| 1. |
- Entezarjou, Artin
(författare)
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eVisits in the digital era of Swedish primary care
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objective: To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,and subsequent care utilization in the digital era of primary care in Sweden.Methods: A mixed-methods approach was adopted across the various papers in the thesis, with all studiesevaluating the eVisit platform Flow in various clinical contexts.- Paper I was a comparative study of digital triage decisions when presented with automated patienthistory reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in apanel of five physicians was compared to triage decisions by a machine learning model trained usingdata labelled by an expert primary care physician.- Paper II was a qualitative focus group study of nurse and physician experiences of digitalcommunication at three primary health care centers using the platform. Themes were generated usingqualitative content analysis as described by Graneheim and Lundman.- Papers III and IV were observational studies comparing office visits in the Skåne Region from Capio,a large private health care provider, to eVisit patients from Capio Go, a national eVisit service. Adultpatients with a chief complaint of sore throat, dysuria, or cough/common cold/influenza were recruited.eVisit patients were recruited prospectively digitally prior to their eVisit, while the office visit controlgroup was recruited retrospectively using letters. Paper III primarily compared antibiotic prescriptionrates per sore throat visit, while paper IV primarily compared subsequent physical health careutilization within two weeks for patients in the Skåne Region.Results: Interrater reliability was low (Cohen κ 0.17) between the panel majority vote and the machine learningmodel. Physicians and nurses experienced digitally filtered primary care, adjusting to a novel medium ofcommunication highlighting challenges in interpreting symptoms through text as well as alterations in practiceworkflow using asynchronous communication. Antibiotics prescription rate within three days was not higher aftereVisits compared to office visits (169/798 (21.2%) vs. 124/312 (39.7%) for sore throat, respectively; P<.001). Nosignificant differences in subsequent physical visits within two weeks (excluding the first 48 h of expected “digi-physical”care) were noted following eVisits compared to office visits (179 (18.0%) vs. 102 (17.6%); P = .854).Conclusions: eVisits do not seem to be associated with over-prescription of antibiotics, or over-utilization ofphysical health care when assessing common infectious symptoms. Given staff experiencing uncertainties ininterpretation of symptoms and triage decisions being inconsistent, eVisits may be best used as one of manymodalities to access primary care, with focus placed on facilitating patient-centered professional judgement bystaff, rather than automation of complex decisions.
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| 2. |
- Lytsy, Per, 1968-
(författare)
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Power of the Pill : Views about Cardiovascular Risk and the Risk-reducing Effect of Statins
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Medical treatments with statins are prescribed to patients with increased risk of cardiovascular events. The benefits from statin treatment are well documented in clinical trials, but long-term adherence in patients is low, indicating that patients have an uncertainty about the necessity and benefits of treatment. The aims of this thesis were to investigate how patients and doctors view different aspects of statin treatment. Further aims were to investigate if the cardiovascular risk level in patients affects their views about different aspects of statin treatment. Yet further aims were to compare health behaviours and views about risk factors in patients using statins to a non-treated population. Data was obtained from patients (n = 829), doctors (n = 330) and a population sample (n = 720) using postal questionnaires. Views about the effect of statin treatment were assessed in different ways for patients and doctors. Patients based their assessments on their own situation, and doctors’ treatment decisions and assessments of anticipated effect of treatment were based on two hypothetical patient cases. The results indicate that patients greatly overestimate the general effect of statins, compared to efficacy results reported from clinical trials. Patients’ previous coronary heart disease or high overall risk were factors not associated with their views and expectations of treatment effect. Statin users with an internally perceived health control and patients satisfied with their doctor’s treatment explanation reported higher beliefs in treatment necessity and benefits. Statin users reported having better health behaviours and generally rated risk factors as more important than the non-treated population. Doctors had suboptimal understanding of the number of patients expected to benefit following five years of statin treatment and had a varying understanding of statins’ ability to prolong life. Overall the results illustrate that patients and doctors have different perspectives and views of the benefits from statin treatment which puts emphasis on how statin treatment is discussed in the clinical setting.
