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  • 51.
    Broqvist, Mari
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    It takes a giraffe to see the big picture - Citizens' view on decision makers in health care rationing2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 128, p. 301-308Article in journal (Refereed)
    Abstract [en]

    Previous studies show that citizens usually prefer physicians as decision makers for rationing in health care, while politicians are downgraded. The findings are far from clear-cut due to methodological differences, and as the results are context sensitive they cannot easily be transferred between countries. Drawing on methodological experiences from previous research, this paper aims to identify and describe different ways Swedish citizens understand and experience decision makers for rationing in health care, exclusively on the programme level. We intend to address several challenges that arise when studying citizens' views on rationing by (a) using a method that allows for reflection, (b) using the respondents' nomination of decision makers, and (c) clearly identifying the rationing level. We used phenomenography, a qualitative method for studying variations and changes in perceiving phenomena. Open-ended interviews were conducted with 14 Swedish citizens selected by standard criteria (e.g. age) and by their attitude towards rationing. The main finding was that respondents viewed politicians as more legitimate decision makers in contrast to the results in most other studies. Interestingly, physicians, politicians, and citizens were all associated with some kind of risk related to self-interest in relation to rationing. A collaborative solution for decision making was preferred where the views of different actors were considered important. The fact that politicians were seen as appropriate decision makers could be explained by several factors: the respondents' new insights about necessary trade-offs at the programme level, awareness of the importance of an overview of different health care needs, awareness about self-interest among different categories of decision-makers, including physicians, and the national context of long-term political accountability for health care in Sweden. This study points to the importance of being aware of contextual and methodological issues in relation to research on how citizens experience arrangements for rationing in health care.

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  • 52.
    Broqvist, Mari
    et al.
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Rättvisan finns i betraktarens öga: röster från medborgare om rättvisa i vården2007Report (Other academic)
    Abstract [sv]

    I så gott som alla relationer i samhället intar rättvisa en central plats. Att befolkningen kan uppfatta hälso- och sjukvårdens fördelningar och prioriteringar som ”rättvisa” framstår som avgörande för den solidariskt finansierade sjukvårdens fortlevnad. Problemområdet är därför av stor betydelse för vårdens huvudmän. Vi behöver dock mer kunskaper om hur allmänheten uppfattar detta. Hur ser rättviseuppfattningen ut hos allmänheten och varierar den från situation till situation?

    Som ett första steg att närma sig dessa frågor har vi genomfört en intervjuundersökning bland den svenska allmänheten. Urvalet har skett enligt strategin maximal variation för att försöka fånga så många olika uppfattningar som möjligt. Det innebär att hänsyn tagits till standardvariabler som yrke, ålder, kön och etnicitet men att vi också har försökt att välja ut intervjupersoner med olika uppfattningar om rättvisa och beslutsfattande i vården. Det har skett genom en enkätundersökning om rättvisa och utifrån resultatet av denna har 14 personer valts ut och intervjuats. De uppfattningar om rättvisa och vård som framkommit i intervjuerna kan sammanfattas på följande sätt;

    • Fenomenet rättvisa förstås som att något delas upp och fördelas mellan några på så sätt att ett resultat som uppfattas som positivt uppstår.
    • Fördelning av vård, som denna undersökning i huvudsak handlar om, uppfattas som ett måste (utifrån resursbrist och oändliga behov). Intervjupersonerna menar också att det är möjligt och önskvärt med en omfördelning av resurser; mellan samhällssektorer, inom vården och från offentlig till egenfinansierad vård.
    • I intervjuerna finns flera olika upplevelser (vilka intervjupersonerna menar kan vara formade av personlighet, personliga erfarenheter och samhällsnormer) av vad som är rättvisa vid fördelning av vård. Rättvisa kan innebära att alla får lika, t ex bemötande eller skyldigheter. Rättvisa kan också vara att lika får lika vård medan olika får olika vård. Det handlar då om att var och en ska få det den behöver eller vad han eller hon förtjänar (t ex den som försöker hålla sig frisk jämfört med den som riskerar sin hälsa). Att flertalet är nöjda kan också ses som en indikation på rättvisa.
    • I intervjuerna beskrivs också reaktioner på en orättvis fördelning av vård. Att stå tillbaka till förmån för andra kan accepteras av solidariska skäl medan egennyttan, att vara sig själv närmast, uppfattas vara en motkraft till acceptans. Även känslor av tvingande resignation och självklar tillit till vården beskrivs liksom avsaknad av reaktion p g a bristande insyn.
    • Resonemangen om rättvisa principer för fördelning av vård handlar om personliga egenskaper, hälsotillstånd, behov, antal drabbade, behandlingsnytta, samhällsnytta, självförvållande och valmöjlighet.
    • Rättvisa beslutsfattare vid fördelning av vård uppfattas vara personer med kompetens, personer som ser till helheten samt personer med rätt sinnelag som har en vilja att göra så rätt som möjligt, är pålitliga, oberoende och modiga.
    • Rättvisa procedurer vid fördelning av vård uppfattas gå till på så sätt att det finns möjlighet att få insyn och förklaringar, att bli lyssnad till, att kunna välja mellan olika alternativ samt att beslut fattas gemensamt av vad som uppfattas som rimliga beslutsfattare.

    Denna studie visar att det finns många olika sätt att se på rättvisa i vården. Vissa uppfattningar är situationsberoende medan andra är mer stabila i så måtto att inga motargument förs fram. Rättvisa i vården upplevs som något mycket viktigt och centralt. Medvetenheten om hur vårdens fördelning ser ut (resultat) och hur fördelningen går till (procedur) är däremot påfallande låg och försvårar de intervjuades möjlighet att bedöma svensk hälso- och sjukvård utifrån ett rättviseperspektiv. Vi har också märkt att uppfattningar ändras under intervjuernas gång på så sätt att de intervjuade uttrycker en ökad förståelse för komplexiteten i det som kan menas med rättvis vård och hur sådan kan uppnås. Bland annat tycks det som om förtroendet för politiker som beslutsfattare ökar efterhand som intervjun pågår. Det tycks med andra ord finnas förutsättningar för att med förhållandevis små insatser uppnå en större medvetenhet om och möjligen också acceptans för en politiskt styrd offentlig vårdsektor. Ett viktigt steg i den riktningen förefaller vara att beskriva vårdens avvägningsproblem för allmänheten mer utförligt än vad som hittills gjorts.

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  • 53.
    Broqvist, Mari
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    To accept, or not to accept, that is the question: citizen reactions to rationing2014In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 17, no 1, p. 82-92Article in journal (Refereed)
    Abstract [en]

    Background  The publicly financed health service in Sweden has come under increasing pressure, forcing policy makers to consider restrictions. Objective  To describe different perceptions of rationing, in particular, what citizens themselves believe influences their acceptance of having to stand aside for others in a public health service. Design  Qualitative interviews, analysed by phenomenography, describing perceptions by different categories. Setting and participants  Purposeful sample of 14 Swedish citizens, based on demographic criteria and attitudes towards allocation in health care. Results  Participants expressed high awareness of limitations in public resources and the necessity of rationing. Acceptance of rationing could increase or decrease, depending on one's (i) awareness that healthcare resources are limited, (ii) endorsement of universal health care, (iii) knowledge and acceptance of the principles guiding rationing and (iv) knowledge about alternatives to public health services. Conclusions  This study suggests that decision makers should be more explicit in describing the dilemma of resource limitations in a publicly funded healthcare system. Openness enables citizens to gain the insight to make informed decisions, i.e. to use public services or to 'opt out' of the public sector solution if they consider rationing decisions unacceptable.

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  • 54.
    Broqvist, Mari
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    The meaning of severity - do citizenś views correspond to a severity framework based on ethical principles for priority setting?2018In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 122, no 6, p. 630-637, article id S0168-8510(18)30081-2Article in journal (Refereed)
    Abstract [en]

    The importance for governments of establishing ethical principles and criteria for priority setting in line with social values, has been emphasised. The risk of such criteria not being operationalised and instead replaced by de-contextualised priority-setting tools, has been noted. The aim of this article was to compare whether citizenś views are in line with how a criterion derived from parliamentary-decided ethical principles have been interpreted into a framework for evaluating severity levels, in resource allocation situations in Sweden. Interviews were conducted with 15 citizens and analysed by directed content analysis. The results showed that the multi-factorial aspects that participants considered as relevant for evaluating severity, were similar to those used by professionals in the Severity Framework, but added some refinements on what to consider when taking these aspects into account. Findings of similarities, such as in our study, could have the potential to strengthen the internal legitimacy among professionals, to use such a priority-setting tool, and enable politicians to communicate the justifiability of how severity is decided. The study also disclosed new aspects regarding severity, of which some are ethically disputed, implying that our results also reveal the need for ongoing ethical discussions in publicly-funded healthcare systems.

  • 55.
    Bucht, Helena
    et al.
    Sunderby sjukhus, Luleå.
    Hall, Birgitta
    Sunderby sjukhus, Luleå.
    Johansson, Ingrid
    Gällivare sjukhus.
    Erlandsson, Sofia
    Samrehab, Oskarshamns sjukhus.
    Tinnert, Agneta
    Habiliterings- och rehabiliteringskliniken (HRK), Länssjukhuset i Kalmar.
    Fränkel, Titti
    Akademikerförbundet SSR.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Kuratorer prioriterar: Tillämpning av den nationella modellen för öppna prioriteringar2013Report (Other academic)
    Abstract [en]

    Since 1997, an ethical platform has been available in Sweden describing the grounds for priority setting in health care. A systematic method, i.e. the National Model for Transparent Prioritisation in Swedish Health Care, is increasingly being used to facilitate implementation of the platform’s principles and intentions. Although many different types of services have tested this model, heretofore no social work services had used the model as grounds for a priority setting process. Hence, the model had been untested in services addressingsocial and psychosocial needs in health care.

    This report aims to inspire and guide mainly medical social workers by describing two concrete examples of how medical social workers have interpreted and applied the national model in their organisations. These examples have been taken from the Kalmar County Council and the Norrbotten County Council, each of which conducted their prioritisation process without being aware of each other. In both instances, the aim was to clarify the roles of medical social workers and ensure optimum utilisation of their expertise. Each process was countywide and included all medical social workers in tertiary care (approximately 20 individuals in each county council) for 1.5 years.

    Initially it was not clear how to describe and categorise the various conditions and interventions to be prioritised (ranked). What became important for the medical social workers ranking was not the illness or injury of the various patient groups, but the psychosocial consequences of illness and injury. In Kalmar County Council they used established classifications, such as the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) and the National Board of Health and Welfare’s Classification of Health Interventions (KVÅ). In Norrbotten County Council they used concepts normally applied in their daily work, which had been accepted by the social work group in an earlier review of social work services. In addition, they classified cases according to the expected duration of the contact.

    To determine the severity level of different conditions, the medical social workers in both county councils used a matrix that had been developed for rehabilitation services in Kalmar County Council, but tested in many different types of services. The matrix describes different aspects regarding severity levels, e.g. impairment of body functions, activity limitations, participation restriction, duration, and risk of not intervening. Moreover, the medical social workers in Kalmar County Council listed complicating factors (e.g. previous trauma) that could further increase the severity levels of different conditions. 

    The patient benefits of social work interventions have been appraised using the same parameters as those used for severity levels – e.g. to what degree does the intervention improve participation? In Kalmar County Council definition of the steps in the patient benefit scale (very high, high, moderate, and low) was worked out and unanimously used.

    Regarding cost effectiveness, medical social workers in both county councils reported that it was not traditional for the individual social worker to consider the cost effectiveness of different interventions in their daily work. During the prioritisation process they discussed the opportunity costs of excluding social work interventions and how the duration and type of social work interventions affect cost effectiveness. Experience in searching for scientific evidence concerning the interventions was also lacking. The medical social workers equipped themselves through various educational activities, but based their assessments mainly on experience-based knowledge and the laws that partially regulate their activities.

    Both services gave high priority to most of the conditions and interventions that medical social workers deal with. One possible reason for this was that low- priority interventions were already being rationed. Another reason could be that unfamiliarity with openly discussing priorities led to caution in differentiating severity levels and patient benefits. However, the priority processes to some degrade crystalised what should receive high and low priority respectively, and what should no longer be included in medical social workers’ tasks.

    In summary, the medical social workers reported that the prioritisation processes had been valuable since they contributed to verbalising and discussing experienced-based knowledge ("tacit knowledge"). They articulated the conditions and interventions they work with daily, which is expected to further improve communication about medical social workers’ tasks, both within health services and with patients and next of kin. Furthermore, the knowledge base for interventions has increased, as has the consensus concerning priorities. Future challenges for members that participated in these two projects include implementing and following up their priorities and patiently continuing to improve the process of priority setting over the long term.

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    Kuratorer prioriterar: Tillämpning av den nationella modellen för öppna prioriteringar
  • 56.
    Burström, Kristina
    et al.
    Karolinska Institute, Stockholm, Sweden; Stockholm County Council, Health Care Services.
    Sun, Sun
    Karolinska Institute, Stockholm, Sweden; Stockholm County Council, Health Care Services.
    Gerdtham, Ulf-G
    Lund University, Sweden.
    Henriksson, Martin
    AstraZeneca Nord, Södertälje, Sweden .
    Johannesson, Magnus
    Stockholm School of Economics, Sweden .
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Zethraeus, Niklas
    Karolinska Institute, Stockholm, Sweden; Dental and Pharmaceutical Benefits Agency, Stockholm, Sweden.
    Swedish experience-based value sets for EQ-5D health states2014In: Quality of Life Research, ISSN 0962-9343, E-ISSN 1573-2649, Vol. 23, no 2, p. 431-442Article in journal (Refereed)
    Abstract [en]

    Purpose

    To estimate Swedish experience-based value sets for EQ-5D health states using general population health survey data.

    Methods

    Approximately 45,000 individuals valued their current health status by means of time trade off (TTO) and visual analogue scale (VAS) methods and answered the EQ-5D questionnaire, making it possible to model the association between the experience-based TTO and VAS values and the EQ-5D dimensions and severity levels. The association between TTO and VAS values and the different severity levels of respondents’ answers on a self-rated health (SRH) question was assessed.

    Results

    Almost all dimensions (except usual activity) and severity levels had less impact on TTO valuations compared with the UK study based on hypothetical values. Anxiety/depression had the greatest impact on both TTO and VAS values. TTO and VAS values were consistently related to SRH. The inclusion of age, sex, education and socioeconomic group affected the main effect coefficients and the explanatory power modestly.

