| 1. |
- Eriksson, Thérèse, 1988-
(författare)
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Promises and pitfalls of value-based reimbursement in healthcare : A mixed method health economic approach
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Financial incentives can be an effective tool to influence behaviour in almost any context and healthcare is no exception. The healthcare market is, however complex, characterised by uncertainty, information asymmetry and multiple agency connections. The reach and limits of financial incentives in healthcare has been widely debated for decades. Some argue that financial incentives increase efficient use of scarce resources, while others voice that it provides a hotbed for unintended and unethical behaviour. A well-functioning value-based reimbursement programme (VBRP) should facilitate alignment between financial incentives and professional values to secure both efficient and equitable healthcare. This thesis explores the promises and pitfalls of value-based reimbursement in the context of a value-based reimbursement programme within elective spine surgery in Region Stockholm, Sweden. By using mixed methods, this thesis explores what incentives arise from introducing a value-based reimbursement programme and how these incentives affect the provision of healthcare services. This thesis consists of four papers. Paper I examines the performance of healthcare providers (spine surgery clinics) on patient-reported outcome measures after the introduction of a value-based reimbursement programme and whether it has any effect on case mix regarding clinical and socio-economic factors. Paper II examines how a value-based reimbursement programme affects the cost of elective spine surgery to a third party payer/regional authority. Paper III explores how the intended incentives of the reimbursement programme was perceived by healthcare providers. In Paper IV, institutional logics within healthcare-providing organisations are identified and how their centrality and compatibility affect the institutionalisation of a value-based reimbursement programme in Region Stockholm. The results show that the VBRP had no effect on patient-reported outcome measures but decreased the mean cost per surgery. Thus, elective spine surgery in Region Stockholm may be considered more effective after the introduction of the VBRP. The removal of a production ceiling allowed healthcare providers to surgically treat more patients than was previously possible. The volume increased by 22 per cent, and the total cost increased by 11 percent. No indications of discrimination against sicker patients were found. A higher value was generated in elective spine surgery after the introduction of the VBRP. The idea of a VBRP was aligned with professional values. However, not all incentives were perceived as intended. The focus on minimising costs of post-discharge care was perceived to have a negative impact on quality aspects of physiotherapy and nursing. Taken together, a well-designed VBRP has the potential to promote a holistic healthcare perspective through 1) the level to which healthcare providers are held accountable for healthcare provision that increase the willingness to collaborate across healthcare providers and medical disciplines, 2) a better overall picture of patients healthcare utilisation and 3) challenging the traditional structures and ideas within healthcare that quality foremost depends on the performance of physicians. However, there are also challenges that needs to be addressed, 1) functioning routines for communication and follow-up between healthcare providers and the regional health authority, 2) to get different professions within a traditional hierarchical organisation to cooperate on equal terms, and 3) to create IT systems that create transparency and an understanding of the reimbursement programme. Continuous communication between healthcare providers and the regional health authority is therefore crucial to make the incentives of the reimbursement programme meaningful.
