I denna rapport beskrivs utvecklingen av läkemedelsbehandling vid hjärtsvikt till följd av de uppdaterade behandlingsrekommendationer som publicerades den 14 januari 2022. Enligt dessa rekommendationer ska hjärtsviktspatienter med nedsatt vänsterkammarfunktion (HFrEF) behandlas med läkemedel från fyra läkemedelsgrupper, så kallad kvadrupelbehandling. För hjärtsviktspatien-ter med måttligt nedsatt vänsterkammarfunktion (HFmrEF) ska kvadrupelbehandling övervägas. Hjärtsviktspatienter med bevarad vänster-kammarfunktion (HFpEF) ska behandlas utifrån symtom och bör i normalfallet inte ges kvadrupelbehandling.

Våra registerbaserade analyser visar att läkemedelsbehandlingen av hjärt-sviktspatienter har genomgått en tydlig förändring mellan januari 2022 och september 2024. Andelen patienter som någon gång provat kvadrupel-behandling har ökat från 5% till 30%. För patienter med underdiagnosen HFrEF är motsvarande siffra drygt 40%. Ökningen av kvadrupelbehandling består till stor del av en ökning av den senast tillkomna läkemedelsklassen SGLT2-hämmare, som är indicerat för alla hjärtsviktspatienter, inklusive de med HFpEF. Andelen incidenta patienter som behandlas med SGLT2-hämmare har ökat från cirka 15% i januari 2022 till cirka 57% i september 2024. För patienter med HFrEF är motsvarande siffror ungefär 35% och 80%.

Generellt har vi sett att patienter med en specificerad underdiagnos har större sannolikhet att få kvadrupelbehandling än de som inte fått det, även om underdiagnosen var HFpEF. Detta beror sannolikt på en tidseffekt, då specificerad diagnosticering har ökat markant sedan behandlingsriktlinjernas publicering. En annan möjlig förklaring är att vårdgivare som är bra på att sätta en specifik underdiagnos också är de som är mest benägna att följa nya behandlingsriktlinjer.

Användningen av både kvadrupelbehandling och SGLT2-hämmare är högre bland män än bland kvinnor och minskar med stigande ålder. Dessa skillnader kan delvis förklaras av mindre användning bland patienter med HFpEF, som både är äldre och har en större andel kvinnor än övriga underdiagnoser.

Även om användningen av kvadrupelbehandling tydligt har ökat över tid, kvarstår stora regionala skillnader. I september 2024 varierade andelen inci-denta patienter som fått kvadrupelbehandling mellan 13% (Region Västmanland) och 32% (Region Gävleborg). Motsvarande siffror för SGLT2-hämmare var mellan cirka 38% (Region Västmanland) och 63% (Region Gävleborg).

Implementeringen av behandlingsrekommendationerna för patienter med hjärtsvikt har varit tämligen framgångsrik, med en markant ökning av andelen patienter som erhåller rekommenderad behandling. Det finns dock utrymme för förbättringar, vilket inte minst framgår av de stora regionala variationerna.

This report describes the development of drug treatment for heart failure following the updated treatment recommendations published on January 14, 2022. According to these recommendations, heart failure patients with reduced left ventricular function (HFrEF) should be treated with medications from four groups, known as quadruple therapy. For heart failure patients with moderately reduced left ventricular function (HFmrEF), quadruple therapy should be considered. Heart failure patients with preserved left ventricular function (HFpEF) should be treated based on symptoms and generally should not receive quadruple therapy. 

Our registry-based analyses show that the drug treatment of heart failure patients has undergone significant changes between January 2022 and September 2024. The proportion of patients who have tried quadruple therapy has increased from 5% to 30%. For patients with the HFrEF sub-diagnosis, the corresponding figure is just over 40%. The increase in quadruple therapy is largely due to the increased use of the latest drug class, SGLT2 inhibitors, which are indicated for all heart failure patients, including those with HFpEF. The proportion of incident patients treated with SGLT2 inhibitors has increased from approximately 15% in January 2022 to approximately 57% in September 2024. For patients with HFrEF, the corresponding figures are roughly 35% and 80%. 