    Conclusions

    A value set for EQ-5D health states based on Swedish valuations has been lacking. Several authors have recently advocated the normative standpoint of using experience-based values. Guidelines of economic evaluation for reimbursement decisions in Sweden recommend the use of experience-based values for QALY calculations. Our results that anxiety/depression had the greatest impact on both TTO and VAS values underline the importance of mental health for individuals’ overall HRQoL. Using population surveys is in line with recent thinking on valuing health states and could reduce some of the focusing effects potentially appearing in hypothetical valuation studies.

  • 57.
    Bäck, Maria
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Important aspects in relation to patients attendance at exercise-based cardiac rehabilitation - facilitators, barriers and physiotherapists role: a qualitative study2017In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 17, article id 77Article in journal (Refereed)
    Abstract [en]

    Background: In order to improve attendance at exercise-based cardiac rehabilitation (CR), a greater insight into patients perspectives is necessary. The aim of the study was to explore aspects that influence patients attendance at exercise-based CR after acute coronary artery disease (CAD) and the role of the physiotherapist in patients attendance at exercise-based CR. Methods: A total of 16 informants, (5 women; median age 64.5, range 47-79 years), diagnosed with CAD, were included in the study at the Cardiology Department, Linkping University Hospital, Sweden. Qualitative interviews were conducted and analysed according to inductive content analysis. Results: Four main categories were identified: (i) previous experience of exercise, (ii) needs in the acute phase, (iii) important prerequisites for attending exercise-based CR and (iv) future ambitions. The categories demonstrate that there are connections between the past, the present and the future, in terms of attitudes to facilitators, barriers and the use of strategies for managing exercise. An overall theme, defined as existential thoughts, had a major impact on the patients attitudes to attending exercise-based CR. The interaction and meetings with the physiotherapists in the acute phase were described as important factors for attending exercise-based CR. Moreover, informants could feel that the physiotherapists supported them in learning the right level of effort during exercise and reducing the fear of exercise. Conclusions: This study adds to previous knowledge of barriers and facilitators for exercise-based CR that patients with CAD get existential thoughts both related to exercise during the rehabilitation process and for future attitudes to exercise. This knowledge might necessitate greater attention to the physiotherapist-patient interaction. To be able to tailor exercise-based CR for patients, physiotherapists need to be aware of patients past experiences of exercise and previous phases of the rehabilitation process as these are important for how patients perceive their need and ability of exercise.

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  • 58.
    Bäckman, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Ett decennium senare: Resursfördelningsprocessen i Landstinget i Östergötland 20122013Report (Other academic)
    Abstract [en]

    For nearly a decade, the Östergötland County Council has been working with prioritization as a basis for allocating resources. However, the process has changed over the years and has become known as the resource allocation process.

    In 2012, the county council’s resource allocation process started with team leaders collecting and ranking proposals from their centres based on what they found to be new needs and interventions requiring additional resources. These proposals were supposed to address interventions estimated to cost at least 2 million Swedish kronor (SEK), and each centre could submit no more than ten proposals. Then, representatives of the various centres were assembled in groups to discuss and arrive at an overall proposal for the county council. Administrators reviewed and processed the proposals, after which politicians on the board of health made decisions on the allocation of new resources. Based on these decisions, the results were incorporated into various agreements and contracts with the county council’s services.

    This is the fifth report on the Ötergöland County Council’s prioritization and resource allocation process. The report describes how the county council addressed resource allocation to meet new needs during 2012. Moreover, the report aims to capture and report on several participants’ experiences and viewpoints regarding the process. The information is based on: observations from county council conferences on resource allocation; interviews with politicians, administrators, and team leaders; and studies of various relevant documents published by the county council regarding the resource allocation process. In summary, the report addresses the following points:

    The motive for county council’s resource allocation process was perceived to be a practical issue, but also focused on creating unity, common understanding, and greater transparency.

    The preconditions affecting the work, i.e. uncertainty about the potential magnitude of supplementary resources and separation of the decisions into temporary one-time funding or fixed increases in framework funding, were seen as both advantages and disadvantages.

    The clarity of the process and its various steps was perceived to be good, but the openness and transparency of the separate components could be greater.

    The directives and instructions guiding the process were perceived as being lucid.

    The changes in the process were viewed to be positive compared to the situation in previous years, e.g. starting the work earlier in the year, adding a kick-off conference day, and including the private-sector providers. However, the separate processing of matters concerning pharmaceuticals during the year was viewed as being negative.

    The roles of the various participants were viewed to be clearly defined; they knew what they were expected to do. Politicians indicated that they should play a more prominent and active role in the process, while the team leaders seemed satisfied with their role.

    The decision-making information for the initial ranking by team leaders was viewed to have improved year after year as the process was repeated. However, variations remained in the quality of the information.

    Internal information and transparency has been a fundamental aim of the process and was viewed to be relatively good.

    External information and transparency, however, has been weak.

    The opportunity for dialogue amongst the various actors was reported to be satisfactory and viewed to function well.

    Continuation of the process was favoured by those interviewed. However, they gave examples of things that should be changed or improved, e.g. increased political transparency and participation, a greater sum to distribute, increased transparency and clarity regarding how the administrative staff process the proposals, and faster processing of certain issues throughout the year.

    The findings of this report will hopefully give readers some insight into the current prioritization and resource allocation process in Östergötland County Council – nearly a decade after the first major county-council-wide prioritization initiative in 2003. The interviewees felt that the county council had achieved its goals, as exemplified by the 2012 resource allocation process.

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    Ett decennium senare: Resursfördelningsprocessen i Landstinget i Östergötland 2012
  • 59.
    Bäckman, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Landstingsövergripande prioriteringar i Region Östergötland: Ett pionjärarbete som fortlever2016In: Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson / [ed] Martin Henriksson, Linköping: Linköping University Electronic Press, 2016, p. 18-23Chapter in book (Other academic)
    Abstract [sv]

    Efter att riksdagen 1997 beslutat om etiska principer och riktlinjer för prioriteringar inom hälso- och sjukvård (1), har flera landsting/regioner arbetat med att utveckla processer för resursfördelning i en riktning mot större systematik och öppenhet.

  • 60.
    Bäckman, Karin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Uppföljning av prioriteringsarbeten: exempel på olika tillvägagångssätt2016Report (Other academic)
    Abstract [sv]

    Denna rapport syftar till att ge inspiration och vara till hjälp för dem somfunderar på hur ett prioriteringsarbete ska kunna följas upp. Vi har samlat exempel på uppföljningar som gjorts med avseende på olika frågeställningar ochtillvägagångssätt. Det är exempel både från landstings-/regionövergripande nivåoch från verksamhetsnivå. I några fall har uppföljningen gjorts internt i den egnaorganisationen medan andra har tagit hjälp av en extern part.

    Eftersom prioriteringsarbeten kan göras med många olika syften kommer därmed även uppföljningen av dem fokusera på olika aspekter och använda sigav olika metoder. De uppföljningar vi har tagit upp i rapporten fokuserar på:

    • följsamhet till prioriteringsbeslut samt dess ekonomiska effekter
    • uppfattningar om prioriteringsprocessen
    • kännedom och uppfattningar om samsyn om prioriteringar
    • patienters/brukares uppfattningar.

    För dessa uppföljningar ger vi exempel på olika angreppssätt för datainsamlingsom använts, såsom:

    • via journalsystem, bokningssystem eller databaser
    • via intervjuer, uppföljningssamtal eller enkäter
    • via interna möten
    • via sammanställning av flera olika källor.

    En avgränsning i rapporten är att vi inte gör någon resultatredovisning eller värdering av det prioriteringsarbete som respektive uppföljning riktar sig mot. Dels fanns det inte resultat ännu för pågående uppföljningar och dels ligger detutanför syftet med denna rapport. Här hänvisar vi istället till den dokumentationsom nämns som referenser eller till att ta kontakt direkt med det aktuellalandstinget/regionen eller verksamheten. Avslutningsvis diskuterar vi kort kring de exempel vi presenterat och om förochnackdelar med olika typer av uppföljningar.

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    Uppföljning av prioriteringsarbeten : Exempel på olika tillvägagångssätt
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  • 61.
    Bäckman, Karin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Prioriteringar över kommunala förvaltningsområden: ett utvecklingsarbete i Motala kommun2017Report (Other academic)
    Abstract [en]

    Motala municipality is the first municipality which has, systematically, taken on priority setting and resource allocation within all its administrative areas, based on the ethical principles and guidelines for priority settings applicable to health care. The work comprises development of a tool for priority setting, adapted to a municipal context, and using it in systematic setting of priorities combined with political goals and visions. The intention is that the setting of priorities will be developed into a sustainable routine, integrated into the existing budget process.

    The purpose of this report is to describe the first stage of the development work with the associated work processes, and to analyse it from an improvement and implementation perspective. The report spans the years 2013-2015.

    The involvement of the National Centre for Priority Setting in Health Care in Motala municipality has meant that we, by so called action research, have studied the development of the priority-setting work, while giving support to the municipality and participating in the development of tools and processes. Data collection was undertaken through observations, documents, surveys and contacts of varying kinds.

    In Motala municipality the priority setting process and its tools were developed in close collaboration with the actors involved, those who would become the users. Priority setting has been integrated into the municipality’s existing management system and routines. The development has taken place gradually in small improvement cycles. In this way, knowledge and learning was built up within the organisation and the work has been characterised by long-term sustainability.

    Motala municipality’s development of tools and processes for priority setting shows that it is possible to be guided by national ethical principles for priority setting within health care, and it is feasible to combine this with political goals and visions. It has also been possible to include all the administrations of the municipality in the setting of priorities, in an open, systematic process linked to regular budgeting.

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  • 62.
    Carlfjord, Siw
    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.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Five years experience of an annual course on implementation science: an evaluation among course participants2017In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 12, article id 101Article in journal (Refereed)
    Abstract [en]

    Background: Increasing interest in implementation science has generated a demand for education and training opportunities for researchers and practitioners in the field. However, few implementation science courses have been described or evaluated in the scientific literature. The aim of the present study was to provide a short-and long-term evaluation of the implementation training at Linkoping University, Sweden. Methods: Two data collections were carried out. In connection with the final seminar, a course evaluation form, including six items on satisfaction and suggestions for improvement, was distributed to the course participants, a total of 101 students from 2011 to 2015 (data collection 1), response rate 72%. A questionnaire including six items was distributed by e-mail to the same students in autumn 2016 (data collection 2), response rate 63%. Data from the two data collections were presented descriptively and analysed using the Kirkpatrick model consisting of four levels: reaction, learning, behaviour and results. Results: The students were very positive immediately after course participation, rating high on overall perception of the course and the contents (reaction). The students also rated high on achievement of the course objectives and considered their knowledge in implementation science to be very good and to a high degree due to course participation (learning). Knowledge gained from the course was viewed to be useful (behaviour) and was applied to a considerable extent in research projects and work apart from research activities (results). Conclusions: The evaluation of the doctoral-level implementation science course provided by Linkoping University showed favourable results, both in the short and long term. The adapted version of the Kirkpatrick model was useful because it provided a structure for evaluation of the short-and long-term learning outcomes.

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  • 63.
    Carlfjord, Siw
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. 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, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lägesrapport inom patientsäkerhetsområdet 2013: Bilaga 2. Landstingens och regionernas patientsäkerhetsberättelser - beskrivning och jämförande analys av uppgifter inrapporterade från vårdgivare i Sverige för åren 2010 och 2011.2013Report (Other academic)
  • 64.
    Carlfjord, Siw
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Öhrn, Annica
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development.
    Gunnarsson, Anna
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Emergency Medicine.
    Experiences from ten years of incident reporting in health care: a qualitative study among department managers and coordinators2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 113Article in journal (Refereed)
    Abstract [en]

    Background: Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care. Using qualitative methods is a way to reveal how IR is used and perceived in health care practice. The aim of the present study was to explore the experiences of IR from two different perspectives, including heads of departments and IR coordinators, to better understand how they value the practice and their thoughts regarding future application. Methods: Data collection was performed in Ostergotland County, Sweden, where an electronic IR system was implemented in 2004, and the authorities explicitly have advocated IR from that date. A purposive sample of nine heads of departments from three hospitals were interviewed, and two focus group discussions with IR coordinators took place. Data were analysed using qualitative content analysis. Results: Two main themes emerged from the data: "Incident reporting has come to stay" building on the categories entitled perceived advantages, observed changes and value of the IR system, and "Remaining challenges in incident reporting" including the categories entitled need for action, encouraged learning, continuous culture improvement, IR system development and proper use of IR. Conclusions: After 10 years, the practice of IR is widely accepted in the selected setting. IR has helped to put patient safety on the agenda, and a cultural change towards no blame has been observed. The informants suggest an increased focus on action, and further development of the tools for reporting and handling incidents.

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  • 65.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Beslutsstöd vid prioriteringar från statliga myndigheter2013In: Att välja rättvist: om prioriteringar i hälso -och sjukvården / [ed] Per Carlsson och Susanne Waldau, Lund: Studentlitteratur, 2013, 1:1, p. 137-147Chapter in book (Other academic)
    Abstract [sv]

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

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

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

  • 66.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Borgquist, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    The Importance of Cost Effectiveness in Prioritising Drugs2014In: Portrait of a health economist: ESSAYS BY COLLEAGUES AND FRIENDS OF BENGT JÖNSSON / [ed] Anthony J Culyer and Gisela Kobelt, Lund: IHE - The Swedish Institute for Health Economics , 2014, p. 17-24Chapter in book (Other academic)
  • 67.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Högskolan i Borås, Institutionen för vårdvetenskap.
    Öppna prioriteringar inom vård och omsorg - var står vi idag och hur ska vi komma vidare?2014In: Vägval för välfärden: En antologi om finansieringsgap, prioriteringar och försäkring som kompletterande lösning / [ed] Kristina Ström Olsson, Stockholm: Svensk Försäkring , 2014, p. 31-61Chapter in book (Other academic)
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    Öppna prioriteringar inom vård och omsorg - var står vi idag och hur ska vi komma vidare?
  • 68.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hoffman, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Health Sciences. Nätverk för läkemedelsepidemiologi (NEPI).
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Högskolan i Borås, Institutionen för vårdvetenskap.
    Wiss, Johanna
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Prioritering av läkemedel för behandling av patienter med sällsynta sjukdomar2014In: Läkemedel för djur, maskinell dos och sällsynta tillstånd: hantering och prissättning. Slutbetänkande av Läkemedels- och apoteksutredningen, Stockholm: Fritzes, 2014, p. 639-699Chapter in book (Other academic)
    Abstract [sv]

    I vilken utsträckning kan särskilda hänsyn tas vid prioritering av särläkemedel och läkemedel för behandling av sällsynta tillstånd? Bör man i vissa speciella situationer kunna acceptera sämre kostnadseffektivitet och lägre krav på vetenskapligt underlag? Om så, vad är det för villkor/kriterier som då bör vara uppfyllda? Hur stämmer ett sådant undantag med den etiska plattformen för prioriteringar? Finns det andra argument som talar för eller mot en särbehandling av sällsynta tillstånd? Detta är frågor som vi diskuterar i denna rapport som tagits fram på uppdrag av Läkemedels- och apoteksutredningen.