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| 3. |
- Westman, Anders, 1946-
(författare)
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Musculoskeletal pain in primary health care : a biopsychosocial perspective for assessment and treatment
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Long-term musculoskeletal pain is a large public health problem with serious consequences for both the individual and society. Psychosocial factors have been shown to be good predictors of long-term disability and play an important role in the transition from acute to chronic pain. Early identification and intervention of those that run the risk of developing long-term disability would offer a great opportunity for reducing costs and personal suffering. The overall aim of this thesis was to assess a biopsychosocial approach to the assessment and management of musculoskeletal pain patients in primary health care. To this end, biopsychosocial assessment and treatment methods were tested in two different populations of primary care patients suffering pain. Results indicated that improvements in quality of life and work capacity one year after early multimodal rehabilitation were basically maintained after five years. The most salient prognostic factors determining return to work were educational level and the individual’s perceived health (Study I). Psychosocial factors as measured by the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) were related to disability and perceived health three years after treatment for non-acute pain problems (Study II). The experimental group in the controlled multimodal pain rehabilitation programme had lower health care utilization and a reduced risk of using large amounts of medication after three years compared with the participants in the control group. However, there were no significant differences between the groups on variables such as work capacity, function, catastrophizing and pain (Study III). Distinct profiles of catastrophizing, fear-avoidance beliefs, and distress were extracted and meaningfully related to future sick leave and dysfunction (Study IV). Our findings provide support for the biopsychosocial model and highlight the importance of psychosocial factors in long-term outcome. The results underscore the need for early identification of patients at risk. Further, multimodal treatment that covers not only biological but also psychosocial factors seems to be a key to successful treatment, and ideally this intervention should be matched to the patients' needs.
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| 4. |
- Ahlander, Britt-Marie, 1954-
(författare)
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Magnetic Resonance Imaging of the Heart : Image quality, measurement accuracy and patient experience
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Non-invasive diagnostic imaging of atherosclerotic coronary artery disease (CAD) is frequently carried out with cardiovascular magnetic resonance imaging (CMR) or myocardial perfusion single photon emission computed tomography (MPS). CMR is the gold standard for the evaluation of scar after myocardial infarction and MPS the clinical gold standard for ischemia. Magnetic Resonance Imaging (MRI) is at times difficult for patients and may induce anxiety while patient experience of MPS is largely unknown.Aims: To evaluate image quality in CMR with respect to the sequences employed, the influence of atrial fibrillation, myocardial perfusion and the impact of patient information. Further, to study patient experience in relation to MRI with the goal of improving the care of these patients.Method: Four study designs have been used. In paper I, experimental cross-over, paper (II) experimental controlled clinical trial, paper (III) psychometric crosssectional study and paper (IV) prospective intervention study. A total of 475 patients ≥ 18 years with primarily cardiac problems (I-IV) except for those referred for MRI of the spine (III) were included in the four studies.Result: In patients (n=20) with atrial fibrillation, a single shot steady state free precession (SS-SSFP) sequence showed significantly better image quality than the standard segmented inversion recovery fast gradient echo (IR-FGRE) sequence (I). In first-pass perfusion imaging the gradient echo-echo planar imaging sequence (GREEPI) (n=30) had lower signal-to-noise and contrast–to-noise ratios than the steady state free precession sequence (SSFP) (n=30) but displayed a higher correlation with the MPS results, evaluated both qualitatively and quantitatively (II). The MRIAnxiety Questionnaire (MRI-AQ) was validated on patients, referred for MRI of either the spine (n=193) or the heart (n=54). The final instrument had 15 items divided in two factors regarding Anxiety and Relaxation. The instrument was found to have satisfactory psychometric properties (III). Patients who prior CMR viewed an information video scored significantly (lower) better in the factor Relaxation, than those who received standard information. Patients who underwent MPS scored lower on both factors, Anxiety and Relaxation. The extra video information had no effect on CMR image quality (IV).Conclusion: Single shot imaging in atrial fibrillation produced images with less artefact than a segmented sequence. In first-pass perfusion imaging, the sequence GRE-EPI was superior to SSFP. A questionnaire depicting anxiety during MRI showed that video information prior to imaging helped patients relax but did not result in an improvement in image quality.
