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  • 151.
    Gustavsson, Erik
    et al.
    Linköpings universitet, Institutionen för kultur och kommunikation, Avdelningen för kultur och estetik. Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Juth, Niklas
    LIME, Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden..
    Principles of Need and the Aggregation Thesis2019Ingår i: Health Care Analysis, ISSN 1065-3058, E-ISSN 1573-3394, Vol. 27, nr 2, s. 77-92Artikel i tidskrift (Refereegranskat)
    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.

  • 152.
    Gustavsson, Erik
    et al.
    Linköpings universitet, Institutionen för kultur och kommunikation, Avdelningen för kulturvetenskaper, KVA. Linköpings universitet, Filosofiska fakulteten.
    Juth, Niklas
    Centre for healthcare ethics, Karolinska institutet, Solna, Sverige.
    Munthe, Christian
    Institutionen för filosofi, lingvistik och vetenskapsteori, Göteborgs universitet, Sverige.
    Sandman, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Institutionen för vårdvetenskap, Högskolan i Borås, Sverige.
    Etiska och praktiska utmaningar med ökat patientinflytande2015Ingår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, artikel-id DD3XArtikel i tidskrift (Övrigt vetenskapligt)
    Abstract [sv]

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

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

    Prioriteringar på gruppnivå kan bli svårare att tillämpa på individnivå. 

    Det kan bli svårare att bedöma nyttan med behandlingar. 

    Det kan bli svårare att få fram evidens för behandlingar. 

    Det tycks komplicera idén om den följsamme patienten. 

    Det kan innebära vissa implikationer för resursanvändning. 

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

  • 153.
    Gustavsson, Erik
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Sandman, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Etisk analys av pre-expositionsprofylax (PrEP) för hiv2018Rapport (Övrigt vetenskapligt)
    Abstract [sv]

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

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

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

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

  • 154.
    Gustavsson, Erik
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Sandman, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. University of Boras, Sweden.
    Health-care needs and shared decision-making in priority-setting2015Ingår i: Medicine, Health care and Philosophy, ISSN 1386-7423, E-ISSN 1572-8633, Vol. 18, nr 1, s. 13-22Artikel i tidskrift (Refereegranskat)
    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.

  • 155.
    Gustavsson, Erik
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälsa och samhälle. Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Sandman, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet. Högskolan i Borås, Institutionen för vårdvetenskap.
    Wiss, Johanna
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Rättviseteorier och prioriteringar2013Ingår i: Att välja rättvist: om prioriteringar i hälso- och sjukvården / [ed] Per Carlsson och Susanne Waldau, Lund: Studentlitteratur, 2013, 1, s. 49-64Kapitel i bok, del av antologi (Övrigt vetenskapligt)
    Abstract [sv]

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

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

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

  • 156.
    Gustavsson, Erik
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälsa och samhälle. Linköpings universitet, Filosofiska fakulteten.
    Wiss, Johanna
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Multikriterieanalyser vid prioriteringar inom hälso- och sjukvården: kriterier och analysmetoder2013Rapport (Övrigt vetenskapligt)
    Abstract [sv]

    Vid prioriteringsbeslut i hälso- och sjukvården tar man i regel hänsyn till ett stort antal aspekter såsom hur stort vårdbehovet är och hur stor nytta en viss åtgärd förväntas göra. Ibland görs prioriteringar av en enskild beslutsfattare medan de andra gånger går igenom komplicerade beslutsprocesser med många personer involverade. I många fall görs avvägningarna implicit utan att det är möjligt för beslutfattare att kunna redogöra för vad legat till grund för beslutet och det är då inte heller möjligt för utomstående att ta del hur man kommit fram till beslutet. Det finns dock en strävan mot att prioriteringsbeslut i ökad utsträckning ska göras på ett systematiskt och mer öppet sätt för att berörda parter ska kunna ta del av resultatet, grunderna och motiven bakom besluten.

    För att detta ska vara möjligt behövs metoder för att systematiskt hantera prioriteringsbeslut som tar hänsyn till komplex information och ger möjlighet till tydliga avvägningar mellan olika kriterier. Dit hör t ex multikriterieanalysmetoder där relevanta kriterier fastställs och ges olika vikter med syftet att rangordna olika beslutsalternativ. Utmärkande för denna ansats är att det inte finns några givna kriterier som ska värderas och viktas utan beslutsfattarna måste själva definiera vad analysen ska omfatta. Internationellt har multikriterieanalys använts i liten skala vid resursfördelning inom hälso- och sjukvården och jag känner inte till någon sådan tillämpning i Sverige.

    Den metod som använts mest i Sverige, den nationella modellen för öppna prioriteringar, syftar också till att skapa systematik och mer genomtänkta beslut och som kan förklaras för allmänheten/berörda parter. Den skiljer sig dock på flera sätt från multikriterieanalysmetoderna ovan. Den största skillnaden är att den i huvudsak är en kvalitativ metod som utgår från den etiska plattformen i riksdagens riktlinjer för prioriteringar. Vid prioriteringar med förutbestämda kriterier t ex svårighetsgrad, patientytta och kostnadseffektivitet finns skäl att anta att även andra aspekter ibland vägs in i bedömningen utan att det beskrivs.

    I rapportens första del, som beskriver kriterier som använts vid prioriteringar i andra länder på nationell och regional nivå, framgår att det förekommer ett stort antal kriterier vid sidan av de som finns i den nationella modellen. Det kan tyda på att man i andra länder accepterar andra grunder för prioriteringar och/eller att prioriteringar som görs i Sverige även väger in aspekter som inte omfattas de explicita kriterierna.

    Erfarenheter från olika prioriteringsarbeten i Sverige visar även att många efterfrågar en möjlighet att tydligare vikta olika kriterier. Eftersom prioriteringar handlar om att göra komplicerade avvägningar grundat på värderingar som skiljer sig åt mellan olika människor är det kanske varken rimligt eller önskvärt att försöka utveckla generella kvantitativa modeller för prioriteringsbeslut. Däremot kan det antagligen vara ett stöd för prioriteringar i avgränsade sammanhang där de involverade personerna enas om hur relevanta kriterier ska viktas.

    Jag tror därför att multikriterieanalyser kan ha en plats i framtiden även i Sverige. Därför är det vår förhoppning att denna rapport ska skapa ett intresse för fortsatt forskning och utveckling inom detta område.

  • 157.
    Hager, Jakob
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Henriksson, Martin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Centrum för medicinsk bildvetenskap och visualisering, CMIV. Linköpings universitet, Hälsouniversitetet.
    Carlsson, Per
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Länne, Toste
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Lundgren, Fredrik
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Changing Conditions - the same Conclusion: Cost-effective to Screen for Abdominal Aortic Aneurysm among 65-year-old Men, based on Data from an Implemented Screening Programme2014Manuskript (preprint) (Övrigt vetenskapligt)
    Abstract [en]

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

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

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

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

  • 158.
    Hager, Jakob
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken ViN.
    Henriksson, Martin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Carlsson, Per
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Länne, Toste
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Region Östergötland, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland. Linköpings universitet, Medicinska fakulteten.
    Lundgren, Fredrik
    Department of Surgery, Kalmar County Hospital, Kalmar, Sweden.
    Revisiting the cost-effectiveness of screening 65-year-old men for abdominal aortic aneurysm based on data from an implemented screening programme.2017Ingår i: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 36, nr 6, s. 517-525Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

  • 159.
    Hager, Jakob
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Fysiologi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Länne, Toste
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Carlsson, Per
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Lundgren, Fredrik
    Linköpings universitet, Institutionen för medicin och hälsa, Fysiologi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Lower Prevalence than Expected when Screening 70-year-old Men for Abdominal Aortic Aneurysm2013Ingår i: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 46, nr 4, s. 453-459Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

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

    Methods

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

    Results

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

    Conclusions

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

  • 160.
    Hager, Jakob
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Länne, Toste
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Carlsson, Per
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Lundgren, Fredrik
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    No benefit of screening for abdominal aortic aneurysm among 70- instead of 65-year-old men2014Ingår i: International Angiology, ISSN 0392-9590, Vol. 33, nr 5, s. 474-479Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