Generally, we have seen that patients with a specified sub-diagnosis are more likely to receive quadruple therapy than those who have not, even if the subdiagnosis was HFpEF. This is likely due to a time effect, as specified diagnosis has increased significantly since the publication of the treatment guidelines. Another possible explanation is that healthcare providers who are good at making specific sub-diagnoses are also those most likely to follow new treatment guidelines. 

The use of both quadruple therapy and SGLT2 inhibitors is higher among men than among women and decreases with increasing age. These differences can partly be explained by lower usage among patients with HFpEF, who are older and have a higher proportion of women than other sub-diagnoses. 

Although the use of quadruple therapy has clearly increased over time, significant regional differences remain. In September 2024, the proportion of incident patients who received quadruple therapy varied between 13% (Region Västmanland) and 32% (Region Gävleborg). The corresponding figures for SGLT2 inhibitors were between approximately 38% (Region Västmanland) and 63% (Region Gävleborg). 

The implementation of treatment recommendations for heart failure patients has been quite successful, with a marked increase in the proportion of patients receiving recommended treatment. However, there is room for improvement, as evidenced by the substantial regional variations.

I denna rapport beskrivs utvecklingen av läkemedelsbehandling vid hjärtsvikt till följd av de uppdaterade behandlingsrekommendationer som publicerades den 14 januari 2022. Enligt dessa rekommendationer ska hjärtsviktspatienter med nedsatt vänsterkammarfunktion (HFrEF) behandlas med läkemedel från fyra läkemedelsgrupper, så kallad kvadrupelbehandling. För hjärtsviktspatien-ter med måttligt nedsatt vänsterkammarfunktion (HFmrEF) ska kvadrupel-behandling övervägas. Hjärtsviktspatienter med bevarad vänsterkammar-funktion (HFpEF) ska behandlas utifrån symtom och bör i normalfallet inte ges kvadrupelbehandling.

Våra registerbaserade analyser visar att läkemedelsbehandlingen av hjärt-sviktspatienter har genomgått en tydlig förändring mellan januari 2022 och april 2025. Andelen patienter som någon gång provat kvadrupelbehandling har ökat från 5% till drygt 30%. För patienter med underdiagnosen HFrEF är motsvarande siffra drygt 40%. Ökningen av kvadrupelbehandling består till stor del av en ökning av den senast tillkomna läkemedelsklassen SGLT2-hämmare, som är indicerat för alla hjärtsviktspatienter, inklusive de med HFpEF. Andelen incidenta patienter som behandlas med SGLT2-hämmare har ökat från cirka 15% i januari 2022 till cirka 58% i april 2025. För patienter med HFrEF är motsvarande siffror ungefär 35% och 81%.

Generellt har vi sett att patienter med en specificerad underdiagnos har större sannolikhet att få kvadrupelbehandling än de som inte fått det, även om underdiagnosen var HFpEF. Detta beror sannolikt på en tidseffekt, då specificerad diagnosticering har ökat markant sedan publiceringen av behandlingsrekommendationerna. En annan möjlig förklaring är att vårdgivare som är bra på att sätta en specifik underdiagnos också är de som är mest benägna att följa nya behandlingsriktlinjer.

Användningen av både kvadrupelbehandling och SGLT2-hämmare är högre bland män än bland kvinnor och minskar med stigande ålder. Dessa skillnader kan delvis förklaras av mindre användning bland patienter med HFpEF, som både är äldre och har en större andel kvinnor än övriga underdiagnoser.

Även om användningen av kvadrupelbehandling tydligt har ökat över tid, kvarstår stora regionala skillnader. I januari 2025 varierade andelen incidenta patienter som fått kvadrupelbehandling mellan 17% (Region Västmanland) och 33% (Region Blekinge). Motsvarande siffror för SGLT2-hämmare var mellan cirka 47% (Region Västmanland) och 71% (Region Gotland).

Implementeringen av behandlingsrekommendationerna för patienter med hjärtsvikt har varit tämligen framgångsrik, med en markant ökning av andelen patienter som erhåller rekommenderad behandling. Det finns dock utrymme för förbättringar, vilket inte minst framgår av de stora regionala variationerna.

This report describes the development of drug treatment for heart failure following the updated treatment recommendations published on January 14, 2022. According to these recommendations, heart failure patients with reduced left ventricular function (HFrEF) should be treated with medications from four groups, known as quadruple therapy. For heart failure patients with moderately reduced left ventricular function (HFmrEF), quadruple therapy should be considered. Heart failure patients with preserved left ventricular function (HFpEF) should be treated based on symptoms and generally should not receive quadruple therapy.

