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  • 301.
    Natanaelsson, Jennie
    et al.
    Nordic School Public Health NHV, Sweden.
    Hakkarainen, Katja M.
    Nordic School Public Health NHV, Sweden; EPID Research, Sweden.
    Hägg, Staffan
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pharmacology. Jonköping County Council, Sweden.
    Andersson Sundell, Karolina
    University of Gothenburg, Sweden.
    Petzold, Max
    University of Gothenburg, Sweden.
    Rehnberg, Clas
    Karolinska Institute, Sweden.
    Jonsson, Anna K.
    National Board Forens Med, Department Forens Genet and Forens Toxicol, Linkoping, Sweden.
    Gyllensten, Hanna
    Nordic School Public Health NHV, Sweden; Karolinska Institute, Sweden.
    Direct and indirect costs for adverse drug events identified in medical records across care levels, and their distribution among payers2017In: Research in Social and Administrative Pharmacy, ISSN 1551-7411, E-ISSN 1934-8150, Vol. 13, no 6, p. 1151-1158Article in journal (Refereed)
    Abstract [en]

    Background: Adverse drug events (ADEs) cause considerable costs in hospitals. However, little is known about costs caused by ADEs outside hospitals, effects on productivity, and how the costs are distributed among payers. Objective: To describe the direct and indirect costs caused by ADEs, and their distribution among payers. Furthermore, to describe the distribution of patient out-of-pocket costs and lost productivity caused by ADEs according to socio-economic characteristics. Method: In a random sample of 5025 adults in a Swedish county, prevalence-based costs for ADEs were calculated. Two different methods were used: 1) based on resource use judged to be caused by ADEs, and 2) as costs attributable to ADEs by comparing costs among individuals with ADEs to costs among matched controls. Payers of costs caused by ADEs were identified in medical records among those with ADEs (n = 596), and costs caused to individual patients were described by socio-economic characteristics. Results: Costs for resource use caused by ADEs were (sic)505 per patient with ADEs (95% confidence interval (sic)345-665), of which 38% were indirect costs. Compared to matched controls, the costs attributable to ADEs were (sic)1631, of which (sic)410 were indirect costs. The local health authorities paid 58% of the costs caused by ADEs. Women had higher productivity loss than men ((sic)426 vs. (sic)109, p = 0.018). Out-of-pocket costs displaced a larger proportion of the disposable income among low-income earners than higher income earners (0.7% vs. 0.2%-0.3%). Conclusion: We used two methods to identify costs for ADEs, both identifying indirect costs as an important component of the overall costs for ADEs. Although the largest payers of costs caused by ADEs were the local health authorities responsible for direct costs, employers and patients costs for lost productivity contributed substantially. Our results indicate inequalities in costs caused by ADEs, by sex and income. (C) 2016 Elsevier Inc. All rights reserved.

  • 302.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Citizenship bricolage: How to make sense of citizenship for people with dementia2014Conference paper (Refereed)
  • 303.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Designing for Legitimacy: Policy Work and the Art of Juggling When Setting Limits in Health Care2012Doctoral thesis, monograph (Other academic)
    Abstract [en]

    Limit-setting in publicly funded healthcare is unavoidable, and increasingly important in the governance and management of the demand for health services. The work of limit-setting takes place in the organising of the provision of health services, where various health workers (professionals, administrators, unit managers, politicians) collectively exercise their skills. Limit-setting often creates tensions which impose the quest for legitimacy; it involves norms and values which are related to the interests of the health workers, and moreover to society at large. In that sense, limit-setting is related to internal processes of legitimacy within the healthcare organisation, i.e. internal legitimacy, and external processes of legitimacy where citizens are legitimating the activities in the healthcare organisation, i.e. external legitimacy.

    The purpose of this thesis was to discover, and increase the understanding of the dilemma associated with sustaining, generating and designing internal legitimacy, when working with a policy of limit-setting in healthcare, in relation to the provision of Assistive Technologies (AT). It has explored what health workers do when they are working with a policy, and in particular how they work out what they should be doing. Finally the role of mediating institutions in supporting and designing internal legitimacy, was explored in the thesis.

    Following a case-study design and a qualitative approach, where fifty-seven semi-structured open-ended interviews were conducted, data allowed the exploration of internal legitimacy in a context of complex interaction and construction of policy work in two Swedish county councils.

    This research produced a number of key findings; in an environment of finite resources health workers encountered situations that were characterised by conflicting pressures, and handled these by way of interaction, sense making, presenting arguments, negotiating and seeking support for an appropriate course of action and practices. The policy work with limit-setting can therefore be regarded as a dynamic interactive process, which incorporates several actors in different situations and locations, together negotiating and institutionalising the policy. Various policy sites, which had the role of mediating institutions, were identified, and were important in the interactive processes of forming a shared collective meaning in order to reach an appropriate act. Hence, designing legitimacy has to acknowledge the interactive policy work, and its contextual character, taking place at the different levels of a healthcare system.

  • 304.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Grasping what to do: Implementation and learning in the case of implementing policy for provision of AT in two Swedish county councils2013Conference paper (Refereed)
  • 305.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences. prioriteringscentrum på Linköpings universitet.
    Vårdprofessionens roll som demokratins väktare i sjukvården2015In: Dagens Medicin, ISSN 1402-1943, Vol. 49, no 15, p. 30-Article in journal (Other (popular science, discussion, etc.))
  • 306.
    Nedlund, Ann-Charlotte
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Priority Setting as a Game of Blame? Political Leadership in Health Care Priority Setting2014Conference paper (Refereed)
  • 307.
    Nedlund, Ann-Charlotte
    et al.
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Nordh, Jonas
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Constructing citizen(ship):: A matter of the power of experts and the politics of time in the case of people with dementia2013Conference paper (Refereed)
  • 308.
    Nedlund, Ann-Charlotte
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Nordh, Jonas
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Health Sciences.
    Constructing citizenship targets:: A matter of labelling and belonging in the case of people with dementia2014Conference paper (Refereed)
  • 309.
    Neher, Margit
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Rehabilitation Center.
    Nygardh, Annette
    Jonkoping Univ, Sweden.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Broström, Anders
    Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Clinical Neurophysiology. Jonkoping Univ, Sweden.
    Johansson, Peter
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in East Östergötland, Department of Internal Medicine in Norrköping.
    Implementing internet-delivered cognitive behavioural therapy for patients with cardiovascular disease and psychological distress: a scoping review2019In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953, Vol. 18, no 5, p. 346-357Article, review/survey (Refereed)
    Abstract [en]

    Background: Comorbid psychological distress (i.e. insomnia and depression) is experienced by 20-40% of patients with cardiovascular disease. This has a considerable impact on their health and quality of life, leading to frequent re-hospitalisations, higher healthcare costs and a shorter life expectancy. Internet-based cognitive behavioural therapy shows great potential for treating psychological distress in cardiovascular disease. Effective and feasible treatments can, however, only benefit patients if they are fully implemented in clinical care. Aim: This scoping review aimed to explore the literature for internet-based cognitive behavioural therapy in cardiovascular disease and for strategies to implement the intervention. Methods: We searched electronic databases, journals and internet sources to find original studies about internet-based cognitive behavioural therapy in cardiovascular disease, adhering to scoping methodology guidelines. After identifying 267 titles, we screened 40 abstracts and chose 11 full-text articles for full-text screening. The results sections in four articles were searched for outcomes that related to the effectiveness and implementation of internet-based cognitive behavioural therapy by directed qualitative content analysis using an implementation framework. Results: Three of the four articles fulfilling the inclusion criteria concerned internet-based cognitive behavioural therapy for treating mild to moderate depressive symptoms in cardiovascular disease, and none focused on insomnia. The studies showed evidence for the effectiveness of internet-based cognitive behavioural therapy, and/or described patient factors influencing clinical effectiveness. Our qualitative content analysis showed that many implementation aspects and stakeholder perspectives remain unexplored. Conclusions: Internet-based cognitive behavioural therapy promises to alleviate patient suffering in cardiovascular disease. There is, however, little research about internet-based cognitive behavioural therapy for cardiovascular disease, and about how this evidence-based intervention is implemented.

  • 310.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development.
    Ericsson, Carin
    Region Östergötland, Heart and Medicine Center.
    Skagerström, Janna
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regional Board, Research and Development Unit.
    Schildmeijer, Kristina
    Linneuniversitet - Kalmar, Sweden .
    Patientmedverkan från retorik till praktik2017In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 114Article in journal (Other academic)
  • 311.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Implementeringsstrategier2014In: Implementering av evidensbaserad praktik / [ed] Per Nilsen, Malmö: Gleerups Utbildning AB, 2014, p. 135-151Chapter in book (Other academic)
  • 312.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Schildmeijer, Kristina
    Department of Health and Care Sciences, Linnaeus University, Kalmar, Sweden.
    Ericsson, Carin
    Region Östergötland, Heart and Medicine Center.
    Seing, Ida
    Linköping University, Department of Behavioural Sciences and Learning, Education and Sociology. Linköping University, Faculty of Arts and Sciences.
    Birken, Sarah
    Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA.
    Implementation of change in health care in Sweden: a qualitative study of professionals’ change responses2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 51Article in journal (Refereed)
    Abstract [en]

    Background

    Implementation of evidence-based practices in health care implies change. Understanding health care professionals’ change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. The aim of this study was to investigate health care professionals’ responses to organizational and workplace changes that have affected their work.

    Methods

    We conducted interviews with 30 health care professionals (physicians, registered nurses and assistant nurses) employed in the Swedish health care system. An inductive approach was applied, using a semi-structured interview guide developed by the authors. We used an analytical framework first published in 1999 to analyze the informants’ change responses in which change responses are perceived as a continuum ranging from a strong acceptance of change to strong resistance to change, describing seven forms of change responses along this continuum. Change response is conceptualized as a tridimensional attitude composed of three components: cognitive, affective and intentional/behavioral.

    Results

    Analysis of the data yielded 10 types of change responses, which could be mapped onto 5 of the 7 change response categories in the framework. Participants did not report change responses that corresponded with the two most extreme forms of responses in the framework, i.e., commitment and aggressive resistance. Most of the change responses were classified as either indifference or passive resistance to changes. Involvement in or support for changes occurred when the health care professionals initiated the changes themselves or when the changes featured their active input and when changes were seen as well founded and well communicated. We did not identify any change responses that could not be fitted into the framework.

    Conclusions

    We found the framework to be useful for a nuanced understanding of how people respond to changes. This knowledge of change responses is useful for the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care.