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| 5. |
- Liljeroos, Maria
(författare)
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Caring needs in patient-partner dyads affected by heart failure : An evaluation of the long-term effects of a dyadic psycho-educational intervention
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: As medical treatment has improved, patients with heart failure (HF) now live longer and care mostly takes place at home with partners providing the main assistance. Taking care of an ill or disabled individual imposes a well-documented burden on the partner’s healthrelated quality of life. The awareness of partners’ burdensome situation is increasing, but few interventions have targeted the needs of patientpartner dyads with HF. The results have been inconclusive and give no clear guidance on how interventional programmes should be designed to improve both patient and partner outcomes.Aim: The overall aim of this thesis was to evaluate the effects of a psychoeducational intervention delivered to patient-partner dyads with HF during long-term follow-up, and to explore the dyads’ perceived caring needs.Methods: The thesis is based on four papers that used both quantitative and qualitative data. Study I and II used a randomized controlled design with a follow-up assessment after 24 months including 155 patientpartner dyads. The control group received care as usual. The intervention group received care as usual, and in addition they participated in the nurse-led psycho-educational intervention. Data was collected using questionnaires before and 24 months after the intervention, in order to determine the long-term effects on patients and partners regarding health related quality of life, perceived control, symptoms of depression and partners’ caregiver burden (I, II). A conceptual health promotion model inspired the intervention. To describe how the model was applied, a qualitative approach analysing nurses’ documentation of the sessions with 71 dyads in the intervention group (III) was used. Study IV has an explorative design. To further explore the dyads’ perceived caring needs, focus groups interviews with 19 patient-partner dyads with heart failure (IV) were performed.Results: The intervention did not have any significant effect on physical or mental health- related quality of life, depressive symptoms, or perceived control over the heart failure among the dyads (I) or caregiver burden in the partners (II) after 24 months. Furthermore, time to first event did not differ significantly between the dyads in the intervention group and the control group (I, II). As for the partners, both the intervention and control group reported decreased physical health between the baseline assessment and the 24-month follow-up (I). The intervention was composed of three components; 1) cognitive 2) supportive, and 3) behavioural component. The analysis of the nurses’ documentation confirmed the coverage of all the components and the analysis revealed a vide range of caring needs among the dyads (III). The dyads described a need to learn about HF to be able to manage everyday life. Regular outpatient clinic visits and access to telephone support were vital and both the patient and the partner need to be present at the clinic visits. Meeting others who are in the same situation and sharing the burden in nurse-led group sessions was proposed as an opportunity to support each other and others (IV).Conclusions: Over the 24-month follow-up period, the intervention had a neutral effect on health- related quality of life, depressive symptoms and perceived control over the HF among the dyads, and on partners’ caregiver burden. Considering the fact that partners serve as a critical extension of the formal healthcare system, and that both patients and partners ask for more support, it will become crucial to find new ways to support dyads affected by heart failure. This thesis may be viewed as a first step in trying to understand dyads’ perceived caring needs, and it can serve as a guide in clinical work and when designing new dyadic interventions.
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| 6. |
- Kernell, Kristina
(författare)
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Cardiac disease in pregnancy and consequences for reproductive outcomes, comorbidity and survival
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundAdvances in medical treatment during the last 50 years have resulted in more individuals with congenital heart disease (CHD) and Marfan syndrome reaching childbearing age. The substantial physiological changes during pregnancy result in a high-risk situation, and pregnancy is a major concern in women with these conditions.AimsTo describe the socio-demographic characteristics, birth characteristics and reproductive patterns of individuals with CHD and women with Marfan syndrome.To investigate obstetric and neonatal outcomes in the firstborn children of individuals with CHD and women with Marfan syndrome.To study long-term cardiovascular outcomes after childbirth in women with Marfan´syndrome.MethodsThe studies are population-based register studies. The study population in the first paper included all women born between 1973 and 1983 who were alive and resident in Sweden at the age of 13 (494 692 women, of whom 2 216 were women with CHD). In the second paper, the same definition of the study population was chosen, except that it involved all men born between 1973 and 1983 (522 216 men, of whom 2 689 men with CHD). The third and fourth papers involved a study population of all Swedish women born between 1973 and 1993 who were still living in Sweden at age 13. This population consisted of 1 017 538 women, 273 of whom had been diagnosed with Marfan syndrome.Results and conclusionsThe individuals studied were more often born preterm, and were small-for-gestational age babies. They were more likely to have been born by cesarean section. In women with CHD, these characteristics were repeated in their firstborn children. No increased risks were found in children of men with CHD or in children of women with Marfan syndrome. There was no increased risk of aortic dissection in women with Marfan syndrome during pregnancy compared to women with Marfan syndrome who did not give birth. Higher frequencies of cardiac arrhythmia and valvular heart disease were found after childbirth in women with Marfan syndrome. Pregnancy in women with CHD is a high-risk situation associated with increased risk of adverse neonatal outcomes for the expected child. Pregnancy in women without CHD, but where the father has CHD is not so associated with increased risk of adverse obstetric or neonatal outcomes. Pregnancy in women with Marfan syndrome is not associated with adverse outcomes for the expected child.