Our registry-based analyses show that the drug treatment of heart failure patients has undergone significant changes between January 2022 and April 2025. The proportion of patients who have tried quadruple therapy has increased from 5% to above 30%. For patients with the HFrEF sub-diagnosis, the corresponding Figure is just over 40%. The increase in quadruple therapy is largely due to the increased use of the latest drug class, SGLT2 inhibitors, which are indicated for all heart failure patients, including those with HFpEF. The proportion of incident patients treated with SGLT2 inhibitors has increased from approximately 15% in January 2022 to approximately 58% in April 2025. For patients with HFrEF, the corresponding Figures are 35% and 81%.

Generally, we have seen that patients with a specified sub-diagnosis are more likely to receive quadruple therapy than those who have not, even if the sub-diagnosis was HFpEF. This is likely due to a time effect, as specified diagnosis has increased significantly since the publication of the treatment recommendations. Another possible explanation is that healthcare providers who are good at making specific sub-diagnoses are also those most likely to follow new treatment guidelines.

The use of both quadruple therapy and SGLT2 inhibitors is higher among men than among women and decreases with increasing age. These differences can partly be explained by lower usage among patients with HFpEF, who are older and have a higher proportion of women than other sub-diagnoses.

Although the use of quadruple therapy has clearly increased over time, significant regional differences remain. In January 2025, the proportion of incident patients who received quadruple therapy varied between 17% (Region Västmanland) and 33% (Region Blekinge). The corresponding Figures for SGLT2 inhibitors were between 47% (Region Västmanland) and 71% (Region Gotland).

The implementation of treatment recommendations for heart failure patients has been quite successful, with a marked increase in the proportion of patients receiving recommended treatment. However, there is room for improvement, as evidenced by the substantial regional variations.

Background: Whole-genome sequencing (WGS) and whole-transcriptome sequencing (WTS), with the ability to provide comprehensive genomic information, have become the focal point of research interest as novel techniques that can support precision diagnostics in routine clinical care of patients with various cancer types, including hematological malignancies. This national multi-center study, led by Genomic Medicine Sweden, aims to evaluate whether combined application of WGS and WTS (WGTS) is technically feasible and can be implemented as an efficient diagnostic tool in patients with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). In addition to clinical impact assessment, a health-economic evaluation of such strategy will be performed.

Methods and Analysis: The study comprises four phases (i.e., retrospective, prospective, real-time validation, and follow-up) including approximately 700 adult and pediatric Swedish AML and ALL patients. Results of WGS for tumor (90×) and normal/germline (30×) samples as well as WTS for tumors only will be compared to current standard of care diagnostics. Primary study endpoints are diagnostic efficiency and improved diagnostic yield. Secondary endpoints are technical and clinical feasibility for routine implementation, clinical utility, and health-economic impact.

Discussion: Data from this national multi-center study will be used to evaluate clinical performance of the integrated WGTS diagnostic workflow compared with standard of care. The study will also elucidate clinical and health-economic impacts of a combined WGTS strategy when implemented in routine clinical care.

Objectives

The aim of this study was to estimate the cost-effectiveness of intermittent electrocardiogram (ECG) screening for atrial fibrillation (AF) among 70-74-year old individuals in primary care. We also aimed to assess adherence to anticoagulants, severe bleeding, stroke and mortality among screening-detected AF cases at three-year follow-up.

Methods

A post hoc analysis based on a cross-sectional screening study for AF among 70-74-year old patients, who were registered at a single primary care center, was followed for three years for mortality. Data about adherence to anticoagulants, incidence of stroke and severe bleeding among screening-detected AF cases, were collected from patients records. Markov model and Monte Carlo simulation were used to assess the cost-effectiveness of the screening program.

Results

The mortality rate among screening-detected AF cases (n = 16) did not differ compared to the 274 individuals with no AF (hazard ratio 0.86, CI 0.12-6.44). Adherence to anticoagulants was 92%. There was no stroke or severe bleeding. The incremental cost-effectiveness ratio of screening versus no screening was EUR 2389/quality-adjusted life year (QALY) gained. The screening showed a 99% probability of being cost-effective compared to no screening at a willingness-to-pay threshold of EUR 20,000 per QALY.