  • 161.
    Hagman, William
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Andersson, David
    Linköpings universitet, Institutionen för ekonomisk och industriell utveckling, Nationalekonomi. Linköpings universitet, Filosofiska fakulteten.
    Västfjäll, Daniel
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Decision Research, Eugene, USA.
    Tinghög, Gustav
    Linköpings universitet, Institutionen för ekonomisk och industriell utveckling, Nationalekonomi. Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Filosofiska fakulteten.
    Public Views on Policies Involving Nudges2015Ingår i: Review of Philosophy and Psychology, ISSN 1878-5158, E-ISSN 1878-5166, Vol. 6, nr 3, s. 439-453Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 162.
    Hallberg, S.
    et al.
    Quantify Research, Sweden.
    Banefelt, J.
    Quantify Research, Sweden.
    Fox, K. M.
    Strateg Healthcare Solut LLC, MD USA.
    Mesterton, J.
    Quantify Research, Sweden; Karolinska Institute, Sweden.
    Johansson, G.
    Uppsala University, Sweden.
    Levin, Lars-Åke
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Sobocki, P.
    Karolinska Institute, Sweden; IMS Heatlh, Sweden.
    Gandra, S. R.
    Amgen Inc, CA 91320 USA.
    Lipid-lowering treatment patterns in patients with new cardiovascular events - estimates from population-based register data in Sweden2016Ingår i: International journal of clinical practice (Esher), ISSN 1368-5031, E-ISSN 1742-1241, Vol. 70, nr 3, s. 222-228Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 163.
    Hallberg, S.
    et al.
    Quantify Research, Sweden.
    Gandra, S. R.
    Amgen Inc, CA 91320 USA.
    Fox, K. M.
    Strateg Healthcare Solut LLC, MD USA.
    Mesterton, J.
    Quantify Research, Sweden; Karolinska Institute, Sweden.
    Banefelt, J.
    Quantify Research, Sweden.
    Johansson, G.
    Uppsala University, Sweden.
    Levin, Lars-Åke
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Sobocki, P.
    Karolinska Institute, Sweden; IMS Heatlh, Sweden.
    Healthcare costs associated with cardiovascular events in patients with hyperlipidemia or prior cardiovascular events: estimates from Swedish population-based register data2016Ingår i: European Journal of Health Economics, ISSN 1618-7598, E-ISSN 1618-7601, Vol. 17, nr 5, s. 591-601Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 164.
    Hallert, Eva
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Husberg, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Kalkan, Almina
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Bernfort, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Reumatoid artrit är fortfarande en kostsam sjukdom – jämförelse mellan två kohorter2016Ingår i: BestPractice Reumatologi, ISSN 1903-6590, nr 27, s. 14-17Artikel i tidskrift (Övrigt vetenskapligt)
    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.

  • 165.
    Hallert, Eva
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Husberg, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Kalkan, Almina
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Bernfort, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Allergicentrum US.
    Rheumatoid arthritis is still expensive in the new decade: a comparison between two early RA cohorts, diagnosed 1996-98 and 2006-092016Ingår i: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 45, nr 5, s. 371-378Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES:

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

    METHOD:

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

    RESULTS:

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

    CONCLUSIONS:

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

  • 166.
    Hallert, Eva
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Husberg, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Kalkan, Almina
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Rahmqvist, Mikael
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Skogh, Thomas
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för neuro- och inflammationsvetenskap. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Reumatologiska kliniken i Östergötland.
    Bernfort, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet. Region Östergötland, Hjärt- och Medicincentrum, Allergicentrum US.
    Changes in sociodemographic characteristics at baseline in two Swedish cohorts of patients with early rheumatoid arthritis diagnosed 1996-98 and 2006-092015Ingår i: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 44, nr 2, s. 100-105Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 167.
    Hallert, Eva
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Reumatologiska kliniken i Östergötland.
    Husberg, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Kalkan, Almina
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Skogh, Thomas
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för inflammationsmedicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Reumatologiska kliniken i Östergötland.
    Bernfort, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Early rheumatoid arthritis 6 years after diagnosis is still associated with high direct costs and increasing loss of productivity: the Swedish TIRA project2014Ingår i: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 43, nr 3, s. 177-183Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

     

  • 168.
    Hass, Ursula
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Andersson, Agneta
    Linköpings universitet, Institutionen för medicin och hälsa, Socialmedicin och folkhälsovetenskap. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Närsjukvården i västra Östergötland, Forsknings- och utvecklingsenheten för Närsjukvården i Östergötland.
    Brodin, Håkan
    Linköpings universitet, Institutionen för ekonomisk och industriell utveckling, Konstruktionsmaterial. Linköpings universitet, Tekniska högskolan.
    Persson, Jan
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Assessment of computer-aided assistive technology: analysis of outcomes and costs1997Ingår i: Augmentative and Alternative Communication: AAC, ISSN 0743-4618, E-ISSN 1477-3848, Vol. 3, nr 2, s. 125-135Artikel i tidskrift (Refereegranskat)
    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

  • 169.
    Hedbrant, Johan
    et al.
    Linköpings universitet, Institutionen för ekonomisk och industriell utveckling, Mekanisk värmeteori och strömningslära. Linköpings universitet, Tekniska högskolan.
    Nordfeldt, Sam
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Nordfeldt, Sam
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för molekylär och klinisk medicin, Pediatrik.
    Ludvigsson, Johnny
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för molekylär och klinisk medicin, Pediatrik. Östergötlands Läns Landsting, Barn- och kvinnocentrum, Barn- och ungdomskliniken i Linköping.
    Ludvigsson, Johnny
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för molekylär och klinisk medicin, Pediatrik. Östergötlands Läns Landsting, Barn- och kvinnocentrum, Barn- och ungdomskliniken i Linköping.
    The Särimner Diabetes Simulator - A Look in the Rear View Mirror2007Ingår i: Diabetes Technology & Therapeutics, ISSN 1520-9156, E-ISSN 1557-8593, Vol. 9, nr 1, s. 10-16Artikel i tidskrift (Refereegranskat)
    Abstract [en]

      

  • 170.
    Hedin, Christina
    et al.
    Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken US.
    Sjödahl, Rune
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för Kirurgi, Ortopedi och Onkologi. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken US.
    Aldman, Åke
    Västerviks sjukhus, Västervik, Sweden.
    Davidson, Thomas
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Kammerlind, Ann-Sofie
    Region Jönköpings län, Jönköping, Sweden.
    Nodbrant, Per
    Onkologiska kliniken, Länssjukhuset Ryhov, Jönköping, Sweden.
    Agrup, Måns
    Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Onkologiska kliniken US. Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för Kirurgi, Ortopedi och Onkologi. Linköpings universitet, Medicinska fakulteten.
    Theodorsson, Elvar
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för mikrobiologi och molekylär medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Diagnostikcentrum, Klinisk kemi.
    Intraoperativ strålbehandling vid primar operation for bröstcancer: TARGIT-A-studien ej konklusiv2018Ingår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 115, artikel-id EWFFArtikel, forskningsöversikt (Refereegranskat)
    Abstract [sv]

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

  • 171.
    Heintz, Emelie
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet. Swedish Council on Health Technology Assessment (SBU), Stockholm.
    Arnberg, Karl
    The Dental and Pharmaceutical Benefits Agency (TLV) Stockholm.
    Levin, Lars-Åke
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    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
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet. Swedish Council on Health Technology Assessment (SBU), Stockholm.
    The impact of health economic evaluations in Sweden.2014Ingår i: Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, ISSN 2212-0289, Vol. 108, nr 7, s. 375-82Artikel i tidskrift (Refereegranskat)
    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.