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| 2. |
- Ennab Vogel, Nicklas, 1981-
(författare)
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Optimizing prehospital acute stroke care in the presence of economic constraints
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Mechanical thrombectomy (MT) has become standard of care for acute anterior circulation ischaemic stroke due to large vessel occlusion since the launch of second-generation stent retrievers for clinical use nearly a decade ago. Up until recently, the treatment was exclusively performed at university hospitals in Sweden. Sundsvall Regional Hospital joined as the eighth treatment facility in late 2023. Scarce resources of healthcare systems across the world hamper the complete implementation of MT in acute stroke care. Hence, efforts to improve patients’ accessibility to and healthcare providers’ utilization of MT remain prioritized. Methods for determining the optimal number and locations of treatment facilities for MT in economically constrained healthcare systems remain unstudied. The optimal number and locations of ambulance helicopters for prehospital transportation of patients with presumed acute stroke too. The aim of the thesis is to solve constrained optimization problems within the framework of cost-effectiveness analysis for prehospital acute stroke care management of patients with AIS. To fill these knowledge gaps, this thesis takes on an interdisciplinary research approach, and combines health economics, operations research, and medicine to identify cost-effective solutions for location problems with respect to the implementation of MT in the Swedish healthcare system. A comprehensive set of consolidated data based on anonymized, patient-level, nation-wide registry data for a study period of six years underlies analyses. This thesis employs predictive modelling, geographic network analysis, optimization, and decision modelling for economic evaluation within the framework of cost-effectiveness analysis to identify the most cost-effective solutions to implement. The fitting of predictive generalized linear models to four treatment modalities in acute stroke care for patients with acute ischaemic stroke established the linear associations in absolute effect measures between the modified Rankin Scale score at 90 days post-stroke and the time from symptom onset to treatment start with intravenous thrombolysis only, MT only and intravenous thrombolysis plus MT, respectively. With imposed economic constraints, the analysis identified the optimal number and locations of thrombectomy centres for the Swedish healthcare system. Furthermore, it identified the optimal number and locations of ambulance helicopters too. Finally, it was possible to determine the combination of optimally located thrombectomy centres and ambulance helicopters that comprises the most cost-effective solution to implement into the Swedish stroke system of care. This thesis demonstrates that economically constrained optimization of thrombectomy centres and ambulance helicopters in acute stroke systems of care comprises highly cost-effective solutions that entail immense health gains in patients with acute ischaemic stroke. Health economics, operational research and medicine can be combined to create a powerful decision-modelling tool in the evaluation of implementation strategies for prehospital acute stroke systems of care.
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| 3. |
- Siverskog, Jonathan, 1988-
(författare)
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Opportunity cost in healthcare priority setting
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The resources available for the public provision of health care are not unlimited. Cost-effectiveness evidence on new healthcare interventions can help us prioritise in order to use scarce resources wisely, but to interpret cost-effectiveness evidence, it may appear as if we must make trade-offs between life and money. This is not so. If we are able to quantify the health improvements that resources would or could have generated in alternative use, a decision about providing or denying treatment can instead be framed as a trade-off between health gained and health forgone. In this thesis, I seek to provide a more robust basis for this way of reporting and interpreting cost-effectiveness evidence.In Chapter II, I discuss the definition of opportunity cost in economic evaluation. The opportunity cost of providing an intervention is what we must give up to provide it. More precisely, it is typically defined as the value of the best alternative forgone. In economic evaluation of health care, opportunity cost has been understood in terms of the least cost-effective, currently funded intervention, which should be displaced when funding new interventions subject to a fixed budget. I show that alternative uses forgone may be neither currently funded nor well-defined, which implies that we should not look to cost-effectiveness evidence on specific interventions for information on opportunity cost. Further, identifying a best alternative use assumes that priority setting is based on objectives that can be summarised into a single measure of value. If economic evaluation is used to inform trade-offs between one measure of value (e.g., quality-adjusted life years, QALYs) and other, unquantified objectives, I suggest that it would be more appropriate to define opportunity cost as value in expected alternative use.To quantify opportunity cost as health forgone, we need evidence on the health that resources would or could have generated in alternative use. In Chapter III, I use panel data on health spending and life expectancy in Swedish regions to estimate the marginal cost of producing a QALY. My findings imply that Swedish health care can produce health at a marginal cost of SEK 180,000 per QALY, which could be used as an expectation on how productive health spending would be in alternative use. I discuss methodological issues with this approach and identify some credibility problems with selection-on-observables strategies plaguing this and similar research to date. I address (some of) these problems by assessing coefficient stability and the causal mechanisms between healthcare resource use and health outcomes, using a second panel on hospital bed capacity and mortality. This analysis finds that health could be gained at a cost of SEK 420,000 per QALY by providing more hospital beds.To illustrate the role of this evidence in healthcare priority setting, Chapter IV considers how it could have been used to inform decision making in a case of pharmaceutical reimbursement. I propose that economic evaluation report cost-effectiveness evidence as QALYs forgone per QALY gained. This frames a decision about providing or denying treatment as a judgement on the relative priority of QALYs gained and QALYs forgone, which is more transparent about a trade-off between equity and efficiency than deciding whether the monetary cost per QALY is too high. Framing decisions as health gained versus health forgone could also lead to better decision making by making opportunity costs more salient to decision makers and the reason for sometimes denying costly treatments easier to communicate.In summary, cost-effectiveness evidence can be used to achieve the theoretical objective of health maximisation, but economic evaluations rarely report opportunity costs explicitly as health forgone. This thesis provides the practical means to be explicit and implications for the definition of opportunity cost and the interpretation of cost-effectiveness evidence when health maximisation is not the sole objective of healthcare priority setting.