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| 7. |
- Forsell, Karl, 1975-
(författare)
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Health hazards and cancer in relation to occupational exposures among Swedish seafarers
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis explores health hazards for seafarers in the Swedish merchant fleet, and occupational risks for lung cancer, mesothelioma and hematologic malignancy (HM). A special focus has been exposure to benzene and biomarker levels for work on product or chemical tankers during the mid-1990’ies.In a case report, we describe two cases of mesothelioma and two cases of lung cancer having worked in the engine room. Cumulative exposure to asbestos were up to 5 fibreyears. Other exposures were carcinogenic PAHs and nitroarenes. A web-based survey to active seafarers in the Swedish merchant fleet revealed noise, the risk of accidents, whole-body vibrations and ergonomic strain as main work environment problems. General health, work ability and safety climate were all rated high. Associations were found between lower airway symptoms and soot (PR 2.4, 95% CI 1.1-5.1) and between hearing impairment and noise exposure (PR 1.5; 95% CI 1.3–1.7). Iso-strain was especially common in the service department. Twenty-two percent of men and 45% of women had been subjected to harassments. The tanker study showed a geometric mean for benzene exposure of 0.45 mg/m3 (4hTWA) during a work shift, with a wide range (0.02-143 mg/m3). Correlations were found between exposure and benzene in alveolar air (p<0.0001), unmetabolised benzene in urine (p<0.0001) and ttMA in urine (p=0.0011). All biomarkers increased significantly during work (p<0.002). In a case-referent study with the observation period 1985 to 2014, the OR for HM was 1.32 (95% CI 0.86-2.02) if work on tankers had started before 1985 and with a cumulated tanker service of at least five years. If work on tankers had started after 1985, the OR was 0.85 (95% CI 0.51-1.43).In conclusion, health hazards in today’s seafaring relate to physical, chemical and psychosocial factors. Work on tankers with mixed open and closed cargo systems might have led to important benzene up-take. Possibly, the risk for HM for seafarers on tankers has decreased during the last decades.
