance of different methods for estimation of QALY weights. This is of interest since it has been argued that the most common methods for estimating QALY weights may not capture all relevant vision-related aspects of quality of life. The analyses comprehend the validity of different methods for estimating QALY weights among patients with DR and if the results of one of the specific methods for estimating QALY weights, the time trade-off (TTO) exercise, are affected by patients’ subjective life expectancy (SLE).

    The empirical results demonstrate that DR is seen in approximately 40% and 30% of patients with type I and type II diabetes respectively, indicating that the prevalence of DR has decreased in both of these patient groups. Healthcare costs vary considerably between different severity levels of the disease, being estimated at €26, €257, €216, and €433 per patient per year for background retinopathy, proliferative diabetic retinopathy (PDR), diabetic macular oedema (DMO), and PDR combined with DMO respectively. Blindness due to DR is associated with an increased use of transportation services, caregiving services, and assistive technologies as well as productivity losses. This suggests that preventing the progression of DR may lower healthcare costs. Patients with vision impairment due to DR have lowered HRQoL in various dimensions, but the diagnosis of DR in itself has only a limited effect on HRQoL.

    The results on the methodological research questions show that different methods for estimating QALY weights seem to give different results. In comparison to EQ-5D, the Health Utilities Index Mark 3 (HUI-3) is the most sensitive method for detecting differences in QALY weights due to DR, and if decisions are to be made based on values from the general public, it can be recommended for use in cost-utility analyses of interventions directed at DR. Neither of the direct methods, TTO and the visual analogue scale, seems to be sensitive to differences in visual function, and more research is needed concerning the role of vision in people’s responses to the TTO exercises. In TTO exercises with time frames based on actuarial life expectancy, the patients’ SLE has an effect on their willingness to trade off years for full health. Thus, applying time frames deviating from patients’ SLE may result in biased QALY weights. Such bias may appear stronger within patient populations than within the general public.

    In conclusion, this thesis offers estimates for prevalence, costs, and QALY weights that can be used in economic evaluations of interventions directed at DR and as benchmarks for future DR research in order to follow up consequences of changes in diabetes care. In addition, it demonstrates that the choice of method for estimating QALY weights may have an impact on whether an intervention is considered cost-effective.

    List of papers
    1. Prevalence and healthcare costs of diabetic retinopathy: a population-based register study in Sweden
    Open this publication in new window or tab >>Prevalence and healthcare costs of diabetic retinopathy: a population-based register study in Sweden
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    2010 (English)In: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 53, no 10, p. 2147-2154Article in journal (Refereed) Published
    Abstract [en]

    Aims/hypothesis

    The aim of the present study was to estimate the prevalence and healthcare costs of diabetic retinopathy (DR).

    Methods

    This population-based study included all residents (n = 251,386) in the catchment area of the eye clinic of Linköping University Hospital, Sweden. Among patients with diabetes (n  = 12,026), those with and without DR were identified through register data from both the Care Data Warehouse in Östergötland, an administrative healthcare register, and the Swedish National Diabetes Register. Healthcare cost data were elicited by record linkage of these two registers to data for the year 2008 in the Cost Per Patient Database developed by Östergötland County Council.

    Results

    The prevalence of any DR was 41.8% (95% CI 38.9–44.6) for patients with type 1 diabetes and 27.9% (27.1–28.7) for patients with type 2 diabetes. Sight-threatening DR was present in 12.1% (10.2–14.0) and 5.0% (4.6–5.4) of the type 1 and type 2 diabetes populations respectively. The annual average healthcare cost of any DR was €72 (€53–91). Stratified into background retinopathy, proliferative DR, maculopathy, and the last two conditions combined, the costs were €26 (€10–42), €257 (€155–359), €216 (€113–318) and €433 (€232–635) respectively. The annual cost for DR was €106 000 per 100,000 inhabitants.

    Conclusions

    This study presents new information on the prevalence and costs of DR. Approximately one-third of patients with diabetes have some form of DR. Average healthcare costs increase considerably with the severity of DR, which suggests that preventing progression of DR may lower healthcare costs.