  • 172.
    Heintz, Emelie
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Gerber-Grote, Andreas
    Institut für Qualität und Wirtschaftlichkeit Gesundheitswes, Germany.
    Ghabri, Salah
    Department of Economic and Public Health Evaluation, Haute Autorite Sante, France.
    Hamers, Francoise F.
    Department of Economic and Public Health Evaluation, Haute Autorite de Sante, France.
    Prevolnik Rupel, Valentina
    Institute for Economic Research, Slovenia.
    Slabe-Erker, Renata
    Institute for Econ Research, Slovenia.
    Davidson, Thomas
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Is There a European View on Health Economic Evaluations? Results from a Synopsis of Methodological Guidelines Used in the EUnetHTA Partner Countries2016Ingår i: PharmacoEconomics (Auckland), ISSN 1170-7690, E-ISSN 1179-2027, Vol. 34, nr 1, s. 59-76Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 173.
    Heintz, Emelie
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Swedish Council Health Technology Assessment SBU, Sweden.
    Lintamo, Laura
    Swedish Council Health Technology Assessment SBU, Sweden.
    Hultcrantz, Monica
    Swedish Council Health Technology Assessment SBU, Sweden; Karolinska Institute, Sweden.
    Jacobson, Stella
    Swedish Council Health Technology Assessment SBU, Sweden; Karolinska Institute, Sweden.
    Levi, Ragnar
    Swedish Council Health Technology Assessment SBU, Sweden.
    Munthe, Christian
    University of Gothenburg, Sweden.
    Tranaeus, Sofia
    Swedish Council Health Technology Assessment SBU, Sweden; Malmö University, Sweden; Karolinska Institute, Sweden.
    Ostlund, Pernilla
    Swedish Council Health Technology Assessment SBU, Sweden; Malmö University, Sweden.
    Sandman, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. University of Boras, Sweden.
    FRAMEWORK FOR SYSTEMATIC IDENTIFICATION OF ETHICAL ASPECTS OF HEALTHCARE TECHNOLOGIES: THE SBU APPROACH2015Ingår i: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 31, nr 3, s. 124-130Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 174.
    Henriksson, Martin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Hälsoekonomiska utvärderingar och beslutsfattande2016Ingår i: Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson / [ed] Martin Henriksson, Linköping: Linköping University Electronic Press, 2016, s. 38-50Kapitel i bok, del av antologi (Övrigt vetenskapligt)
  • 175.
    Henriksson, Martin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson2016Samlingsverk (redaktörskap) (Övrigt vetenskapligt)
    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

  • 176.
    Henriksson, Martin
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Linköpings universitet, Centrum för medicinsk bildvetenskap och visualisering, CMIV. PAREXEL Int, Sweden.
    Jindal, Ramandeep
    PAREXEL Int, India.
    Sternhufvud, Catarina
    AstraZeneca, Sweden.
    Bergenheim, Klas
    AstraZeneca, Sweden.
    Sorstadius, Elisabeth
    AstraZeneca, Sweden.
    Willis, Michael
    Swedish Institute Health Econ, Sweden.
    A Systematic Review of Cost-Effectiveness Models in Type 1 Diabetes Mellitus2016Ingår i: PharmacoEconomics (Auckland), ISSN 1170-7690, E-ISSN 1179-2027, Vol. 34, nr 6, s. 569-585Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

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

  • 177.
    Henriksson, Martin
    et al.
    Linköpings universitet, Centrum för medicinsk bildvetenskap och visualisering, CMIV. Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet. Astra Zeneca Nordic-Baltic, Södertälje, Sweden.
    Nikolic, Elisabet
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Ohna, Audun
    Astra Zeneca Nordic-Baltic, Södertälje, Sweden.
    Wallentin, Lars
    Uppsala University, Sweden.
    Janzon, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Kardiologiska kliniken US.
    Ticagrelor treatment in patients with acute coronary syndrome is cost-effective in Sweden and Denmark2014Ingår i: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 48, nr 3, s. 138-147Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 178.
    Henriksson, Martin
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Linköpings universitet, Centrum för medicinsk bildvetenskap och visualisering, CMIV.
    Siverskog, Jonathan
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Johannesen, Kasper
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Eriksson, Thérèse
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Tröskelvärden och kostnadseffektivitet: innebörd och implikationer för ekonomiska utvärderingar och beslutsfattande i hälso- och sjukvården2018Rapport (Övrigt vetenskapligt)
    Abstract [sv]

    Resultaten från hälsoekonomiska utvärderingar redovisas oftast som en inkrementell kostnadseffektivitetskvot (ICER efter engelskans incremental cost-efectiveness ratio) vilken anger kostnaden per uppnådd effektenhet för den åtgärd som utvärderas. En åtgärd kan vara ett preventionsprogram, en diagnostisk metod eller en behandling i form av ett kirurgiskt ingrepp eller ett läkemedel (vi använder fortsättningsvis begreppet interventioner som ett samlingsnamn för alla dessa åtgärder). Vanligtvis används ett hälsorelaterat mått såsom kvalitetsjusterade levnadsår (QALYs) som effektmått. För att en ICER på ett meningsfullt sätt skall kunna tolkas och tillämpas i beslutsfattande krävs att vi har en uppfattning om vad resultaten representerar och vad de kan jämföras med. Inte sällan anges ett gräns-värde för när en intervention kan anses vara kostnadseffektiv i litteraturen, ett så kallat tröskelvärde för kostnadseffektivitet. Ambitiösa försök att skatta detta värde har nyligen presenterats och bidrar med ny kunskap på området. I ljuset av denna forskning är det också tydligt att det finns olika tolkningar av tröskelvärdet, vilket kan bidra till otydlighet i både beslutsfattande och diskussioner om vad som kan anses vara en rimlig gräns för kostnadseffektivitet. Syftet med föreliggande rapport är att beskriva olika tolkningar av tröskelvärdet, sammanfatta vilken empirisk kunskap vi har om detta värde idag och slutligen diskutera vidare forskning i en svensk kontext.

    I rapporten illustreras de två huvudsakliga definitionerna av tröskelvärde som återfinns i litteraturen.

    Konsumtionsvärdet av hälsa kan tänkas representera vad individer på marginalen är villiga att ge upp i konsumtion för att erhålla ytterligare en QALY. I den internationella litteraturen har detta värde kommit att benämnas v.

    Marginalproduktiviteten i hälso- och sjukvårdssektorn kan tänkas representera kostnaden för att generera ytterligare en QALY på marginalen i hälso- och sjukvårdssektorn. Tröskelvärdet med denna tolkning bör utgöra kostnaden per QALY för den minst kostnadseffektiva interventionen som återfinns inom hälso- och sjukvårdssektorn. I den internationella litteraturen benämns detta värde k.

    I rapporten diskuteras implikationerna av att använda de olika definitionerna i beslutsfattande samt hur de hänger ihop med alternativkostnader i olika delar av samhället. När en intervention tar resurser i anspråk som annars skulle ha använts till sjukvård är alternativkostnaden förlorad hälsa. Denna alternativkostnad kan representeras av marginalproduktiviteten i hälso- och sjukvårdssektorn, k. När en intervention tar resurser i anspråk som annars skulle ha använts för privat konsumtion är alternativ-kostnaden istället förlorad konsumtion, vilken kan representeras av konsumtionsvärdet av hälsa, v. Vilket perspektiv som anses relevant samt i vilken sektor konsekvenserna av olika interventioner upp-står bör därmed vara avgörande för vilken eller vilka definitioner av tröskelvärdet som kan behöva beaktas.

    Empiriska studier har i större utsträckning försökt skatta konsumtionsvärdet av hälsa (v) jämfört med marginalproduktiviteten i hälso- och sjukvårdssektorn (k). Kunskapen om båda storheterna är begränsad ur ett svenskt perspektiv. En större studie från England utgör det första och mest ambitiösa försöket att explicit skatta tröskelvärdet ur ett marginalproduktivitetsperspektiv med hjälp av större data-material. I den studien skattades tröskelvärdet till en kostnad per QALY motsvarande ungefär 150 000 kronor. I ett försök att översätta dessa skattningar till tröskelvärden i andra länder redovisas en kostnad per QALY i intervallet 170 000 till 210 000 kronor för Sverige. Skattningarna får anses vara behäftade med en hög grad av osäkerhet. Nyligen publicerade studier från Australien och Spanien redovisar skattningar motsvarande 185 00 och 250 000 kronor per QALY. I studier som undersökt konsumtions-värdet av hälsa redovisas skattningar på 30 000 till flera miljoner kronor per QALY.