    I rapporten konstaterar vi att särläkemedel är en relativt heterogen grupp av läkemedel och att det finns andra läkemedel med motsvarande egenskaper som inte ansökt eller kunnat ansöka om status som särläkemedel. Ur prioriteringssynpunkt är det därför mer relevant att fokusera på alla typer av läkemedel, som används för sällsynta tillstånd, när vi diskuterar vilka principer för prioriteringar som bör gälla.

    Utifrån litteratur och erfarenheter i andra länder, som formulerat kriterier för en särskild hantering av läkemedel vid sällsynta sjukdomar, drar vi den preliminära slutsatsen att samhället bör kunna betala mer per hälsovinst (kostnad per kvalitetsjusterat levnadsår (QALY)) och acceptera lägre krav på vetenskapligt underlag vid prioritering av läkemedel för behandling av sällsynta sjukdomar om samtliga följande villkor är uppfyllda:

    • att behandlingen har en hög kostnad per hälsovinst som en konsekvens av att den omfattar endast få patienter,
    • att det rör sig om ett tillstånd med mycket stor svårighetsgrad,
    • att det behandlingsalternativ som övervägs på goda grunder ska antas ha en väsentlig effekt,
    • att det inte finns någon alternativ behandling med en väsentlig effekt som förväntas förebygga, bota, fördröja försämring eller lindra det aktuella tillståndet.

    Om dessa kriterier anses uppfyllda kan läkemedlet bedömas i relation till ett förhöjt tröskelvärde för kostnadseffektivitet. Hur högt detta värde kan vara för att anses rimligt tar vi inte ställning till i rapporten, men en viktig ståndpunkt är att det måste finnas en övre gräns för hur hög kostnad per QALY samhället kan acceptera. Detta bör gälla även om ovanstående kriterier är uppfyllda, annars riskerar det uppstå oacceptabla undanträngningseffekter av andra prioriterade åtgärder. Även lägre krav på vetenskapligt underlag skakunna accepteras....

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    Prioritering av läkemedel för behandling av patienter med sällsynta sjukdomar
  • 69.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hoffmann, Mikael
    Nätverk för läkemedelsepidemiologi, NEPI.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Wiss, Johanna
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Prioritering och finansiering av läkemedel för behandling av patienter med sällsynta sjukdomar: Reviderad version2015Report (Other academic)
    Abstract [en]

    To what extent can special consideration be given towards prioritising orphan drugs and drugs for treating rare conditions? In certain special situations should we accept lower cost effectiveness and lower standards for scientific evidence? If so, what are the conditions/criteria that should be fulfilled? How would such exceptions fit in with the ethical platform for priority setting? Are there other arguments that speak for or against special handling of rare conditions? These are questions we discuss in this report commissioned by the Committee on Pharmaceuticals and Pharmacies.

    In this report we describe orphan drugs as a relatively heterogeneous group of pharmaceuticals, and discuss that other drugs with similar characteristics have not applied for, or were able to apply for, status as orphan drugs. Hence, from a priority setting perspective it is more relevant to focus on all types of drugs used for rare conditions when we discuss the principles that should apply when setting priorities.

    Based on literature and experiences from other countries that have formulated criteria for special handling of drugs for rare diseases, we have drawn the preliminary conclusion that society should be able to pay more per health gain (cost per quality-adjusted life year [QALY]) and accept lower standards for scientific evidence when prioritising drugs for treating rare diseases if all of the following conditions are met:

    • that treatment has a high cost per health gain as a consequence treating only a few patients
    • that it involves a health condition with a very high level of severity
    • that the treatment option being considered is assumed, based on firm grounds, to have a substantial effect
    • that no alternative treatment having a substantial effect is available that can be expected to prevent, cure, delay, or ameliorate the health condition in question.

    If these criteria are met, the drug can be evaluated in relation to an elevated threshold value for cost effectiveness. In this report we do not address how high this value should be to be considered reasonable, but an important point is that there must be an upper limit regarding how high of a cost per QALY society can accept. This should apply even if the above criteria are met to avoid the risk of unacceptable displacement of other prioritised interventions. Even lower standards for scientific evidence could be acceptable.

    These preliminary conclusions were tested against the Swedish ethical platform and from a perspective of welfare economics.

    Our conclusions from the ethical analysis are:

    The human dignity principle allows for special handling of rare conditions that can generate high treatment costs. Hence, our first criterion is acceptable based on the ethical platform. When a higher threshold value (cost per health gain achieved) for treating rare conditions is accepted, these patients are given greater equity in access to health compared to other patients (assuming that the other criteria are also met). However, this does not automatically mean that all rare conditions generating high treatment costs should receive special handling.

    According to the needs and solidarity principle society should strive, to the extent possible, to give all citizens equal opportunities for care; but also enable them to achieve a level of health that is as equitable as possible. The latter assumes that we primarily prioritise those who are furthest from such an equitable level, i.e. those with the greatest needs. To be able to influence the opportunities and outcomes regarding health, it is essential that the interventions used can actually help people approach more equitable outcomes, i.e. that these interventions have a substantial effect on health.

    The cost-effectiveness principle states that a reasonable relationship between costs and effects should be pursued in choosing between different interventions or areas of activity. Very severe conditions should take precedence over minor conditions, even if the interventions, in contrast to the former, are associated with relatively higher costs per health gain. When the above criteria are met in treating a rare condition it only means that the treatment can be subject to evaluation of whether a higher threshold value can be accepted. Hence, this does not automatically mean that the treatment should be offered or that a drug, for example, should be included among the pharmaceutical benefits. Even when these criteria are met, and hence there is reason for special handling of the treatment, decisions makers in this context should decide what constitutes a reasonable relationship between costs and effects, i.e. what is an acceptable threshold value in a particular decision-making situation.

    In conclusion, we believe that the current ethical platform along with the modification of the cost effectiveness principle, which appears in more recent legislation, offers the opportunity to give special consideration when prioritising drugs targeted at rare and very severe conditions. For a drug to be considered for special handling, it should have a substantial effect on the condition in question. There is a difference between treatments that have poor cost effectiveness due to minor effects and those that have poor cost effectiveness due to high costs. The difference arises since the effect size of the treatment influences its potential to contribute to an outcome in line with the health and quality of life of the rest of the population, where a greater effect size approaches this in a better way. Our interpretation is that if there are two interventions with the same cost effectiveness ratio and the same severity level, but where one has greater effects on the condition than the other, it is the one with the greatest effects that should be given priority.

    We also studied whether there are any arguments from a socioeconomic efficiency standpoint that speak in favour of or against special handling of rare conditions. This has been done based on theoretical and empirical literature on the subject and preliminary data from a Swedish study. Some studies suggest there is a social value: first in the knowledge that people receive care regardless of the situation, which creates greater security and confidence in society based on self interest since everyone in society is at risk for severe conditions; and second, based on more altruistic motivation where people in general can be influenced in a positive way knowing that they live in a compassionate society.

    However, purely empirical studies do not offer any evidence that people in general think that treatment of rare diseases should receive special handling, everything else being equal. In other words, no empirical studies show that rarity per se is a relevant criterion in priority setting – this was also the conclusion of our previous ethical argument in this context (see Carlsson et al 2012). Preliminary data from an ongoing Swedish study support this conclusion to some extent. When complementing the analysis in the same study with attitude questions and focus group interviews, a more detailed picture emerges – namely, support can be found for special handling if the condition is rare, has a high level of severity, and is the only treatment option.

    After deciding that special consideration can be given in prioritising drugs for severe and rare conditions, based on the ethical platform and from a welfare economy perspective, positions must be taken on a series of practical considerations in designing procedures for priority setting, namely:

    • Based on the goal to reduce differences and guarantee care on equal terms for rare conditions, it would be preferable to use a model involving national decision making. The same principles for prioritising drugs for rare and severe conditions should apply regardless of how the drug reaches the patient, i.e. regardless of whether it involves prescribed or requisitioned drugs. Whether one or more bodies set priorities is an organisational issue that we do not address in this report.
    • From a priority setting standpoint there should be no difference between orphan drugs and other drugs used for rare conditions. When it comes to decisions on whether orphan drugs in general should be included under the pharmaceutical benefits system, they should be assessed and approved by the Dental and Pharmaceutical Benefits Agency in usual fashion, while drugs targeted at conditions that are both very rare and very severe may need special consideration and handled according to a modified procedure. This should include the cost per health gain and dealing with uncertainty of the scientific evidence, and should apply whether or not the drug has orphan status.
    • In some situations where the scientific evidence is uncertain, problems arise in deciding on general use of expensive drugs for severe diseases on a group level. In this context it seems reasonable to initially allow some exceptions in the evidence for cost effectiveness related to severe diseases when, for various reasons, practical factors stand in the way of producing such evidence. However, a conflict can arise in both accepting a higher willingness to pay and accepting greater uncertainty in the scientific evidence. In such cases it is particularly important to pursue adequate follow-up and try to reduce uncertainty as quickly as possible and reassess the decision.
    • Various principles are available to define patient groups with very severe and rare conditions. Groups may be defined based on the prevalence of the condition in the population or on the number of patients with a given condition that the drug in question will be used to treat (in other words, the number of patients who are potential candidates for treatment). The latter method appears to be advantageous when the particular problem we address here relates to the fact that few patients are candidates for treatment, not how usual/unusual the condition/disease is. In the report we do not take a definitive position on what constitutes a suitable limit. This needs further study. However, we believe that such a limit should be set much lower than the usual definition for orphan drugs. In Sweden’s case, a reasonable starting point for discussion could be that the expected estimated size of the patient group should not exceed 200 patients (1 in 50 000 inhabitants) during 5 years. Experience from England, for instance, supports this definition.
    • One way to arrive at a reasonable threshold for cost effectiveness in different situations involving rare conditions is to designate some entity to make decisions transparently. Such decisions could then be discussed broadly and possibly be subject to reassessment. By comparing with other situations in health care and society where decisions are made on interventions for severe conditions and small patient groups, the development of accepted practice can be accelerated. Even comparisons with decisions in other countries can give an indication of reasonable threshold values in various situations.
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  • 70.
    Carlsson, Per
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Kärvinge, Christina
    Socialstyrelsen, Stockholm.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Eklund, Kristina
    Socialstyrelsen, Stockholm.
    Hallin, Bo
    Västra Götalandsregionen.
    Jacobsson, Catrine
    Svensk sjuksköterskeförening/Vårdförbundet.
    Jacobsson Ekman, Gunilla
    Stockholms läns landsting.
    Källgren Peterson, Christina
    Landstinget i Östergötland.
    Lindh, Marion
    Stockholms läns landsting.
    Nordlander, Britt
    Svenska Läkaresällskapet.
    Rosén, Per
    Södra sjukvårdsregionen.
    Sjöblom, Urban
    Södra sjukvårdsregionen.
    Sohlberg, Anna
    Socialstyrelsen.
    National Model for Transparent Vertical Prioritisation in Swedish Health Care2007Report (Other academic)
    Abstract [en]

    The proposed national model described in this report has been developed by a working group comprised of staff from the National Board of Health and Welfare, the National Centre for Priority Setting in Health Care, and other organisations involved in vertical prioritisation – including the Östergötland County Council, Stockholm County Council, Västra Götaland, the Health Services Region of Southern Sweden, the Swedish Society of Medicine, the Swedish Society of Nursing, and the Swedish Association of Health Professionals. Throughout the process of designing the model, the Swedish Federation of Occupational Therapists and the Swedish Association of Registered Physiotherapists were regularly informed and given opportunities to review and comment on the proposal. Furthermore, the report was reviewed and discussed at a meeting with invited representatives from the other county councils, the Pharmaceutical Benefits Board, and several professional interest groups. Viewpoints were also obtained at a seminar arranged by PrioNet, a network of individuals interested in prioritisation.

    Potentially, the working model described in Chapter 4 could be used in any context where vertical prioritisation takes place, e.g. activities arranged by the state, county councils, municipalities, hospital departments, and professional groups.

    This report is designed to be a useful tool for those working on development projects in priority setting. We believe that the contents must be adapted, with the help of relevant examples and some simplifications; to fit the specific needs of different projects or groups. The text must also be adapted to a target group’s knowledge and previous experience in dealing with transparent priority setting. It must be the responsibility of each provider and other affected organisation to adapt the material to the given situation and project. The National Centre for Priority Setting in Health Care, the National Board of Health and Welfare, and others who have participated actively in this effort can be helpful to various target groups in adapting this report.

    When and how to engage in practically implementing vertical prioritisation are questions that need to be answered at the local level. Primarily, it is the duty of the local authorities/providers to take responsibility for implementation. Professional organisations also play an important role. Public agencies, universities, and knowledge centres should be sources of support for the local authorities/providers.

    The Riksdag’s resolution on prioritisation served as the foundation for developing the model.

    Where there are areas of uncertainty in how to translate these guidelines in practice, or where practical implementation might conflict with the principles, we have pointed this out.