    Keywords
    Costs, Diabetes mellitus, Diabetic retinopathy, Epidemiology, Prevalence, Registries
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-59070 (URN)10.1007/s00125-010-1836-3 (DOI)000281612600011 ()
    Available from: 2010-09-08 Created: 2010-09-08 Last updated: 2017-12-12Bibliographically approved
    2. QALY weights for diabetic retinopathy: a comparison of health state valuations with HUI-3, EQ-5D, EQ-VAS, and TTO.
    Open this publication in new window or tab >>QALY weights for diabetic retinopathy: a comparison of health state valuations with HUI-3, EQ-5D, EQ-VAS, and TTO.
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    2012 (English)In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 15, no 3, p. 475-484Article in journal (Refereed) Published
    Abstract [en]

    Objective: To estimate quality-adjusted life-year weights for patients with diabetic retinopathy by using various methods and to investigate the empirical validity of the different measures.

    Methods: The study population comprised 152 patients with diabetes in Östergötland County, Sweden. Participants were interviewed by telephone by using the time trade-off (TTO) method and a visual analogue scale (EQ-VAS) (direct valuations) as well as the EuroQol five-dimensional questionnaire (EQ-5D) and the health utilities index mark 3 (HUI-3) (indirect valuations). The quality-adjusted life-year weights were adjusted for potential confounders by using analysis of covariance. The empirical validity of the measures was examined by testing their ability to detect hypothetical differences between severity levels of diabetic retinopathy and by investigating the correlation between the measures and the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25).

    Results: All measures detected significant differences in scores between patient groups classified according to visual impairment in the better eye (analysis of covariance, P < 0.05), but only HUI-3 and EQ-VAS detected significant differences between patient groups classified according to visual impairment or pathological progression in the worse eye. HUI-3 recorded a difference of 0.43 in values between normal vision and blindness in the better eye, which was more than twice the differences captured by the other measures (0.15–0.20). In addition, HUI-3 showed the highest correlation with NEI VFQ-25 (r = 0.54; P < 0.001).

    Conclusions: In cost-utility analyses, the choice of quality-adjusted life-year measure may affect whether an intervention is considered cost-effective. Furthermore, if decisions are to be based on values from the general public, HUI-3 can be recommended for cost-utility analyses of interventions directed at diabetic retinopathy.

    Place, publisher, year, edition, pages
    Elsevier, 2012
    Keywords
    diabetes mellitus, diabetic retinopathy, EQ-5D, health utility index mark 3, NEI-VFQ-25, QALY, time trade-off, TTO, VAS
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-76280 (URN)10.1016/j.jval.2011.11.031 (DOI)000303940600011 ()22583458 (PubMedID)
    Note

    funding agencies|AstraZeneca AB||

    Available from: 2012-04-02 Created: 2012-04-02 Last updated: 2017-12-07Bibliographically approved
    3. Health-related quality of life profiles of patients with diabetic retinopathy
    Open this publication in new window or tab >>Health-related quality of life profiles of patients with diabetic retinopathy
    Show others...
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Purpose: There are various instruments for estimating health-related quality of life (HRQoL) in patients with diabetic retinopathy (DR). However, if the results are to be compared with those for other diseases, it is essential to use measures that are applicable to all disease areas. The aim of this study was to explore the HRQoL profiles of patients with DR using two generic multi-attribute instruments, the Health State Utilities Index Mark 3 (HUI-3) and the EQ-5D questionnaire, and to investigate these questionnaires’ sensitivity to differences in HRQoL due to DR.

    Methods: The study population comprised 166 Swedish diabetes patients diagnosed with DR at different severities. Patients were interviewed over the telephone using HUI-3 and EQ-5D. The vision-specific National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25) was also included, to give an empirical framework for the results of the generic instruments. Linear and logistic regression models were used to adjust for possible confounders.

    Results: Patients with vision impairment (VI) reported lower scores in Vision, Ambulation, and Pain in HUI-3 and more problems with Usual activities and Anxiety/depression in EQ-5D. However, even though NEI VFQ-25 showed a negative association between DR severity and Mental health and Near activities, neither EQ-5D nor HUI-3 identified a negative relationship between DR severity and HRQoL.