  • 313.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development.
    Skagerström, Janna
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regional Board, Research and Development Unit.
    Ericsson, Carin
    Region Östergötland, Heart and Medicine Center.
    Schildmeijer, Kristina
    Linneuniversitet, Kalmar, Sweden.
    Många faktorer påverkar om patienter kan medverka till säkrare vård - Intervjustudie visar läkares och sjuksköterskors perspektiv2017In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 114Article in journal (Refereed)
    Abstract [en]

    Patient participation for safer health care - interviews with physicians and nurses

    Patient participation to achieve safer care is an area of growing policy, research and health care management and practice interest. Patients are uniquely placed to observe their treatment, care and physical environment throughout their journey in the health care system. However, very few studies have investigated health care providers attitudes and beliefs concerning patient participation for improved patient safety. This study explored factors that acted as facilitators and/or barriers to patient participation for safer care, as perceived by physicians and nurses in Swedish health care. Interviews were conducted with 13 physicians and 11 nurses, using a purposeful sampling strategy to achieve a heterogeneous sample of providers. We identified nine categories of factors, many of which functioned as barriers to patient participation to achieve safer care.

  • 314.
    Nilsson, Andreas
    et al.
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping. Linköping University, Department of Medical and Health Sciences, Division of Nursing Science.
    Szabó, Zoltán
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Harangi, Márta
    Linköping Municipality, Department of Education, Admissions Office of the Introduction Program, Common Management and Qualified Operational Support, Reception Group for Introduction Programs, Linköping, Sweden.
    Davidsson, Bo
    Linköping Municipality, Division of Research and Development, Linköping, Sweden.
    Dual professional focus clinical case processed in an interprofessional postgraduate case seminar: Experiences from participants and the perceptions of a professional observer2016In: MedEdPubish, ISSN 2312–7996Article in journal (Refereed)
    Abstract [en]

    Background: Inadequate communication between professionals in operating theaters results in impaired medical performance or even in critical events. Interprofessional case seminars, however, can enhance team communication by promoting a deeper understanding of complex situations. Our aim was to evaluate how an interprofessional case seminar using a dual professional focus case in anesthesiology was perceived by the participants. Method: A case seminar was held for 20 nurse anesthetists enrolled in a postgraduate course and for six anesthesiology residents. Transcripts of the case were distributed in advance for individual study and group discussion. The evaluation was based on the responses provided by participants who completed a semistructured questionnaire and from the perceptions of a professional observer. Results: Twenty participants completed the questionnaire; 53% of the respondents had previous experience with case methodology, and 89 different statements were obtained. Of these, 48% were positive and 11% were negative. The remaining 40% of the statements related to previous experiences with case methodology and to suggested improvements. The positive statements proposed that case methodologies are suitable for sensitive issues and beneficial for meetings and exchanges between different professionals. Negative statements focused instead on lack of time, overly large groups, too much speculation, and inadequate preparation or presentations by the participants. Conclusion: Interprofessional case seminars using a dual professional focus may be suitable for postgraduate education in anesthesia. This technique may improve interprofessional communication and may call attention to the importance of soft issues, such as ethics, communication, organization, and leadership in addition to that of the medical dimension.

  • 315.
    Nordenfelt, Lennart
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Arts and Sciences.
    Ability, Competence and Qualification: Fundamental Concepts in the Philosophy of Disability2009In: Philosophical Reflections on Disability / [ed] Ralston, D. Christopher; Ho, Justin, Dordrecht: Springer , 2009, 1, p. 37-54Chapter in book (Refereed)
    Abstract [en]

    This project draws together the diverse strands of the debate regarding disability in a way never before combined in a single volume. After providing a representative sampling of competing philosophical approaches to the conceptualization of disability as such, the volume goes on to address such themes as the complex interplay between disability and quality of life, questions of social justice as it relates to disability, and the personal dimensions of the disability experience. By explicitly locating the discussion of various applied ethical questions within the broader theoretical context of how disability is best conceptualized, the volume seeks to bridge the gap between abstract philosophical musings about the nature of disease, illness and disability found in much of the philosophy of medicine literature, on the one hand, and the comparatively concrete but less philosophical discourse frequently encountered in much of the disability studies literature. It also critically examines various claims advanced by disability advocates, as well as those of their critics. In bringing together leading scholars in the fields of moral theory, bioethics, and disability studies, this volume makes a unique contribution to the scholarly literature, while also offering a valuable resource to instructors and students interested in a text that critically examines and assesses various approaches to some of the most vexing problems in contemporary social and political philosophy.

  • 316.
    Nordenfelt, Lennart
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Arts and Sciences.
    Dignity in Care for Older People2009Collection (editor) (Refereed)
    Abstract [en]

    The notion of quality of life has for several decades been well-established in ethical debate about health care and the care of older people. Dignity in Care for Older People highlights the notion of dignity within the care of the elderly, focusing on the importance of theoretical concepts. Primarily based on a Research Project, Dignity and Older Europeans, funded by the European Commission, this book provides a thorough investigation of the concept of dignity and related concepts such as quality of life and autonomy. It includes a chapter devoted to the dignity of human embodiment, emphasizing the importance of the notion of the lived body in the context of elderly care. As a result of the conceptual study a model of dignity emerges in which four variants of dignity stand out: dignity of merit, dignity as moral status, dignity of identity and Menschenwurde (the specifically human value). From this follows a discussion of how these variants of dignity can be used in characterizing the care of the elderly. The notions of dignity and dignified care are discussed particularly in relation to demented persons and dying persons. The book also contains a chapter on the dignity of the dead person. International in focus, Dignity in Care for Older People provides a contemporary discussion of the care of older people, and will be of use to qualified nurses and social care practitioners working with older people, as well as those on ethics and gerontology courses

  • 317.
    Nordenfelt, Lennart
    Linköping University, The Tema Institute, Health and Society. Linköping University, Faculty of Arts and Sciences.
    Livskvalitet och hälsa: Teori och kritik2004Book (Other academic)
    Abstract [sv]

    Denna bok har skrivits parallellt i två olika former, dels som en akademisk avhandling på engelska, dels som en mer populariserad bok på svenska. De analyser som ligger till grund för bokens framställning om lycka och livskvalitet samt mätningen av dessa företeelser utfördes huvudsakligen under min vistelse i Edinburgh, Skottland, våren 1989. Jag är tack skyldig till The Institute for Advanced Studies in the Humanities som erbjöd mig forskarplats under denna period. Jag är också tacksam för de inspirerande samtal om livskvalitet och lycka som jag där hade med professor Timothy Spigge och Dr. Elizabeth Telfer. Dr Telfers egen avhandling Happiness (1989) är kanske den enskilda skrift som mest påverkat mitt eget synsätt i dessa frågor.

    Den grundsyn på hälsa och sjukdom som presenteras i denna bok finns mera utförligt redovisad i mitt arbete On the Nature of Health (1987). Texten i kapitel 1 utgör en bearbetning av min tidigare uppsats: Livskvalitet, en studie av ett begrepp, som publiceras i boken Häsa och värde (1991).

    Liksom i mina tidigare större projekt har jag fått stöd och många kloka synpunkter från professor Ingmar Pörn, Helsingfors. Två danska experter, Erik Ostenfeld och Anton Aggernaes, har givit mig flera värdefulla synpunkter. Jag tackar också mina kollegor på Tema Hälsa och sjukvården i samhället i Linköping för att de hjälpt mig förbi flera av de blindskär som det är så lätt att kollidera med i en framställning som denna. Jag vill särskilt framhålla Bo Petersson, Ingmar Nordin och Per-Erik Liss som läst och kommenterat hela mitt manuskript.

    Linköping i juni 1991

    Lennart Noredenfelt

  • 318.
    Nordenfelt, Lennart
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Quality of Life, Health and Happiness1993Book (Refereed)
    Abstract [en]

    The basic work for this book was carried out during the spring of 1989 in Edinburgh, where I had been granted a research position at The Institute for Advanced Studies in the Humanities. I should like to express here my indebtedness to the Institute for the opportunity thus afforded me. I should also like to say how very grateful I am for the stimulating conversations I had there with Professor Timothy Sprigge and Dr. Elizabeth Telfer. Dr. Telfers’s own treatise Happiness (1980) has been a major influence on my view of the questions involved.

    The basic view of health and illness presented in this book is more fully set out in my On the Nature of Health (1987).

    As in the case of my previous larger projects, I have received a great amount of support and may wise comments from Professor Ingmar Pörn, Helsinki. Three Danish experts – Anton Aggernaes, Erik Ostenfeld and Peter Sandøe – have made valuable comments. Professor Heng ten Have, Nijmegen, has improved my reading of the philosophy of Jeremy Bentham. I should also like to thank my colleagues at the Department of Health and Society, University of Linköping, for helping me to avoid a number of the pitfalls that can so easily stumble into when it comes to a treatise like this. Especially I should like to mentioned Per-Erik Liss, Ingemar Nordin and Bo Petersson, all three of whom have read and commented on the entire manuscript.

    A Swedish version of this book, Livskvalitet och hälsa, came out in 1991. I have been made quite a number of corrections and additions, one type of addition being replies to critical points made in reviews of the Swedish version.

    I should like to thank Malcolm Forbes for valuable help putting my English into publishable condition.

    Linköping, May 1993

    Lennart Noredenfelt

  • 319.
    Nordenfelt, Lennart
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Samtal om hälsan: En dialog om hälsans natur1996Book (Other academic)
    Abstract [sv]

    Denna bok är skriven i dialogens form. Den utgör ett försök att förmedla resultatet av ett forskningsarbete i en annan form än den traditionellt akademiska. Det är dock en form som har antika anor och som under klassisk tid användes särskilt för att förmedla filosofiska kunskaper. Min egen forskning är filosofisk, och de idéer jag vill förmedla har många gånger kommit till i ett slags dialogsituation, antingen en äkta dialog med en kollega eller vän, eller en inre dialog med en fiktiv samtalspartner. På ett sätt är dialogen därför den mes naturliga formen för presentation både av filosofiska problem och av filosofiska lösningsförslag.

    I boken ställs många frågor kring hälsans natur och andra närbesläktade begrepp. Svaren överensstämmer i allt väsentligt med mina egna åsikter idag. Jag har emellertid för läsbarhetens skull inte alltid skrivit så precist och omständligt som en analytisk filosof förväntas göra i en akademisk avhandling. Jag uppfyller sådana krav något bättre i skrifter som On the Natur of Health (1987, 1995), Quality of Life and Happiness (1993) och Action, Ability and Health (under utgivning). Den forskare som vill kritiskt granska mina idéer bör därför i första hand uppsöka dessa skrifter. Avsikten med denna bok har inte varit att presentera mina teorier och resultat för forskarsamhället. Min huvudavsikt har istället varit att på ett någorlunda lättläst och livfullt sätt förmedla tankar om så abstrakta ting som begreppen hälsa och lycka till en större publik. Här och var har detta intressant nog inneburit att jag har gått längre i mina analyser än jag gjort i de vetenskapliga skrifterna.

