| 1. |
- Arvidsson, Eva
(författare)
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Priority Setting and Rationing in Primary Health Care
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Studies on priority setting in primary health care are rare. Priority setting and rationing in primary health care is important because outcomes from primary health care have significant implications for health care costs and outcomes in the health system as a whole.Aims: The general aim of this thesis has been to study and analyse the prerequisites for priority setting in primary health care in Sweden. This was done by exploring strategies to handle scarce resources in Swedish routine primary health care (Paper I); analysing patients’ attitudes towards priority setting and rationing and patients’ satisfaction with the outcome of their contact with primary health care (Paper II); describing and analysing how general practitioners, nurses, and patients prioritised individual patients in routine primary health care, studying the association between three key priority setting criteria (severity of the health condition, patient benefit, and cost-effectiveness of the medical intervention) and the overall priority assigned by the general practitioners and nurses to individual patients (Paper III); and analysing how the staff, in their clinical practise, perceived the application of the three key priority setting criteria (Paper IV).Methods: Both qualitative (Paper I and IV) and quantitative (Paper II and III) methods were used. Paper I was an interview study with medical staff at 17 primary health care centres. The data for Paper II and Paper III were collected through questionnaires to patients and staff at four purposely selected health care centres during a 2-week period. Paper IV was a focus group study conducted with staff members who practiced priority setting in day-to-day care.Results: The process of coping with scarce resources was categorised as efforts aimed to avoid rationing, ad hoc rationing, or planned rationing. Patients had little understanding of the need for priority setting. Most of them did not experience any kind of rationing and most of those who did were satisfied with the outcome of their contact with primary health care. Patients, compared to medical staff, gave relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions when prioritising individual patients in day-today primary health care. When applying the three priority setting criteria in day-to-day primary health care, the criteria largely influenced the overall prioritisation of each patient. General practitioners were most influenced by the expected cost-effectiveness of the intervention and nurses were most influenced by the severity of the condition. Staff perceived the criteria as relevant, but not sufficient. Three additional aspects to consider in priority setting in primary health care were identified, namely viewpoint (medical or patient’s), timeframe (now or later) and evidence level (group or individual).Conclusion: There appears to be a need for, and the potential to, introduce more consistent priority setting in primary health care. The characteristics of primary health care, such as the vast array of health problems, the large number of patients with vague symptoms, early stages of diseases, and combinations of diseases, induce both special possibilities and challenges.
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| 2. |
- Ekerstad, Niklas, 1969-
(författare)
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Micro Level Priority Setting for Elderly Patients with Acute Cardiovascular Disease and Complex Needs : Practice What We Preach or Preach What We Practice?
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Demographic trends and other factors are expected to continue widening the gap between health care demands and available resources, especially in elder services. This growing imbalance signals a need for priority setting in health care. The literature has previously described problems in constructing useable means of priority setting, particularly when evidence is sparse, when patient groups are not satisfactorily defined, when interpretation of the term patient need is unclear, and when uncertainty prevails on how to weigh different ethical values. The chosen study object illustrates these problems. Moreover, the Swedish Government recently stated that care for elderly persons with complex health care needs remains underfunded. The general aim of this thesis is: to study micro-level priority setting for elderly heart patients with complex needs, as illustrated by those with non-ST-elevation myocardial infarction (NSTEMI); to relate the findings to evidence-based priority setting, e.g. guidelines for heart disease; and to analyse how complex needs could be appropriately categorised from a perspective of evidence-based priority setting.Paper I presents a register study that uses data from the Patient Register to describe inpatient care utilization, costs, and characteristics of elderly patients with multiple diseases. Paper II presents a confidential survey study from a random sample of 400 Swedish cardiologists. Paper III presents a prospective, clinical, observational multicentre-study of elderly patients with myocardial infarction (NSTEMI). Paper IV presents a questionnaire study from a purposeful, stratified sample of Swedish cardiologists.The results from Paper I show that elderly patients with multiple diseases have extensive and complex needs, frequently manifesting chronic and intermittently acute disease and consuming health care at various levels. A large majority have manifested cardiovascular disease. Results from Paper II indicate that although 81% of cardiologists reported extensive use of national guidelines in their clinical decision-making generally, the individual clinician’s personal clinical experience and the patient’s views were used to a greater extent than national guidelines, when making decisions about elderly multiple-diseased patients. Many elderly heart disease patients with complex needs manifest severe, acute or chronic, comorbid conditions that constitute exclusion criteria in evidence-generating studies, thereby limiting the generalisability of evidence and applicability of guidelines for these patients. This was indicated in papers I-IV. Paper III reports that frailty is a strong independent risk factor for adverse, short-term, clinical outcomes, e.g. one-month mortality for elderly NSTEMI patients. Particularly frail patients with a high comorbidity burden manifested a markedly increased risk.In the future, prospective clinical studies and registries with few exclusion criteria should be conducted. Consensus-based judgments based on a framework for priority setting as regards elderly patients with complex needs may offer an alternative, estimating the benefitrisk ratio of an intervention and the time-frame of expected benefits in relation to expected life-time. Such a framework, which is tentatively outlined in this thesis, should take into account comorbidity, frailty, and disease-specific risk.
