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  • 1.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kalkan, Almina
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Preferenser och perspektiv vid beräkning av QALY2012In: QALY som effektmått inom vården: möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, p. 15-29Chapter in book (Other academic)
  • 2.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, The Institute of Technology.
    Krevers, Barbro
    Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Teknik för personer med demens: En utvärderingsstudie av teknikintervention för personer med demenssjukdom och deras närstående2008Report (Other academic)
    Abstract [en]

    The overall aim of this study was to study costs and effects of an assistive technology intervention that included assistive technology, support and strategies for persons with dementia and their relatives. Further, the aim was to study the quality of the intervention process and how it was perceived by the participants in the project.

    This assessment study was performed within a project called “Technology and Dementia – development work, create methods and increase competence”. This project was coordinated by the Swedish Institute of Assistive Technology in collaboration with the Alzheimer Society in Sweden and the Dementia Association and was funded by the Swedish Inheritance Fund, Linköping University and the County Council of Östergötland. Two national resource centres were appointed within the project. These developed the assistive technology intervention.

    The study was designed as a pre/post study. Data was collected at three different occasions of measurement: baseline, first follow-up (four weeks after the intervention) and second follow-up (twelve weeks after the intervention). Different outcome measures were used to study the effect of the intervention: health related quality of life (HRQoL), support/caregiving situation, quality of sleep, perception of time and ability to perform everyday life activities. The costs in the study had a societal perspective. A process oriented instrument was used to study the quality of the intervention process. Persons with dementia as well as their relatives answered questionnaires and interviews in the study.

    Data was collected via interviews at the resource centres, via self ratings and through telephone interviews from the research team. The total population included in the analyses was 48 persons with dementia and 47 relatives.

    The results showed that there were no significant differences in effects between baseline and the two follow-ups, except for ability to perform everyday activities where data indicated deterioration during the study period. In one dimension of HRQoL for the relatives there was also a significant difference; the relatives rated greater difficulties at the second follow-up. Cognitive ability was used as a measure for disease stability during the study, and showed no significant differences. There was, however, a rather large drop-out at the second follow-up (15 %) in data on cognitive ability, therefore this result should be interpreted with caution; the persons with dementia may have deteriorated during the study period. This could be reflected in the deterioration in the ability to perform everyday life activities measure.

    The persons with dementia rated their HRQoL higher than the relatives’ proxy ratings (i.e. relatives’ ratings of the HRQoL of the persons with dementia), the differences between the proxy ratings and the persons’ own ratings were significant at all three occasions of measurement. The relatives rated their own HRQoL somewhat higher than the persons with dementia rated their own HRQoL. There were no significant differences between baseline and the followups.

    The intervention included many different types of assistive technologies. The cost of the intervention was 16 000 SEK/person with dementia and relative. There were no significant differences in costs of formal care during the study period. Many relatives performed informal care many hours of the day. Even though the differences in informal caregiving between baseline and the second follow-up were not significant there was a tendency of a slight increase in informal care time of everyday life activities and there was also a decrease in time spent supervising, a little less than one hour per day.

    An evaluation of the quality of the intervention process and how it was perceived was performed. Most relatives perceived that their needs were well fulfilled during the intervention process. Some aspects were brought forward where the intervention process could be improved. Seventy-two percent of the relatives rated the intervention as of great importance, 28 percent rated the intervention as of some importance or of no importance. The persons with dementia had higher expectations on the intervention than the relatives and most persons with dementia perceived the intervention as of great importance.

    Technology and Dementia was a trial project where potential effects and costs were studied. The study was explorative and contributes to increasing the knowledge on use of assistive technology in dementia and also on assessment methodology within this field. There were limitations in the study regarding size of the study population and lack of a comparison group.

    Assessing assistive technology for persons with dementia and their relatives from a socioeconomic perspective entails certain methodological challenges. A model for assessment of assistive technology interventions was developed and tried in this study. Results and methodology are discussed in relation to the assessment model. From this assessment study, areas have been identified for future studies. Future studies will be performed through subgroup analyses to identify groups where the intervention was successful and groups where the intervention was not successful.

     

  • 3.
    Aronsson, Mattias
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hälsoekonomisk förstudie av digital patologi: Var finns de potentiella vinsterna?2015Report (Other academic)
    Abstract [en]

    Background

    There is an ongoing development in pathology laboratories towards increased digital storage and analysis of images from tissue samples through computer screens instead of conventional microscopes. The digital storage of information has a number of potential advantages. The information can be used by several individuals simultaneously, even remotely, which facilitates the use of expert knowledge and provide opportunities for increased capacity utilization.

    An expected increase in costs resulting from the implementation of digital pathology combined with uncertainty about the positive effects makes health economic analyses requested. Lack of data regarding the effects of digitalization has not yet allowed any adequate evaluations of the health economic aspects. Despite the practical difficulties that exist today, there are reasons to start thinking about what we want to investigate, how to do it and the possibility to fill current knowledge gaps.

    Purpose

    The purpose of this study is to investigate how a health economic evaluation of digital pathology can be designed, the possibility to make such an evaluation based on available data and identify the need for additional research.

    Method

    Digitalization of a pathology laboratory includes and affects many of the current activities at the unit in a complex manner. Therefore, the total economic effect of time savings, increased costs due to added operations, storage, and new equipment need to be studied.

    To make an early attempt to identify the costs and benefits of digital pathology in the present analysis we used three models with different perspectives. Shortterm and long-term potential effects of a full-scale implementation were analyzed with the use of the three analytical models.

    Results

    Important information is missing regarding the situation today, but above all,about the effects of a digitalization. This means that it is currently impossible tomake calculations or well-informed conclusions regarding the health economicimpact of a digitalization. However, using the three models we could make someconclusions. We have speculated on the potential benefits of a full-scale digitalization in two of the three models. Model 1 can be used to analyze an improved work flow within the pathology unit, above all, it is interesting to try to measure the average processing time per slide for the pathologist. Model 2 can be used to study how a reduction in waiting times for PAD-results affects the patient in terms of reduced anxiety. Based on Model 3, we conclude that it is unlikely that any shortened waiting times as a result of a digitalization means measurable medical benefit. However, it is important to point out that we only studied one example where a medical benefit could be expected.

    Conclusions

    • No scientific evaluation of the effects and costs regarding the diglization ofpathology laboratories in a Swedish setting were identified.
    • In the current situation it is not possible to make exact calculations or wellinformedconclusions regarding the health economic impact of a digitalizationas basic performance data and reliable cost data are not available.
    • With the help of the three models developed in this analysis it is possible todraw some conclusions about what types of data that are relevant to study.Model 1 can be used to analyze an improved work flow within the pathologyunit. Model 2 can be used to study how a reduction in waiting times for PADresultsaffect the patient in terms of reduced anxiety. Model 3 can be used as abasis for identification and analyze of situations in the health care where ashorter response time can influence clinical decisions.

    Studies of patient´s quality of life while waiting for test results is an exampleof data that need to be investigated for future health economic analyses. Suchanalyses would also benefit from an improved reporting of cost data. A thirdarea concerns studies of unnecessary or inaccurate health care due to false testresults.

  • 4.
    Arvidsson, Eva
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    André, Malin
    Falun.
    Borgquist, Lars
    Linköping University, Department of Department of Health and Society, General Practice. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Lindström, Kjell
    Falun.
    Så resonerar läkare och sjuksköterskor vid prioriteringar av patienter i primärvård2007Report (Other academic)
    Abstract [en]

     

    Background

    Experience from work with priority setting in health and medical care indicates that the ethical guidelines that are at the heart of Swedish Parliament’s principles for priority  setting  are difficult  to implement  into practical  clinical  decision- making. The same can be said of the model for priority setting drawn up by the Swedish National Board of Health and Welfare in the national guidelines  for care and treatment. For this reason, we need more knowledge on how principles for priority setting and related concepts are perceived by medical care personnel, the relevance of these concepts, and if there are other aspects that also impact the priority setting situation.  We also need to develop  new work methods  to meet Parliament’s intentions with priority setting in health and medical care.

    To contribute  to the development  of new  work  methods,  we chose  to study priority setting in primary care practice. Our primary purpose was to describe the way in which general practitioners and district nurses perceive the concepts severity  of  illness,  benefit  and  cost-effectiveness  when  they  rank  priority  for individual patients. Our secondary purpose was to compare medical personnel’s perception of the concepts severity of illness, benefit and cost-effectiveness with the definitions  of these  concepts  in the model  for vertical  priority  setting  as established by the National Board of Health and Welfare.

    Methods

    Focus group interviews as a source of data collection was selected as the method since the study was explorative and the intention was to obtain as many aspects as possible pertaining  to priority setting concepts.  The method is suitable for collecting a large amount of information within a previously unexplored subject. Interviews were conducted with eight groups of physicians and nurses from four different primary care centers. The respondents  selected had participated  in a prospective  study  on  practical  priority  setting,  i.e.  they  had  experience  of implementing the concepts severity of illness, benefit, and cost-effectiveness in setting priorities in their daily work.

    Results and Conclusions

    Both  the  physicians  and  nurses  expressed  a  simplified  interpretation  of  the concepts severity of illness and benefit. One example of such simplification was that many nurses said that when ranking the severity of a condition, they based their decision on how imperative  it was for the patient to see a physician.  A

     

    common response was that the concepts could be assessed from both patient and staff perspectives  but that these assessments  could differ. When asked to set priorities according to a specific template, respondents said that it was easier to rank patients with an acute condition that had a tangible effect on function and that could be immediately treated, than to rank patients according to factors that were a risk to their future health. This means that priority judgements based on knowledge of a patient category were perceived as uncertain and more difficult to use than direct personal experience of treating an individual patient. This was discussed, above all, by the physicians. Respondents gave several examples of actions taken despite that medical staff did not feel that there was any benefit to the patient.

    In a comparison  of how these three concepts  are described  in the model for priority setting on the policy level drawn up by the National Board of Health and Welfare and how medical personnel implemented the concepts, we found both similarities and dissimilarities.

    A model based on these concepts can be of use in priority setting in primary care, but it must be supplemented  and improved  to be applicable  to ranking patients  in day-to-day  medical  care. Supplements  that may be necessary  are; clarification that a combination of medical and patient perspectives is intended, clarification of how to use the concept cost-effectiveness, and the addition of a time factor and factors related to the individual patient. There is also a need for a more  structured  way  of working  with evidence-based  care.  We also  need  to clarify the differences between setting priorities for patient categories and for individual patients in day-to-day medical care.

    In our opinion, the model for priority setting on the patient category level can be improved  to  be  more  applicable  as  a  template  for  decision-making  on  the individual patient level, however a supplementary  model may be necessary to support priority setting on the individual level.