    Mina ambitioner på det litterära planet är mycket blygsamma. Jag inbillar mig inte att jag genom ett enkelt knep som att skriva i dialogform skall kunna närma mig dialogens stora mästare Platon och Cicero. Jag har därför inte heller försökt beskriva en bakgrund eller ett sammanhang där dessa samtal utspinner sig. Läsaren kan tänka sig att de äger rum i ett seminarierum, eller kanske ännu hellre under filosofiska promenader i natursköna miljöer som den bohuslänska kusten, det öländska allvaret eller den lappländska fjällvärlden. Jag har funnit att skådandet av öppna vidder har varit befruktande för filosofisk reflektion.

    I dialogerna uppträder två personer benämnda I och F. ”I” står helt enkelt för intervjuaren, ”F” för filosofen. Saken är inte alltid så enkel att F är mitt alter ego. Några gånger har jag krupit in under intervjuarens skinn. Läsaren kan kanske ana när jag h yser dubier om mina egna åsikter. Oftast är dock I en person utanför mig själv. Ibland har I varit förkroppsligad i någon av de många personer som jag mött som handledare eller föreläsare om hälsans filosifi.

    Som alla vetenskapliga författare idag har jag fått kämpa med användningen av personliga pronomina när jag avser att tala om en människa i allmänhet och inte om en människa av ett bestämt kön. Jag använder ömsom ”han” ömsom ”hon” i dessa sammanhang,. Det är min förhoppning att jag lyckats med detta utan att resultatet har blivit vare sig förvirrande eller könsdiskriminerande.

    Linköping våren 1996

    Lennart Nordenfelt

  • 320.
    Nordh, Jonas
    et al.
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    The work of citizenship: How do welfare-state policy workers interpret 'reasonable standard of living' in the case of people with dementia2014Conference paper (Refereed)
  • 321.
    Nordh, Jonas
    et al.
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    To Coordinate Information in Practice: Dilemmas and Strategies in Care Management for Citizens with Dementia2017In: Journal of social service research, ISSN 0148-8376, E-ISSN 1540-7314, Vol. 43, no 3, p. 319-335Article in journal (Refereed)
    Abstract [en]

    This qualitative study, based on 19 interviews with care managers, explores the experiences of care-managers involved in assessing the need for social services for people with dementia. The study shows that social workers, as care managers, face several dilemmas in their practice concerning people with dementia, in relation to the exchange of information and in regards to conflicting interests between different actors involved in the assessment of the need for support for people with dementia. Strategies used to handle problematic situations that arise in their work are using other sources for information (e.g., relatives and actors from other professions), persuading, and pursuing creative forms of consent. However, the study shows that dilemmas and strategies used generate other, prominently moral, dilemmas for care managers in their practice, which relate to participation and self-determination by the person with dementia. The study shed light on the problematic situation for care managers in their work to coordinate information and further the new “realities“ that they encounter as well as on how to handle these new situations. This study suggests possible ways to improve the everyday work of care managers, as well as how policies concerning social work and people with dementia can be improved.

  • 322.
    Nygard Tonheim, Aleksander
    et al.
    Linköping University, Department of Biomedical Engineering. Linköping University, Faculty of Science & Engineering. Univ Bergen, Norway.
    Babic, Ankica
    Linköping University, Department of Biomedical Engineering, Division of Biomedical Engineering. Linköping University, Faculty of Science & Engineering. Univ Bergen, Norway.
    Multiple Sclerosis Application Design with Medical Expert Evaluation2019In: WORLD CONGRESS ON MEDICAL PHYSICS AND BIOMEDICAL ENGINEERING 2018, VOL 1, SPRINGER , 2019, Vol. 68, no 1, p. 457-461Conference paper (Refereed)
    Abstract [en]

    This paper presents a high-fidelity prototype of a mobile application for patient self-management within the field of Multiple Sclerosis (MS). Method. Development included mixed and high-fidelity prototypes which were based on the information needs inquired from the potential user groups and their reflection on publicly available applications. The aim was to design an application to suit Norwegian user groups. It is evident from the results that the application has four selected modules: Diary module, Physical activity module, Summary module, and a To-do list. Two medical experts were interviewed at two different times at the Haukeland University hospital in Bergen, Norway, to evaluate two design iterations. The semi-structured interview consisted of two parts; one with questions on which the experts could elaborate, and one with evaluation of the prototype msHealth using System Usability Scale (SUS). Results. The results have suggested that healthcare personnel would be interested in patient data from a mobile diary, and how a patient should plan a day if suffering from symptoms. These are the two most prominent functionalities. Conclusions. Feedback from medical staff using SUS was promising. Several suggestions were given, as how to personalise the prototype to encourage the user to plan desired activities and learn how to live with the disease. All these new functionalities are being implemented to reduce stress, and include the prototype application as a decision support during a patient-physician consultation.

  • 323.
    Nygren, Mikaela
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Nilsen, Per
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    Facilitators and barriers influencing patient safety in Swedish hospitals: a qualitative study of nurses' perceptions2014In: BMC nursing, ISSN 1472-6955, Vol. 13, no 23Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sweden has undertaken many national, regional, and local initiatives to improve patient safety since the mid-2000s, but solid evidence of effectiveness for many solutions is often lacking. Nurses play a vital role in patient safety, constituting 71% of the workforce in Swedish health care. This interview study aimed to explore perceived facilitators and barriers influencing patient safety among nurses involved in the direct provision of care. Considering the importance of nurses with regard to patient safety, this knowledge could facilitate the development and implementation of better solutions.

    METHODS: A qualitative study with semi-structured individual interviews was carried out. The study population consisted of 12 registered nurses at general hospitals in Sweden. Data were analyzed using qualitative content analysis.

    RESULTS: The nurses identified 22 factors that influenced patient safety within seven categories: 'patient factors', 'individual staff factors', 'team factors', 'task and technology factors', 'work environment factors', 'organizational and management factors', and 'institutional context factors'. Twelve of the 22 factors functioned as both facilitators and barriers, six factors were perceived only as barriers, and four only as facilitators. There were no specific patterns showing that barriers or facilitators were more common in any category.

    CONCLUSION: A broad range of factors are important for patient safety according to registered nurses working in general hospitals in Sweden. The nurses identified facilitators and barriers to improved patient safety at multiple system levels, indicating that complex multifaceted initiatives are required to address patient safety issues. This study encourages further research to achieve a more explicit understanding of the problems and solutions to patient safety.

  • 324.
    OBrien, Bridget C.
    et al.
    University of Calif San Francisco, CA 94143 USA.
    Warren Little, Judith
    University of Calif Berkeley, CA 94720 USA.
    Wamsley, Maria
    University of Calif San Francisco, CA 94143 USA.
    Cook, Joseph G.
    University of Calif San Francisco, CA 94143 USA.
    Yuan, Patrick
    University of Calif San Francisco, CA 94143 USA.
    Rivera, Josette
    University of Calif San Francisco, CA 94143 USA.
    Cianciolo, Anna T.
    Southern Illinois University, IL 62794 USA.
    Abrandt Dahlgren, Madeleine
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Ng, Stella L.
    University of Toronto, Canada.
    Stillsmoking, Kristina L.
    University of Texas Rio Grande Valley, TX USA.
    Emergent is Authentic: A Sociomaterial Perspective on Simulation-Enhanced Interprofessional Education2017In: Teaching and learning in medicine, ISSN 1040-1334, E-ISSN 1532-8015, Vol. 29, no 4, p. 363-367Article in journal (Refereed)
    Abstract [en]

    This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Western Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. The commentary explores the implications of sociomaterial perspectives for conceptualizing authenticity in the design and evaluation of simulation-enhanced interprofessional education.

  • 325.
    Olaison, Anna
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Creating images of older people as home-care receivers: Categorizing needs in social work case files2010In: Qualitative Social Work, Vol. 9, no 4, p. 500-518Article in journal (Refereed)
    Abstract [en]

    Central to the assessment process in case management is how older people’s needs are constructed through documentation and case files. This article examines how older people’s needs are categorized in written documentation. Sixteen case files from three social work districts in Sweden were studied using discourse analysis. The results identified two general types of case files; the fact-oriented (using objective language) and eventoriented case file (using more personal language) – which depicted the older individuals quite differently. All case files employed several need categories; though social needs were important in describing living conditions, it was medical and physical needs that impinged on home care decisions. This raises questions about how case documentation depicts older people through society’s eyes and about the discourses prevailing in gerontological social work.

  • 326.
    Olaison, Anna
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Negotiating needs: Processing older persons as home care recipients in gerontological social work practices2009Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The study concerns the needs assessment processes that older persons undergo to gain access to home care. The participation of older persons, their relatives and municipal care managers was studied from a communicative perspective. The assessment meetings functions as formal problem-solving events. The older persons´ accounts are negotiated discursively in interaction. Various storylines are used by the older persons and their relatives whether they view home care as an intrusion, as a complement or as a right. In case of divergent opinions the older person has the final say as prescribed by the Swedish social service act. One conclusion is that the role of relatives is not defined and a family perspective is not present. In the study the institutional structure of the assessment process was also analyzed. Older persons are processed into clients; their needs are fitted within the framework of documentation and institutional categories. In the transfer of talk to text all the particulars are not reflected and two types of documentation was identified; a fact-oriented objective language or an event-oriented personal language. Care management models and a managerialist thinking has influenced the assessment process by bureaucratisation of older people trough people processing, which is in contradiction to the individual-centric perspective prescribed by the law. The introduction of care management models in gerontological social work has lead to an embedded contradiction and constitutes a welfare political dilemma. Improved communicative methods are needed in order to achieve a holistic assessment situation.

    List of papers
    1. Assessment for home care: Negotiating solutions for individual needs
    Open this publication in new window or tab >>Assessment for home care: Negotiating solutions for individual needs
    2006 (English)In: Journal of Aging Studies, ISSN 0890-4065, E-ISSN 1879-193X, Vol. 20, no 4, p. 367-380 Article in journal (Refereed) Published
    Abstract [en]

    This article explores care management as an activity that regulates the distribution of society's resources for home care. It focuses on interaction in assessment meetings, which are part of the planning of services and care for old people in Sweden. The aim was to acquire an understanding of how old people, as applicants, account for their needs for care, and how these accounts are negotiated and positioned in talk. Twenty home care assessments were audio-taped and the data were analyzed using discursive analysis. It was found that the assessment meetings had an institutional structure within, which old people, as applicants and with individual needs for care, were assessed within fixed institutional categories. Furthermore, analysis showed how interaction during assessment meetings functioned as formal problem-solving, in which applicants' accounts of their health issues were negotiated, contributing to the construction of their identity as home care receivers.