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| 4. |
- Aronsson, Mattias, 1989-
(författare)
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Health Economic Evaluations of Screening Programs - Applications and Method Improvements
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Screening to detect diseases early is attractive as it can improve the prognosis and decrease costs, but it is often a problematic concept and there are several pitfalls. Many healthy individuals have to be investigated to avoid a disease in a few, which results in a dilemma because to save a few, many are exposed to a procedure that could potentially harm them. Other examples of problems associated with screening are latent diseases and over-treating. The question of optimal design of a screening program is another source of uncertainty for decision-makers, as a screening program may potentially be implemented in very different ways. This highlights the need for structured analyses that weigh benefits against the harms and costs that occur as consequences of the screening.The aim of this thesis is, therefore, to explore, develop and implement methods for health economic evaluations of screening programs. This is done to identify problems and suggest solutions to improve future evaluations and in extension policy making.This aim was analysed using decision analytic cost-effectiveness analyses constructed as Markov models. These are well-suited for this task given the sequential management approach where all relevant data are unlikely to come from a single source of evidence. The input data were in this thesis obtained from the published literature and were complemented with data from Swedish registries and the included case studies. The case studies were two different types of screening programs; a program of screening for unknown atrial fibrillation and a program to detect colorectal cancer early. Further, the implementation of treatment with thrombectomy and novel oral anticoagulants were used to illustrate how factors outside the screening program itself have an impact on the evaluations.As shown by the result of the performed analyses, the major contribution of this thesis was that it provided a simple and systematic approach for the economic evaluation of multiple screening designs to identify an optimal design.In both the included case studies, the screening was considered costeffective in detecting the disease; unknown atrial fibrillation and colorectal cancer, respectively. Further, the optimal way to implement these screening programs is dependent on the threshold value for cost-effectiveness in the health care sector and the characteristics of the investigated cohort. This is because it is possible to gain increasingly more health benefits by changing the design of the screening program, but that the change in design also results in higher marginal costs. Additionally, changes in the screening setting were shown to be important as they affect the cost-effectiveness of the screening. This implies that flexible modelling with continuously updated models are necessary for an optimal resource allocation.
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| 5. |
- Berglund, Eva Caroline, et al.
(författare)
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A Study Protocol for Validation and Implementation of Whole-Genome and -Transcriptome Sequencing as a Comprehensive Precision Diagnostic Test in Acute Leukemias
- 2022
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Ingår i: Frontiers in Medicine. - Lausanne, Switzerland : Frontiers Media SA. - 2296-858X. ; 9, s. 1-9
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Tidskriftsartikel (refereegranskat)abstract
- 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. Clinical Trial Registration: [https://doi.org/10.1186/ISRCTN66987142], identifier [ISRCTN66987142].
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| 6. |
- Cuppen, Edwin, et al.
(författare)
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Implementation of Whole-Genome and Transcriptome Sequencing Into Clinical Cancer Care
- 2022
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Ingår i: JCO Precision Oncology. - : American Society of Clinical Oncology. - 2473-4284. ; 6
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 7. |
- Egeberg, Alexander, et al.
(författare)
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Real-world dose adjustments of biologic treatments in psoriasis and their economic impact : a Swedish national population study
- 2022
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Ingår i: Clincal and Experimental Dermatology. - : Wiley. - 0307-6938 .- 1365-2230. ; 47:11, s. 1968-1975
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 8. |
- Ghazal, Faris, et al.