    Our conclusions and proposals are the following:

    • When facing a choice – regardless of whether it involves allocating new resources for different purposes, or to implement cutbacks – it can be advantageous to rank the possible choices in order of priority. In our model, only the relevant options can be ranked by priority. The consequences of this ranking are not obvious at the outset, but can serve as a basis either to allocate more resources or ration by some means.
    • In vertical prioritisation, it is advantageous to organise the prioritization process starting from a general categorisation of health problems/disease groups. As a rule, these categories cover many organisational units/clinical departments, specialties, or professional groups, thus providing a more multidimensional view of the problem. Furthermore, this allows the process to start from a patient/population perspective, which appears to be more goal-oriented than an organisational/staff perspective.
    • That which is ranked, i.e. one of the choices, we refer to as a prioritization object. We suggest that prioritisation objects consist of different combinations of health conditions and interventions.1 When deciding on the appropriate level of detail, the decision must be based on the context in which prioritisation is carried out. A starting point would be to focus on typical cases, large-volumes services, and controversial care.
    • All forms of vertical prioritisation should be based on the ethical principles that the Riksdag decided should apply in prioritising health services. However, these ethical principles must be made known, clarified, and perhaps complemented before they can be applied to practical priority setting. Furthermore, we believe that the Riksdag’s four so-called priority groups should not be part of the model.
    • The human dignity principle, i.e. that all people should have equal value and equal rights to care irrespective of their personal characteristics and function in society, is the undisputed cornerstone in priority setting. When personal characteristics such as age, gender, lifestyle, or function of a group are expressions of the presence of special needs, so that benefits of the interventions are different, these personal characteristics could be addressed in a priority at the group level. Further discussion is needed regarding the question of how external effects (i.e. the effects of an intervention on families and groups other than the individual directly affected by the intervention) should be valued in priority setting.
    • The concept of need in health care includes both the severity level of the condition and the expected benefits of intervention. As a patient, one needs only those interventions that can be expected to yield benefits. Based on this definition of need, a person does not need an intervention that does not improve health and quality of life, i.e. an intervention with no benefit. In such cases, health services have a responsibility to refer people who seek care for some type of problem, to other appropriate services.
    • The Riksdag’s guidelines regarding the cost-effectiveness principle (applied to individual patients) are too limited to provide guidance for vertical prioritisation at the group level. From the outset, the Government’s bill (Priority Setting in Health Care) highlighted the importance of differentiating a cost-effectiveness principle that applied to choices among various interventions for the individual patient (where the principle can be applied as the Commission of Inquiry proposed) and the aim of health services to achieve high cost-effectiveness in health care generally. Here we also refer to the Riksdag’s directive to the Pharmaceutical Benefits Board. In its decisions on subsidising (prioritising) a drug, the Board should determine, e.g. whether the drug is cost effective from a societal perspective, which requires comparing the patient benefits of the drug to its cost. In such decisions, the cost effectiveness should be considered along with the needs and solidarity principle and the human dignity principle.
    • The proposed working model essentially concurs with the working model used by the National Board of Health and Welfare in developing national guidelines. In describing a national working model, it is not possible to include every aspect that might be considered. Hence, one must start from the model and decide which other relevant aspects should be included. For instance, the International Classification on Functioning, Disability, and Health (ICF) can be used as guidance to describe the severity of health conditions.
    • Due to the wealth of variety in outcome measures for different activities, and the limited experience in working with explicit threshold values, we believe would be premature to recommend standardised categories, e.g. risk levels. However, it is important that those working with prioritization describe their reasoning. Primarily, the categories applied by the Swedish Council on Technology Assessment in Health Care (SBU) to grade the scientific evidence of an intervention’s effects should be used. Local prioritisation projects with limited resources at their disposal should describe (text) their appraisal of the scientific evidence and reference the scientific sources used. The strength of evidence should be expressed in numbers only when supporting a conclusion of a systematic review by SBU, or other literature reviews of good quality.
    • Prioritisation projects having access to health economic evaluation should, until further notice, adhere to the approach used by the National Board of Health and Welfare and present cost-effectiveness on a scale from low to very high cost per life-year gained or cost per quality-adjusted life-year. Economic evidence should be presented according to the principles applied by the National Board of Health and Welfare. In local projects with limited resources, or problems in consistently acquiring information on cost effectiveness, we recommend that the authors at least discuss cost effectiveness in cases where the priority ranking would be decisively affected when costs are weighed in.
    • A 10-level ranking list should be used. The ranking list should be complemented by a “don’t do” list for methods that should not be used at all, or not used routinely, and a research and development (R&D) list for methods where the evidence still insufficient to motivate their use in standard practice. In the absence of an objective quantitative/mathematical method, a qualitative method should be used in the appraisal. Here too, we believe that it is not yet possible to establish standard criteria to determine within which ranking level a prioritisation object should fall.
    • Results should be presented as a ranking list. The parameters used as a basis for prioritisation should also be presented in a uniform manner in ranking lists that are shared with other parties. For pedagogic reasons, details concerning language and format need to be adapted to the respective target groups.
    • Thresholds for what constitutes an acceptable coverage of need (care quality, volume, and percentage of the patient group with access to services) are regional and local issues, and hence are not included in the national model.
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  • 71.
    Carlsson, Per
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment.
    Kärvinge, Christina
    Socialstyrelsen, Stockholm.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Eklund, Kristina
    Socialstyrelsen, Stockholm.
    Hallin, Bo
    Västra Götalandsregionen.
    Jacobsson, Catrine
    Svensk sjuksköterskeförening/Vårdförbundet.
    Jacobsson Ekman, Gunilla
    Stockholms läns landsting.
    Källgren Peterson, Christina
    Landstinget i Östergötland.
    Lindh, Marion
    Stockholms läns landsting.
    Nordlander, Britt
    Svenska Läkaresällskapet.
    Rosén, Per
    Södra sjukvårdsregionen.
    Sjöblom, Urban
    Södra sjukvårdsregionen.
    Sohlberg, Anna
    Socialstyrelsen.
    Nationell modell för öppna vertikala prioriteringar inom svensk hälso- och sjukvård2007Report (Other academic)
    Abstract [sv]

    En arbetsgrupp med personer från Socialstyrelsen och PrioriteringsCentrum, andra organisationer som arbetat med vertikala prioriteringar såsom Landstinget i Östergötland, Stockholms läns landsting, Västra Götaland, Södra sjukvårdsregionen, Svenska Läkaresällskapet, Svensk sjuksköterskeförening och Vårdförbundet har tagit fram detta förslag. Förslaget har fortlöpande förankrats hos Förbundet Sveriges Arbetsterapeuter och Legitimerade Sjukgymnasters Riksförbund som kunnat lämna synpunkter på utformningen av  odellen.Dessutom har rapporten varit föremål för granskning och diskussion vid ett möte med inbjudna representanter från övriga landsting, Läkemedelsförmånsnämnden och flera yrkesorganisationer. Synpunkter har också inkommit från ett seminarium som arrangerades av PrioNet, ett nätverk av personer med intresse för prioriteringar.

    Den arbetsmodell som beskrivs i kapitel 4 ska kunna användas i alla sammanhang där vertikala prioriteringar sker såsom aktiviteter som arrangeras av staten, landsting, kommuner, kliniker, professionella grupper eller motsvarande.

    Rapporten är skriven på ett sådant sätt att den ska kunna användas i första hand som ett stöd till dem som bedriver utvecklingsarbete rörande prioriteringar. Vi tror att innehållet måste anpassas till olika verksamheter eller personalgruppers specifika behov med hjälp av kompletterande exempel och vissa förenklingar. Texten måste givetvis också anpassas till de kunskaper och tidigare erfarenheter som den aktuella målgruppen har när det gäller arbete med öppna prioriteringar. Sådana situations- och verksamhetsanpassade versioner måste det åligga varje sjukvårdshuvudman och andra berörda organisationer att utarbeta. PrioriteringsCentrum, Socialstyrelsen och andra parter som deltagit aktivt i detta arbete kan givetvis vara behjälpliga i arbetet med att bearbeta denna rapport för olika målgrupper.

    Frågan om när och hur arbetet med vertikala prioriteringar ska bedrivas i praktiken kan också endast besvaras lokalt. Det är i första hand ett  nsvar för huvudmännen att ta ansvar för implementeringen. Professionella organisationer har också en viktig roll. Myndigheter, universitet och kunskapscentra ska vara ett stöd till huvudmännen.

    Utgångspunkten i modellutvecklingen är Riksdagens beslut om prioriteringar. När det finns oklarheter om hur dessa riktlinjer ska omsättas i praktiken eller att praktiken kan förefalla i konflikt med principerna har vi påpekat detta.

    • När man står inför ett val - oavsett om det handlar om att fördela nya resurser till olika ändamål eller att genomföra besparingar - kan det vara en fördel att kunna rangordna tänkbara valmöjligheter i enprioriteringsordning. I vår modell innebär prioritering enbart att de relevanta alternativen rangordnas. Konsekvenserna av denna rangordning är inte på förhand given utan kan ligga till grund såväl för tillskott av resurser som för ransonering av något slag.
    • Vid en vertikal prioritering är det en fördel att organisera prioriteringsarbetet så att det utgår från en grov uppdelning i hälsoproblem/sjukdomsgrupper. En sådan uppdelning innebär i regel att flera organisationsenheter/kliniker, specialiteter eller yrkesgrupper berörs och man får en mer allsidig belysning av problemet. Dessutom utgår man från ett patient/befolkningsperspektiv vilket förefaller mer ändamålsenligt än ett organisatoriskt/personalperspektiv.
    • Det som rangordnas och som någon väljer mellan benämner vi prioriteringsobjekt. Vi föreslår att prioriteringsobjektet utgörs av olika kombinationer av hälsotillstånd och åtgärder1. När det gäller att bestämma en lämplig detaljeringsgrad måste det avgöras utifrån sammanhanget prioriteringar ska göras i. En utgångspunkt är att fokusera på typfall, vård som representerar stor volym och kontroversiell vård.
    • Alla former av vertikala prioriteringar ska baseras på de etiska principer som riksdagen beslutat ska gälla vid prioriteringar inom  hälso- och sjukvården. De etiska principerna behöver dock göras kända, förtydligas och eventuellt kompletteras för att kunna omsättas i praktiska prioriteringar. Vidare anser vi att riksdagens fyra så kallade prioriteringsgrupper inte ska ingå i modellen.
    • Människovärdesprincipen, som innebär att alla människor bör ha lika värde och samma rätt till vård oberoende av personliga egenskaper och funktioner i samhället, är den självklara utgångspunkten vid prioriteringar. När personliga egenskaper såsom ålder, kön, livsstil eller funktion hos en grupp är ett uttryck för att speciella behov föreligger så att nytta med insatserna blir olika ska de personliga egenskaperna kunna beaktas i en prioritering på gruppnivå. Frågan om hur externa effekter, d v s effekten av en insats för närstående och andra grupper än den individ som är direkt berörd av insatsen, ska värderas vid en prioritering behöver diskuteras ytterligare.
    • Med behov av hälso- och sjukvård menas både tillståndets svårighetsgrad och den förväntade nyttan av en åtgärd. Som patient har man endast behov av sådana vårdåtgärder som man förväntas ha nytta av. Motsatt gäller att en människa enligt detta sätt att definiera behov inte behöver åtgärder som inte förbättrar hälsan och livskvaliteten, sådana som hon inte har nytta av. Här har givetvis hälso- och sjukvården ett ansvar att lotsa människor de kommer i kontakt med, och som far illa på något sätt, till andra lämpliga aktörer.
    • Riksdagens riktlinjer, när det gäller kostnadseffektivitetsprincipen (tillämpad för enskilda patienter), är för begränsad för att vägleda vid vertikala prioriteringar som gäller prioritering på gruppnivå. Regeringen konstaterade redan i prioriteringspropositionen att det är angeläget att skilja på en kostnadseffektivitetsprincip som gäller val mellan olika åtgärder för den enskilde patienten (där principen kan tillämpas som utredningen föreslår) och på hälso- och sjukvårdens strävan efter en hög kostnadseffektivitet när det gäller vårdens verksamhet i allmänhet. Här stödjer vi oss på Riksdagens direktiv till Läkemedelsförmånsnämnden. Nämnden ska vid beslut om subvention (prioriteringar) av ett läkemedel bl a bedöma om det är  kostnadseffektivt i ett samhälleligt perspektiv, vilket innebär att man ställer patientnyttan av läkemedlet mot kostnaden. I bedömningen ska kostnadseffektiviteten vägas samman med behovs- och solidaritetsprincipen och människovärdesprincipen.
    • Den föreslagna arbetsmodellen överensstämmer i allt väsentligt  med den arbetsmodell som används av Socialstyrelsens vid framtagning av nationella riktlinjer. Det är inte möjligt att rymma alla aspekter som kan vara aktuella att beakta vid beskrivning av en nationell arbetsmodell. Man måste därför utgå från modellen och fundera på vilka andra relevanta aspekter som dessutom bör vägas in. T ex kan den internationella klassifikationen för funktionsförmåga (ICF) användas som vägledning.
    • På grund av den stora variationsrikedomen av effektmått i olika verksamheter och de begränsade erfarenheter som finns att arbeta med sådana explicita gränsvärden anser vi att det är för tidigt att rekommendera en enhetlig indelning i t ex risknivåer. Det är dock viktigt att de som arbetar med prioriteringar redovisar hur de har resonerat.
    • SBU:s klassifikation för att gradera den vetenskapliga evidensen för en åtgärds effekt bör användas i första hand. Lokala prioriteringsprojekt med begränsade resurser till sitt förfogande föreslås redovisa bedömningen av det vetenskapliga underlaget med ord och referera till det kunskapsunderlag som använts. Evidensstyrkan bör endast uttryckas med siffror då man stöder en slutsats på en systematisk kunskapsöversikt från SBU eller en annan översikt av god kvalitet.
    • Prioriteringsarbeten där hälsoekonomiska data finns tillgängliga bör tills vidare ansluta till Socialstyrelsens arbetssätt och ange kostnadseffektivitet i en skala från låg till mycket hög kostnad per vunnet levnadsår eller kostnad per kvalitetsjusterat levnadsår. Den hälsoekonomiska evidensen bör redovisas i enlighet med de principer som Socialstyrelsen tillämpar. I lokala projekt med små resurser eller svårigheter att konsekvent få fram uppgifter om kostnadseffektivitet rekommenderar vi att man åtminstone resonerar om kostnadseffektivitet i de fall prioriteringsordningen på ett avgörande sätt påverkas när kostnaderna vägs in.
    • Tio nivåer bör användas för rangordning samt att rangordningslistan kompletteras med en ”icke-göra-lista” för metoder som inte bör utföras alls eller rutinmässigt samt en FoU-lista för metoder där det fortfarande saknas tillräcklig evidens för att kunna motivera ett införande i rutinsjukvården. Sammanvägningen sker företrädesvis med en kvalitativ metod i avsaknad av en invändningsfri  kvantitativ/matematisk metod. Likaså tror vi att det för närvarade inte är möjligt att fastställa entydiga kriterier som avgör inom vilken rangordningsnivå ett prioriteringsobjekt ska hamna.
    • Resultatet bör presenteras i form av en rangordningslista. De parametrar som ligger till grund för prioriteringen bör också på ett enhetligt sätt redovisas i sådana rangordningslistor som visas för andra. I detalj kan språket och utseendet av pedagogiska skäl behöva anpassas för respektive målgrupp.
    • Gränser för vad som är acceptabel behovstäckning (vårdkvalitet, mängd liksom andel av de i patientgrupp som får tillgång till insatsen) är en regional och lokal fråga och ingår därför inte i den nationella modellen.
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  • 72.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Högskolan i Borås, Institutionen för vårdvetenskap.
    Att skapa ett kunskapsunderlag2013In: Att välja rättvist: om prioriteringar i hälso- och sjukvården / [ed] Per Carlsson och Susanne Waldau, Lund: Studentlitteratur, 2013, 1:1, p. 89-99Chapter in book (Other academic)
    Abstract [sv]

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

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

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

  • 73.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    "Dags att utveckla den etiska plattformen för prioriteringar"2015In: Dagens Medicin, ISSN 1104-7488Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Hälso- och sjukvården har under senare år ställts inför en rad utmaningar när det gäller användningen av de begränsade resurserna. Exempelvis har nya effektiva men mycket dyra läke­medel som Zytiga, Soliris eller läkemedel mot hepatit C lett till prioriteringsbeslut som har kritiserats men också blottlagt brister i den etiska plattform som ska vägleda beslutsfattare. Därför menar vi att plattformen behöver en parlamentarisk översyn.