    En stor del av variationen i resultaten kan troligtvis hänföras till metodologiska aspekter. Studierna varierar i flera dimensioner; praktisk undersökningsmetod (online, intervjuer eller pappersenkäter), utformning av svarsalternativ, statistiska metoder för att analysera data, typ av hälsoförändring som värderats (enbart livskvalitet, enbart livslängd eller en kombination), om värderade hälsoförändringar uppnås med säkerhet eller med en viss sannolikhet samt om hälsoförändringen som värderas tillfaller respondenten själv eller någon annan. Få studier med data från svenska individer där generella hälso-förändringar värderats av ett urval från allmänheten har identifierats. Den enda studien som vi identifierat i referentgranskade tidskrifter redovisar skattningarna för Sverige i intervallet 150 000 till 350 000 kronor. I en relativt ny svensk rapport som finns tillgänglig på Institutet för Hälso- och Sjukvårds-ekonomis (IHE) hemsida redovisas skattningar på 2,4 miljoner kronor per QALY.

    En slutsats i vår rapport är att det behöver tydliggöras hur valet av perspektiv faktiskt påverkar vilken eller vilka definitioner av tröskelvärdet som bör vara relevanta när hälsoekonomiska utvärderingar används som underlag vid beslutsfattande inom hälso- och sjukvården. Om ett bredare samhällsperspektiv anses relevant kan både konsumtionsvärdet av hälsa (v) och marginalproduktiviteten i hälso- och sjukvården (k) behöva beaktas.

    En annan slutsats är att oavsett vilken definition av tröskelvärde som anses relevant så har vi mycket begränsad kunskap om både marginalproduktiviteten i hälso- och sjukvårdssektorn och konsumtions-värdet av hälsa i en svensk kontext. Statistisk modellering av befintliga datakällor kan vara en fram-komlig väg för att skatta marginalproduktiviteten medan välgjorda experiment eller metoder för att studera individers värderingar av hälsa via faktiska beslut och ageranden i icke-experimentella situationer kan vara en framkomlig väg för att studera konsumtionsvärdet av hälsa.

  • 179.
    Hofmann, Bjorn
    et al.
    Norwegian Univ Sci and Technol NTNU, Norway; Univ Oslo, Norway.
    Bond, Ken
    CADTH, Canada.
    Sandman, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Evaluating facts and facting evaluations: On the fact-value relationship in HTA2018Ingår i: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 24, nr 5, s. 957-965Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 180.
    Holmbom, Martin
    et al.
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för mikrobiologi och molekylär medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Urologiska kliniken i Östergötland.
    Giske, Christian G.
    Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden.; Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden..
    Fredrikson, Mats
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för neuro- och inflammationsvetenskap. Linköpings universitet, Medicinska fakulteten.
    Östholm Balkhed, Åse
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för mikrobiologi och molekylär medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Infektionskliniken i Östergötland.
    Claesson, Carina
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för mikrobiologi och molekylär medicin. Linköpings universitet, Medicinska fakulteten.
    Nilsson, Lennart E
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för mikrobiologi och molekylär medicin. Linköpings universitet, Medicinska fakulteten.
    Hoffmann, Mikael
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Hanberger, Håkan
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för mikrobiologi och molekylär medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Infektionskliniken i Östergötland.
    14-Year Survey in a Swedish County Reveals a Pronounced Increase in Bloodstream Infections (BSI). Comorbidity: An Independent Risk Factor for Both BSI and Mortality2016Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, nr 11Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

  • 181.
    Holm-Larsen, Tove
    et al.
    Pharma Evidence, Denmark; University of Copenhagen, Denmark.
    Andersson, Fredrik
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    van der Meulen, Egbert
    Ferring Int PharmaScience Centre, Denmark.
    Yankov, Vladimir
    Ferring Pharmaceut Inc, NJ USA.
    Rosen, Raymond C.
    New England Research Institute, MA USA.
    Peter Norgaard, Jens
    Ferring Int PharmaScience Centre, Denmark.
    The Nocturia Impact Diary: A Self-Reported Impact Measure to Complement the Voiding Diary2014Ingår i: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 17, nr 6, s. 696-706Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 182.
    Husberg, Magnus
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Davidson, Thomas
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Hallert, Eva
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Non-medical costs during the first year after diagnosis in two cohorts of patients with early rheumatoid arthritis, enrolled 10 years apart2017Ingår i: Clinical Rheumatology, ISSN 0770-3198, E-ISSN 1434-9949, Vol. 36, nr 3, s. 499-506Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 183.
    Husberg, Magnus
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Bernfort, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Hallert, Eva
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Sinnescentrum, Smärt och rehabiliteringscentrum.
    Costs and disease activity in early rheumatoid arthritis in 1996-2000 and 2006-2011, improved outcome and shift in distribution of costs: a two-year follow-up2018Ingår i: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 47, nr 5, s. 378-383Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 184.
    Häggman-Henrikson, B.
    et al.
    Malmö University, Sweden; Umeå University, Sweden; Malmö University, Sweden.
    Alstergren, P.
    Malmö University, Sweden; SCON, Sweden; Skåne University Hospital, Sweden.
    Davidson, Thomas
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Malmö University, Sweden.
    Hogestatt, E. D.
    Lund University, Sweden.
    Ostlund, P.
    Umeå University, Sweden; Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Tranaeus, S.
    Umeå University, Sweden; Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Vitols, S.
    Swedish Agency Health Technology Assessment and Assessment, Sweden; Karolinska Institute, Sweden.
    List, T.
    Malmö University, Sweden; SCON, Sweden; Skåne University Hospital, Sweden.
    Pharmacological treatment of oro-facial pain - health technology assessment including a systematic review with network meta-analysis2017Ingår i: Journal of Oral Rehabilitation, ISSN 0305-182X, E-ISSN 1365-2842, Vol. 44, nr 10, s. 800-826Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

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

  • 185.
    Iwarsson, Erik
    et al.
    Karolinska University Hospital, Sweden.
    Jacobsson, Bo
    Gothenburg University, Sweden; Institute Public Heatlh, Norway.
    Dagerhamn, Jessica
    Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Davidson, Thomas
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Bernabe, Eduardo
    Kings Coll and St Thomas Hospital, England.
    Heibert Arnlind, Marianne
    Karolinska Institute, Sweden.
    Analysis of cell-free fetal DNA in maternal blood for detection of trisomy 21, 18 and 13 in a general pregnant population and in a high risk population - a systematic review and meta-analysis2017Ingår i: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 96, nr 1Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

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

  • 186.
    Jaarsma, Pier
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Gelhaus, Petra
    Region Östergötland. Institute for Ethics, History and Philosophy of Medicine, University of Muenster, Muenster, Germany.
    Medium-Range Narratives as a Complementary Tool to Principle-Based Prioritization in Sweden: Test Case "ADHD"2019Ingår i: Journal of Bioethical Inquiry, ISSN 1176-7529, E-ISSN 1872-4353, Vol. 16, nr 1, s. 113-125Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 187.
    Jaarsma, Pier
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Welin, Stellan
    Linköpings universitet, Institutionen för kultur och kommunikation, Avdelningen för kulturvetenskaper, KVA. Linköpings universitet, Filosofiska fakulteten.
    Editorial Material: Autism, Accommodation and Treatment: A Rejoinder to Chong-Ming Lims Critique in BIOETHICS, vol 29, issue 9, pp 684-6852015Ingår i: Bioethics, ISSN 0269-9702, E-ISSN 1467-8519, Vol. 29, nr 9, s. 684-685Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

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

  • 188.
    Jacobs, Maartje S.
    et al.
    Univ Groningen, Netherlands; Martini Hosp, Netherlands.
    Schouten, Jeroen F.
    Univ Groningen, Netherlands.
    de Boer, Pieter T.
    Univ Groningen, Netherlands.
    Hoffmann, Mikael
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Levin, Lars-Åke
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Postma, Maarten J.
    Univ Groningen, Netherlands; Univ Med Ctr Groningen, Netherlands; Univ Med Ctr Groningen, Netherlands.
    Secondary adherence to non-vitamin-K antagonist oral anticoagulants in patients with atrial fibrillation in Sweden and the Netherlands2018Ingår i: Current Medical Research and Opinion, ISSN 0300-7995, E-ISSN 1473-4877, Vol. 34, nr 10, s. 1839-1847Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 189.
    Janzon, Magnus
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Kardiologiska kliniken US.
    Henriksson, Martin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Linköpings universitet, Centrum för medicinsk bildvetenskap och visualisering, CMIV.
    Hasvold, Pål
    AstraZeneca Nordic-Baltic, Södertälje, Sweden.
    Hjelm, Hans
    Nyköping Hospital, Nyköping, Sweden.
    Thuresson, Marcus
    Statisticon AB, Uppsala, Sweden.
    Jernberg, Tomas
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm, Sweden.
    Long-term resource use patterns and healthcare costs after myocardial infarction in a clinical practice setting - results from a contemporary nationwide registry study2016Ingår i: European Heart Journal - Quality of Care and Clinical Outcomes, ISSN 2058-5225, Vol. 2, s. 291-298Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aims Long-term contemporary nationwide data on resource use and healthcare costs after myocardial infarction (MI) in a clinical practice setting are not widely studied, and the aim of this study was to investigate resource use patterns and healthcare costs in patients with MI in a nationwide clinical practice setting.

