| 1. |
- Johansson, Naimi, 1988-, et al.
(författare)
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Place or patient as the driver of regional variation in healthcare spending – Discrepancies by category of care
- 2024
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Ingår i: Social Science and Medicine. - : Elsevier. - 0277-9536 .- 1873-5347. ; 342
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Tidskriftsartikel (refereegranskat)abstract
- We study how much regional variation in healthcare spending is driven by place- and patient-specific factors using a random sample of 53,620 regional migrants in Sweden. We find notable differences depending on the category of care, with place-specific factors having a significantly larger impact on specialized outpatient care compared to inpatient and pharmaceutical care. The place effect is estimated to 75% of variation in specialized outpatient care, but 26% or less in variations in inpatient care, and 5% in prescription drug spending. We also find that the empirical estimator has a substantial impact on the estimates of the place-specific effect. The results based on the traditional approach in the literature with two-way fixed effects and event-study models produce much larger estimates of the place-specific effect compared to results based on recently developed heterogeneity-robust models. For total healthcare spending, the traditional two-way fixed effects model estimates a place effect of 78%, while the heterogeneity-robust estimator finds a place effect around 10%. This finding indicates that previous results in this literature, all based on traditional two-way fixed-effects regressions, should be interpreted with care.
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| 2. |
- Svensson, Mikael, 1980, et al.
(författare)
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Analyses of quality of life in cancer drug trials - a review of measurements and analytical choices in post-reimbursement studies
- 2024
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Ingår i: BMC Cancer. - : BioMed Central (BMC). - 1471-2407. ; 24:1
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Forskningsöversikt (refereegranskat)abstract
- Objectives: For drugs reimbursed with limited evidence of patient benefits, confirmatory evidence of overall survival (OS) and quality of life (QoL) benefits is important. For QoL data to serve as valuable input to patients and decision-makers, it must be measured and analyzed using appropriate methods. We aimed to assess the measurement and analyses of post-reimbursement QoL data for cancer drugs introduced in Swedish healthcare with limited evidence at the time of reimbursement. Methods: We reviewed any published post-reimbursement trial data on QoL for cancer drugs reimbursed in Sweden between 2010 and 2020 with limited evidence of improvement in QoL and OS benefits at the time of reimbursement. We extracted information on the instruments used, frequency of measurement, extent of missing data, statistical approaches, and the use of pre-registration and study protocols. Results: Out of 22 drugs satisfying our inclusion criteria, we identified published QoL data for 12 drugs in 22 studies covering multiple cancer types. The most frequently used QoL instruments were EORTC QLQ-C30 and EQ-5D-3/5L. We identified three areas needing improvement in QoL measurement and analysis: (i) motivation for the frequency of measurements, (ii) handling of the substantial missing data problem, and (iii) inclusion and adherence to QoL analyses in clinical trial pre-registration and study protocols. Conclusions: Our review shows that the measurements and analysis of QoL data in our sample of cancer trials covering drugs initially reimbursed without any confirmed QoL or OS evidence have significant room for improvement. The increasing use of QoL assessments must be accompanied by a stricter adherence to best-practice guidelines to provide valuable input to patients and decision-makers.
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| 3. |
- Chauca Strand, Gabriella, 1995, et al.
(författare)
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Cancer Drugs Reimbursed with Limited Evidence on Overall Survival and Quality of Life : Do Follow-Up Studies Confirm Patient Benefits?