    Place, publisher, year, edition, pages
    Elsevier, 2006
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-15964 (URN)10.1016/j.jaging.2005.11.004 (DOI)
    Available from: 2008-12-18 Created: 2008-12-18 Last updated: 2017-12-14
    2. Home care as a family matter?: Discursive positioning, storylines and decision-making in assessment talk
    Open this publication in new window or tab >>Home care as a family matter?: Discursive positioning, storylines and decision-making in assessment talk
    2008 (English)In: Communication & Medicine: An Interdisciplinary Journal of Healthcare, Ethics and Society, ISSN 1612-1783, E-ISSN 1613-3625, Vol. 5, no 2Article in journal (Refereed) Published
    Abstract [en]

    Home care arrangements for older people are coordinated via a client-centred assessment process. This article describes how storylines and discursive positioning are used among older people and their relatives when divergent opinions of care needs are expressed. Eleven assessment interviews were studied using discourse analysis. The results show that relatives and older people advanced three major storylines, and positioned themselves within them with respect to the need for help. These storylines were based on whether the persons viewed home care as an intrusion into daily routines and relationships or as a complement and support in everyday life, or as a right. The content of the storylines and the ways in which positions were shaped within them illustrate how positioning is incorporated as part of the ongoing reflexive process in interaction in which participants form an image of the older person's needs. Assessments clarify the views of the participants on home care, but they also reflect the discourses that are prevalent in the aged care community and in society in general. The article raises questions about strengthening older people’s participation in the decision making process and also whether a new communicative practice is needed for assessments, i.e., one that proceeds on the basis of a broader family perspective.

    Keywords
    Assessment interviews, aged care, storylines, positioning, discourse analysis, decision making
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-15965 (URN)
    Available from: 2008-12-18 Created: 2008-12-18 Last updated: 2017-12-14
    3. Creating images of older people as home-care receivers: Categorizing needs in social work case files
    Open this publication in new window or tab >>Creating images of older people as home-care receivers: Categorizing needs in social work case files
    2010 (English)In: Qualitative Social Work, Vol. 9, no 4, p. 500-518Article in journal (Refereed) Published
    Abstract [en]

    Central to the assessment process in case management is how older people’s needs are constructed through documentation and case files. This article examines how older people’s needs are categorized in written documentation. Sixteen case files from three social work districts in Sweden were studied using discourse analysis. The results identified two general types of case files; the fact-oriented (using objective language) and eventoriented case file (using more personal language) – which depicted the older individuals quite differently. All case files employed several need categories; though social needs were important in describing living conditions, it was medical and physical needs that impinged on home care decisions. This raises questions about how case documentation depicts older people through society’s eyes and about the discourses prevailing in gerontological social work.

    Place, publisher, year, edition, pages
    Sage Publications, 2010
    Keywords
    Case files; documentation; categorization; case management; discourse analysis; gerontological social work
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-15966 (URN)10.1177/1473325010367820 (DOI)
    Available from: 2008-12-18 Created: 2008-12-18 Last updated: 2015-01-19Bibliographically approved
    4. Requests and outcomes in care management: Processing older persons as clients in old age care
    Open this publication in new window or tab >>Requests and outcomes in care management: Processing older persons as clients in old age care
    (English)Manuscript (Other academic)
    Abstract [en]

    Old age care has undergone a marketisation in recent years in which various models for care management have been introduced with the aim of making assessments efficient. This article investigates the effects the care management model has on resource allocation for home care when handling the requests of older persons in the needs assessment process. Sixteen tape-recorded assessment conversations with associated case-file texts were analysed through discourse analysis. The results show that managerialist thinking has had a partial impact on the assessment process where the documentation requirements have entailed bureaucratisation in terms of the transfer that occurs from talk to text. The findings from the study nevertheless indicate that the assessment conversations have clear elements of an individual-centred perspective in which there is room for a care rational dialogue. This constitutes a welfare policy dilemma today. Providing for older people’s requests should be on the basis of quality and an individual-centred perspective and care management has had a contrary effect in which focus is directed instead towards needs assessment and bureaucratic processes.

    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-15967 (URN)
    Available from: 2008-12-18 Created: 2008-12-18 Last updated: 2015-01-19
  • 327.
    Olaison, Anna
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Requests and outcomes in care management: Processing older persons as clients in old age careManuscript (Other academic)
    Abstract [en]

    Old age care has undergone a marketisation in recent years in which various models for care management have been introduced with the aim of making assessments efficient. This article investigates the effects the care management model has on resource allocation for home care when handling the requests of older persons in the needs assessment process. Sixteen tape-recorded assessment conversations with associated case-file texts were analysed through discourse analysis. The results show that managerialist thinking has had a partial impact on the assessment process where the documentation requirements have entailed bureaucratisation in terms of the transfer that occurs from talk to text. The findings from the study nevertheless indicate that the assessment conversations have clear elements of an individual-centred perspective in which there is room for a care rational dialogue. This constitutes a welfare policy dilemma today. Providing for older people’s requests should be on the basis of quality and an individual-centred perspective and care management has had a contrary effect in which focus is directed instead towards needs assessment and bureaucratic processes.

  • 328.
    Olaison, Anna
    et al.
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Cedersund, Elisabet
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Assessment for home care: Negotiating solutions for individual needs2006In: Journal of Aging Studies, ISSN 0890-4065, E-ISSN 1879-193X, Vol. 20, no 4, p. 367-380 Article in journal (Refereed)
    Abstract [en]

    This article explores care management as an activity that regulates the distribution of society's resources for home care. It focuses on interaction in assessment meetings, which are part of the planning of services and care for old people in Sweden. The aim was to acquire an understanding of how old people, as applicants, account for their needs for care, and how these accounts are negotiated and positioned in talk. Twenty home care assessments were audio-taped and the data were analyzed using discursive analysis. It was found that the assessment meetings had an institutional structure within, which old people, as applicants and with individual needs for care, were assessed within fixed institutional categories. Furthermore, analysis showed how interaction during assessment meetings functioned as formal problem-solving, in which applicants' accounts of their health issues were negotiated, contributing to the construction of their identity as home care receivers.

  • 329.
    Olaison, Anna
    et al.
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Cedersund, Elisabet
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Social and Welfare Studies, Äldre - vård - civilsamhälle (ÄVC) .
    Home care as a family matter?: Discursive positioning, storylines and decision-making in assessment talk2008In: Communication & Medicine: An Interdisciplinary Journal of Healthcare, Ethics and Society, ISSN 1612-1783, E-ISSN 1613-3625, Vol. 5, no 2Article in journal (Refereed)
    Abstract [en]

    Home care arrangements for older people are coordinated via a client-centred assessment process. This article describes how storylines and discursive positioning are used among older people and their relatives when divergent opinions of care needs are expressed. Eleven assessment interviews were studied using discourse analysis. The results show that relatives and older people advanced three major storylines, and positioned themselves within them with respect to the need for help. These storylines were based on whether the persons viewed home care as an intrusion into daily routines and relationships or as a complement and support in everyday life, or as a right. The content of the storylines and the ways in which positions were shaped within them illustrate how positioning is incorporated as part of the ongoing reflexive process in interaction in which participants form an image of the older person's needs. Assessments clarify the views of the participants on home care, but they also reflect the discourses that are prevalent in the aged care community and in society in general. The article raises questions about strengthening older people’s participation in the decision making process and also whether a new communicative practice is needed for assessments, i.e., one that proceeds on the basis of a broader family perspective.

  • 330.
    Olsen Faresjö, Åshild
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Walter, Susanna
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Gastroentorology. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Norlin, Anna-Karin
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Primary Care Center, Primary Health Care Center Ekholmen, Linköping.
    Faresjö, Tomas
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Jones, Michael P.
    Macquarie Univ, Australia.
    Gastrointestinal symptoms - an illness burden that affects daily work in patients with IBS2019In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 17, article id 113Article in journal (Refereed)
    Abstract [en]

    BackgroundIrritable Bowel Syndrome (IBS) is a chronic gastrointestinal disorder characterised by recurrent abdominal pain and disturbed bowel habits and unclear aetiology. IBS is also associated with psychosocial factors, impaired quality of life and lost work productivity. This study sought to determine whether the association between IBS and lost work productivity might be accounted for by poor coping strategies and loss of confidence in the healthcare system.MethodsCase-control design was employed sampling IBS and non-gastrointestinal (non-GI) primary healthcare seekers in a defined region in Sweden. Non-GI patients were of similar age and sex distribution to the IBS patients. Questionnaires applied in this study included instruments designed to measure confidence in the social security system and in the community, as well as questions about whether gastrointestinal problems might affect working life and Sense of coherence (SOC) questionnaire. The studys primary hypothesis was evaluated via an a priori path model.ResultsStatistically significant differences were found between IBS cases (n=305) and controls (n=369) concerning abdominal pain or discomfort affecting everyday performance at work (pamp;lt;0.0001). IBS cases also showed significantly lower (p=0.001) confidence in public healthcare. The studys hypothesis was supported with the finding of a statistically significant indirect association via poor coping strategies, although the indirect associations were lesser in magnitude than the direct association.ConclusionsThis study found a clear association between clinically diagnosed IBS status and interference in work by gastrointestinal symptoms in which sense of coherence might be of importance.

  • 331.
    Omar, Faisal
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Just Waiting: Ethical Challenges in Priority Setting Posed by Organ Scarcity in Kidney Transplantation2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Over the last few decades kidney transplantation has transformed from an experimental treatment to the treatment of choice for end-stage renal disease. Unfortunately, however, the established organ donation models in many countries, relying chiefly on altruism, fail to motivate a sufficient number of donors. As a consequence, many lives which could be saved are lost, and others which can be improved are left to deteriorate.

    Dealing with the challenge of scarcity in kidney transplantation requires a dual approach. In the immediate term, we must ensure the fair distribution of kidney transplantation as a scarce medical resource. In the long term, we must find a policy level solution to mitigate the root issue of scarcity. The policy approach promoted in this thesis is the introduction of incentive based organ donation. Fair resource allocation, and incentive based donation are two themes which raise interesting normative questions, and ethical challenges. Each theme corresponds to two paperswhich form the basis for the thesis.