  • 5.
    Bartha, Erzsébet
    et al.
    Linköping University, Department of Medicine and Care, Anaesthesiology. Linköping University, Faculty of Health Sciences.
    Kalman, Sigga
    Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Anaesthesiology and Intensive Care VHN. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Postoperativ smärtlindring - till vilket pris?: En hälsoekonomisk modellanalys av två smärtlindringsmetoder2006Report (Other academic)
    Abstract [en]

    The  common  method  for  postoperative  pain  control  after  major  abdominal surgery in routine care is epidural analgesia (EDA) using a combination of local anaesthetics  with  opiate  and  patient-controlled   intravenous  analgesia  using opiate (PCIA). It is a matter of dispute which method is better and should be favoured in different clinical situations. The superior analgesic effect of epidural analgesia reported in clinical trials has been difficult to transform into clinical practice.  In a large number  of patients  the epidural  analgesia  is discontinued earlier  than planned  because  of technical  difficulties.  The influence  of better analgesic effect on outcome in terms of mortality and morbidity has also been an issue  of  controversy.  There  are  no  clear  recommendations  which  treatment should  be  selected  in  specific  situations.  According  to  the  guidelines  of  the Swedish  Society  of Anaesthesiology  both  EDA  and  PCIA  can  be chosen  in several  situations.  Apart  from  efficacy  and  effectiveness  a  policy  decision should    also    consider    cost-effectiveness.    Since    economic    analyses    on postoperative pain treatment are rare an analysis of costs and consequences of planned  and discontinued  treatment  is of interest  when  comparing  these  two strategies. The aim of this report is to estimate cost-effectiveness  of treatment with EDA and PCIA under clinical circumstances by a decision analytic model using a clinical database as datasource.

    Using   a   decision-tree,   treatment   with   EDA   was   compared   with   PCIA (morphine) by describing the possible clinical pathways for the successful and early-terminated treatments. The length of treatment was 3 days. A database on 644 patients collected for the purpose of quality control during 1997-99 was the main data source. By using the model costs and effects were established. The effects were expressed as number of pain-free days and the costs in Swedish krona (SEK). Number of pain-free days at rest (pain intensity<30 using visual analogue  scale  1-100  mm)  was  the  primary  measure  of  effect.  The  cost- effectiveness,  the average cost for reaching a particular outcome with a given treatment, is expressed as cost-effectiveness ratio (CER). When decision has to be  taken  to  replace  a  treatment  with  a  more  expensive  and  more  effective treatment, an estimate of the additional resources that have to be used to obtain the additional benefit is needed. That is the incremental cost-effectiveness ratio (ICER).

    The result of the main analysis is that the cost for each pain-free day is 6.489 SEK for treatment with EDA and 2.602 SEK for PCIA. The incremental cost- effectiveness  ratio  is  50.215  SEK.  This  is  the  additional  cost  for  each  of additional  pain-free  day in a situation  when treatment  strategy  from PCIA is converted to EDA. The sensitivity analysis of our result shows that the result of the cost analysis is robust. However changes in assumptions of effect size have substantial impact on the result*.

    *  See  an  English  version  of  the  report.  Bartha  E,  Carlsson  P,  Kalman  S. Evaluation  of  costs  and  effects  of  epidural  analgesia  and  patient-controlled intravenous  analgesia after major abdominal  surgery. Br J Anaesth. 2005 Oct 28; [Epub ahead of print]

  • 6.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Hälsoekonomiska utvärderingar: Vad menas och hur gör man?2009Report (Other academic)
    Abstract [en]

    Health economic assessment is a tool for estimating cost-effectiveness ofresource uses in health care. Information on cost-effectiveness constitutes onepart of the foundation on which priority setting decisions are made, in order tomake the best possible use of available resources.

    The aim of this report is to describe the methods, meaning, and implications ofhealth economic assessments. Methodological issues are discussed, and thereport is formulated to reflect the standpoints of health economists working at CMT.

    The theoretical foundation of health economic assessments is in welfare theory,prescribing a societal perspective of the analyses. A societal perspectiveprescribes that all relevant costs and effects are to be included in the analysis.Direct costs are dominated by the use of health care resources and indirect costsmainly consist of production losses, due to the fact that unhealthy people areunable to perform their work. The theory also prescribes that resourcesconsumed are to be valued according to the opportunity cost approach, i.e. thevalue of a resource in its best alternative use. In practice health economicassessments contain some deviations from what is prescribed by welfare theory,for instance when it comes to costing it is often necessary to settle with rougherestimates.

    Below are examples of questions that are dealt with in this report:

    • What theoretical foundation should form the basis of our analyses?
    • What perspective should be taken in the analysis, that of the society orthat of the health care sector?
    • Should costs associated with informal care be included in the analysis,and if so how should they be valued?
    • How should costs associated with production losses be valued?
    • Should costs of added life years be included in the analysis?
    • What alternative ways are there for measuring quality of life (QALYweights),and which of these is the most appropriate?
    • Which level of discount rate should be used in analyses stretching overlonger times than one year?

    Further questions related to the analysis are described, such as the appropriatetime-frame of the analysis, simulation of future costs and consequences, andsensitivity analyses.

  • 7.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    QALY som effektmått inom vården: Möjligheter och begränsningar2012Report (Other academic)
    Abstract [en]

    As health care resources are finite priorities are necessary in order to attain an optimal use of resources. To support priority setting an increasing number of health economic assessments are undertaken, in which costs for different treatment strategies are compared to the positive effects on health/quality of life that they result in. These positive effects are often expressed as quality adjusted life years (QALYs) and the result of a health economic assessment is expressed as a cost per QALY gained. However, it is not self-evident what a QALY stands for as it can be measured and calculated in different ways.

    This report is dedicated to QALY with respect to what it means, what it is meant to represent, how it is measured, theoretical and methodological problems, and possible alternative procedures. The purpose of the report is furthermore to identify interesting and relevant research questions regarding QALY and the measurement of health care effects.

    The report starts with an introductory chapter putting the QALY-approach into context through a background and theoretical basis. Then prospect theory is briefly outlined. Prospect theory was launched as a critique against the basis of the traditional QALY-approach (i.e. the expected utility theory) and might constitute a possible alternative approach for measuring effects in health care. Chapter 2 describes from which perspectives QALY-weights can be measured and the significance of choice of perspective to the result. By perspective is here mainly meant who should be asked for how good or bad a state of ill health is, affected patients or representatives of the public? In chapter 3 methods for measuring and valuing QALY-weights are described. Both direct and indirect methods are explained. Methodological problems are described and pros and cons of different methods are discussed together with expected differences in results. Chapter 4 is dedicated to the special issues of negative QALY-weights, i.e. health states worse than death, and valuation of temporary health states. Methods for measuring QALY-weights in these situations and its methodological problems are discussed. In chapter 5 the QALY-approach is put into context by relating it to the concept of fairness. Issues discussed are for instance whether the QALY-approach is compatible with a fair distribution of resources and if fairness should be taken into account or not in the QALYapproach. In chapter 6 the QALY-approach is linked to theories of happiness. Might theories of happiness enrich the traditional health economic approach? Can theories of happiness contribute to better methods for measuring health care outcomes, i.e. what we usually call QALY? The report is closed with a discussion leading to interesting and important research questions.

  • 8.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Fernell, Elisabeth
    Astrid Lindgrens barnsjukhus, Karolinska universitetssjukhuset.
    Hur påverkas vardagslivet av ADHD och närliggande funktionsnedsättningar?: Analys och sammanfattning av en enkätstudie riktad till Riksförbundet Attentions medlemmar2005Report (Other academic)
  • 9.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Region Östergötland, Heart and Medicine Center, Allergy Center.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Rahmqvist, Mikael
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Chronic pain in an elderly population in Sweden: Impact on costs and quality of life2015Report (Other academic)
    Abstract [en]

    Chronic pain among elderly people has long been a well-known problem, in terms of both societal costs and the quality of life of affected individuals. To estimate the magnitude of the problems associated with chronic pain in an elderly population, data on both costs and quality of life were gathered. A postal questionnaire was sent out to a stratified sample of 10 000 inhabitants 65 years and older in Linköping and Norrköping. The survey included questions on demographics, habits, and life situation, and different kinds of questions and instruments related to well-being (e.g., quality-of-life and pain-specific questions). In the questionnaire respondents were asked whether they were receiving any help—informal care—from a relative. If they answered yes, they were asked for permission to contact the informal caregiver and to provide contact details. The amount of informal care provided by relatives to persons with chronic pain was investigated by use of a questionnaire directed to the caregiving relatives, containing questions about time spent providing informal care.

    Data on costs were collected from registers of consumption of health care, drugs, and municipal services.

    The results of the study showed a very clear association between existence and severity of chronic pain and societal costs. The study population was subdivided into three groups with respect to having chronic pain or not, and a pain intensity during the last week of 0–4 (mild), 5–7 (moderate), or 8–10 (severe) on a scale of 0–10. Taking all costs (health care, drugs, municipal services, and informal care) into account, persons in the severe chronic pain group consumed on average 72% more resources than persons in the moderate chronic pain group and 143% more than those in the no or mild chronic pain group. Differences were most pronounced concerning municipal services and informal care costs.

    Even more alarming are the results on the quality of life of persons in the different groups. On the EQ-5D index, the average value for persons in the no or mild chronic pain group was 0.82. For those in the moderate chronic pain group the average value was 0.64, and for those in the severe chronic pain group the average value was only 0.38. EQ-VAS resulted in less pronounced but still clearly significant differences.

    It is concluded that this study, reaching a rather large part of the target population, shows that existence and severity of chronic pain among people 65 years and older affects costs to society and the quality of life of affected individuals in a massive way.

  • 10.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Bakgrund till QALY som effektmått2012In: QALY som effektmått inom vården: möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, p. 3-14Chapter in book (Other academic)
  • 11.
    Bernfort, Lars
    et al.
    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.
    Kostnadseffektivitet av allergen immunterapi: analys och genomgång av kunskapsläget2019Report (Other academic)
    Abstract [sv]

    Allergier orsakar mycket besvär för drabbade individer och stora kostnader för hälso- och sjukvården och samhället. Tidigare forskning tyder på att allergen immunterapi (AIT) kan vara ett framgångsrikt sätt att behandla personer med allergisk rinit/rinokonjunktivit. Tidigare genomförda hälsoekonomiska studier tyder också på en acceptabel kostnadseffektivitet för AIT jämfört med enbart symtomatisk behandling.

    Syftet med denna studie var att kartlägga evidensläget för att undersöka möjligheterna att uttala sig om för vilka patienter som AIT är lämpligt, samt när förskrivning kan bedömas som kostnadseffektiv. Grundtanken var att försöka dela in patienter i subgrupper med olika egenskaper, behandlingseffekt och kostnadseffektivitet. Indelningen i subgrupper var i första hand tänkt att baseras på ålder, typ av allergen, symtomens svårighetsgrad och symtomens varaktighet.

    Tidigt beslutades att evidensläget inte tillåter analys av subkutan (SCIT) och sublingual (SLIT) immunterapi separat, utan dessa behandlas i klump med det förenklade antagandet om en jämn fördelning mellan SCIT och SLIT. Denna analys genomfördes som en modellanalys med antagandet att personer startar AIT-behandling vid 25 års ålder. Det generella resultatet av analysen var att med ett samhällsperspektiv är AIT dominant, dvs. att behandlingen både sparar kostnader och genererar hälsovinster jämfört med enbart symtomatisk behandling. Med ett hälso- och sjukvårdsperspektiv blev kostnadseffektivitetskvoten av AIT jämfört med enbart symtomatisk behandling cirka 245 000 kronor per kvalitetsjusterat levnadsår (QALY).