- 2023
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Ingår i: Clinical drug investigation. - : Springer. - 1173-2563 .- 1179-1918. ; 43:8, s. 621-633
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Tidskriftsartikel (refereegranskat)abstract
- Background and ObjectiveCancer drug costs have increased considerably within healthcare systems, but many drugs lack quality-of-life (QoL) and overall survival (OS) data at the time of reimbursement approval. This study aimed to review the extent of subsequent literature documenting improvements in OS and QoL for cancer drug indications where no such evidence existed at the time of reimbursement approval.MethodsDrug indications with claims of added therapeutical value but a lack of evidence on OS and QoL that were reimbursed between 2010 and 2020 in Sweden were included for review. Searches were conducted in PubMed and ClinicalTrial.gov for randomized controlled trials examining OS and QoL.ResultsOf the 22 included drug indications, seven were found to have at least one trial with conclusive evidence of improvements in OS or QoL after a mean follow-up of 6.6 years. The remaining 15 drug indications either lacked subsequent randomized controlled trial data on OS or QoL (n = 6) or showed no statistically significant improvements (n = 9). Only one drug demonstrated evidence of improvement in both OS and QoL for its indication.ConclusionsA considerable share of reimbursed cancer drug indications continue to lack evidence of improvement in both OS and QoL. With limited healthcare resources and an increasing cancer burden, third-party payers have strong incentives to require additional post-reimbursement data to confirm any improvements in OS and QoL.
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| 4. |
- Fledsberg, Stephanie, et al.
(författare)
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Lifetime healthcare expenditures across socioeconomic groups in Sweden.
- 2023
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Ingår i: European journal of public health. - : Oxford University Press. - 1464-360X .- 1101-1262. ; 33:6, s. 994-1000
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Tidskriftsartikel (refereegranskat)abstract
- Individuals of lower socioeconomic status generally have higher healthcare expenditures than individuals of higher socioeconomic status. However, little is known about how expenditures are distributed across socioeconomic groups over a lifetime, once accounting for differences in life expectancy. This study describes how lifetime healthcare expenditures are distributed across age, sex and socioeconomic groups in Sweden while adjusting for differences in life expectancy.Healthcare utilization from 2016 were linked to demographic and socioeconomic data for a random sample of individuals aged 20 and above in the four largest Swedish regions (n=440659). Mortality data were used to estimate income- and sex-specific survival rates. Expected lifetime healthcare expenditures were estimated by combining survival rates with mean healthcare expenditures over age, by sex, and income quintile.We find that expected lifetime healthcare expenditures are highest among the first (lowest) income quintile despite their evident lower life expectancy. Expected lifetime expenditures were 17.9% (16.8%) higher in the first income quintile compared to the fifth (highest) quintile for women (men). Individuals in the first income quintile had higher expected lifetime expenditures for all care categories except for primary care.We conclude that despite a lower life expectancy, the quintile of the lowest socioeconomic status still had higher lifetime healthcare expenditures.
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| 5. |
- Johansson, Naimi, 1988-, et al.
(författare)
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Reductions in out-of-pocket prices and forward-looking moral hazard in health care demand
- 2023
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Ingår i: Journal of Health Economics. - : Elsevier. - 0167-6296 .- 1879-1646. ; 87
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Tidskriftsartikel (refereegranskat)abstract
- Little is known about how patients dynamically respond to a forthcoming reduction in health care out-of-pocket prices. Using a kinked Donut Regression Discontinuity design with kinks entering and exiting the donut, we evaluate a Swedish cost-sharing policy, where primary care out-of-pocket prices were eliminated at age 85. We find evidence of forward-looking moral hazard with older adults delaying primary care visits up to four months before the out-of-pocket elimination and shifting these visits until shortly after. These health care delays are driven by non-urgent care: non-physician visits, planned visits and follow up visits. We find no evidence of severe negative health effects in the short-term as a result of the delay. Contrary to our finding of forward-looking behavior with respect to out-of-pocket prices, we do not find evidence of typical moral hazard, as we do not find a persistent increase in primary health care use after the copayment elimination.
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| 6. |
- Alkmark, Mårten, 1973, et al.