    Conclusion: The generic instruments show lowered HRQoL for patients with VI in various dimensions but were not sensitive to decrements related to the diagnosis of DR alone. The questionnaire of HUI-3 was more sensitive than EQ-5D to differences in HRQoL due to DR-related VI.

    Keywords
    diabetes, diabetic retinopathy, health-related quality of life, health profile, EQ-5D, Health Utilities Index, HUI-3, National Eye Institute Visual Functioning Questionnaire 25, NEI VFQ-25
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-76281 (URN)
    Available from: 2012-04-02 Created: 2012-04-02 Last updated: 2018-09-01Bibliographically approved
    4. The impact of patients' subjective life expectancy on time trade-off valuations
    Open this publication in new window or tab >>The impact of patients' subjective life expectancy on time trade-off valuations
    2013 (English)In: Medical decision making, ISSN 0272-989X, E-ISSN 1552-681X, Vol. 33, no 2, p. 261-270Article in journal (Refereed) Published
    Abstract [en]

    Background. Quality-adjusted life-year (QALY) calculations in economic evaluations are typically based on general public or patient health state valuations elicited with the time tradeoff method (TTO). Such health state valuations elicited among the general public have been shown to be affected by respondents subjective life expectancy (SLE). This suggests that TTO exercises based on time frames other than SLE may lead to biased estimates. It has not yet been investigated whether SLE also affects patient valuations. Objective. To empirically investigate whether patients SLE affects TTO valuations of their current health state. Methods. Patients with different severities of diabetic retinopathy were asked in a telephone interview to value their own health status using TTO. The TTO time frame (t) presented was based on age- and sex-dependent actuarial life expectancy. Patients were then asked to state their SLE. Simple and multiple regression techniques were used to assess the effect of the patients SLE on their TTO responses. Results. In total, 145 patients completed the telephone interview. Patients TTO values were significantly influenced by their SLE. The TTO value decreased linearly with every additional year of difference between t and the patients SLE; that is, patients were more willing to give up years the shorter their SLE compared with t. Conclusion. Patients SLE influenced their TTO valuations, suggesting that respondents SLE may be the most appropriate time frame to use in TTO exercises in patients. The use of other time periods may bias the TTO valuations, as the respondents may experience the presented time frame as a gain or a loss. The effect seems to be larger in patient valuations than in general public valuations.

    Place, publisher, year, edition, pages
    SAGE Publications (UK and US), 2013
    Keywords
    utility measurement, preferences and quality of life, health state preferences, utilities, valuations, utility inconsistencies, time tradeoff, quality adjusted life year weights, QALYs
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-76282 (URN)10.1177/0272989X12465673 (DOI)000316684200014 ()
    Note

    Funding Agencies|Astra Zeneca AB Sweden||Ostergotland County Council||

    Available from: 2012-04-02 Created: 2012-04-02 Last updated: 2017-12-07Bibliographically approved
  • 190.
    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.

  • 191.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Bourghardt Peebo, Beatrice
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Ophthalmology UHL/MH.
    Wiréhn, Ann-Britt
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Rosenqvist, Ulf
    Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Department of Medical Specialist.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Health-related quality of life profiles of patients with diabetic retinopathyManuscript (preprint) (Other academic)
    Abstract [en]

    Purpose: There are various instruments for estimating health-related quality of life (HRQoL) in patients with diabetic retinopathy (DR). However, if the results are to be compared with those for other diseases, it is essential to use measures that are applicable to all disease areas. The aim of this study was to explore the HRQoL profiles of patients with DR using two generic multi-attribute instruments, the Health State Utilities Index Mark 3 (HUI-3) and the EQ-5D questionnaire, and to investigate these questionnaires’ sensitivity to differences in HRQoL due to DR.

    Methods: The study population comprised 166 Swedish diabetes patients diagnosed with DR at different severities. Patients were interviewed over the telephone using HUI-3 and EQ-5D. The vision-specific National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25) was also included, to give an empirical framework for the results of the generic instruments. Linear and logistic regression models were used to adjust for possible confounders.