    Tillgänglig evidens tillåter tyvärr inte subgruppsanalyser på det sätt som var tänkt. Detta beroende på att behandlingseffekt specificerat på allergentyp, allergins svårighetsgrad och symtomens varaktighet inte analyserats och rapporterats i tidigare publicerade studier. Den enda uppdelningen som befanns vara någorlunda meningsfull var den baserad på ålder. Inte heller avseende denna variabel har skillnader i behandlingseffekt studerats. Däremot antogs olika indirekta kostnader (produktionsförluster) för barn, ungdomar och vuxna. Dessa kostnader saknar betydelse i en analys med hälso- och sjukvårdsperspektiv varför detta resultat inte påverkas. Med ett samhällsperspektiv däremot befanns AIT mest kostnadseffektiv riktad till vuxna (dominant), följt av barn (179 000 kronor/QALY) och ungdomar (245 000 kronor/QALY). För att kunna genomföra en mer komplett kostnadseffektanalys behövs en del information som i dagsläget saknas. Exempel på kunskapsluckor som identifierats är:

    • En meningsfull uppdelning i tillstånd baserat på svårighetsgrad (lindrig/måttlig/svår), utifrån biomarkörer och/eller symtom.
    • Effektiviteten av AIT och dess inverkan på övergångar mellan tillstånd.
    • Livskvalitet och kostnader förknippade med olika tillstånd.
    • Skillnader i behandlingseffektivitet för olika subgrupper (ålder, svårighet och varaktighet av symtom, olika allergener).
    • Evidens som möjliggör jämförelse mellan SCIT och SLIT, när är den ena respektive den andra mest effektiv/kostnadseffektiv?
    • Långtidseffekt av vissa AIT-terapier.
  • 12.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Allergy Center.
    Nyström Kronander, Ulla
    Östergötlands Läns Landsting, Heart and Medicine Center, Allergy Center.
    Allergenspecifik immunoterapi vid behandling av allergisk rinit: Behandlingseffekter, kostnader och kostnadseffektivitet2012Report (Other academic)
    Abstract [sv]

    Prevalensen av allergier har skattats till omkring 20 % i Sverige. Allergisk rinit är vanligast bland unga vuxna och prevalensen är högre i länder med hög levnadsstandard. På individnivå har miljön i tidig barndom stor betydelse för utveckling av allergier senare i livet. Symtomen förknippade med allergisk rinit ger upphov till nedsatt livskvalitet, vårdkostnader, och produktionsförluster till följd av sjukskrivningar.

    Tidigare fanns endast symtomlindrande behandlingar att tillgå, men på senare år har sjukdomsmodifierande behandlingar lanserats. Dessa består av allergenspecifika immunoterapier (ASIT) som bygger på en successivt ökad tillvänjning av allergenextrakt för att skapa immunitet. ASIT kan bestå av subkutan immunoterapi (SCIT) eller sublingual immunoterapi (SLIT). Det finns läkemedel av detta slag som ingår i den svenska läkemedelsförmånen, men med begränsningen att de får förskrivas endast när bästa möjliga symtomdämpande behandling inte ger ett tillfredsställande resultat. Syftet med denna rapport var att genom en litteraturgenomgång undersöka vilken evidens som finns för klinisk effekt, inverkan på kostnader, samt kostnadseffektivitet av ASIT jämfört med enbart symtomatisk behandling vid allergisk rinit. Litteraturgenomgången utgjorde sedan grund för en bedömning av behovet av att genomföra en svensk kostnadseffektstudie.

    Vad gäller klinisk effekt av ASIT jämfört med symtomatisk behandling hittades flera studier av såväl SCIT som SLIT. Studierna visade genomgående på signifikanta förbättringar jämfört med symtomatisk behandling med avseende på symtom, livskvalitet, och behov av symtomatisk medicinering. Även vårdkostnader andra än de för symtomatisk behandling är lägre med ASIT.

    Kostnadseffektiviteten av ASIT har analyserats i flera studier gällande europeiska förhållanden. I ett par av dessa studier har även svenska förhållanden studerats specifikt. Samtliga publicerade studier fann att kostnadseffektiviteten av ASIT var god, med kostnader per QALY under 200 000 kronor om bara direkta kostnader beaktas och betydligt lägre kostnader per QALY om även indirekta kostnader beaktas. Dessa resultat bekräftas i ett räkneexempel utifrån kända fakta som avslutar denna rapport.

    Sammantaget talar publicerade vetenskapliga studier enhälligt för att ASIT, jämfört med enbart symtomatisk behandling, är en kostnadseffektiv behandling. Det finns ingen anledning att tro att denna slutsats skulle förändras av att genomföra en kostnadseffektstudie under svenska förhållanden. Vid en sådan studie bör extra fokus ligga på att utreda effekter på livskvalitet (QALYs) och produktionsförluster.

  • 13.
    Bistoletti, Peter
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Sennfält, Karin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    En hälsoekonomisk modellstudie av primärscreening mot livmoderhalscancer med cellprov- och HPV DNA-test2008Report (Other academic)
    Abstract [en]

    Title: A modelling study of the cost-effectiveness of primary cytology and HPV DNA cervical cancer screening (En hälsoekonomisk modellstudie av primärscreening mot livmoderhalscancer med cellprov och HPV DNA-test)

    Organisation: Center for Medical Technology Assessment, Department of Medical and Health Sciences, Linköping university, S- 581 83 Linköping, Sweden.

    Contact person: Peter Bistoletti, peterbistoletti@yahoo.com.

    Language: Swedish

    Publication type: Health Technology Assessment report

    Technology type: Screening

    Objectives: The general objective of this report was to assess the costeffectiveness of different cervical cytology screening strategies with and without HPV DNA-testing in primary cervical cancer screening. Four strategies were compared: 1) cervical cytology screening at age 32, 35, 38, 41, 44, 47, 50, 55 and 60, 2) same strategy with addition of testing for HPV DNA persistence at age 32, 3) screening with combined cytology and HPV DNA-testing at age 32, 41 and 50, 4) no screening

    Methods: Input data were derived from a population-based HPV screening trial, from population-based screening registries and health service costs. A probabilistic Markov model was used to estimate life expectancy and health-care costs per woman during the remaining lifetime.

    Results: Cytology screening between 32-60 years of age in 3-5 year intervals increased life expectancy and life time costs were reduced from 533 to 248 US Dollars per women compared with no screening. Addition of HPV DNA-testing at age 32 increased costs from 248 to 284 US Dollars without benefit on life expectancy. Screening with both cytology and HPV DNA testing at ages 32, 41 and 50 reduced costs from 248 to 210 US Dollars with slightly increased life expectancy.

    Recommendations: Population-based, organized cervical cytology screening between age 32 to 60 in this setting is an effective health care policy which both prevents cervical cancer and can produce overall health care cost savings. If screening intervals are increased to nine years, combined cytology and HPV DNA screening appeared to be at least equally effective and less costly.

  • 14.
    Brodtkorb, Thor-Henrik
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Förutsättningar för etablering av en nationell prioriteringskommitté i hälso- och sjukvården: Erfarenheter från andra länder2011Report (Other academic)
    Abstract [sv]

    Syftet med denna studie är att redovisa förutsättningar för en nationell kommitté eller motsvarande för utvärdering och prioritering vid beslut avseende införande av andra sjukvårdsteknologier än läkemedel i hälso- och sjukvården samt att presentera för- och nackdelar med olika lösningar.

    Huvuddelen av underlaget till studien kommer från intervjuer med ett flertal internationella aktörer - för att fånga ett brett faktaunderlag om hur andra länder har agerat i frågan. De länder som har ingått i studien är Australien, England, Kanada, Nederländerna, Norge, Nya Zeeland och Spanien. Utöver intervjuer med nyckelpersoner i respektive land har vi genomfört två workshops med representanter från Nationella samordningsgruppen för kunskapsstyrning. Statliga myndigheter och företrädare för medicintekniska företag har varit inbjudna att delta.

    Vi bedömer att det är realistiskt och motiverat att överväga införande av ett nationellt system för utvärdering och beslut om införande och utmönstring av icke-farmakologiska sjukvårdsteknologier. I ett sådant system förutsätts att beslut fattas av någon typ av nationell prioriteringskommitté eller nämnd, fortsättningsvis i rapporten förkortad NPK.

    Vårt uppdrag har varit att presentera och diskutera olika praktiska och principiella komponenter i ett sådant system. Hur organisationen bör utformas i detalj har vi inte tagit ställning till då frågan ligger utanför vårt uppdrag. I genomgången har vi pekat på fördelar och nackdelar med olika lösningar för de tio komponenter som vi menar utgör byggstenarna för en NPK. Baserat på dessa för- och nackdelar, men utan att ta ställning till organisatoriska eller tidsmässiga aspekter, eller omfattningen på verksamheten, så framträder för oss ett huvudalternativ. Detta huvudalternativ bör diskuteras i relation till alternativa lösningar och preciseras ytterligare.

    Med tanke på att utgångspunkten för denna rapport har varit att undersöka förutsättningar för etablering av en nationell prioriteringskommitté i hälso- och sjukvården, är det också naturligt att vi haft den nationella nivån som utgångspunkt. Varje land vi har undersökt har ett system som är utformat för att passa in i den sjukvårdsstruktur och finansiering som finns i det enskilda landet. Då ansvaret för Sveriges hälso- och sjukvård delas mellan stat och landsting, förefaller det mest adekvat att staten får ansvar för samordning, tillhandahållande av beslutsstöd och kompetens (via myndigheter och kommittéer) och att en NPK formas och drivs av staten tillsammans med sjukvårdshuvudmännen. De sistnämnda har ansvar för att producera och finansiera hälso- och sjukvården. En sådan organisation vore mest i linje med dagens sjukvårdssystem och hur finansieringsansvaret är uppdelat. Alternativet är att bilda ett nationellt organ med enbart företrädare från regioner och landsting. Mot detta talar att statens expertkompetens utnyttjas i lägre grad och att det finns en risk att regionalpolitiska hänsynstaganden kan spela en alltför stor roll.

    Med tanke på att budgetansvaret för att bekosta nya teknologier i hälso- och sjukvården i Sverige i huvudsak ligger på landstingen så förfaller det ologiskt att förorda direkt budgetansvar för NPK. Därmed inte sagt att kostnadsmedvetenhet inte är mycket viktigt i en sådan kommitté. Det bör därför vara en kommitté som kan balansera budgethänsyn med kostnadseffektivitet och rättvis fördelning av resurser.

    De flesta länder strävar mot ett system som är inkluderande när det gäller vilka typer av teknologier som ska ingå i utvärderingarna. De flesta typer av teknologier, både gamla och nya, ter sig därför som aktuella även i Sverige. Samtidigt är det tydligt att det inte går att utvärdera alla teknologier med tanke på den stora arbetsmängd detta skulle leda till. Den svenska branschorganisationen Swedish Medtech uppskattar att det idag finns cirka en halv miljon unika medicintekniska produkter och utifrån detta så förstår vi att inflödet av enbart nya medicintekniska produkter är mycket stort. Dessutom innebär många av dessa endast marginella förändringar jämfört med tidigare teknologier. Vi förespråkar ett system som prioriterar vilka teknologier som ska utvärderas baserat på deras konsekvenser (hälsoeffekt, ekonomisk omfattning, etisk kontrovers etc.) snarare än typ av teknologi eller om den är gammal eller ny. På detta sätt undviks att vissa typer av teknologier får ”fribrev” in isystemet.