(författare)
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Induction of labour at 41weeks of gestation versus expectant management and induction of labour at 42weeks of gestation: a cost-effectiveness analysis
- 2022
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Ingår i: BJOG: An International Journal of Obstetrics and Gynaecology. - : Wiley. - 1470-0328 .- 1471-0528. ; 129:13, s. 2157-2165
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To assess the cost-effectiveness of induction of labour (IOL) at 41weeks of gestation compared with expectant management until 42weeks of gestation. Design: A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial. Setting: Fourteen Swedish hospitals during 2016–2018. Population: Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41weeks of gestation to IOL or to expectant management and induction at 42weeks of gestation. Methods: Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping. Main outcome measures: The cost per gained life year and per gained QALY. Results: The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was €4108 in the IOL group (n=1373) and €4037 in the expectant management group (n=1373), with a mean difference of €71 (95%CI −€232 to €379). The ICER for IOL compared with expectant management was €545 per life year gained and €623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes. Conclusions: Induction of labour at 41weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42weeks of gestation using standard threshold values for acceptable cost per life year/QALY. Tweetable abstract: Induction of labour at 41weeks of gestation is cost-effective compared with expectant management until 42weeks of gestation.
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| 7. |
- Chauca Strand, Gabriella, 1995, et al.
(författare)
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Assessment of the clinical and cost-effectiveness evidence in the reimbursement decisions of new cancer drugs
- 2022
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Ingår i: ESMO Open. - : Elsevier. - 2059-7029. ; 7:5
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Tidskriftsartikel (refereegranskat)abstract
- Background: This study aimed to describe the clinical and cost-effectiveness evidence supporting reimbursementdecisions of new cancer drugs and analyze the influence of trial characteristics and the cost per quality-adjusted lifeyears (QALYs) on the likelihood of reimbursement in Sweden.Patients and methods: Data were extracted from all appraisal dossiers for new cancer drugs seeking reimbursement inSweden and claiming added therapeutical value between the years 2010 and 2020. The data were analyzed usingdescriptive statistics, and logistic regression models were also used with the cost per QALY, study design,comparator, and evidence on final outcomes in the clinical trials as predictors of reimbursement.Results: All 60 included appraisals were based on trial evidence that assessed at least one final outcome (overallsurvival [OS] or quality of life [QoL]), although rarely as a primary outcome. Of the appraisals with a final decision(n ¼ 58), 79% were approved for reimbursement. Among the reimbursed drugs, only half had trial evidencedemonstrating improved OS or QoL. Only one drug had trial evidence supporting improvements in both OS andQoL. The average cost per QALY for reimbursed cancer drugs was estimated to be 748 560 SEK (V73 583). A highercost per QALY was found to decrease the likelihood of reimbursement by 9.4% for every 100 000 SEK (V9830)higher cost per QALY (P ¼ 0.03). For cost-effectiveness models without direct evidence of improvements in finaloutcomes, a larger QALY gain was observed compared with those with evidence mainly relying on intermediate andsurrogate outcomes.Conclusions: There are substantial uncertainties in the clinical and cost-effectiveness evidence underlyingreimbursement decisions of new cancer drugs. Decision makers should be cautious of the limited evidence onpatient-centered outcomes and the implications of allocating resources to expensive treatments with uncertainvalue for money.
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| 8. |
- Johansson, Naimi, 1988, et al.
(författare)
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Regional variation in prescription drug spending: Evidence from regional migrants in Sweden
- 2022
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Ingår i: Health Economics. - : Wiley. - 1057-9230 .- 1099-1050. ; 31:9, s. 1862-1877
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Tidskriftsartikel (refereegranskat)abstract
- There is substantial variation in drug spending across regions in Sweden, which can be justified if caused by differences in health need, but an indication of inefficiencies if primarily caused by differences in place-specific supply-side factors. This paper aims to estimate the relative effect of individual demand-side factors and place-specific supply-side factors as drivers of geographical variation in drug spending in Sweden. We use individual-level register data on purchases of prescription drugs matched with demographic and socioeconomic data of a random sample of about 900,000 individuals over 2007-2016. The primary empirical approach is a two-way fixed effect model and an event study where we identify demand- and supply-side effects based on how regional and local migrants change drug spending when moving across regional and municipal borders. As an alternative approach in robustness checks, we also use a decomposition analysis. The results show that the place-specific supply-side effect accounts for only about 5%-10% of variation in drug spending and remaining variation is due to individual demand-side effects. These results imply that health policies to reduce regional variation in drug spending would have limited impact if targeted at place-specific characteristics.