    Methods and results This retrospective cohort study included all patients identified in the compulsory Swedish nationwide patient register with a diagnosis of MI between 1 July 2006 and 30 June 2011. Cardiovascular hospitalization and outpatient visits data from the patient register were combined with data from the cause of death register and the drug utilization register. For a subset of patients, data were also available from a primary care register. Healthcare resource use patterns and annual costs [reported in 2014 euros (€) converted from Swedish kronor (SEK) using the exchange rate €1 = SEK 9.33)] were estimated for the year prior to the occurrence of MI as well as for a maximum follow-up period of 6 years post-MI. The study included 97 252 patients with a diagnosis of MI with a total number of 285 351 observation years. The majority of healthcare consumption occurred within the first year of MI where patients were on average hospitalized 1.55 times, made 1.08 outpatient care visits, and 3.80 primary care visits. In the long term, for the majority of resource use categories, average consumption was higher in the years after MI compared with the year prior to MI. Healthcare costs at 6 years of follow-up were approximately €20 000 of which €12 460 occurred in the first year, and the major part was attributed to hospitalizations.

    Conclusion For patients with 6 years of follow-up after MI, healthcare costs were approximately €20 000. The major part of costs occurred in the first year after MI and was driven by hospitalizations

  • 190.
    Janzon, Magnus
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Kardiologiska kliniken US.
    James, S
    Uppsala Univ, Dept Med Sci, Uppsala, Sweden Uppsala Univ, Uppsala Clin Res Ctr, Uppsala, Sweden.
    Cannon, C P
    ] Brigham & Womens Hosp, Thrombolysis Myocardial Infarct TIMI Study Grp, Boston, MA 02115 USA Harvard Univ, Sch Med, Boston, MA USA .
    Storey, R F
    Univ Sheffield, Dept Cardiovasc Sci, Sheffield, S Yorkshire, England.
    Mellström, C
    AstraZeneca R&D, Molndal, Sweden.
    Nicolau, J C
    Univ Sao Paulo Med Sch, Heart Inst InCor, Sao Paulo, Brazil.
    Wallentin, L
    Uppsala Univ, Dept Med Sci, Uppsala, Sweden Uppsala Univ, Uppsala Clin Res Ctr, Uppsala, Sweden.
    Henriksson, Martin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. AstraZeneca Nord Balt, Sodertalje, Sweden.
    Health economic analysis of ticagrelor in patients with acute coronary syndromes intended for non-invasive therapy2015Ingår i: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 101, nr 2, s. 119-25Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To investigate the cost effectiveness of ticagrelor versus clopidogrel in patients with acute coronary syndromes (ACS) in the Platelet Inhibition and Patient Outcomes (PLATO) study who were scheduled for non-invasive management.

    METHODS: A previously developed cost effectiveness model was used to estimate long-term costs and outcomes for patients scheduled for non-invasive management. Healthcare costs, event rates and health-related quality of life under treatment with either ticagrelor or clopidogrel over 12 months were estimated from the PLATO study. Long-term costs and health outcomes were estimated based on data from PLATO and published literature sources. To investigate the importance of different healthcare cost structures and life expectancy for the results, the analysis was carried out from the perspectives of the Swedish, UK, German and Brazilian public healthcare systems.

    RESULTS: Ticagrelor was associated with lifetime quality-adjusted life-year (QALY) gains of 0.17 in Sweden, 0.16 in the UK, 0.17 in Germany and 0.13 in Brazil compared with generic clopidogrel, with increased healthcare costs of €467, €551, €739 and €574, respectively. The cost per QALY gained with ticagrelor was €2747, €3395, €4419 and €4471 from a Swedish, UK, German and Brazilian public healthcare system perspective, respectively. Probabilistic sensitivity analyses indicated that the cost per QALY gained with ticagrelor was below conventional threshold values of cost effectiveness with a high probability.

    CONCLUSIONS: Treatment of patients with ACS scheduled for 12 months' non-invasive management with ticagrelor is associated with a cost per QALY gained below conventional threshold values of cost effectiveness compared with generic clopidogrel.

    TRIAL REGISTRATION NUMBER: NCT000391872.

  • 191.
    Jendle, J
    et al.
    Faculty of Medical Sciences, Örebro University, Örebro, Sweden.
    Sandberg, A
    Novo Nordisk A/S, Vandtårnsvej 114, DK-2860 Søborg, Denmark.
    Buchs, S
    Novo Nordisk A/S, Vandtårnsvej 114, DK-2860 Søborg, Denmark.
    Swinburn, P
    Patient-Centered Outcomes, Mapi, London, UK.
    Hadi, M
    Patient-Centered Outcomes, Mapi, London, UK.
    Levin, Lars-Åke
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    A utility valuation study assessing the impact of postprandial glucose control on quality of life of individuals with type 1 or type 2 diabetes2017Ingår i: Journal of patient-reported outcomes, ISSN 2509-8020, Vol. 2, nr 1, artikel-id 20Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Consideration of health-related quality of life (HRQOL) in diabetes has been associated with long-term and short-term complications such as hypoglycaemia, but not with short-term glucose control. This study aimed to collect health utilities related to different degrees of poorly controlled postprandial glucose (PPG) and its impact on HRQOL in the UK and in Sweden.

    Methods: Three health state descriptions were developed based on literature reviews and interviews with people with diabetes and healthcare professionals, characterising mild, moderate and severe impact of postprandial hyperglycaemic symptoms on HRQOL. Time Trade-Off (TTO) interviews with a 10-year trade-off period were conducted with samples of the UK general public and of Swedish people with diabetes. Mean TTO-derived health state values were expressed on a scale from 0 (death) to 1 (full health).

    Results: One hundred fifty participants from the general population were interviewed in the UK (57% female, mean age 35 years) and 150 participants with diabetes in Sweden (64% female, mean age 51 years, 42% type 1 and 58% type 2 diabetes). The mean TTO-derived health state values were for the UK and Swedish participants: mild impact of poorly PPG control (0.89/0.76); moderate (0.75/0.71); severe (0.56/0.58).

    Conclusions: Glucose lowering treatments associated with improved control over PPG levels could have important benefits to people with type 1 and type 2 diabetes since findings suggest that increasing severity in postprandial hyperglycaemic symptoms is perceived as having significant negative impact on HRQOL of individuals with type 1 or type 2 diabetes.

  • 192.
    Jernberg, Tomas
    et al.
    Karolinska Inst, Sweden.
    Lindholm, Daniel
    Uppsala Clin Res Ctr, Sweden.
    Hasvold, Lars Pal
    AstraZeneca Nord, Norway.
    Svennblad, Bodil
    Uppsala Clin Res Ctr, Sweden.
    Bodegard, Johan
    AstraZeneca Nord, Norway.
    Andersson, Karolina Sundell
    AstraZeneca RandD, Sweden.
    Thuresson, Marcus
    Statisticon, Sweden.
    Erlinge, David
    Lund Univ, Sweden.
    Janzon, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Kardiologiska kliniken US.
    Impact of ischaemic heart disease severity and age on risk of cardiovascular outcome in diabetes patients in Sweden: a nationwide observational study2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 4, artikel-id e027199Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To compare short-term cardiovascular (CV) outcome in type 2 diabetes (T2D) patients without ischaemic heart disease (IHD), with IHD but no prior myocardial infarction (MI), and those with prior MI; and assess the impact on risk of age when initiating first-time glucose-lowering drug (GLD). Design Cohort study linking morbidity, mortality and medication data from Swedish national registries. Participants First-time users of GLD during 2007-2016. Outcomes Predicted cumulative incidence for the CV outcome (MI, stroke and CV mortality) was estimated. A Cox model was developed where age at GLD start and CV risk was modelled. Results 260 070 first-time GLD users were included, 221 226 (85%) had no IHD, 16 294 (6%) had stable IHD-prior MI and 22 550 (9%) had IHD+ MI. T2D patients without IHD had a lower risk of CV outcome compared with the IHD populations (+/- prior MI), (3-year incidence 4.78% vs 5.85% and 8.04%). The difference in CV outcome was primarily driven by a relative greater MI risk among the IHD patients. For T2D patients without IHD, an almost linear association between age at start of GLD and relative risk was observed, whereas in IHD patients, the younger (amp;lt; 60 years) patients had a relative greater risk compared with older patients. Conclusions T2D patients without IHD had a lower risk of the CV outcome compared with the T2D populations with IHD, primarily driven by a greater risk of MI. For T2D patients without IHD, an almost linear association between age at start of GLD and relative risk was observed, whereas in IHD patients, the younger patients had a relative greater risk compared with older patients. Our findings suggest that intense risk prevention should be the key strategy in the management of T2D patients, especially for younger patients.