    Papers I &II, evaluate fairness in the priority setting processes underpinning access to kidney transplantation; this is done both within Sweden's four transplant centers and the Toronto General Hospital in Canada. The criteria, values, and procedures used in clinical decision-making are analyzed to identify barriers to fairness and how such barriers can be removed.

    Papers III and IV, propose incentive based living kidney donation and incentive based deceased donation, respectively, as policy solutions to the organ scarcity. The most frequently raised ethical objections against incentive based models are discussed in a bid to demonstrate the moral permissibility of incentive based organ donation.

    The discussion about fairness, and incentive based models, highlights that the ethical challenges raised by kidney scarcity are inherently difficult. While we may not find infallible solutions we certainly can work towards better solutions. We can create clinical priority setting processes, that while not perfect, move us closer towards increased fairness by removing clear obstacles to just distribution. We can create organ donation policies while not free of ethical challenges; do not shy away from all risk, or from asking the difficult questions.

    List of papers
    1. Priority setting in kidney transplantation: A qualitative study evaluating Swedish practices
    Open this publication in new window or tab >>Priority setting in kidney transplantation: A qualitative study evaluating Swedish practices
    Show others...
    2013 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 41, no 2, p. 206-215Article in journal (Refereed) Published
    Abstract [en]

    Background: Kidney transplantation is the established treatment of choice for end-stage renal disease; it increases survival, and quality of life, while being more cost effective than dialysis. It is, however, limited by the scarcity of kidneys. The aim of this paper is to investigate the fairness of the priority setting process underpinning Swedish kidney transplantation in reference to the Accountability for Reasonableness (A4R) framework. To achieve this, two significant stages of the process influencing access to transplantation are examined: assessment for transplant candidacy, and allocation of kidneys from deceased donors.

    Methods: Semi-structured interviews were the main source of data collection. Fifteen Interviewees included transplant surgeons, nephrologists, and transplant coordinators representing centers nationwide. Thematic analysis was used to analyze interviews, with the Accountability for Reasonableness framework serving as an analytical lens.

    Results: Decision-making both in the assessment and allocation stages are based on clusters of factors that belong to one of three levels: patient, professional, and the institutional levels. The factors appeal to values such as maximizing benefit, priority to the worst off, and equal treatment which are traded off.

    Discussion and Conclusions: The factors described in this paper and the values on which they rest on the most part satisfy the relevance condition of the accountability for reasonableness framework. There are however two potential sources for unequal treatment which we have identified: clinical judgment and institutional policies relating both to assessment and allocation. The appeals mechanisms are well developed and supported nationally which help to offset differences between centers. There is room for improvement in the areas of publicity and enforcement. The development of explicit national guidelines for assessing transplant candidacy and the creation of a central kidney allocation system would contribute to standardize practices across centers; and in the process help to better meet the conditions of fairness in reference to the A4R. The benefits of these policy proposals in the Swedish kidney transplant system merit serious consideration.

    Place, publisher, year, edition, pages
    Sage Publications, 2013
    Keywords
    Ethics, fairness, kidney transplantation, priority setting, Sweden
    National Category
    Social Sciences
    Identifiers
    urn:nbn:se:liu:diva-71309 (URN)10.1177/1403494812470399 (DOI)000315233100014 ()
    Available from: 2011-10-11 Created: 2011-10-11 Last updated: 2017-12-08Bibliographically approved
    2. Priority Setting in the Assessment for Kidney Transplant Candidacy: a Canadian Case Study
    Open this publication in new window or tab >>Priority Setting in the Assessment for Kidney Transplant Candidacy: a Canadian Case Study
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    The benefits of kidney transplantation for treating kidney failure are well documented in terms of life expectancy, quality of life, and cost savings, making it the treatment of choice. It is however limited by the chronic shortage of kidneys. This study’s objective is to examine the fairness of the priority setting process underpinning the assessment for kidney transplant candidacy in one of Canada’s largest transplant programs at the Toronto General Hospital (TGH). This is done in reference to the Accountability for Reasonableness; a leading international framework in health care priority setting.

    The study relies on three sources for data collection: semi structured interviews, process observation, and review of relevant documents.

    The process underpinning the assessment for kidney transplantation is based on clusters of medical criteria reflecting the Canadian national consensus guidelines on eligibility for kidney transplantation. The process is permeated by ethical principles such as: maximizing benefit, equal treatment, and respect for autonomy; which are widely considered relevant in the distribution of scarce medical resources and in medical ethics generally. The criteria for assessment are well publicized and easily accessible while appeals through second opinions are well developed and supported. The process underpinning access to kidney transplantation at the TGH readily satisfies the conditions for fairness in references to the Accountability for Reasonableness framework.

    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:liu:diva-71311 (URN)
    Available from: 2011-10-11 Created: 2011-10-11 Last updated: 2011-10-11Bibliographically approved
    3. Compensated Living Kidney Donation: A Plea for Pragmatism
    Open this publication in new window or tab >>Compensated Living Kidney Donation: A Plea for Pragmatism
    2010 (English)In: HEALTH CARE ANALYSIS, ISSN 1065-3058, Vol. 18, no 1, p. 85-101Article in journal (Refereed) Published
    Abstract [en]

    Kidney transplantation is the most efficacious and cost-effective treatment for end-stage renal disease. However, the treatments accessibility is limited by a chronic shortage of transplantable kidneys, resulting in the death of numerous patients worldwide as they wait for a kidney to become available. Despite the implementation of various measures the disparity between supply and needs continues to grow. This paper begins with a look at the current treatment options, including various sources of transplantable kidneys, for end-stage renal disease. We propose, in accordance with others, the introduction of compensated kidney donation as a means of addressing the current shortage. We briefly outline some of the advantages of this proposal, and then turn to examine several of the ethical arguments usually marshaled against it in a bid to demonstrate that this proposal indeed passes the ethics test. Using available data of public opinions on compensated donation, we illustrate that public support for such a program would be adequate enough that we can realistically eliminate the transplant waiting list if compensation is introduced. We urge a pragmatic approach going forward; altruism in living kidney donation is important, but altruism only is an unsuccessful doctrine.

    Keywords
    End-stage renal disease, Dialysis, Transplantation, Compensated donation, Ethics, Cost-effectiveness, Public opinions
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-54072 (URN)10.1007/s10728-008-0110-z (DOI)000274334600005 ()
    Available from: 2010-02-22 Created: 2010-02-22 Last updated: 2011-10-11
    4. Incentivizing deceased organ donation: A Swedish priority-setting perspective.
    Open this publication in new window or tab >>Incentivizing deceased organ donation: A Swedish priority-setting perspective.
    2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 2, p. 156-163Article in journal (Refereed) Published
    Abstract [en]

    AIMS: The established deceased organ donation models in many countries, relying chiefly on altruism, have failed to motivate a sufficient number of donors. As a consequence organs that could save lives are routinely missed leading to a growing gap between demand and supply. The aim of this paper is twofold; firstly to develop a proposal for compensated deceased organ donation that could potentially address the organ shortage; secondly to examine the compatibility of the proposal with the ethical values of the Swedish healthcare system.

    METHODS: The proposal for compensating deceased donation is grounded in behavioural agency theory and combines extrinsic, intrinsic and signalling incentives in order to increase prosocial behaviour. Furthermore the compatibility of our proposal with the values of the Swedish healthcare system is evaluated in reference to the principles of human dignity, needs and solidarity, and cost effectiveness.

    RESULTS: Extrinsic incentives in the form of a €5,000 compensation towards funeral expenses paid to the estate of the deceased or family is proposed. Intrinsic and signalling incentives are incorporated by allowing all or part of the compensation to be diverted as a donation to a reputable charity. The decision for organ donation must not be against the explicit will of the donor.

    CONCLUSIONS: We find that our proposal for compensated deceased donation is compatible with the values of the Swedish healthcare system, and therefore merits serious consideration. It is however important to acknowledge issues relating to coercion, commodification and loss of public trust and the ethical challenges that they might pose.

    Place, publisher, year, edition, pages
    SAGE, 2011
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-65395 (URN)10.1177/1403494810391522 (DOI)000288065000006 ()21239479 (PubMedID)
    Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2017-12-11Bibliographically approved
  • 332.
    Omar, Faisal
    et al.
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Wright, Linda
    Joint Center for Bioethics, Deptartment of Surgery, Faculty of Medicine, University of Toronto, Canada.
    Priority Setting in the Assessment for Kidney Transplant Candidacy: a Canadian Case StudyManuscript (preprint) (Other academic)
    Abstract [en]

    The benefits of kidney transplantation for treating kidney failure are well documented in terms of life expectancy, quality of life, and cost savings, making it the treatment of choice. It is however limited by the chronic shortage of kidneys. This study’s objective is to examine the fairness of the priority setting process underpinning the assessment for kidney transplant candidacy in one of Canada’s largest transplant programs at the Toronto General Hospital (TGH). This is done in reference to the Accountability for Reasonableness; a leading international framework in health care priority setting.

    The study relies on three sources for data collection: semi structured interviews, process observation, and review of relevant documents.

    The process underpinning the assessment for kidney transplantation is based on clusters of medical criteria reflecting the Canadian national consensus guidelines on eligibility for kidney transplantation. The process is permeated by ethical principles such as: maximizing benefit, equal treatment, and respect for autonomy; which are widely considered relevant in the distribution of scarce medical resources and in medical ethics generally. The criteria for assessment are well publicized and easily accessible while appeals through second opinions are well developed and supported. The process underpinning access to kidney transplantation at the TGH readily satisfies the conditions for fairness in references to the Accountability for Reasonableness framework.