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| 8. |
- E:son Jennersjö, Pär, 1956-
(författare)
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Risk factors in type 2 diabetes with emphasis on blood pressure, physical activity and serum vitamin D
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundType 2 diabetes is a common chronic disease with a two-fold increased risk for cardiovascular morbidity and mortality and has an increasing prevalence worldwide. This thesis is based on a study conducted in primary health care in Östergötland and Jönköping, Sweden. The aim of the thesis was to evaluate new risk markers to identify patients with high risk of developing cardiovascular disease in middle-aged men and women with type 2 diabetes.MethodsData from the cohort study CArdiovascular Risk in type 2 DIabetes – a Prospective study in Primary care (CARDIPP) was used. In paper III data were also used from CARDIPP-Revisited where all participants in the CARDIPP study were invited four years after the baseline investigation for a re-investigation. In paper IV data were used from CAREFUL which is a control group of 185 subjects without diabetes. The investigation included a standard medical history including data on diabetes duration and on-going medication. Anthropometric data were recorded and both office and ambulatory blood pressure were measured. The patients filled out a detailed questionnaire and physical activity was measured by using waist-mounted pedometers. Pedometer-determined physical activity was classified in four groups: Group 1: <5000 steps/day (‘sedentary’); Group 2: 5000-7499 steps/day (‘low active’); Group 3: 7500-9999 steps/day (‘somewhat active’); Group 4: and ≥10 000 steps/day (‘active’). Blood samples were drawn for routine analyses and also frozen for later analyses. The investigations at the departments of physiology included echocardiography, measurements of the carotid intima-media thickness, applanation tonometry and measurements of sagittal abdominal diameter.ResultsPaper 1:Patients with a non-dipping systolic blood pressure pattern showed higher left ventricular mass index and pulse wave velocity (PWV) compared with patients with ≥10% decline in nocturnal systolic blood pressure. Patients with <10% decline in nocturnal systolic blood pressure had higher BMI and sagittal abdominal diameter, lower GFR and higher albumin:creatinine ratio and also higher levels of NT-proBNP than patients with a dipping pattern of the nocturnal blood pressure.Paper 2:The number of steps/day were inversely significantly associated with BMI, waist circumference and sagittal abdominal diameter, levels of CRP, levels of interleukin-6 and PWV.Paper 3:At the 4-year follow-up the change in PWV (ΔPWV) from baseline was calculated. The group with the lowest steps/day had a significantly higher increase in ΔPWV compared with the group with the highest steps/day. The associations between baseline steps/day and ΔPWV remained after further adjustment in a multivariate linear regression statistically significant (p=0.005). 23% of the variation in the study could be explained by our model. Every 1000 extra steps at baseline reduced the change in ΔPWV by 0.103 m/s between baseline and follow-up.Paper 4:Low vitamin D levels were associated with significantly increased risk for premature mortality in men with type 2 diabetes. High levels of parathyroid hormone were associated with significantly increased risk for premature mortality in women with type 2 diabetes. These relationships were still statistically significant also when two other well-established risk markers for mortality, PWV and carotid intima-media thickness, were added to the analyses.ConclusionsAmbulatory blood pressure recording can by addressing the issue of diurnal blood pressure variation, explore early cardiovascular organ damage and microvascular complications that goes beyond effects of standardised office blood pressure measurements. Pedometer-determined physical activity may serve as a surrogate marker for inflammation and subclinical organ damage in patients with type 2 diabetes. There is novel support for the durable vascular protective role of a high level of daily physical activity, which is independent of BMI and systolic blood pressure. The use of pedometers is feasible in clinical practice and provides objective information not only about physical activity but also the future risk for subclinical organ damage in middle-aged people with type 2 diabetes. Our results indicate that low vitamin D levels in men or high parathyroid hormone levels in women give independent prognostic information of an increased risk for total mortality.
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| 9. |
- Klaff, Rami, 1971-
(författare)
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Disease-Specific Survival in Prostate Cancer Patients : Results from the Scandinavian Prostate Cancer Group (SPCG) Trial No. 5 and Regional Cancer Register Data
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- IntroductionProstate cancer (PCa) is the most common cancer among men in Sweden. The clinical course varies considerably, which makes it difficult to predict the prognosis in the individual case. In order to explore the early as well as the late course of the disease, large study groups and population-based cohorts are necessary.AimsTo explore factors that influence the long-term outcome of men with low-risk tumours in a population-based register, to predict the long-term course, and to assess the mortality rate for men with prostate cancer (Paper I)To analyse long-term outcome and to investigate factors associated with long-term survival in patients with metastases to the skeleton (Paper II)To analyse early androgen deprivation treatment (ADT) failure and to define clinical predictors associated with short survival due to early ADT failure in prostate cancer patients with bone metastases (Paper III)To analyse the prognostic significance of the extent of bone metastases in relation to other pretreatment variables in prostate cancer patients, and to explore the impact of bone metastases on quality-of-life (Paper IV)Material and methodsThe study groups were assembled from The South East Region Prostate Cancer Register (SERPCR), and The Scandinavian Prostate Cancer Group (SPCG) Trial No. 5. In the first study, prognostic factors and long-term disease-specific mortality rates of low-risk prostate cancer patients from the early PSA era were analysed. In the second study, patient-related factors, quality-of-life (QoL) and long-term survival in 915 PCa patients with bone metastases (M1b) under ADT, were analysed. In Study III factors predicting primary failure to respond to ADT were identified. Study IV explored the impact of the extent of bone metastases on survival and QoL for these men.Result and conclusionsThe long-term disease-specific mortality of low-risk localised PCa is low, but the annual mortality rate gradually increases. This indicates that some tumours slowly develop into lethal cancer, particularly in men 70 years or older and with a PSA level ≥ 4 μg/L. From the SPCG Trial No. 5, a subgroup of patients with M1b disease and favourable set of predictive factors survived more than 10 years under ADT with an acceptable QoL. Independent predictors of long-term survival were identified as performance status (PS) < 2, limited extent of bone metastases, and a PSA level < 231 μg/L at the time of enrolment in the trial. However, four independent clinical predictors of early ADT failure could be defined. Men exhibiting these features should be considered for an alternative treatment. Patient grouping based on three categories of extent of bone metastases related to PS, haemoglobin, and QoL at presentation, as independent predictors of mortality, may provide improved accuracy of prognosis.