  • 74.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Sjödahl, Rune
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Theodorsson, Elvar
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Chemistry.
    Robotassisterad kirurgi ökar – trots osäker kostnadseffektivitet2016In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 113, no 48, p. 1-5Article, review/survey (Refereed)
  • 75.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Läkemedel: när är det rimligt att betala själv?2013 (ed. 1)Book (Other academic)
    Abstract [sv]

    Samhällets ekonomiska resurser är begränsade och därför finns det ingen möjlighet att offentligt finansiera alla vårdtjänster som har en positiv effekt. Prioritering och ransonering av hälso- och sjukvård är därmed ofrånkomlig. Ett sätt att göra detta på är att låta individen finansiera vissa produkter och tjänster direkt ur egen ficka. Gränsdragningen mellan det individuella och det offentliga ansvaret för finansiering av sjukvård är dock en komplex och politiskt känslig fråga, men den förtjänar likväl en öppen och konstruktiv diskussion. Vår utgångspunkt är att den svenska hälso- och sjukvården under överskådlig tid i huvudsak kommer att förbli offentligt finansierad, men vi konstaterar att en betydande andel av vården idag är privat finansierad. För att personer ska kunna ta ett eget ansvar för finansieringen krävs vissa förutsättningar. Det är därför viktigt att uppmärksamma var, när och hur det är rimligt att individen får ta ett eget ansvar för att finansiera sin vård, och när motsatsen gäller. Denna diskussion kan ta sin utgångspunkt i de etiska principer för prioriteringarsom gäller i Sverige: människovärdesprincipen, behovs-solidaritetsprincipen och kostnadseffektivitetsprincipen.

    Det övergripande syftet med denna rapport är att analysera och diskutera grunden för egenansvar vid finansiering av vård. Syftet är också att presentera ett ramverk för att bedöma lämpligheten av egenfinansiering och applicera detta ramverk på läkemedelsområdet.

    Ramverket består av sex kriterier/egenskaper kopplade till den specifika vårdinsatsen/produkten som bör vara delvis eller helt uppfyllda för att egenfinansiering ska bedömas som rimlig.

    1. Den aktuella vårdinsatsen/produkten bör vara sådan att flertalet individer har god förmåga att värdera behov och kvalitet både före och efter användning.
    2. Den aktuella vårdinsatsen/produkten bör främst utnyttjas av individer som kan betecknas som autonoma och reflekterande i sitt  beslutsfattande.
    3. Den aktuella vårdinsatsen/produkten bör ge små posi tiva externa effekter.
    4. Kostnaden för den aktuella vårdinsatsen/produkten bör vara överkomlig för de flesta som har behov av den.
    5. Efterfrågan på den aktuella vårdinsatsen/produkten bör vara tillräckligt omfattande och regelbunden för att en privat marknad ska kunna uppstå.
    6. Vårdinsatser/produkter som syftar till att förbättra prestationer, funktion eller utseende, utöver vad som anses normalt snarare än medicinsk nödvändigt, är mer lämpade för privat finansiering.

    Sammanfattningsvis dras följande slutsatser i rapporten:

    • Det finns idag en inte obetydlig mängd läkemedel som finansieras privat. Motiven för vad som finansieras privat eller offentligt är dock ofta oklara. Det finns också olikheter mellan landsting när det gäller finansiering av vårdtjänster och sjukvårdsprodukter.
    • Det finns två huvudsakliga typer av egenansvar som kan beaktas vid prioriteringsbeslut: Ansvar för egen hälsa som fokuserar på individers tidigare hälsorelaterade livsstilsval. Ansvar för egen vård som fokuserar på vilka sjukvårdstjänster individer faktiskt klarar att ombesörja och finansiera själva.
    • Ansvar för egen vård är den mest policyrelevanta formen av egenansvar eftersom det kan vara svårt att fastställa samband mellan beteende och ohälsa.
    • Tillräcklig kunskap, individuell autonomi, externa effekter, tillräcklig efterfrågan, överkomligt pris och livsstilsförbättring är relevanta faktorer att beakta vid bedömning av egenfinansiering av läkemedel. Den form av egenansvar för finansiering som presenteras i rapporten 11 är i hög grad förenlig med intentionerna i människovärdesprincipen och behovs-solidaritetsprincipen.
    • Det kan uppstå en konflikt mellan det presenterade ramverket och kostnadseffektivitetsprincipen när kostnadseffektiva läkemedel möjliggör egenansvar och därför med fördel kan finansieras privat trots en god kostnadseffektivitet.
    • Mycket dyra läkemedel som inte är kostnadseffektiva är inte heller lämpliga för egenansvar. Samtidigt har samhället svårt att neka personer tillgång till verksamma läkemedel vid svår sjukdom. För att lösa detta dilemma bör man överväga möjligheten att samhället betalar för sådana läkemedel upp till den nivå där dessa bedöms kostnadseffektiva. Kostnaden därutöver skulle patienten kunna få möjlighet att finansiera själv. Sådana lösningar innebär antagligen en rad komplikationer som behöver utredas noga.
    • För att egenansvar ska kunna tillämpas systematiskt och öppet vidprio riteringar behöver antagligen ett tidigare förslag från Socialstyrelsen till regeringen om att genomföra en översyn av den etiska plattformen aktualiseras på nytt.
    • Det är angeläget att studera i vilken utsträckning privat finansiering leder till ökade skillnader i konsumtion och hälsa inom olika socioekonomiska grupper.
    • Det finns inga perfekta lösningar för hur samhället ska dra gränsen för det offentliga åtagandet. Olika värden måste alltid balanseras mot varandra i syfte att uppnå en hälso- och sjukvård som är både rättvis och effektiv.
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    Läkemedel – när är det rimligt att betala själv?
  • 76.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Tinghög, Gustav
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Vilken vård bör vi betala själva?2013In: Svenska Dagbladet, ISSN 1101-2412Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Det saknas tydliga principer i vården för att avgöra vad som ska finansieras privat respektive offentligt. Därför blir besluten ofta godtyckliga. Varför ska vi till exempel betala privat för glasögon medan hörapparater står det offentliga för?

  • 77.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Waldau, SusanneVästerbottens läns landsting. Umeå universitet, Institutionen för folkhälsa och klinisk medicin.
    Att välja rättvist: Om prioriteringar i hälso- och sjukvården2013Collection (editor) (Other academic)
    Abstract [sv]

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

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

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

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  • 78.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Waldau, Susanne
    Västerbottens läns landsting. Avdelningen epidemiologi och global hälsa, Inst för folkhälsa och klinisk medicin, Umeå universitet.
    Öppna prioriteringar i hälso- och sjukvården2013In: Att välja rättvist: om prioriteringar i hälso- och sjukvården / [ed] Per Carlsson och Susanne Waldau, Lund: Studentlitteratur, 2013, 1:1, p. 17-33Chapter in book (Other academic)
    Abstract [sv]

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

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

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

  • 79.
    Chevallier, Julien
    et al.
    IPAG Business Sch, France; Univ Paris 08, France.
    Nguyen, Duc Khuong
    IPAG Business Sch, France.
    Siverskog, Jonathan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Uddin, Gazi Salah
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Market integration and financial linkages among stock markets in Pacific Basin countries2018In: Journal of Empirical Finance, ISSN 0927-5398, E-ISSN 1879-1727, Vol. 46, p. 77-92Article in journal (Refereed)
    Abstract [en]

    Financial development and globalization have significantly integrated stock markets around the world. This higher degree of interdependence and integration not only provides firms with higher access to international capital markets with lower cost of equity but also generates upward vulnerabilities for local markets due to their exposure to global and regional shocks. This article focuses on the level of interdependence across the Pacific Basin stock markets using the return spillover measure proposed by Diebold and Yilmaz (2009, 2012), given their increasing role in global trade and finance. We are also interested in investigating the effect of shocks affecting the United States and the Japanese stock markets as well as their transmission to the emerging markets. We mainly find that: (1) the interdependence of the emerging stock markets in the ASEAN countries is driven by a higher exposure to the US shocks than to shocks affecting the developed economies of East Asia, and (ii) the cross-market linkages in the Pacific Basin region have become stronger over time, which may reduce the benefit of regional diversification strategies and expose the countries of the region to increasing contagion risk. These results have important implications for public policies related to the issue of regional and global financial integration. (C) 2017 Elsevier B.V. All rights reserved.

  • 80.
    Christell, Helena
    et al.
    Malmo Univ, Sweden; Helsingborg Hosp, Sweden.
    Gullberg, Joanna
    Malmo Univ, Sweden.
    Nilsson, Kenneth
    Malmo Univ, Sweden.
    Olofsson, Sofia Heidari
    Malmo Univ, Sweden.
    Lindh, Christina
    Malmo Univ, Sweden.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Willingness to pay for osteoporosis risk assessment in primary dental care2019In: Health Economics Review, ISSN 2191-1991, E-ISSN 2191-1991, Vol. 9, article id UNSP 14Article in journal (Refereed)
    Abstract [en]

    BackgroundFragility fracture related to osteoporosis among postmenopausal women is a significant cause of morbidity. The care and aftercare of these fractures are associated with substantial costs to society. A main problem is that many individuals suffer from osteoporosis without knowing it before a fracture happens. Dentists may have an important role in early identification of individuals with osteoporosis by assessment of dental radiographs already included in the dental examination. The aim of this study was therefore to investigate postmenopausal womens preferences for an osteoporosis risk assessment in primary dental care.ResultsMost respondents (129 of 144 (90%)) were willing to pay for an osteoporosis risk assessment in primary dental care. The overall mean willingness to pay (WTP) including respondents that denoted none or zero WTP was 44.60 Euro (CI 95% 38.46-50.74 Euro) (median 34.75 Euro). A majority (80.6%) of the respondents that denoted WTP also gave a motivation for their answer. The two most common reasons denoted for being willing to pay for osteoporosis risk assessment were the importance of early diagnosis and preventive care to avoid fractures (41.0%) and the importance of knowledge of a risk of osteoporosis (26.4%). A majority of respondents (67.8%) considered it valuable if dental clinics would offer osteoporosis risk assessment.ConclusionsPostmenopausal women seem to find it valuable to be offered osteoporosis risk assessment in primary dental care and are willing to pay for such a risk assessment. From a societal perspective early diagnosis of osteoporosis by risk assessment in primary dental care could prevent osteoporotic related fractures and benefit womens health and quality of life, as well as have a major impact on the health-care budget in terms of cost-savings.

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  • 81.
    Cowper, Patricia A.
    et al.
    Duke University, NC USA.
    Pan, Wenqin
    Duke University, NC USA.
    Anstrom, Kevin J.
    Duke University, NC USA.
    Kaul, Padma
    University of Alberta, Canada.
    Wallentin, Lars
    Uppsala University, Sweden.
    Davidson-Ray, Linda
    Duke University, NC USA.
    Lundborg, Elisabet
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Cannon, Christopher P.
    Brigham and Womens Hospital, MA 02115 USA.
    Harrington, Robert A.
    Stanford University, CA 94305 USA.
    Mark, Daniel B.
    Duke University, NC USA.
    Economic Analysis of Ticagrelor Therapy From a US Perspective2015In: Journal of the American College of Cardiology, ISSN 0735-1097, E-ISSN 1558-3597, Vol. 65, no 5, p. 465-476Article in journal (Refereed)
    Abstract [en]

    BACKGROUND Based on results of the PLATO (Platelet Inhibition and Patient Outcomes) trial comparing ticagrelor with clopidogrel therapy, the U.S. Food and Drug Administration approved ticagrelor in 2011 for reducing thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) with the proviso that it be taken with low-dose aspirin. OBJECTIVES This study sought to assess the cost and cost effectiveness of ticagrelor therapy relative to clopidogrel in treating ACS patients from the perspective of the U.S. health care system. METHODS We estimated within-trial resource use and costs using U.S. low-dose aspirin patients in PLATO (n = 547). Quality-adjusted life expectancy was estimated using the total PLATO population (n = 18,624), combined with baseline risk and long-term survival data from an external ACS patient cohort. Study drugs were valued at current costs. Cost effectiveness was assessed, as was the sensitivity of results to sampling and methodological uncertainties. RESULTS One year of ticagrelor therapy, relative to that of generic clopidogrel, cost $29,665/quality-adjusted life-year gained, with 99% of bootstrap estimates falling under a $100,000 willingness-to-pay threshold. Results were robust to extensive sensitivity analyses, including variations in clopidogrel cost, exclusion of costs in extended years of life, and a recalibrated estimate of survival reflecting a lower underlying mortality risk in the United States. CONCLUSIONS For PLATO-eligible ACS patients, a U.S. perspective comparison of the current standard of dual antiplatelet therapy of aspirin with clopidogrel versus aspirin plus ticagrelor showed that the ticagrelor regimen increased life expectancy at an incremental cost well within accepted benchmarks of good value for money. (C) 2015 by the American College of Cardiology Foundation.