  • 333.
    Palacio-Vieira, J.
    et al.
    Govt Catalonia, Spain.
    Segura, L.
    Govt Catalonia, Spain.
    Anderson, P.
    Newcastle Univ, England; Maastricht Univ, Netherlands.
    Wolstenholme, A.
    Kings Coll London, England.
    Drummond, C.
    Kings Coll London, England; South London and Maudsley NHS Fdn Trust, England.
    Bendtsen, Preben
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Wojnar, M.
    Med Univ Warsaw, Poland.
    Kaner, E.
    Newcastle Univ, England.
    Keurhorst, M. N.
    Radboud Univ Nijmegen, Netherlands.
    van Steenkiste, B.
    Maastricht Univ, Netherlands.
    Kloda, K.
    Pomeranian Med Univ, Poland.
    Mierzecki, A.
    Pomeranian Med Univ, Poland.
    Parkinson, K.
    Newcastle Univ, England.
    Newbury-Birch, D.
    Teesside Univ, England.
    Okulicz-Kozaryn, K.
    State Agcy Prevent Alcohol Related Problems, Poland.
    Deluca, P.
    Kings Coll London, England.
    Colom, J.
    Govt Catalonia, Spain.
    Gual, A.
    Hosp Clin Barcelona, Spain; IDIBAPS, Spain; Inst Carlos III, Spain.
    Improving screening and brief intervention activities in primary health care: Secondary analysis of professional accuracy based on the AUDIT-C2018In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 24, no 2, p. 369-374Article in journal (Refereed)
    Abstract [en]

    Introduction and objectiveThe ODHIN trial found that training and support and financial reimbursement increased the proportion of patients that were screened and given advice for their heavy drinking in primary health care. However, the impact of these strategies on professional accuracy in delivering screening and brief advice is underresearched and is the focus of this paper. MethodFrom 120 primary health care units (24 in each jurisdiction: Catalonia, England, the Netherlands, Poland, and Sweden), 746 providers participated in the baseline and the 12-week implementation periods. Accuracy was measured in 2 ways: correctness in completing and scoring the screening instrument, AUDIT-C; the proportion of screen-negative patients given advice, and the proportion of screen-positive patients not given advice. Odds ratios of accuracy were calculated for type of profession and for intervention group: training and support, financial reimbursement, and internet-based counselling. ResultsThirty-two of 36711 questionnaires were incorrectly completed, and 65 of 29641 screen-negative patients were falsely classified. At baseline, 27% of screen-negative patients were given advice, and 22.5% screen-positive patients were not given advice. These proportions halved during the 12-week implementation period, unaffected by training. Financial reimbursement reduced the proportion of screen-positive patients not given advice (OR=0.56; 95% CI, 0.31-0.99; Pamp;lt;.05). ConclusionAlthough the use of AUDIT-C as a screening tool was accurate, a considerable proportion of risky drinkers did not receive advice, which was reduced with financial incentives.

  • 334.
    Paneque, Milena
    et al.
    University of Porto, Portugal.
    Serra-Juhe, Clara
    University of Pompeu Fabra, Spain; Institute Salud Carlos III, Spain.
    Pestoff, Rebecka
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences.
    Cordier, Christophe
    Synlab Genet, Switzerland.
    Silva, Joao
    University of Porto, Portugal.
    Moldovan, Ramona
    Babes Bolyai University, Romania.
    Ingvoldstad, Charlotta
    Uppsala University, Sweden; Karolinska Institute, Sweden; Uppsala University, Sweden.
    Complementarity between medical geneticists and genetic counsellors: its added value in genetic services in Europe2017In: European Journal of Human Genetics, ISSN 1018-4813, E-ISSN 1476-5438, Vol. 25, no 8, p. 918-923Article in journal (Refereed)
    Abstract [en]

    Clinical genetic services have progressed significantly the last few decades. This has led to the need for non-medical health-care professionals working as genetic counsellors in Europe and worldwide. However, there is no unified approach to genetic counsellors role in health-care services in Europe, as in most countries the profession is still emerging and the educational backgrounds diverge noticeably, within and between countries. This qualitative study aims to describe the potential added value of genetic counsellors in clinical genetics teams and to explore their tasks and responsibilities in different European countries. A total of 143 participants providing genetic counselling in Europe at the time of the survey responded. The results show differences in activities of genetic counsellors, although there is a wide range of roles, which are similar. The ability to establish a quality relationship with consultands was frequently mentioned as one of the strengths of genetic counsellors, as well as a patient-centred approach. It is believed that genetic counsellors add a more holistic approach of psychosocial and familial dimensions of genetic concerns to the multidisciplinary teams. This study provides examples of successful integration of genetic counsellors in teams, as complementariness with medical geneticist became clear in several cases. Although the added value of genetic counsellors was manifested, professional recognition of genetic counsellors across Europe is still needed in order to support the quality of patients care and safety of practice.

  • 335.
    Peolsson, Anneli
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Peterson, Gunnel
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Uppsala Univ, Sweden.
    Hermansen, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Activity and Health.
    Landén Ludvigsson, Maria
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Rehabilitation in Motala.
    Dedering, Asa
    Univ Hosp, Sweden; Karolinska Inst, Sweden.
    Lofgren, Hakan
    Ryhov Hosp, Sweden.
    Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 2, article id e027387Article in journal (Refereed)
    Abstract [en]

    Introduction Patients suffering from remaining disability after anterior cervical decompression and fusion (ACDF) surgery for cervical disc disease may be prescribed physical activity (PPA) or neck-specific exercises (NSEs). Currently, we lack data for the success of either approach. There is also a knowledge gap concerning the use of internet-based care for cervical disc disease. The scarcity of these data, and the high proportion of patients with various degrees of incapacity following ACDF, warrant increased efforts to investigate and improve cost-effective rehabilitation. The objective is to compare the effectiveness of a structured, internet-based NSE programme, versus PPA following ACDF surgery. Methods and analysis This is a prospective, randomised, multicentre study that includes 140 patients with remaining disability (amp;gt;= 30% on the Neck Disability Index, NDI) following ACDF for radiculopathy due to cervical disc disease. Patient recruitment occurs following attendance at routine clinical appointments, scheduled at 3 months postsurgery. Patients are then randomised to one of two groups (70 patients/group) for a 3-month treatment programme/period of either internet-based NSE or PPA. Questionnaires on background data, pain and discomfort, physical and mental capacity, satisfaction with care, and health and workplace factors are completed, along with physical measures of neck-related function conducted by independent test leaders blinded to randomisation. Measures are collected at inclusion, after the 3-month treatments (end of treatment) and at a 2-year follow-up. Radiography will be completed at the 2-year follow-up. Preoperative data will be collected from the Swedish Spine Registry. Data on healthcare consumption, drug use and sick leave will be requested from the relevant national registers. Ethical considerations This study was approved by the Regional Ethical Review Board in Linkoping Ref. 2016/283-31 and 2017/91-32. The scientists are independent with no commercial ties. Patients are recruited after providing written informed consent. Patient data are presented at group level such that no connection to any individual can be made. All data are anonymised when reported, and subject to the Swedish Official Secrets Health Acts. The test leaders are independent and blinded for randomisation. Exercises, both general and neck-specific, have been used extensively in clinical practice and we anticipate no harm from their implementation other than a risk of muscle soreness. Both randomisation groups will receive care that is expected to relieve pain, although the group receiving NSE is expected to demonstrate a greater and more cost-effective improvement versu s the PPA group. Any significant harm or unintended effects in each group will be collected by the test leaders. All questionnaires and test materials are coded by the research group, with code lists stored in locked, fireproof file cabinets, housed at the university in a room with controlled (card-based) access. Only individuals in receipt of a unique website address posted by the researchers can access the programme; patients can neither communicate with each other nor with caregivers via the programme. Study participation might lead to improved rehabilitation versus non-participation, and might therefore be of benefit. The results of this study should also contribute to more effective and flexible rehabilitation, shorter waiting times, lower costs and the possibility to implement our findings on a wider level. Dissemination If effective, the protocols used in this study can be implemented in existing healthcare structures. The results of the study will be presented in scientific journals and popular science magazines of relevance to health. The findings will also be presented at local, regional, national and international conferences and meetings, as well as in the education of university students and at public lectures. Information about the results will be communicated to the general population in cooperation with patient organisations and the media.

  • 336.
    Persson, Emil
    et al.
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Back, Lovisa
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Johannisson, Emma
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Discrepancy between Health Care Rationing at the Bedside and Policy Level2018In: Medical decision making, ISSN 0272-989X, E-ISSN 1552-681X, Vol. 38, no 7, p. 881-887Article in journal (Refereed)
    Abstract [en]

    Background. Whether doctors at the bedside level should be engaged in health care rationing is a controversial topic that has spurred much debate. From an empirical point of view, a key issue is whether there exists a behavioral difference between rationing at the bedside and policy level. Psychological theory suggests that we should indeed expect such a difference, but existing empirical evidence is inconclusive. Objective. To explore whether rationing decisions taken at the bedside level are different from rationing decisions taken at the policy level. Method. Behavioral experiment where participants (n = 573) made rationing decisions in hypothetical scenarios. Participants (medical and nonmedical students) were randomly assigned to either a bedside or a policy condition. Each scenario involved 1 decision, concerning either a life-saving medical treatment or a quality-of-life improving treatment. All scenarios were identical across the bedside and policy condition except for the level of decision making. Results. We found a discrepancy between health care rationing at policy and bedside level for scenarios involving life-saving decisions, where subjects rationed treatments to a greater extent at the policy level compared to bedside level (35.6% v. 29.3%, P = 0.001). Medical students were more likely to ration care compared to nonmedical students. Follow-up questions showed that bedside rationing was more emotionally burdensome than rationing at the policy level, indicating that psychological factors likely play a key role in explaining the observed behavioral differences. We found no difference in rationing between bedside and policy level for quality-of-life improving treatments (54.6% v. 55.7%, P = 0.507). Conclusions. Our results indicate a robust bedside effect in the life-saving domain of health care rationing decisions, thereby adding new insights to the understanding of the malleability of preferences related to resource allocation.

  • 337.
    Persson, Emil
    et al.
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Barrafrem, Kinga
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Meunier, Andreas
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    The effect of decision fatigue on surgeons clinical decision making2019In: Health Economics, ISSN 1057-9230, E-ISSN 1099-1050Article in journal (Refereed)
    Abstract [en]

    The depleting effect of repeated decision making is often referred to as decision fatigue. Understanding how decision fatigue affects medical decision making is important for achieving both efficiency and fairness in health care. In this study, we investigate the potential role of decision fatigue in orthopedic surgeons decisions to operate, exploiting a natural experiment whereby patient allocation to time slots is plausibly randomized at the level of the patient. Our results show that patients who met a surgeon toward the end of his or her work shift were 33 percentage points less likely to be scheduled for an operation compared with those who were seen first. In a logistic regression with doctor-fixed effects and standard errors clustered at the level of the doctor, the odds of operation were estimated to decrease by 10.5% (odds ratio=0.895, pamp;lt;.001; 95% CI [0.842, 0.951]) for each additional patient appointment in the doctors work shift. This pattern in surgeons decision making is consistent with decision fatigue. Because long shifts are common in medicine, the effect of decision fatigue could be substantial and may have important implications for patient outcomes.