(författare)
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Cost-effectiveness of screening for atrial fibrillation in a single primary care center at a 3-year follow-up
- 2022
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Ingår i: Scandinavian Cardiovascular Journal. - Abingdon, Oxfordshire, United Kingdom : Taylor & Francis. - 1401-7431 .- 1651-2006. ; 56:1, s. 35-41
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Tidskriftsartikel (refereegranskat)abstract
- ObjectivesThe 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.MethodsA 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.ResultsThe 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.ConclusionScreening 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.
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| 9. |
- Guenther, L., et al.
(författare)
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Impact of fixed-dose combination Cal/BD foam on the work productivity of patients with psoriasis: results from the 52-week randomized, double-blind, PSO-LONG trial
- 2022
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Ingår i: Journal of the European Academy of Dermatology and Venereology. - : WILEY. - 0926-9959 .- 1468-3083. ; 36:7, s. 1054-1063
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 10. |
- Johannesen, Kasper, 1982-
(författare)
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The value of evaluating and implementing pharmaceuticals
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Pharmaceuticals are a central part of high-quality health care and a resource for improving population health. However, high prices set by private companies who develop and own the rights to new pharmaceuticals question the value that they contribute to the health care system. Publicly funded health care systems need to get the most from limited health care resources, which has become even more apparent in recent years with ageing populations, rapid technological development, and more recently the impact of COVID-19. Reducing pharmaceutical prices increase the current value that they offer to health care systems, but price reduction also decreases incentives to develop future treatments. Hence, the health care systems must balance the objective of improving the value from the treatments available today and incentivising the development of future treatments. Governments and health care decision makers use a variety of policies to control prices and use of pharmaceuticals. However, these policies are rarely the focus of formal analysis and their effect on short- and long-term population health is often unclear. The aim of this thesis was to investigate how policies that control pharmaceutical prices and implementation impact population health and incentives for pharmaceutical research and development (R&D). The first study in this thesis outlines a framework for assessing the effect of pharmaceutical policies on population health and pharmaceutical earnings and shows that price reducing policies can increase the current value of pharmaceuticals to health care systems while lowering R&D incentives. The design of specific policies determines the impact as well as the distribution of the gains of lower prices across patients, health care providers, pharmacies, and other affected parties. The second study analyses the trade-off between accuracy and cost of the cost-effectiveness appraisals for pharmaceuticals by viewing it as a diagnostic test that aims to identify costeffective treatments. The study identifies some policy relevant conclusions, including that the process should be flexible over time and depend on characteristics of the treatment undergoing assessment. Study three, investigating the impact of regional implementation variation of the antiplatelet ticagrelor, found that an additional 1,100 Quality Adjusted Life Years (QALYs) could have been gained from achieving equal implementation across health care regions. This represents a value of SEK 285 million from avoiding regional implementation variation of ticagrelor (given a value of SEK 250,000 per QALY). The study also shows that avoiding delays due to sequential decisions on reimbursement, treatment guidelines, and funding could have significant value. Finally, the fourth study investigates the comparative effectiveness of ticagrelor using observational data collected as part of routine clinical care in the SWEDEHEART registry. The study finds similar reduction in mortality as observed in the pivotal randomised clinical trial of ticagrelor, the PLATO trial. Furthermore, the importance of appropriate methods for observational research on comparative effectiveness are demonstrated, highlighting the importance of using appropriate methods when investigating the effectiveness of treatments used in clinical practice. In conclusion, this thesis shows the importance of analysing and understanding the effect of policies that control price and implementation of pharmaceuticals, whether the goal is to maximise the value from currently available pharmaceuticals or to also incentivise the development of new pharmaceuticals. Although the value of improving implementation may not be as obvious or tangible as savings from lowering pharmaceutical prices, improving implementation may contribute more to population health than reinvesting potential savings from price reductions.
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