  • 82.
    Danielsson, Marita
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Operations management Region Östergötland, Övrig enhet.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Rutberg, Hans
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Carlfjord, Siw
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    The professional culture among physicians in Sweden: potential implications for patient safety2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, no 1, article id 543Article in journal (Refereed)
    Abstract [en]

    Background

    Patient safety culture, i.e. a subset of an organization’s culture, has become an important focus of patient safety research. An organization’s culture consists of many cultures, underscoring the importance of studying subcultures. Professional subcultures in health care are potentially important from a patient safety point of view. Physicians have an important role to play in the effort to improve patient safety. The aim was to explore physicians’ shared values and norms of potential relevance for patient safety in Swedish health care.

    Methods

    Data were collected through group and individual interviews with 28 physicians in 16 semi-structured interviews, which were recorded and transcribed verbatim before being analysed with an inductive approach.

    Results

    Two overarching themes, “the competent physician” and “the integrated yet independent physician”, emerged from the interview data. The former theme consists of the categories Infallible and Responsible, while the latter theme consists of the categories Autonomous and Team player. The two themes and four categories express physicians’ values and norms that create expectations for the physicians’ behaviours that might have relevance for patient safety.

    Conclusions

    Physicians represent a distinct professional subculture in Swedish health care. Several aspects of physicians’ professional culture may have relevance for patient safety. Expectations of being infallible reduce their willingness to talk about errors they make, thus limiting opportunities for learning from errors. The autonomy of physicians is associated with expectations to act independently, and they use their decisional latitude to determine the extent to which they engage in patient safety. The physicians perceived that organizational barriers make it difficult to live up to expectations to assume responsibility for patient safety. Similarly, expectations to be part of multi-professional teams were deemed difficult to fulfil. It is important to recognize the implications of a multi-faceted perspective on the culture of health care organizations, including physicians’ professional culture, in efforts to improve patient safety.

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  • 83.
    Danielsson, Marita
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Operations management Region Östergötland, Övrig enhet.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Rutberg, Hans
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Årestedt, Kristofer
    Faculty of Health and Life Sciences, Linnaeus University, Kalmar; The Research Unit, Kalmar County Hospital, Kalmar, Sweden..
    A National Study of Patient Safety Culture in Hospitals in Sweden2019In: Journal of patient safety, ISSN 1549-8417, E-ISSN 1549-8425, Vol. 15, no 4, p. 328-333Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Using the Hospital Survey on Patient Culture, our aim was to investigate the patient safety culture in all Swedish hospitals and to compare the culture among managers, physicians, registered nurses, and enrolled nurses and to identify factors associated with high overall patient safety.

    METHODS: The study used a correlational design based on cross-sectional surveys from health care practitioners in Swedish health care (N = 23,781). We analyzed the associations between overall patient safety (outcome variable) and 12 culture dimensions and 5 background characteristics (explanatory variables). Simple logistic regression analyses were conducted to determine the bivariate association between each explanatory variable and the outcome variable. The explanatory variables were entered to determine the multivariate associations between the variables and the outcome variable.

    RESULTS: The highest rated culture dimensions were "teamwork within units" and "nonpunitive response to error," and the lowest rated dimensions were "management support for patient safety" and "staffing." The multivariate analysis showed that long professional experience (>15 years) was associated with increased probability for high overall patient safety. Compared with general wards, the probability for high overall patient safety was higher for emergency care but lower for psychiatric care. The probability for high overall patient safety was higher for both enrolled nurses and physicians compared with managers.

    CONCLUSIONS: The safety culture dimensions of the Hospital Survey on Patient Culture contributed far more to overall patient safety than the background characteristics, suggesting that these dimensions are very important in efforts to improve the overall patient safety culture.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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  • 84.
    Danielsson, Marita
    et al.
    Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Health and Developmental Care. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Öhrn, Annica
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Rutberg, Hans
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Fock, Jenni
    Östergötlands Läns Landsting, Center for Health and Developmental Care.
    Carlfjord, Siw
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: a qualitative study.2014In: BMC nursing, ISSN 1472-6955, Vol. 13, no 1, p. 39-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Patient safety culture emerges from the shared assumptions, values and norms of members of a health care organization, unit, team or other group with regard to practices that directly or indirectly influence patient safety. It has been argued that organizational culture is an amalgamation of many cultures, and that subcultures should be studied to develop a deeper understanding of an organization's culture. The aim of this study was to explore subcultures among registered nurses and nurse assistants in Sweden in terms of their assumptions, values and norms with regard to practices associated with patient safety.

    METHODS: The study employed an exploratory design using a qualitative method, and was conducted at two hospitals in southeast Sweden. Seven focus group interviews and two individual interviews were conducted with registered nurses and seven focus group interviews and one individual interview were conducted with nurse assistants. Manifest content analysis was used for the analysis.

    RESULTS: Seven patient safety culture domains (i.e. categories of assumptions, values and norms) that included practices associated with patient safety were found: responsibility, competence, cooperation, communication, work environment, management and routines. The domains corresponded with three system levels: individual, interpersonal and organizational levels. The seven domains consisted of 16 subcategories that expressed different aspects of the registered nurses and assistants nurses' patient safety culture. Half of these subcategories were shared.

    CONCLUSIONS: Registered nurses and nurse assistants in Sweden differ considerably with regard to patient safety subcultures. The results imply that, in order to improve patient safety culture, efforts must be tailored to both registered nurses' and nurse assistants' patient safety-related assumptions, values and norms. Such efforts must also take into account different system levels. The results of the present study could be useful to facilitate discussions about patient safety within and between different professional groups.

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  • 85.
    Dannapfel, Petra
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Peolsson, Anneli
    Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8Article in journal (Refereed)
    Abstract [en]

    Background

    Evidence-based practice has increasingly been recognized as a priority by professional physiotherapy organizations and influential researchers and clinicians in the field. Numerous studies in the past decade have documented that physiotherapists hold generally favorable attitudes to evidence-based practice and recognize the importance of using research to guide their clinical practice. Research has predominantly investigated barriers to research use. Less is known about the circumstances that actually support use of research by physiotherapists. This study explores the conditions at different system levels that physiotherapists in Sweden perceive to be supportive of their use of research in clinical practice.

    Methods

    Patients in Sweden do not need a referral from a physician to consult a physiotherapist and physiotherapists are entitled to choose and perform any assessment and treatment technique they find suitable for each patient. Eleven focus group interviews were conducted with 45 physiotherapists, each lasting between 90 and 110 minutes. An inductive approach was applied, using topics rather than questions to allow the participants to generate their own questions and pursue their own priorities within the framework of the aim. The data were analyzed using qualitative content analysis.

    Results

    Analysis of the data yielded nine favorable conditions at three system levels supporting the participant’s use of research in clinical practice: two at the individual level (attitudes and motivation concerning research use; research-related knowledge and skills), four at the workplace level (leadership support; organizational culture; research-related resources; knowledge exchange) and three at the extra-organizational level (evidence-based practice guidelines; external meetings, networks, and conferences; academic research and education).

    Conclusions

    Supportive conditions for physiotherapists’ use of research exist at multiple interdependent levels, including the individual, workplace, and extra-organizational levels. Research use in physiotherapy appears to be an interactive and interpretative social process that involves a great deal of interaction with various people, including colleagues and patients.

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  • 86.
    Dannapfel, Petra
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Peolsson, Anneli
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Ståhl, Christian
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Applying self-determination theory for improved understanding of physiotherapists rationale for using research in clinical practice: a qualitative study in Sweden2014In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 30, no 1, p. 20-28Article in journal (Refereed)
    Abstract [en]

    Physiotherapists are generally positive to evidence-based practice (EBP) and the use of research in clinical practice, yet many still base clinical decisions on knowledge obtained during their initial education and/or personal experience. Our aim was to explore motivations behind physiotherapists use of research in clinical practice. Self-Determination Theory was applied to identify the different types of motivation for use of research. This theory posits that all behaviours lie along a continuum of relative autonomy, reflecting the extent to which a person endorses their actions. Eleven focus group interviews were conducted, involving 45 physiotherapists in various settings in Sweden. Data were analysed using qualitative content analysis and the findings compared with Self-Determination Theory using a deductive approach. Motivations underlying physiotherapists use of research in clinical practice were identified. Most physiotherapists expressed autonomous forms of motivation for research use, but some exhibited more controlled motivation. Several implications about how more evidence-based physiotherapy can be achieved are discussed, including the potential to tailor educational programs on EBP to better account for differences in motivation among participants, using autonomously motivated physiotherapists as change agents and creating favourable conditions to encourage autonomous motivation by way of feelings of competence, autonomy and a sense of relatedness.

  • 87.
    Davidson, Thomas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Bergström, Anders
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    En pilotstudie av självtestning vid behandling med oral antikoagulantia: Hälsoekonomiska aspekter2013Report (Other academic)
    Abstract [en]

    To avoid the occurrence of thromboembolic events and ischemic stroke in the diagnoses that lead to increased risk of blood clotting, anticoagulant treatment, primarily in the form of warfarin (Waran®), is used. Warfarin requires regular testing to ensure efficient treatment. This testing is normally done at clinics but can also be performed by patients themselves by self-testing.

    This pilot study studies patients who self-test their warfarin therapy in the county of Östergötland, with a focus on costs and cost effectiveness.

    The study has a pre-post design for 12 months where the patients are their own controls. Twenty patients with warfarin therapy were included. The primary outcome measure is the time within therapeutic range before and after the selftesting. Patients answered at three times the instruments EQ-5D and SF-36 as well as questions regarding how much they would hypothetically be willing to pay to use self-testing equipment.

    Mean age was 56 years and 67 percent were male. Percentage of treatment within the therapeutic range was between 57 and 100 percent, with an average of 86 percent. Minor bleeding occurred in 3 patients but no thrombosis occurred. The study is too small to ensure no clinical differences. In total, self-testing cost SEK 180 per session, which was lower than the cost at the clinic (SEK 370). Patients' quality of life (measured in QALY weights) indicated a tendency to rise during the studied 12 months. The willingness-to-pay decreased from SEK 11,526 at baseline to SEK 6,490 after 12 months. As costs have been spared and the effects are expected to be equivalent, self-testing can be considered costeffective. Moreover, since it has been shown that there is a societal willingness to pay for the equipment this strengthens the result that self-testing is costeffective.

    The study’s findings suggest that self-testing leads to lower costs and a trend toward improved quality of life for patients. No clinical differences have been demonstrated. This makes self-testing considered a cost-effective measure of the studied patient population. However, this is a small pilot study and its results need to be verified in larger studies.

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    n pilotstudie av självtestning vid behandling med oral antikoagulantia: Hälsoekonomiska aspekter
  • 88.
    Davidson, Thomas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Lindelof, Ann
    Region Östergötland, Local Health Care Services in East Östergötland.
    Wallen, Torbjorn
    Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Internal Medicine in Norrköping. Vastervik Hospital, Sweden.
    Lindahl, Tomas
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Chemistry.
    Hallert, Claes
    Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Internal Medicine in Norrköping. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland.
    Point-of-care monitoring of warfarin treatment in community dwelling elderly - A randomised controlled study2015In: Journal of Telemedicine and Telecare, ISSN 1357-633X, E-ISSN 1758-1109, Vol. 21, no 5, p. 298-301Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to assess clinical effectiveness and costs of launching point-of-care monitoring of warfarin treatment in community dwelling frail elderly patients. A prospective multicentre controlled randomised study over 12 months comparing a point-of-care strategy with usual monitoring routines was carried out in primary healthcare centres and anticoagulation clinics in southeast Sweden. The subjects were community dwelling elderly across rural southeast Sweden on chronic warfarin treatment. Main outcome measures were time in therapeutic range (TTR), rate of treatment-related adverse events and costs. The study comprised 103 elderly people (61% women) mean age 86 yrs (range 75-98) treated with warfarin for median 9 yrs (range 1-18). Patients randomised to start point-of-care monitoring (n = 55) showed 75.9% in TTR before trial vs. 72.6% during trial (ns). The patients randomised to continue on usual monitoring routines (n = 48) showed 75.2% in TTR prior to trial vs. 72.9% during trial (ns). The point-of-care monitoring showed potential savings of SEK 624 per patient annually (based partly on effects that were not statistically significant). The study shows that point-of-care monitoring of warfarin treatment in community dwelling elderly in rural areas is as effective as usual monitoring routines and that it may offer savings to society.

  • 89.
    Davidson, Thomas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Council Health Technology Assessment, Sweden.
    Rohlin, Madeleine
    Malmö University, Sweden.
    Hultin, Margareta
    Karolinska Institute, Sweden.
    Jemt, Torsten
    University of Gothenburg, Sweden; Branemark Clin, Sweden.
    Nilner, Krister
    Malmö University, Sweden.
    Sunnegardh-Gronberg, Karin
    Umeå University, Sweden.
    Tranaeus, Sofia
    Swedish Council Health Technology Assessment, Sweden; Malmö University, Sweden; Karolinska Institute, Sweden.
    Nilsson, Mats
    County Hospital Ryhov, Sweden.
    Reimbursement systems influence prosthodontic treatment of adult patients2015In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 73, no 6, p. 414-420Article in journal (Refereed)
    Abstract [en]

    Objective. To evaluate the influence of reimbursement system and organizational structure on oral rehabilitation of adult patients with tooth loss. Materials and methods. Patient data were retrieved from the databases of the Swedish Social Insurance Agency. The data consisted of treatment records of patients aged 19 years and above claiming reimbursement for dental care from July 1, 2007 until June 30, 2009. Before July 1, 2008, a proportionately higher level of subsidy was available for dental care in patients 65 years and above, but thereafter the system was changed, so that the subsidy was the same, regardless of the patients age. Prosthodontic treatment in patients 65 years and above was compared with that in younger patients before and after the change of the reimbursement system. Prosthodontic treatment carried out in the Public Dental Health Service and the private sector was also analyzed. Results. Data were retrieved for 722,842 adult patients, covering a total of 1,339,915 reimbursed treatment items. After the change of the reimbursement system, there was a decrease in the proportion of items in patients 65 years and above in relation to those under 65. Overall, there was a minimal change in the proportion of treatment items provided by the private sector compared to the public sector following the change of the reimbursement system. Conclusions. Irrespective of service provider, private or public, financial incentive such as the reimbursement system may influence the provision of prosthodontic treatment, in terms of volume of treatment.