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| 9. |
- Holst, Anna, et al.
(författare)
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Cost-effectiveness analysis of internet-mediated cognitive behavioural therapy for depression in the primary care setting : results based on a controlled trial
- 2018
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Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 8:6
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Tidskriftsartikel (refereegranskat)abstract
- Objective To perform a cost-effectiveness analysis of a randomised controlled trial of internet-mediated cognitive behavioural therapy (ICBT) compared with treatment as usual (Tall) for patients with mild to moderate depression in the Swedish primary care setting. In particular, the objective was to assess from a healthcare and societal perspective the incremental cost-effectiveness ratio (ICER) of ICBT versus TaU at 12 months follow-up. Design A cost-effectiveness analysis alongside a pragmatic effectiveness trial. Setting Sixteen primary care centres (PCCs) in south-west Sweden. Participants Ninety patients diagnosed with mild to moderate depression at the PCCs. Main outcome measure ICERs calculated as (Cost(ICBT)-Cost(TaU))/(Health outcome(ICBT)-Health outcome(TaU))=Delta Cost/Delta Health outcomes, the health outcomes being changes in the Beck Depression Inventory-II (BDI-II) score and quality-adjusted life-years (QALYs). Results The total cost per patient for ICBT was 4044 Swedish kronor (SEK) ((sic)426) (healthcare perspective) and SEK47679 ((sic)5028) (societal perspective). The total cost per patient for TaU was SEK4434 ((sic)468) and SEK50 343 ((sic)5308). In both groups, the largest cost was associated with productivity loss. The differences in cost per patient were not statistically significant. The mean reduction in BDI-ll score was 13.4 and 13.8 units in the ICBT and Tall groups, respectively. The mean QALYs per patient was 0.74 and 0.79 in the ICBT and TaU groups, respectively. The differences in BDI-11 score reduction and mean QALYs were not statistically significant. The uncertainty of the study estimates when assessed by bootstrapping indicated that no firm conclusion could be drawn as to whether ICBT treatment compared with Tall was the most cost-effective use of resources. Conclusions ICBT was regarded to be as cost-effective as TaU as costs, health outcomes and cost-effectiveness were similar for ICBT and TaU, both from a healthcare and societal perspective.
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| 10. |
- Johansson, Naimi, 1988-, et al.
(författare)
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Regional variation in health care utilization in Sweden : The importance of demand-side factors
- 2018
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Ingår i: BMC Health Services Research. - London, UK : BioMed Central. - 1472-6963. ; 18:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Differences in health care utilization across geographical areas are well documented within several countries. If the variation across areas cannot be explained by differences in medical need, it can be a sign of inefficiency or misallocation of public health care resources. Methods: In this observational, longitudinal panel study we use regional level data covering the 21 Swedish regions (county councils) over 13 years and a random effects model to assess to what degree regional variation in outpatient physician visits is explained by observed demand factors such as health, demography and socio-economic factors. Results: The results show that regional mortality, as a proxy for population health, and demography do not explain regional variation in visits to primary care physicians, but explain about 50% of regional variation in visits to outpatient specialists. Adjusting for socio-economic and basic supply-side factors explains 33% of the regional variation in primary physician visits, but adds nothing to explaining the variation in specialist visits. Conclusion: 50-67% of regional variation remains unexplained by a large number of observable regional characteristics, indicating that omitted and possibly unobserved factors contribute substantially to the regional variation. We conclude that variations in health care utilization across regions is not very well explained by underlying medical need and demand, measured by mortality, demographic and socio-economic factors.
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