    Results: Patients with vision impairment (VI) reported lower scores in Vision, Ambulation, and Pain in HUI-3 and more problems with Usual activities and Anxiety/depression in EQ-5D. However, even though NEI VFQ-25 showed a negative association between DR severity and Mental health and Near activities, neither EQ-5D nor HUI-3 identified a negative relationship between DR severity and HRQoL.

    Conclusion: The generic instruments show lowered HRQoL for patients with VI in various dimensions but were not sensitive to decrements related to the diagnosis of DR alone. The questionnaire of HUI-3 was more sensitive than EQ-5D to differences in HRQoL due to DR-related VI.

  • 192.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Wiréhn, Ann-Britt
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Bourghardt Peebo, Beatrice
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Ophthalmology in Linköping.
    Rosenqvist, Ulf
    Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    QALY weights for diabetic retinopathy: a comparison of health state valuations with HUI-3, EQ-5D, EQ-VAS, and TTO.2012In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 15, no 3, p. 475-484Article in journal (Refereed)
    Abstract [en]

    Objective: To estimate quality-adjusted life-year weights for patients with diabetic retinopathy by using various methods and to investigate the empirical validity of the different measures.

    Methods: The study population comprised 152 patients with diabetes in Östergötland County, Sweden. Participants were interviewed by telephone by using the time trade-off (TTO) method and a visual analogue scale (EQ-VAS) (direct valuations) as well as the EuroQol five-dimensional questionnaire (EQ-5D) and the health utilities index mark 3 (HUI-3) (indirect valuations). The quality-adjusted life-year weights were adjusted for potential confounders by using analysis of covariance. The empirical validity of the measures was examined by testing their ability to detect hypothetical differences between severity levels of diabetic retinopathy and by investigating the correlation between the measures and the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25).

    Results: All measures detected significant differences in scores between patient groups classified according to visual impairment in the better eye (analysis of covariance, P < 0.05), but only HUI-3 and EQ-VAS detected significant differences between patient groups classified according to visual impairment or pathological progression in the worse eye. HUI-3 recorded a difference of 0.43 in values between normal vision and blindness in the better eye, which was more than twice the differences captured by the other measures (0.15–0.20). In addition, HUI-3 showed the highest correlation with NEI VFQ-25 (r = 0.54; P < 0.001).

    Conclusions: In cost-utility analyses, the choice of quality-adjusted life-year measure may affect whether an intervention is considered cost-effective. Furthermore, if decisions are to be based on values from the general public, HUI-3 can be recommended for cost-utility analyses of interventions directed at diabetic retinopathy.

  • 193.
    Hendriks, Jeroen
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Univ Adelaide, Australia; Royal Adelaide Hosp, Australia.
    Heidbuchel, Hein
    Antwerp Univ, Belgium; Univ Hosp, Belgium; Hasselt Univ, Belgium.
    The management of atrial fibrillation: An integrated team approach - insights of the 2016 European Society of Cardiology guidelines for the management of atrial fibrillation for nurses and allied health professionals2019In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953, Vol. 18, no 2, p. 88-95Article in journal (Refereed)
    Abstract [en]

    The 2016 European Society of Cardiology guidelines for the management of atrial fibrillation recommends integrated care in the treatment of atrial fibrillation and follows a patient-centred, multidisciplinary team approach. Nurses and allied health professionals have a significant role to play in the management of chronic conditions such as atrial fibrillation, which is underlined by this guideline and the integrated care approach. In this article, members of the task force writing committee highlight significant evidence from this particular guideline as well as clinical implications for nurses and allied health professionals in their daily work with atrial fibrillation patients and their caregivers.