    Det finns tre huvudalternativ med tanke på vem som tar fram kunskapsunderlag till utvärderingarna: 1. Enbart företagen; 2. Enbart den beslutande kommittén eller motsvarande; 3. Dessa två kombinerat. Baserat på våra erfarenheter från andra länder och även de återkopplingar vi har fått från referensgruppen tror vi att det vore olyckligt att införa ett system som helt utesluter företagen som uppgiftslämnare. Framför allt kommer NPK i sådana fall att gå miste om dataunderlag som ännu inte är publicerat men som kan vara av stor vikt för besluten. Dock behöver företagsbaserade underlag givetvis granskas av någon oberoende instans innan beslutet fattas.

    Det finns behov av tydliga incitament för att lyfta frågor till utvärdering och beslut. Erfarenheter från Västra Götalandsregionen tyder på att den startfinansieringsmodell som tillämpas där har varit ett lyckat sätt för att få in förslag på teknologier som bör utvärderas. Incitament behöver dock inte alltid vara av ekonomisk art utan kan även vara av administrativ karaktär. Registrering av alla nya teknologier (produkter och procedurer) i ett register innan de får användas skulle kunna bidra till att identifiera kandidater för utvärdering.

    Samtliga länder vi har undersökt har valt att ha flera aktörer involverade i processerna för identifiering, utvärdering, prioritering och beslut angående införande. Flera informanter har även framhållit vikten av att separera den organisation som fattar beslutet från den eller de som tar fram beslutsunderlaget för att öka legitimiteten. Det kan vara administrativt mer komplicerat med två separata organisationer men våra intryck från denna studie tyder på att denna nackdel uppvägs av de fördelar som uppnås.

    Det är en fördel om processerna för identifiering, utvärdering och beslut är så öppna som möjligt. Stor öppenhet i alla steg medför dock en stor arbetsbörda och kostnader. Frågan om öppenhet och medverkan från allmänheten förefaller vara en avvägning mellan tillräcklig grad av sekretess och öppenhet rörande både process och beslut för att uppnå legitimitet. Att vid ett eventuellt införande av NPK starta med en relativt sluten process där enbart besluten redovisas men sedan ha en tydlig ambition och plan för att bli mer öppen i hela processen efter hand kan vara en framkomlig väg. Vi bedömer att den värdegrund och det utvecklingsarbete av öppna prioriteringar som redan pågår i Sverige är av hög relevans för NPK. Vi ser därför inget behov av en särskild värdegrund för NPK, utöver den som blir resultatet av de pågående  prioriteringsdiskussionerna. Det är dock angeläget att ett eventuellt bildande av NPK föregås av framtagning av tydliga direktiv till NPK om hur den ska förhålla sig till och tillämpa riksdagens riktlinjer för prioriteringar.

    Med avseende på politisk involvering eller inte i besluten har det i samtliga länder vi har undersökt varit en tydlig politisk koppling till själva beslutet om införande eller inte av teknologin. Detta står i kontrast till hur det för närvarande fungerar i Sverige med t.ex. TLV, där besluten inte involverar politiker. I denna fråga verkar det snarare handla om att skapa ett system som gör att den kommitté eller person som ska fatta införandebeslutet har tillräckligt förtroende och legitimitet att förvalta denna uppgift. Det kan betyda att politiker inkluderas i en kommitté som befolkningsföreträdare eller representanter för den part som ansvarar för finansieringen. Lika väl kan det fungera med personer i kommittén som medverkar på personliga mandat, som har en adekvat kompetens och erfarenhet men också ett förtroende från andra att lösa uppgiften.

    Formen för ”Omprövning” är starkt sammankopplad med valet av andra strukturella komponenter. Vår utgångspunkt är dock att det bör finnas någon typ av omprövningsmekanism under processen samt efter beslut. Skulle det bli en myndighet som fattar bindande beslut på liknande sätt som TLV gör i dag bör det vara möjligt för företag att överklaga beslutet till domstol. I andra fall är det NPK som bör utveckla egna rutiner för omprövning på eget eller andras initiativ.

    Vi har i denna studie undersökt förutsättningar för etablering av en nationell prioriteringskommitté i Sverige för icke-farmakologiska sjukvårdsteknologier i hälso- och sjukvården. Arbetet har baserats på erfarenheter från länder med existerande system för beslut om införande av sjukvårdsteknologier samt diskussioner i Sverige med en referensgrupp samt styrgrupp för projektet. Vi har i vårt arbete identifierat tio viktiga komponenter för uppbyggnaden av en sådan kommitté och fört en diskussion kring dessa. Vi ser möjligheter och fördelar med att etablera en nationell prioriteringskommitté i Sverige för identifiering, utvärdering och prioritering vid beslut avseende införande av andra sjukvårdsteknologier än läkemedel i hälso- och sjukvården. För- och nackdelar med olika tänkbara lösningar har diskuterats i rapporten, medan de mer exakta formerna för en nationell prioriteringskommitté är en fråga för fortsatt utredning.

  • 15.
    Brodtkorb, Thor-Henrik
    et al.
    RTI Health Solutions, Lund.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kalkan, Almina
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Metoder för värdering av QALYS2012In: QALY som effektmått inom vården: Möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, p. 30-53Chapter in book (Other academic)
  • 16.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Brodtkorb, Thor-Henrik
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Tinghög, Gustav
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Nationellt system för utvärdering, prioritering och införandebeslut av icke-farmakologiska sjukvårdsteknologier: en förstudie2010Report (Other academic)
    Abstract [en]

    The need for a national system to evaluate medical technologies other than pharmaceuticals is being considered. Several proposals advocate establishing a type of “Treatment Benefits Board”. To highlight problems and analyse the conditions for national assessments in this context, the National Board of Health and Welfare, the Medical Products Agency, the Swedish Council on Technology Assessment in Health Care (SBU), and the Dental and Pharmaceutical Benefits Agency (TLV) jointly appointed the Centre for Medical Technology Assessment (CMT) at Linköping University to conduct a preliminary study. The preliminary study should provide a foundation for the agencies to decide whether or not the issue needs to be investigated further.

    The preliminary study aims to develop background information concerning how Sweden and other countries currently assess, prioritise, and implement decisions involving new nonpharmaceutical health technologies. The basic questions addressed are:

    1. How can nonpharmaceutical technologies be defined and categorised for the purpose of setting parameters for an approval process?
    2. How is the current process of assessment, prioritisation, and approval in Sweden structured, focusing on SBU, the Medical Products Agency, the National Board of Health and Welfare, and TLV?
    3. How have other countries organised their systems for assessment, prioritisation, and approval of nonpharmaceutical technologies?

    Within the framework of the project it was not possible to conduct detailed, onsite studies of the healthcare systems in other countries. Hence, we relied on descriptions of other countries’ systems as reported in scientific articles, reports, and official documents available from various organisations and other sources via the Internet. In some instances the information was complemented by interviewing key individuals. The same applies to the descriptions of Swedish agencies. Information concerning the prevalence of various technologies was collected from official reports/reviews and registry data. We present information from six countries where we found sufficient information to preliminarily answer the questions we formulated in advance. The countries are Australia, New Zealand, England, Spain, Italy, Canada, and the USA.

    We draw the following conclusions from the preliminary study: It is relatively complicated to define nonpharmaceutical technologies and delineate the technologies that potentially could be subject to regulation. Our practical attempts to describe the technologies that SBU Alert has assessed show that:

    surgical and medical interventions dominate, but a relatively high number of screening programmes have also been assessed;

    • medical equipment and pharmaceuticals are the predominant input factors. Active implants and biological products are also relatively common. Assistive devices and dental products are seldom considered to be primary input factors;
    • most technologies are used primarily for treatment purposes. Diagnostic technologies are also relatively common.

    By removing pharmaceuticals from the equation and combining interventions and input factors, SBU Alert arrived at 18 different categories of health technologies that it assesses. The predominant combination is surgical intervention and biomedical equipment. This is followed by surgical intervention and insertion of active implants. In the report, we propose a way to define and classify technologies that we found to be appropriate for the purpose. This does not exclude pharmaceuticals. Rather, pharmaceuticals are included as one input factor among others.

    Another aim was to produce background information describing how Sweden and other countries currently assess, prioritise, and approve new nonpharmaceutical technologies. We identified several key components that we believe are worth considering in designing a national system for assessing, prioritising, and approving new nonpharmaceutical health technologies. These components are:

    • Organisational level – At what organisational level should the approval of nonpharmaceutical health technologies take place?
    • Scope – Should an all-inclusive or selective approach be taken towards inclusion/selection of health technologies for assessment?
    • Base package – Should there be a basic list showing what is financed with public funds, or is it sufficient to present only new decisions on the margin?
    • Diversity of actors – Should a single actor, or many actors, be responsible for assessment, prioritisation, and decisions regarding financing?
    • Fact producer – Who would be most appropriate to manage the factual information base?
    • Transparency – How transparent should one be in presenting the decisionmaking process and its results?
    • Political involvement – How politically independent should the decisions be?
    • Budgetary responsibility – Should the unit that recommends or decides on approval have a budgetary responsibility?
    • New and old – Should the decisions apply both to introducing new technology and phasing out old technology?
    • Fundamental values – Should there be an explicit set of fundamental values for prioritisation, and how should it be formulated?
    • Appeals – Should there be a mechanism to appeal decisions?

    To summarise, we see a trend in other countries towards an increasing level of assessment and prioritisation in decisions regarding the introduction of nonpharmaceutical health technologies. Our preliminary impression is that nearly every system that we studied continues to develop and remains “a work in progress”. For instance, in Australia and New Zealand official inquiries are under way to suggest or present proposals for improvement.

    Our studies of systems in different countries, although limited, indicate there is no perfect system to copy directly. The way in which the various systems are organised is somewhat related to how health care is organised in the respective countries and how many resources they have decided to dedicate to this purpose. The results from our preliminary study show, however, that several countries have more experience in “approving” nonpharmaceutical-based technologies than what we have in Sweden. The most interesting countries are England, New Zealand, Canada, and Australia. Spain could also be of interest. Hence, there is good reason to consider what might be the best way to analyse these countries’ systems in detail and complement this information with data from other nations that we were unable to include in the preliminary study, e.g. the Netherlands and Israel.

    To more rigorously analyse other systems, if this project is continued, investigators should probably start from one or more models for a Swedish mechanism. To arrive at one or more tentative models in this context, the county councils should be involved in the project. The format could be a workshop that engages representatives from public agencies, county councils, and professional associations, where they jointly outline conceivable models that could then be analysed and discussed in light of the experiences of other nations.

  • 17.
    Carlsson, Per
    et al.
    Linköping University, Faculty of Health Sciences.
    Garpenby, Peter
    Linköping University, Faculty of Health Sciences.
    Bonair, Ann
    Kan sjukvården styras?: En rapport om spridning och kontroll av medicinsk teknologi1991Report (Other academic)
  • 18.
    Carlsson, Per
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Hedbrant, Johan
    System Analysis Group, Linköping University.
    Pedersen, Knud
    The Department of Urology, Ryhov County Hospital in Jönköping, Sweden.
    Varenhorst, Eberhard
    The Department of Urology, Norrköping County Hospital, Sweden.
    Gray, Darryl
    Sector of Clinical Epidemiology, Mayo Clinic, Rochester, USA.
    An evaluation of prostate cancer screening using a decision analytic model1993Report (Other academic)
    Abstract [en]

    As early prostate cancer is often asymptomatic, the disease is often not diagnosed until it has reached an advanced, incurable stage. However, if diagnosed when it is still confined to the prostate, prostate caner is potentially curable. At present, there are no completed prospective evaluations or other scientific evidence to suggest that prostate cancer mortality is reduced or that quality of life is increased either by curative treatment or by screening programmes. However, the potential effects of a screening programme can be modelled using decision analytic computer software.