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| 10. |
- Wiss, Johanna
(författare)
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Healthcare Priority Setting and Rare Diseases : What Matters When Reimbursing Orphan Drugs
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The rarity of a disease can give rise to challenges that differ from conventional diseases. For example, rarity hampers research and development of new drugs, and patients with severe, rare diseases have limited access to qualified treatments. When drugs are available, clinical evidence has higher uncertainty and the drugs can be very expensive. When setting priorities in the healthcare sector, treatments aimed at patients with rare diseases, so called orphan drugs, have become a source of concern. Orphan drugs seldom show solid evidence of effectiveness or cost-effectiveness. Still, treatments for rare disease patients, available on the European market, has increased rapidly since the adoption of a regulation offering incentives for research and development of orphan drugs. The question arises as to whether the publicly funded health care system should provide such expensive treatments, and if so, to what extent.This doctoral thesis aims to investigate healthcare priority setting and rare diseases in the context of orphan drug reimbursement. Priority setting for orphan drugs is located at the intersection of economic, ethical and psychological perspectives. This intersection is explored by studying the public’s view on the relevance of rarity when setting priorities for orphan drugs, and by examining how orphan drugs are managed when making reimbursement decisions in practice. Papers I and II in this thesis employ quantitative, experimental methods in order to investigate preferences for prioritising rare diseases, and the extent to which psychological factors influence such preferences. Papers III and IV employ qualitative methods to further explore what factors (apart from rarity) influence priority-setting decisions for orphan drugs, as well as how decisions regarding orphan drugs are made in practice in England, France, the Netherlands, Norway and Sweden. Combining quantitative and qualitative methods has provided a more comprehensive understanding of the topic explored in the thesis, and the methods have complemented each other.Paper I shows that there is no general preference for giving higher priority to rare disease patients when allocating resources between rare and common disease patients. However, results show that preferences for treating the rare patients are malleable to a set of psychological factors, in particular “proportion dominance”. Paper II shows that the identifiability of an individual has no, or a negative, influence on the share of respondents choosing to allocate resources to him/her (compared to a nonidentified individual). Paper III confirms that rarity per se is not seen as a factor that should influence priority-setting decisions (i.e. accept a greater willingness to pay for orphan drugs), however, other factors such as disease severity, treatment effect and whether there are treatment alternatives were seen as relevant for consideration. Paper IV explores the challenges with and solutions for orphan drug reimbursement, as perceived by different actors in five European countries. Perceived challenges are related to the components involved when making reimbursement decisions, to the reimbursement system, and to the acceptance of the final decision. Solutions are either specific for orphan drugs, or general measures that can be used for orphan drugs as well as for other drugs.In conclusion, priority setting for orphan drugs is complex and requires particular attention from decision makers. There are many factors to consider when making reimbursement decisions for orphan drugs. The consequences of a decision are potentially severe (both for rare disease patients and for common disease patients, depending on the decision) and psychological factors can potentially influence decisions.
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