  • 90.
    Davidson, Thomas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University Sweden.
    Tranaeus, Sofia
    Health Technology Assessment-Odontology, Faculty of Odontology, Malmö University; Swedish Agency for Health Technology Assessment of Social Services (SBU); Karolinska Institutet, Dept of Dental Medicine, Hudding.
    Time to Assess Cost-Effectiveness of Technologies in Dentistry2016In: International Journal of Dentistry and Oral Health, ISSN 2378-7090, Vol. 2, no 5Article in journal (Refereed)
    Abstract [en]

    Objective: Health economic evaluations provide decision makers with important information regarding the cost-effectiveness of technologies. However, such evaluations are still rare in most dental areas, and there is furthermore a need for methodological development in estimating costeffectiveness within dentistry. The purpose of this paper is to give an overview of methods used for estimating cost-effectiveness, and provide guidance for performing health economic evaluations within dentistry.

    Methods: Available health economics methods are discussed and analysed according to their usefulness when assessing cost-effectiveness in dentistry.

    Results: All types of health economic analyses may be suitable for evaluation in dentistry. It is most important that the outcome should be relevant to the decision problem. For this reason, various clinical outcomes are often used, such as DMFT or mm adjustment, number of infections, construction survival, etc. depending on what technology is assessed. It would be of value to also use quality-adjusted life-years (QALYs) as this is the most commonly used outcome measure in health economic evaluation, but this has rarely been done.

    Conclusion: There is a need for more health economic evaluations within dentistry to be able to use scarce resources efficiently. In this paper we discuss methods for how this can be done, with a focus on the use of outcome measures relevant for decision makers.

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  • 91.
    de Fine Licht, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Öppna prioriteringar och extern legitimitet: En experimentell undersökning om hur människor uppfattar information om prioriteringar av sjukvård2011Report (Other academic)
    Abstract [en]

    One of the great challenges of our time concerns how to allocate scarce healthcare resources in a way that the population can accept and trust. Projections indicate that the need to set priorities in health care is more likely to increase than decrease in pace with advancing medical technology and an aging population. Concurrently, the population’s demands and expectations on health services are growing stronger.

    This report explores the potential to gain acceptance for prioritisation decisions and create confidence in health services through transparent information about the decisions and the decision-making processes in priority setting. The focus is on external legitimacy, i e legitimacy in relation to citizens. The report presents a review of the theoretical literature on transparency and procedural equity, discussing arguments that support and oppose a positive effect from transparent prioritisation. The report also presents two Web-based experiments that empirically test how people react to information about the decisions and the decision-making processes in priority setting. Participants were asked to read a fictitious prioritisation case and then answer standardised questions that enabled statistical comparisons. They were also asked to describe their reactions and opinions in their own words. One experiment involved horizontal prioritisation where choices were made between different treatments at a general level, and another involved principles for vertical prioritisation where choices were made between patients.

    The results of the study suggest that we face considerable educational challenges in explaining the necessity of prioritisation to the population. Some groups perceive priority setting in health care as a threat against the principle that everyone has equal worth, or against the common belief that human life should not be valued in monetary terms. Likewise, some people place great faith in efficiency, redistribution, or tax increases as means to solve the problem of resource shortages, without the need for prioritisation.

    The study also presents several effects that can be perceived as positive for those who aim to work with transparent prioritisation 

    Although confidence in health services is at risk of temporarily declining when people are informed of prioritisation decisions and decision-making processes, their confidence appears to return again after only a month unless the person becomes deeply engaged in the issue. This might be a risk that decision makers are willing to take to be open and clear about how priorities are set, which is in line with democratic ideals. Moreover, there is a

    tendency that some type of information, either the reasons behind the decisions or details about the decision-making process, could improve public acceptance more than if people were simply asked for their opinion about a particular decision.

    People do not appear to give much weight to the design of the decision- making process, but seem to be satisfied by knowing the reasons behind the decisions. Since providing more detailed information on the decision making process does not appear to enhance legitimacy, perhaps energy and resources could be saved on this front. Furthermore, nothing was found that suggests that people would be more likely to accept a particular decision if it were made by physicians, or via a process involving a citizen panel, instead of by politicians. Findings show, however, some support indicating that it is viewed as positive when decision makers agree on the decision.

    How to distribute healthcare resources in an acceptable and trustworthy manner is an important question of major concern. There is every reason to pursue further research in this exciting area fundamental to the welfare state.

    The writer of this report extend her sincere appreciation to those who participated in the seminar held by the National Centre for Priority Setting in Health Care and to Daniel Naurin, Marcia Grimes, and Karl Persson for their valuable comments on earlier drafts. Also, a special thanks goes to all e- panel participants who took time to respond to the – at times difficult and complex – questions in this investigation.

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    Öppna prioriteringar och extern legitimitet: En experimentell undersökning om hur människor uppfattar information om prioriteringar av sjukvård
  • 92.
    de Groot, Folkert
    et al.
    ToendersdeGroot B.V. Boomstede 281, 3608 AN, Maarssen, The Netherlands.
    Capri, Stefano
    School of Economics and Management, LIUC University, Castellanza, Italy.
    Castanier, Jean-Claude
    Independent Consultat, Bandol, France.
    Cunningham, David
    South East Commissioning Support Unit, London, UK.
    Flamion, Bruno
    University of Namur, Namur, Belgium.
    Flume, Mathias
    Kassenärztliche Vereinigung Westfalen, Lippe, Dortmund, Germany.
    Herholz, Harald
    Kassenärztliche Vereinigung Hessen, Frankfurt, Germany.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Solà-Morales, Oriol
    Health Institute for Technology Transfer (HITT), Barcelona, Spain.
    Rupprecht, Christoph J
    AOK Rheinland/Hamburg, Düsseldorf, Germany.
    Shalet, Natalie
    NAS Healthcare Solutions Ltd., Surbiton, UK.
    Walker, Andrew
    University of Glasgow, Glasgow, UK.
    Wong, Olivier
    Mediqualité Omega, Parin, France.
    Ethical Hurdles in the Prioritization of Oncology Care.2017In: Applied Health Economics and Health Policy, ISSN 1175-5652, E-ISSN 1179-1896, Vol. 15, no 2, p. 119-126Article in journal (Refereed)
    Abstract [en]

    With finite resources, healthcare payers must make difficult choices regarding spending and the ethical distribution of funds. Here, we describe some of the ethical issues surrounding inequity in healthcare in nine major European countries, using cancer care as an example. To identify relevant studies, we conducted a systematic literature search. The results of the literature review suggest that although prevention, access to early diagnosis, and radiotherapy are key factors associated with good outcomes in oncology, public and political attention often focusses on the availability of pharmacological treatments. In some countries this focus may divert funding towards cancer drugs, for example through specific cancer drugs funds, leading to reduced expenditure on other areas of cancer care, including prevention, and potentially on other diseases. In addition, as highly effective, expensive agents are developed, the use of value-based approaches may lead to unacceptable impacts on health budgets, leading to a potential need to re-evaluate current cost-effectiveness thresholds. We anticipate that the question of how to fund new therapies equitably will become even more challenging in the future, with the advent of expensive, innovative, breakthrough treatments in other therapeutic areas.

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  • 93.
    Dong, Huan-Ji
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Larsson, Britt
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Is excess weight a burden for older adults who suffer chronic pain?2018In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 18, article id 270Article in journal (Refereed)
    Abstract [en]

    BackgroundObesity and chronic pain are common comorbidities and adversely influence each other. Advanced age is associated with more comorbidities and multi-morbidities. In this study, we investigated the burden of overweight/obesity and its comorbidities and their associations with chronic pain in a random population sample of Swedish older adults.MethodsThe cross-sectional analysis involved a random sample of a population65years in south-eastern Sweden (N=6243). Data were collected from a postal questionnaire that addressed pain aspects, body mass index (BMI), and health experiences. Chronic pain was defined as pain during the previous three months. According to the 0-10 Numeric Rating Scale, pain scored 7 corresponds to severe pain. Binary logistic regression was used to determine the variables associated to pain aspects.ResultsA total of 2633 (42%) reported chronic pain. More obese older adults (BMI 30kg/m(2)) experienced chronic pain (58%) than those who were low-normal weight (BMI amp;lt;25kg/m(2), 39%) or overweight (25BMI amp;lt;30kg/m(2), 41%). Obese elderly more frequently had pain in extremities and lower back than their peers. In the multivariate model, obesity (Odds Ratio (OR) 1.59, 95% Confidence Interval (CI) 1.33-1.91) but not overweight (OR 1.08, 95% CI 0.95-1.22) was associated with chronic pain. Obesity (OR 1.53, 95% CI 1.16-2.01) was also significantly related to severe pain. We also found other comorbidities - i.e., traumatic history (OR 2.52, 95% CI 1.99-3.19), rheumatic diseases (OR 5.21, 95% CI 4.54-5.97), age85years (OR 1.66, 95% CI 1.22-2.25), and depression or anxiety diagnosis (OR 1.83, 95% CI 1.32-2.53) - showed stronger associations with pain aspects than weight status. Conclusion: In older adults, excess weight (BMI 30 or above) is a potentially modifiable factor but not the only risk factor that is associated with chronic pain and severe pain. Future studies should investigate the effectiveness of interventions that treat comorbid pain and obesity in older adults.

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  • 94.
    Doupi, Persephone
    et al.
    National Institute Health and Welf, Finland.
    Svaar, Helge
    Svaar Konsult, Norway.
    Bjorn, Brian
    Danish Soc Patient Safety, Denmark.
    Deilkas, Ellen
    Akershus University Hospital, Norway; Norwegian Directorate Heatlh, Norway.
    Nylen, Urban
    Karolinska University Hospital, Sweden.
    Ruthberg, Hans
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Use of the Global Trigger Tool in patient safety improvement efforts: Nordic experiences2015In: Cognition, Technology & Work, ISSN 1435-5558, E-ISSN 1435-5566, Vol. 17, no 1, p. 45-54Article in journal (Refereed)
    Abstract [en]

    The Global Trigger Tool (GTT) developed by the Institute for Healthcare Improvement is a method for retrospective patient record review based on the use of triggers-signals of potential adverse events that have caused patient harm. The method has the purpose of patient safety measurement and monitoring among adult inpatient populations and has been increasingly popular among Nordic countries. Use of the GTT in the Nordic area has been part of broader legal and policy actions and initiatives supportive of patient safety promotion and is being used to establish also national level estimates of patient safety incidents. Limitations of the method are its dependency on quality of documentation and the varying inter-rater reliability observed in many studies. Strengths of the GTT are its ability to detect larger numbers, as well as different types of adverse events when compared to other incident detection methods, hence it is a good addition to the palette of means for organizational patient safety monitoring. Research on reliability, usefulness and implementation approaches of the GTT, including its automation, is ongoing in the Nordic countries and is expected to generate useful input for the international patient safety community.

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  • 95.
    Dragioti, Elena
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Larsson, Britt
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Association of insomnia severity with well-being, quality of life and health care costs: A cross-sectional study in older adults with chronic pain (PainS65+)2018In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 22, no 2, p. 414-425Article in journal (Refereed)
    Abstract [en]

    BackgroundInsomnia is one of the most common complaints in chronic pain. This study aimed to evaluate the association of insomnia with well-being, quality of life and health care costs. MethodsThe sample included 2790 older individuals (median age=76; interquartile range [IQR]=70-82) with chronic pain. The participants completed a postal survey assessing basic demographic data, pain intensity and frequency, height, weight, comorbidities, general well-being, quality of life and the insomnia severity index (ISI). Data on health care costs were calculated as costs per year (Euro prices) and measured in terms of outpatient and inpatient care, pain drugs, total drugs and total health care costs. ResultsThe overall fraction of clinical insomnia was 24.6% (moderate clinical insomnia: 21.9% [95% CI: 18.8-23.3]; severe clinical insomnia: 2.7% [95% CI: 1.6-3.2]). Persons who reported clinical insomnia were more likely to experience pain more frequently with higher pain intensity compared to those reported no clinically significant insomnia. Mean total health care costs were Euro 8469 (95% CI: Euro4029-Euro14,271) for persons with severe insomnia compared with Euro 4345 (95% CI: Euro4033-Euro4694) for persons with no clinically significant insomnia. An association between severe insomnia, well-being, quality of life, outpatient care, total drugs costs and total health care costs remained after controlling for age, sex, pain intensity, frequency, body mass index and comorbidities using linear regression models. ConclusionsOur results determine an independent association of insomnia with low health-related quality of life and increased health care costs in older adults with chronic pain. SignificanceThe concurrence and the severity of insomnia among older adults with chronic pain were associated with decreased well-being and quality of life, and increased health care costs to society.

  • 96.
    Dragioti, Elena
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Larsson, Britt
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    A cross-sectional study of factors associated with the number of anatomical pain sites in an actual elderly general population: results from the PainS65+cohort2017In: Journal of Pain Research, ISSN 1178-7090, E-ISSN 1178-7090, Vol. 10, p. 2009-2019Article in journal (Refereed)
    Abstract [en]

    Background: Several studies have illustrated that multisite pain is more frequent than single pain site, and it is associated with an array of negative consequences. However, there is limited knowledge available about the potential factors associated with multisite pain in the elderly general population. Objective: This cross-sectional study examines whether the number of anatomical pain sites (APSs) is related to sociodemographic and health-related factors in older adults including oldestold ages using a new method (APSs) to assess the location of pain on the body. Materials and methods: The sample came from the PainS65+ cohort, which included 6,611 older individuals (mean age = 76.0 years; standard deviation [SD] = 7.4) residing in southeastern Sweden. All the participants completed and returned a postal survey that measured sociodemographic data, total annual income, pain intensity and frequency, general well-being, and quality of life. The number of pain sites (NPS) was marked on a body manikin of 45 sections, and a total of 23 APSs were then calculated. Univariable and multivariable models of regression analysis were performed. Results: Approximately 39% of the respondents had at least two painful sites. The results of the regression analysis showed an independent association between the APSs and the age group of 75-79 years, women, married, high pain intensity and frequency, and low well-being and quality of life, after adjustments for consumption of analgesics and comorbidities. The strongest association was observed for the higher frequency of pain. Conclusion: Our results suggest that APSs are highly prevalent with strong relationships with various sociodemographic and health-related factors and concur well with the notion that multisite pain is a potential indicator of increased pain severity and impaired quality of life in the elderly. Our comprehensive method of calculating the number of sites could be an essential part of the clinical presentation, assessment, and treatment of multisite pain.