    The aim of this project was to develop a model for comparing the expected quality-adjusted life expectancy for a group of men subjected to a programme of screening for prostate cancer to that of a control group with conventional case-finding, given limited empirical data on the effectiveness of both strategies.

    Due to limitations of existing data, the analysis was developed during the early stages of evaluating a prostate cancer screening programme. We wish to illustrate how an analytic tool such as this model can be used in the future.

    The model was functionally separated into two parts. The first part, the observation submodel, covers the first 6 years of the programme and classifies the screened population into different quality of life states, based on observed outcomes. The second part, the simulation submodel, predicts quality adjusted life-years for healthy participants and for prostate cancer patients who receiving curative treatment or expectant management. Data for the model were obtained from a pilot programme on screening for prostate cancer in which a randomly selected population sample has been screened by digital rectal examination in Norrköping Sweden in 1987 and 1990. The outcome evaluated in the model was quality-adjusted life expectancy for individuals in the cohort invited to the screening programme, compared to results for population controls.

    While the preliminary results identify some health benefits associated with screening, more accurate empirical data for a number of key variables could improve the evaluation. One feature of this model is that it combines solid, empirical data from the observation submodel with simulated results. When better empirical data on the actual consequences of different strategies are available, they can easily be analysed by using this model.

  • 19.
    Ceder, Monika
    et al.
    Östergötlands Läns Landsting.
    Garpenby, Peter
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Patientinformation avseende bröstcancer och diabetes: en utvärdering1998Report (Other academic)
    Abstract [sv]

    Avsikten med studien var att i första hand undersöka hur patientinformation uppfattas av personer med två sjukdomar - bröstcancer och diabetes. den patientinformation som avsågs var dels information från hälso- och sjukvården och dels information från andra källor. Ett delsyfte var att låta personer med erfarenhet av tidigare nämnda sjukdomar bedöma den patientinformation avseende bröstcancer och diabetes som finns i den medicinska faktadatabasen MARS. Underlaget för studien utgörs av materiel från fokusgrupper och efterföljande telefonintervjuer.

  • 20.
    Davidson, Thomas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    CMT rapport: kostnader och kostnadseffektivitet av ett införande av dabigatran hos patienter med förmaksflimmer2011Report (Other academic)
    Abstract [sv]

    Förmaksflimmer är den vanligaste arytmin i Sverige och orsakar stora kostnader inom hälso- och sjukvården. Förutom att patienterna vanligen drabbas av försämrad livskvalitet går det också åt stora resurser för komplikationer i form av tromboembolier och stroke. De flesta behandlingar inom förmaksflimmer kombineras med antikoagulationsbehandling för att förebygga eller förhindra uppkomst av tromboembolier och ischemisk stroke. Vid denna behandling krävs noggrann dosering för att sänka risken för stroke utan att kraftigt höja risken för blödningar. Warfarin har under lång tid varit det mest effektivaantikoagulationsläkemedlet för skydd mot tromboembolier vid  förmaksflimmer. Ett annat behandlingsalternativ är acetylsalicylsyra (ASA). Ett nytt antikoagulationsläkemedel som heter dabigatran (Pradaxa®) har nyligen godkänts som förebyggande behandling av stroke och systemisk embolism hos patienter med förmaksflimmer. Dabigatran har i en stor studie, (RE-LY), visat sig reducera risken för stroke jämfört med warfarin.

    Det övergripande syftet med denna rapport är att beräkna hälsoekonomiska konsekvenser i form av kostnader och kostnadseffektivitet av ett införande av dabigatran (Pradaxa®) som förebyggande behandling av stroke och systemisk embolism hos patienter med förmaksflimmer. I grundanalysen analyseras dabigatran 150 mg två gånger per dag för personer som är under 80 år och dabigatran 110 mg två gånger per dag för personer 80 år eller äldre. Jämförelser görs med warfarin och ASA, och warfarinbehandlingen delas dessutom in i tre subgrupper; välinställda, dåligt inställda samt warfarin-naïva patienter.

    En simuleringsmodell har skapats för att beräkna långsiktiga kostnader och effekter för de olika behandlingsalternativen. Effekterna mäts i antal förhindrade stroke, antal vunna levnadsår samt antal vunna kvalitetsjusterade levnadsår (QALYs). Priset för de båda dagliga doserna av dabigatran (150 mg gånger två och 110 mg gånger två) är 25,39 kronor per dag.

    Analyserna i den här rapporten visar att kostnaden för förmaksflimmer i Sverige beräknas till drygt 4,1 miljarder kronor år 2010. Denna kostnad förväntas sjunka vid införande av dabigatran, till följd av besparingar inom vården av stroke och ett sänkt produktionsbortfall. Kostnaden per vunnet QALY för dabigatran 150 mg / 110 mg jämfört med warfarin, hos patienter som är 65 år gamla och följs upp i 20 år, har beräknats till 74 216 kronor. Vid jämförelse med välinställd warfarinbehandling höjs kostnaden per vunnet QALY till 107 186 kronor. Om dabigatran 110 mg två gånger dagligen jämförs med ASA leder det till lägre kostnader och bättre effekter, vilket innebär att dabigatran 110 mg två gånger dagligen är en dominant behandling för patienter som inte är lämpliga för warfarinbehandling.

    Ett införande av dabigatran leder till kostnadsförskjutningar inom flera olika områden. En ökad kostnad uppkommer för läkemedel, medan  sänkta kostnader uppkommer till följd av färre stroke. För patienten innebär dabigatran lägre risk för stroke och färre besök i sjukvården.

  • 21.
    Davidson, Thomas
    et al.
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Kostnaden för förmaksflimmer i Östergötland2006Report (Other academic)
    Abstract [en]

    Atrial  fibrillation  (AF)  is  the  most  common  arrhythmic  disease  in  Sweden. Persons  with  AF  have  a  significant  increased  risk  of  stroke  and  the  main treatment  is  therefore  intended  to  prevent  stroke  by  anticoagulation  with warfarin. There is no existing calculation of the cost of AF in Sweden today and since new treatments soon may become available there is a need to know the societal cost of AF. The aim of this report was therefore to calculate the cost of AF in the Östergötland County in Sweden. This was done by identifying all relevant  costs  and  by  quantifying  and  valuing  them.  The  cost  of  AF  was calculated by using a model, which was also used to forecast the cost of the coming years. The focus in the calculation has been on the side effects caused by AF and treatments intended to lower the risks for these events. The treatment of AF is often not aimed at curing the disease but rather to prevent the negative events connected to it.

    Three  possible  treatments  for  a  person  with  AF  have  been  included  in  the calculation; treatment with warfarin, treatment with ASA or no treatment. Only patients with moderate or high risk for stroke were included in the calculation. Only about 50 per cent of the patients receive treatment with warfarin although the recommendation is that most persons with AF should receive Warfarin, and this low use of warfarin may cause extra costs for the society.

    The total cost of AF in Östergötland has been calculated to SEK 137 million in year 2006 and the prognosis for 2008 is SEK 155 million and SEK 177 million in year 2010, which is an increase of almost 30 per cent within these four years. If only direct costs were included, the result for 2006 is SEK 115 millions. The cost for stroke is the main cost and counts for 84 per cent of the total cost for AF when also the indirect costs are included.

    Because the prevalence of AF is increasing for persons above 60 years and is very high among persons over 80 years, the expected number of persons with AF is increasing as the number of elderly persons in the society is increasing. This generates large and increasing costs for the society. Due to potential new treatments of either curing the disease or by lowering the risks for stroke, it is possible that the societal costs may be less in the long run compared to the calculation in this report.

  • 22.
    Davidson, Thomas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Närståendes konsekvenser: Hur kan de inkluderas i den hälsoekonomiska analysen?2008Report (Other academic)
    Abstract [en]

    There is a need for cost-effectiveness analyses to include relatives’ consequences in order to fulfil the recommendation of having a societal perspective. Being a relative to a patient with a disease or a disablement can cause consequences, and these consequences may be separated between costs and effects. The costs are mainly caused by the need of providing informal care. The effects are caused by relatives’ affected quality of life. The cost for informal care is sometimes included in cost-effectiveness analyses, but relatives’ effects are, as far as we have seen, never included.

    In this report we discuss relatives’ consequences, how they can be measured and valued, and also how they could be incorporated in the cost-effectiveness analysis. The recommended approach to calculate the cost of informal care is to value lost paid production as the salary including employment fees, and lost unpaid production to be valued as the relative’s own valuation of this leisure time. It is more difficult to give recommendations about how to measure and value relatives’ affected quality of life (and more studies about this are needed). One possible solution is to use instruments that measures relative-related quality of life. Another potential method is to study relatives’ willingness to pay for an improvement of the patient’s health.

    It is important to avoid double counting in a cost-effectiveness analysis. This must therefore be acknowledged when relatives’ consequences are included. Cost of informal care may incorporate some of the effects on relatives’ quality of life. Furthermore there is a risk for double counting when both the patient’s and the relatives’ effects are included in the analysis. It is therefore of importance that these risks are considered in the choice of methods to measure and value relatives’ consequences.

    An outcome measure that is often used to measure the effects of a treatment is quality-adjusted life years (QALY). One potential method to incorporate relatives’ effects in the cost-effectiveness ratio, which is discussed in this report, is to measure relatives’ effects in the new outcome R-QALY weights. These weights are defined as the change in relatives’ QALY weights caused by being a relative to a patient with a disease or disablement. When these weights are used to create QALYs, they can be summed with the patient’s QALYs and placed together in the denominator of the cost-effectiveness ratio. This method is however controversial as the denominator normally only includes the patient’s effects. An alternative of combining the patient’s QALY weight with relatives’ R-QALY weights could be to find a monetary value of the R-QALY weight and include this value together with the other costs in the analysis. Because of the difficulties of including relatives’ consequences we recommend to present the results both with and without relatives’ consequences. This would furthermore enable the analysis to be compared with other analyses.

    As cost-effectiveness analyses often are used for decision making, we argue that it is of importance to find methods which enable the incorporation of all consequences of the relatives in the analysis. This field is evolving and more research is needed before further recommendations can be made.

  • 23.
    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.

  • 24.
    Eriksson, Thérèse
    et al.
    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.
    Utvärdering av vårdval ryggkirurgi i Stockholms län2018Report (Other academic)
    Abstract [sv]

    Uppdrag och syfte

    Centrum för utvärdering av medicinsk teknologi vid Linköpings Universitet fick under 2014 i uppdrag av Stockholms Läns Landsting (SLL) att utvärdera vårdval ryggkirurgi (VVR). I VVR används ett värdebaserat ersättningssystem vilket gör att VVR skiljer sig från andra vårdval inom Stockholms län.

    Syftet med denna utvärdering är att 1) utifrån registerdata utvärdera VVR utifrån volym, kostnad samt hälsoutfall med Region Östergötland som kontroll, 2) redogöra för hur anställda inom SLL respektive de privata vårdgivarna har upplevt utformning, implementering, förvaltning av VVR och hur det har påverkat deras arbete samt hur de upplevde beslutsprocessen för införandet.