Conclusion

Screening for AF among 70-74-year olds in primary care using intermittent ECG appears to be cost-effective at 3-year follow-up with high anticoagulants adherence and no increased mortality.

Background Psoriasis contributes to unemployment, work impairment, missed workdays and substantial indirect costs due to lost productivity. Combination Cal/BD foam is the only topical that is approved for long-term maintenance treatment of plaque psoriasis for 52 weeks. This is the first known investigation of the effect of topical psoriasis therapy on productivity. Objective To examine the change in work productivity and activity impairment after 4 weeks of treatment with fixed-dose combination calcipotriol 50 mu g/g/betamethasone dipropionate 0.5 mg/g (Cal/BD) foam and observe long-term changes after 52 weeks of long-term management (proactive or reactive treatment). Methods This is a post-hoc analysis of the PSO-LONG trial - a phase 3, randomized, double-blind, vehicle-controlled, parallel group, international multi-centre trial of treatment with combination Cal/BD foam. Work and activity impairment due to psoriasis were assessed by the Dermatology Life Quality Index (DLQI) and the Work Productivity and Activity Impairment Psoriasis (WPAI:PSO) questionnaire at baseline, week 4, week 28 and week 56. The improvement in hours of work productivity was translated into monthly and annual indirect cost savings estimates for patients in Italy, Sweden, United Kingdom, Canada and Germany. Results Using fixed-dose combination Cal/BD foam for four weeks significantly reduced psoriasis-related work presenteeism, total work productivity impairment (TWPI) and total activity impairment (TAI) over 56 weeks, with significant improvements observed as early as 4 weeks after the baseline visit. The proportion of patients reporting impact on work productivity (as measured by presenteeism and TWPI) and activity impairment (as measured by both DLQI-Q7b and TAI) also decreased. Conclusion Fixed-dose combination Cal/BD foam used for long-term management of psoriasis significantly reduces psoriasis-related work productivity and activity impairment which may result in substantial indirect cost savings.

PURPOSE The combination of whole-genome and transcriptome sequencing (WGTS) is expected to transformdiagnosis and treatment for patients with cancer. WGTS is a comprehensive precision diagnostic test that isstarting to replace the standard of care for oncology molecular testing in health care systems around the world;however, the implementation and widescale adoption of this best-in-class testing is lacking.

METHODS Here, we address the barriers in integrating WGTS for cancer diagnostics and treatment selection andanswer questions regarding utility in different cancer types, cost-effectiveness and affordability, and otherpractical considerations for WGTS implementation.

RESULTS We review the current studies implementing WGTS in health care systems and provide a synopsis of theclinical evidence and insights into practical considerations for WGTS implementation. We reflect on regulatory,costs, reimbursement, and incidental findings aspects of this test.

CONCLUSION WGTS is an appropriate comprehensive clinical test for many tumor types and can replacemultiple, cascade testing approaches currently performed. Decreasing sequencing cost, increasing number ofclinically relevant aberrations and discovery of more complex biomarkers of treatment response, should pave theway for health care systems and laboratories in implementing WGTS into clinical practice, to transform diagnosisand treatment for patients with cancer.

Background To date, evidence on the dose adjustments of biologics in the real-world treatment of psoriasis is limited. However, dose adjustments may have important clinical and economic implications. Aims To study the dose adjustments of individual biologics over time in real-world practice in Sweden. Methods A retrospective observational study of adults with moderate to severe psoriasis was conducted based on Swedish national registry data from 2010 to 2018. Treatment episodes were identified for individual patients from the date of drug dispensation to the end of the supply of the drug. Dosing data were expressed as the proportion of treatment episodes with accumulated syringes/vials equal to, above or below the recommended guidelines. Real-world costs were calculated and compared with costs predicted from dosing guidelines. Results The mean dose was above recommended levels for all biologics investigated. Weighted mean dose adjustments for adalimumab, etanercept, secukinumab and ustekinumab were 13%, 23%, 8% and 3%, respectively, over the entire treatment period. Higher doses translate to higher costs, including notable increases over time vs. expected costs for secukinumab. Conclusions Dose adjustments of biologics are frequent in clinical practice but differ for the various biologics. The mean observed increases in dose above guideline recommendations might indicate perceptions of suboptimal efficacy for biologics, with implications for the cost and cost-effectiveness of these treatments. Further research is warranted to understand the reasons for dose adjustments in clinical practice.