  • 194.
    Hendry, Gillian
    et al.
    University of Strathclyde, Scotland.
    Winn, Philip
    University of Strathclyde, Scotland.
    Wiggins, Sally
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Turner, Christopher J.
    University of Colorado Anschutz Medical Campus, CO USA.
    Qualitative Evaluation of a Practice-based Experience Pilot Program for Master of Pharmacy Students in Scotland2016In: American Journal of Pharmaceutical Education, ISSN 0002-9459, E-ISSN 1553-6467, Vol. 80, no 10, article id 165Article in journal (Refereed)
    Abstract [en]

    Objective. To determine the views of pharmacists in central Scotland regarding experiential education for MPharm students. Methods. A thematic analysis was completed by Ms. Gillian Hendry and Dr. Sally Wiggins of interviews conducted with ten practicing pharmacists paired with first-year master of pharmacy (MPharm) students during the 2011-2012 academic year. Relevant comments from the interviews were manually sorted in a Microsoft Excel spreadsheet to bring similarly themed material together to facilitate the identification and naming of recurring themes and subthemes. Results. The pharmacists were unanimous in their opinion that experiential education was valuable for MPharm students and, in particular, that it helped students to develop self-confidence. The pharmacists derived personal satisfaction in developing mentor/mentee relationships with students. They also recognized the value that students provided to the workforce as well as the educational value to themselves in supervising students. The participants primary dissatisfaction was that the pharmacy workflow limited the time they could spend mentoring students. Conclusion. The results provide guidance to the academic community and the pharmacy practice community in the United Kingdom (UK) regarding the design and integration of experiential education courses in MPharm degree programs.

  • 195.
    Henriksson, Martin
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Cost-effectiveness and Value of Further Research of Treatment Strategies for Cardiovascular Disease2007Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Economic evaluations provide a tool to estimate costs and health consequences of competing medical technologies, ultimately to aid decision makers when deciding which medical technologies should be funded from available resources. Such decisions inevitably need to be taken under uncertainty and it is not clear how to approach them in health care decision-making. Recent work in economic evaluation has proposed an analytic framework where two related, but conceptually different decisions need to be considered: (1) should a medical technology be adopted given existing evidence; and (2) whether more evidence should be acquired to support the adoption decision in the future. The proposed analytic framework requires a decision-analytic model appropriately representing the clinical decision problem under consideration, a probabilistic analysis of this model in order to determine cost-effectiveness and characterise current decision uncertainty, and estimating the value of additional information from research to reduce decision uncertainty. The main aim of this thesis is to apply the analytic framework on three case studies concerning treatment strategies for cardiovascular disease in order to establish whether the treatment strategies should be adopted given current available information and if more information should be acquired to support the adoption decisions in the future. The implications for policy and methodology of utilising the analytic framework employed in the case studies are also discussed in this thesis.

    The results of the case studies show that a screening programme for abdominal aortic aneurysm in 65-year-old men is likely to be cost-effective in a Swedish setting and there appears to be little value in performing further research regarding this decision problem; an early interventional strategy in non-ST-elevation acute coronary syndrome is cost-effective for patients at intermediate to high risk of further cardiac events in a UK setting; endarterectomy in patients with an asymptomatic carotid artery stenosis is cost-effective for men around 73 years of age or younger in a Swedish setting and conducting further research regarding this decision problem is potentially worthwhile.

    Comparing the results of the present analyses with current clinical practice shows a need for changing clinical practice in Sweden regarding screening for abdominal aortic aneurysm and endarterectomy in patients with asymptomatic carotid artery stenosis. Furthermore, employing the analytic framework applied in the case studies can improve treatment guidelines and recommendations for further research. In particular, treatment guidelines ought to consider in which particular subgroups of patients an intervention is cost-effective.

    The case studies indicate that it is feasible to apply the analytic framework for economic evaluation of health care. Methodological development can improve the accuracy with which cost-effectiveness and value of information is estimated, but may also lead to comprehensive and complex evaluations. The nature of the decision problem should determine the level of comprehensiveness required for a particular evaluation.

    List of papers
    1. Decision-anaytical model with lifetime estimation of costs and health outcomes for one-time screening for abdominal aortic aneursm in 65-year-old men
    Open this publication in new window or tab >>Decision-anaytical model with lifetime estimation of costs and health outcomes for one-time screening for abdominal aortic aneursm in 65-year-old men
    2005 (English)In: British Journal of Surgery, ISSN 0007-1323, Vol. 92, no 8, p. 976-983Article in journal (Refereed) Published
    Abstract [en]

    Background: Abdominal aortic aneurysm (AAA) causes about 2 per cent of all deaths in men over the age of 65 years. A major improvement in operative mortality would have little impact on total mortality, so screening for AAA has been recommended as a solution. The cost-effectiveness of a programme that invited 65-year-old men for ultrasonographic screening was compared with current clinical practice in a decision-analytical model.