  • 193.
    Johannesen, Kasper
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Department of Health Economics, AstraZeneca Nordic, Södertälje, Sweden .
    Henriksson, Martin
    Department of Health Economics, AstraZeneca Nordic, Södertälje, Sweden.
    Getting value today and incentivising for the future: Pharmaceutical development and healthcare policies2017Ingår i: Nordic Journal of Health Economics, ISSN 1892-9729, E-ISSN 1892-9710, Vol. 5, nr 1, s. 77-96Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    To manage the challenge of limited healthcare resources and unlimited demand for healthcare, decision makers utilise a variety of demand side policies, such as health technology appraisals and international reference pricing to regulate price and utilisation. By controlling price and utilisation demand side policies determine the earnings potential, and hence the incentives to invest in research and development (R&D) of new technologies. However, the impact of demand side policies on R&D incentives is seldom formally assessed. Based on the key assumption that intellectual property rights, i.e. patents, and expected rent are key drivers of pharmaceutical R&D, this work outlines a framework illustrating the link between demand side policies and pharmaceutical R&D incentives. By analysing how policies impact expected rent and consumer surplus, the framework is used to understand how commonly used demand side policies (including timing and length of reimbursement process, international reference pricing, parallel trade, and sequential adoption into clinical practice) may influence R&D incentives. The analysis demonstrates that delayed reimbursement decisions as well as sequential adoption into clinical practise may in fact reduce both expected rent and consumer surplus. It is also demonstrated how international reference pricing is likely to increase consumer surplus at the expense of lower rent and thus lower R&D incentives. Although this work illustrates the importance of considering how demand side policies may impact long-term R&D incentives, it is important to note that the purpose has not been to prescribe which demand side policies should be utilised or how. Rather, the main contribution is to illustrate the need for a structured approach to the analysis of the complex, and at times highly politicised question of how demand side policies ultimately influence population health, both in the short and in the long term.

  • 194.
    Johannesen, Kasper M
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Claxton, Karl
    Centre for Health Economics, University of York, York, UK.
    Sculpher, Mark J.
    Centre for Health Economics, University of York, York, UK.
    Wailoo, Allan J
    Health Economics and Decision Science, University of Sheffield, Sheffield, UK.
    How to design the cost‐effectiveness appraisal process of new healthcare technologies to maximise population health: A conceptual framework2018Ingår i: Health Economics, ISSN 1057-9230, E-ISSN 1099-1050, Vol. 27, nr 2, s. e41-e54Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This paper presents a conceptual framework to analyse the design of the cost‐effectiveness appraisal process of new healthcare technologies. The frameworkcharacterises the appraisal processes as a diagnostic test aimed at identifyingcost‐effective (true positive) and non‐cost‐effective (true negative) technologies.Using the framework, factors that influence the value of operating an appraisalprocess, in terms of net gain to popula tion health, are identified. The frame-work is used to gain insight into current policy questions including (a) howrigorous the process should be, (b) who should have the burden of proof, and(c) how optimal design changes when allowing for appeals, price reductions,resubmissions, and re‐evaluations.The paper demonstrates that there is no one optimal appraisal process and theprocess should be adapted over time and to the specific technology underassessment. Optimal design depends on country‐specific features of (future)technologies, for example, effect, price, and size of the patient population,which might explain the difference in appraisal processes across countries. Itis shown that burden of pro of should be placed on the producers and that theimpact of price reductions and patient access schemes on the producer's pricesetting should be considered when designing the appraisal process.

  • 195.
    Jonasson, Lise-Lotte
    et al.
    Univ Boras, Sweden.
    Sandman, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten. Univ Boras, Sweden.
    Bremer, Anders
    Univ Boras, Sweden; Linnaeus Univ, Sweden.
    Managers experiences of ethical problems in municipal elderly care: a qualitative study of written reflections as part of leadership training2019Ingår i: Journal of Healthcare Leadership, ISSN 1179-3201, E-ISSN 1179-3201, Vol. 11, s. 63-74Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Managers in elderly care have a complex ethical responsibility to address the needs and preferences of older persons while balancing the conflicting interests and requirements of relatives demands and nursing staffs work environment. In addition, managers must consider laws, guidelines, and organizational conditions that can cause ethical problems and dilemmas that need to be resolved. However, few studies have focused on the role of health care managers in the context of how they relate to and deal with ethical conflicts. Therefore, the aim of this study was to describe ethical problems experienced by managers in elderly care. Methods: We used a descriptive, interpretative design to analyze textual data from two examinations in leadership courses for managers in elderly care. A simple random selection of 100 out of 345 written exams was made to obtain a manageable amount of data. The data consisted of approximately 300 pages of single-spaced written text. Thematic analysis was used to evaluate the data. Results: The results show that managers perceive the central ethical conflicts relate to the older persons autonomy and values versus their needs and the values of the staff. Additionally, ethical dilemmas arise in relation to the relatives perspective of their loved ones needs and preferences. Legislations, guidelines, and a lack of resources create difficulties when managers perceive these factors as conflicting with the care needs of older persons. Conclusion: Managers in elderly care experience ethical conflicts that arise as unavoidable and perennial values conflicts, poorly substantiated values, and problematic organizational conditions. Structured approaches for identifying, reflecting on, and assessing ethical problems in the organization should therefore be implemented.

  • 196.
    Järvstråt, Lotta
    et al.
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Medicinska fakulteten.
    Spetz, Anna-Clara
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Barn- och kvinnocentrum, Kvinnokliniken i Linköping.
    Lindh-Åstrand, Lotta
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Barn- och kvinnocentrum, Kvinnokliniken i Linköping.
    Hoffmann, Mikael
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys.
    Fredrikson, Mats
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för neuro- och inflammationsvetenskap. Linköpings universitet, Hälsouniversitetet.
    Hammar, Mats
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Barn- och kvinnocentrum, Kvinnokliniken i Linköping.
    Use of hormone therapy in Swedish women aged 80 years or older2015Ingår i: Menopause: The Journal of the North American Menopause, ISSN 1072-3714, E-ISSN 1530-0374, Vol. 22, nr 3, s. 275-278Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Menopausal symptoms such as hot flashes and night sweats may persist for 10 to 20 years or even longer. Information about the extent to which older women use hormone therapy is limited. The aim of this study was to determine the use of hormone therapy in Swedish women aged 80 years or older.Methods: The study is based on national register data on dispensed drug prescriptions (ie, prescribed therapy that has been provided to individuals by pharmacies) for hormone therapy and local low-dose estrogens.Results: Of 310,923 Swedish women who were aged at least 80 years, 609 (0.2%) were new users of hormone therapy. A total of 2,361 women (0.8%) were current users of hormone therapy. The median duration of hormone therapy use in new users was 257 days (25th to 75th percentiles, 611-120 d). About one in six women aged 80 years or older had used local vaginal estrogen therapy for at least four 3-month periods. The drugs were mainly prescribed by gynecologists and general practitioners.Conclusions: Our results show that a number of women aged 80 years or older still use hormone therapy and that most women who started a new treatment period had only one or two dispensations despite the median duration of treatment being more than half a year. Because at least some of the women aged 80 years or older who used hormone therapy probably did so owing to persistent climacteric symptoms, vasomotor symptoms and hormone therapy are still relevant issues that need to be discussed when counseling women around and after age 80.