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| 3. |
- Kalkan, Almina, 1985-
(författare)
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Diffusion, implementation and consequences of new health technology : The cases of biological drugs for rheumatoid arthritis and the Swedish national guidelines
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Improvements in health technology raise hopes for better patient outcomes and a more efficient delivery of health care. However, the processes of diffusion and implementation of new health technology have been shown to be complicated and to pose a number of challenges for the healthcare sector. Many at tempts have been made to influence and manage the introduction and diffusion of health technology. One prominent example is the Swedish nat ional guidelines that aim at influencing both clinical and political decision - making in the health sector.The overall aim of this thesis is to describe and analyze the factors influencing the diffusion and economic consequences of the introduction of a new technology with large variations in use, and to explore the process of implementation of nationally produced guidelines as an instrument for improv ing effectiveness and equity. The empirical focus is kept on the biological drugs (bDMARDs) for rheumatoid arthritis (RA), since they implied a substantial treatment change when they were first int roduced and they are relatively costly; and on the national guidelines for cardiac care, since they were the first nat ional guidelines, hence allowing a long-term perspect ive in the exploration of their implementat ion.Paper I presents a register study that uses data from national and regional registries on healt hcare use and work disability of patients with RA and shows that there was a 32 percent increase in the total fixed cost of RA during 1990-2010, mainly after the introduct ion of bDMARDs. Paper II shows that choosing to initiate treatment with bDMARDs varied substantially among 26 rheumatologists presented with hypothetical patient cases, and that there were also disparities between rheumatologists practicing in the same clinic. Paper III presents data from the Swedish Rheumatology Quality Register covering 4010 patients with RA, and shows that when using multivariate logistic regression to adjust for patient characterist ics, disease activity and t he physician’s local context, physician preference was an import ant predict or for prescription of bDMARDs. Paper IV is a qualitative study about prescribing decisions, showing that a constellat ion of various factors and their interact ion influenced the prescribing decisions according to the 26 interviewed rheumatologists. The factors included the individual rheumatologist ’s experiences and perceptions of t he evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participat ion in clinical trials. The patient as an actor emerged as an important factor. Paper V is a longitudinal qualitat ive study exploring the responses among four Swedish county councils to the national guidelines for cardiac care through 155 interviews with politicians, administ rators and clinical managers. The results show that unilateral responses to the national guidelines within the county councils have been rare, but there have been at tempts to compromise and to at tain a balance between multiple constituents. There are examples of local information meetings, the use of the national guidelines in local healthcare programs, and performing audits with the national guidelines as a base. However, performing explicit prioritizat ion as advised in the NGCC is rarely found. Over t ime, however, a more systematic use of the national guidelines has been noted.In conclusion, the diffusion of new health technology is influenced by a wide array of factors both at individual and organizational levels, as well as their interact ion. The diffusion resulted in large economic consequences and unequal access due to variations also at clinical level. Moreover, given that healthcare decision-making is influenced by many different factors, the simple influx of evidence-based guidelines will unlikely result in automat ic implementat ion. At tempts to influence healthcare decisions need to have a systems perspect ive and to account for the interact ion of factors between different actors.
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| 4. |
- Tinghög, Gustav, 1979-
(författare)
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The Art of Saying No : The Economics and Ethics of Healthcare Rationing
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- It follows from resource scarcity that some form of healthcare rationing is unavoidable. This implies that potentially beneficial medical treatments must be denied to patients to avoid unacceptable sacrifices in other areas of society. By focusing on four, core, conceptual themes – individual responsibility, paternalism, incentives, and inequality – this thesis explores the matter of finding justifiable grounds for saying no in the context of health care.By combining the perspectives of welfare economics and population-level ethics, the author explicate and discusses conflicting moral values involved in healthcare rationing. Four papers form the foundation for this thesis. Paper I articulates the potential role of individual responsibility as a welfarepromoting, rationing tool by exploring when healthcare services exhibit characteristics that facilitate individual responsibility for private financing. Paper II explores the normative relevance of individuals’ time preferences in healthcare rationing and when paternalism can be justified in the context of individuals’ intertemporal health choices. Paper III examines the compatibility between incentive-based organ donation and the ethical platform for setting priorities in Sweden. Paper IV empirically investigates the existence of horizontal inequalities in using waiting lists to ration care.From the discussion it is suggested, inter alia, that: I) Prospective responsibility as opposed to retrospective responsibility is a more productive notion of responsibility when discussing actual policies. However, potential positive effects need to be weighed against the increased economic inequality that it is likely to invoke. II) Although cost-effectiveness analysis provides valuable input when making rationing decisions it should not be viewed as a decision rule, since it is based on utilitarian values that constantly need to be balanced against other nonutilitarian values. III) Potentially, increased health could negatively affect individuals’ well-being if it creates opportunities that they are unable to take advantage of. This needs to be taken into account before embarking on paternalistic policies to improve health – policies that often target the lower socioeconomic segment.The author concludes that decisions on rationing cannot be computed through a simple formula. Moreover, given that rationing is bound to be associated with reasonable disagreements we are unlikely to ever fully resolve these disagreements. However, by explicitly stating conflicting moral values we are more likely to narrow the disagreements and achieve a healthcare system that is both fairer and more efficient.
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| 5. |
- 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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