    Methods: In a probabilistic Markov model, costs and health outcomes of a screening programme and current clinical practice were simulated over a lifetime perspective. To populate the model with the best available evidence, data from published papers, vascular databases and primary research were used.

    Results: The results of the base-case analysis showed that the incremental cost per gained life-year for a screening programme compared with current practice was €7760, and that for a quality-adjusted life-year was €9700. The probability of screening being cost-effective was high.

    Conclusion: A financially and practically feasible screening programme for AAA, in which men are invited for ultrasonography in the year in which they turn 65, appears to yield positive health outcomes at a reasonable cost.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14658 (URN)10.1002/bjs.5122 (DOI)
    Available from: 2007-09-24 Created: 2007-09-24 Last updated: 2009-05-18
    2. Informing the efficient use of health care and health care research resources: the case of screening for abdominal aortic aneurysm in Sweden
    Open this publication in new window or tab >>Informing the efficient use of health care and health care research resources: the case of screening for abdominal aortic aneurysm in Sweden
    2006 (English)In: Health Economics, ISSN 1057-9230, Vol. 15, no 12, p. 1311-1322Article in journal (Refereed) Published
    Abstract [en]

    Background: An analytical framework using Bayesian decision theory and value-of-information analysis has recently been advocated for the economic evaluation of health technologies. The purpose of this study was to apply this framework to screening for abdominal aortic aneurysm (AAA) in Sweden and to compare the conclusions from this study with the conclusions presented in an assessment performed by the Swedish Council of Technology Assessment (SBU).

    Methods: A probabilistic decision-analytical model was developed to establish the cost-effectiveness of a screening programme for AAA relative to current clinical practice and to calculate the value-of-information.

    Results: The cost per quality-adjusted life-year for screening was €9700. The expected value of perfect information for the assessment of overall cost-effectiveness was low, suggesting little benefit in conducting further research. Expected value of perfect partial information indicated that rupture probabilities were associated with the highest uncertainty. By contrast, the SBU report concluded there was limited evidence of cost-effectiveness and proposed further research.

    Conclusion: The investigated screening programme for AAA is likely to be cost-effective and conducting another clinical trial is unlikely to add much valuable information to this decision problem. These recommendations contrast with the vaguer recommendations from SBU that more evidence is required of costs-effectiveness.

    Keywords
    cost-effectiveness, decision making, prioritising research, abdominal aortic aneurysm
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14659 (URN)10.1002/hec.1130 (DOI)
    Available from: 2007-09-24 Created: 2007-09-24
    3. The cost-effectiveness of an early interventional strategy in non-ST-elevation acute coronary syndrome based on the RITA 3 trial
    Open this publication in new window or tab >>The cost-effectiveness of an early interventional strategy in non-ST-elevation acute coronary syndrome based on the RITA 3 trial
    Show others...
    2008 (English)In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 94, p. 717-723Article in journal (Refereed) Published
    Abstract [en]

    Background: Evidence suggests that an early interventional strategy for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) can improve health outcomes but also increase costs when compared with a conservative strategy.

    Objective: The aim of this study was to assess the cost-effectiveness of an early interventional strategy in different risk groups from a UK health-service perspective.

    Design: Decision-analytic model based on randomised clinical trial data.

    Main outcome measures: Costs in UK Sterling at 2003/2004 prices and quality-adjusted life years (QALYs) combined into an incremental cost-effectiveness ratio.

    Methods: Data from the third Randomised Intervention Trial of unstable Angina (RITA 3) was employed to estimate rates of cardiovascular death and myocardial infarction, costs and health-related quality of life. Cost-effectiveness was estimated over patients’ lifetimes within the decision-analytic model.