    Metod

    Att kombinera kvantitativa och kvalitativa metoder kan vara värdefullt vid utvärdering av en komplex intervention med många faktorer att ta hänsyn till. Kvantitativ och kvalitativ metod erbjuder olika sätt att beskriva ett fenomen, vilket innebär att metoderna kan generera olika resultat. Man bör inte utgå ifrån att resultaten ska replikera varandra utan snarare att man ska få en djupare förståelse för fenomenet. I denna utvärdering är utgångspunkten att metoderna kan och bör användas som komplement till varandra.

    Den kvalitativa delen i denna rapport bygger på intervjuer med anställda på Hälso- och sjukvårdsförvaltningen (HSF) vid SLL samt anställda hos de privata vårdgivarna1. Ändamålsenlig urvalsteknik har använts för att välja intervjupersoner och intervjuerna baseras på en explorativ ansats. Den kvantitativa delen baseras på registerdata från fem olika registerhållare, deskriptiva data presenteras och statistiska analysmetoder har använts för att jämföra grupper och utveckling över tid före och efter införandet av VVR. Utvärderingen grundar sig på Donabedians ramverk för utvärdering av kvalitet inom sjukvården (1).

    Resultat baserat på registerdata

    Volym

    Antalet indexoperationer har ökat med 17 procent efter införandet av VVR. Volymökningen kan förklaras med att det operationstak som fanns vid upphandling har tagits bort och att den nya ersättningsnivån kräver en högre produktion. Även tillgängligheten har ökat, dels på grund av det finns fler vårdgivare, dels på grund av utökade öppettider samt fler mer centralt belägna mottagnings- och rehabiliteringslokaler.

    Hälsoutfall

    Under de tre år som har gått sedan införandet av VVR har 1006 fler patienter opererats jämfört med motsvarande period före införandet. Detta motsvarar en vinst på 210 QALYs till följd av VVR. Livskvalitetsvinsten efter operation per patient har inte påverkats av VVR, men justerat för vårdtyngd och socioekonomiska faktorer har den postoperativa livskvaliteteten ökat med 0,04 i EQ-5D-index.

    Kostnader

    SLL:s kostnad för elektiv ryggkirurgi har i genomsnitt ökat med 20 miljoner kronor per år efter införandet av VVR. Den totala kostnaden för elektiv ryggkirurgi har ökat med 16 procent jämfört med motsvarande period före vårdvalet. Kostnadsökningen kan förklaras av volymökningen som uppgick till 17 procent. Kostnaden per operation har minskat med 7 procent. Även kostnaden per vårdepisod2 har minskat med 9 procent.

    Den inkrementella kostnadseffektkvoten för VVR estimerades till drygt 50 000 kronor per vunnet kvalitetsjusterat levnadsår (QALY). Om kostnaden för vård under hela vårdepisoden och indirekta kostnader kopplade till sjukfrånvaro inkluderades i analysen uppgick den inkrementella kostnadseffektkvoten till 230 000 kronor per vunnen QALY.

    Individ- och prestationsersättning

    Baserat på patientens svar på Global Assessment såg den prestationsbaserade ersättningen i genomsnitt ut enligt följande:

    • Helt försvunnen smärta: 3 651 kr
    • Mycket förbättrad smärta: 1 167 kr
    • Något förbättrad smärta: -1 746 kr
    • Oförändrad smärta: -4 453 kr
    • Försämrad smärta: -6 215 kr
    • Hade inte smärta: 529 kr

    Tanken var att prestationsersättningen skulle uppgå till ungefär 10 procent av bas- och garantiersättning, i realiteten blev andelen som högst knappt 7 procent. I de flesta fall uppgick prestationsersättningen till cirka ±2 procent av bas- och garantiersättningen. Den individbaserade justeringen låg i majoriteten av fallen på ca ±2 procent.

    I jämförelse med de kostnader som uppkommer på grund av kostnadsansvaret för postoperativ vård menade vårdpersonal att den värdebaserade ersättningen (baserat på GA) var för låg. De ansåg därför att det inte var värt att följa upp den värdebaserade ersättningen och därmed har incitamenten inte haft önskad effekt då fokus främst ligger på att hålla de postoperativa kostnaderna nere istället för på hur den värdebaserade ersättningen kan maximeras.

    Sjukskrivning

    Andelen sjukskrivna patienter minskar efter införandet av VVR. Antalet sjukskrivningsdagar har ökat, främst på grund av längre sjukskrivning före operation.

    Konsumtion av smärtstillande läkemedel

    Andelen patienter som använder opioidbaserade läkemedel postoperativt har minskat med VVR, även doseringen per patient har minskat. Andelen patienter som använder antiepileptika har preoperativt och i samband med operation ökat, men postoperativt minskat. Andelen patienter som använde antidepressiva postoperativt ökade efter införandet av VVR, likaså doseringen preoperativt och i samband med operation.

    Resultat baserat på intervjuer

    Utformning, implementering och förvaltning

    Hos vårdgivare var beslutet att införa VVR väl förankrat, mycket på grund av att professionen fick komma till tals under utformningen av vårdvalet. Hos Hälso- och sjukvårdsförvaltningen (HSF) hade beslutet inte samma stöd då man tidigare bedömt att elektiv ryggkirurgi inte lämpade sig som vårdval samt att landstingets system inte kunde stödja den typen av ersättningssystem som diskuterades.

    Generellt har kommunikationen upplevts som god mellan vårdgivare och HSF under utformningen av VVR. Personal hos vårdgivare upplevde kommunikationen som särskilt god i jämförelse med hur kommunikationen varit i utformningen av andra vårdval.

    Flera intervjupersoner menade att det saknades stöd för hur man praktiskt skulle arbeta med det nya systemet, vilket kan förklaras av att VVR var nytt även för personalen på HSF. Personal hos vårdgivarna upplevde att det tog för lång tid att få svar på frågor vilket i sin tur ledde till att ärenden samlades på hög och personal kände stress över att antalet olösta ärenden ökade. Vårdvalet upplevdes som personbundet, särskilt under de första åren efter införandet av VVR.

    På HSF fanns en medvetenhet om att de inte riktigt hade resurser till löpande uppföljning och revidering av avtalen med vårdgivare. Det gav upphov till viss frustration över att veta vad som bör förändras utan att ha de resurser som krävs för att genomföra det. För att ekonomiska incitament ska vara långsiktigt effektiva är det viktigt med kontinuerlig uppföljning och justering.

    Arbetsprocesser

    Vårdgivare

    VVR är utformat så att vårdgivarna är fria att utforma sina arbetsprocesser på det sätt som de själva anser är bäst. Den enda begränsningen är ersättningen som landstinget har bestämt baserat på kostnadsdata från en av vårdgivarna. Det tvärprofessionella arbetet var mer påtagligt hos två av de fyra intervjuade vårdgivarna.

    Efter införandet av VVR uppgav vårdpersonal att de blivit mer enhetliga i registreringsförfarandet och mer stringenta i sina bedömningar av operationsindikationer. En negativ sidoeffekt som framkommit är att särskilda ingrepp inte gått att utföra inom vårdvalets ramar. Därför anser vårdgivarna att en justering av tillåtna kombinationer vore lämpligt så att fler diagnoser och ingrepp inkluderas för att undvika att patienter hamnar utanför systemet.

    Vårdgivarna inom VVR har ett postoperativt kostnadsansvar för patienten vilket ger dem anledning att bygga upp ett förtroende hos patienterna för att öka chansen för att patienten kommer tillbaka vid komplikationer samt efterlever läkarens anvisningar. Då patienterna är fria att söka sig till en annan vårdgivare skulle det underlätta för vårdgivarna om de blev informerade när deras patient vårdades på annat håll för att på så vis ge dem en chans att själva åtgärda komplikationen. Det postoperativa kostnadsansvaret har dock upplevts som administrativt krävande då IT-systemet inte är tillräckligt förfinat för att urskilja vård kopplad till VVR från annan vård. Därutöver uppgav intervjupersoner en upplevd avsaknad av struktur och stöd för hur man praktiskt skulle inkludera sjukgymnastik. Samordningen av sjukgymnastik har varit komplicerat för alla vårdgivare och det är svårt att styra patienter som har ett fritt val. Detta ansvar har blivit en central del i vårdgivarnas arbete varför många tycker att större vikt borde

    ha lagts på utformningen av detta ansvar. Det kan därför uppfattas som att inkluderingen av sjukgymnastik var ett för stort steg att ta i samband med införandet av VVR men samtidigt ett steg i rätt riktning som egentligen skulle ha krävt både bättre utformade system och en bättre samverkan med sjukgymnastik som område.

    Hälso- och sjukvårdsförvaltningen (HSF)

    Generellt har HSF inte haft möjlighet att genomföra den kontinuerliga uppföljning och revidering som vårdvalet kräver på grund av relativt små personella resurser. Istället har arbetssättet gällande vårdval generellt kännetecknats av större revideringar med några års mellanrum. Detta arbetssätt påminner i stor utsträckning om det arbetssätt som råder under upphandlingsförfaranden inom SLL. En utav grundidéerna med vårdval går därför till viss del förlorad när avtalsrevideringarna är stora och sker sällan istället för att mindre justeringar görs fortlöpande för att anpassa systemet. Vidare skulle HSF:s arbete gynnas av att få in ökad kompetens som kan hantera och utveckla de typer av informationssystem som är en förutsättning för att upprätthålla ett komplext vårdval som VVR.

    Arbetsbelastning

    Den administrativa bördan upplevs ha ökat för personal både på HSF och hos vårdgivarna. Den största orsaken till den ökade administrativa bördan är det nya ersättningssystemet som krävt mycket manuellt arbete, främst på grund av hanteringen av det postoperativa kostnadsansvaret. För vårdgivare upplevs även den kliniska arbetsbelastningen ha ökat då de genomför fler operationer på grund av den lägre ersättningsnivån, ökad konkurrens och för att det inte finns något operationstak.

    Inställningen till VVR med ett värdebaserat ersättningssystem

    Införandet av VVR upplevs generellt som positivt eftersom det ger vårdgivarna större utrymme för långsiktighet. Det finns dock en oro för att fortsatt effektivisering ska leda till negativa effekter för patienter. Vårdgivare betonade därför vikten av indexuppräkning av ersättningsnivån. Generellt finns en positiv inställning till att ersättningen är kopplad till patientutfall, men med nuvarande utformning och ersättningsnivå ligger inte fokus på att maximera patientutfall utan på att minimera potentiellt undvikbara oönskade händelser (PUOH) och fysioterapi. Det nya ersättningssystemet kopplat till VRR uppfattas som komplext vilket till stor del kan bero på brist på transparens kring hur olika patientfaktorer påverkar ersättningen. Lämpligheten att basera ersättningsnivån på det patientrapporterade utfallsmåttet global assessment (GA) har också ifrågasatts. Dels för att GA baseras på en subjektiv värdering, dels för att en för stor vikt i ersättningen ligger på att patienten ska bli helt smärtfri, vilket inte är vanligt för patientgruppen inom VRR.

    Vilka faktorer upplevs ha störst betydelse för utfallet?