Over the last decades, rapid technological and scientific advances have led to a merge of molecular sciences and clinical medicine, resulting in a better understanding of disease mechanisms and the development of novel therapies that exploit specific molecular lesions or profiles driving disease. Precision oncology is here used as an example, illustrating the potential of precision/personalized medicine that also holds great promise in other medical fields. Real-world implementation can only be achieved by dedicated healthcare connected centers which amass and build up interdisciplinary expertise reflecting the complexity of precision medicine. Networks of such centers are ideally suited for a nation-wide outreach offering access to precision medicine to patients independent of their place of residence. Two of these multicentric initiatives, Genomic Medicine Sweden (GMS) and the Centers for Personalized Medicine (ZPM) initiative in Germany have teamed up to present and share their views on core concepts, potentials, challenges, and future developments in precision medicine. Together with other initiatives worldwide, GMS and ZPM aim at providing a robust and sustainable framework, covering all components from technology development to clinical trials, ethical and legal aspects as well as involvement of all relevant stakeholders, including patients and policymakers in the field.

Purpose: Using financial incentives has been criticised for putting too much focus on things that can be measured. Value-based reimbursement may better align professional values with financial incentives. However, professional values may differ between actor groups. In this article, the authors identify institutional logics within healthcare-providing organisations. Further, the authors analyse how the centrality and compatibility of the identified logics affect the institutionalisation of external demands.

Design/methodology/approach: 41 semi-structured interviews were conducted with representatives from healthcare providers within spine surgery in Sweden, where a value-based reimbursement programme was introduced. Data were analysed using thematic content analysis with an abductive approach, and a conceptual framework based on neo-institutional theory.

Findings: After the introduction of the value-based reimbursement programme, the centrality and compatibility of the institutional logics within healthcare-providing organisations changed. The logic of spine surgeons was dominating whereas physiotherapists struggled to motivate a higher cost for high quality physiotherapy. The institutional logic of nurses was aligned with spine surgeons, however as a peripheral logic facilitating spine surgery. To attain holistic and interdisciplinary healthcare, dominating institutional logics within healthcare-providing organisations need to allow peripheral institutional logics to attain a higher centrality for higher compatibility. Thus, allowing other occupations to take responsibility for quality and attain the feeling of professional pride.

Originality/value: Interviewing spine surgeons, physiotherapists, nurses, managers and administrators allows us to deepen the understanding of micro-level behaviour as a reaction (or lack thereof) to macro-level decisions.

Introduction Biologic treatments for psoriasis are commonly switched. Treatment persistence represents an important parameter related to long-term therapeutic performance. The objective of the study was to analyse the real-world persistence with biologics over time in the treatment of psoriasis. Methods A retrospective observational study of adults with psoriasis was conducted based on Swedish national registry data from 2010 to 2018. Patients included were treated with a biologic between 2010 and 2018. Treatment episodes were identified from the drugs date of dispensation recorded in the Prescribed Drug Register to the end of supply of the drug. Median persistence was estimated by Kaplan-Meier survival curves for patients who received adalimumab, etanercept, secukinumab, ustekinumab and ixekizumab. Descriptive analysis of change in persistence over time for 3-year running cohorts was also carried out. Results A total of 2292 patients were analysed. Patients who received ustekinumab had the longest median persistence [49.3 months, 95% confidence interval (CI) 38.0-59.1] and etanercept the shortest (16.3 months, 95% CI 14.5-19.0). Median persistence was longer in biologic-naive than biologic-exposed patients. Persistence for ustekinumab decreased by almost 50% over the study period, from a median of 62.3 (95% CI 45.6-infinity) months in 2010-2011 to 32.7 (21.2-49.3) months in 2014-2016. Conclusions Persistence with biologics was, on average, relatively low, given the chronic nature of psoriasis. Changes in persistence over time seemed to be attributable to changes in the therapeutic landscape, providing patients with more options to switch biologic treatments if their current management was considered suboptimal.