  • 338.
    Persson, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Abstract book: 12th biannual International Conference of the International Society on Priorities in Health, 13–15 September 2018, Linköping, Sweden2018Conference proceedings (editor) (Other academic)
    Abstract [en]

    Welcome

    From the President of ISPH

    Dear delegate,

    I am delighted to welcome over 160 participants to our 12th biennial international conference in Linköping University, Sweden. The theme of the conference is “Priorities in health: Ideas in practice’.

    This theme follows up nicely on the discussions at the previous conference in Birmingham. That conference conveyed a clear message, as highlighted in an editorial in the Int J Health Policy and Management authored by recent presidents of the Society. “Countries around the world are experiencing an ever-increasing need to make choices in investments in health and healthcare. This makes it incumbent upon them to have formal processes in place to optimize the legitimacy of eventual decisions. There is now growing experience among countries on the implementation of stakeholder participation, and a developing convergence of methods to support decision-makers within health authorities.” The authors called for further interaction among health authorities and the research community, to develop best practices.

    The present conference aims to do exactly that – bringing ideas in practice. And ideally not only in terms of the further development of methods, but also in the organisation, development of institutional processes and support for priority setting.

    I am looking forward to your contribution to these vexing questions and wish you a fruitful conference.

    Prof. Rob Baltussen

    President International Society

    for Priorities in Health 2016-2018

  • 339.
    Persson, Josefine
    et al.
    University of Gothenburg, Sweden.
    Aronsson, Mattias
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Holmegaard, Lukas
    University of Gothenburg, Sweden.
    Redfors, Petra
    University of Gothenburg, Sweden.
    Stenlof, Kaj
    University of Gothenburg, Sweden.
    Jood, Katarina
    University of Gothenburg, Sweden.
    Jern, Christina
    University of Gothenburg, Sweden.
    Blomstrand, Christian
    University of Gothenburg, Sweden.
    Forsberg-Warleby, Gunilla
    University of Gothenburg, Sweden.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. University of Gothenburg, Sweden.
    Long-term QALY-weights among spouses of dependent and independent midlife stroke survivors2017In: Quality of Life Research, ISSN 0962-9343, E-ISSN 1573-2649, Vol. 26, no 11, p. 3059-3068Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to investigate whether the dependency of midlife stroke survivors had any long-term impact on their spouses QALY-weights. Data on stroke survivors, controls, and spouses were collected from the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke. Health-related quality of life was assessed by the SF-36, and the preference-based health state values were assessed with the SF-6D. Spouses of dependent and independent stroke survivors were categorized according to their scores on the modified Rankin Scale. An ordinary least squares regression analysis was used to evaluate whether the dependency of the stroke survivors had any impact on the spouses QALY-weights. Cohabitant dyads of 247 stroke survivors aged amp;lt; 70 at stroke onset and 245 dyads of controls were included in the study. Spouses of dependent stroke survivors (n = 50) reported a significant lower mean QALY-weight of 0.69 in comparison to spouses of independent stroke survivors (n = 197) and spouses of controls, (n = 245) who both reported a mean QALY-weight of 0.77. The results from the regression analysis showed that higher age of the spouse and dependency of the stroke survivor had a negative association with the spouses QALY-weights. The QALY-weights for spouses of dependent midlife stroke survivors were significantly reduced compared to spouses of independent midlife stroke survivors. This indicates that the inclusion of spouses QALYs in evaluations of early treatment and rehabilitation efforts to reduce stroke patients dependency would capture more of the total effect in dyads of stroke survivors.

  • 340.
    Persson, Josefine
    et al.
    University of Gothenburg, Sweden.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. University of Gothenburg, Sweden.
    Holmegaard, Lukas
    University of Gothenburg, Sweden.
    Redfors, Petra
    University of Gothenburg, Sweden.
    Jood, Katarina
    University of Gothenburg, Sweden.
    Jern, Christina
    University of Gothenburg, Sweden.
    Blomstrand, Christian
    University of Gothenburg, Sweden.
    Forsberg-Warleby, Gunilla
    University of Gothenburg, Sweden.
    Stroke survivors long-term QALY-weights in relation to their spouses QALY-weights and informal support: a cross-sectional study2017In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 15, article id 150Article in journal (Refereed)
    Abstract [en]

    Background: Healthcare interventions that have positive effects on the stroke survivors health-related quality of life (HRQoL) and quality-adjusted life-years (QALYs) might also have positive effects for their spouses in terms of improved HRQoL and/or reduced spousal informal support. However, knowledge about stroke survivors HRQoL and QALY and the consequences for their spouses HRQoL and QALY is limited. Therefore, the aim of this study was to describe the HRQoL and QALY-weights in dyads of stroke survivors in comparison with dyads of healthy controls, and to study the relationship between the stroke survivors QALY-weights and consequences for spouses in terms of QALY-weight and annual cost of informal support, using a long-term perspective. Methods: Data on stroke survivors, controls, and spouses were collected from the seven-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). HRQoL was assessed by the SF-36, and the preference-based health state values were assessed with the SF-6D. The magnitude of the support was assessed with a study specific time-diary. An ordinary least squares (OLS) regression was used to estimate the association between stroke survivors and spouses QALY-weights. A two-part econometric model was used to estimate the association between stroke survivors QALY-weights and the time spent and cost of spouses informal support. Results: Cohabitant dyads of 248 stroke survivors aged amp;lt;70 at stroke onset and 245 controls were included in the study. Stroke survivors had lower HRQoL in the SF-36 domains physical functioning, physical role, general health, vitality (P amp;lt; 0. 001), and social functioning (P = 0.005) in comparison with their cohabitant spouses. There was no significant difference in HRQoL for the dyads of controls. The results from the regression analyses showed that lower QALY-weights of the stroke survivors were associated with lower QALY-weights of their spouses and increased annual cost of spousal informal support. Conclusion: Our results show that the QALY-weights for stroke survivors had consequences for their spouses in terms of annual cost of spousal informal support and QALY-weights. Hence, economic evaluation of interventions that improve the HRQoL of the stroke survivors but ignore the consequences for their spouses may underestimate the value of the intervention.

  • 341.
    Pestoff, Rebecka
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pathology and Clinical Genetics.
    Ingvoldstad, Charlotta
    CLINTECH, Obstretrics and Gynaecology, Karolinska Institute, Solna, Sweden.
    Skirton, Heather
    Department of Applied Health Genetics, Plymouth University, Plymouth, UK.
    Genetic counsellors in Sweden: their role and added value in the clinical setting.2016In: European Journal of Human Genetics, ISSN 1018-4813, E-ISSN 1476-5438, Vol. 24, no 3, p. 350-355Article in journal (Refereed)
    Abstract [en]

    Genetic testing is becoming more commonplace in general and specialist health care and should always be accompanied by genetic counselling, according to Swedish law. Genetic counsellors are members of the multi-disciplinary team providing genetic counselling. This study examined the role and added value of genetic counsellors in Sweden, using a cross-sectional on-line survey. The findings showed that the genetic counsellors added value in the clinical setting by acting as the 'spider-in-the-web' regarding case management, having a more holistic, ethical and psychological perspective, being able to offer continuous support and build a relationship with the patient, and being more accessible than medical geneticists. The main difference between a genetic counsellor and medical geneticist was that the doctor had the main medical responsibility. Thus genetic counsellors in Sweden contribute substantially to the care of patients in the clinical genetic setting.

  • 342.
    Piltén, Carina
    et al.
    Intensive Care Unit, Capio S:t Gorans Hospital, Stockholm.
    Eldh, Ann Catrine
    Intensive Care Unit, Capio S:t Gorans Hospital, Stockholm.
    Lung recruitment--a nurse and/or physician task. A national survey on requirements for education, regulations and guidelines.2009In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 25, no 1, p. 4-9Article in journal (Refereed)
    Abstract [en]

    International and national guidelines on requirements for performing lung recruitment manoeuvres are lacking. This paper presents a nationwide descriptive survey of the occurrence of and conditions for lung recruitment in adult patients treated with mechanical ventilation in intensive care units (ICUs) in Sweden. All ICUs except neurological, cardiac, paediatric and neonatal ICUs were invited (N=73); of these, 60 ICUs participated in the study (82%). The main outcome measures were prevalence of lung recruitment, whether ICU nurses and/or physicians carried out lung recruitment, requirements for nurses to perform lung recruitment and the existence of local guidelines. Lung recruitment was performed at 92% of the ICUs. Only physicians performed lung recruitment at 27 ICUs (49%), and in 28 units (51%) both physicians and nurses performed this treatment. Lung recruitment was performed more often in units where both physicians and nurses performed lung recruitment than in units where only physicians performed the manoeuvres (46% vs. 12%, p=0.03). Further, local guidelines on lung recruitment manoeuvres were more common in units where both physicians and nurses performed this treatment (71% vs. 41%, p=0.02). The results suggest that recommendations of repeated and prompt lung recruitment manoeuvres are better met if nurses, along with physicians, perform lung recruitment.

  • 343.
    Piotrowicz, Ewa
    et al.
    Institute Cardiol, Poland.
    Piepoli, Massimo F.
    Guglielmo da Saliceto Hospital, Italy.
    Jaarsma, Tiny
    Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Lambrinou, Ekaterini
    Cyprus University of Technology, Cyprus.
    Coats, Andrew J. S.
    Monash University, Australia; University of Warwick, England.
    Schmid, Jean-Paul
    University Hospital Bern, Switzerland.
    Corra, Ugo
    IRCCS Fdn S Maugeri, Italy.
    Agostoni, Piergiuseppe
    IRCCS, Italy.
    Dickstein, Kenneth
    University of Bergen, Norway.
    Seferovic, Petar M.
    University of Belgrade, Serbia.
    Adamopoulos, Stamatis
    Onassis Cardiac Surg Centre, Greece.
    Ponikowski, Piotr P.
    Wroclaw Medical University, Poland.
    Telerehabilitation in heart failure patients: The evidence and the pitfalls2016In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 220, p. 408-413Article, review/survey (Refereed)
    Abstract [en]

    Accessibility to the available traditional forms of cardiac rehabilitation programs in heart failure patients is not adequate and adherence to the programs remains unsatisfactory. The home-based telerehabilitation model has been proposed as a promising new option to improve this situation. This papers aims are to discuss the tools available for telemonitoring, and describing their characteristics, applicability, and effectiveness in providing optimal long termmanagement for heart failure patients who are unable to attend traditional cardiac rehabilitation programs. The critical issues of psychological support and adherence to the telerehabilitation programs are outlined. The advantages and limitations of this long term management modality are presented and compared with alternatives. Finally, the importance of further research, multicenter studies of telerehabilitation for heart failure patients and the technological development needs are outlined, in particular interactive remotely controlled intelligent telemedicine systems with increased inter-device compatibility. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

  • 344.
    Pirhonen, Laura
    et al.
    Centrum för hälsoekonomi, Göteborgs universitet, Sverige.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. SBU – Swedish Council on Health Technology Assessment, Stockholm, Sweden.
    Experiences of including costs of added life years in health economic evaluations in Sweden2014In: Farmeconomia. Health Economics and Therapeutic Pathways, ISSN 1721-6915, Vol. 15, no 2, p. 45-53Article in journal (Refereed)
    Abstract [en]

    It is of importance to include the appropriate costs and outcomes when evaluating a health intervention. Sweden is the only country where the national guidelines of decisions on reimbursement explicitly state that costs of added life years should be accounted for when presenting health economic evaluations. The aim of this article is to, from a theoretical and empirical point of view, critically analyze the Swedish recommendations used by the Dental and Pharmaceutical Benefits Agency (TLV), when it comes to the use of costs of added life years in economic evaluations of health care. The aim is furthermore to analyze the numbers used in Sweden and discuss their impact on the incremental cost‑effectiveness ratios of assessed technologies. If following a societal perspective, based on welfare economics, there is strong support for the inclusion of costs of added life years in health economic evaluations. These costs have a large impact on the results. However this fact may be in conflict with ethical concerns of allocation of health care resources, such as favoring the younger part of the population over the older. It is important that the estimates of production and consumption reflect the true societal values, which is not the case with the values used in Sweden.