    Det postoperativa kostnadsansvaret menar vårdgivarna är den aspekt i VRR som har haft störst påverkan i det dagliga arbetet. Det har genererat en obruten vårdkedja som bidragit till att man som vårdgivare får en närmare relation till patienten. Med det postoperativa kostnadsansvaret kan vårdgivarna följa patienten hela vägen från bedömning till ettårsuppföljning. Därutöver framhävs också avtalsformen, att bedriva verksamhet enligt Lagen om valfrihetssystem (LOV) underlättar planering av verksamheten på lång sikt och ger utrymme för att arbeta mer mot kvalitet jämfört med avtalsformen under Lagen om offentlig upphandling (LOU). Under intervjuerna framförde många att även om VVR inte givit någon mätbar effekt ännu (2013-2016), så har kopplingen av ersättning till hälsoutfall varit viktig då det upplevts som en fingervisning om var fokus bör ligga på för att uppnå bättre kvalitet.

    Slutsatser

    • Antalet opererade patienter har ökat med 17 procent efter införandet av VVR.
    • Den totala kostnaden har ökat med 16 procent, däremot har medelkostnaden per operation minskat.
    • Vårdvalet har inte haft någon effekt på den individuella livskvalitetsvinsten, men då fler patienter opereras ökar den aggregerade livskvalitetsvinsten.
    • Den minskade genomsnittliga kostnaden per operation indikerar en effektivare vård då livskvalitetsvinsten inte har påverkats negativt.
    • Den prestationsbaserade ersättningens andel av den totala ersättningen behöver bli större för att generera effekt.
    • Individjusteringen upplevs inte vara tillräcklig för att motverka skillnader i ekonomisk risk mellan patienter.
    • Istället för fokus på postoperativ hälsomaximering ligger fokus på postoperativ kostnadsminimering.
    • Vårdvalet har inte haft någon större effekt på patientsammansättningen.
    • Andelen sjukskrivna patienter minskar efter införandet av VVR.
    • Den generella uppfattningen av vårdval ryggkirurgi var positiv bland personal hos de privata vårdgivarna och HSF.
    • Uppfattningen hos vårdpersonal var att det postoperativa kostnadsansvaret hade haft störst effekt på det dagliga arbetet och att det gav vårdgivarna en bättre helhetssyn av patientens behov.
    • Kopplingen av ersättning till patientrapporterat utfallsmått upplevdes också som viktigt, även om den i dagsläget var för låg för att generera effekt.
    • Vårdvalet har medfört en hög administrativ arbetsbörda på grund av det nya beskrivnings- och ersättningssystemet. Idag kvarstår relativt mycket manuellt arbete med den komplexa ersättningsmodellen.
    • Hur forskning och utveckling ska bedrivas och finansieras behöver lösas, särskilt eftersom de offentliga sjukhusen inte är inkluderade i VVR och de privata aktörerna opererar majoriteten av patienterna inom elektiv ryggkirurgi.
    • Resultaten tyder på en omställningsperiod de första åren efter införandet av VVR och därför är det viktigt att följa utvecklingen från år 2016 och framåt för mer långsiktiga effekter av VVR.
  • 25.
    Garpenby, Peter
    Linköping University, Faculty of Health Sciences.
    Att omsätta psykiatrireformen i handling: en första redovisning från Östergötland1996Report (Other academic)
  • 26.
    Garpenby, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Evidensbaserade policybeslut i hälso- och sjukvård: Redovisning av nio strategier2015Report (Other academic)
    Abstract [en]

    In Sweden, the importance of a "knowledge-based health care" has been emphasized in official documents and agreements between the government and the regional health authorities, at least since the mid- 1990s. Within the concept of evidence-based policy (EBP), however there is a much broader ambition than merely to substantiate the clinical part of health service decision-making with evidence. The intention behind EBP is to increase the influence of “evidence” in both administrative and political decision-making.

    Available review articles indicate that the actual knowledge about how to promote EBP is very limited. The few articles that exist point in the same direction, namely that two areas essential: (a) personal relationships and contacts between producers of research and users of research and (b) measures to make research results clear and accessible so that their use will increase.

    This report presents nine different strategies to enhance EBP: those that focus on the evidence base, the interaction between producers and users of evidence, and increased understanding of the conditions prevailing in collective decision-making. A distinction should be made between approaches that have a limited view of what constitutes evidence – the focus is usually on research evidence - and those strategies that are based on assumptions that EBP is best promoted through a broader view of what constitutes evidence. Strategies that bring together producers and users of evidence, where for example "knowledge broker" is one form, constitutes a more interactive approach.

    A further expanded perspective on EBP is through strategies that focus on the development and use of evidence in relation to complex or "wicked" problems”. Here the decision maker is not only expected to use evidence but to apply a leadership to unconditionally identify evidence, using a multiplicity of actors. A broader view on the evidence base in collective decision-making need not entail that research-generated knowledge is given a limited role. It may instead be interpreted as a reason to advance the understanding of how different forms of knowledge can serve as complementary input in collective decisionmaking in a democratic society.

  • 27.
    Garpenby, Peter
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Inställningen till vårdprogram bland personal inom barn- och ungdomspsykiatrin i Östergötland: en kompletterande intervjustudie2007Report (Other academic)
    Abstract [en]

    Background

    In 1998 the child and adolescent psychiatry service in the County Council of Östergötland initiated the process of developing their own evidence-based clinical guidelines. By 2006 seven guidelines had been formulated and were published. In 1999 (just before the first guideline was published) and again in 2003, the Center for Medical Technology Assessment (CMT) at Linköping University conducted surveys of the views of members of staff working in the child and adolescent psychiatry service on the process of guideline development and the usefulness of the guidelines. The two surveys indicated differences between professional groups in their evaluation of the usefulness. In order to provide further understanding of the results of the quantitative studies, a qualitative follow-up study was initiated.

    Methods

    In 2006 interviews were carried out with different categories of professionals working in child and adolescent psychiatry in clinical outpatient teams. A purposive sample of 17 professionals (5 psychiatrists, 6 psychologists and 6 social workers) were interviewed regarding their view of the local clinical guidelines (vårdprogram). The interviews addressed the issues of the application of knowledge in general in child and adolescent psychiatry, the criteria used in developing the clinical guidelines, personal experience of using the guidelines in clinical work, and the implementation of the guidelines in the local organisation.

    Results

    The views of the staff on the development and use of the clinical guidelines vary from those who regard evidence-based practice as the primary method the organisation should follow, to those who consider the guidelines of limited value as they only cover a minor part of the methods in use in child and adolescent psychiatry today. Few of the participants in the study used the guidelines as a “recipe book” in their daily clinical work Some of those interviewed felt uneasy about the implementation of guidelines as a type of standardised clinical practice. Irrespective of the participants’ view of the usefulness in their daily work, many acknowledged the potential of the guidelines as part of a larger process to enhance the development of knowledge in the local organisation. Obstacles to implementing such a process in the organisation were also recognised, mainly the lack of time for group discussions.

    Conclusions

    The findings highlight a situation in which the implementation of the guidelines depends to a large extent on the individual members of staff. Among the different professionals there are many who would like to see the guidelines become an integral part of a collective process of continuous learning.

  • 28.
    Garpenby, Peter
    Linköping University, Faculty of Health Sciences.
    Introduktion av metoder inom psykiatrin i Blekinge, Västmanland och Östergötland: en jämförande studie1994Report (Other academic)
  • 29.
    Garpenby, Peter
    Linköping University, Faculty of Health Sciences.
    Ny organisation för psykiatrin i Östergötland: en studie av implementering inom ett landsting1991Report (Other academic)
  • 30.
    Garpenby, Peter
    Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.
    Procedurrättvisa och praktisk prioritering: tre fall från svensk hälso och sjukvård2006Report (Other academic)
    Abstract [en]

    In the health care sector, priority setting often takes the form of rationing (i.e. waiting lists) or even the exclusion of treatment for which there are inadequate funds.  This  situation  is  notoriously  difficult  for  decision-makers  to  handle, whether they are clinicians or elected politicians.

    In this study we have used a well-known ethical framework for "fair" priority setting (accountability for reasonableness) to analyse three cases drawn from the regional  health  care  service  in Sweden.  The  aim  was  to investigate  to what extent "procedural justice" can be applied to "real-life" cases of priority setting and rationing. The cases used in the study are cosmetic surgery, the allocation of disability aids and infertility treatment (IVF). In addition, the local politicians responsible for health care in three local authorities were asked to express their views on issues such as legitimacy and fairness in relation to priority setting.

    It is important to take into consideration that priority setting in the public health care system consists of at least four different processes, i.e. those that can be regarded as internal (within the health care delivery system itself and between the delivery system and political decision-makers)  and those that are external (between the delivery system and patients and between the public provider of health care and the general public).

    The intention was not to grade the three cases with regard to the "fairness" of the  priority-setting  process.  Nevertheless,  it  can  be  noted  that  in  case  A (cosmetic surgery) very little focus was given to the element of "publicity" i.e. information  to  or  dialogue  with  patients  and  the  general  public  about  the priority-setting process. In case B (new policy for disability aids) we noted that the internal legitimacy was far better, although the medical staff responsible for prescribing disability aids found it difficult to develop their own procedures for priority setting. The final case C, (infertility treatment) represents the traditional way to handle the gap between demand and supply in the public sector. In the local authority studied, the political level of decision-makers  had delegated all the  priority-setting  decisions  to  the  clinical  level,  but  instead  of  adopting  a "muddling  through  strategy",  the  clinicians  in  charge  had  spent  time  on developing procedures for disseminating information to patients (publicity) and for ensuring fairness (equal rights).

    The interviews indicate that Swedish local politicians responsible for health care have a relatively good understanding of  the problems related to limited resource and the need for priority  setting.  They are trying  to find new solutions,  and above all to develop a better dialogue with the general public. Most politicians appreciate  the  importance  of  "internal  legitimacy"  i.e.  the  interrelationship between the different decision-making levels within the local authority, and the need for a clear-cut message to patients and the public. On the other hand, the politicians are not in agreement about how the responsibility for communicating the information about priority-setting should be divided between the clinicians and themselves.