    Results: The mean incremental cost per QALY gained for an early interventional strategy was approximately £55 000, £22 000 and £12 000 for patients at low, intermediate and high risk, respectively. The early interventional strategy is approximately 1%, 35% and 95% likely to be cost-effective for patients at low, intermediate and high risk, respectively, at a threshold of £20 000 per QALY. The cost-effectiveness of early intervention in low-risk patients is sensitive to assumptions about the duration of the treatment effect.

    Conclusion: An early interventional strategy in patients presenting with NSTE-ACS is likely to be considered cost-effective for patients at high and intermediate risk, but this is less likely to be the case for patients at low risk.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14660 (URN)10.1136/hrt.2007.127340 (DOI)
    Available from: 2007-09-24 Created: 2007-09-24 Last updated: 2017-12-13
    4. Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
    Open this publication in new window or tab >>Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
    2008 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 6, p. 714-720Article in journal (Refereed) Published
    Abstract [en]

    Background: Long-term health outcomes and costs are important when deciding whether a strategy of carotid endarterectomy in addition to best medical management should be recommended for patients with asymptomatic carotid artery stenosis. This study investigated the cost-effectiveness of such a strategy compared with a strategy of best medical management alone.

    Methods: Based on data from the randomized Asymptomatic Carotid Surgery Trial (ACST), a national vascular database and other published sources, expected costs and health outcomes in terms of quality-adjusted life years (QALYs) of both treatment strategies were estimated using decision-analytical modelling. Cost-effectiveness was established for a Swedish setting from a societal perspective.

    Results: Base-case analysis showed that the incremental cost per QALY of a strategy with carotid endarterectomy for 65- and 75-year-old men (women) was 34 557 (311 133) and 58 930 (779 776) respectively. Sensitivity analyses indicated that the duration of the treatment effect after 5 years of follow-up in the ACST was important for the cost-effectiveness results.

    Conclusion: Carotid endarterectomy in addition to best medical management can be considered cost-effective in men aged 73 years or less but is less likely to be cost-effective in older men or in women.

    Place, publisher, year, edition, pages
    Chichester, West Sussex, United Kingdom: John Wiley & Sons, 2008
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14661 (URN)10.1002/bjs.6157 (DOI)000258391500009 ()
    Available from: 2007-09-24 Created: 2007-09-24 Last updated: 2017-12-13Bibliographically approved
    5. The value of further research into the cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
    Open this publication in new window or tab >>The value of further research into the cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
    2007 (English)Article in journal (Refereed) Submitted
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14662 (URN)
    Available from: 2007-09-24 Created: 2007-09-24
  • 196.
    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)
  • 197.
    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

  • 198.
    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.

  • 199.
    Hill, Loreena
    et al.
    Queens Univ, North Ireland.
    McIlfatrick, Sonja
    Ulster Univ, North Ireland; All Ireland Inst Hosp and Palliat Care, Ireland.
    Taylor, Brian J.
    Ulster Univ, North Ireland.
    Jaarsma, Tiny
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Mary MacKillop Inst Hlth Res, Australia.
    Moser, Debra
    Univ Kentucky, KY USA; Univ Kentucky, KY USA.
    Slater, Paul
    Ulster Univ, North Ireland.
    McAloon, Toni
    Ulster Univ, North Ireland.
    Dixon, Lana
    Belfast Hlth and Social Care Trust, North Ireland.
    Donnelly, Patrick
    South Eastern Hlth and Social Care Trust, North Ireland.
    Strömberg, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Fitzsimons, Donna
    Queens Univ, North Ireland; All Ireland Inst Hosp and Palliat Care, Ireland.
    Patient and Professional Factors That Impact the Perceived Likelihood and Confidence of Healthcare Professionals to Discuss Implantable Cardioverter Defibrillator Deactivation in Advanced Heart Failure Results From an International Factorial Survey2018In: Journal of Cardiovascular Nursing, ISSN 0889-4655, E-ISSN 1550-5049, Vol. 33, no 6, p. 527-535Article in journal (Refereed)
    Abstract [en]