  • 345.
    Poksinska, Bozena Bonnie
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering.
    Lean Healthcare: What Is the Contribution to Quality of Care?2015In: Management Innovations for Healthcare Organizations: Adopt, Abandon or Adapt? / [ed] Anders Örtenblad; Carina Abrahamson Löfström; Rod Sheaff, New York: Routledge, 2015, p. 119-133Chapter in book (Refereed)
  • 346.
    Poksinska, Bozena Bonnie
    et al.
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering.
    Fialkowska-Filipek, Malgorzata
    Wroclaw University of Technology, Wroclaw, Poland.
    Engström, Jon
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering.
    Does Lean healthcare improve patient satisfaction?: A mixed-method investigation into primary care2017In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 26, no 2, p. 95-103Article in journal (Refereed)
    Abstract [en]

    Background Lean healthcare is claimed to contribute to improved patient satisfaction, but there is limited evidence to support this notion. This study investigates how primary-care centres working with Lean define and improve value from the patient's perspective, and how the application of Lean healthcare influences patient satisfaction.

    Methods This paper contains two qualitative case studies and a quantitative study based on results from the Swedish National Patient Survey. Through the case studies, we investigated how primary-care organisations realised the principle of defining and improving value from the patient's perspective. In the quantitative study, we compared results from the patient satisfaction survey for 23 primary-care centres working with Lean with a control group of 23 care centres not working with Lean. We also analysed changes in patient satisfaction over time.

    Results Our case studies reveal that Lean healthcare implementations primarily target efficiency and little attention is paid to the patient's perspective. The quantitative study shows no significantly better results in patient satisfaction for primary-care centres working with Lean healthcare compared with those not working with Lean. Further, care centres working with Lean show no significant improvements in patient satisfaction over time.

    Conclusions Lean healthcare implementations seem to have a limited impact on improving patient satisfaction. Care providers need to pay more attention to integrating the patient's perspective in the application of Lean healthcare. Value needs to be defined and value streams need to be improved based on both the knowledge and clinical expertise of care providers, and the preferences and needs of patients.

  • 347.
    Poksinska, Bozena
    et al.
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering.
    Cronemyr, Peter
    Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering.
    Measuring quality in elderly care: possibilities and limitations of the vignette method2017In: Total quality management and business excellence (Online), ISSN 1478-3363, E-ISSN 1478-3371, Vol. 28, no 9-10, p. 1194-1207Article in journal (Refereed)
    Abstract [en]

    Listening to citizens is seen as an important source of information about public service performance. In Sweden, to secure the quality of elderly care, the National Board of Health and Welfare conducts a yearly survey of in-home elderly care services and nursing homes. A central problem of the existing survey methodology is the interpersonal incomparability of survey responses due to differences in preferences and health conditions. One way to deal with this problem is to use the survey methodology with anchoring vignettes. The purpose of the paper is to investigate the possibilities and limitations of using anchoring vignettes as a general survey method and specifically to test the method for measuring elderly care quality. The vignettes were developed interactively with professionals working in elderly care and evaluated with 1600 users of in-home elderly care services and nursing homes. The results showed that anchoring vignettes reduce the impact of respondents personal characteristics on survey results. In general, anchoring vignettes give more robust answers that reduce the problem of incomparability. However, anchoring vignettes increase the complexity of the questionnaire and have limited value in elderly care. Our results indicate that the method might be applicable when using healthier and younger respondents.

  • 348.
    Rahmqvist, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Hur fungerar punktprevalensmetoden som mätinstrument i sluten sjukhusvård?: Kostnader och prevalenser för vårdrelateradei nfektioner i somatisk slutenvård i Östergötland 20122016Report (Other academic)
    Abstract [en]

    In hospital care a constant alert is payed to Healthcare-associated infections (HAI). Patients who suffers from a HAI requires additional care in terms of, medication, longer hospital stays and these patients also have a higher mortality risk than average. This methodological study attempts to provide information on how much of health care resources is devoted to patients affected by a HAI. By merging two registers, the Healthcare register for Region Östergötland (HCR) and local data from a set of Prevalence point surveys (PPS), it was possible to add length of stay (LOS) and health care costs and one year overall mortality to the PPS data collected in the county of Östergötland 2012.

    In the merge of the two registers it was found that the patient composition in the PPS was not representative for the total patient mix in the region and that all similar point prevalence measurements more or less automatically gives an overrepresentation of patients with long hospital stays. With this over-representation of patients with LOS above average, follows an overestimation of the prevalence of HAI. An analysis of the material revealed that at least 15% of patients in the PPS were included just because of their long LOS.

    However, the PPS gives another unbiased answer that can be used for cost-calculations, this since it tells us the number of occupied beds are used by patients with a registered HAI. The average prevalence of HAI was 10 % in 2012 and thereby follows that 10 % of the beds lodge a patient with a documented HAI, the particular day of survey. Roughly this means that 10 % of the costs for caring patients in somatic inpatient care is related to patients with a HAI. That does not equal that 10 % of the costs are related to HAI but that 10 % of the costs are related to patients with a HAI.

    Several studies (including this) have found that patients with an HAI, on average has a twice as long LOS compared to patients without any registered HAI. Such a proportion makes 5 % of the total costs attributable to the HAI itself. After adjustments for the true expenditures of hospital bed days at different departments it was considered that 5.3 % of the health care costs was attributable to the additional treatment of the HAI. If a reduction of the prevalence of HAI could be 40 %, and only affect 6 % of the bed days per year, there would be a total cost reduction of 2.1 % per year in somatic inpatient care in the county of Östergötland.

    However, a validation survey of one PPS showed that the prevalence figures of HAI was significant underestimated and if the proportion of patients that suffers from a HAI are larger, the portion of the total costs increases, but the gain in any reduction can in turn be even more favorable.

  • 349.
    Rahmqvist, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Infektioner i slutenvård: Omfattning och kostnader i Östergötland – en pilotstudie2013Report (Other academic)
    Abstract [en]

    Healthcare-associated infections (HAI) is an increasingly recognized problem in health care. Approximately 10 percent of all hospitalized patients in Sweden is expected to be hit by a HAI but there is considerable variation between the medical specialties. This study is exploratory and aims primarily to present a model to estimate the additional costs for medical care related to HAI. The material consists of the Point Prevalence Survey (PPM) which was conducted in Östergötland in 2011 and also the information from the County Council's Health Care register that was current for the patients who were hospitalized on days when PPM was conducted.

    There was a strong correlation between the recorded risk factors and the occurrence of an HAI. The two most prevalent risk factors were "Surgery" and "KAD" (indwelling urinary catheter) . The number of hospital days were twice as many compared to those not affected (25 days vs. 13 days) for those affected by a HAI on a number of included units. The cost per patient in that case was more than twice as high for the affected patients compared with those who were not affected ( SEK 331,000 compared with SEK 145,000). No age differences were noted between the groups.

    The patients who suffered a HAI on the included units of the University Hospital was one quarter of patients (24%) but these patients accounted for 40 percent of the total health care costs. The corresponding proportions for the entire county was that 16 percent of the patients had a certain infection and these patients accounted for 30 percent of the total costs. If the number of patients who suffer from a HAI could be reduced by one-third, or up to half of all recent cases, it would be theoretically possible to reduce total overall healthcare costs for inpatient care with between 4-12 percent.

    The pilot study resulted in limited opportunities to analyze the material in detail and therefore have a study with several years of data from the PPM together with records from Health Care register started.

  • 350.
    Rahmqvist, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Läkarbesök och läkemedelskonsumtion bland barn med astma, diabetes och andra kroniska sjukdomar: Ett metodexempel på hur journaldata kan omvandlas till epidemiologi och sjukvårdskostnader2017Report (Other academic)
    Abstract [en]

    There are few studies about the Swedish health care costs for children with asthma or diabetes, and there are few publications that describes how to transform data from medical records into epidemiology. This report can help to bring some clarity in both these areas.

    Young patients with asthma and diabetes type 1 contribute to the example about health care costs. These two diseases are quite different in character, and this difference mirror how well medical records can be suitable for epidemiology. In principle, all children in the group with diabetes in the county of Östergötland could be found in the medical records of visits to a physician during a year, while for the children with asthma less than 50% was found, even when the records covered 7 years.

    Children with chronic diseases, according to the definition used here, that could be found in these medical records constituted 5% of the population 2-17 years in 2012. However, their costs for doctor visits at hospitals together with the actual costs for drugs represented 22% of the health care costs. When the costs of inpatient hospital services were added, the proportion remain, and those affected children accounted for 23% of the total annual health care costs.

    The average annual cost of care for those with blood diseases or diabetes was about 12 times higher compared to those who had no chronic problems registered. Patient groups with other types of chronic problems had a lower cost, and overall, the average cost of care for children with chronic problems was about 6 times higher than the residents without these problems.

    In health economics several different costs is usually calculated, such as; patient visits, costs for inpatient care and pharmaceuticals, as well as costs for loss of productivity and eventually also costs for premature death. Putting together all these different types of costs down to the individual level often requires fairly advanced data management. In this report it is described how raw data is transposed from single medical records into individual journal data, and then merged together to build the individual's own cohesive "record" and history.

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