  • 197.
    Kalkan, Almina
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Diffusion, implementation and consequences of new health technology: The cases of biological drugs for rheumatoid arthritis and the Swedish national guidelines2015Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Improvements in health technology raise hopes for better patient outcomes and a more efficient delivery of health care. However, the processes of diffusion and implementation of new health technology have been shown to be complicated and to pose a number of challenges for the healthcare sector. Many at tempts have been made to influence and manage the introduction and diffusion of health technology. One prominent example is the Swedish nat ional guidelines that aim at influencing both clinical and political decision - making in the health sector.

    The overall aim of this thesis is to describe and analyze the factors influencing the diffusion and economic consequences of the introduction of a new technology with large variations in use, and to explore the process of implementation of nationally produced guidelines as an instrument for improv ing effectiveness and equity. The empirical focus is kept on the biological drugs (bDMARDs) for rheumatoid arthritis (RA), since they implied a substantial treatment change when they were first int roduced and they are relatively costly; and on the national guidelines for cardiac care, since they were the first nat ional guidelines, hence allowing a long-term perspect ive in the exploration of their implementat ion.

    Paper I presents a register study that uses data from national and regional registries on healt hcare use and work disability of patients with RA and shows that there was a 32 percent increase in the total fixed cost of RA during 1990-2010, mainly after the introduct ion of bDMARDs. Paper II shows that choosing to initiate treatment with bDMARDs varied substantially among 26 rheumatologists presented with hypothetical patient cases, and that there were also disparities between rheumatologists practicing in the same clinic. Paper III presents data from the Swedish Rheumatology Quality Register covering 4010 patients with RA, and shows that when using multivariate logistic regression to adjust for patient characterist ics, disease activity and t he physician’s local context, physician preference was an import ant predict or for prescription of bDMARDs. Paper IV is a qualitative study about prescribing decisions, showing that a constellat ion of various factors and their interact ion influenced the prescribing decisions according to the 26 interviewed rheumatologists. The factors included the individual rheumatologist ’s experiences and perceptions of t he evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participat ion in clinical trials. The patient as an actor emerged as an important factor. Paper V is a longitudinal qualitat ive study exploring the responses among four Swedish county councils to the national guidelines for cardiac care through 155 interviews with politicians, administ rators and clinical managers. The results show that unilateral responses to the national guidelines within the county councils have been rare, but there have been at tempts to compromise and to at tain a balance between multiple constituents. There are examples of local information meetings, the use of the national guidelines in local healthcare programs, and performing audits with the national guidelines as a base. However, performing explicit prioritizat ion as advised in the NGCC is rarely found. Over t ime, however, a more systematic use of the national guidelines has been noted.

    In conclusion, the diffusion of new health technology is influenced by a wide array of factors both at individual and organizational levels, as well as their interact ion. The diffusion resulted in large economic consequences and unequal access due to variations also at clinical level. Moreover, given that healthcare decision-making is influenced by many different factors, the simple influx of evidence-based guidelines will unlikely result in automat ic implementat ion. At tempts to influence healthcare decisions need to have a systems perspect ive and to account for the interact ion of factors between different actors.

    Delarbeten
    1. Costs of rheumatoid arthritis during the period 1990–2010: a register-based cost-of-illness study in Sweden
    Öppna denna publikation i ny flik eller fönster >>Costs of rheumatoid arthritis during the period 1990–2010: a register-based cost-of-illness study in Sweden
    Visa övriga...
    2014 (Engelska)Ingår i: Rheumatology, ISSN 1462-0324, E-ISSN 1462-0332, Vol. 53, nr 1, s. 153-160Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    Objectives. The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990–2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs.

    Methods. A prevalence-based cost-of-illness study was conducted based on data from national and regional registries.

    Results. There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990–2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010.

    Conclusion. By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment.

    Ort, förlag, år, upplaga, sidor
    Oxford University Press, 2014
    Nationell ämneskategori
    Medicin och hälsovetenskap Klinisk medicin
    Identifikatorer
    urn:nbn:se:liu:diva-100004 (URN)10.1093/rheumatology/ket290 (DOI)000329041900022 ()24136064 (PubMedID)
    Tillgänglig från: 2013-10-24 Skapad: 2013-10-24 Senast uppdaterad: 2017-12-06Bibliografiskt granskad
    2. Individual variations in treatment decisions by Swedish rheumatologists regarding biological drugs for rheumatoid arthritis
    Öppna denna publikation i ny flik eller fönster >>Individual variations in treatment decisions by Swedish rheumatologists regarding biological drugs for rheumatoid arthritis
    Visa övriga...
    2015 (Engelska)Ingår i: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 44, nr 4, s. 265-270Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    Objective: In Sweden, reports indicate surprisingly large regional variation in prescription of biological drugs, despite a growing number of clinical studies describing their beneficial effects and guidelines by professional organizations and agencies. Our objective was to ascertain whether there is also variation between individual rheumatologists in prescribing biologics to patients with rheumatoid arthritis (RA) and to evaluate reasons for treatment choices.

    Methods: Ten hypothetical patient cases were constructed and presented to 26 rheumatologists in five regions in Sweden. The cases were based on actual cases and were thoroughly elaborated by a senior rheumatologist and pre-tested in a pilot study. The respondents were asked whether they would treat the patients with a biological agent (YES/NO) and to explain their decisions.

    Results: The response rate was 26/105; 25%. Treatment choices varied considerably between the rheumatologists, some prescribing biologics to 9/10 patients and others to 2/10. In five of the ten hypothetical cases, approximately half of the respondents would prescribe biologics. No regions with particularly high or low prescription were identified. Both the decision to prescribe biologics, as well as not to prescribe, were mainly motivated by medical reasons. Some rheumatologists also referred to lifestyle-related factors or social function of the patient.

    Conclusion: The choice of initiation of biologics varied substantially among rheumatologists presented with hypothetical patient cases, and there were also disparities between rheumatologists practising at the same clinic. Treatment choices were primarily motivated by medical reasons. This situation raises concerns about a lack of consensus in RA treatment strategies.

    Ort, förlag, år, upplaga, sidor
    Informa Healthcare, 2015
    Nationell ämneskategori
    Klinisk medicin
    Identifikatorer
    urn:nbn:se:liu:diva-113301 (URN)10.3109/03009742.2014.997286 (DOI)000359960100002 ()
    Anmärkning

    DOI does not work: 10.3109/03009742.2014.997286

    Tillgänglig från: 2015-01-15 Skapad: 2015-01-15 Senast uppdaterad: 2018-12-13Bibliografiskt granskad
    3. Physician Preferences and Variations in Prescription of Biologic Drugs for Rheumatoid Arthritis: A Register-Based Study of 4,010 Patients in Sweden
    Öppna denna publikation i ny flik eller fönster >>Physician Preferences and Variations in Prescription of Biologic Drugs for Rheumatoid Arthritis: A Register-Based Study of 4,010 Patients in Sweden
    Visa övriga...
    2015 (Engelska)Ingår i: Arthritis care & research, ISSN 2151-464X, E-ISSN 2151-4658, Vol. 67, nr 12, s. 1679-1685Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    Objective. The prescription of biologic drugs for rheumatoid arthritis (RA) patients has varied considerably across different regions. Previous studies have shown physician preferences to be an important determinant in the decision to select biologic disease-modifying antirheumatic drugs (bDMARDs) rather than nonbiologic, synthetic DMARDs (sDMARDs) alone. The aim of this study was to test the hypothesis that physician preferences are an important determinant for prescribing bDMARDs for RA patients in Sweden. Methods. Using data from the Swedish Rheumatology Quality Register, we identified 4,010 RA patients who were not prescribed bDMARDs during the period 2008-2012, but who, on at least 1 occasion, had an sDMARD prescription and changed treatment for the first time to either a new sDMARD or a bDMARD. Physician preference for the use of bDMARDs was calculated using data on each physicians prescriptions during the study period. The relationship between prescription of a bDMARD and physician preference, controlling for patient characteristics, disease activity, and the physicians local context was evaluated using multivariate logistic regression. Results. When adjusting for patient characteristics, disease activity, and the physicians local context, physician preference was an important predictor for prescription of bDMARDs. Compared with patients of a physician in the lowest preference tertile, patients of physicians in the highest and middle tertiles had an odds ratio for receiving bDMARDs of 2.8 (95% confidence interval [95% CI] 2.13-3.68) and 1.28 (95% CI 1.05-1.57), respectively. Conclusion. Physician preference is an important determinant for prescribing bDMARDs.