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  • 97.
    Dragioti, Elena
    et al.
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Larsson, Britt
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Allergy Center.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Prevalence of different pain categories based on pain spreading on the bodies of older adults in Sweden: a descriptive-level and multilevel association with demographics, comorbidities, medications, and certain lifestyle factors (PainS65+)2016In: Journal of Pain Research, ISSN 1178-7090, E-ISSN 1178-7090, Vol. 9, p. 1131-1141Article in journal (Refereed)
    Abstract [en]

    Background and objective: There is limited knowledge about the prevalence of pain and its relation to comorbidities, medication, and certain lifestyle factors in older adults. To address this limitation, this cross-sectional study examined the spreading of pain on the body in a sample of 6611 subjects amp;gt;= 65 years old (mean age = 75.0 years; standard deviation [SD] = 7.7) living in southeastern Sweden. Methods: Sex, age, comorbidities, medication, nicotine, alcohol intake, and physical activity were analyzed in relation to the following pain categories: local pain (LP) (24.1%), regional pain medium (RP-Medium) (20.3%), regional pain heavy (RP-Heavy) (5.2%), and widespread pain (WSP) (1.7%). Results: RP-Medium, RP-Heavy, and WSP were associated more strongly with women than with men (all pamp;lt;0.01). RP-Heavy was less likely in the 80-84 and amp;gt;85 age groups compared to the 65-69 age group (both pamp;lt;0.01). Traumatic injuries, rheumatoid arthritis/osteoarthritis, and analgesics were associated with all pain categories (all pamp;lt;0.001). An association with gastrointestinal disorders was found in LP, RP-Medium, and RP-Heavy (all pamp;lt;0.01). Depressive disorders were associated with all pain categories, except for LP (all pamp;lt;0.05). Disorders of the central nervous system were associated with both RP-Heavy and WSP (all pamp;lt;0.05). Medication for peripheral vascular disorders was associated with RP-Medium (pamp;lt;0.05), and hypnotics were associated with RP-Heavy (pamp;lt;0.01). Conclusion: More than 50% of older adults suffered from different pain spread categories. Women were more likely to experience greater spreading of pain than men. A noteworthy number of common comorbidities and medications were associated with increased likelihood of pain spread from LP to RP-Medium, RP-Heavy, and WSP. Effective management plans should consider these observed associations to improve functional deficiency and decrease spreading of pain-related disability in older adults.

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  • 98.
    Dragioti, Elena
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Larsson, Britt
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Insomnia severity and its relationship with demographics, pain features, anxiety, and depression in older adults with and without pain: cross-sectional population-based results from the PainS65+cohort2017In: Annals of General Psychiatry, ISSN 1744-859X, E-ISSN 1744-859X, Vol. 16, article id 15Article in journal (Refereed)
    Abstract [en]

    Background: Insomnia is a major cause of concern in the elderly with and without pain. This study set out to examine the insomnia and its correlates in a large sample of community adults aged amp;gt;= 65 years. Methods: A cross-sectional postal survey was completed by 6205 older individuals (53.8% women; mean age = 76.2 years; SD = 7.5). The participants also completed the Insomnia Severity Index (ISI) and questionnaires assessing pain intensity, pain spreading, anxiety, depression, and basic demographic information. The sample was divided into three groups based on the presence and duration of pain: chronic pain (CP; n = 2790), subacute pain (SP; n = 510), and no pain (NP; n = 2905). Results: A proportion of each of the groups had an ISI score of 15 or greater (i.e., clinical insomnia): CP = 24.6%; SP = 21.3%; and NP = 13.0%. The average scores of ISI differed significantly among CP, SP, and NP groups (p amp;lt; 0.001). Stratified regression analyses showed that pain intensity, pain spreading, anxiety, and depression were independently related to insomnia in the CP group. Anxiety and depression were independently related to insomnia in the SP group, but only anxiety was significantly associated with insomnia in the NP group. Age and sex were not associated with insomnia. Conclusions: This study confirms that insomnia is not associated with chronological aging per se within the elderly population. Although the possible associations of insomnia with pain are complex, ensuing from pain intensity, pain spreading, anxiety, and depression, our results highlighted that anxiety was more strongly associated with insomnia in all groups than the depression and pain characteristics. Therapeutic plans should consider these relations during the course of pain, and a comprehensive assessment including both pain and psychological features is essential when older people are seeking primary health care for insomnia complaints.

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  • 99.
    Duvetorp, Albert
    et al.
    Skane Univ Hosp, 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.
    Engerstedt Mattsson, Emma
    LEO Pharma AS, Denmark.
    Ryttig, Lasse
    LEO Pharma AS, Denmark.
    A Cost-utility Analysis of Calcipotriol/Betamethasone Dipropionate Aerosol Foam versus Ointment for the Topical Treatment of Psoriasis Vulgaris in Sweden2019In: Acta Dermato-Venereologica, ISSN 0001-5555, E-ISSN 1651-2057, Vol. 99, no 4, p. 393-399Article in journal (Refereed)
    Abstract [en]

    Psoriasis is a chronic inflammatory disorder that imposes a substantial economic burden. We conducted a cost-utility analysis from a Swedish healthcare payers perspective using a decision-tree model with a 12-week time horizon. Patients with psoriasis vulgaris could have two 4-week cycles of topical treatment with calcipotriol 50 mu g/g and betamethasone 0.5 mg/g as dipropionate (Cal/BD) foam or Cal/BD ointment before progressing to phototherapy/methotrexate. In the base-case analysis, Cal/BD foam dominated over Cal/BD ointment. The increased efficacy of Cal/BD foam resulted in fewer consultations and a decreased risk of progressing to phototherapy/methotrexate. Although Cal/BD foam costs more than Cal/BD ointment, this was offset by lower costs for phototherapy/methotrexate or consultation visits. Sensitivity analyses revealed that the base-case net monetary benefit was robust to plausible variations in key parameters. In conclusion, Cal/BD foam was predicted to be more cost-effective than Cal/BD ointment in the treatment of psoriasis vulgaris.

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  • 100. Order onlineBuy this publication >>
    Eckard, Nathalie
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    The matter of economic evaluations in health policy decision-making: The case of the Swedish national guidelines for heart diseases2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Economic evaluations are used to inform decision makers about the efficient allocation of scarce healthcare resources and are generated with the direct intent to support decisions in healthcare. Producing guidelines is a complex process and the inclusion of health-economic aspects in the formulation of the Swedish national guidelines as a basis for the written recommendations (priority gradings), distinguishes them from their European counterparts. Despite the increased use of cost-effectiveness data in decision-making, little is known about the actual use of such data. This thesis covers issues concerning how economic evaluations matter in health policy decision-making. The thesis includes four papers based on the Swedish national guidelines for heart diseases, one of the most prominent examples in Sweden of following the notion of evidence-based policy (EBP), in order to inform explicit priority setting.

    Both Papers I and II followed a qualitative case study design, based on the same data set. Paper I explored how a specific working group, the Priority Setting Group (PSG), handled the various forms of evidence and values when producing the national guidelines. Two themes were identified in reaching collective agreement in priority gradings; group facilitation activities and avoiding deadlock in the discussion. The work process involved disagreement and negotiation as part of that task. Paper I contributes to the theoretical and practical debate on EBP. Paper II focused on the use of cost-effectiveness data as decision support in the PSG work process. The paper addressed availability of cost-effectiveness data, evidence understanding, interpretation difficulties, and the reliance on evidence. Three themes were identified. The paper contributes to knowledge on how cost-effectiveness evidence was used in actual decision-making. The use of cost-effectiveness evidence was one of many tools employed to avoid deadlock in discussion and to reach a priority grading, when the overall evidence base was weak, in times of uncertainty and on the introduction of new expensive medical technologies.

    Quantitative research methods were used for both Papers III and IV. Paper III explored how the PSG was presented with cost-effectiveness evidence as decision support and as a basis for their priority gradings. Cost-effectiveness ratios (ICERs) were provided, based on a  systematic literature review, as well as how the results may be conveyed and communicated, for the treatment of heart diseases using a cost-effectiveness ranking or league and providing valid information within a limited space, aiding decision makers on the allocation of healthcare resources. The thesis also includes decision support in the form of cost-effectiveness analysis on catheter ablation treatment. Paper IV provides an example of presenting evidence in the form of a decision-analytic model. The modelling approach provides an analytic framework for decision-making, specifically under conditions of uncertainty as in the introduction of new medical technology. Catheter ablation was associated with reduced cost and an incremental gain in quality adjusted life years (QALYs), and was considered a cost-effective treatment strategy compared to the medical treatment strategy in a lifetime perspective.

    List of papers
    1. Reaching agreement in uncertain circumstances: the practice of evidence-based policy in the case of the Swedish National Guidelines for heart diseases
    Open this publication in new window or tab >>Reaching agreement in uncertain circumstances: the practice of evidence-based policy in the case of the Swedish National Guidelines for heart diseases
    2017 (English)In: Evidence and Policy: A Journal of Research, Debate and Practice, ISSN 1744-2648, no 4, p. 687-707Article in journal (Refereed) Published
    Abstract [en]

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

    Place, publisher, year, edition, pages
    Informa Healthcare, 2017
    Keywords
    cost-effectiveness; evidence-based policy; healthcare; national guidelines; priority setting; sense-making
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy Other Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-121280 (URN)10.1332/174426416X14788795557982 (DOI)000417405400007 ()
    Available from: 2015-09-11 Created: 2015-09-11 Last updated: 2017-12-29Bibliographically approved
    2. Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden
    Open this publication in new window or tab >>Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden
    2014 (English)In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 3, no 6, p. 323-332Article in journal (Refereed) Published
    Abstract [en]

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

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

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

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

    Place, publisher, year, edition, pages
    Kerman University of Medical Sciences, 2014
    Keywords
    Health Policy, Cost-Effectiveness, Policy Decision-Making, Priority Setting, Heart Diseases
    National Category
    Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-112150 (URN)10.15171/ijhpm.2014.105 (DOI)25396208 (PubMedID)
    Available from: 2014-11-17 Created: 2014-11-17 Last updated: 2017-12-05Bibliographically approved
    3. Compilation of cost-effectiveness evidence for different heart conditions and treatment strategies
    Open this publication in new window or tab >>Compilation of cost-effectiveness evidence for different heart conditions and treatment strategies
    2011 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 45, no 2, p. 72-76Article, review/survey (Refereed) Published
    Abstract [en]

    Objectives. Despite the continuing interest in health economic research, we could find no accessible data set on cost-effectiveness, useful as practical information to decision makers who must allocate scarce resources within the cardiovascular field. The aim of this paper was to present cost-effectiveness ratios, based on a systematic literature search for the treatment of heart diseases. Design. A comprehensive literature search on cost-effectiveness analyses of intervention strategies for the treatment of heart diseases was conducted. We compiled available cost-effectiveness ratios for different heart conditions and treatment strategies, in a cost-effectiveness ranking table. The cost-effectiveness ratios were expressed as a cost per quality adjusted life year (QALY) or life year gained. Results. Cost-effectiveness ratios, ranging from dominant to those costing more than 1,000,000 Euros per QALY gained, and bibliographic references are provided for. The table was categorized according to disease group, making the ranking table readily available. Conclusions. Cost-effectiveness ranking tables provide a means of presenting cost-effectiveness evidence. They provide valid information within a limited space aiding decision makers on the allocation of health care resources. This paper represents an extensive compilation of health economic evidence for the treatment of heart diseases.

    Place, publisher, year, edition, pages
    Informa Healthcare, 2011
    Keywords
    Cost, cost-effectiveness, rankings, heart disease, priority setting, evidence-based medicine
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-67153 (URN)10.3109/14017431.2011.557438 (DOI)000288326200002 ()
    Note
    Original Publication: Nathalie Eckard, Magnus Janzon and Lars-Åke Levin, Compilation of cost-effectiveness evidence for different heart conditions and treatment strategies, 2011, Scandinavian Cardiovascular Journal, (45), 2, 72-76. http://dx.doi.org/10.3109/14017431.2011.557438 Copyright: Informa Healthcare http://informahealthcare.com/ Available from: 2011-04-01 Created: 2011-04-01 Last updated: 2017-12-11
    4. Cost-Effectiveness of Catheter Ablation Treatment for Patients with Symptomatic Atrial Fibrillation
    Open this publication in new window or tab >>Cost-Effectiveness of Catheter Ablation Treatment for Patients with Symptomatic Atrial Fibrillation
    2009 (English)In: Journal of Atrial Fibrillation, ISSN 1941-6911, Vol. 1, no 8, p. 461-470Article in journal (Refereed) Published
    Abstract [en]

    Background:  Atrial Fibrillation is the most common cardiac arrhythmia.  It increases the risk of thromboembolic events and many atrial fibrillation patients suffer quality of life impairment due to disturbed heart rhythm.  Pulmonary vein isolation using radiofrequency catheter ablation treatment is aimed at maintaining sinus rhythm ultimately improving quality of life.  Randomized clinical trial have shown that catheter ablation is more effective than antiarrhythmic drugs for the treatment of atrial fibrillation, but its impact on quality of life and cost-effectiveness has not been widely studied.  Aims:  To assess the cost-effectiveness of radiofrequency ablation (RFA) vs. antiarrhythmic drug (AAD) treatment, among symptomatic atrial fibrillation patients not previously responding to AAD.  Methods:  A decision-analytic Markov model was developed to assess costs and health outcomes in terms of quality adjusted life years (QALYs) of RFA and AAD over a lifetime time horizon.  We conducted a literature search and used data from several sources as input variables of the model.  One-year rates of atrial fibrillation with RFA and AAD, respectively, were available from published randomized clinical trials.  Other data sources were published papers and register data.  Results:  The RFA treatment strategy was associated with reduced costs and an incremental gain in QALYs compared to the AAD treatment strategy.  The results were sensitive to whether long-term quality of life improvement is maintained for the RFA treatment strategy and the risk of stroke in the different atrial fibrillation health states.  Conclusion:  This study shows that the short-term improvement in atrial fibrillation associated with RFA is likely to lead to long-term quality of life improvement and lower costs indicating that RFA is cost-effective compared to AAD. 

    Keywords
    Cost, cost-effectiveness, decision-analytic model, ablation, atrial fibrillation, cardiovascular disease
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-20923 (URN)10.4022/jafib.v1i8.543 (DOI)
    Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2015-09-11
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    The matter of economic evaluations in health policy decision-making: The case of the Swedish national guidelines for heart diseases
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