    Background: Rate of implantable cardioverter defibrillator (ICD) implantations is increasing in patients with advanced heart failure. Despite clear guideline recommendations, discussions addressing deactivation occur infrequently. Aim: The aim of this article is to explore patient and professional factors that impact perceived likelihood and confidence of healthcare professionals to discuss ICD deactivation. Methods and Results: Between 2015 and 2016, an international sample of 262 healthcare professionals (65% nursing, 24% medical) completed an online factorial survey, encompassing a demographic questionnaire and clinical vignettes. Each vignette had 9 randomly manipulated and embedded patient-related factors, considered as independent variables, providing 1572 unique vignettes for analysis. These factors were determined through synthesis of a systematic literature review, a retrospective case note review, and a qualitative exploratory study. Results showed that most healthcare professionals agreed that deactivation discussions should be initiated by a cardiologist (95%, n = 255) or a specialist nurse (81%, n = 215). In terms of experience, 84% of cardiologists (n = 53) but only 30% of nurses (n = 50) had previously been involved in a deactivation decision. Healthcare professionals valued patient involvement in deactivation decisions; however, only 50% (n = 130) actively involved family members. Five of 9 clinical factors were associated with an increased likelihood to discuss deactivation including advanced age, severe heart failure, presence of malignancy, receipt of multiple ICD shocks, and more than 3 hospital admissions during the previous year. Furthermore, nationality and discipline significantly influenced likelihood and confidence in decision making. Conclusions: Guidelines recommend that healthcare professionals discuss ICD deactivation; however, practice is suboptimal with multifactorial factors impacting on decision making. The role and responsibility of nurses in discussing deactivation require clarity and improvement.

  • 200.
    Hjelm, Katarina
    et al.
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences.
    Apelqvist, Jan
    Diabetes-och Endokrin kliniken, Universitetssjukhuset i Malmö, Lunds universitet.
    Migrants with diabetes believe diabetic foot ulcers being unavoidable and impossible to prevent.2015In: 50th annual meeting of the EUROPEAN DIABETES EPIDEMIOLOGY GROUP.25-28 April 2015. Les Fontaines, Gouvieux-Chantilly, France.Study group of the European Association for the Study of Diabetes (EASD), Paris, France.: EUROPEAN DIABETES EPIDEMIOLOGY GROUP - EDEG , 2015Conference paper (Refereed)
    Abstract [en]

    Background: Since type 2 diabetes is developing into a pandemic, particularly affecting migrants in industrializing countries, the prevalence of diabetes complications is expected to increase. Diabetic foot disorders are the predominant source of complications and are serious and costly but highly preventable particularly by self-care. Health-related behavior, including self care and health care seeking, is guided by beliefs about health/illness but has not previously been studied in different migrant groups. We aim to describe beliefs about health/illness in foreign-born persons with diabetic foot ulcers that might affect self-care and health care seeking and to study whether there are dissimilarities related to origin. ‘

    Material and methods: Qualitative descriptive study. Semi-structured interviews with 26 persons, aged 38-86 years, whereof 13 born in European and 13 in non European countries, all except one in the Middle East, being residents in Sweden between 7-60 years (Md 18 yrs).

    Results: Most believed foot ulcers being unavoidable and problematic to detect, and mainly caused by internal factors such as diabetes, sometimes combined with external factors as inappropriate foot wear, hot water, or bare foot walking. Perceived health had deteriorated after onset of the foot problems due to immobility and pain. Middle Easterners differed as they discussed the importance to adapt to the will of Allah, leading to even poorer quality of life and view of future health. They described more foot problems and perceived religion (Muslim) with washing rituals of the feet being of importance for health. They were less often regularly monitored than European migrants. Economy affected health, more so in Europeans, due to expenses for medications and shoes. Many described limited activity in self-care, few had searched help for their foot problems and if so solely among professionals and had limited knowledge about the influence of glycaemic control on diabetes/foot status.

    Conclusions: Foreign-born persons perceived foot ulcers being impossible to prevent, experienced problems with detection, and had limited knowledge about self-care. Dissimilarities in beliefs related to origin were found that negatively affected self-care of the feet why it is important to assess individual beliefs and plan care and education accordingly. 

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