    Ort, förlag, år, upplaga, sidor
    WILEY-BLACKWELL, 2015
    Nationell ämneskategori
    Klinisk medicin
    Identifikatorer
    urn:nbn:se:liu:diva-124498 (URN)10.1002/acr.22640 (DOI)000367681900008 ()26097219 (PubMedID)
    Anmärkning

    Funding Agencies|Norrbacka-Eugenia Foundation; Swedish Rheumatism Association

    Tillgänglig från: 2016-02-02 Skapad: 2016-02-01 Senast uppdaterad: 2017-11-30
    4. Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study
    Öppna denna publikation i ny flik eller fönster >>Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study
    2014 (Engelska)Ingår i: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, nr 153Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors.

    Ort, förlag, år, upplaga, sidor
    BioMed Central, 2014
    Nyckelord
    Prescription; Rheumatoid arthritis; Biological drugs; Implementation; Physicians; Clinical decision-making; Practice variations; Qualitative; CFIR
    Nationell ämneskategori
    Klinisk medicin
    Identifikatorer
    urn:nbn:se:liu:diva-113028 (URN)10.1186/s13012-014-0153-5 (DOI)000345438200001 ()25304517 (PubMedID)
    Tillgänglig från: 2015-01-12 Skapad: 2015-01-08 Senast uppdaterad: 2017-12-05
    5. Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden
    Öppna denna publikation i ny flik eller fönster >>Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden
    2015 (Engelska)Ingår i: Social Policy & Administration, ISSN 0144-5596, E-ISSN 1467-9515, Vol. 49, nr 7, s. 911-927Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    In the last ten years, the concept of management by knowledge has gained growing attention inSwedish healthcare, as well as internationally. In Sweden, the most prominent example ofmanagement by knowledge is the National Guidelines, aimed at influencing both clinical andpolitical decision-making in the health sector. The objective of this article is to explore the response among four Swedish county councils to the National Guidelines for Cardiac Care (NGCC). Empirical material was collected through 155 expert interviews with the target groups of the NGCC, politicians, administrators and clinical managers. Analysis of the responses to this multifaceted policy instrument was addressed by drawing on implementation theory (Matland 1995) and institutional theory (Oliver 1991). The NGCC are primarily based on the voluntary diffusion of norms. The county councils are a long way from having adapted all the means suggested by the National Board of Health and Welfare (NBHW): explicit prioritization, healthcare programmes and dialogue between the various actor groups. The high degree of ambiguity in the content of the NGCC, the inherent conflict and the multiplicity and uncertainty in the context of the county councils, have often resulted in avoidance and compromise. The strategic responses we observe can be viewed as an attempt to balance multiple constituents and achieve the various internal organizational goals. The ambiguity and conflict inherent in the policy of the NGCC influence the strategic responses made by the organization. The question remains how far management by knowledge can be applied in a political context.

    Ort, förlag, år, upplaga, sidor
    John Wiley & Sons, 2015
    Nyckelord
    Policy implementation; Institutional pressure; Strategic responses; Swedish National Guidelines
    Nationell ämneskategori
    Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi
    Identifikatorer
    urn:nbn:se:liu:diva-113304 (URN)10.1111/spol.12102 (DOI)000368267400006 ()
    Tillgänglig från: 2015-01-15 Skapad: 2015-01-15 Senast uppdaterad: 2018-11-09Bibliografiskt granskad
  • 198.
    Kalkan, Almina
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Hallert, Eva
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för samhällsmedicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Sinnescentrum, Smärt och rehabiliteringscentrum.
    Bernfort, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Husberg, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Carlsson, Per
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Costs of rheumatoid arthritis during the period 1990–2010: a register-based cost-of-illness study in Sweden2014Ingår i: Rheumatology, ISSN 1462-0324, E-ISSN 1462-0332, Vol. 53, nr 1, s. 153-160Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives. The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990–2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs.

    Methods. A prevalence-based cost-of-illness study was conducted based on data from national and regional registries.

    Results. There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990–2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010.

    Conclusion. By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment.

  • 199.
    Kalkan, Almina
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Hallert, Eva
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Carlsson, Per
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Roback, Kerstin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Hälsouniversitetet.
    Sjöwall, Christopher
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för neuro- och inflammationsvetenskap. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Reumatologiska kliniken i Östergötland.
    Individual variations in treatment decisions by Swedish rheumatologists regarding biological drugs for rheumatoid arthritis2015Ingår i: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 44, nr 4, s. 265-270Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: In Sweden, reports indicate surprisingly large regional variation in prescription of biological drugs, despite a growing number of clinical studies describing their beneficial effects and guidelines by professional organizations and agencies. Our objective was to ascertain whether there is also variation between individual rheumatologists in prescribing biologics to patients with rheumatoid arthritis (RA) and to evaluate reasons for treatment choices.

    Methods: Ten hypothetical patient cases were constructed and presented to 26 rheumatologists in five regions in Sweden. The cases were based on actual cases and were thoroughly elaborated by a senior rheumatologist and pre-tested in a pilot study. The respondents were asked whether they would treat the patients with a biological agent (YES/NO) and to explain their decisions.

    Results: The response rate was 26/105; 25%. Treatment choices varied considerably between the rheumatologists, some prescribing biologics to 9/10 patients and others to 2/10. In five of the ten hypothetical cases, approximately half of the respondents would prescribe biologics. No regions with particularly high or low prescription were identified. Both the decision to prescribe biologics, as well as not to prescribe, were mainly motivated by medical reasons. Some rheumatologists also referred to lifestyle-related factors or social function of the patient.

    Conclusion: The choice of initiation of biologics varied substantially among rheumatologists presented with hypothetical patient cases, and there were also disparities between rheumatologists practising at the same clinic. Treatment choices were primarily motivated by medical reasons. This situation raises concerns about a lack of consensus in RA treatment strategies.

  • 200.
    Kalkan, Almina
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Husberg, Magnus
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Hallert, Eva
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Roback, Kerstin
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Thyberg, Ingrid
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för neuro- och inflammationsvetenskap. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Reumatologiska kliniken i Östergötland.
    Skogh, Thomas
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för neuro- och inflammationsvetenskap. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Hjärt- och Medicincentrum, Reumatologiska kliniken i Östergötland.
    Carlsson, Per
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
    Physician Preferences and Variations in Prescription of Biologic Drugs for Rheumatoid Arthritis: A Register-Based Study of 4,010 Patients in Sweden2015Ingår i: Arthritis care & research, ISSN 2151-464X, E-ISSN 2151-4658, Vol. 67, nr 12, s. 1679-1685Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective. The prescription of biologic drugs for rheumatoid arthritis (RA) patients has varied considerably across different regions. Previous studies have shown physician preferences to be an important determinant in the decision to select biologic disease-modifying antirheumatic drugs (bDMARDs) rather than nonbiologic, synthetic DMARDs (sDMARDs) alone. The aim of this study was to test the hypothesis that physician preferences are an important determinant for prescribing bDMARDs for RA patients in Sweden. Methods. Using data from the Swedish Rheumatology Quality Register, we identified 4,010 RA patients who were not prescribed bDMARDs during the period 2008-2012, but who, on at least 1 occasion, had an sDMARD prescription and changed treatment for the first time to either a new sDMARD or a bDMARD. Physician preference for the use of bDMARDs was calculated using data on each physicians prescriptions during the study period. The relationship between prescription of a bDMARD and physician preference, controlling for patient characteristics, disease activity, and the physicians local context was evaluated using multivariate logistic regression. Results. When adjusting for patient characteristics, disease activity, and the physicians local context, physician preference was an important predictor for prescription of bDMARDs. Compared with patients of a physician in the lowest preference tertile, patients of physicians in the highest and middle tertiles had an odds ratio for receiving bDMARDs of 2.8 (95% confidence interval [95% CI] 2.13-3.68) and 1.28 (95% CI 1.05-1.57), respectively. Conclusion. Physician preference is an important determinant for prescribing bDMARDs.

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