  • 31.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Byrsjö, Johan
    Den medicinska faktadatabasen MARS inom Socialstyrelsen: en utvärdering1998Report (Other academic)
  • 32.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Faculty of Health Sciences.
    Nationella kvalitetsregister inom hälso- och sjukvården: en uppföljande studie1996Report (Other academic)
  • 33.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment.
    Carlsson, Per
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment.
    Utvärdering och förslag till organisation av nationella register för kvalitetskontroll inom hälso- och sjukvården1994Report (Other academic)
  • 34.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Götherström, Ulla-Christel
    Larsson, Sussanne
    Linköping University.
    Inställningen till vårdprogram bland personal inom barn- och ungdomspsykiatrin: en uppföljande studie2003Report (Other academic)
  • 35.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Faculty of Health Sciences.
    Hälsoinformation idag och i morgon: Östgötarnas användning av och förtroende för olika informationskällor2000Report (Other academic)
  • 36.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Larsson, Sussanne
    Linköping University.
    Att genomföra psykiatrireformen i vardagen: en uppföljande studie1998Report (Other academic)
  • 37.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Larsson, Sussanne
    Linköping University.
    Hälsoinformation via Internet, bibliotek och patientinformationscentraler: en systematisk litteraturgranskning1999Report (Other academic)
  • 38.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Larsson, Sussanne
    Linköping University.
    Inställningen till vårdprogram bland personal inom barn- och ungdomspsykiatrin: en lägesrapport från Östergötland1999Report (Other academic)
  • 39.
    Garpenby, Peter
    et al.
    Linköping University, Faculty of Health Sciences.
    Lindvall, Paul
    Primärvård Under Kommunalt Huvudmannaskap: CMT:s analys av försöket i Katrineholm1997Report (Other academic)
  • 40.
    Garpenby, Peter
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Nedlund, Ann-Charlotte
    Linköping University, Department of Medical and Health Sciences, Division of Health and Society. Linköping University, Faculty of Health Sciences.
    Ordnat införande av metoder i klinisk verksamhet: En studie av försök med dialogmöten inom Landstinget i Östergötland2013Report (Other academic)
    Abstract [en]

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

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

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

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

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

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

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

  • 41.
    Grundström, Christina
    et al.
    Linköping University, Department of Management and Engineering, Industrial Marketing and Industrial Economics.
    Uddenberg, Anders
    Growth Ambitions vs. Actual Growth in Established SMEs2015In: XXVI ISPIM Conference: Budapest, Hungary (2015): Shaping the Frontiers of Innovation Management / [ed] Huizingh Eelko, Torkkeli Marko, Conn Steffen, and Bitran Iain, 2015Conference paper (Other academic)
    Abstract [en]

    With the purpose to explore what characterizes established SMEs with growth ambitions, literature on growth and in particular growth ambitions was reviewed. Five dimensions of growth ambition were used: important to grow as regards turnover, important to take risks, prioritizes growth to profitability, prioritizes market share to profitability and prioritizes to reinvest to profit. Variables previously found to characterize fast-growing SMEs were included. A sample of 384 Swedish SMEs was used where growth ambitions were collected in 2011 and financial data was obtained for 2009 and 2013. Regardless of dimension, firms with the higher values had a 50 % higher increase employee growth. For most dimensions, a higher percentage of the turnover invested in completely new products and younger managing director/shorter managing director time with the firm and a stronger focus on increasing the domestic market share characterized the firms stressing growth in turnover and not prioritizing profitability.

  • 42.
    Hallert, Eva
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Östergötlands Läns Landsting, Reconstruction Centre, Department of Rehabilitation Medicine UHL. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Schmidt, Andrea
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Jonsson, Dick
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Sjukdomsförlopp, kostnader och livskvalitet vid nydebuterad reumatoid artrit2007Report (Other academic)
    Abstract [en]

    Rheumatoid  arthritis  (RA)  is  a  chronic  progressive  inflammatory   disease, associated with tissue destruction and functional disability. The yearly incidence of RA in Sweden is 25/100 000 and the prevalence is 0.5-0.7%, with women being more often affected than men. The economic consequences of the disease are substantial  for the  individual  and  their  families  and  for the society  as a whole.   Previous   studies   have   reported   that   early   treatment   limits   joint destruction and improves functional outcome.

    In 1996 a multicenter study TIRA was started in Linköping in cooperation with 10 rheumatology units and Center for Medical Technology Assessment (CMT) TIRA is the Swedish acronym for ‘early intervention  in rheumatoid  arthritis’. The   main   goal   was   to   obtain   early   diagnosis,   rapid   multiprofessional intervention  and  a  regular  follow-up.  Further,  the  TIRA  project  aimed  at forming  a research  database  and health economic  evaluation  in patients  with recent-onset RA.

    This study describes disease activity, functional ability, direct and indirect costs as well as self-reported health and quality of life (QoL) in patients with recent- onset RA, during the first 3 years after diagnosis.

    320 subjects were enrolled in the study from January 1996 through April 1998, 2/3  being  women.  At  inclusion  most  patients  had  high  disease  activity  and impaired functional capacity. More than half of patients < 65 were on sick leave and a few were already early retired.

    Highly significant improvements were seen within the first 3 months regarding disease  activity  and functional  ability,  but 15% of the patients  had sustained high or moderate disease activity throughout the study period, despite traditional treatment. The scores of ‘Health Assessment Questionnaire’ (HAQ) were similar for men and women at baseline, but had a less favourable course in women, who also had DMARDs  more frequently prescribed,  suggesting  that women might have a more severe disease.

    At inclusion QoL did not differ between groups concerning different housing, marital   status,   income   or  other  socio-demographic   factors.   Most  patients experienced their health as worse compared with others of the same age. During the first 2 years QoL was improved as well as general mobility and ability to perform activities of daily living. During year 3 a slight deterioration was noted.

    The average direct costs per patient during the first year was SEK 36 000 and indirect costs SEK 89 000 (price level of 2001). All direct costs decreased from year 1 to 3, except costs of drugs and surgery which on the contrary increased. Indirect costs were substantially unchanged over the years. Sick-leave decreased but was offset by an increase in early retirement. Indirect costs were 2-3 times higher than direct costs.

    More than 90% of the patients were satisfied or very satisfied with treatment and availability and information from the medical staff in the participating hospitals.

  • 43.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    The cost-effectiveness of foetal monitoring with ST analysis2008Report (Other academic)
    Abstract [en]

    How to allocate resources in the health care sector is academically dealt with within the subject of health economics. Economic evaluations are within this area used to compare the costs and effects of medical interventions with the purpose to help decision makers decide how to allocate resources.

    Oxygen deficiency in the foetus during birth can lead to severe life long injuries in the child. In high-risk deliveries, there is therefore considered necessary to use foetal surveillance with a scalp electrode and the choice is between surveillance with internal cardiotocography (CTG) and surveillance with ST analysis. The standard procedure is in most hospitals currently CTG, which records the foetal heart rate and the uterine contractions. The second strategy, in this thesis referred to as ST analysis, complements CTG with foetal electrocardiography (ECG) and ST analysis.

    The objective of this report is to from a societal perspective determine the costeffectiveness of using ST analysis in complicated deliveries, compared to the use of CTG alone. A cost-utility analysis was performed based on a probabilistic decision model incorporating the relevant strategies and outcomes. The costs and effects of the two different treatment strategies were compared in a decision tree. Discounted costs and quality-adjusted life-years (QALYs) were measured and simulated over a life-time perspective.

    The analysis resulted in an incremental effect of 0.005 QALYs for the ST analysis strategy, when compared to the CTG strategy. ST analysis was also associated with a €30 lower cost. Thus, CTG is dominated by the ST analysis strategy. The probability that ST analysis is the cost-effective alternative is high for all values of willingness-to-pay for a QALY, which means that a decision to implement the ST analysis strategy based on the results of this thesis would be surrounded by a low degree of uncertainty.

  • 44.
    Henriksson, Martin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Siverskog, Jonathan
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Johannesen, Kasper
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Eriksson, Thérèse
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Tröskelvärden och kostnadseffektivitet: innebörd och implikationer för ekonomiska utvärderingar och beslutsfattande i hälso- och sjukvården2018Report (Other academic)
    Abstract [en]

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

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

  • 45.
    Jacobsson, Fredric
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Lycka och hälsa2012In: QALY som effektmått inom vården: Möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, p. 76-95Chapter in book (Other academic)
  • 46.
    Jacobsson, Fredric
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Mål och mått: En dokumentation och utvärdering av en resultatbaserad ersättning inom primärvården2008Report (Other academic)
    Abstract [en]

    There is a growing interest for the use of economic incentives to motivate and govern employees in the health care sector. One way to encourage effort is to pay for performance. The aim of this study is to document and evaluate the implementation of a pay for performance program called “mål och mått” (objectives and measures) directed toward the primary care in the county council of Östergötland. This is a way to learn more about the practical effects of performance based reimbursement. The main reimbursement principle toward the primary care in Östergötland is capitation and the performance based part consists of approximately 4 % of the total reimbursement. The aim of the performance based reimbursement is to promote quality and availability. Since the start in 2002, the areas in which this performance based reimbursement has been used have shifted. The most important areas are: diagnostic routines, prescriptions for physical activity, registrations in the Swedish national diabetes register, accessibility by telephone, asthma nurse practice, psychosocial capability and influenza vaccinations.

    This study shows sizable increases in performance, especially in conjunction with implementation but also while the reimbursement is at use. In the consequence of the complex context, we can not be absolutely sure about the causes to the effects. Many indices, however, point at the reimbursement as the most important cause, especially as the performance drops when the performance based reimbursement is derated.

    Other important areas related to performance based reimbursement that are discussed in this paper are for example: the importance of knowing the starting point and the objective of the reimbursement implementation, pros and cons of performance based reimbursement, practical differences between different types of performance based reimbursements, Donabedians theories concerning structure, process and result in relation to performance based reimbursement

  • 47.
    Jacobsson, Fredrik
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Monetära ersättningsprinciper i hälso- och sjukvård2007Report (Other academic)
    Abstract [en]

    To create economic incentives for those working in the health care sector, the choice and design of provider payment systems are important factors. In the first part of this paper a typology for classifying these payment systems is presented. Three dimensions are identified. The degree of activity indicates if there is a link between the provider’s activity and earnings. The time perspective indicates if the actual costs will influence the earnings of the provider, and the object indicates the area at which the incentives are aimed. The created incentives are also compared with general objectives of health care. Because economic incentives caused by payment systems constitute only part of all the factors that motivate those working in the health care sector, it is difficult to know what the final results of a new payment system will be. This is confirmed in the second part of this paper where the practical effects of different payment systems are investigated. One important, often forgotten motivator is the intrinsic motivation that derives from job satisfaction per se, compliance with ethical standards or standards of fairness (for one’s own sake), and the achievement of personal goals. To make use of desirable effects of provider payment systems and avoid undesirable effects, different payment principles are often combined. An interesting advance in this area is the great interest in mixing performance related payment with other payment principles. The fundamental objective of health care ought to be the production of health. In this perspective, payment related to health gains is of interest. The problem is measuring health gains in an objective way. Performance related payment to providers in the health care sector is outlined in the last part of the paper. To be able to design payment systems in the future that are as good as possible, both research and practical experience are needed.

  • 48.
    Johannesson, Magnus
    et al.
    Linköping University, Department of Thematic Studies, Health and Society. Linköping University, Faculty of Arts and Sciences.
    Hedbrant, Johan
    Center of Technology Transfer, Institute of Technology, Linköping Universitgy, Sweden.
    Jönsson, Bengt
    Linköping University, Department of Thematic Studies, Health and Society. Linköping University, Faculty of Arts and Sciences.
    A computer simulation model for cost-effectiveness analysis of cardiovascular disease prevention1991Report (Other academic)
    Abstract [en]

    In this paper a computer simulation model for cost-effectiveness analysis of cardiovascular disease prevention is presented. The computer simulation model was written in Turbo Pascal to be used on an IBM-PC compatible. The model was based on the 8-year logistic multivariate risk equations for coronary heart disease (CHD) and stroke from the Framingham heart study, but the regression coefficients can easily be changed if local data exists. The main advantages of the model are that it is easy to use, transparent, and flexible. The model was mainly developed for scientific purposes, but should be useful also for educational purposes and clinical decision analysis. The modelling approach should also be useful in many other medical areas.

  • 49.
    Larsson, Sussanne
    et al.
    Linköping University.
    Garpenby, Peter
    Linköping University, Faculty of Health Sciences.
    Lindvall, Paul
    Kommunal primärvård i Katrineholm: perspektiv på utveckling och samverkan1997Report (Other academic)
  • 50.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Tillstånd med negativa QALY-vikter och mätning av temporära hälsotillstånd2012In: QALY som effektmått inom vården: Möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, p. 54-64Chapter in book (Other academic)
12 1 - 50 of 70
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